SUITES AT SOMEREN GLEN CARE CENTER, THE

A survey prompted by #CO38730 and #CO39813 was completed from 4/29/25 to 4/30/25. Two deficiencies were cited.

Based on observations, record review and interviews, the facility failed to ensure residents had the right to a dignified existence for one (#6) of three residents out of seven sample residents. Specifically, the facility failed to ensure Resident #6 experienced a dignified learning experience when certified nurse aide (CNA) #1 provided inappropriate redirection to the resident after the resident spilled a drink. Findings include:I. Resident #6A. Resident statusResident #6, age 70, was admitted on 2/1/25. According to the April 2025 computerized physician orders (CPO), diagnoses included unspecified dementia, severe with mood disturbances and Parkinson's disease. The 4/17/25 minimum data set (MDS) assessment revealed the resident was unable to participate in the brief interview for mental status (BIMS) assessment. Per the staff assessment for mental status, the resident had short-term and long-term memory impairment and required substantial assistance with decisions regarding tasks of daily life. The MDS assessment revealed the resident did not display physical behaviors directed towards others. B. Resident observationOn 4/29/25 at 12:55 p.m., during observation of the lunch meal service, Resident #6 got up from her dining room chair and walked to the food preparation counter located within the common area space on the unit. Resident #6 spilled a glass of clear liquid, either juice or water, that was on the counter. CNA #1 approached Resident #6 from behind. Without saying anything to the resident, CNA #1 placed both hands under the resident's armpits and physically redirected Resident #6 away from the area. -CNA #1 did not provide any verbal explanation, reassurance, or calming interaction to support the resident during this redirection. -CNA #1 did not implement the person-centered redirection strategies as outlined in the resident's care plan (see record review below). C. Record reviewResident #6's communication care plan, revised 3/16/25, revealed the resident had impaired communication related to dementia and primarily spoke Vietnamese. Interventions included providing verbal redirection and allowing adequate time for the resident to respond, repeating statements as necessary, not rushing the resident to respond to verbal cues, facing the resident while speaking, reducing environmental noise and using simple and consistent words. Resident #6's behavior care plan, revised 4/21/25, revealed the resident had impaired cognitive functioning related to dementia, with non-aggressive behaviors, such as pacing, wandering and placing non-food objects in the mouth, as reported by family. Interventions included explaining all procedures before starting a care task, allowing the resident time to adjust to changes, intervening to protect the rights and safety of others, speaking to the resident in a calm manner, redirecting the resident to a safe alternate location as needed, and minimizing disruptive behavior and offering activities and tasks that diverted the resident's attention. Resident #6's cognition care plan, revised 4/21/25, revealed the resident had impaired cognitive functioning related to dementia and senile degeneration of the brain. Interventions included providing verbal and visual cues to support recall and orientation, reorienting the resident as appropriate and supervising tasks of daily life. -Review of the comprehensive care plan revealed that physical redirection was not included as an intervention approach. -Despite the development of the person-centered care plan interventions for Resident #6, CNA #1 failed to implement any of the interventions when the resident spilled water on the kitchen counter. D. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 4/30/25 at 8:47 a.m. LPN #1 said she observed CNA #1 attempt to stop Resident #6 after the resident spilled her drink by grabbing her under the arms and physically redirecting her. LPN #1 said CNA #1 should have provided the resident with verbal redirection instead. LPN #1 said she pulled CNA #1 aside afterward and told her to be more careful and advised CNA #1 that next time she should reach for the cup rather than the resident. LPN #1 explained that the facility expected staff to use verbal redirection or offer comforting objects such as a baby doll to effectively redirect residents. The director of nursing (DON) was interviewed on 4/30/25 at 4:19 p.m. The DON said CNA #1 told her that Resident #6 was pouring water onto food and that she reacted by moving the resident's arm down to stop her. The DON said Resident #6 had a history of pouring hot liquids, such as soup, and staff were expected to respond quickly out of concern for her safety. The DON said the reaction of CNA #1 was not well thought through but was a reflex due to the resident's unpredictable behavior. The DON acknowledged that CNA #1's actions were inappropriate, but she said they were not intentional. The DON said staff received education on how to respond to potentially dangerous resident behavior while still acting appropriately as a caregiver. The DON said she planned to provide additional education to CNA #1 regarding appropriate redirection of residents.

Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received appropriate treatment and services to maintain personal hygiene for two (#7 and #3) of three residents reviewed for ADLs out of seven sample residents. Specifically, the facility failed to offer toileting or timely incontinence care for Resident #7 and Resident #3. Findings include:I. Facility policy and procedureThe Urinary Management (UM) policy, dated December 2024, was provided by the nursing home administrator (NHA) on 4/30/25 at 7:03 p.m. It read in pertinent part, "The facility will manage urinary incontinence as part of the person-centered resident care. Treatment for urinary incontinence depends on the type of incontinence, its causes, and the capabilities of the resident."A comprehensive assessment will be completed upon move-in, change of condition and annually to determine diagnosis or reason for incontinence. Residents will be monitored through the standard MDS/RAI (minimum data set /resident assessment instrument) process. If incontinence is identified and based on the type of incontinence, a care plan will be written for incontinent residents, utilizing the appropriate interventions to achieve or maintain as much as normal urinary function as possible. The interdisciplinary team (IDT) will determine if the resident is appropriate for a bladder re-training program or a toileting schedule following a review of the three-day data collection, assessment, and cognitive status of the resident. The care plan will be updated and communicated to the nursing associates if there are any suggested toileting plans for the resident based upon the information obtained from the data collection and assessment. A resident with or without a catheter receives the appropriate care and services to prevent infections to the greatest extent possible."II. Resident #7 A. Resident status Resident #7, age greater than 65, was admitted on 2/8/23. According to the April 2025 computerized physician orders (CPO), diagnoses included Alzheimer's disease and dementia. The 4/14/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment and was unable to participate in the brief interview for mental status (BIMS) assessment. Per the staff assessment for mental status, the resident was unable to make decisions regarding tasks of daily life. The resident was dependent on one staff member for assistance with eating, oral care, personal hygiene, toileting, bathing, dressing and transferring. B. ObservationsDuring a continuous observation on 4/30/25, beginning at 8:25 a.m. and ending at 12:30 p.m., the following was observed:At 8:25 a.m. Resident #7 was eating breakfast in the dining room, where she was assisted with eating and hydration. At 10:24 a.m. Resident #7 finished her breakfast and an unidentified staff member wheeled her from the dining room to the common area. -The unidentified staff member did not check the resident for incontinence or provide toileting assistance to the resident before placing the resident in the common area. At 11:46 a.m. the resident's hospice aide (HA) arrived and wheeled her from the common area to the spa room for a shower.-Per staff interview, Resident #7 was provided incontinent care at 7:45 a.m., four hours prior to the HA taking the resident for a shower (see certified nurse aide (CNA) #2's interview below). C. Record reviewResident #7's bladder incontinence care plan, revised 2/16/24, revealed the resident had bladder incontinence and was at risk for falls, skin irritation, moisture-associated skin damage (MASD), urinary tract infections (UTI), social isolation, embarrassment, curtailment of fluids and reduced activity participation. Interventions included observing and reporting any potential causes of incontinence, such as bladder infection, constipation, loss of bladder tone, weakening of control muscles and decreased bladder capacity. Staff were directed to observe and document signs and symptoms of UTI, including pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, fever, chills, urinary frequency, foul-smelling urine, altered mental status or changes in behavior or eating patterns. Resident #7's activities of daily living (ADL) care plan, revised 2/9/23, revealed the resident had a self-care performance deficit related to muscle weakness from Alzheimer's disease with late onset. Interventions included assisting the resident with toileting throughout the day and always upon rising in the morning. Resident #7's skin care plan, revised 4/21/25, documented the resident was at risk for pressure ulcers related to bladder and bowel incontinence, fragile skin, limited mobility, and low body mass index (BMI). D. Staff interviewsThe HA was interviewed on 4/30/25 at 12:10 p.m. The HA said she worked for Resident #7's hospice services provider, not the facility, and came to the facility twice a week to provide the resident with showers. The HA said when she changed Resident #7's incontinence brief, the resident was soiled with urine and had a small red area near her tailbone that was not open. The HA said she applied barrier cream to the reddened area. CNA #2 was interviewed on 4/30/25 at 12:26 p.m. CNA #2 said she was aware of the expectation to provide incontinence care and change a resident's brief every two hours. She said she typically provided incontinence care for Resident #7 in the morning when the resident got up, after breakfast, after lunch and before dinner. CNA #2 said today (4/30/25) the resident got up sometime between 7:00 a.m. and 8:00 a.m. and she changed the resident's briefs around 7:45 a.m. She said she intended to change Resident #7 again after breakfast but decided not to because the HA was scheduled to arrive and provide care. CNA #2 said, based on her experience, the resident typically did not get very wet and usually did not require frequent changes. She said that during the 7:45 a.m. change, the resident's incontinence brief was damp with urine, but not heavily soiled, and there was no bowel movement.-Resident #7 was not offered or provided with incontinence care or toileting assistance for four hours (see observation above). The director of nursing (DON) was interviewed on 4/30/25 at 4:19 p.m. The DON said incontinence care was provided on an as-needed basis, with general expectations that day shift staff provide a resident's incontinence care or toileting assistance when getting a resident up out of bed, between breakfast and lunch and again between lunch and dinner. She said staff were expected to offer care assistance when checking on a resident. The DON said it was important for nursing staff to follow the facility's rigorous skin check process and monitor residents closely for skin concerns. The DON said Resident #7 could not tell staff when she needed to be changed and said that the presence of redness near the tailbone would require increased monitoring and potentially more frequent changes. III. Resident #3A. Resident statusResident #3, age greater than 65, was admitted on 2/12/2020. According to the April 2025 CPO, diagnoses included Parkinsonism, neurogenic bladder and chronic pain. The 2/10/25 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. The resident required assistance with all of her ADLs and was on a urinary and bowel toileting program. She was occasionally incontinent of bladder and frequently incontinent of bowel. The MDS assessment indicated the resident was dependent on staff assistance for toileting hygiene. B. Observations and interviews During a continuous observation on 4/30/25, beginning at 8:00 a.m. and ending at 11:30 a.m., the following was observed:At 8:00 a.m., Resident #3 was lying in her bed. At 8:30 a.m. CNA #4 brought breakfast to the resident. CNA #4 placed the meal on the over-the-bed table in front of Resident #3, uncovered the meal and left the resident without asking her if she needed any care assistance or incontinence care. Resident #3 started eating her meal as CNA #4 left the room. At 9:30 a.m. CNA #4 entered the resident's room a second time to retrieve the resident's meal tray. CNA #4 asked Resident #3 if she wanted to get up. Resident #3 said no. CNA #4 left the resident's room and did not check the resident's brief or ask her if she needed to be changed or toileted. CNA #4 was interviewed on 4/30/25 at 9:32 a.m. CNA #4 said that the morning shift CNA told her Resident #3 was last changed around 5:00 a.m. (on 4/30/25). CNA #4 said the day shift was running behind in providing care for residents and she had not had enough time to change Resident #3 yet because her morning was so busy with other tasks. She said she thought that Resident #3 would use her call light if she needed to be changed. CNA #4 said she was familiar enough with Resident #3 that she knew when she needed to be changed. CNA #4 said she usually changed the resident before breakfast and after lunch. At 10:40 a.m. CNA #4 and a hospice nurse entered Resident #3's room. Resident #3 was found to be soiled with urine and CNA #4 and the hospice nurse proceeded to change the resident's wet incontinence brief while she remained in bed. The soiled incontinence brief was wet and heavy and it made a thudding sound when it was thrown in the trash can. Resident #3 was interviewed on 4/30/25 at 2:00 p.m. Resident #3 said she was wet (soiled with urine) but she was not sure how long she had been wet. She said she needed the staff's assistance with getting cleaned up and changed. Resident #3 said she would press the call light when she needed to be changed. She did not mention having a whistle to call for staff assistance (see DON interview below). Resident #3 attempted to press her call light, but she did not have the strength to fully press and activate the call light. At 2:20 p.m. CNA #5 entered Resident #3`s room. Resident #3 asked for water and CNA #5 assisted her. The resident did not ask CNA #5 for assistance with incontinence care and CNA #5 did not ask the resident if she needed to be changed or toileted before exiting the resident's room. C. Resident's representative interviewResident #3's representative was interviewed on 4/29/25 at 2:45 p.m. Resident #3's representative said Resident #3 had some continence ability and was able to get up and sit on the toilet with assistance and a Hoyer lift. However, she said because the resident was dependent on staff to complete toileting tasks, she wore an incontinence brief in case she was unable to wait for staff assistance. The representative said a CNA told her it was easier on the staff if residents urinated into their briefs and then staff changed them in their beds. The representative did not remember which CNA had told her that. D. Record reviewThe Bowel and Bladder Elimination record from 4/29/25 to 4/30/25 was reviewed on 4/30/25 at 10:03 a.m. The record revealed that the last recorded toileting assistance was provided for Resident #3 on 4/30/25 at 5:03 a.m. for urinary incontinence. Review of Resident #3's progress notes between 3/25/25 and 4/30/25 revealed there was no documentation to indicate that Resident #3 refused incontinence care assistance from staff. E. Staff InterviewsLicensed practical nurse (LPN) #2 was interviewed on 4/30/25 at 11:30 a.m. LPN #2 said it was the CNAs responsibility to check and change residents. She said CNAs recorded incontinence brief changes in the electronic medical record (EMR) for the nurses to reference. She said the CNAs gave verbal reports to each other at shift change so they would be aware of any resident needs. She said the CNAs knew the residents well enough to know when they needed to be changed, but she said staff should ask residents before and after meals if they needed to get cleaned up or get changed. LPN #2 said the general rule was for CNAsto check a resident every two to three hours and assist them with toileting or brief changes when needed. LPN #2 looked at Resident #3's Bowel and Bladder Elimination records and found said Resident #3 had last been changed at 5:03 a.m. that morning (4/30/25). The assistant director of nursing (ADON) was interviewed on 4/30/25 at approximately 3:00 p.m. The ADON said she had met with Resident #3 and asked her about the timing of her care this morning (4/30/25). She said Resident#3 told her she had not been changed before breakfast (see observation above). The DON was interviewed on 4/30/25 at 4:33 p.m. The DON said Resident #3 would call for staff assistance if she needed help. She said the resident was having difficulty with the call button so they had provided her with a whistle to call staff if she was unable to use the call light button. The DON said the resident had both the call button and the whistle because she sometimes forgot she had the whistle. The DON said a lot of residents in the facility had mixed incontinence and sometimes knew when they had to go to the bathroom and sometimes did not know they had to go and experienced incontinent episodes. She said Resident #3 did not always know when she had to go to the bathroom and was occasionally incontinent. The DON said for residents with mixed incontinence, the checking frequency could appropriately be every four hours because they sometimes were able to recognize they needed to be changed and could call for staff assistance. The DON said the CNAs knew the residents well enough to know how often to check on them for toileting or incontinence care. As a practice, she said the overnight staff should be toileting the residents between 9:00 p.m. and 6:00 a.m. and the day and evening shifts should check and change the residents before and after meals.-However, observations revealed staff did not offer toileting or incontinence care to Resident #3 for two hours and 40 minutes, even though she had not been toileted or provided incontinence care prior to breakfast (see observations above).-Additionally, record review and interviews revealed Resident #3 had not been changed or toileted from 5:03 a.m. until 10:40 a.m. (a period of five hours and seven minutes) when the hospice nurse and CNA #4 provided the resident with incontinence care (see record review and CNA #4's interview above).

A document revisit was completed with all deficiencies being corrected with the exception of any waived deficiency or deficiencies. All waived deficiencies will be corrected at a later date as per the approved waiver. A plan of correction is not required.

A revisit survey was completed on 6/24/24 for all previous deficiencies cited on 4/25/24. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 6/24/24 for all previous deficiencies cited on 4/25/24. The facility is in compliance with all regulations surveyed.

INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and represent the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The facility is a two (2) story, Type V (111) construction; there is no basement although part of the first floor is below grade. The assisted living facility occupies the second-floor level and is not separated by a two (2)-hour floor. The facility was constructed in 1988. This facility is licensed for 109 beds, and the census on the date of this survey was 89. The facility is fully protected throughout by a National Fire Protection Association (NFPA) 13 automatic fire sprinkler system that consists of a wet fire sprinkler system. This survey was conducted on May 14, 2024, for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies."The deficiencies cited were discussed with the Maintenance Director during the survey and again during the exit conference conducted on May 14, 2024.

Based on the record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.6Fire drills closer than an hour apart not at varied timesNFPA 101, 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. This deficiency can potentially affect occupants, including residents, staff, and visitors throughout the facility. The administrator and maintenance director discussed deficient items at the exit conference.

Based on record review and staff interviews during the course of the survey, it was determined that the facility failed to maintain emergency power systems in accordance with Section 9.1.3 of the Life Safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems Chapter 8 This deficient practice has the potential to affect all residents, staff, and visitors in the event of power loss. This was evidenced by the following. No Monthly generator transfer switch inspections. NFPA 110 2010 8.6.4 Transfer switches shall be operated monthly. This deficiency can potentially affect occupants, including residents, staff, and visitors within the entire facility. Deficient items were discussed with the Maintenance director at the exit conference.

Based on observation during the survey, it was determined that the facility failed to maintain a hazardous area per NFPA 99 and NFPA 55. This was evidenced by the following:1. Oxygen Transfill rooms need a vent 12" off the floor 2. Full and empty containers were not separated. NFPA 556.15.7 Inlets to the Exhaust System. 6.15.7.1 The exhaust ventilation system design shall take into account the density of the potential gases released. 6.15.7.2 For gases that are heavier than air, exhaust shall be taken from a point within 12 in. (304.8 mm) of the floor. 6.15.7.3 For gases that are lighter than air, exhaust shall be taken from a point within 12 in. (304.8 mm) of the ceiling. NFPA 99 11.6.5.2 If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors throughout the facility. The administrator and Maintenance director discussed deficient items at the exit conference.

