Every finding on record at Acacia Health Center

Based on clinical record review, staff interviews, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure a minimum data set (MDS) assessment was completed accurately for one resident (#54) out of 68 sampled residents. The deficient practice could result in further incomplete MDS assessments.Findings include:Resident #54 was admitted on [DATE] with diagnoses that included displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, pain in right hip, and type 2 diabetes mellitus.A review of the Admission/Medicare-5 day MDS assessment dated [DATE] revealed that Resident #54 had a brief interview for mental status (BIMS) score of 15, which meant the resident was cognitively intact. MDS assessment revealed Resident #54 had received injections for 2 days during the last 7 days or since admission/entry or reentry if less than 7 days. Additionally, Section N0350 Insulin, had 2 days entered for Insulin injections, that were received during the last 7 days or since admission/entry or reentry if less than 7 days.A review of the care plan revealed no focus area for the diagnosis of diabetes or mention of insulin or other diabetic medications.An interview was conducted with Resident #54 on December 24, 2025 at 10:55 a.m. who stated was not diabetic, had not received insulin at the facility or prior to coming to the facility while in the hospital, and did not have any glucose monitoring of fingers. Resident #54 stated had received shots or injections, but not for diabetes.An interview was conducted with licensed practical nurse (LPN) Staff #5 on December 24, 2025 at 10:59 a.m. who revealed that there were no orders to check Resident #54's finger glucose checks; and that, no insulin was given or orders to give insulin to Resident #54.An interview was conducted with MDS coordinators Staff #155 and Staff #22 on December 24, 2025 at 11:05 a.m. who revealed that there were three MDS coordinators who performed the facility's MDS assessments. Two MDS coordinators were able to review Resident #54's assessment and confirmed that they (Staff #155 and Staff #22) did not perform the documented assessment. Staff #96 who was not present, did the assessment. Staff #22 revealed that they reviewed hospital records, read hospital information, review all the medications, treatments and do a good portion of the care plan, over the past 7 days and confirmed that the resident did get 2 injections, but not insulin. MDS coordinators (Staff #155 and Staff #22) confirmed that the mistake was an error. Staff #155 confirmed that Resident #54 received a flu shot. Staff #22 stated Resident #54 received a covid vaccine; and that, those were the only 2 injections.An interview was conducted with director of nursing (DON) Staff #191 on December 24, 2025 at 11:47 a.m. who revealed that the expectation with the resident assessment was to be completed thoroughly and accurately.Another medical record review of the MDS assessment was conducted on December 24, 2025 at 1225 p.m. which revealed that Staff #22 showed that the MDS was corrected and sent.Review of the job description for MDS Coordinator revealed that the MDS nurse was responsible for the overall supervision, coordination, maintenance and timely completion of the MDS, care plans and medical records for residents. Section: Principle duties, number 2. Assure accuracy and completeness of entire medical record.Review of the policy Resident Assessments version 2.0 (H5MAPL0755) revealed that the resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews.

Based on observations, staff interviews, and facility policies, the facility failed to ensure food items were appropriately stored and labeled; and, failed to ensure that food was not expired. The deficient practice may result in the food items not kept according to professional standards for food service safety.Findings include:During initial observation of the kitchen conducted on December 22, 2025, at 8:23 am, with the Dietary Manager (Staff #215), items were found to be opened and not labeled. Observation revealed an open container of turkey base with an open date of November 27, and without a year or use by or expiration date. Two zested oranges unlabeled with a use by date. An open container of ketchup with an illegible open date behind an unopened container of ketchup. An opened bottle of maple syrup dated August 8, with no year and thick brown buildup on the inside walls of the bottle above the level of remaining syrup. A bag of potato pancakes was open to air with no open date, use-by date, or expiration date.An interview was conducted on December 22, 2025, at 8:31 am with Staff #215 who stated that the standard practice included that items should be used within 30 days of opening. Staff #215 stated that the expectation was that oranges used for zesting are discarded after use because they do not serve raw oranges to residents. A second interview was conducted on December 22, 2025, at 8:40am with Staff #215 who confirmed that the date on the ketchup container was smudged; and that, he could not read it. Staff #215 stated that the process for storing new products was to use the first-in, first-out method - the first product to come in is used first. He described the maple syrup found as having separation and stated food items should be discarded if there is no year marked. Staff #215 stated that food should be closed and labeled when it is going back in the freezer. An interview was conducted on December 24, 2025, at 8:59am with the Administrator (Staff #203), who stated that once items are opened they are dated, and discarded after seven days. Staff #203 stated that the expectation was that if something was opened, the it should be dated. Staff #203 stated that the risk involved with not labeling food is that the food could be potentially outdated and could be expired. Staff #203 further stated that the risk involved with giving residents expired food is that they could get sick. She did not want to expand upon this. Another observation of unit refrigerators and unit dry storage snacks was conducted on December 24, 2025, at 7:53 am, the following foods were found to be expired: 5 containers Special K Original Toasted [NAME] Cereal with an expiration date of December 7, 2025; 3 containers of Special K Original Toasted [NAME] Cereal with an expiration date of November 11, 2025; 4 containers of Cheerios Toasted Whole Grain Cereal with an expiration date of November 26, 2025; 1 container of Cheerios Toasted Whole Grain Cereal with an expiration date of November 21, 2025.Another interview was conducted on December 24, 2025, at 8:20 am with Staff #215 who stated the expectation was that staff look at each dried cereal package and discard it away if it is expired. Staff #215 stated that it was similar to the process for foods stored in the fridge and freezer if it has expired -- the practice is to discard it and the risk involved is potential foodborne illness.An interview was conducted on December 24, 2025, at 8:59 am with the Administrator (staff #203) who stated the process for expired foods was that they be discarded. The administrator further stated that the risk involved with a resident having expired food was that they could become sick.Review of the facility policy titled Food Storage and Datemarking revealed that old stock is always used first, with the first-in - first-out method and that the person designated to manage stock should be trained to rotate it properly. Additionally, leftover food items should be stored in covered containers or wrapped carefully, securely and clearly labeled, dated before being refrigerated, that leftover food should be used within seven days or discarded.

