Every finding on record at Accura Healthcare of Newton East, LLC

Based on facility record review and staff interviews, the facility failed to ensure daily Registered Nurse (RN) coverage for 2 separate days within a 30-day schedule review. The facility reported a census of 52.Findings include: Review of nursing schedules from 1/16/26 to 2/14/26 revealed no RN scheduled for 2/8/26 & 2/14/26. On both days, two Licensed Practical Nurses (LPNs) provided the needed licensed nurse coverage. One LPN for the 12-hour day shift and another LPN for the 12-hours night shift. During an interview on 2/18/26 at 1:00 PM, the Administrator acknowledged and confirmed the lack of RN coverage for 2/8/26 and 2/14/26. This was an oversight as a result of recent staffing changes that reduced the number of floor RNs availability. The facility does not have a staffing policy which outlines the need for RN coverage at least 8 consecutive hours 7 days a week.

Based on observation, staff interview, facility document review, and facility policy reivew, the facility failed to ensure temperatures were checked regularly for food to be served, refrigerator and freezer food storage, and dishwasher sanitation when temperature logs lacked documentation during 2 of 2 kitchen observations. The facility additionally failed to regularly test chemical solution to ensure sanitation of surfaces during 2 of 2 kitchen observations. The facility further failed to prevent cross contamination when raw beef thawed on a tray placed on top of a container with ready to eat ham and cheese sandwiches during 1 of 2 kitchen observations. The facility reported a census of 52 resident. Findings include: 1. During an initial kitchen observation on 2/15/26 at 10:30 AM and during a follow up observation on 2/16/26 at 11:50 AM, 4 of 4 refrigerators and 2 of 2 freezers stored various foods and beverages for resident meals. All refrigerators and freezers observed had a temperature log taped to the front or top, all logs had multiple entries left blank. A. Review of the facility provided documents titled, Refrigerator Temperature Log, dated February 2026, indicated that refrigerator temperatures were to be checked twice per day (AM and PM) and instructed staff to notify supervisor and maintenance if the refrigerator temperature was above 41 degrees Fahrenheit. Logs were reviewed between the dates of 2/01/26 and 2/16/26 for the following refrigerators: a1. Refrigerator Temperature Log, Location identified as: DA Cooler, dated February 2026, lacked documentation of temperature check on 4 out of 16 morning shifts and 4 out of 16 evening shifts. a2. Refrigerator Temperature Log, Location identified as: Cook, dated February 2026, lacked documentation of temperature check on 3 out of 16 morning shifts and 2 out of 16 evening shifts. a3. Refrigerator Temperature Log, Location: (blank-contained only milk), dated February 2026, lacked documentation of temperature check on 2 out of 16 morning shifts and 6 out of 16 evening shifts. a4. Refrigerator Temperature Log, Location: (blank- contained eggs and various foods), dated February 2026, lacked documentation of temperature check on 2 of 16 evening shifts. B. Review of the facility provided documents, titled Freezer Temperature Log, dated February 2026, indicated that freezer temperatures were to be checked twice per day (AM and PM) and instructed staff to notify supervisor and maintenance if the freezer temperature was above 0 degrees Fahrenheit. Logs were reviewed between the dates of 2/01/26 and 2/16/26 for the following freezers: b1. Freezer Temperature Log, Location identified as: Meat/ice cream, dated February 2026, lacked documentation of temperature check on 11 out of 16 morning shifts and 2 out of 16 evening shifts. b2. Freezer Temperature Log, Location: (blank), dated February 2026, lacked documentation of temperature check on 2 of 16 evening shifts. 2. During an initial kitchen observation on 2/15/26 at 10:30 AM and during a follow up observation on 2/16/26 at 11:50 AM, one dishwasher was used to sanitize dishes. A dishwasher temperature log, posted on the wall, near the dish machine, lacked all but 1 entry between the dates of 2/01/26 and 2/16/26. C. Review of the facility provided document, titled Dishwasher Temperature Log, dated February 2026, indicated that a water temperature and chlorine sanitizer level were to be checked twice per day (AM and PM) to ensure proper sanitation levels were maintained. All entries between 2/01/26 and 2/16/26 were blank, except one entry recorded on 2/16/26 morning shift3. During an initial kitchen observation on 2/15/26 at 10:30 AM and during a follow up observation on 2/16/26 at 11:50 AM, 1 of 1 red bucket, chemical solution and water mix stations, used for sanitation of surfaces, was observed. A red bucket log, posted on the wall, next to station reviewed between the dates of 2/01/26 and 2/16/26, had multiple entries left blankD. Review of the facility provided document, titled Red Bucket Sanitizer Log, indicated that a chemical solution level was to be checked six times per day (6:00 AM, 9:00 AM, 12:00 PM, 2:00 PM, 5:00 PM, 7:00 PM), listed sanitizer concentration levels to be between 150 and 400 parts per million (ppm), and instructed staff to report any variations to the supervisor. Log reviewed between 2/01/26 and 2/16/26, lacked documentation of 6 times per day solution check for 11 of 16 days. 4. During an initial kitchen observation on 2/15/26 at 10:30 AM and during a follow up observation on 2/16/26 at 11:50 AM, a binder contained temperature logs for food to be served from the steamtable to ensure food served was fully cooked at each meal. Food temperature logs were reviewed between the dates of 2/01/26 and 2/16/26 had many meal entries left blank. E. Review of the facility provided document, titled Steamtable Temperature Log, dated February 2026, indicated that a temperature was to be checked for each food item served, three times a day (breakfast, lunch, dinner). Log reviewed between 2/01/26 and 2/16/26, lacked documentation of food temperatures for 6 of 16 breakfast meals served, 8 of 16 lunch meals served, and for 4 of 16 dinner meals served.5. During an initial kitchen observation on 2/15/26 at 10:30 AM, a refrigerator stored a plastic container of ready to eat ham and cheese sandwiches, dated 2/14/26, on the bottom shelf and set on top of the sandwich container was a tray with package of thawing raw beef. During an interview on 2/15/26 at 10:30 AM, the Dietary Manager confirmed that temperature logs had not been completed during the initial kitchen observation. During an interview on 2/17/26 at 1:50 PM, the Dietary Manager reported being in role for approximately 2 months and stated education was provided to all dietary staff as of 2/17/26 on checking and completing all temperature logs per policy. The Dietary Manager reported that ham and cheese sandwiches were discarded due to raw product kept above ready to eat products and stated that education would also be provided to all dietary staff to remind about cross contamination when storing food. Review of the facility provided document, titled Education Form, revealed the following statement for staff to sign and date as acknowledged:As an employee in the dietary department, it is my responsibility to ensure temperature logs are checked and filled out per policy. And notify the Executive Director (ED) for any changes. The facility denied having policies or procedures for food storage, food temperatures, or sanitation upon request.

Based on clinical record review, observation, staff interviews, and policy review, the facility failed to implement Enhanced Barrier Precautions (EBP) for 3 of 3 residents reviewed for EBP (Residents #7, #40 and #47), failed to properly handle, transport and process linens properly for 2 residents in Transmission Based Precautions (Residents #4 and #56), and failed to change out a resident's urinal in a timely manner (Resident #10). The facility reported a census of 52.Findings include:1. The Electronic Health Record (EHR) indicated that Resident #40 had an abscess on her left knee 11/16/25 that was drained on 11/18/25 and required a dressing change including packing. The dressing order changed on 2/16/26 but still included packing. The Care Plan initiated on 3/29/24 indicated that Resident #40 was placed in EBP on 11/27/24 for wounds. During an observation on 2/16/26 at 11:31 AM Staff A, RN performed wound care to Resident #40's left knee. She did not wear a gown during the dressing change. There was an EBP sign on Resident #40's door. 2. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 had diagnoses neurogenic bladder. It also indicated that she had an indwelling catheter. The Care Plan initiated on 2/5/20 indicated that Resident #47 had an indwelling catheter. It also indicated that she was placed in EBP on 4/1/24. During an observation on 02/16/2026 at 7:36 AM Staff J, CNA took R#47 to the shower room on a shower chair. He then went to her room and was making her bed and putting an adult brief in her bed for when she returned from the shower. He was not wearing a gown or gloves. There is an EBP sign on the outside of her room. 3. The Electronic Health Record (EHR) indicated that Resident #4 returned from the hospital on an antibiotic due to a urinary tract infection (UTI). The Care Plan initiated 6/13/24 lacked documentation that Resident #4 was in Transmission Based Precautions. During an observation on 02/16/2026 at 7:53 AM Resident #4's room had a contact precautions sign on the door and a Personal Protective Equipment (PPE) container outside the door. 4. The Electronic Health Record (EHR) indicated that Resident #56 was diagnosed with bacteremia and getting antibiotic transfusions at the transfusion center. The Care Plan initiated 10/18/24 indicated that Resident #56 was in EBP and lacked documentation that he was in Transmission Based Precautions. During an observation on 02/16/2026 at 7:53 AM Resident 56's room had a contact precautions sign on the door and a Personal Protective Equipment (PPE) container outside the door. During an observation on 2/17/26 at 11:54 AM no setting was noted on the washers for isolation linen. During an observation on 02/17/2026 at 11:43 AM Staff D, Environmental Services Director put out a special container with yellow isolation bags for isolation linen by both TBP rooms. In an interview on 02/17/2026 at 10:54 AM Staff D, Environmental Services Director stated that she does not get isolation linen in a different colored bag and was not aware it needed to be washed separate or last. Stated she would confirm with her boss. In an interview on 02/17/2026 at 11:45 AM Staff E, CNA and Staff F, CNA both stated that they do not put isolation linen in its own colored bag. In an interview on 2/18/25 at 10:49 AM the ADON stated that staff are notified resident in EBP with signs, education and with new cases. She also stated that EBP would be required with wounds, catheters and feeding tubes. The DON stated that Personal Protective Equipment (PPE) required for EBP would be a gown, gloves and eye protection if something would splash. The surveyor reviewed the lack of PPE for catheter care, gastrostomy tube (tube inserted into stomach for nutrition) care, and wound care. Both the ADON and DON stated PPE should have worn in the 3 cases presented. In an interview on 2/18/26 at 1:55 PM the DON stated that residents who are in isolation should have their linens sent to laundry separately and should be in yellow biohazard bags. They will be doing that from now on. 5.The MDS completed on 11/25/25 revealed Resident #10 requires partial assistance for toileting hygiene. During an observation on 2/15/26 at 12:30 PM, a urinal was sat on Resident #10's bedside table. It was heavily soiled with a yellow residue as well as black grime around the opening. The date on the urinal was 1/16. Resident #10 confirmed they still use the urinal and confirmed the date on it. The only sink in the room was full of empty pop bottles and unusable. During an observation on 2/17/26 at 10:10 AM, the same urinal was noted on Resident #10's bedside table. The sink remained full of empty pop bottles. During an interview on 2/17/26, Staff L, CNA, explained Resident #10 prefers to use a urinal. Staff L believed the night shift staff change out urinals monthly. In an interview on 2/17/26 at 2:45 PM, the Assistant Director of Nursing (ADON) stated urinals should be changed out weekly or when needed due to infection control issues. When discussed the condition of the urinal, the ADON suspects staff may have attempted to change but the resident declined. However, the condition of the urinal in use is unacceptable. The Administrator confirmed, via an email on 2/18/26, there is not a policy related to changing out urinals. 6. Review of the MDS assessment, dated 12/18/25, revealed Resident #7 had problem with both short term and long term memory and had moderately impaired cognitive skills for daily decision making. The list of diagnoses included Cerebrovascular Accident (stroke), hemiparesis or hemiplegia (one sided weakness or decreased sensation); aphasia (inability to speak), and malnutrition. The MDS identified that Resident #7 required feeding tube while a resident and received 51% or more of total calories per day and 501 milliliters (mL) or more of fluid intake per day. Review of the Care Plan, revised on 11/13/25, revealed a Focus area for artificial nutrition received with Percutaneous Endoscopic Gastrostomy (PEG tube or G-tube) related to stroke and dysphagia (difficulty swallowing). The Care Plan lacked identification of Focus area or intervention related to risk for infection or EBP utilized by staff for resident's indwelling device. During an observation on 2/15/26 at 11:30 AM, Resident #7's room lacked signage posted inside or outside of room to inform staff of EBP required for Resident #7's indwelling device. Observed a pole next to bed with 1/2 full bottle of nutritional solution and 1/2 full bag of water hung with tubing lined into an electronic dispensing pump. During an observation on 2/15/26 at 12:33 PM, Staff J, Certified Nursing Assistant (CNA), transported Resident #7 via wheelchair into Resident #7's room, Staff J did not apply any additional PPE upon entrance into room. At 12:37 PM, Staff J exited Resident #7's room and retrieved linens from the clean linen closet and re-entered Resident #7's room, again without additional PPE applied. At 12:39 PM, Staff J, exited Resident #7's room, without wearing or removing any additional PPE, and held Resident #7's soiled personal clothing in one hand and a closed trash bag in the other hand, walked through hallway to a soiled linen closet. During an observation on 2/17/26 at 9:05 AM, signage for EBP posted outside of Resident #7's room with PPE supplies available in a cart set near room. During an observation on 2/17/26 at 2:11 PM, Staff A, Registered Nurse (RN) performed flush of Resident #7's feeding tube, no EBP additional PPE worn during procedure. Review of the facility policy, titled Enhanced Barrier Precautions, updated 11/13/24, revealed the policy Statement as follows: It is the policy of this facility to implement Enhanced Barrier Precautions for the prevention of transmission of multi-drug resistant organisms (MDRO). The policy defined Enhanced Barrier Precautions (EBP) as referring to an infection control intervention designed to reduce transmission of multi-drug resistant organisms that employs targeted gown and gloves use during high contact resident care activities. The Section titled, Policy Explanation and Compliance Guidelines, instructed the following: b. Initiation of EBP: 2. An order for EBP will be obtained for residents with any of the following: i) Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous statis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO. ii) Infection or colonization with a CDC (Centers for Disease Control)- targeted MDRO when contact precautions do not otherwise apply. c. Implementation of EBP: 1. Make gowns and gloves readily accessible to staff. Note: face protection may also be needed if performing activity with risk of splash or spray (i.e., wound irrigation, tracheostomy care). 2. PPE for EBP is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. 3. Ensure alcohol-based hand rub is readily available for staff. 4. Position a trash can inside the resident room and/or near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room. 5. The Infection Preventionist will incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education. 6. Provide education to residents and visitors. 7. Do no restrict room placement or out-of-room activities due to EBP. d. High-contact resident care activities include: 1. Dressing 2. Bathing 3. Transferring 4. Providing hygiene 5. Changing linens 6. Changing briefs or assisting with toileting 7. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes 8. Wound care: any skin opening requiring a dressing (excluding shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage or similar dressing. h. EBP should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk.