A recertification survey was conducted from 4/22/24 to 4/25/24. Six deficiencies were cited.

An Emergency Preparedness survey was conducted from 4/22/24 to 4/25/24. No deficiencies were cited.

Based on observation, record review and interviews, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries for two (#1 and #27) of three residents out of 39 sample residents. Resident #27, who was known to be at risk for skin breakdown due to immobility, developed two stage 3 pressure injuries to his left and right ischium (lower part of the pelvic bone that helps absorb weight when sitting) on 4/17/24. Resident #27's care plan documented the resident was to be offered repositioning at night during care and encouraged to lie in bed after lunch. Additionally, the resident was always incontinent of urine and frequently incontinent of bowel. However, the care plan failed to include an intervention to encourage the resident to reposition while he was sitting in his recliner and offer toileting/incontinence care to the resident frequently. Continuous observations during the survey revealed Resident #27 was not offered frequent repositioning or toileting by the staff. Due to the facility's failures to provide Resident #27 with timely interventions, such as frequent repositioning and incontinent care, the resident developed two Stage 3 pressure injuries to his left and right ischium. Additionally, Resident #1, who was frequently incontinent of urine, always incontinent of bowel and at risk for developing pressure injuries due to a decrease in mobility, was identified by a nurse to have an open area to her coccyx on 4/1/24 during a routine skin assessment. However, there was no further documentation in the resident's electronic medical record (EMR) to indicate the wound care physician (WCP) was notified of the wound and no new physician's orders were obtained to treat the wound. On 4/14/24, Resident #1 it was identified by another nurse that she had pressure wounds on her coccyx and left buttock. A physician's order was obtained for wound treatment. The facility failed to initiate a treatment to the unstageable pressure wounds to Resident #1's coccyx and left buttock for 13 days following the initial identification. Furthermore, Resident #1's care plan failed to include interventions for frequently repositioning the resident while she was in her recliner and providing frequent incontinent care. Continuous observations during the survey revealed Resident #1 was not offered frequent repositioning or toileting by the staff. Due to the facility's failures to provide Resident #1 with timely interventions, such as frequent repositioning and incontinent care, the resident developed unstageable pressure injuries to her coccyx and left buttock. Findings include:I. Professional referenceThe Pressure Ulcer and Other Wounds in the Post-Acute and Long-Term Care Settings (2018), retrieved on 4/29/24 from https://online.fliphtml5.com/zlds/jffd/#p=2, revealed in pertinent part "Employ repositioning or offloading measures for wound prevention."According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, Emily Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved on 4/29/24 from https://www.internationalguideline.com/guideline, "Pressure ulcer classification is as follows:"Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage)Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk)."Category/Stage 2: Partial Thickness Skin LossPartial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation."Category/Stage 3: Full Thickness Skin LossFull thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable."Category/Stage 4: Full Thickness Tissue LossFull thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures (fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable"Unstageable: Depth UnknownFull thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed."Suspected Deep Tissue Injury: Depth UnknownPurple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment."II. Facility policy and procedureThe Pressure Injury Prevention and Management policy and procedure, dated November 2022, was received from the nursing home administrator (NHA) on 4/25/24 at 8:47 a.m. It revealed in pertinent part "To prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries."Preventative interventions can be, but not limited to, frequent position changing and support of pressure points, adequate hydration and nutrition, appropriate exercise and movement, frequent perineal care and application of barrier cream for incontinence, proper lifting technique, correct application of pressure relieving devices and frequent inspection and assessment of skin integrity."Compliance with interventions will be documented in the medical record."III. Resident #27A. Resident statusResident #27, age greater than 65, was admitted on 3/19/15. According to the April 2024 computerized physician orders (CPO), diagnoses included heart failure, type II diabetes, chronic kidney disease and atrial fibrillation (abnormal heart function). The 3/21/24 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of nine out of 15. He required extensive one to two person assistance with toileting, transfers and bed mobility. He required set up assistance with personal hygiene and eating. The assessment documented Resident #27 was at risk for developing pressure injuries but did not have a pressure injury. B. ObservationsOn 4/22/24 at 12:35 p.m. Resident #27 was sitting in his recliner in his room. On 4/23/24, during a continuous observation beginning at 10:35 a.m. and ending at 2:04 p.m., Resident #27 was sitting in his recliner. At 12:22 p.m. Resident #27's lunch tray was delivered by CNA #1. Resident #27 remained sitting in his recliner for lunch. -CNA #1 failed to offer Resident #27 repositioning or toileting before lunch. At 2:04 p.m. Resident #27 was assisted by CNA #1 and licensed practical nurse (LPN) #1 to lay in bed. CNA #1 exited Resident #27 room with a trash bag containing Resident #27's brief. The brief was observed to be visibly wet as the inside of the trash bag was noted to be wet.-Resident #27 was not provided with toileting or repositioning in his recliner for three hours and 30 minutes. On 4/24/24 at 1:04 p.m. the regional nurse consultant (RNC) assessed the edge of the cushion Resident #27 was sitting on in his recliner and said it was a gel type cushion. The RNC assessed Resident #27's air mattress and said it was a mattress that could alternate pressure. On 4/24/24 at 2:00 p.m. Resident #27's wound care was observed with the wound care physician (WCP). The old dressings were removed from the resident's wounds and the wound beds were pink with no signs of infection. The wounds were cleaned with normal saline, skin prep applied to the peri wounds, honey gel applied to the wound beds and covered with border dressings. -On 4/24/24 at 2:30 p.m. the gel cushion in Resident #27's recliner did not have cushion cover on it and the resident was sitting directly on the plastic surface of the gel cushion. C. Record reviewResident #27's comprehensive care plan, dated 3/27/24, revealed Resident #27 had a potential for impairment to skin related to decreased mobility. The interventions included a pressure reducing cushion to chair and mattress (initiated 8/3/22), offering to reposition Resident #27 at night during care and encouraging the resident to lie on his bed after lunch (initiated on 1/20/23).-The care plan only addressed repositioning the resident during night care and not throughout the day. The 4/17/24 skin and wound evaluation form identified two new stage three pressure injuries to the left and right ischium. The wound appeared pink and moist with no signs of infection. The wound area was cleansed with Dakin's, honey gel was applied to the wound bed, skin prep the peri wound and covered with border gauze. Resident #27's 4/19/24 Braden scale (a tool used to determine the risk of pressure injury development) revealed Resident #27 was at risk of developing a pressure ulcer. It revealed his skin was occasionally moist requiring an extra linen change daily. Resident #27 was chair fast, his ability to walk was severely limited and he was unable to bear weight and required assistance into a chair or wheelchair. Resident #27 had very limited mobility, was able to make occasional slight changes in body position but was unable to make frequent or significant changes independently. Resident #27's April 2024 CPO revealed the following physician's order:Cleanse the left and right ischium with Dakin's (specialized wound cleaner), apply honey gel (used to remove dead tissue)to the wound bed, skin prep the peri wound (area around the opening) and cover with border gauze dressing once daily, ordered on 4/18/24. Resident #27's initial wound physician visit on 4/17/24 revealed stage three pressure injuries to both the right and left ischium. The left ischium wound measured 3.4 centimeters (cm) by 2 cm by 0.2 cm with 100% granulation (new connective tissue) tissue and minimal drainage. The right ischium measured 1 cm by 2.5 cm by 0.2 cm with 100 % granulation tissue and no drainage. Orders were given to cleanse the wounds with Dakin's, apply skin prep to peri wounds, apply honey gel to wound beds and cover with bordered gauze dressings daily and as needed.-Review of Resident #27's care plan, progress notes and MDS assessment did not reveal any documentation which indicated the resident frequently refused care or repositioning (see interviews below). D. Staff interviewsCNA #1 was interviewed on 4/23/24 at 4:10 p.m. CNA #1 said Resident #27 was changed this morning (4/23/24) when he got up and then when he was laid in bed around 2:00 p.m. CNA #1 said Resident #27 did not always tell staff when he needed to be changed so staff should be checking in with him every couple of hours. CNA #1 was aware Resident #27 had a wound on his bottom and should be offered repositioning. CNA #1 said Resident #27 often refused to be repositioned when asked, however, she said the resident had not refused care that day (4/23/24). CNA #1 did not know where to document any refusal of care for repositioning.-Despite CNA #1's interview indicating Resident #27 frequently refused repositioning, the resident's EMR did not reveal documentation that the resident refused care or repositioning (see record review above). -Despite CNA #1's interview indicating Resident #27 should be offered repositioning and staff should check on him every couple of hours, the resident was not offered repositioning during continuous observations for three and half hours (see observations above). LPN #1 was interviewed on 4/23/24 at 4:21 p.m. LPN #1 said she was unaware Resident #27 had not been offered repositioning in at least three and a half hours. LPN #1 said Resident #27 would benefit from repositioning due to the pressure injuries on his bottom. The WCP was interviewed on 4/24/24 at 2:29 p.m. The WCP said he was unable to determine if Resident #27's pressure injuries were avoidable or unavoidable as he was still speaking with facility staff to determine possible causes of the wounds. The WCP said facility staff told him Resident #27 refused to change positions and preferred to sit in his recliner during the day.-However, there was no evidence of documented refusals of care (see record review above). IV. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on 12/1/22. According to the April 2024 CPOs, diagnoses included diabetes mellitus (abnormal blood glucose), dementia (memory impairment) and chronic kidney disease (abnormal kidney function). The 4/9/24 MDS assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 11 out of 15. She required substantial assistance for transfers, toileting, dressing and supervision for eating. The assessment documented the resident was at risk of developing a pressure injury but did not have a pressure injury. B. Observations On 4/22/24 at 10:30 a.m. Resident #1 was sitting in her recliner leaning to her left side. On 4/22/24 at 1:35 p.m. Resident #1 was sitting in her recliner and continued to lean to her left. On 4/23/24, during a continuous observation beginning at 10:35 a.m. and ending at 2:51 p.m., Resident #1 was sitting in her recliner, leaning to her left side. At 12:22 p.m. Resident #1's lunch tray was delivered while the resident was asleep and remained sitting in the recliner. At 12:34 p.m. LPN #1 entered Resident #1's room, woke the resident up and offered her assistance with eating. Resident #1 said she was not having a good day because her bottom hurt. LPN #1 told Resident #1 that she got a new dressing on her bottom and the wound physician would be in the next day. -LPN did not offer repositioning to the resident. At 2:26 p.m. LPN #1 entered Resident #1's room and told the resident as soon as the CNA returned from lunch, she would assist the CNA to lay the resident in bed. Resident #1 remained sitting in the recliner leaning to her left side. -At 2:51 p.m. LPN #1 and CNA #1 entered Resident #1's room with the sit to stand mechanical lift. Resident #1 was assisted with the use of thesit to stand lift to the bathroom. Resident #1's brief was removed and was observed to have been soiled with bowel and urine.-Resident #1 was not provided with toileting or repositioning in her recliner for four hours and 15 minutes. LPN #1 collected items to complete the resident's dressing change due to the dressing being soiled. CNA #1 used the sit to stand lift to take Resident #1 out of the bathroom. The old dressing was removed and noted to be soiled with feces on the edges of the dressing. The wound bed to the coccyx was pink and moist and the area around the wound was nonblanchable (discoloration of skin that does not turn white when pressed) when the nurse pressed the surrounding tissue with her finger. The left buttock wound had eschar (dead tissue) around the upper edge of the wound and yellow tissue (slough) throughout. The surrounding tissue of the wound was nonblanchable. LPN #1 cleaned the wounds with Dakins, dried the wounds with gauze, applied skin prep to the peri wounds, added honey gel to the wound beds, and covered the wounds with a border dressing. Resident #1 told LPN #1 it hurt when the nurse was cleaning the wounds. On 4/24/24 at 1:01 p.m. Resident #1 was observed to be seated on a cushion in her recliner. The RNC touched the chair cushion without moving Resident #1 from her seated position in the recliner and identified the cushion as a standard foam cushion. The RNC identified the resident's pressure relieving mattress as an air mattress that could alternate pressure. On 4/24/24 at 2:10 p.m. Resident #1's wound dressing changes were observed with the WCP.The coccyx wound had a pink wound bed. The wound area was cleansed with Dakin's, dried with gauze, skin prep was applied to the periwound, honey gel was applied to the wound bed and the area was covered with border gauze. The left buttock wound was observed to have yellow colored tissue in the center and the upper corner of the wound was observed to have eschar (dead tissue). The wound area was cleaned with Dakin's, dried with gauze, skin prep was applied to the peri wound, honey gel was applied to the wound bed and the area was covered with border gauze. C. Record ReviewResident #1's comprehensive care plan, dated 3/29/24, revealed potential impairment to skin related to decreased mobility with interventions of pressure reducing cushion while up in chair, pressure reducing mattress and follow facility protocol for treatment of injury, initiated 12/13/22. Apply nutrishield cream to coccyx every shift and at each incontinence episode initiated on 5/24/23-There was no intervention for repositioning or frequent incontinent care documented on Resident #1's care planResident #1's 1/7/24 Braden scale assessment revealed Resident #1 was at moderate risk for developing pressure injuries. It revealed Resident #1's skin was very moist requiring extra linen changes, the resident was chair fast (requiring assistance to a chair or wheelchair) and had very limited mobility (unable to make frequent or significant changes independently). Resident #1's weekly skin assessment dated 4/1/24 revealed the resident had an open area starting on her coccyx but did not document a stage of the wound or measurements. It revealed Resident #1 was more comfortable lying on her sides than lying flat because lying flat caused her extreme pain.-The assessment did not document Resident #1 frequently refused repositioning (see interviews below).-There was no progress note indicating whether or not the WCP was notified of the wound and no new physician orders were added for treatment of the wound. Resident #1's weekly skin assessment dated 4/8/24 revealed a pressure injury to the resident's coccyx but had no measurements or narrative notes.-There was no progress note indicating whether or not the WCP was notified of the wound and no new physician orders were added for treatment of the wound. A progress note dated 4/14/24 revealed CNAs were changing Resident #1 and an open area to theresident's coccyx measuring 2 cm by 2.2 cm was found. The area was cleaned and a dry dressing was applied. Resident #1 also had a shearing area to the left buttock measuring 3 cm by 2.2 cm, the area was cleansed with normal saline and nutrashield cream was applied. The nurse notified the unit manager to speak with Resident #1's representative about getting a new cushion for her wheelchair.-The wounds were initially identified by a nurse on 4/1/24, however, there was no further documentation of the wounds or treatment orders obtained until 4/14/24.-There was no documentation to indicate whether a new cushion was provided to Resident #1. Resident #1's April 2024 CPO documented the following physician's orders:Pressure relief mattress: check inflation and settings every shift, ordered on 2/2/24. Apply nutrishield cream to coccyx every shift and with every incontinence episode, ordered on 5/23/23. Wound care order for coccyx: Clean open areas to coccyx with normal saline and apply dry dressing once daily, ordered on 4/14/23.-The order did not specify a treatment for the left buttock wound.-The order was not put into place until 13 days after the initial identification of the open area to Resident #1's coccyx. Wound care order for coccyx and left buttock, cleanse with Dakin's, apply honey gel to wound bed, skin prep the periwound and cover with border gauze once daily, ordered on 4/18/24. The WCPs initial encounter with Residents #1's wounds for the coccyx and left buttock on 4/17/24 revealed the coccyx and left buttocks were unstageable pressure injuries. The coccyx wound measured 1.1 (cm) by 1 cm by 0.1 cm and the left buttock wound measured 0.9 cm by 1.3 cm by 0.1.-Review of Resident #1's care plan, progress notes and MDS assessment did not reveal any documentation which indicated the resident frequently refused care or repositioning (see interviews below). D. Staff interviewsCNA #1 was interviewed on 4/23/24 at 4:10 p.m. CNA #1 said residents should be offered toileting or repositioning every two hours to ensure they were not soiled and to off load pressure areas. CNA #1 said Resident #1 would not call if she was soiled so staff needed to offer toileting and check her for incontinence episodes. CNA #1 said Resident #1 was changed around 9:00 a.m. and then at around 3:00 p.m. (on 4/23/24). CNA #1 did not have a response as to why Resident #1 was not offered repositioning or toileting in almost six hours. CNA #1 said Resident #1 had wounds on her buttocks.-Despite CNA #1's interview indicating Resident #1 should be offered repositioning and staff should check on her every couple of hours, the resident was not offered repositioning during continuous observations for four hours and 15 minutes (see observations above). LPN #1 was interviewed on 4/23/24 at 4:21 p.m. LPN #1 said residents should be offered repositioning every two hours especially if they had pressure injuries or were at risk of developing pressure injuries. LPN #1 said repositioning would be beneficial to residents with pressure injuries to promote healing. LPN #1 was unaware if Resident #1 was not offered repositioning or toileting between 10:35 a.m. and 2:51 p.m. LPN #1 said Resident #1 had not had the pressure injuries long but would refuse staff when she was asked to reposition. LPN #1 said she had not documented any Resident #1 refusal of repositioning.-Despite LPN #1's interview indicating Resident #1 frequently refused repositioning, the resident's EMR did not reveal documentation that the resident refused care or repositioning (see record review above). The WCP was interviewed on 4/24/24 at 2:10 p.m. The WCP said he felt Resident #1's pressure injuries were avoidable but when he talked with the facility staff he was told Resident #1 refused to change positions.-However, there was no documented refusal of care (see record review above). V. Additional interviewsThe WCP was interviewed again on 4/24/24 at 2:48 p.m. The WCP said Resident #1's and #27's wounds would benefit from frequent positioning changes despite them both sitting on cushions when up in their recliners. The WCP said a pressure injury could develop within two hours and incontinence increased the risk of a wound developing or worsening. The WCP said wound textbooks recommended a resident in bed be repositioned every two to three hours and, when in a chair, they should be repositioned every two hours to offload pressure. The director of nursing (DON) was interviewed on 4/25/24 at 10:10 a.m. The DON said Resident #1 started having skin issues on 4/1/24, however, she said the floor nurse did not relay this information to the unit manager. The DON said Resident #1's skin issue was brought up again on 4/14/24 by another nurse. She said the facility started to review what could have caused the wounds and found the weekly skin documentation dated 4/1/24. The DON said the facility immediately started wound care treatment for Resident #1's wounds on 4/14/24 and had the WCP see the resident on his next wound round visit, which was 4/17/24. The DON said Resident #1 did not like to be repositioned and liked to sit in her recliner. The DON said Resident #27 did not like to be moved from his recliner but should still be offered position changes every two hours.-Despite the DON's interview indicating Resident #1 and Resident #27 frequently refused repositioning, the residents' EMRs did not reveal documentation that the residents refused care or repositioning (see record review above). -The DON did not provide any documentation for refusal of care for Resident #1 or Resident #27. The DON said residents should be repositioned every two hours to help prevent pressure injuries and promote wound healing if they had a pressure injury. The DON said if a resident refused to be repositioned it should be documented in the nurses progress notes. The DON said residents should be offered toileting upon rising, before and after meals and as needed.