Based on clinical record review, interviews, and facility documentation and policy the facility failed to ensure that medical records accurately documented skin impairments identified for resident #024. The deficient practice could result in medical records that do not accurately and completely reflect the care and services provided. The sample size was 3, and the facility census was 75. Findings Include:Resident # 024 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease with acute exacerbation, hypertensive heart disease with heart failure, paroxysmal atrial fibrillation, and generalized muscle weakness. The resident was discharged from the facility on December 18, 2024. A provider's order dated November 22, 2024, directed staff to cleanse the right second toe with wound cleanser, apply betadine, and cover with a Band-Aid daily.A provider's order dated November 23, 2024, directed staff to cleanse the open area of the left knee with wound cleanser, apply a medical-grade honey dressing, cover with a petrolatum gauze dressing and gauze, and wrap with a rolled gauze dressing, secured with tape and a stockinette.A review of the admission Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. Further review of the MDS indicated that Resident #74 had two venous/arterial ulcers and skin tears present. The MDS identified skin condition treatments included pressure-reducing devices for chair and bed, nutrition and hydration interventions, application of nonsurgical dressings, ointments or medications, and application of dressings to the feet with or without topical medications. The MDS also identified that the resident and representative were active participants in the assessment process and that the overall goal was discharge to the community.A provider's order dated December 16, 2024, directed staff to cleanse the right first toe with wound cleanser, pat dry, apply betadine, and leave open to air daily . A review of the Skin and Wound Evaluation dated December 16, 2024, revealed that the front of the left knee had a skin tear with complete tissue loss, and treatment orders were in place for the application of a medical-grade honey dressing.A review of the Skin and Wound Evaluation dated December 16, 2024, revealed the following: the arterial ulcer on the first digit of the left dorsum was treated with sodium hypochlorite, debrided with an autolytic, and covered with calcium alginate and foam dressings; and the arterial ulcer to the right first digit (hallux) was circular in shape and had an area with 70% slough and 30% non-granular tissue, that was circular in shape. A review of the Skin and Wound Evaluation dated December 16, 2024, described the arterial ulcer on the right dorsum as scabbed, circular in shape, with no surrounding redness. Further review revealed that the ulcer was cleansed with sodium hypochlorite and dressed with an antimicrobial dressing.A review of the Transition of Care and Discharge summary, dated [DATE], revealed that the discharge summary instructions received by the resident's representative and present in the electronic record were inconsistent with the resident's clinical record, due to omissions related to the resident's skin impairments.A provider's order dated December 17, 2024, directed staff to cleanse the left lateral hallux wound with wound cleanser.A review of the Home Health Care Referral Form dated December 17, 2024, revealed special instructions to include wound care.A review of the Health Services Concern and Comment form, dated February 28, 2025, indicated that the resident's representative expressed concern regarding the resident's wound care and the discharge wound care process. According to the document, the facility's investigation determined that incorrect documentation related to the resident's wound care was submitted on the discharge assessment. Further review of the document revealed that the facility provided education to licensed nursing staff regarding wound care documentation, discharge documentation, and communication.An interview was conducted on October 28, 2025, at 9:08 a.m., with the resident's representative. The representative expressed concern regarding insufficient communication from the facility to the consulting provider about the resident's wounds. The representative reported receiving written discharge instructions but indicated dissatisfaction that the discharge paperwork did not accurately reflect active skin impairments. The representative stated feeling equipped to manage the wounds but emphasized a desire that facility staff had communicated the condition of the wounds more accurately.An interview was conducted on October 28, 2025, at 9:42 a.m., with Certified Nursing Assistant (CNA) Staff #21. Staff #21 stated that any changes in a resident's skin integrity are immediately reported to the nurse. Additionally, Staff #21 explained that on resident shower days, it is their responsibility to document any abnormalities on the shower sheet and submit the completed form to the nurse. Staff #21 emphasized that accurate documentation and communication are essential to advocate for residents and ensure that floor staff receive effective nursing reports.An interview was conducted on October 28, 2025, at 9:55 a.m , with the dually titled Wound Care Nurse and Director of Nursing (DON). Staff # 01 revealed the resident foot wounds were classified as arterial ulcers in etiology. Regarding the right arterial ulcer, the nurse revealed on November 27, 2024 the area was scabbed over, but the wound area continued to receive therapy, as it is facility policy to continue. Staff #01 revealed providing weekly round reports to the medical director/ the resident's attending physician. Staff #01 stated reports directly to the attending provider, not the consultant provider unless instructed to do so by the attending/medical director. Staff #01 revealed that at discharge, the facility arranged for mobile wound clinic service to follow up with the resident.An interview was conducted on October 28, 2025, at 2:15 p.m. with Registered Nurse (RN/Staff #44). Staff #44 stated that proper documentation in the resident record is important to ensure that, if any issues arise in the future, accurate information is available regarding what actually occurred. Staff #44 further stated that inaccurate documentation can impact a resident's ability to receive appropriate treatment, such as in wound care. Staff #44 added that if the correct wound treatment is not properly documented, it may negatively affect the healing process.A follow-up interview was conducted on October 28, 2025, at approximately 2:55 p.m., with Staff #01. Staff #01 stated that preparing the discharge summary is a coordinated effort among nursing, social services, and dietary. Staff #01 explained that the facility ensures discharge information sent to the receiving provider is accurate, complete, and up to date by sending the most recent orders and relevant documentation. Staff #01 further stated that there is an expectation to verify that the discharge summary reflects the resident's most current clinical status, and the nurse completing the summary uses the most current records.Staff #01 mentioned that more than one nurse can work on the discharge assessment. Staff #01 explained that the facility's electronic record system highlights completed areas in green. Staff #01 provided an example in which a night shift nurse may begin the assessment and a day shift nurse completes it, so sections highlighted in green may not be rechecked, based on the assumption that the information entered is accurate and complete.Staff #01 revealed that following the discovery of omissions in the resident's discharge summary during a conference with the resident's representative, the facility identified the staff responsible for the incorrect documentation and provided re-education. Staff #01 stated that the re-education included ensuring the accuracy of skin condition documentation and reviewing the specific sections of the assessment being signed off on to prevent future errors.Review of the Discharge Summary and Plan policy, Revised December 2016, revealed that the discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of discharge in accordance with established regulations governing release of resident information as permitted by the resident. The policy further states that a copy of the discharge summary will be provided to the resident and receiving facility, and a copy will be filed in the resident's medical records. Review of the Transfer or Discharge Documentation policy, Revised December 2016, revealed that when a resident is transferred or discharged from the facility , the following information will be documented in the medical record: A summary of the resident's overall medical, physical, and mental condition.

Based on observation, residents and staff interviews, a facility document, and policy review, the facility failed to ensure the wall was repaired in one resident's (#41) room. The deficient practice prevented the resident's room from having a homelike environment. Findings include: During an interview conducted on August 24, 2022 at 2:34 p.m. with the resident #41, there were deep cracks observed in the wall approximately 3 inches by 6 inches to the left of the bed behind the recliner. It was also observed that the area was not painted along with two other areas on the left wall adjacent to the wall where the bed was located. The resident stated that no one has come to the room to look at the cracks and missing paint on the wall. The resident's spouse was present at the time of the interview and stated the cracks in the wall and the missing paint were present when the resident was admitted to the facility on [DATE]. Review of a work order with no submission date, stated wall repair was assigned to maintenance on August 24, 2022. The work order also stated that the work was to be completed within 3 business days. Patch was completed on August 24, 2022 and sand and paint to be completed on August 25, 2022. An interview was conducted on August 24, 2022 at 2:35 p.m. with a registered nurse (RN/staff #131). She stated that they submit orders to the front desk when something needs repair and the front desk submits an order to maintenance. The RN stated that an order to repair the wall was submitted to maintenance before the resident was admitted to the room and maintenance is aware of it. An interview was conducted on August 25, 2022 at 8:27 a.m. with the Administrator (staff #200) with the Director of Nursing (DON/staff #18) present. Staff #200 stated the maintenance director inspects the facility daily and completes work orders. She said that staff can identify any repairs needed and put an order in with the front desk. She stated some wall repair and painting is considered general repair and not an emergency. She said that they have had problems with the recliners hitting the wall in the rooms and are currently installing plastic on the wall, so the recliner does not scrape the wall. She said that if a resident is upset about something that is considered a general repair, it would be repaired. She said that she had seen the wall and saw the cracks. She also stated the housekeepers go into the rooms daily and would/should report any repairs needed. At 8:29 a.m., the Facility's Manager (staff #79) joined the interview. He stated that he reviews the facility daily, but he does not do daily rounds in every single room. He stated when he does inspect rooms, he picks them at random. He stated that he does not have an order for the wall repair except for the order that he received yesterday. He stated that he was in the resident's room on Monday and did not see the cracks or missing paint on the walls, but that he inspected the water, lights, and ceiling. He said that after he was informed of the wall damage, he inspected it and it looked like the wall had been damaged by the recliner. He stated he did not ask the resident how long it had been there. During the interview, he reviewed the work order and stated that the wall repair and painting was categorized as repairs that needed to be completed within 3 days. The facility's policy, Work Orders, Maintenance, revised April 2010 states: -In order to establish a priority of maintenance service, work orders must be completed in the work order system. -It shall be the responsibility of the department directors to request or complete work orders that need to be completed to the maintenance department. -Any staff may report a work order needed to the front desk concierge and leave a message after hours. -Work orders are reviewed daily.

Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure advance directive information was accurate for one resident (#13). The sample size was 2. The deficient practice could result in residents' wishes not being honored. Findings include: Resident #13 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's care plan initiated on [DATE] revealed the resident was a full code. Review of the advanced directives with the date [DATE] revealed the resident was a Do Not Resuscitate (DNR). During an interview conducted with the resident on [DATE] at 9:30 am, the resident stated that their code status was full code. During an interview conducted on [DATE] at 8:55 AM with the Director of Social Services (staff #159), she stated that they review advanced directives with the resident and the resident initials and signs the document to execute it. Staff #159 stated the documentation should be consistent. In an interview conducted with a Registered Nurse (RN/staff #97) at approximately 9:05 am on [DATE], the RN stated they would look for a resident's code status on the report sheet first. She stated the report sheet indicated CPR (cardiopulmonary resuscitation) should be initiated. She stated next, they would check the computer to verify. She stated the computer indicates to initiate CPR. She stated they would also check the physical chart, which has a green sheet indicating that CPR should be performed. Continued review of the resident physical chart revealed other forms behind the green sheet. The RN stated the advanced directive statement indicates the resident does not want CPR. She stated the advance care planning tracking form states do not resuscitate. The RN stated that she would notify the Director of Nursing. An interview was conducted with the DON (staff #18) on [DATE] at approximately 9:52 am. She stated her expectation is that the order would be followed. She stated there is a binder at the nurses' station that the nurse would be expected to refer to, and there is also information in the computer. After reviewing the clinical record, the DON stated the advanced directive statement is DNR and was signed by resident's POA (power of attorney) on [DATE]. She stated the advance care planning tracking form indicated DNR was signed by the resident's POA on [DATE]. The DON stated the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated the resident would be treated as full code because the full code sheet is signed by the resident's POA and full code is consistently in the computer. She stated the expectation would be that communication of changes should have happened. The facility's policy Advance Directives revised [DATE] stated advance directives will be respected in accordance with state law and facility policy. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. The policy stated the attending physician will be notified of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care.

Based on review of nursing staffing information, staff interview, and policy review, the facility failed to ensure that nurse staffing information posted on a daily basis included the total number of licensed and unlicensed staff, and the actual hours worked by licensed and unlicensed nursing staff. The deficient practice resulted in information not being readily available to residents and visitors. Findings include: Review of the Daily Staff Postings dated August 6, 14, and 17, 2022 revealed the date, census, a category for licensed and unlicensed staff, and the total number of hours scheduled for licensed and unlicensed staff. The postings did not reveal the total number of licensed and unlicensed staff scheduled to work for each shift, and the actual hours worked by licensed and unlicensed nursing staff during each shift. An interview was conducted on August 25, 2022 at 9:07 a.m. with the Staffing and Transportation Coordinator (staff #116) with the Director of Nursing (DON/staff #18) present. Staff #116 stated the receptionist is responsible for completing the Daily Staff Posting and she reviews the posting afterwards. She stated she makes changes to the posting when she is told and the DON or night nurse makes the changes when she is not present. She stated that the Daily Staff Posting must include the date, census, categories of nursing staff, (Licensed Practical Nurses/LPNs, Registered Nurses/RNs, Certified Nursing Assistants/CNAs), total number of each category of staff (LPNs, RNs, CNAs) working on each shift, the total number of hours scheduled to work for each category of staff, and the total number of actual hours worked by each category (LPNs, RNs, CNAs) of staff. Staff #116 also stated that the purpose for the posting is so family members/visitors can see the staffing ratios. During the interview, staff #116 reviewed the Daily Staff Posting for August 6, 14, and 17, 2022 and said the postings did not contain the total number of each category of staff (LPNs, RNs, CNAs) working on each shift and the actual hours worked is not documented because it is the same as the total number of scheduled hours documented on the postings. The facility's policy, Posting Direct Care Daily Staffing Numbers, revised December 2021 stated that within two (2) hours of the beginning of each shift, the number of licensed nurses (RNs, LPNs, and Licensed Vocational Nurses/LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. Shift staffing information shall be recorded on the Nursing Staff Directly Responsible for Resident Care form for each shift. The information recorded on the form shall include the following: a. The name of the facility. b. The date for which the information is posted. c. The resident census at the beginning of the shift for which the information is posted. d. Twenty-four (24)-hour shift schedule operated by the facility. e. The shift for which the information is posted. f. Type (RN, LPN, LVN, or CNA) and category (licensed or non-licensed) of nursing staff working during that shift. g. The actual time worked during that shift for each category and type of nursing staff. h. Total number of licensed and non-licensed nursing staff working for the posted shift.

Based on clinical record review, staff interviews, and policies, the facility failed to ensure one resident's (#205) medical record confidentiality was maintained by failing to ensure parts of resident #205's medical record was not included in resident #200's medical records. Findings include: -Resident #205 was admitted (MONTH) 25, (YEAR) with [DIAGNOSES REDACTED]. -Resident #200 was admitted to the facility on (MONTH) 6, (YEAR) with [DIAGNOSES REDACTED]. Review of the clinical record revealed resident #200 left the faciity on (MONTH) 20, (YEAR) for an appointment around 4:10 p.m. However, when the resident arrived at the physician's office, included in the resident's paperwork were the face sheet and the medication profile for resident #205. An interview was conducted on (MONTH) 26, 2019 at 1:46 p.m. with the medical records coordinator (staff #33). She stated that when a resident goes out to an appointment, the medical records department uses a check sheet to gather the needed documentation which would include the face sheet, progress notes, medication records, and any other documentation that the appointment would require. Staff #33 stated that the documentation is placed in an envelope and the check list is attached to the envelope. She stated that each resident's record is assembled individually and should not contain any other resident's paperwork in the packet. The coordinator stated that the envelope is given to the nurse who will give it to the resident, the resident's family member, or the driver to ensure the physician's office receives it. She further one of the staffing coordinators (staff #124) had prepared resident #200's packet. She also stated that had the physician's office notified them of the problem, she would have directed them to destroy the documents as it would be a HIPAA (Health Insurance Portability and Accountability Act) violation. During an interview conducted on (MONTH) 26, 2019 at 2:38 p.m. with the Director of Nursing (DON/staff #12), she stated that up until recently the staffing coordinator had been assembling the information packet for the residents to take with them to the physician's office. She stated that once the packet was completed, the staffing coordinator would give the envelope to the nurses who would give it to the resident, the resident's family member, or the driver. The DON stated that the envelope should only contain documents related to the resident. She further stated that the physician's office should have contacted them for clarification regarding resident #200 and that they would have requested that they destroy the second resident's documents. An interview was conducted on (MONTH) 26, 2019 at 2:50 p.m. with the staffing coordinator (staff #124). She stated that she had been responsible for assembling the paperwork for each resident's office visits. Staff #124 stated that she would include a copy of the face sheet, current medication list, progress notes, lab results, and other documents needed by the physician's office and place them in an envelope. She stated the envelope is then given to the nurse who will give it to the transportation driver, resident, or the resident's family member. Staff #124 also stated that she generally assembled one resident's record at a time but that occasionally she had assembled two or three resident's records at the same time. The facility's policy regarding Confidentiality of Information and Personal Privacy revealed the facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. The policy included access to resident personal and medical records will be limited to authorize staff and business associates. Review of the facility's policy titled Privacy Notice revealed the facility is required by law to maintain the privacy of Protected Health Information (PHI).