Based on employee file review, staff interview, and policy review, the facility failed to ensure the completion of dependent adult abuse training for 1 of 5 employees reviewed (Staff K, Certified Nurse's Aide [CNA]). The facility reported a census of 52. Findings include: Employee file review of Staff K, Certified Nurses Aide (CNA) revealed a hire date of 8/6/25. The file lacked documentation that Staff K completed dependent adult abuse training within six months of the hire date. During an interview on 2/18/26 at 1:00 PM, the Facility Administrator acknowledged and confirmed the lack of dependent adult abuse training for Staff K. The policy Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting policy, updated 10/22/22, noted the following: a. Within six months of hire, each employee shall be required to complete an initial 2-hour training course provided by the Iowa Department of Human Services relating to the identification and reporting of dependent adult abuse training; b. All nurses' aide shall receive initial and annual resident adult abuse prevention training.

Based on electronic heath record (EHR) review, observation, resident interview, staff interview, and policy review, the facility failed to consistently complete smoking assessments for 1 of 1 residents reviewed for smoking (Resident #22). The facility reported a census of 52. Findings include: The Annual Minimum Data Set (MDS) Assessment completed on 11/13/25 noted the use of tobacco for Resident #22. The MDS documented that the resident had a readmission date of 8/22/25 from a short-term hospital stay. The MDS documented a Brief Interview for Mental Status score of 15 out 15, which revealed intact cognitive skillsDuring an observation on 2/16/26 at 1:15 PM, Resident #22 was observed vaping in the designated smoking area. Upon review of completed Smoking Assessments, no assessments were completed during all of 2025. The two most recent assessments were dated 10/23/24 and 2/11/26. In an interview on 2/16/26 at 3:15 PM Staff L, Certified Nurse's Aide, reported Resident #22 was vaping since they started working at the facility in September 2025. Staff L reported Resident #22 may smoke a cigarette once in a while when their vape pen is not fully charged. In an interview on 2/16/26 at 3:50 PM, Resident #22 explained they had stopped smoking in January 2025 but then started vaping sometime between July 2025 and September 2025. Resident #22 confirmed the occasional use of cigarettes. In an interview on 2/17/26 at 2:45 PM, the Assistant Director of Nursing (ADON) noted smoking assessments are completed quarterly by nursing staff or the MDS Coordinator. The ADON confirmed Resident #22 had stopped smoking for a time and then started vaping. The ADON was not sure when this occurred. Upon review of the EHR, the ADON acknowledged and confirmed the lack of smoking assessments for late 2025. These assessments should have resumed once it was identified that the resident was vaping. The policy Resident Smoking, updated 4/14/25, noted the following: a. Residents will be asked about tobacco use during the admission process and during each quarterly or comprehensive MDS assessment process b. Residents who smoke will be furthered assess, using the Resident Safe Smoking Assessment, to determine whether or not supervision is required for smoking or is resident is safe to smoke at all c. Safe smoking assessment will be completed on residents using e-cigarettes

Based on electronic health record (EHR) review, observations, resident interview, staff interviews, and policy review, the facility failed to update the Care Plans for 2 of 17 Care Plans reviewed (R#22 for vaping, and R#36 for driving). The facility reported a census of 52. Findings include: The Minimum Data Set (MDS) Assessment completed on 11/13/25 noted the use of tobacco for Resident #22.During an observation on 2/16/26 at 1:15 PM, Resident #22 observed vaping in the designated smoking area. The Care Plan, with an end target date of 5/13/26, lacked a Focus Area and Interventions related to active smoking. Upon further review, smoking was addressed on previous Care Plan updates but removed on 7/28/25.In an interview on 2/16/26 at 3:50 PM, Resident #22 explained they had stopped smoking in January 2025 but then started vaping sometime between July 2025 and September 2025. Resident #22 confirmed the occasional use of cigarettes. In an interview on 2/17/26 at 2:45 PM, the Assistant Director of Nursing (ADON) noted floor nursing staff, activities staff, and the dietitian all have access to resident Care Plans. The ADON voiced Care Plans should be updated as needed and not wait until the resident's Comprehensive Assessments or MDS are due. The ADON acknowledged and confirmed Resident #22's Care Plan should have been updated when they started to vape. The policy Comprehensive Care Plans, updated 12/3/25, outlined the following: a. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care; b. The comprehensive Care Plan will describe Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity; c. The comprehensive Care Plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. The Care Plan will be updated in a timely manner to ensure that services are furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 2. The Electronic Health Record (EHR) indicated that Resident #36 (R#36) had diagnoses of malignant neoplasm of the liver, reduced mobility and unspecified abnormalities of gait and mobility. It indicated he was receiving chemotherapy treatments through 2/6/26. The current MDS completed on 2/5/26 indicated R#36 had a Basic Interview for Mental Status (BIMS) score of 10. R#36 had a BIMS of 15 upon admission on [DATE], on five other MDS assessments he also scored a 15, and on 8/14/25 he scored 13. The clinical record lacked documentation to address the drop in the BIMS score from a 15 to a 10, and it lacked documentation of evaluation of his ability to drive a vehicle safely. The Progress Notes indicated that the current Director of Nursing (DON) documented on 11/19/25 that she asked R#36 if he would like to drive himself in the vehicle he keeps at the facility to his medical appointment, or if she should arrange transportation. He requested that she arrange transportation.The Care Plan initiated 9/9/24 lacked documentation that Resident #36 was driving or had a vehicle at the facility. In addition, it did not identify that Resident #36 needed to sign-out or could leave the campus without supervision.During an observation on 2/15/26 at 11:15 AM Resident #36 was noted to go outside of the building. He then entered a vehicle outside, left his walker on the sidewalk and drove away. During an observation on 2/15/26 at approximately 11:30 AM R#36 parked his vehicle next to his walker. He had a sack with him then that he placed on his walker and re-entered the facility.During an observation on 2/17/26 at 1:50 PM the facility resident sign out book lacked documentation that Resident #36 had left the faciity on 2/15/26 despite him leaving on that date.In an interview on 2/16/26 at 9:45 AM R#36 stated he can drive and the only thing is he has to wear his glasses. He added that he does have to sign in and out as well.In an interview on 2/17/26 at 10:11 AM Staff B, Life Enrichment Coordinator stated that R#36 has his car outside. She stated she was told he had insurance and a driver's license but was not sure if anyone checked his ability to drive.In an interview on 02/17/2026 at 10:40 AM with the Corporate Nurse, DON and the Administrator, the Corporate Nurse stated that she has been asking around to staff and R#36 may go out and sit in the car but he does not drive it. The surveyor informed them of the observation of him leaving the facility in his car on 2/15/26. All stated that they were unaware he was driving.In an interview on 2/17/26 at 12:40 PM Staff C, Designated Medical Practitioner (DMP) stated she was unaware that R#36 was driving and she had never heard of such a thing. None of the resident's drive and would definitely not be supportive of it. She added that she would be writing an order for no driving before she left the facility.In an interview on 2/18/26 at 12:07 PM the Administrator stated that R#36 should not have been driving and that a lot of people have driver's licenses that are not safe to drive.A policy for residents driving was requested and the Administrator stated they did not have a policy for residents driving.

Based on clinical record review, observation, and staff interviews, the facility failed to perform wound care as the physician ordered for 1 of 1 resident (Resident #40) reviewed for wound care.Findings include: The Electronic Health Record (EHR) indicated that Resident #40 had an abscess on her left knee 11/16/25 that was drained on 11/18/25 and required a dressing change including packing. The dressing order changed on 2/16/26 but still included packing. The Physician's Orders included lidocaine external gel 2% that was discontinued on 1/16/26. The new dressing change order lacked an order for lidocaine to be placed on the wound prior to the dressing change.The Care Plan initiated on 3/29/24 indicated that Resident #40 was placed in Enhanced Barrier Precautions (EBP) on 11/27/24 for wounds. It lacked documentation on the location of the wound. It directed staff to administer medications as ordered.During an observation on 2/16/26 at 11:31 AM Staff A, RN performed wound care to Resident #40's left knee. After removal of the old dressing and cleaning of the wound, Staff A applied lidocaine (medication to numb the area) gel directly over the wound site and waited one minute to let it take effect.In an interview on 2/18/26 at 9:20 AM Staff A stated that the wound nurse gave dressing change orders for Resident #40 to the ADON. When the surveyor questioned her about the order she looked it up and stated that it did not include an order for lidocaine. She looked up lidocaine and stated that lidocaine had been discontinued 1/16/26. She assumed it was part of the order as they used it when packing previously.In an interview on 2/18/26 at 9:25 AM the ADON stated that she did rounds with the wound nurse and obtained the new wound order from her. The new order did not include lidocaine gel. It was used in the past as the resident was experiencing pain during the dressing change but did not experience pain during the new dressing change. Therefore, it was not included in the new dressing change order. Stated it should not have been used and if the nurse that used it felt she needed it, she should have called the physician and obtained an order.On 2/18/26, a policy on Physician's orders was requested and the Corporate Nurse stated they did not have a policy on it. They should simply follow the Physician's orders.

Based on observation, resident interview, staff interviews, and electronic health record (EHR), and policy review, the facility failed to identify, evaluate and analyze hazard(s) and risk(s) to prevent potential avoidable accidents for 1 of 1 reviewed, (Resident#36). In addition, the facility failed to assess if the Resident was safe to drive a vehicle on his own. The facility reported a census of 52. Findings include:The Electronic Health Record (EHR) indicated that Resident #36 had diagnoses including malignant neoplasm of the liver, reduced mobility and unspecified abnormalities of gait and mobility. It indicated he was receiving chemotherapy treatments through 2/6/26. He currently had a Basic Interview for Mental Status (BIMS) score of 10 from the Quarterly Minimum Data Set (MDS) dated [DATE], which indicated difficulty with cognitive skills. (The BIMS score was down from 15 at the time of his previous MDS assessment.) The EHR lacked documentation of evaluation of his ability to drive a vehicle safely.The Progress Notes indicated that the current Director of Nursing (DON) documented on 11/19/25 that she asked Resident #36 if he would like to drive himself in the vehicle he keeps at the facility to his medical appointment, or if she should arrange transportation. He requested that she arrange transportation.Health Status Note dated 1/24/26 at 7:50AM documented a call placed to oncology for clarification on cancer drug, discontinue pill forms because the resident will be starting infusions due to increased size of tumor. Infusion port to be placed on 1/28/26. Progress Note dated 2/6/26 at 1:347PM documented the resident had chemo pump removed today.The Care Plan initiated 9/9/24 lacked documentation that Resident #36 was driving or had a vehicle at the facility.The Care Plan for the resident documented a goal with revision date of 10/10/25 as follows; the resident will adequately use coping mechanisms through review date. The Care Plan included the following interventions for staff; assess for change in condition/function, assess for contributing factors for behavior, assess for coping mechanisms for when the resident is upset, and perform labs as ordered.A focus area in the Care Plan for Resident #36 initiated on 11/12/25 indicated Resident #36 had potential for impaired cognitive function/dementia or impaired thought processes related to (r/t) Disease Process Cancer.During an observation on 2/15/26 at 11:15 AM Resident #36 was noted to go outside of the building. He then entered a vehicle outside, left his walker on the sidewalk and drove away. During an observation on 2/15/26 at approximately 11:30 AM Resident #36 parked his vehicle next to his walker. He had a sack with him then that he placed on his walker and re-entered the facility.During an observation on 2/17/26 at 1:50 PM the facility resident sign out book lacked documentation that Resident #36 had left the faciity on 2/15/26 despite him leaving on that date.In an interview on 2/16/26 at 9:45 AM Resident #36 stated he can drive and the only thing is he has to wear his glasses. He added that he does have to sign in and out as well.In an interview on 2/17/26 at 10:11 AM Staff B, Life Enrichment Coordinator stated that Resident #36 had his car outside. She stated she was told he had insurance and a driver's license but was not sure if anyone checked his ability to drive.In an interview on 02/17/2026 at 10:40 AM with the Corporate Nurse, DON and the Administrator, the Corporate Nurse stated that she has been asking around to staff and Resident #36 may go out and sit in the car but he does not drive it. The surveyor informed them of the observation of him leaving the facility in his car on 2/15/26. All stated that they were unaware he was driving.In an interview on 2/17/26 at 12:40 PM Staff C, Designated Medical Practitioner (DMP) stated she was unaware that Resident #36 was driving and she had never heard of such a thing. None of her resident's drive and would definitely not be supportive of it. She added that she would be writing an order for no driving before she left the facility.In an interview on 2/18/26 at 12:07 PM the Administrator stated that Resident #36 should not have been driving and that a lot of people have driver's licenses that are not safe to drive.The American Cancer Society lists a possible side effect of taking chemotherapy as having trouble remembering things, focusing, finishing tasks or learning something new. These are symptoms of cognitive impairment, also known as chemo brain or brain fog.A policy for residents driving was requested and the Administrator stated they did not have a policy for that. No documents were provided concerning Resident #36's ability to safely drive or that the vehicle was in safe working order. The only thing provided was a current driver's license for Resident #36.