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of those reviews for five of five certified nurse aides. Specifically, the facility had not completed annual performance reviews for certified nurse aide (CNA) #4, CNA #5, CNA #6, CNA #7 and CNA #8, in order to determine potential training needs. Findings include:I. Facility policy and procedure -The facility did not have a performance evaluation policy per the nursing home administrator (NHA). II. Record reviewOn 4/23/24 at 3:00 p.m. annual performance reviews were requested for CNA #4 (hired 12/10/2020), CNA #5 (hired 6/2/22), CNA #6 (hired 3/31/2008), CNA #7 (hired 8/3/2020) and CNA #8 (hired 8/3/2020). On 4/25/24 at 9:14 a.m. the NHA said CNA #4, CNA #5, CNA #6, CNA #7, CNA #8 did not have an annual performance review and had not completed annual inservice education based on the outcome of their reviews on 4/25/24 at 9:14 a.m (see interview below). Cross-reference F947 failure to ensure CNAs received adequate training as required. III. Staff interviews The NHA was interviewed on 4/25/24 at 9:14 a.m. The NHA said annual performance evaluations had not been completed and should have been completed annually. The NHA said going forward the facility would reinitiate a process to ensure all performance evaluations were completed timely, as well as inservice education based on the outcomes. The director of nursing (DON) was interviewed on 4/25/24 at 11:13 a.m. The DON said performance evaluations should be conducted annually. The DON said the facility scheduled a performance evaluation fair, however the facility was coming out of an illness outbreak and it was not well attended by staff. The DON said the facility would schedule a performance evaluation fair in the near future to complete the evaluations per the regulation.

Based on observations, record review and staff interviews, the facility failed to ensure staffing information was posted in a prominent place, readily accessible to residents and visitors. Specifically, the facility failed to post the total number of actual hours worked by the licensed and unlicensed staff directly responsible for resident care per shift. Findings include:I. Failure to have staffing postedObservations in the facility on 4/22/24 at 9:00 a.m. revealed that, on the first floor, staffing was posted and dated 4/22/24. -However, it did not include the actual working hours for the licensed and unlicensed staff. Observations in the facility on 4/23/24 at 11:15 a.m. revealed that, on the first floor, staffing was posted and dated for the previous day 4/22/24. -It did not include the actual working hours for the licensed and unlicensed staff and was not for the current day. Observations in the facility on 4/24/24 at 10:05 a.m. revealed that, on the first floor, staffing was posted and dated 4/24/24.-However, it did not include the actual working hours for the licensed and unlicensed staff. Observations in the facility on 4/25/24 at 10:15 a.m. revealed that, on the first floor, staffing was posted and dated for the previous day 4/24/24. -It did not include the actual working hours for the licensed and unlicensed staff. II. Staff interviewsThe director of nursing (DON) was interviewed on 4/25/24 at 11:13 a.m. The DON said on 4/23/24 a receptionist who only worked when the facility needed her to fill in was working and did not post a current staffing schedule. The DON said she was not sure why the actual working hours were not in place on the daily postings. The nursing home administrator (NHA) was interviewed on 4/25/24 at 11:15 a.m. The NHA said he was aware that the regulation required the actual working hours to be included on the daily staffing post and was not sure why it was not included. The NHA said he would immediately correct the posting.

Based on observations and interviews, the facility failed to ensure medications and biologicals were stored and labeled properly in one of three medication carts and one of two medication storage rooms. Specifically the facility failed to:-Ensure expired medications were not stored with current medications in the medication carts;-Ensure insulin pens (medication used for glucose control) were labeled with resident names and open dates; and,-Ensure medications were not stored in a dormitory style refrigerator/freezer combination. Findings include:I. Professional reference According to the Vaccine Storage and Temperature Monitoring Equipment (January 2023), retrieved on 4/25/24 from https://www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf,"Do not store any vaccines in a dormitory-style or bar-style combined refrigerator/freezer unit under any circumstances. These units have a single exterior door and an evaporator plate/cooling coil, usually located in the freezer compartment. These units pose a significant risk of freezing vaccines, even when used for temporary storage."According to the Lantus glargine insulin package insert, retrieved on 4/29/24 from https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/021081s076lbl.pdf, "When not in use store in refrigerated temperatures of 36 to 46 degrees. When in use can be kept at room temperature for up to 28 days."According to the Trulicity package insert, retrieved on 5/1/24 from https://uspl.lilly.com/trulicity/trulicity.html#mg, "Store Trulicity in the refrigerator, do not freeze Trulicity. Do not use Trulicity if it has been frozen."II. Facility policy and procedure The Medication Storage policy, dated January 2023, was received from the nursing home administrator (NHA) on 4/25/24 at 8:47 a.m. It read in pertinent part, "Medications and biologicals were stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe and effective drug administration."Note the date on the label for insulin vials and pens when first used."The refrigerator should be kept clean and frost free. To protect refrigerated medications from freezing."Outdated, contaminated, discontinued, or deteriorated medications and those in containers that were cracked, soiled or without secure closure were immediately removed from stock."III. Observations and staff interviewsOn 4/24/24 at 9:53 a.m. the Juniper medication cart was observed with licensed practical nurse (LPN) #3. The following items were found:-An open bottle of one milligram (mg) of Melatonin (sleep aid medication) that expired in January 2024. One Lantus insulin pen had no resident name or open date on the pen. LPN #3 said the Melatonin should have been removed from the medication cart when it expired in January. LPN #3 said the Lantus insulin pen should have had a resident's name on it to ensure it was used for only one resident and an open date to ensure the medication was used before the use by date of 28 or 30 days from first use. LPN #3 said if insulin was used past the open date it was not as effective for treating high blood glucose levels for the resident.-However, according to the medication package insert, Lantus insulin should be discarded after 28 days (see professional reference above). The Juniper medication room was observed on 4/24/24 at 10:00 a.m. with LPN #3. The medication refrigerator was dormitory style. The freezer compartment had ice build up around it and the freezer lid was unable to open due to the amount of ice build up. -The ice build up was touching a box of Trulicity (injectable medication for treatment of high blood glucose) that was on the top shelf of the refrigerator. LPN #3 was interviewed on 4/24/24 at 10:04 a.m. LPN #3 said she did not feel the medications in the refrigerator were compromised due to the ice build up from the freezer. LPN #3 said she did not know medications and injectables were not to be stored in a dormitory style refrigerator. The director of nursing (DON) was interviewed on 4/25/24 at 10:10 a.m. The DON said it was the responsibility of the nurses to ensure medication carts were kept free of expired medications. The DON said the night shift staff had a schedule to indicate when to clean the medication carts and check the carts for expired medications. The DON said open dates on medications, such as insulin, were important to ensure the medication was not used past the recommended use date and that insulins were good for 28 days. The DON said medications should have residents' names on them to identify who they belonged to and multiple dose medications needed to be resident specific. The DON said the medication refrigerators were monitored daily for temperatures to ensure medications were stored appropriately. The DON said she did not know medications should not be stored in a dormitory style refrigerator. The DON said she was not concerned that any of the medications in the refrigerator were compromised as the temperature logs did not document any temperatures out of range.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Specifically the facility failed to:-Ensure a foley catheter was stored in a sanitary manner; and,-Ensure mechanical lifts were cleaned between residents. Findings include:I. Foley catheterA. Facility policy and procedureThe Foley Catheter policy and procedure, dated November 2022, was received from the nursing home administrator (NHA) on 4/25/24 at 8:47 a.m. It read in pertinent part "Foley catheters are to be placed in a dignity bag to provide privacy for the resident."B. Observations and resident interviewOn 4/22/24 at 12:46 p.m. Resident #69' s foley catheter collection bag was on the floor next to the resident who was lying in bed. On 4/22/24 at 2:26 p.m. Resident #69' s foley catheter bag was on the floor as the resident was sitting up in bed. On 4/24/24 at 9:25 a.m. Resident #69 was sitting up at the bedside eating breakfast and the foley catheter bag was laying on the floor. Resident #69 said his catheter bag was always on the floor unless he was in his wheelchair. On 4/24/24 at 9:32 a.m. registered nurse (RN) #1 said Resident #69' s foley catheter bag was on the floor. C. Staff interviewsRN #1 was interviewed on 4/24/24 at 9:29 a.m. RN #1 said catheter bags should not be stored on the floor as it could lead to the resident getting a urinary tract infection. RN #1 said the foley catheter bag should be stored in a dignity bag or placed into a basin on the floor to provide a barrier from the floor. She said the catheter bag could also be hung above the ground using a hook. The director of nursing (DON) was interviewed on 4/25/24 at 10:10 a.m. The DON said foley catheter bags should not be on the floor as the floor was dirty and it could lead to infections. II. Multiple use durable medical equipmentA. Professional referenceAccording to The Centers for Disease Control and Prevention (CDC) Disinfection and Sterilization, retrieved on 4/29/24 from https://www.cdc.gov/infectioncontrol/guidelines/disinfection/index.html#anchor_1555613917. It read in pertinent part, "Ensure that, at a minimum, noncritical patient-care devices are disinfected when visibly soiled and on a regular basis such as after use on each patient." B. ObservationOn 4/23/24 at 3:28 p.m. certified nurse aide (CNA) #1 was transferring Resident #1 from the recliner to the bathroom with the use of the sit to stand mechanical lift. After transferring Resident #1 from the bathroom to the recliner, CNA #1 proceeded to use the sit to stand lift to transfer Resident #1' s roommate from bed to the bathroom.-CNA #1 did not disinfect the sit to stand mechanical lift between residents. CNA #1 did not disinfect the sit to stand lift after it was in the bathroom and she left it in the resident' s room. C. Staff interviewCNA #1 was interviewed on 4/23/24 at 4:10 p.m. CNA #1 said it was the responsibility of the night shift CNAs to clean the sit to stand mechanical lift. Licensed practical nurse (LPN) #1 was interviewed on 4/23/24 at 4:21 p.m. LPN #1 said the mechanical lifts should be cleaned between each resident with the purple top sanitization wipes or sprayed with Oxivir disinfectant. LPN #1 was unsure where the CNAs kept the sanitization wipes with the purple lid to clean the mechanical lifts between uses but she had some locked in her medication cart. The DON was interviewed on 4/25/24 at 4:10 p.m. The DON said the sit to stand mechanical lift should be cleaned between residents with the sanitization wipes with the purple lid to disinfect them. The DON said the flushing mechanism of the toilet could splatter droplets from the toilet onto the sit to stand lift, therefore it should be cleaned after taking a resident to the restroom to prevent the spread of bacteria.