Based on personnel record review, staff interviews, and policy and procedures, the facility failed to ensure one staff member (#127) had evidence of freedom from [MEDICAL CONDITION] (TB), prior to working in the facility. Findings include: A review of the personnel records was conducted on November 30, 2017 at 1:30 p.m. Further review revealed that a maintenance worker (staff #127) was hired on March 6, 2017. However, there was no evidence that staff #127 was free of TB. In an interview conducted on November 30, 2017 at 1:45 p.m. with the Human Resources Coordinator (staff #203), staff #203 stated that when she was getting the files ready she realized that staff #127 did not have a current TB test in his file, so she had him get one this morning. She stated the staff member was working when he received the test and continued to work after receiving the test. An interview was conducted on December 1, 2017 at 3:15 p.m., with the Maintenance Supervisor (staff #90). Staff #90 stated that he sent the staff member home until the test results were confirmed. He stated staff #127 does go all over the building to repair things. An interview was conducted with the Infection Preventionist (IP/registered nurse/staff #39) on December 4, 2017 at 9:04 a.m. Staff #39 stated that previously HR had let staff know when TB testing was needed and the nurses on the floor would administer them and read them. Staff #39 further stated that staff #127 should have been sent home after receiving the test until it was determined if the staff member was free from TB. Staff #39 stated if a staff member has a TB test due and it is not completed by the required date or prior to hire, the staff member cannot be scheduled until the test or screening is completed. Review of a policy titled [MEDICAL CONDITION], Employee Screening revealed that all employees shall be screened for TB infection and disease, using a two-step [MEDICATION NAME] skin test or blood assay. The policy further stated that each newly hired employee will be screened for TB infection and disease after an employment offer has been made, but prior to the employee's duty assignment.

Based on clinical record review, staff interviews and policy review, the facility failed to ensure a written notice of transfer/discharge was provided to one resident (#57) and that a copy was sent to the Office of the State Long Term Care Ombudsman. Findings include: Resident #57 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of a nursing note dated September 6, 2016 at 9:21 a.m., revealed the resident was lethargic, weak and slow to respond. The physician was notified and orders were received to transfer the resident to the emergency department for further evaluation. A physician's orders [REDACTED].#57) to the emergency department for further evaluation, due to lethargy, decreased urine output and abnormal labs. A nursing note dated September 6, 2017 at 10:28 a.m. included the resident was transported to the hospital at 9:55 a.m., and a message was left for the resident's medical power of attorney. Review of the clinical record revealed no evidence that the resident/resident's representative and the ombudsman received written notification of the transfer/discharge. An interview was conducted on December 4, 2017 at 11:47 a.m., with the social services coordinator (staff #156). She stated when resident's are transferred to the hospital and will not be returning to the facility, the resident or the resident's representative should be notified via phone of the resident's discharge. She stated that she was unaware that the ombudsman was to be notified of a residents transfer and discharge. She further stated the ombudsman was not notified that resident #57 was discharged . An interview was conducted on December 4, 2017 at 11:47 a.m., with another social services coordinator (staff #103). She stated notifications of transfer and discharge are to be sent to the ombudsman. An interview was conducted with the Director of Nursing on December 4, 2017 at 12: 24 p.m. She stated the expectation is for the facility to send a written notice of transfer or discharge to residents or their representatives, as well as the ombudsman. Review of the facility's Transfer or Discharge Notice policy revealed that a resident and/or the resident's representative will be provided a 30 day written notice of an impending transfer or discharge. The policy also included that the notice will be given as soon as it is practicable, but before the transfer or discharge, if an immediate transfer or discharge is required based on the resident's urgent medical needs. The policy further included that a copy of the notice will be sent to the Office of the State Long Term Care Ombudsman.

Based on staff interviews, the facility failed to conduct a facility wide assessment to determine what resources are necessary to care for residents competently during day to day operations and emergencies. Findings include: An entrance conference was conducted on November 28, 2017 at 8:35 a.m. At this time, a copy of the facility assessment was requested from the Assistant Director of Nursing (ADON/staff #87). An interview was conducted with the ADON on November 29, 2017 at 2:15 p.m. The ADON stated that they were putting the information together, but it was not done. In an interview conducted on December 1, 2017 at 10:30 a.m. with the Administrator (staff #201), he stated that he did not know what needed to be included in the facility assessment. He stated the facility assessment has not been completed. A policy was requested regarding the Facility Assessment, however, the ADON stated that they did not have a policy.

Based on clinical record review and staff interviews, the facility failed to ensure that one resident's (#27) clinical record contained a physician's order for discharge. Findings include: Resident #27 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed social service documentation dated July 20, 2016, which indicated that the Medical Power of Attorney (MPOA) was contacted regarding the resident's transfer to a behavioral health facility for evaluation and that the MPOA had approved the transfer. The Minimum Data Set Discharge assessment dated [DATE] revealed the resident had severe cognitive impairment and required extensive assistance with activities of daily living. Further review of the clinical record revealed nursing documentation that the resident was transferred to a behavioral health facility on July 20, 2016. The documentation further included that the nurse gave report to the receiving facility. However, continued review of the clinical record revealed no documentation of a physician's order for the resident's discharge. During an interview on December 22, 2016 at 2:40 p.m. with a licensed practical nurse (LPN/staff #81), she stated that prior to discharge, the physician is to be notified for orders. During an interview on December 28, 2016 at 11:16 a.m. with the Director of Nursing (staff #59), she stated that the physician is to be notified for orders, prior to a resident's discharge. She stated that in this particular case, they had been communicating with the physician and the family regarding the resident's behaviors and the need for them to be assessed, and the mental health facility called with a vacancy and they transferred the resident without contacting the physician for orders.