Based on clinical record review, observation, and staff interview, the facility failed to initiate adequate interventions to prevent significant weight loss for 1 of 1 resident (Resident #12) reviewed for nutrition.Findings include:The Minimum Data Set (MDS) assessment dated [DATE] for Resident #12 identified a Brief Interview for Mental Status (BIMS) score of 5 indicating severe cognitive impairment. It also indicated that the resident ate independently.The Care Plan initiated on 10/21/23 indicated that Resident #12 ate in the dining room independently with set up. It identified that Resident #12 was at risk for altered nutrition due to a history of mild protein-calorie malnutrition, irritable bowel syndrome and rheumatoid arthritis. The directives for staff included the following:Invite the resident to activities that promote additional intake. Provide and serve diet as ordered. Provide and serve supplements and fortified foods as ordered.RD to evaluate and make diet change recommendations as needed. The resident needs cueing, tray set-up and socialization at meals. Assist with filling out the menu.It also identified that Resident #12 had an unplanned or unexpected weight loss related to poor food intake. The directives for staff included the following:Give the resident supplements as ordered. Alert nurse or dietitian if not consuming on a routine basis. If weight decline persists, contact physician and dietician immediately. Labs as ordered. Report results to the physician and ensure the dietician is aware.Monitor and evaluate any weight loss. Determine percentage lost and follow facility protocol for weight loss.Monitor and record food intake at each meal. Offer substitutes as requested or indicated. Weigh at the same time of day and record: as directed.The Electronic Health Record (EHR) indicated that between February 1st-17th, 2026 at lunch that 26 meals lacked documentation for the amount of meal eaten by Resident #12. It also indicated that between January 1st-31st, 2026 that 24 meals lacked documentation for the amount of meal eaten as well.The dietary notes revealed the following: On 12/15/25 at 8:56AM it was documented that Resident #12's weight was 147.8 pounds (lbs). It indicated significant weight loss at 30, 90 and 180 days. Percentages were 5, 15 and 20% respectively. Weights were 155.8 lbs on 11/3/25, 174.9 lbs on 9/2/25 and 186 lbs on 6/4/25. She is often seen getting up and leaving without eating or eating very little. She would benefit from sitting with other tablemates and staff for tray set-up, cueing and socialization. Likes to snack throughout the day- can offer higher nutrition snacks such as 1/2 sandwich and milk, banana and peanut butter, yogurt.On 1/5/26 it is documented that Resident #12's weight was 142.6 lbs. It indicated weight loss at 30 days and significant weight loss at 90 and 180 days. Percentages were 3.5, 13 and 20% respectively. Weights were 147.8 lbs on 12/1/25, 164.8 lbs on 10/5/25 and 178.2 lbs on 7/1/25. She would benefit from sitting at the assisted table with staff cueing. She is able to tell staff what she wants to eat for meals and would need set-up to be independent in dining with cueing.During continuous observation on 2/16/26 at 8:46AM Resident #12 was sitting at her dining room table not eating. Staff had cut up pancakes and opened her syrup but no other assistance or encouragement was provided for 20 minutes. No substitute was offered.During continuous observation on 2/16/26 at 9:14 AM Resident #12 still had not eaten any food. She did drink all her fluids. No staff assistance or encouragement was provided for an additional 13 minutes. No substitute was offered.During an observation on 2/16/26 at 9:27 AM Staff J, CNA showed up and assisted Resident #12 out of the dining room. During an observation on 2/16/26 at 12:15 PM Resident #12 received her tray at her normal table. She moved her bread around and then picked up her spoon and took one bite and no more. She drank all of her liquids. No prompting or cueing noted from the staff. At 12:31 PM she got up and ambulated away from the table with her walker. No substitute was offered.During an observation on 2/17/26 at 8:44 AM Resident #12 was eating toast at the breakfast table alone. No cueing or encouragement noted from the staff. She got up and walked away from the table with her walker.During an observation on 2/18/26 at 8:40 AM Resident #12 was sitting at the assist table next to Staff J and had just a little egg left on her plate. She was talking and interacting with staff. She had a toy cat she was fake attacking Staff J with.In an interview on 2/17/26 at 7:42 AM Staff A, RN stated that Resident #12 needs reminders to eat. She has had significant weight loss recently with rapid mental decline as well. They were considering moving her to the assisted table but had not yet as they moved her room in December and didn't want to move her table too soon and interfere with her routine.In an interview on 2/17/26 at 11:05 AM Staff H, Dietician confirmed her documentation on 12/15/25 and 1/05/26 in the EHR. She was last at the facility at the end of January 2026. She made sure that the facility was aware of her recommendations as they didn't always have meetings. Could not remember the staff she notified but is aware that they might not be there either due to high turn over. She does supply reports to the facility. She feels the Resident #12 needed to be at the assisted table and had recommended it repeatedly for months as she needs cues and often just stands up and walks off. She was told there was no room at the assisted table.In an interview on 2/17/26 at 12:20 PM Staff G, ARNP stated she was aware of Resident #12's weight loss. She feels that her cognitive decline has attributed to it. She believed that on 1/15/26 when she documented continued weight decline with Dietary following that Resident #12 was sitting at the assisted table. She was not aware that she was not and felt she should be. In an interview on 2/18/26 at 8:35 AM the Corporate Nurse stated she had the dietician's notes from 12/15/25 and 1/5/26 but they lacked information where she usually puts new items. Her recommendations were still noted to be in the documentation as listed in the EHR notes. The information was just not listed in the column that indicated new items. She stated that the facility does not have a policy on weight loss.In an interview on 2/18/26 at 8:40 AM Staff I, CNA stated that Resident #12 ate pretty well this morning.In an interview on 2/18/26 at 8:40 AM Staff J, CNA stated that Resident #12 ate her toast and all but a little bit of her 3 eggs along with 3 glasses of water.In an interview on 2/18/26 at 9:40 AM Staff A, RN stated that Resident #12 was moved to the assist table last night and she ate well then as well.

Based on observation, clinical record review, the facility's meal schedule, staff and resident interviews, the facility failed to serve 2 of 2 meals observed in a timely manner according to the facility dining schedule. The facility reported a census of 54 residents.Findings include:The undated facility's Dining Times listed breakfast at 8:00 AM, lunch at 12:00 PM, and dinner at 5:00 PM.On 8/5/25 at 11:54 AM, Resident #6 explained she often got her meals late and received her lunch at 2:30 PM.The observation of the delivery of the lunchroom trays on 8/5/25 revealed the Dining Services Manager delivered Resident #14's meal at 1:25 PM, Resident #15's meal at 1:27 PM, Resident #16's meal at 1:28 PM, and Resident 17's meal at 1:29 PM.On 8/5/25 at 2:33 PM, Staff A, Licensed Practical Nurse (LPN), stated the facility had a lot of staff turnover in the kitchen and had times the staff could serve lunch between 1:00 PM and 2:00 PM. On 8/6/25 at 8:30 AM, Resident #19 stated he didn't receive his lunch until 1:30 PM. The observation of the delivery of the breakfast trays on 8/6/25 revealed the staff delivered Resident #18's meal at 8:53 AM.On 8/6/25 at 3:04 PM, the Dining Services Manager stated they had a goal for staff to pass breakfast and lunchroom trays at 7:30 AM and 12:30 PM respectively. She explained the kitchen had staffing issues and they worked on improving this. She stated she received several grievances related to late meal service.On 8/6/25 at 3:46 PM, the Administrator stated the facility worked on improving the meal services by making sure the staff prepared for the meals such as thawing meats and making desserts ahead of time. She stated the kitchen had some barriers to getting the meals out on time such as performance issues.

Based on clinical record review, policy review, staff, and resident interviews, the facility failed to report an allegation of missing money for 1 of 3 residents reviewed (Resident #6) for abuse. The facility reported a census of 54 residents.Findings include:Resident #6's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of anxiety disorder, depression, and schizophrenia.On 8/5/25 at 11:54 AM, Resident #6 stated she had $10 missing her friend gave her on 8/4/25. She stated she informed the Administrator that she had missing money. She added she felt one of the Certified Nursing Assistants (CNAs) took it. Resident #6 reported this concern to the State Agency again on the morning of 8/6/25.On 8/5/25 at 4:02 PM, the Administrator stated Resident #6 reported the missing money to her the day before. She stated Resident #6 changed her story many times and no staff witnessed the friend visit. She stated because the story changed, she didn't report the claim of missing money.On 8/6/25 at 12:40 PM, the Administrator stated she didn't contact Resident #6's friend regarding the missing money. She explained she didn't know she had to report the incident since Resident #6's story changed many times.The facility lacked documentation they reported the allegation to the State Agency.The facility's Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy updated 10/19/22, instructed the facility to report all allegations of abuse to the State Agency no later than two (2) hours after receiving the allegation. The policy included misappropriation of resident property as a type of abuse.

Based on clinical record review, resident and staff interviews, the facility failed to ensure residents received showers and/or baths at least once a week for 1 of 3 residents reviewed for bathing (Resident #5). The facility reported a census of 54 residents. Findings include: Resident #5's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. The MDS included diagnoses of hemiplegia (weakness or paralysis on one side of the body), heart failure, and depression. The MDS listed Resident #5 as independent with bathing. The Care Plan Focus initiated 3/25/24 indicated Resident #5 had an activities of daily living (ADLs) deficit related to a cerebral vascular accident (stroke). The Intervention initiated 6/30/24 directed Resident #5 required assistance from 1 staff for bathing. During an interview on 8/4/25 at 1:44 PM, Resident #5 reported she went 3 weeks at times without a shower. Resident #5 said the staff always had something going on, they say they would give her a shower the next day however they would forget to do it. Resident #5 added she didn't refuse showers and at times when she tried to accommodate staff when they say they are busy and behind, she suggested doing her bath the next day but then she didn't get a shower the next day.Review of the facility form titled, Bath Aide Report, reflected Resident #5 had the following number of showers: 1. March 2025- 32. April 2025- 33. May 2025- 24. June 2025- 35. July 2025- 2Resident #5's electronic health record (EHR) for the previous 30 days reflected documentation of a refusal to shower on 7/24/25. The EHR lacked further documentation regarding her showers and/or baths in the previous 30 days. During an interview on 8/6/25 at 8:55 AM, the Director of Nursing (DON) explained she expected residents get showers 2 times a week unless a resident requested otherwise such as 3 times a week and they had a few who wanted 1 shower a week. The DON reported if a resident refused a shower, they should offer again the next day. The DON added if a resident refused their shower sheets should be reflect it should on the computer. The DON reported the bath aide should document in the EHR the day they gave the shower.