Based on record review and interviews, the facility failed to ensure certified nurse aides (CNA) received the required 12 hours of annual in-service training for continued competence. Specifically, the facility failed to ensure one CNA (#9) of five CNAs received 12 hours of annual training. Findings include:I. Facility policy and procedureThe Team Member Orientation and Training Program policy, revised July 2018, was provided by the nursing home administrator (NHA) on 4/25/24 at 4:33 p.m. It read in pertinent part, "The Community recognizes the need to present comprehensive orientation and training programs designed to prepare associates to successfully perform their role. Successful orientation and training programs play a critical role in determining the effectiveness of the community in realizing its values, goals, and strategies."All team members are expected to participate in training programs that facilitate acquisition of specific skills and knowledge. These programs teach associates how to perform particular activities or a specific job, become proficient in a skill, or learn about policies, procedures, regulations and requirements. The Community strives to conduct a regular training needs analysis to determine appropriate training topics. Some issues examined in this needs analysis include community vision and goals, successful onboarding, and legal and regulatory compliance."The Executive Director or designee is responsible for developing, implementing and evaluating the orientation and training program."II. Training reviewA review of CNA #9' s training was reviewed on 4/24/24 at 1:15 p.m. It revealed CNA #9 had only completed .75 hours of the required 12 hour continued education units (CEU). III. Staff interviewsThe director of nursing (DON) was interviewed on 4/25/24 at 11:13 a.m. The DON said all CNAs should have completed 12 hours of CEU annually. The DON said CNA #9 had been written up for not completing his 12 hours of CEU. The NHA was interviewed on 4/25/24 at 12:01 p.m. The NHA said the facility just hired a new staff development coordinator who would be responsible for tracking and ensuring the CNAs were completing their required training. The NHA said CNA #9 was a good CNA and he was not sure why he had not completed most of his annual training.

A licensure survey was completed on 4/22/24 to 4/25/24. One deficiency was cited.