Based on clinical record review, facility documentation, staff interviews, and policy review, the facility failed to ensure that pre and post [MEDICAL TREATMENT] assessments were provided and that the [MEDICAL TREATMENT] center's instructions for the care of the [MEDICAL TREATMENT] site were implemented for one resident (#59). Findings include: Resident #59 was originally admitted on [DATE], and was readmitted on [DATE]. [DIAGNOSES REDACTED]. Review of the October and November 2016 physician's orders [REDACTED]. A review of the October and November 2016 nursing notes revealed that a [MEDICAL TREATMENT] (arteriovenous fistula) was located on the resident's left upper extremity. Review of the [MEDICAL TREATMENT] center records revealed care instructions for the facility to implement for the arteriovenous fistula. The instructions included the following: -Clean the skin over the fistula everyday with soap and water. -Take the bandage off the fistula 4 to 6 hours after [MEDICAL TREATMENT]. However, there was no clinical record documentation that the [MEDICAL TREATMENT] center's instructions had been implemented. In addition, there was no documentation that the facility assessed the resident before and after [MEDICAL TREATMENT]. An interview was conducted on December 22, 2016 at 10:15 a.m., with a Registered Nurse (staff #48), who stated that the facility does not utilize a specific pre and post [MEDICAL TREATMENT] assessment form, but licensed staff were supposed to provide those assessments and document it in the nursing notes. Following a review of the clinical record, she stated that she was unable to located any documented evidence that pre and post [MEDICAL TREATMENT] assessments had been provided. In addition, staff #48 stated that the [MEDICAL TREATMENT] center's instructions for the care of the resident's arteriovenous fistula were suppose to be implemented, however, she was unable to locate any documented evidence that those instructions had been provided. An interview was conducted on December 22, 2016 at 10:25 a.m., with the Director of Nursing (staff #59), who stated that the [MEDICAL TREATMENT] center's instructions for the arteriovenous fistula should have been implemented and then documented on the treatment administration record. Staff #59 also stated that pre and post [MEDICAL TREATMENT] assessments should have been done and included the status of the [MEDICAL TREATMENT] site, any signs of bleeding, other adverse sign/symptoms and the resident's general condition before and after [MEDICAL TREATMENT] treatments. An interview was conducted on December 23, 2016 with a LPN (staff #104), who stated that the nurses were supposed to follow the [MEDICAL TREATMENT] center's instructions regarding the resident's arteriovenous fistula and document it in the clinical record. A facility policy titled, [MEDICAL TREATMENT] Access Care included the following: 3. Care involves the primary goals of preventing infection and maintaining patency of the catheter. 4. To prevent infection and/or clotting: a. Keep the access site clean at all times. The policy also included, The general medical nurse should document in the resident's medical record every shift as follows: 1. Location of catheter. 2. Condition of dressing. 3. If [MEDICAL TREATMENT] was done during shift. 4. Any part of report from [MEDICAL TREATMENT] nurse post [MEDICAL TREATMENT] being given. 5. Observations post [MEDICAL TREATMENT].

Based on clinical record reviews, staff interviews, and policy and procedures, the facility failed to ensure that pain medications were administered per the physician ordered pain parameters and that additional pain medications had parameters for administration for two resident's (#33 and #137). Findings include: -Resident #33 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the pain care plan revealed the resident had pain related to a femur fracture. The goal was that the resident would achieve an acceptable level of pain control through the next review. Interventions included to provide pain medication as ordered and to notify the physician of any abnormal findings. Review of the physician's orders [REDACTED]. Review of the November 2016 Medication Administration Record [REDACTED]. However, there were multiple times when the medications were given outside of the physician ordered pain parameters. According to the physician orders, the [MEDICATION NAME] was discontinued on November 28, 2016. New physician's orders [REDACTED]. As the [MEDICATION NAME] order was still active, the [MEDICATION NAME] and the [MEDICATION NAME] orders had overlapping pain parameters for administration. Review of the MAR from December 1 through 13, 2016 revealed the resident received [MEDICATION NAME] on several occasions for a pain level between 3-6. The resident also received one tablet of [MEDICATION NAME] on several occasions for pain pain levels between 3-6. On December 13, 2016, the [MEDICATION NAME] orders were changed. The physician's orders [REDACTED]. The order did not include any pain parameters, in order to determine when to administer the [MEDICATION NAME] versus the [MEDICATION NAME]. Review of the MAR for December 14 through December 22, 2016 revealed the resident received [MEDICATION NAME] on several occasions, two of which the medication was given for a pain level under 6. Review of the nursing notes from November 11 through December 22, 2016 revealed no documentation as to why the resident was receiving pain medications outside of the physician ordered parameters. There was no evidence that the physician had been contacted regarding the pain medication orders. In an interview with a Registered Nurse (RN/staff #112) at 1:45 p.m. on December 22, 2016, she stated that when she provides pain medications, she expects that each pain medication would have it's own parameters for use, for example, one would indicate for minor pain of 1-5 and another would be for more serious pain of 6-10. She stated that as needed pain medications should always have parameters and should be followed. She stated if there was an order without pain parameters, she would contact the physician to clarify the order. She stated that she provides the medications per the ordered parameters and would not give medications outside of the ordered pain parameters. An interview was conducted with the interim Director of Nursing (DON/staff #59) at 11:10 a.m. on December 28, 2016. She stated that it is her expectation that pain medications are ordered with parameters for their use. She provided the example of Tylenol for a pain level of 1-5 and [MEDICATION NAME] for a pain level of 6-10. She stated if an order does not have parameters, she would expect that the order would be clarified with the physician. She stated there are occasions when a pain medication is given outside of the ordered parameters, but she would expect this would be documented and the physician would be contacted regarding the change. After reviewing the MAR, she stated that she was not sure why the medications were administered outside of the parameters, as she could not locate any notes from nursing staff. -Resident #137 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the admission physician's orders [REDACTED]. Another physician's orders [REDACTED]. The orders further included for [MEDICATION NAME] 5mg one tablet every 6 hours PRN for pain. However, the order did not include any pain parameters for when to administer [MEDICATION NAME]. According to the December 2016 MAR, the resident received [MEDICATION NAME] twice for a pain level of 5 on December 4. However, per the orders, the resident should have been administered [MEDICATION NAME]. Further review of the MAR from December 5-8, revealed there were times when the resident was administered [MEDICATION NAME] for pain levels of 6 and 7, and was administered [MEDICATION NAME] for pain levels of 5-8. A physician's orders [REDACTED]. Another physician's orders [REDACTED]. Again, the order did not include any pain parameters for when to administer. During an interview on December 28, 2016 with a Licensed Practical Nurse (LPN/staff #94), she stated that if a resident had Tylenol ordered for a pain level of 1-5, and [MEDICATION NAME] or another narcotic pain medication ordered for a pain level of 6-10, she would give the medications as ordered. She stated that she would not give [MEDICATION NAME] or other narcotics outside of the parameters under any circumstances. She also stated that if a resident only had an order for [REDACTED]. Review of the facility's pain protocol policy and procedure revealed to administer pain medication as ordered.