Based on observation, interview, clinical record review, and facility policy review, the facility failed to ensure the safety of 5 residents in a designated smoking area when on 2/10/25 at 1:15 PM, Resident #32, with a portable oxygen tank, kept in a bag on the back of his wheelchair, smoked alongside other residents while staff were providing supervision. Per interview with Resident#32 he reported that since November 2024 he had been on oxygen, and sometimes he had the oxygen tank on his wheelchair during smoke breaks. The facility reported 9 residents who smoke or vape. Facility additionally failed to ensure foot pedals had been in place on a wheelchair before transporting Resident #25 from dining room to resident room. This failure resulted in Immediate Jeopardy to the health, safety, and security of the resident. The facility reported a census of 48 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 2/10/25 at 4:20 PM. The IJ began on 11/28/24, the day Resident #32's oxygen order was initiated. Facility staff removed the Immediate Jeopardy on 2/11/25 at 2:11 PM through the following actions: - On 2/10/25, staff education provided to ensure, all staff and all departments, were aware oxygen equipment cannot be on residents or in the designated smoking area while residents smoked. All staff educated on 2/10/2025, or prior to the start of their next shift. - On 2/10/2025, facility educated Resident #32, and the other residents who smoke, that oxygen equipment cannot be with them while smoking. - Facility posted a sign near the exit to the designated smoking area stating that oxygen use is not allowed in the designated area. - Facility posted a sign near the front entrance for visitors stating that oxygen use is not allowed while smoking. - Facility planned to audit for compliance to ensure oxygen equipment not present in the designated smoking area while residents are smoking and any concerns to be reported to the Administrator immediately and addressed in facility Quality Assurance meeting. The scope lowered from K to E at the time of the survey after ensuring the faiclity implemented education and their policy and procedure. Findings include: 1. The Annual Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated intact cognition. Resident #32 utilized wheelchair for mobility and dependent upon staff to transfer into and out of chair. Diagnoses included paraplegia, Chronic Obstructive Pulmonary Disease (COPD), and asthma. The Care Plan, revised on 11/05/24, revealed Resident #32 smoked and chewed tobacco with a goal that Resident #32 would remain safe and intervention for staff supervision when smoking, as per facility policy. The Care Plan additionally revealed a focus area, initiated 2/04/25, for Resident #32's use of oxygen therapy, related to Congestive Heart Failure and ineffective gas exchange and informed that Resident #32 is non-compliant with continuous oxygen order. The Medication and Treatment Administration Record (MAR/TAR), dated February 2025. revealed an order, initiated on 11/28/24, for supplemental oxygen to be administered at 2 liters (L) to maintain oxygen saturations greater than 90% (normal oxygen saturation range between 90-100%). The MAR/TAR additionally revealed order, initiated on 11/28/24, for supplemental oxygen to be administered at 2L as needed to maintain oxygen saturation above 90%. A Smoking Assessment, dated 11/19/24, revealed that Resident #32 would go outside to smoke between 2-5 times per day (morning, afternoon, and evening) and required supervision while smoking. No additional Smoking Assessments completed following order initiated for supplemental oxygen therapy. The facility document, titled Resident Kardex, dated 2/11/25, informed direct care worker staff that Resident #32 had order for continuous supplemental oxygen and is non-compliant with it. On 2/10/25 at 11:08 AM, Resident #32 in room, laying in bed with eyes closed, no supplemental oxygen being utilized. On 2/10/25 at 1:00 PM, Resident #32 sat in his wheelchair, near door leading to designated outdoor smoking area, an oxygen tank kept in a bag on the back of wheelchair. Nasal cannula oxygen tubing was attached and wrapped around the top of the oxygen tank. On 2/10/25 at 1:15 PM, Resident #32 outside in designated smoking area with lit cigarette and actively smoking. Resident #32 continued to sit in wheelchair with oxygen tank kept in a bag on the back of wheelchair. The nasal cannula oxygen tubing still attached to tank and wrapped around top of oxygen tank, oxygen not being administered. Staff F, Housekeeping Aide, supervised as Resident #32 and 4 other residents smoked. On 2/10/25 at 1:30 PM, Resident #32 self propelled wheelchair from smoking area back to his room. On 2/10/25 at 1:45 PM, Resident #32 sat in wheelchair in his room, oxygen tank kept in bag on back of wheelchair had an attached meter that read 1/2 full and the dial to control flow of oxygen, set to 0. Resident #32 reported that he goes outside to smoke 3 to 4 times a day. Resident #32 stated he sometimes wears the oxygen and when asked if he goes outside to smoke with oxygen tank kept on back of wheelchair he stated, yeah. On 2/10/25 at 2:00 PM, Staff F, Housekeeping Aide, employed at facility for 3 years, reported that housekeeping staff often supervise the 10:00 AM and 1:00 PM designated resident smoking times. Staff F stated Resident #32 would usually go out to smoke at these times. Staff F acknowledged that Resident #32 had recently been started on oxygen and when asked if she would remove tank before he smokes, Staff F stated the nurses would remove resident's oxygen and housekeeping staff did not touch the oxygen tanks. On 2/10/25 at 2:54 PM, Staff G, Licensed Practical Nurse (LPN), confirmed Resident #32 required supplemental oxygen and stated sometimes he will refused to wear it. Staff G stated Resident #32's oxygen tank should be removed from bag on wheelchair before going outside to smoke. On 2/10/25 at 3:45 PM, Facility Administrator, stated no oxygen should be present in smoking areas due to resident safety risks. On 2/11/25 at 9:07 AM, in an interview with a resident who goes outside to smoke during designated smoking times, the resident reported he had seen Resident #32 go outside with oxygen tank on back of wheelchair a couple of times, but stated that staff will remove it from the back of his wheelchair if seen. On 2/11/25 at 9:52 AM, Staff H, Housekeeping Aide, reported sometimes taking residents out to smoke at 1:00 PM and stated if a resident is on oxygen she would tell the nurse if it's still on and have the nurse take it off. Staff H denied ever seeing an oxygen tank in the designated smoking area, and stated this would not be allowed. On 2/11/25 at 12:20 PM, the Director of Nursing (DON) confirmed that housekeeping staff were helping to supervise residents during 1:00 PM smoking time but facility is discussing just having Certified Nursing Assistant (CNA) staff be with the residents while smoking as they have had training on oxygen. Facility provided an untitled, undated document that revealed resident designated smoking times would be at 10:00 AM, 1:00 PM, 4:00 PM, and 8:00 PM. Document also listed 9 residents who currently smoked, which included Resident #32. A Nursing Progress Note, dated 2/11/25 at 10:37 PM, revealed a new physician's order received that Resident #32 could have oxygen removed for smoking times. The facility policy, titled Resident Smoking Process, dated 4/21/22, revealed oxygen use is prohibited in smoking areas for the safety of the residents. Policy instructed that an order must be obtained to remove oxygen for smoking for residents on continuous oxygen. 44512 #2. The Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #25 revealed diagnoses of dementia, venous thrombosis and embolism (blood clot), weakness, and dependent for transfers and ambulation not attempted due to medical condition or safety concerns. The Brief Interview for Mental Status (BIMS) revealed a score of 3 that suggested a severe cognitive impairment. The Care Plan dated 1/14/25 for Resident #25 revealed limited mobility and directed to provide extensive assistance of 1 staff and the resident could maneuver the wheelchair slowly. During an observation on 2/10/25 at 1:07 PM, Staff O, Certified Nursing Assistant (CNA) transferred Resident #25 from the dining room, down the hall to his room with a wheelchair without foot peddles. During an interview on 2/17/25 at 1:43 PM The Director of Nursing (DON) stated the expectation of the nursing staff was that they utilize wheelchair pedals when transporting residents in wheelchairs.

Based on staff interviews, employee job description and policy , the facility failed to ensure adequate, trained, dietary staff for a clean kitchen environment. The dietary manager did not meet the regulated educational qualifications, the kitchen lacked appropriate sanitary conditions (photos available). The facility reported a census of 48 residents. Findings include: During an interview on 2/10/25 at 9:25 AM Staff B, Kitchen Manager reported working at the facility only a few months, beginning, December 2024. Staff B relayed the previous kitchen manager left and had recommended Staff A, laundry/housekeeper for promotion to kitchen manager. Staff B reported dietary training in several fast food environments, which included a course in food safety for managers and had not yet completed the Certification for Dietary Manager (CDM) coursework. On 2/10/25 at 9:30 AM Staff B, Kitchen Manager (KM) reported each shift is supposed to clean the kitchen at the end of the shift and it is apparent that had not occurred over the weekend. Staff B, KM acknowledged the dirty floors, equipment and uncovered food were unsanitary. On 02/10/25 at 10:34 AM Staff C, Registered Dietician (RD) relayed the food provider and owner company provide kitchen staff training, revealed dietician can consult, had not addressed cleanliness with staff and stated today is the worst it had ever seen. Staff C relayed thought staff should have mopped before start of food preparation. On 2/10/25 at 10:56 AM the Administrator walked thru the kitchen and relayed the kitchen should be cleaned every night at end of shift, most all the kitchen staff are new and improvement is needed. On 2/13/25 the Administrator relayed in an email, the dietary services manager is in the process of completing her certified food manager training. The Administrator confirmed the KM had not finished the program or passed the credentialing exam. A Document titled, Job description: Director of Dining services was signed on 1/16/25 by Staff B, documented the job summary, responsibilities included day to day planning, organizing, developing the management of the overall operations of the dietary services department in accordance with current federal, state and local standards, guidelines and regulations governing the facility and as may be directed by the Executive Director to assure quality services provided on a daily basis and that the dietary services department is maintained in a clean, safe and sanitary manner. Education and qualifications include must meet state requirements for food service manager and dietary managers. The facility provided a policy titled Cleaning and Sanitation of Dining and food service area dated 2021 and directed staff as follows; food and nutrition services staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. The director of food and nutrition services will determine all cleaning and sanitation tasks needed for the department. Tasks shall be designated to be the responsibility of specific positions in the department. Staff will be trained on the frequency of cleaning, as necessary, included sample of methods and guidelines, schedule will be posted for all cleaning tasks, and staff will initial the tasks as completed. Staff will be held accountable for cleaning assignments.

Based on observations, resident and staff interviews, the facility failed to provide food that was palatable and at an appetizing temperature for 5 out of 5 residents reviewed (Res #8, #13, #17, #35, & #43). The facility reported a census of 48 residents. Finds include: 1. The Quarterly Minimum Data Set (MDS) dated [DATE] Resident #13 revealed the Brief Interview for Mental Status (BIMS) was 15 which indicated an intact cognition. During an interview on 2/10/25 at 12:07 PM Resident #13 stated that the lunch food that was to be served at noon came at 1:30 PM and her lettuce in the chef salad was wilted. Resident #13 stated the breakfast food was cold all of the time. 2. The MDS dated [DATE] Resident #17 revealed the BIMS was 15 which suggested an intact cognition. During an interview on 2/10/25 at 10:29 AM Resident #17 was in a wheelchair in her room with a meal tray covered with plastic on her bedside table untouched. She stated it was cold. 3. The MDS dated [DATE] Resident #35 revealed the BIMS was 15 which suggests an intact cognition. During an interview on 2/10/25 Resident #35 stated lunch came late 1:30 PM but was warm enough, then stated that breakfast is cold. 4. The Quarterly MDS dated [DATE] Resident #43 revealed the BIMS was 15 which suggests an intact cognition. During an interview on 2/10/25 at 12:25 PM Resident #43 stated the room tray food was always cold, the eggs, sausage and toast and the milk was lukewarm. During an observation on 2/11/25 at 9:00 AM, 5 breakfast room trays sat in the kitchen/dining window for 15 minutes (Picture obtained). The residents trays were #8, #13, #17, #35, and #43. The variegated blind to the kitchen was lowered but not closed. Two housekeeping staff were cleaning the dining room and one dietary staff was cleaning the dining tables. At 9:16 AM, nursing staff took covered trays to Residents #13, #17 and #43. During an interview on 2/11/25 at 10:21 AM, Resident #13 stated the breakfast was cold. During an interview on 2/11/25 at 9:47 AM Resident #17 stated the breakfast was cold and she could not eat it. The breakfast tray was on her nightstand untouched. During an interview on 2/11/25 at 9:40 AM Resident #43 stated breakfast was cold but she was hungry and ate it. During an interview on 2/18/25 at 9:39 AM, the Administrator stated there were attempts to assist the kitchen staff with training. She stated all of the staff in the kitchen are new.

Based on observations, food provider documents and staff interviews, the facility failed to prepare food to meet the needs for 8 of 8 residents who required the meal to be mechanical soft (Residents #27, #32, #11, #26, #15, #9, #2, #29). The facility reported a census of 48 residents. Findings include: During an observation on 2/13/25 at 12:14 PM, Staff B, Dietary Manager prepared mechanical soft meat by placing 6 chicken pieces into the food processor then put the prepared meat into a metal pan on the steam table. Further observation revealed Staff N, [NAME] utilized a scoop and shook the prepared chicken in attempt to level it and meat fell out, less than a scoop, placed it on a plate and another plate was served with a scoop full. Staff B made a plate with mechanical soft chicken and put 2 scoops on one plate and another with a little more than a scoop full. During an interview on 2/13/25 at 1:48 PM, Staff N, [NAME] stated he did not know what size of scoop he was using to serve. Staff N stated he was new to cooking in a facility as he was working in a fast food restaurant prior to this employment. During an interview on 2/13/25 at 1:49 PM, Staff B, Dietary Manager stated she used the scoop size for the ground chicken by the food provider chart that came with the food. She opened the book and identified 3 ounces (oz) chicken as the serving size. When inquired about the size of the scoop used to serve the mechanical soft chicken, Staff B stated it was 2 oz but she made them heaping. She was unaware that the cook served the scoop size or less for this meal. A document titled Resident Diet Roster revealed 8 residents who required a mechanical soft diet (Residents #27, #32, #11, #26, #15, #9, #2, #29). A document titled Menu signed by the Registered Dietitian on 11/11/24 revealed the lunch menu for 2/13/25 included 3 ounces of baked Swiss chicken for regular and ground or mechanical soft diets. During an interview on 2/10/25 at 10:34, Staff C, Registered Dietician (RD) stated that the food provider and owner company provide kitchen staff training, and revealed she can consult. During an interview on 2/18/25 at 9:39 AM, the Administrator stated there were attempts to assist the kitchen staff with training. She stated all of the staff in the kitchen are new and the dietitian was here 1 day a week.