Based on observation, record review and interviews, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries for two (#1 and #27) of three residents out of 39 sample residents. Resident #27, who was known to be at risk for skin breakdown due to immobility, developed two stage 3 pressure injuries to his left and right ischium (lower part of the pelvic bone that helps absorb weight when sitting) on 4/17/24. Resident #27's care plan documented the resident was to be offered repositioning at night during care and encouraged to lie in bed after lunch. Additionally, the resident was always incontinent of urine and frequently incontinent of bowel. However, the care plan failed to include an intervention to encourage the resident to reposition while he was sitting in his recliner and offer toileting/incontinence care to the resident frequently. Continuous observations during the survey revealed Resident #27 was not offered frequent repositioning or toileting by the staff. Due to the facility's failures to provide Resident #27 with timely interventions, such as frequent repositioning and incontinent care, the resident developed two Stage 3 pressure injuries to his left and right ischium. Additionally, Resident #1, who was frequently incontinent of urine, always incontinent of bowel and at risk for developing pressure injuries due to a decrease in mobility, was identified by a nurse to have an open area to her coccyx on 4/1/24 during a routine skin assessment. However, there was no further documentation in the resident's electronic medical record (EMR) to indicate the wound care physician (WCP) was notified of the wound and no new physician's orders were obtained to treat the wound. On 4/14/24, Resident #1 it was identified by another nurse that she had pressure wounds on her coccyx and left buttock. A physician's order was obtained for wound treatment. The facility failed to initiate a treatment to the unstageable pressure wounds to Resident #1's coccyx and left buttock for 13 days following the initial identification. Furthermore, Resident #1's care plan failed to include interventions for frequently repositioning the resident while she was in her recliner and providing frequent incontinent care. Continuous observations during the survey revealed Resident #1 was not offered frequent repositioning or toileting by the staff. Due to the facility's failures to provide Resident #1 with timely interventions, such as frequent repositioning and incontinent care, the resident developed unstageable pressure injuries to her coccyx and left buttock. Findings include:I. Professional referenceThe Pressure Ulcer and Other Wounds in the Post-Acute and Long-Term Care Settings (2018), retrieved on 4/29/24 from https://online.fliphtml5.com/zlds/jffd/#p=2, revealed in pertinent part "Employ repositioning or offloading measures for wound prevention."According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, Emily Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved on 4/29/24 from https://www.internationalguideline.com/guideline, "Pressure ulcer classification is as follows:"Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage)Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk)."Category/Stage 2: Partial Thickness Skin LossPartial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation."Category/Stage 3: Full Thickness Skin LossFull thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable."Category/Stage 4: Full Thickness Tissue LossFull thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures (fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable"Unstageable: Depth UnknownFull thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed."Suspected Deep Tissue Injury: Depth UnknownPurple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment."II. Facility policy and procedureThe Pressure Injury Prevention and Management policy and procedure, dated November 2022, was received from the nursing home administrator (NHA) on 4/25/24 at 8:47 a.m. It revealed in pertinent part "To prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries."Preventative interventions can be, but not limited to, frequent position changing and support of pressure points, adequate hydration and nutrition, appropriate exercise and movement, frequent perineal care and application of barrier cream for incontinence, proper lifting technique, correct application of pressure relieving devices and frequent inspection and assessment of skin integrity."Compliance with interventions will be documented in the medical record."III. Resident #27A. Resident statusResident #27, age greater than 65, was admitted on 3/19/15. According to the April 2024 computerized physician orders (CPO), diagnoses included heart failure, type II diabetes, chronic kidney disease and atrial fibrillation (abnormal heart function). The 3/21/24 facility assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of nine out of 15. He required extensive one to two person assistance with toileting, transfers and bed mobility. He required set up assistance with personal hygiene and eating. The assessment documented Resident #27 was at risk for developing pressure injuries but did not have a pressure injury. B. ObservationsOn 4/22/24 at 12:35 p.m. Resident #27 was sitting in his recliner in his room. On 4/23/24, during a continuous observation beginning at 10:35 a.m. and ending at 2:04 p.m., Resident #27 was sitting in his recliner. At 12:22 p.m. Resident #27's lunch tray was delivered by CNA #1. Resident #27 remained sitting in his recliner for lunch. -CNA #1 failed to offer Resident #27 repositioning or toileting before lunch. At 2:04 p.m. Resident #27 was assisted by CNA #1 and licensed practical nurse (LPN) #1 to lay in bed. CNA #1 exited Resident #27 room with a trash bag containing Resident #27's brief. The brief was observed to be visibly wet as the inside of the trash bag was noted to be wet.-Resident #27 was not provided with toileting or repositioning in his recliner for three hours and 30 minutes. On 4/24/24 at 1:04 p.m. the regional nurse consultant (RNC) assessed the edge of the cushion Resident #27 was sitting on in his recliner and said it was a gel type cushion. The RNC assessed Resident #27's air mattress and said it was a mattress that could alternate pressure. On 4/24/24 at 2:00 p.m. Resident #27's wound care was observed with the wound care physician (WCP). The old dressings were removed from the resident's wounds and the wound beds were pink with no signs of infection. The wounds were cleaned with normal saline, skin prep applied to the peri wounds, honey gel applied to the wound beds and covered with border dressings. -On 4/24/24 at 2:30 p.m. the gel cushion in Resident #27's recliner did not have cushion cover on it and the resident was sitting directly on the plastic surface of the gel cushion. C. Record reviewResident #27's comprehensive care plan, dated 3/27/24, revealed Resident #27 had a potential for impairment to skin related to decreased mobility. The interventions included a pressure reducing cushion to chair and mattress (initiated 8/3/22), offering to reposition Resident #27 at night during care and encouraging the resident to lie on his bed after lunch (initiated on 1/20/23).-The care plan only addressed repositioning the resident during night care and not throughout the day. The 4/17/24 skin and wound evaluation form identified two new stage three pressure injuries to the left and right ischium. The wound appeared pink and moist with no signs of infection. The wound area was cleansed with Dakin's, honey gel was applied to the wound bed, skin prep the peri wound and covered with border gauze. Resident #27's 4/19/24 Braden scale (a tool used to determine the risk of pressure injury development) revealed Resident #27 was at risk of developing a pressure ulcer. It revealed his skin was occasionally moist requiring an extra linen change daily. Resident #27 was chair fast, his ability to walk was severely limited and he was unable to bear weight and required assistance into a chair or wheelchair. Resident #27 had very limited mobility, was able to make occasional slight changes in body position but was unable to make frequent or significant changes independently. Resident #27's April 2024 CPO revealed the following physician's order:Cleanse the left and right ischium with Dakin's (specialized wound cleaner), apply honey gel (used to remove dead tissue)to the wound bed, skin prep the peri wound (area around the opening) and cover with border gauze dressing once daily, ordered on 4/18/24. Resident #27's initial wound physician visit on 4/17/24 revealed stage three pressure injuries to both the right and left ischium. The left ischium wound measured 3.4 centimeters (cm) by 2 cm by 0.2 cm with 100% granulation (new connective tissue) tissue and minimal drainage. The right ischium measured 1 cm by 2.5 cm by 0.2 cm with 100 % granulation tissue and no drainage. Orders were given to cleanse the wounds with Dakin's, apply skin prep to periwounds, apply honey gel to wound beds and cover with bordered gauze dressings daily and as needed.-Review of Resident #27's care plan, progress notes and facility assessment did not reveal any documentation which indicated the resident frequently refused care or repositioning (see interviews below). D. Staff interviewsCNA #1 was interviewed on 4/23/24 at 4:10 p.m. CNA #1 said Resident #27 was changed this morning (4/23/24) when he got up and then when he was laid in bed around 2:00 p.m. CNA #1 said Resident #27 did not always tell staff when he needed to be changed so staff should be checking in with him every couple of hours. CNA #1 was aware Resident #27 had a wound on his bottom and should be offered repositioning. CNA #1 said Resident #27 often refused to be repositioned when asked, however, she said the resident had not refused care that day (4/23/24). CNA #1 did not know where to document any refusal of care for repositioning.-Despite CNA #1's interview indicating Resident #27 frequently refused repositioning, the resident's EMR did not reveal documentation that the resident refused care or repositioning (see record review above). -Despite CNA #1's interview indicating Resident #27 should be offered repositioning and staff should check on him every couple of hours, the resident was not offered repositioning during continuous observations for three and half hours (see observations above). LPN #1 was interviewed on 4/23/24 at 4:21 p.m. LPN #1 said she was unaware Resident #27 had not been offered repositioning in at least three and a half hours. LPN #1 said Resident #27 would benefit from repositioning due to the pressure injuries on his bottom. The WCP was interviewed on 4/24/24 at 2:29 p.m. The WCP said he was unable to determine if Resident #27's pressure injuries were avoidable or unavoidable as he was still speaking with facility staff to determine possible causes of the wounds. The WCP said facility staff told him Resident #27 refused to change positions and preferred to sit in his recliner during the day.-However, there was no evidence of documented refusals of care (see record review above). IV. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on 12/1/22. According to the April 2024 CPOs, diagnoses included diabetes mellitus (abnormal blood glucose), dementia (memory impairment) and chronic kidney disease (abnormal kidney function). The 4/9/24 facility assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 11 out of 15. She required substantial assistance for transfers, toileting, dressing and supervision for eating. The assessment documented the resident was at risk of developing a pressure injury but did not have a pressure injury. B. Observations On 4/22/24 at 10:30 a.m. Resident #1 was sitting in her recliner leaning to her left side. On 4/22/24 at 1:35 p.m. Resident #1 was sitting in her recliner and continued to lean to her left. On 4/23/24, during a continuous observation beginning at 10:35 a.m. and ending at 2:51 p.m., Resident #1 was sitting in her recliner, leaning to her left side. At 12:22 p.m. Resident #1's lunch tray was delivered while the resident was asleep and remained sitting in the recliner. At 12:34 p.m. LPN #1 entered Resident #1's room, woke the resident up and offered her assistance with eating. Resident #1 said she was not having a good day because her bottom hurt. LPN #1 told Resident #1 that she got a new dressing on her bottom and the wound physician would be in the next day. -LPN did not offer repositioning to the resident. At 2:26 p.m. LPN #1 entered Resident #1's room and told the resident as soon as the CNA returned from lunch, she would assist the CNA to lay the resident in bed. Resident #1 remained sitting in the recliner leaning to her left side. -At 2:51 p.m. LPN #1 and CNA #1 entered Resident #1's room with the sit to stand mechanical lift. Resident #1 was assisted with the use of the sitto stand lift to the bathroom. Resident #1's brief was removed and was observed to have been soiled with bowel and urine.-Resident #1 was not provided with toileting or repositioning in her recliner for four hours and 15 minutes. LPN #1 collected items to complete the resident's dressing change due to the dressing being soiled. CNA #1 used the sit to stand lift to take Resident #1 out of the bathroom. The old dressing was removed and noted to be soiled with feces on the edges of the dressing. The wound bed to the coccyx was pink and moist and the area around the wound was nonblanchable (discoloration of skin that does not turn white when pressed) when the nurse pressed the surrounding tissue with her finger. The left buttock wound had eschar (dead tissue) around the upper edge of the wound and yellow tissue (slough) throughout. The surrounding tissue of the wound was nonblanchable. LPN #1 cleaned the wounds with Dakins, dried the wounds with gauze, applied skin prep to the peri wounds, added honey gel to the wound beds, and covered the wounds with a border dressing. Resident #1 told LPN #1 it hurt when the nurse was cleaning the wounds. On 4/24/24 at 1:01 p.m. Resident #1 was observed to be seated on a cushion in her recliner. The RNC touched the chair cushion without moving Resident #1 from her seated position in the recliner and identified the cushion as a standard foam cushion. The RNC identified the resident's pressure relieving mattress as an air mattress that could alternate pressure. On 4/24/24 at 2:10 p.m. Resident #1's wound dressing changes were observed with the WCP.The coccyx wound had a pink wound bed. The wound area was cleansed with Dakin's, dried with gauze, skin prep was applied to the periwound, honey gel was applied to the wound bed and the area was covered with border gauze. The left buttock wound was observed to have yellow colored tissue in the center and the upper corner of the wound was observed to have eschar (dead tissue). The wound area was cleaned with Dakin's, dried with gauze, skin prep was applied to the peri wound, honey gel was applied to the wound bed and the area was covered with border gauze. C. Record ReviewResident #1's comprehensive care plan, dated 3/29/24, revealed potential impairment to skin related to decreased mobility with interventions of pressure reducing cushion while up in chair, pressure reducing mattress and follow facility protocol for treatment of injury, initiated 12/13/22. Apply nutrishield cream to coccyx every shift and at each incontinence episode initiated on 5/24/23-There was no intervention for repositioning or frequent incontinent care documented on Resident #1's care planResident #1's 1/7/24 Braden scale assessment revealed Resident #1 was at moderate risk for developing pressure injuries. It revealed Resident #1's skin was very moist requiring extra linen changes, the resident was chair fast (requiring assistance to a chair or wheelchair) and had very limited mobility (unable to make frequent or significant changes independently). Resident #1's weekly skin assessment dated 4/1/24 revealed the resident had an open area starting on her coccyx but did not document a stage of the wound or measurements. It revealed Resident #1 was more comfortable lying on her sides than lying flat because lying flat caused her extreme pain.-The assessment did not document Resident #1 frequently refused repositioning (see interviews below).-There was no progress note indicating whether or not the WCP was notified of the wound and no new physician orders were added for treatment of the wound. Resident #1's weekly skin assessment dated 4/8/24 revealed a pressure injury to the resident's coccyx but had no measurements or narrative notes.-There was no progress note indicating whether or not the WCP was notified of the wound and no new physician orders were added for treatment of the wound. A progress note dated 4/14/24 revealed CNAs were changing Resident #1 and an open area to the resident's coccyx measuring 2 cm by 2.2 cm was found. The area was cleaned and a dry dressing was applied. Resident #1 also had a shearing area to the left buttock measuring 3 cm by 2.2 cm, the area was cleansed with normal saline and nutrashield cream was applied. The nurse notified the unit manager to speak with Resident #1's representative about getting a new cushion for her wheelchair.-The wounds were initially identified by a nurse on 4/1/24, however, there was no further documentation of the wounds or treatment orders obtained until 4/14/24.-There was no documentation to indicate whether a new cushion was provided to Resident #1. Resident #1's April 2024 CPO documented the following physician's orders:Pressure relief mattress: check inflation and settings every shift, ordered on 2/2/24. Apply nutrishield cream to coccyx every shift and with every incontinence episode, ordered on 5/23/23. Wound care order for coccyx: Clean open areas to coccyx with normal saline and apply dry dressing once daily, ordered on 4/14/23.-The order did not specify a treatment for the left buttock wound.-The order was not put into place until 13 days after the initial identification of the open area to Resident #1's coccyx. Wound care order for coccyx and left buttock, cleanse with Dakin's, apply honey gel to wound bed, skin prep the periwound and cover with border gauze once daily, ordered on 4/18/24. The WCPs initial encounter with Residents #1's wounds for the coccyx and left buttock on 4/17/24 revealed the coccyx and left buttocks were unstageable pressure injuries. The coccyx wound measured 1.1 (cm) by 1 cm by 0.1 cm and the left buttock wound measured 0.9 cm by 1.3 cm by 0.1.-Review of Resident #1's care plan, progress notes and facility assessment did not reveal any documentation which indicated the resident frequently refused care or repositioning (see interviews below). D. Staff interviewsCNA #1 was interviewed on 4/23/24 at 4:10 p.m. CNA #1 said residents should be offered toileting or repositioning every two hours to ensure they were not soiled and to off load pressure areas. CNA #1 said Resident #1 would not call if she was soiled so staff needed to offer toileting and check her for incontinence episodes. CNA #1 said Resident #1 was changed around 9:00 a.m. and then at around 3:00 p.m. (on 4/23/24). CNA #1 did not have a response as to why Resident #1 was not offered repositioning or toileting in almost six hours. CNA #1 said Resident #1 had wounds on her buttocks.-Despite CNA #1's interview indicating Resident #1 should be offered repositioning and staff should check on her every couple of hours, the resident was not offered repositioning during continuous observations for four hours and 15 minutes (see observations above). LPN #1 was interviewed on 4/23/24 at 4:21 p.m. LPN #1 said residents should be offered repositioning every two hours especially if they had pressure injuries or were at risk of developing pressure injuries. LPN #1 said repositioning would be beneficial to residents with pressure injuries to promote healing. LPN #1 was unaware if Resident #1 was not offered repositioning or toileting between 10:35 a.m. and 2:51 p.m. LPN #1 said Resident #1 had not had the pressure injuries long but would refuse staff when she was asked to reposition. LPN #1 said she had not documented any Resident #1 refusal of repositioning.-Despite LPN #1's interview indicating Resident #1 frequently refused repositioning, the resident's EMR did not reveal documentation that the resident refused care or repositioning (see record review above). The WCP was interviewed on 4/24/24 at 2:10 p.m. The WCP said he felt Resident #1's pressure injuries were avoidable but when he talked with the facility staff he was told Resident #1 refused to change positions.-However, there was no documented refusal of care (see record review above). V. Additional interviewsThe WCP was interviewed again on 4/24/24 at 2:48 p.m. The WCP said Resident #1's and #27's wounds would benefit from frequent positioning changes despite them both sitting on cushions when up in their recliners. The WCP said a pressure injury could develop within two hours and incontinence increased the risk of a wound developing or worsening. The WCP said wound textbooks recommended a resident in bed be repositioned every two to three hours and, when in a chair, they should be repositioned every two hours to offload pressure. The director of nursing (DON) was interviewed on 4/25/24 at 10:10 a.m. The DON said Resident #1 started having skin issues on 4/1/24, however, she said the floor nurse did not relay this information to the unit manager. The DON said Resident #1's skin issue was brought up again on 4/14/24 by another nurse. She said the facility started to review what could have caused the wounds and found the weekly skin documentation dated 4/1/24. The DON said the facility immediately started wound care treatment for Resident #1's wounds on 4/14/24 and had the WCP see the resident on his next wound round visit, which was 4/17/24. The DON said Resident #1 did not like to be repositioned and liked to sit in her recliner. The DON said Resident #27 did not like to be moved from his recliner but should still be offered position changes every two hours.-Despite the DON's interview indicating Resident #1 and Resident #27 frequently refused repositioning, the residents' EMRs did not reveal documentation that the residents refused care or repositioning (see record review above). -The DON did not provide any documentation for refusal of care for Resident #1 or Resident #27. The DON said residents should be repositioned every two hours to help prevent pressure injuries and promote wound healing if they had a pressure injury. The DON said if a resident refused to be repositioned it should be documented in the nurses progress notes. The DON said residents should be offered toileting upon rising, before and after meals and as needed.