Based on observations, staff interviews and policy and procedures, the facility failed to ensure that garbage was disposed of properly. Findings include: An observation of the outside garbage receptacle area was conducted at 8:40 a.m. on December 20, 2016. There were two top-loading dumpsters and each dumpster had two lids. Observations revealed that all four lids were open. One of the dumpsters was overflowing with bags of trash. Also, there were paper towels and paper trash on the ground near the dumpsters. On the wall near the area, there was a sign that stated to keep the dumpster lids shut. In an interview with the dietary manager (staff #128) at 8:45 a.m. on December 20, 2016, he stated that the facility used to have a larger dumpster outside, but that a staff member had hurt her shoulder trying to get the trash up into the dumpster, so they switched to two smaller dumpsters. He said the trash company picks up the trash daily, but this might not be enough because the trash is overflowing and the facility's census has been increasing, which has created more trash. He stated that he checks the dumpsters daily to ensure that there is no trash around the dumpsters and that the lids are closed, but this is challenging because multiple staff members use the dumpsters and may not clean up the trash which is dropped or close the lids. A second observation was conducted at 10:15 a.m. on December 22, 2016. Both dumpsters were overfilled with trash bags. One of the dumpsters was overfilled with trash, which prevented the lids from closing all the way. The second dumpster's lids were completely off and were on the ground next to the dumpster. An interview was conducted with staff #128 at 10:20 a.m. on December 22, 2016. He stated that he had just checked the dumpsters and the lids were closed and he did not know why the lids were completely off one of the dumpsters. He stated the trash has been an issue for the last two weeks or so, because the census in the facility had risen. He stated that the facility had emailed the trash company today to get the lids fixed and for larger dumpsters. Review of the facility's garbage disposal policy and procedure revealed that the policy is to dispose of garbage and refuse properly. The policy included that there shall be a sufficient number of containers for the amount of waste, and that the containers shall be of adequate size. The policy further noted that the outside dumpsters must be kept closed and free of litter around the dumpster area, and the area around the dumpsters will be swept daily.