Based on observation, staff interview, and policy review, the facility failed to maintain a clean sanitary environment in the kitchen and failed to store food in accordance with professional standards for food service safety included food not covered. The facility reported a census of 48. Findings include: On 2/10/25 at 9:25 AM observations during initial tour of the facility kitchen revealed the following; a. the floor tiles under the sink missing with gray/ black residue on flooring b. grime and water stains evident under the sinks c. refrigerator handle and interior tray with food crumbs present d. front of the stove revealed dripping residue and traces of food e. the stainless appliances were not clean f. sand like debris on top of the dishwasher g. various items on the floor included silverware, cup, papers, food crumbs and spills h. bowls of cereal uncovered and a tub of peanut butter half empty covered loosely with a piece of plastic g. sticky pest traps in most corners (photos available). On 2/10/25 at 9:30 AM Staff B, Kitchen Manager (KM) reported each shift is supposed to clean the kitchen at the end of the shift, and it was apparent that had not occurred over the weekend. The KM acknowledged the dirty floor and uncovered food were unsanitary. The KM stated the peanut butter should have a lid, and food should be covered. The KM reported the sand like debris on the dishwasher was likely left after a wall was repaired in mid-January. On 02/10/25 at 10:34 AM Staff C, Registered Dietician (RD), reported that she would consult, the food provider and owner company provide kitchen staff training. Staff C stated she had not addressed cleanliness with staff and stated today is the worst she had ever seen. Staff C relayed that staff should have mopped before start of food preparation. When questioned about the multiple pest traps, Staff C acknowledged bugs have been a concern with the age of the building and exceptional job cleaning is important. On 2/10/25 at 10:56 AM the Administrator walked thru the kitchen and relayed the kitchen should be cleaned every night at end of shift, most all the kitchen staff are new and improvement is needed. The facility provided a policy titled Cleaning and Sanitation of Dining and food service area dated 2021 directed staff as follows; food and nutrition services staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. The director of food and nutrition services will determine all cleaning and sanitation tasks needed for the department. Tasks shall be designated to be the responsibility of specific positions in the department. Staff will be trained on the frequency of cleaning, as necessary, included sample of methods and guidelines, schedule will be posted for all cleaning tasks, and staff will initial the tasks as completed. Staff will be held accountable for cleaning assignments.

Based on observation, staff interview and facility assessment review the facility failed to maintain essential equipment available to be used in safe operating conditions. A washing machine noted out of order, debris behind the washers related to water backing up, a dryer did not automatically cool down or shut off. The facility had reported a census of 48. Findings include: 1. On 2/10/25 at 10:06 AM initial laundry tour observed two large industrial size washers, one with a sign on the front documented out of order, behind the washer were water stains on the piping and grayish dirty debris on the floor and the pipes. Observed two industrial size dryers, one had a sign taped that read, Keep eye on dryer, wont shut off by its self (photos available). On 2/10/25 at 10:10 AM Staff A, Laundry/Housekeeper (LH) explained only one of the large washers is working. Queried Staff A regarding the debris behind the washer, Staff A responded the pipes can back up from grease or oils and had pillow stuffing shoot out back of the washer as well. Staff A relayed the sign on the dryer reflected the dryer does not shut off automatically and the clothes do not cool down. Felt a sensor is bad and relayed zippers or metal parts can be very hot coming out of the dryer. On 2/12/25 at 12:17 PM the Administrator relayed the washing machine is not out of order, both large washing machines cannot run simultaneously because they will overload the circuit panel. Also relayed was unaware a dryer was not cooling down, would have maintenance director look at it. The facility assessment documented physical equipment, dated 7/17/24 and each department manager, or designee, follows procedures for maintaining inventory and assessing the condition of all equipment and determining what is needed.

Based on observations, staff interviews and commercial pest control documents, the facility failed to maintain an effective pest control program so that the facility would be free of pests. The facility also failed to follow through with recommendations provided by the commercial pest control to prevent pest entry and clean and proper disposal of food waste in the kitchen. The facility reported a census of 48 residents. Findings include: During an observation on 2/10/25 at 10:06 AM the back door of the kitchen adjoins the laundry room. Multiple pest traps were noted throughout the kitchen and into the laundry room. During an interview on 2/10/25 at 10:06 AM Staff J, Laundry stated there are more pest traps in the cupboards and they are roach traps. Staff J stated that roaches have been in the laundry bins and occasionally in the clothes. Staff J stated she had killed a roach this morning. During an observation on 2/11/25 at 9:41 AM, a large kitchen trash lid was on the floor and food debris and spatters were on the wall behind the trash and on the side of the oven which was next to the trash can. The food prep sink lower cupboard was open and water was leaking from the sink into the lower cupboard that contained a food processor in it and the water spilling out onto the floor. The sink contained a metal pan with a package of meat and overflowed with water into the sink that did not contain a plug. Staff B, kitchen manager arrived with a mop and stated she had notified the maintenance staff. During an interview on 2/13/25 at 10:05 AM, Staff I, Maintenance Director stated he had received a text on 2/12/25 that the kitchen sink was leaking and he had fixed it. Staff I stated he was informed this morning that it was leaking again via text. A document titled Commercial Pest Control dated 11/22/24 revealed: a. Completed service and inspection, treated interior with Alpine WSG and serviced all devices. b. Spoke with Staff K, Certified Medication Aide (CMA). c. Treated/observed spider, cricket and sowbug activity near doorways and captured in monitors. d. Treated/observed German cockroach activity in kitchen area and captured in monitors. A document titled Commercial Pest Control dated 12/27/24 revealed: a. Completed service and inspection, treated interior with Alpine WSG and serviced all devices. b. Spoke with Staff L Environmental Services. c. Treated/observed cricket and ground beetle activity near the doorways and in capture monitors. d. Treated/observed German roach activity in the kitchen area. Added Adivion roach bait. e. Exterior activity: light feeding observed at bait stations. A document titled Commercial Pest Control dated 1/4/25 revealed: a. Completed service and inspections, treated interior with Alpine WSG and serviced all devices. b. Spoke with Administrator. c. Treated/observed spider and sowbug activity near doorways and captured in monitors. d. Treated/observed German cockroach activity in kitchen area. e. Replaced Advion cockroach bait to cracks/crevices and replaced all monitors. f. Previously noted conditions are still active and observable, notes regarding the interior in all areas, reported on 7/9/24 revealed: 1. Holes in walls, an unsecured opening or access in a wall was identified, this may allow pest entry. Action: Seal or repair the hole. 2. Piping penetration gaps, an unsecured opening in a wall was identified, this may allow pest entry. Action: Seal or repair hole. g. Previously noted conditions are still active and observable, notes regarding the interior staff lounge, reported on 8/28/24 revealed: 1. Missing or damaged door sweeping, allowing pests entry to area. Action: Repair or replace the door sweep in order to deny pest entry. h. Previously noted conditions are still active and observable, notes regarding the interior kitchen, reported on 1/24/25 revealed: 1. Food debris, food waste was found not properly disposed of. Action: Clean up the food waste and ensure that it is disposed of in a proper manner. During an interview on 2/10/25 at 10:34, Staff C, Registered Dietician (RD) stated that the food provider and owner company provide kitchen staff training, revealed she can consult, had not addressed cleanliness with staff and stated today was the worst she had ever seen. Staff C stated she thought the kitchen staff should have mopped before the start of food preparation. When inquired about the multiple pest traps, she acknowledged bugs have been a concern with the age of the building, exceptional job cleaning would be very important. During an interview on 2/19/25 at 2:47 PM, Staff B, Dietary Manager stated that management nor pest control had spoken to her directly on what she needed to make improvements to aide in the pest control. She stated a man had come in and put new paper traps on the floor in the pantry, under the dishwasher, behind the coolers and under the 3 compartment sink. Staff B stated that they are trying. During an interview on 2/19/25 at 2:52 PM, Staff M, [NAME] stated that the facility had a cleaning list in the kitchen and that they tried to do most of it but it was lacking. Staff M stated he was new and worked five days a week. During an interview on 2/19/25 at 3:01 PM, the Administrator stated she had not spoken to Staff B, Dietary Manager about the pest control but did talk about cleanliness. The Administrator stated she had to call for the report the pest control completed last week. She stated the man didn't talk to her, she just signed the document for him when he was here and she was unaware of his findings.

Based on observations, clinical record review and staff interviews the facility failed to assure services were provided to meet acceptable standard of practice during medication administration for 2 out of 5 residents (Residents #5 and #47). The facility reported a census of 48 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #5 revealed a diagnosis of dementia. The Care Plan for Resident #5 revealed an impaired cognitive function or impaired thought processes due to dementia and directed staff to administer medications as ordered, monitor and document side effects, cue, reorient and supervise as needed. On 2/11/25 at 9:32AM Resident#5 was in her room with medications in a cup, no staff were in the room to provide supervision. Staff D, Licensed Practical Nurse (LPN) was across the hall by the medication cart. During an interview on 2/17/25 at 1:17 PM, Staff D, LPN stated Resident #5 did not have difficulty taking medications and was aware the facility policy directed nursing staff to stay with residents until they had taken their medications. 2. The Physician orders for Resident #47 revealed an order for Ozempic (medication used to lower blood sugar) 2 milligrams (mg) every Monday. During medication administration for Resident #47 on 2/13/25 at 8:58 AM, Staff E, Registered Nurse (RN) removed a clear zipper bag that contained 3 insulin pens, removed 2 and prepared them to be administered and left the 3rd syringe, the Ozempic, in the zipper bag on the medication cart and entered Resident #47's room to administer medication. Staff E then returned to the medication cart in the hall and placed the 2 insulin pens back into the zipper bag with the Ozempic pen and secured it in the medication cart. During an interview on 2/13/25 at 9:04 AM, Staff E, RN stated Resident #47 did not receive the Ozempic since it was not a Monday and did not acknowledge that it was left unsecured on top of the medication cart while she was in the resident room administering other medication. During an interview on 2/17/25 at 1:43 PM, The Director of Nursing (DON) stated the expectation of the nursing staff was that they stay with a resident until the resident had taken all of their medications and to store all medications in the medication cart before walking away to administer medication. A Policy titled Medication Administration dated 1/30/24 revealed: a. Medications are administered by licensed nurses or other staff who are legally authorized to do so in this state as ordered by the physician and in accordance with professional standards of practice. b. Observe resident consumption of medication.