A complaint survey, prompted by #CO34422 was conducted on 12/18/23. No deficiencies were cited.

A revisit to the 1/30/2023 survey was completed on 4/14/2023. The facility was in compliance with the regulation surveyed.

A focused infection control survey with complaint #CO30607 was conducted 1/23/23 to 1/30/23. One deficiency was cited.

An Emergency Preparedness focused infection control survey was conducted 1/23/23 to 1/30/23. No deficiencies were cited.

Based on interviews and record review, the facility failed to conduct testing in a manner that was consistent with current standards of practice for conducting COVID-19 tests for three (#1, #2, #3) of three residents reviewed out of four sample residents. Specifically, the facility failed to:-Document in the residents medical record the results of COVID-19 tests for all residents, and;-Document/log COVID-19 point-of-care/rapid testing or results for staff consistent with requirements. Findings include:I. Facility policy and procedureThe Infection Prevention and Control policy and procedure, approval date December 2022, was provided by the assistant director of nursing (ADON) on 1/23/23 at 4:05 p.m. It read in pertinent part, "It is a policy of this community to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections. The role of the infection preventionist or delegatee include: managing outbreaks, tracking lab testing results, educating staff and visitors on infection prevention and control. A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable disease for residents and associates. Nurses participate in surveillance through assessment of residents and reporting changes in condition and reporting of communicable diseases and infections."II. County positivity rateThe facility was located in Arapahoe county where the level of community transmission rate was "substantial" the week of 1/20/23 to 1/26/23, retreived from https://covid19.colorado.gov/healthcare-providers/long-term-care-facilities/healthcare-community-transmission-levels. The facility was currently in outbreak status. III. Record reviewThree residents (#1, #2, and #3) were reviewed for COVID-19 testing results from 1/1/23 to 1/23/23. The resident's medical record/chart did not have the testing results or that testing had been offered and completed. Of these three residents all had tested positive, Resident #1 on 1/12/23; Resident #2 on 1/15/23; and Resident # 3 on 1/15/23. Although Residents #1,#2, #3 did not have COVID-19 test results in the chart, per nursing interview the facility was not uploading COVID-19 testing results to any of the resident's charts (see staff interview). Request for review of staff documentation from 1/1/23 to 1/23/23 for documentation the testing was completed and the results of each staff test was not provided by the facility. IV. Staff interviewsThe ADON was interviewed on 1/23/23 at 11:00 a.m. She said that COVID-19 testing results had not been uploaded to the resident's charts. The ADON said testing was every other day for residents and the polymerase chain reaction (PCR). The ADON said the agency staff were COVID-19 rapid testing at each shift and the regular staff were testing when they had symptoms. The director of nursing (DON)/infection preventionist (IP) was interviewed on 1/23/23 at 2:48 p.m. She said the facility notified all families of all positive COVID-19 testing results with a phone call. The DON said the executive director also sends out COVID-19 communications via email or preferred communication method to notify families of the outbreak in the memory care neighborhood. The DON said the staff were rapid testing but she was not tracking/documenting staff testing, but she did verify verbally with staff that they did test. The DON said she had not uploaded the COVID testing results to any of the resident's charts. The DON said she and ADON had access to the resident testing results through the lab system. The DON said she needed to work on that and that she used to keep track of testing of staff. The DON said she would reinstate it and get it going again to be in compliance and for better documentation.

A revisit survey was completed on 1/19/23 for all previous deficiencies cited on 12/1/22. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 1/19/23 for all previous deficiencies cited on 12/1/22. The facility is in compliance with all regulations surveyed.