Based on clinical record review, staff interview, facility documentation and review of facility policy and procedure, the facility failed to ensure that one resident (#17) received care and services to prevent a pressure ulcer to the right elbow, which required surgical intervention. Findings include: Resident #17 was admitted on [DATE], with [DIAGNOSES REDACTED]. A Nursing Evaluation dated April 18, 2013, revealed the resident was assessed as follows: alert and oriented to person with a confused mental status, requires verbal and physical prompts and assistance; incontinent of both bowel and bladder; and required two or more person assist for ambulation to the bathroom. Also contained in this document was a Norton Skin Risk assessment, which identified the resident was at risk for developing a pressure ulcer. Further review of the nursing assessment revealed there was no documentation the resident had any pressure ulcers to the right elbow upon admission. admission orders [REDACTED]. This order did not address how long the sling should remain on or off. The orders also did not address how often to check the resident's skin to the right arm for skin breakdown, due to the use of the sling. The orders only included for weekly skin checks to be done. A nurse's note dated April 18, described that the resident had a right humerus fracture, with a sling on at all times. An initial care plan for pressure ulcer/skin risk dated April 19, included a goal to prevent/heal pressure sores. However, there were no definitive interventions listed except for "Other pressure Ulcer/Skin at Risk Interventions" and "Position Preventative Tissue tolerance test." An occupational therapy (OT) care plan dated April 19, assessed the resident to have muscle insufficiency, balance deficits, and exhibited confusion with orientation to self, and ability to follow simple commands, with varying degrees of compliance at different times of the day. Review of the treatment administration record (TAR) from admission through April 30, 2013, revealed that the sling to the resident's arm was initialed for all three shifts. A physician's order dated May 7, included to continue the use of the sling "24/7" for one month, due to worsening displacement, along with a note that documented no external rotation. A Skilled Nursing Clinical Review dated May 9, 2013, documented that the resident was on a Turn/Reposition Plan. However, review of the clinical record revealed a lack of ongoing documentation that the resident was being consistently turned or repositioned. In addition, there was no clinical record documentation of any skin concerns to the resident's right elbow. A Wound Review report dated May 9, now documented the resident had a wound to the right elbow which measured 2 x 2 x .1 cm. The wound bed was described as having slough, with serosanguinous drainage, and surrounding skin was reddened. The note indicated the wound was a stage 2, despite documentation that the wound bed had slough. The note also documented the physician was notified on May 9. However, a physician's order for wound care was not obtained until three days later on May 12, 2013. The order included to cleanse the right elbow with wound cleanser, pat dry, apply [MEDICATION NAME], cover with an Allevyn dressing and change every three days. Review of the May 2013 TAR revealed the above treatment order, however, there was no indication the treatments were done. In addition, an entry on the TAR referred to this order being discontinued on May 15, 2013. However, there was no physician's order in May to discontinue this treatment. A physician's progress note dated May 12, 2013, revealed the resident was status [REDACTED]. There was no reference regarding a right elbow wound. A physician's clarification order dated May 13, included that the right arm sling was to be worn at all times and may be removed for bathing. The order also included for non-weight bearing to the RUE. Review of the Skilled Nursing Clinical Review for May 14 and 15, revealed under the skin section that the resident's skin was within normal limits and was dry and intact. A physician's progress note dated May 16, 2013, included the resident had a sling to the right upper extremity, however, there was no documentation regarding any wound to the right elbow. Further review of the May 2013 TAR revealed a change in wound treatment that was initiated on May 16, which included to cleanse the wound to the right elbow with sterile water, pat dry, apply [MEDICATION NAME] ointment, apply [MEDICATION NAME] AG, and cover with a dry dressing daily until healed. However, review of the clinical record did not reflect a physician's order for this treatment. A care plan for at risk for impaired skin integrity effective May 16, included a goal that the resident's skin will remain intact. Interventions included to turn and reposition frequently, provide wound care/dressing changes as ordered, initiate pressure relieving measures as needed, and monitor and document skin integrity with each bath. The care plan did not reflect the presence of a wound to the right elbow, nor any additional interventions. The next wound assessment was not completed until May 19, ten days after the last assessment. Per the Wound Review, the right elbow wound measured 2.0 x 2.0 x 0.1 cm. The wound bed was described as having slough with serosanguinous drainage and surrounding skin was reddened. Despite this, the stage of the wound was still documented as a stage 2. This entry also noted that the onset date was May 9. A nurse's note dated May 26, 2013, (but entered on May 30) revealed that the resident refused a wound review. According to the subsequent nurse's notes, there was no documentation of any further attempts made to reassess the wound. The next documented wound assessment was completed eight days later on May 27. According to the Visual Skin Evaluation, the appearance of the wound was described as greenish-yellow pink, with a small amount of purulent-yellow drainage, with no odor present. No measurements were documented. There was no clinical record documentation that the physician was notified that the wound had deteriorated. Further review of the May 2013 TAR revealed that the orders to continue to use the sling 24 hours a day, seven days a week, and that it may be removed during bathing, were initialed as being completed. Physician orders dated May 30, 2013, included for a wound assessment to be done every Sunday to the right elbow, despite documentation that the last assessment identified the wound had purulent-yellow drainage. A Wound Review dated June 2, 2013, documented the right elbow wound measured 2.2 x 2.2 x .2 cm, with pink granulation, and surrounding skin was blanchable and pink. There was no yellow slough at this time. However, the note also included there was a moderate amount of purulent-yellow drainage and "exposed tendon". Despite this, the wound was still assessed as a stage 2. The note further documented to refer to the orthopedic surgeon for additional orders. The date of onset noted on this document was May 18, 2013, which contradicted the onset date of May 9, as previously documented. Also, included on this wound assessment was an area to document if the care plan had been updated and it was marked "no". A physician progress notes [REDACTED]. There was no mention of a wound to the resident's right elbow. Physician's orders from the physical therapy outpatient clinic dated June 3, 2013, documented to avoid pressure to the right elbow. This was the first reference addressing the need to relieve pressure to the elbow. The orders also included may cleanse wound with soap and water, change the dressing of Polymen silver every 48-72 hours and cover with a dry dressing. Physician orders for plastic surgery dated June 4, included to cleanse the right elbow wound with normal saline, cover with [MEDICATION NAME] AG and change daily for one week, then every other day. This order was transferred to a telephone order on June 5, 2013. Review of a PT Progress note dated June 5, 2013, noted the resident was "...adamantly refusing to participate in PT today. Pt is upset about wound on right elbow and is very agitated." Review of an OT progress note dated June 7, revealed that OT was informed of a stage four decubitus ulcer to the right elbow region and that the resident's arm rest was turned around to avoid undue pressure to the area. This was the first documented intervention to relieve pressure to the resident's right elbow. The next wound assessment was completed on June 9, 2013.The wound to the right elbow measured 1 x 1.5 cm, with no depth documented. The wound bed was described as healing with slough, intact wound edges, and the surrounding skin was pink. Review of the Wound Review dated June 16, 2013, now documented the right elbow wound was a stage four, measuring 2 x 1.5 x 0.3 cm. The wound bed was assessed to have granulation noted on one side, but still had yellow slough and yellow drainage, with no foul odor. The note documented to continue with [MEDICATION NAME] AG. Further review of the resident's care plans revealed they were not updated to reflect the resident had a Stage 4 pressure ulcer to the right elbow, nor any additional interventions that were implemented. A physician's order June 18, included that the resident was having surgery to the elbow on June 19, 2013. A nurse's note dated June 18, 2013, documented the resident was having surgery on June 19, on the "left elbow," however, per staff, this was an error and the surgery was for the right elbow. A wound observation was unable to be conducted during the survey, as the resident was out for a surgery appointment for the right elbow. An interview with a certified nursing assistant (CNA) on June 19, 2013 at 1:08 p.m., revealed that during showers, skin observations were done and if skin issues were found it was reported verbally to the nurse and documented on a skin sheet for the nurse. With regards to the resident's right elbow pressure ulcer, the CNA stated that he was not aware that the resident had a pressure sore, as it was not communicated to him. Per the CNA, the resident does not like to take showers, but prefers to give himself a daily sponge bath, which he performs in his room. During an interview with an RN on June 19, 2013, the RN stated that wound treatments and wound measurements were performed by the medication nurse on the floor. The schedule for wound measurements completed by licensed staff was reported to be on Sundays, with a wound nurse coming during the week. Per the RN, open areas are referred to the wound nurse and communicated to her through the phone or computer system. The RN further explained that skin assessments were done for new admissions, then weekly thereafter, and skin issues were also reported by CNA staff. As part of some interventions initiated for residents with pressure ulcers, the RN stated that a turn schedule would be implemented. She also stated that CNAs were informed of a resident with an open area through verbal report and would be added to the computer charting used by the CNAs. On June 19, 2013 at 2:00 p.m., an interview with OT staff revealed that the resident was admitted with non-weight bearing status to the right upper extremity, due to a fracture of his right shoulder. She added that the resident wore a sling at all times, except during bathing and therapy. The therapist described the resident as requiring positional needs as he was a "leaner" which she explained that he leaned on things, specifically to his right, such as his arm rest on his wheelchair. Due to poor memory, the OT stated that the resident needed frequent verbal cues to remind him to keep his arm off of the wheelchair arm rests. She further stated that department head meetings to discuss residents who had skin issues, was held weekly. She acknowledged she only worked with the resident a few times and could not recall observing a wound to the resident's right arm during therapy or if an open area to the resident's right elbow was reported to her by OT staff or other interdisciplinary members in the meetings. In an interview conducted on June 19, 2013 at 2:30 p.m., the charge nurse explained that licensed nurses were responsible to remove and don slings and braces on residents. However, she could not explain the frequency of how often resident's extremities were checked for circulation or pressure when these devices were used. On June 19, 2013 at 2:50 p.m., a CNA stated that she worked with the resident for approximately one month, from the time of admission to the end of May. She said she would remove the sling with the OT during showers and for a short time when changing the resident's shirt and then would reapply the sling on her own. She stated that the sling would be removed for about 10 minutes twice a week for showers and two minutes every other day when changing the resident's shirt. The CNA did not recall observing an open area to the resident's right elbow, nor was there information in their computer charting regarding an open area to the resident's elbow. During an interview with the wound care nurse on June 20, 2013 at 8:08 a.m., the wound nurse stated that she performed a review of wound notes once a week on Mondays, and that these notes were also printed by the director of nursing (DON). Per the wound nurse, when she received the wound notes she reviewed them to see if measurements were done correctly, whether measurements had increased in size, and what was happening with the wound, as well as general monitoring of wound care and physician orders. The wound nurse continued by stating that she attended morning meetings during the week and would be alerted during these meetings of new skin issues. During these meetings it was reported that physician orders would also be reviewed. The wound nurse was not able to recall if it was communicated to her of a pressure area to the resident's right elbow. She stated that possibly during the time the resident had developed the pressure ulcer she was given more responsibility over the assisted living section of the facility and was beginning to transition the floor nurses to take over wound care. With regards to the resident's surgery on June 19, 2013, the wound care nurse stated that she thought the resident was having a flap to the right elbow. When questioned how nursing staff monitor resident's skin when devices such as slings or braces were ordered, the wound care nurse replied that nurses should check for pressure and circulation at least every shift and should chart this or noncompliance with this in the nursing notes and care plan. Another interview with OT staff was conducted on June 20, 2013 at 11:15 a.m., to clarify if a sitting evaluation was ever performed, aside from verbal reminders to prevent the resident from leaning on his right arm. The therapist stated that she did not recall if one was completed, but believed that attempts were made. She explained that the resident was noncompliant and would not have participated, for example, of having a cushion placed to help with positioning, but continued by stating that if an evaluation or attempts were performed it would have been documented in the progress notes. Review of OT progress notes did not reveal that an evaluation was completed to assess if the resident was a candidate for positioning devices or aids. An interview was conducted on June 20, 2013, with the MDS Coordinator (who was the former DON during this time). He stated that the pressure ulcer to the resident's right elbow was found while the resident was on a follow-up clinic appointment for his right arm and that an investigation was conducted that lead him to determine that the source of pressure to the right elbow was caused either from the sling, wheelchair, or both, as well as the resident leaning on his right side. He added that the sling was kept on due to a right shoulder fracture and staff's fear was that movement to this area would lead to dislocation if the sling were removed. He further stated that the resident's pressure ulcer was discussed during the daily morning meetings attended by the interdisciplinary team. He acknowledged that verbal cues was not enough to prevent the resident from leaning to his right side and that it would have been helpful to have had therapy evaluate the resident's sitting position or implement a cushioned arm rest. He could not explain why the resident's care plan was not updated to include the resident's pressure ulcer. Review of the facility's wound protocol described a stage four pressure ulcer as a full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (i.e. tendon, joint capsule). It further included that Stage four pressure ulcers were assessed for location, size, drainage amount, and presence of tunneling/undermining and that the wound was to be assessed daily for signs or symptoms of infection. The protocol referred to general wound care of a stage four pressure ulcer. However, it did not include information, such as identification of at risk residents, preventative guidelines, care planning and revision, interdisciplinary involvement, implementation and timely interventions and evaluations.