Based on observation, record review, and staff and resident interviews, the facility failed to provide care and services in accordance with professional standards of practice to prevent pressure sore development and prevent deterioration of existing pressure sores for 1 of 1 resident (Resident #3) reviewed with identified pressure sores. Resident #3 had been identified as at risk for pressure sore development and had an existing open area on a bony prominence which resulted in the development of 2 facility acquired pressure sores. The facility reported a census of 45 residents. Findings include: According to the Minimum Data Set (MDS) Assessment tool dated 12/14/21, Resident #3 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed Resident #3 scored 15 out of 15 possible points on the Brief Interview for Mental Status (BIMS) test, which meant the resident experienced intact cognitive function. The MDS documented the resident showed no sign of [CONDITION(S)] and required extensive assistance of at least 1 staff for bed mobility and repositioning, transfers, dressing, toilet use, bathing, and personal hygiene. The MDS documented the resident could not stand or ambulate (walk), used a catheter for urinary elimination, and was always incontinent of bowel. The MDS also documented the resident had a pressure reduction device in their chair, received applications of ointments/medications other than to the feet, and was at risk for pressure ulcer development, but without actual pressures ulcers present at the time of the assessment. The Care Area Assessment (CAA) Summary completed 12/22/21 documented the resident had a pressure sore and directed staff to develop and implement a care plan for the resident's pressure ulcer. Non-ulcer skin assessments revealed: a. On 12/10/21, Staff N, licensed practical nurse (LPN) documented an abrasion on the resident's coccyx from shearing that measured 1.0 centimeters (cm) by 0.5 cm, without depth on Resident #3's admission (12/7/21). Staff N also documented the resident had a current care plan that contained skin interventions. b. On 12/17/21, the Director of Nursing (DON) documented the resident's coccyx abrasion measured 1.0 cm by 0.5 cm with no depth and a red wound bed without drainage or odor. The DON also documented the resident's care plan was current with skin interventions. c. On 12/24/21, the DON documented the coccyx abrasion measured 1.5 cm by 0.7 cm with no depth and contained a red wound bed with no drainage or odor. The DON also documented the wound's status had declined. d. On 12/31/21 the DON documented the coccyx wound measured 2.0 cm by 1.0 cm, without depth, drainage or odor, wound bed red, and wound status declined. Ulcer skin assessments revealed: a. On 1/7/22, the DON described the coccyx wound first identified on 12/7/21 as now a facility acquired Stage II pressure sore which measured 3.5 cm by 2.5 cm by 0.3 cm deep, with slough tissue present, moderate tan colored drainage with odor, and the surrounding tissue erythematous and macerated - wound status declined. The DON documented they obtained a culture of the wound and consulted a physician/extender wound provider for involvement in the resident's wound care. b. On 1/10/22, the DON described a purple suspected deep tissue injury (DTI) pressure sore on the left heel that measured 8.0 cm by 5.5 cm, without drainage. The DON also documented they directed staff to provide pressure relieving boots at all times, with skin treatments initiated. c. On 1/14/22, the DON documented a Stage II coccyx pressure sore that measured 3.5 cm by 2.4 cm by 0.3 cm. The wound bed contained slough tissue and moderate tan drainage: wound status declined. d. On 1/14/22, the DON documented a Stage II, suspected DTI pressure sore on the left heel which measured 8.0 cm by 5.5 cm. The DON described a purple area, without depth or drainage Wound Care Nurse Practitioner (NP) Progress notes revealed: a. On 1/7/22, the NP documented an unstageable pressure sore located on the coccyx which measured 3.5 cm by 2.4 cm by 0.3 cm. The wound bed contained 100 percent slough tissue and moderate serous drainage with foul odor. The resident rated the pain as a 6 on a 0 to 10 pain scale, with 10 used to describe the worst pain. b. On 1/23/22, the NP documented an unstageable coccyx pressure sore that measured 3.6 cm by 3.2 cm by 1.0 cm deep, with ).8 undermining at 3 o'clock. The wound contained 80 percent slough tissue, 20 percent red granulation tissue, moderate serous drainage with odor, and pain rated at 6 on a 0 to 10 pain scale. The NP also documented a Stage III pressure sore located on the left heel that measured 2.2 cm by 3.5 cm by 0.1 cm, 15 percent eschar tissue, 20 percent red granulation tissue, and 65 percent epithelial tissue. The wound contained minimal serosanguinous drainage without odor and pain rated at 2. The NP mechanically debrided both wounds during the visit. c. 1/28/22, unstageable pressure sore on coccyx measured 3.8 cm by 3.0 cm by 1.5 cm, 1.4 cm undermining at 3 o'clock, 70 percent slough tissue, 30 percent red granulation tissue, moderate drainage without odor, pain rated at 6 on a 0 to 10 pain scale. Left heel Stage III pressure sore measured 3.0 cm by 3.5 cm by 0.1 cm, 10 percent eschar tissue, 90 percent epithelial tissue, minimal serosanguinous drainage without odor, pain rated at 2 on a 0 to 10 pain scale. Both wounds mechanically debrided by the NP during the visit. d. 2/4/22, unstageable coccyx pressure sore measured 3.7 cm by 3.0 cm by 1.1 cm, 1.4 cm undermining at 3 o'clock, 65 percent slough tissue, 35 percent red granulation tissue, moderate serous drainage, pain rated at 6 on a 0 to 10 pain scale. Stage III pressure sore left heel measured 3.0 cm by 4.0 cm by 0.1 cm, 5 percent eschar, 95 percent epithelial tissue, no drainage, pain rated at 2 on a 0 to 10 pain scale. Both wounds mechanically debrided by the NP during the visit. e. 2/11/22, unstageable coccyx pressure sore measured 3.4 cm by 3.3 cm by 1.5 cm, 60 percent slough tissue, 40 percent red granulation tissue, moderate serous drainage, pain rated at 6 on a 0 to 10 pain scale. Stage III pressure sore left heel measured 3.0 cm by 3.6 cm by 0.1 cm, 5 percent eschar tissue, 95 percent epithelial tissue, no drainage, pain rated at 2 on a 0 to 10 pain scale. Both wounds mechanically debrided by the NP during the visit. f. 2/25/22, unstageable coccyx pressure sore measured 3.4 cm by 2.5 cm by 1.0 cm, 0.8 cm undermining at 3 o'clock, 60 percent slough tissue, 40 percent red granulation tissue, moderate serous drainage, pain rated at 6 on a 0 to 10 pain scale. Stage III pressure sore left heel measured 3.5 cm by 3.5 cm by 0.1 cm, 10 percent deep tissue injury, 90 percent epithelial tissue, no drainage, pain rated at 2 on a 0 to 10 pain scale. Both wounds mechanically debrided by the NP during the visit. Wound care orders directed staff: a. 12/22/21: Cleanse coccyx wound with wound cleanser of choice, apply foam bordered dressing, and change 3 times a week on Monday, Wednesday and Friday, and as needed. b. 1/7/22: Discontinue previous coccyx wound treatment orders, cleanse wound with wound cleanser, apply [MEDICATION(S)] to the wound bed, cover with silicone super absorbent dressing, change 3 times a week and as needed. Apply air mattress to bed, use Equagel cushion in chair with cover on it, start house protein supplement. c. 1/10/22: Apply Skin-Prep to bilateral heels twice daily. (Order discontinued on 1/17/22) d. 1/17/22: Apply Skin-Prep to right heel twice daily. Cleanse left heel with wound cleanser of choice, apply [MEDICATION(S)] soaked gauze, wrap with rolled gauze daily and as needed. e. 1/23/22: Continue to cleanse coccyx wound with wound cleanser, apply [MEDICATION(S)] to wound bed, cover with silicone super absorbent dressing daily and as needed. f. 1/28/21: Discontinue previous coccyx wound treatment order. Cleanse coccyx wound with wound cleanser, apply [MEDICATION(S)] to the wound bed, pack with saline moist gauze, and cover with silicone super absorbent dressing daily and as needed. g. 2/4/22: Discontinue previous left heel wound treatment order. Cleanse left heel with wound cleanser, apply Skin-Prep daily and allow to dry. An initial nursing care plan dated 12/7/21 contained no skin-related interventions except that a wheel chair cushion was needed. A care plan that addressed alteration in skin integrity related to unstageable pressure area to right heel and Stage II to coccyx, initiated 1/10/22 directed staff: a. Assess wound, obtain measurements and document weekly until healed. b. Notify physician and follow treatment orders. c. Pressure relieving boots when in bed. d. Specialty cushion to wheelchair, recliner, dining room chair. e. Specialty mattress to bed: low air loss. f. Treatment to wound as ordered by wound provider. A care plan initiated on 2/24/22 addressed the resident's self-care deficit on the nursing care plan and directed staff to provide: a. Assist of 2 staff for bed mobility due to total dependence. b. Dressing assist by staff. c. Bathing assist by staff. d. Grooming and hygiene assist by staff. Observation of wound care on 2/22/22 at 9:08 a.m. revealed: a. The resident had just completed a shower and was positioned in bed on their back, with pillows under both lower legs. b. Staff H, registered nurse (RN), placed wound supplies on top of a barrier on the resident's overbed table. c. Staff H removed the pillows from under the resident's legs, pulled down the resident's pants, and positioned her on her right side. d. Staff H sanitized their hands, applied gloves, squeezed the tube of [MEDICATION(S)], and applied the ointment to a 4 inch by 4 inch non-stick gauze dressing and placed the dressing inside the wound bed. The wound appeared approximately 3 cm wide, oval shaped, approximately 1/2 cm to 1 cm deep, with a deep pink colored wound bed. e. Staff H applied a silicone island dressing with a bordered adhesive and covered the coccyx wound. Staff H did not apply saline soaked gauze to the wound. f. Staff H removed gloves, sanitized their hands, applied new gloves, opened a package of Skin-Prep, removed the applicator pad and wiped the left heel. The left heel was dark pink/purple colored, not open, and without drainage. Observation on 2/28/22 at 10:31 a.m. revealed the resident up in a chair and in the dining room for a BINGO activity. On 2/23/22 at 7:08 a.m., the DON stated she ordered an air mattress and put it on the resident's bed on 1/10/22 when the pressure sores were identified, and purchased a $300 wheel chair cushion for the resident, but the resident preferred to use a cushion provided by a family member. Staff encouraged the resident to get up, but the resident didn't want to get up. The resident had agreed to get up for 1 meal a day, but continued to refuse to get up. On 3/1/22 at 11:32 a.m., the DON stated staff used the non-pressure skin assessment forms for the resident's coccyx abrasion, and should have called it pressure from shearing and used the pressure skin assessment form from the start. The resident didn't have a care plan that addressed the resident's potential for pressure sores when the initial MDS was completed as the MDS nurse was new and didn't know it was required. On 3/2/22 at 8:55 a.m., the DON stated staff should always provide wound care as ordered and follow physician orders, or notify her if they are unable to follow an order. During an interview 2/22/22 at 9:08 a.m., the resident stated she was encouraged when staff reported that her coccyx wound looked better and it wasn't as sore as it had been, but added it did hurt when she sat up.

Based on clinical record review, staff and resident interviews, and facility policy review the facility failed to ensure 1 of 4 residents received adequate supervision to protect against hazards in the environment. Record review and interviews revealed Resident #1 required assistance of two staff with a mechanical lift transfer. On 11/8/21, one nursing staff person assisted Resident #1 to transfer without a gait belt using what was described as a hug transfer, which resulted in a fracture of the left upper arm, which required hospital admission and surgical repair of the fracture. The facility reported a census of 47 residents. Findings include: The Minimum Data Set (MDS) assessment with a reference date of 10/12/21 for Resident #1 documented a score of 15 of 15 on Brief Interview for Mental Status (BIMS) test which indicated no cognitive impairment. The resident had diagnoses that included Diabetes Mellitus, [CONDITION(S)], [CONDITION(S)], cancer, [CONDITION(S)] and end stage renal disease and required extensive assistance of two staff for bed mobility, and personal hygiene and totally dependent on assistance of two staff for transfer, and toilet use. An Admission Elopement Risk assessment dated [DATE] documented Resident #1 required a hoyer (mechanical lift) transfer, and Resident #1 unable to push himself once in a wheelchair. A Rehabilitation Screen last completed on 8/1/21 confirmed that Resident #1 was evaluated for transfer requirements. The recommendation directed resident should be maintained as a hoyer (mechanical lift) transfer for safety. A Nursing Care Plan dated as initiated on 7/8/21 and revised on 9/28/21 identified a focus area: ADL (Activities of Daily Living) deficit related to weakness, spinal stenosis, and impaired balance, with a goal of maintaining current level of function and try to do some ADL's, directed the following interventions: Resident required assistance of 2 with hoyer lift for all transfers. A facility document titled, CNA (Certified Nursing Assistant) Resident Information Sheet (RIS), Hall B, utilized by staff as a pocket care plan, directed Resident #1 a hoyer (mechanical lift) transfer. The facility failed to provide an Incident/Accident Report related to the incident. In an interview on 11/17/21 at 10:45 a.m., Resident #1 recalled that he had heard his arm break when that girl transferred him. Resident #1 further stated that she hadn't used the lift, and had completed the transfer by herself without using a gait belt. Resident responded that there had not been any urgency to complete the transfer. Resident #1's description of the transfer included: she stood in front of him, wrapped her arms around him like a hug, and lifted under his arm. Again, stated he knew it was broken right away, but hadn't started hurting until later. Resident #1 added that other staff had transferred him without using the lift prior to this incident. In an interview on 11/23/21 at 1:00 p.m., Staff A, NA (Uncertified Nursing Assistant) confirmed on 11/8/21 at approximately 2:30 p.m. she transferred Resident #1 from his chair to his wheelchair by herself and had not used a gait belt for the transfer. Staff A responded that she had requested help from Staff B, CNA. Staff B had instructed her to transfer Resident #1 from his chair to his wheelchair, and she would assist her to get to bed. Staff A denied that Resident #1 had yelled out in pain, or stated that he'd hurt his arm, no mention of pain during or after transfer. Staff A's description of the transfer included: She stood in front of Resident #1 facing him, wrapped her arms around resident in a bear hug with his arms above her arms, and pivot transferred from stationary chair to wheelchair. Staff A confirmed she had maintained the mechanical lift sling under the resident even though had not used. Later that shift Staff C, Registered Nurse (RN) approached staff about Resident #1's report of left arm pain. Staff A responded that she had transferred Resident #1 by herself and reported no knowledge of left arm pain. Staff A stated she had not ever used a mechanical lift to transfer Resident #1. Responded that she had seen the lift sling under the resident and should have known was a mechanical lift transfer, however stated she had never seen anyone use the mechanical lift for Resident #1's transfer, except when State was in the building. Staff A stated she had a gait belt, but had lost it. She was shown how to buckle the gait belt, and instructed to use on any resident who required assistance with standing and walking, however reported that she had never seen staff use, so she also hadn't used. Staff A further stated she was aware there was a care plan book, and admitted she had seen the Resident Information Sheet however denied that she carried with her to refer to, and was unaware of where to get an updated copy. In an interview on 11/22/21 at 11:40 a.m. Staff B, CNA confirmed on 11/8/21 at approximately 2:45 p.m. Staff A requested assistance transferring Resident #1. Staff B reported she was busy assisting another resident with Staff D, CNA. Staff B responded that she had directed Staff A to get Resident #1 ready for transfer, and they would assist when finished. Staff B stated they went to Resident #1's room to assist and found Resident #1 was already in the wheelchair with the sling under him, she assumed someone else had assisted Staff A with the transfer. Staff B reported she and Staff D proceeded to Hall C to get residents up for supper. Staff B confirmed that Staff C, RN approached staff regarding Resident #1's reports of left arm pain later that afternoon. Staff B reported she heard Staff A confirm to Staff C, RN that she had transferred Resident #1 by herself. Staff B denied that she had ever transferred Resident #1 without a mechanical lift, but confirmed that she had seen other staff transfer without using. Staff B confirmed that a gait belt is to be used for all assisted transfers, and the RIS directives for transfer are to be followed. Staff B reported she had transferred the resident using a mechanical lift with Staff A multiple times, and feels certain that Staff A knew to use a mechanical lift. Staff B denied that she had directed Staff A to transfer the resident by herself, and that Staff A absolutely knew that she would be there to assist her shortly. In an interview on 11/22/21 at 12:15 p.m. Staff D, CNA confirmed on 11/8/21 was assigned to work with Staff B, CNA. Recalled at approximately 2:45 p.m. Staff A, NA had requested assistance. Staff D heard Staff B state that they were assisting another resident and would be down to help as soon as finished. Staff D heard Staff B direct Staff A to get the sling under the resident. Staff D responded that there was no urgency to the request, and Staff B in no way indicated an unwillingness to help. Staff D reported that she had assisted to use a mechanical lift to transfer resident earlier in the day, and had transferred using the mechanical lift with Staff A, NA previously. Staff D responded that gait belts are expected to be used for all assisted transfers, and the RIS is to be carried at all times and directives followed for transfers. Staff D produced her current RIS sheet from her pocket. In an interview on 11/17/21 at 1:04 p.m. Staff C, RN Assistant Director of Nursing confirmed on 11/8/21 at approximately 3:30 she stopped in to visit Resident #1. He reported that he couldn't move his left arm. She observed that his left arm was inside the wheelchair arm but hanging. Resident stated that he thought it was broken and it hurt. Stated that the girl had moved him and now it hurts. Staff C assessed a big knot above the elbow of the left arm. Staff A, NA reported to Staff C, RN that she had transferred Resident #1 by herself to the wheelchair. Staff C informed Staff A, that the resident is a mechanical lift transfer not a one assist. Staff A responded that she had been trained to do as an assist of one. Staff C responded that she would expect all staff to carry the RIS and complete transfer as directed. Additionally, would expect to use a gait belt for any assisted transfer. Staff C, RN contacted the resident's provider who directed to monitor. An X-ray Report dated 11/9/21 at 1:28 p.m. revealed x-ray findings included: a minimally displaced comminuted fracture of the distal humeral diaphysis. Presumably acute. [CONDITION(S)] changes are seen proximally and distally with mild osteopenia. Review of Emergency Department Report dated 11/9/21 at 4:01 p.m. documented Resident #1 presented for evaluation of major upper arm injury. Resident non-ambulatory and uses a wheelchair to move. As he was being lifted by staff at the nursing home to transfer him to his wheelchair, he heard a snap in his left arm. Resident has experienced pain in the affected extremity since this occurred. X-rays of his arm taken at the nursing home determined that he had suffered an oblique, comminuted fracture (broken in three or more places) of his left distal humerus (lower portion of the upper arm). Resident is right hand dominant. Condition identified as stable, resident was admitted . A Hospital Progress Note dated 11/14/21 documented left humerus fracture ORIF (open reduction and internal fixation) on 11/11/21. ORIF is a surgical procedure used to stabilize and heal a broken bone. A typed timeline of the investigation provided by the Executive Director documented on 11/9/21 at 1:30 p.m., the Executive Director and the Director of Nursing (DON) interviewed Staff A, NA. Staff A admitted to transferring Resident #1 from his recliner to his wheelchair as a one assist. Staff A stated that Staff B had told her to move him from the recliner to the wheelchair and then staff would help her transfer him from the wheelchair to the bed. It was determined that the transfer occurred at approximately 3:30 p.m. on 11/8/21. In an interview on 11/17/21 at 2:29 p.m. the Executive Director reviewed her typed summary and confirmed that Staff A, NA had admitted she had transferred Resident #1 by herself from his recliner to wheelchair. Staff A additionally admitted she had not used a gait belt. The Executive Director stated both are expectations. Staff are expected to use a gait belt with appropriate transfer, and have the RIS available so knowledgeable of the correct transfer prior to completing. The Executive Director stated Staff A was suspended right away, and had not worked with resident again. In an interview on 11/17/21 at 11:10 a.m. the Director of Nursing (DON) responded Resident #1 had been a mechanical lift transfer since admitted . She wouldn't expect staff to transfer any other way. The DON provided a copy of the RIS, which she described as the walking care plan, and stated she expected all staff carry the RIS and refer to prior to providing care/transfer. Further interview on that same date at 1:35 p.m. confirmed the DON was present for interview with Staff A, NA on 11/9/21. The DON confirmed that Staff A admitted to transferring Resident #1 alone on 11/8/21 from his chair to wheelchair. Staff A additionally admitted to not using a gait belt for this transfer. The DON stated the gait belt is expected to be part of the uniform and is expected to be used for all assisted transfers and ambulation. In an interview on 11/23/21 at 10:40 a.m. Staff E, CNA admitted to not using the directed mechanical lift transfer for Resident #1 prior to the incident. Responded that he knew he was expected to follow the care plan, and regretted not. Staff E, admitted to transferring Resident #1 with two person assist and a gait belt. Further stated he had observed other staff had transferred Resident #1 not according to the plan of care. In an interview on 11/22/21 at 3:03 p.m. the Primary Care Provider, Nurse Practitioner stated she had reviewed the x-ray reports and her opinion was that the left arm fracture was not related to having [CONDITION(S)]. Stated the x-ray report would indicate an osteoporotic break. Resident #1 had identified the transfer as the cause, and the x-ray identified an acute break. Following the incident, education was provided to all staff. A form titled Educational Counseling Form included: All resident transfers/ambulation are to be followed as per the Care Plan and Resident Information Sheet. If a resident is an assist of one or more with ambulation or transfers, a gait belt is to be used at all times. Your gait belt is part of your uniform and the expectation is that you will have it with you at all times. An Employee Corrective Action Form revealed Staff A received a suspension on 11/9/21. The infraction/incident cited the staff member had not followed the RIS (plan of care) and transferred a resident as a one assist pivot transfer when the resident is supposed to be a 2 assist with a hoyer (mechanical lift) transfer. The expectation moving forward identified that Staff A would keep the RIS on her person at all times to ensure plan of care followed correctly at all times. Staff member expected to direct questions to the DON or ADON (Assistant Director of Nursing) immediately, then follow as directed.