Based on review of clinical records, observation, staff interviews and review of records facility policies and procedures, the facility failed to ensure that one resident (#25) was free from significant medication errors. Findings include: Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Clinical record review revealed that the resident was admitted from the hospital with prescription orders [MEDICATION NAME] milligrams (mg) 1 tablet orally twice a day with ten tablets total, (five days) [MEDICATION NAME] 500 mg orally three times a day with 15 tablets total (five days) and Fluconazole 200 mg orally every day with seven tablets total (seven days). Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].[MEDICATION NAME] given 14 days longer than prescribed, with the resident receiving 28 extra doses. [MEDICATION NAME], an antiprotozoal and antibacterial agent, had been administered to the resident from May 30 through June 18, 2013. [MEDICATION NAME] was given 14 days longer than prescribed, with the resident receiving 42 extra doses. Fluconazole, an antifungal antibiotic, had been administered from May 31 through June 18, 2013. Fluconazole was given 12 days longer than prescribed, with the resident receiving 12 extra doses. On June 19, 2013 at 11:32 a.m., an observation was made of the medication packages for the three medications with notation from the pharmacy that an end date was needed for the three medications. On June 19, 2013 at 11:32 a.m., an interview was conducted with a registered nurse at the Ocotillo station. The nurse stated that the prescription slips from the hospital indicated how long the resident should have been receiving the three medications. The nurse stated that staff should have received an end date for the medications in report. The nurse stated that it looked like the prescription slips had not been faxed to the pharmacy as per normal facility routine. On June 19, 2013 in the afternoon the interim director of nursing stated that the Cipro, [MEDICATION NAME] and Fluconazole the resident was receiving should have been stopped on June 6, 2013. He also stated administering the medications after June 6, 2013 was a medication error and that the facility would do an incident report and call the resident's family to notify them of the medication errors. On June 19, 2013 at 3:15 p.m., a pharmacist from the facility's pharmacy stated that the resident should have a liver enzyme test done as he had been receiving Fluconazole for too long. Review of the facility's policies and procedures entitled 'Administering Medications' revealed the policy which stated "medications must be administered in accordance with the orders, including any required time frame."

Based on clinical record review, staff interviews, and facility policy review, the facility failed to ensure that one resident (#35) was informed of risks and benefits of [MEDICATION NAME]. Findings include: Resident #35 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's order was written on April 26, 2013, for the use of [MEDICATION NAME] 150 milligrams (mg) by mouth two times every day for [MEDICAL CONDITION] disorder, as well as three other medications for depression. Review of clinical records for resident #35 revealed no documented evidence that the resident was infored of the risk verses benefits for the [MEDICATION NAME]. An interview was conducted with the director of nursing (DON) on June 19, 2013. The DON stated that he did not know that a consent was required for the [MEDICATION NAME]. Review of the facility policy on consents revealed that a policy was requested, but was unable to be provided by the facility.

Based on observations, clinical record review, and staff interviews, the facility failed to ensure that one resident (#18) had an accessible call light. Findings include: Resident #18 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) revealed that the annual assessment was completed on February 14, 2013. Section G. of the MDS assessment noted that the resident required extensive assistance for bed mobility and transfers, totally dependent on staff for bathing, and has a functional limitation in range of motion; impairment on both sides of upper body. During an initial observation on June 18, 2013, the resident was unable to locate her call light that was in her bed. An interview was conducted with the director of nursing (DON) on June 19, 2013. The DON stated that this resident has a special ball type call light that she is able to use with her limited ability. An observation was made with the DON on June 19, 2013, that revealed the call light was in the bedding and the resident was unable to reach the call light. The DON stated that the call light is to be placed in the resident's hand so that she can call for assistance. Review of the facility's policy on accommodation of needs revealed that the facility was unable to provide the requested policy.

Based on clinical record review, staff interview, and review of the resident assessment instrument (RAI) manual for the minimum data set (MDS) version 3.0, the facility failed to ensure that one resident (#17) had an MDS assessment that accurately reflected the resident's condition. Findings include: Resident #17 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of two Wound Review records dated May 9, 2013, revealed the resident to have stage 2 wounds to the right buttock and medial sacrum. Dated May 16, 2013, was an MDS, Prospective Payment System (PPS) 30 day scheduled, assessment which revealed that the resident was assessed to have unhealed pressure ulcers. An interview with the former director of nursing (DON), who was also responsible for MDS assessments, was conducted on June 20, 2013 at 11:38 a.m. The acting DON acknowledged that the stage 2 pressure ulcers were not included in the above MDS and could not explain why it had been missed, only that it should have been included in the assessment. A policy and procedure was requested regarding the accuracy of MDS assessments from the current DON. However, the DON stated on June 20, 2013 at 8:48 a.m., that they referenced the RAI manual for MDS assessment guidelines. Review of the RAI manual for MDS 3.0, last updated on May 29, 2013, revealed that the "RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status..."

Based on clinical record review, staff interview, and review of the resident assessment instrument (RAI) manual for the minimum data set (MDS) version 3.0, the facility failed to ensure that one resident (#17) had an updated care plan to reflect new pressure ulcers. Findings include: Resident #17 was admitted on [DATE], with [DIAGNOSES REDACTED]. An admission MDS assessment dated [DATE], revealed that the resident was not identified to have unhealed pressure ulcers. Section V of this MDS assessment revealed that the resident triggered pressure ulcer as one of the care area assessments with a decision to proceed to care plan. A review of Wound Review records dated May 9, 2013 revealed that the resident developed stage 2 pressure ulcers to the right buttock and medial sacrum. Dated May 18, 2013, was a Wound Review record which noted the resident to have a stage 2 to the right elbow. The wound to this site was later documented to have worsened to a stage 4 pressure ulcer as documented in a Wound Review dated June 2, 2013. A care plan for risk for impaired skin integrity dated as effective from May 16, 2013 to present and with a dated goal of August 9, 2013, did not reflect the stage 2 wounds identified on May 9, 2013, nor did it reflect the changes in wound stage to the right elbow. During an interview with the former director of nursing (DON)/MDS Coordinator on June 20, 2013 at 11:38 a.m., after review of the above care plan, acknowledged that the care plan was not updated to reflect the pressure ulcers, but could not explain why it was missed. Policy and procedures were requested regarding revision of care plans from the current DON. However, the DON stated on June 20, 2013 at 8:48 a.m., that they referenced the RAI manual for care plan updates. Review of the RAI manual for MDS 3.0, last updated on May 29, 2013, revealed that "Nursing homes should also evaluate the appropriateness of the care plan after each Quarterly assessment and modify the care plan on an ongoing basis, if appropriate."