Based on record review and interviews with staff and physician, the facility failed to monitor anticoagulant medication for one (1) of three (3) residents reviewed. Resident #6 returned from the hospital on [DATE] with a physician order's to obtain a blood test on 6/24/13 for International Normalized Ratio (INR) which monitor's blood clotting. The nursing staff continued to administer [MEDICATION NAME]/[MEDICATION NAME] medication (blood thinner) without monitoring the impact of the anticoagulant medication on 6/24/13 or anytime thereafter. On 7/21/13 the resident transferred to the emergency room and his/her INR was elevated to high critical level of 21 (with a therapeutic INR range between 2.0 to 3.0.) The resident required 10 units of vitamin K therapy to promptly reduce his/her elevated INR. The findings constitute an immediate jeopardy to the resident's health and safety. The facility identified a census of 52 residents. Findings include: According to the July 2013 Medication Record revealed Resident #6 had a [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] revealed Resident #6 had severe cognitive impairments. Resident #6 required extensive assistance of two staff with transfers, dressing, toilet use and bathing. The Care Plan dated 7/10/13 identified a potential concern or actual risk for abnormal bleeding related to taking blood thinning medications. The Care Plan directed the staff to complete the following as needed: a. notify the physician as necessary b. medication as ordered by the physician c. medication review as needed d. treatment as ordered by the physician e. observe for abnormal signs and symptoms of bleeding (bruising, drop in blood pressure, increased pulse rate, occult blood or hemorrhage) f. educate resident as needed to possible side effects. Resident #6's clinical record revealed the following laboratory (labs) results and physician's orders [REDACTED]. The lab results on 6/11/13 showed his/her [MEDICATION NAME] (PT) at 51.3 (high) and his/her International Normalization Ratio (INR) at 4.6 (high). (The INR therapeutic range recommendation for resident's with [MEDICAL CONDITION] or stroke prevention advised INR maintained between 2.0 to 3.0; and the INR therapeutic ranges for mechanical heart valve at 2.5 to 3.5 INR.) (The INR test is used to determine the clotting tendency of the blood in measure of [MEDICATION NAME] dosage.) The physician changed the resident's [MEDICATION NAME] to 2.5 milligrams (mg) on Monday, Wednesday and Friday; and 5 mg on Tuesday, Thursday and Saturday and Sunday. ([MEDICATION NAME] is a blood thinning medication used to treat [MEDICAL CONDITION].) The physician ordered to recheck the resident's INR in one week. On 6/15/13, the nursing home staff noted on the lab results the resident had been in the hospital. The resident returned to the nursing home on 6/20/13, with a [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The sheet revealed an order to check the resident's INR on 6/24/13. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident #6 remained on skilled services from 6/21/13 to 7/10/13. The Consultant Pharmacist's Medication Regime Review sheet dated 6/28/13 revealed the Pharmacist could not locate the current INR. The Pharmacist made a note to see if it was done in the hospital and clarify when the next INR needed to be done as Resident #6 readmitted on [MEDICATION NAME] (antibiotic). The sheet had a column for Follow-Through. The Follow -Through column on the sheet contained no documentation. The Nursing Assessment Checklist put into effect 7/1/13 directed the staff to put all appointments and labs on the calendar or appointment log. Nurse's notes dated 7/20/13 at 7:25 a.m. revealed Resident #6 had an area on his/her inner right thigh up to the knee that measured 20 (x) by 9 centimeters (cm). The bruise had been assessed with [REDACTED]. The note documented the bruise area may have been sheering by a cloth brief and the physician had been notified by facsimile (FAX). The FAX to the physician on 7/20/13 at 1:57 p.m. revealed Resident #6 had a 20 by 9 centimeter deep purple-red bruise on his/her right inner thigh. The note revealed the bruise possibly due to sheering from a cotton brief against the resident's leg. (The physician returned the facsimile on 7/22/13.) Nurse's notes dated 7/21/13 at 9:30 a.m. revealed the resident's thigh bruise remained purple-red in color. The notes revealed Resident #6 could not hold up his/her head or propel him/her(self) in the wheelchair, eat or drink independently. The nurse assessed the resident and took his/her vital signs. A FAX to the physician dated 7/21/13 documented the resident had a decline in condition. The resident could not hold his/her head up or propel him/her (self) in wheelchair, eat or drink properly. The nurse reported vital signs and asked the physician," would you like Labs or can you come see him/her?" Resident #6's clinical record lacked any laboratory test/results completed on 6/24/13, or anytime thereafter until hosptalized on [DATE]. The transfer form dated 7/21/13 revealed the resident had an increase in confusion and lethargic when transferred to the emergency room . The hospital lab sheet dated 7/21/13 revealed Resident #6 had a Very High INR of "21.0". This constitutes an immediate jeopardy to the resident's health and safety. The History and Physical with an admission date of [DATE] revealed Resident #6 received 10 milligrams (mg) of oral vitamin K (oral vitamin K therapy promptly reduces an elevated INR.) The physician noted the resident would be admitted to the hospital and given IV (intravenous fluids) for hydration. The physician identified the resident's medications especially [MEDICATION NAME] would be held. The physician documented Resident #6 had received a dose of vitamin K in the ER and they would have to see if that was enough to correct the greatly elevated INR. The resident's past medical history listed pneumonia, [MEDICAL CONDITIONS] [MEDICAL CONDITIONS], diabetes and [MEDICAL CONDITION] disorder. The Consultant Pharmacist's Medication Regime Review sheet dated 7/29/13 revealed the Pharmacist made a note he/she could not locate the current INR. The sheet had Follow - Through documented that Resident #6 had the last INR on 6/20/13 at the hospital and Resident #6 discharged to the hospital on [DATE]. An interview on 8/12/13 at 1:42 p.m. the Director of Nurses (DON) verified the 6/24/13 INR was not completed. The DON reported the order did not get placed on the schedule in the lab book. The DON reported the nurse that did the admitting orders did not put the order on the lab book and she usually double checks the labs. The DON reported she had been on maternity leave when this happened on 6/20/13. An interview on 8/7/13 at 6:30 p.m. with the interim DON from May 20 to July 17, 2013, she stated she missed the lab order for PT/INR on 6/24/13 when she checked the orders. An interview on 8/12/13 at 1:22 p.m. revealed the physician reported the bruising on Resident #6's inner thigh (measuring 20 x 9 cm on 7/21/13) had been caused by the elevated INR. The physician stated he had not been informed of the missing INR lab for 6/24/13 until the resident went to the hospital (7/21/13). The physician stated he responds to FAXES on the same day Monday -Thursday, but is off work on Friday's. The facility abated the IJ on 8/14/13 when they implemented the following: 1). Updated the DON Admission checklist on 8/14/13 to included checking/verifying labs are in the lab book. 2). The PT/INR Tracking Log implemented on 8/14/13. 3). Trained all nurses on the [MEDICATION NAME] education information. The facility reviewed all residents' charts on 8/16/13 to ensure no further lab orders were missed. The facility implemented the tracking log on 8/14/13. Staff were trained on 8/13/13 and 8/14/13 regarding the prior. These actions lowered the deficiency from a scope and severity of J to D, with the need for ongoing monitoring of labs when the DON is not present.

Based on clinical record review and interviews, the facility failed to provide the necessary treatment and services to promote healing and prevent new pressure sores from developing for one (1) of six (6) residents (Residents #6). The facility identified a census of 52 residents. Findings include: According to the July 2013 Medication Record revealed Resident #6 had a [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] revealed Resident #6 had severe cognitive impairments. Resident #6 required extensive assistance of two staff with transfers, dressing, toilet use and bathing. The resident's skin condition revealed the resident had zero (0) unhealed pressure ulcers at Stage 1 or higher. The assessment documented the resident did not have any of the following skin conditions: infection of the foot (for example [MEDICAL CONDITION]); [MEDICAL CONDITION](s); other open lesion(s) on the foot or open lesion(s) such as skin tear(s), burn(s), surgical wound(s), moisture associated skin damage (from incontinence, perspiration, or drainage). The facility checked the box on the MDS assessment which indicated the resident had none of the prior. The Care Plan dated 5/17/13 directed the staff to assess skin condition, dietary measures, use specialty mattress for the bed. The care plan directed staff to use barrier ointment after incontinence care, treatment per doctors order, and increase mobility and activity as tolerated. The care plan also directed staff to assess footwear, notify doctor as needed and therapy as ordered. The Care Plan updated 7/21/13 revealed Resident #6 had a fluid filled blister to the right heel and a red area to the left heel. The Care Plan updated 7/22/13 directed the staff to provide treatments as ordered and apply heel protectors. The Braden Scale - For Predicting Pressure Sore Risk dated 6/20/13 revealed the resident scored 15 which represented a low risk for developing pressure sores. The Nurse's Notes dated 7/19/13 at 7:20 a.m. revealed Resident #6 had a 3.2 by 1.2 centimeter red beefy area with a 1.0 by 0.6 centimeter yellow area to the right coccyx. The staff faxed the physician. The Nurse's Notes dated 7/19/13 at 7:00 p.m. revealed the area on Resident #6's coccyx remained and had some serosanguinous drainage. The Nurse's Notes dated 7/20/13 at 7:25 a.m. revealed the area to Resident #6's coccyx remained opened. The staff cleansed the area and applied barrier cream. The Patient Report facsimile (FAX) dated 7/21/13 revealed Resident #6 had a 5.1 by 4.1 centimeter clear fluid filled blister to the right heel and a 7.0 by 9.0 centimeter red area with a 5.0 by 4.0 white area to the left heel. The facility staff requested to please advise. Review of the Treatment sheets for July 2013 revealed the staff failed to treatment for [REDACTED]. The undated Communication Book entry informed the staff that Resident #6 had skin breakdown and to please reposition. The prior entry dated 7/20/13. An interview with the primary physician on 8/12/13 at 1:22 p.m. revealed the physician reported the pressure areas were due to Resident #6 immobile status. The physician reported he/she did not work on Fridays and faxes were not responded to but he/she did respond to faxes the same day on Monday through Thursday. An interview on 8/13/13 at 3:15 p.m. the Director of Nurses (DON) reported he/she could not find the fax that the staff sent to the physician on 7/19/13. The DON checked with the physician's office and they had not record of it. The DON was unaware that Resident #6's physician did not work on Fridays. An interview on 8/12/13 at 1:42 p.m. the DON verified the Care Plan was not updated to reflect the open area on Resident #6's coccyx. The DON reported Resident #6 was not at risk for developing pressure areas. The DON reported interventions used when a resident develops an pressure area included a nutritional program, increase calories and protein, use a cushion to the chair and add a vitamin. The DON reported Resident #6 moved to the assist dining room on 7/15/13 and other than that the DON did not know what interventions were put into place. During an interview with the Staff E, LPN (licensed practical nurse) on 8/18/13 at 2:18 p.m. she revealed she worked the day Resident #6 got the open areas on his/her bottom and the day he/she got the open areas on his/her heels. Staff E reported the aide reported he/she had an open area on bottom and she notified the physician by FAX and completed an assessment. She reported she did not call the physician, as he's not in the office on Fridays. Staff E reported Resident #6 had increased weakness and had been sitting in the wheelchair. Staff E reported noticing the changes on 7/19/13 to 7/21/13. On Sunday 7/21/13, an aide reported Resident #6 had a blister on his/her right heel and the left heel had redness. Staff E stated it (the pressure areas) was probably from pressure from the bed. Staff E reported the physician does not respond to faxes on the weekends. Staff E reported she did not recall putting intervention in place for the resident's heels and she did not chart any interventions. Staff E reported Resident #6 was not feeding him/her(self) and immobile in wheelchair.

Based on observation, clinical record review, interviews and facility policy review, the facility failed to assess and provide timely interventions to aid in the prevention of skin breakdown and promote healing for two (2) of four (4) residents (Residents #1 and #2). The facility identified a census of 44 residents. Findings include: 1. According to a Minimum Data Set (MDS) assessment dated [DATE] the resident had a Brief Interview for Mental Status (BIMS) score of 8 out of 15. A BIMS score of 8 revealed the resident had moderate cognitive impairments for daily decision making skills. The assessment identified Resident #1 dependent on two staff members for bed mobility, transfers, personal hygiene and for using the bathroom. The resident had an indwelling catheter and continent of his/her bowels. The assessment indicated the resident frequently complained of moderate pain and received as needed (PRN) pain medications. The assessment indicated the resident at risk for developing pressure ulcers and had one Stage 2 pressure ulcer present on admission. A hospital transfer form dated 1/21/13 indicated the resident had a 2 centimeter (cm) shallow open area to his/her right buttock that had been caused by friction/shearing. The form indicated the hospital staff had placed a Meplix dressing over the open area on 1/18/13. A Nursing Admission assessment dated [DATE] indicated the resident had a skin risk assessment score of 13. (A score of 12 or less represented a high risk). The assessment identified Resident #1 ' s skin was usually dry. The assessment determined Resident #1 had very limited mobility or ability to change and control body position and could occasional make slight changes in body position but unable to make frequent or significant changes independently. The assessment also identified Resident #1 required moderate to maximum assistance in moving. The nurse completing the assessment wrote the resident was bed bound, unable to get up in wheelchair at hospital due to weakness in legs. The form indicated Resident #1 had [DIAGNOSES REDACTED]. The assessment indicated the resident had numerous bruises and an open area to his/her coccyx. The facility staff indicated that due to a lack of supplies and no available Meplix dressing an assessment had not been completed to the resident's ulcered area on his/her coccyx. An Initial Care Plan (undated) indicated the resident had a pressure ulcer on his/her coccyx that required assessments and treatment of [REDACTED]. A Nurses Notes entry dated 1/21/13 at 3:45 p.m. indicated the resident had been admitted to the facility with a large Meplix dressing that covered his/her coccyx with no specific orders for a dressing change so the device had been left in place and no assessment had been completed. A Nurses Notes entry dated 1/21/13 at 6:45 p.m. indicated a treatment order clarification had been faxed to the physician. A Heritage Manor Nursing Home Patient Report form dated 1/21/13 at 6:45 p.m. and signed by the physician 1/22/13 indicated the facility received an order to change the Meplix dressing on the resident's coccyx every day (QD). A Nurses Notes entry dated 1/21/13 at 11:30 p.m. indicated the Meplix dressing on the resident's coccyx remained in place. A Nurses Notes entry dated 1/22/13 at 2 p.m. indicated the physician's orders [REDACTED]. A Nurses Notes entry dated 1/23/13 at 10 a.m. indicated the Meplix dressing on the resident's coccyx as in place and that the facility staff as waiting for the pharmacy to deliver the new dressing supplies. A Heritage Manor Nursing Home Patient Report form dated 1/25/13 at 3:40 p.m. indicated the following physician's order [REDACTED]. bordered foam dressing applied to his/her coccyx every day (QD) and PRN (as needed). A Treatment Administration Record (TAR) dated 1/1/13 indicated the resident had an order dated 1/22/13 for placement of a Meplix dressing on his/her coccyx QD to have been placed the 6 a.m. to 2 p.m. shift. The form revealed the following documentation: a. 1/23/13 - N/A (not applicable) b. 1/24/13 - N/A c. 1/25/13 - N/A d. 1/26/13 - nothing written (no staff initials present). e. 1/27/13 - staff initials present. f. 1/28/13 - staff initials present. g. 1/29/13 - staff initials present. A Nutritional Evaluation History and Data Collection form dated 1/24/13 indicated the resident had an open area on his/her coccyx with a recommendation for a supplement two times a day (BID). A Nurses Notes entry dated 1/24/13 at 2:45 p.m. indicated the resident received an order for [REDACTED]. A Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A Nurses Notes entry dated 1/25/13 at 9 p.m., indicated the Meplix dressing to the resident's buttocks had been removed which revealed a 2.5 cm x 4 cm dark purple discoloration to the left buttock and a 4 cm x 6 cm purple discoloration with peeling skin on the resident's coccyx with no bleeding, swelling or signs and symptoms of infection. The nurses note entry indicated a new Meplix dressing had been placed and a skin sheet had been initiated. A Nurses Notes entry dated 1/26/13 at 3:40 p.m. indicated a Meplix dressing on the resident's buttock and coccyx as intact. A Nurses Notes entry dated 1/27/13 at 10 a.m., indicated the resident's coccyx as intact with 2 blue/black areas. A Weekly Pressure Ulcer Progress Report documented the following information for the coccyx pressure ulcer: a. 1/28/13 - A stage I purple colored pressure ulcer that measured 4 cm x 6 cm with a superficial depth (skin peeling off) and no drainage or odor. b. 1/29/13 - A 5.5 cm x 6 cm unstageable purple/red area. A Weekly Pressure Ulcer Progress Report documented the following information for the pressure ulcer on the resident's right buttock. a. 1/25/13 - A stage I purple colored pressure ulcer that measured 2.5 cm by 4 cm with no depth, drainage or odor. b. 1/29/13 - A purple/red 3 cm x 4 cm area that had the appearance of sheared skin. During an interview 3/14/13 at 1:30 p.m., the DON confirmed the ulcered area should have been documented as on the left buttock. During an interview 3/13/13 at 2:45 p.m., Staff A, Licensed Practical Nurse (LPN) described the resident's gluteal ulcers as follows: a. The coccyx area as a deep purple color which had been lighter colored the day prior. b. The area on the left gluteal region as a deep purple area with blood present and the top layer skin removed. The staff member indicated area had been open less that 0.1 cm the day of the transfer and as not open the day prior. During an interview 3/14/13 at approximately 12:30 p.m., the DON described the resident's gluteal ulcers as follows: a. The coccyx area with a dark purple/black (escarp) area approximately silver dollar size with the surrounding tissue whitish in color but not soft or mushy. b. The area on the left gluteal region as a red patch of sheered skin, as if the top layer of skin had been removed and that the wound bed had been bright red. The DON indicated the surrounding skin as purple around the edges with no black color noted. A Nurse's Notes entry dated 1/29/13 at 9 a.m. indicated the resident had an 5.5 cm x 6 cm unstageable purple/red area on his/her buttocks and a 3 cm x 4 cm area of sheered skin on his/her left buttock. A Physicians Order Sheet and Progress Note form dated 1/29/13 indicated the resident with a 10 cm x 7.5 cm sacral pressure ulcer, the left buttock with a deep tissue injury and a necrotic area on his/her right inner buttock adjacent to the gluteal cleft. A Transfer Sheet dated 1/29/13 indicated the resident had open areas to his/her coccyx and right gluteal cheek. An Emergency Medical Record (EMR) dated 1/29/13 indicated the resident arrived to the unit at 2:38 p.m. A EMR form dated 1/29/13 at 4:57 p.m. indicated the resident had the following skin issues: a. A pressure ulcer to the sacrum and buttocks. b. The right inner buttocks adjacent to the gluteal cleft with dark brown, thick necrotic tissue. c. The left inner buttocks with a deep tissue injury. d. The right lower buttock with a shallow ulcer that measured 4 cm x 4 cm with a partially attached skin flap. The wound bed had been documented as beefy red and moist. A hospital Consultation form dated 1/30/13 indicated the physician assessed the resident's chronic ulceration with isthmian and necrosis in the sacral area with a plan for debridement. An Operative Report dated 1/31/13 indicated the resident received a surgical debridement of an ischemic necrotic sacrum decubitus ulcer. A EMR form dated 1/31/13 at 8:27 p.m. indicated the resident's coccyx pressure ulcer measured 4 cm x 4 cm with a clean, moist and pink wound bed and the surrounding skin pink and intact. A EMR form dated 2/1/13 at 4:41 p.m. indicated the resident's sacrum/coccyx pressure ulcer measured 7.5 cm by 7.5 cm x 2 cm with a moist wound appearance, blistered surrounding tissue and minimal drainage. An Operative Report dated 2/4/13 indicated the resident received another surgical sharp debridement of the sacral decubitus ulcer. A EMR form dated 2/4/13 at 8:40 p.m. indicated the resident's sacrum/coccyx pressure ulcer measured 7.5 cm by 7.5 cm x 2 cm with a pink wound bed. A EMR form dated 2/5/13 at 10 a.m. indicated the resident's sacrum/coccyx pressure ulcer measured 7.5 cm by 7.5 cm x 2 cm with a moist wound appearance, blistered surrounding tissue and minimal drainage. A EMR form dated 2/6/13 at 9:15 a.m. indicated the resident had the following skin issues: a. A sacrum/coccyx pressure ulcer that measured 9.5 cm x 7.6 cm x 3 cm with a moist wound bed with 40% red granulation tissue and 60% slough. b. A 15 cm x 13 cm reddened peri wound area with a minimal amount of sanguinous drainage from the drain. c. Bilateral lower buttocks skin tears. d. A right lower buttock skin tear that measured 2 cm x 3 cm with a moist wound bed and 50 % red tissue and 50 % slough. A physician progress notes [REDACTED]. A Discharge Summary form electronically signed by a physician 2/20/13 indicated the resident as admitted to the hospital with [REDACTED]. A Discharge Summary form signed by the physician 2/20/13 indicated the resident passed away peacefully on 2/18/13 and that the resident had originally been admitted to the hospital for wound management and TPN. During an interview on 3/15/13 at 2:25 p.m. the surveyor received a return call back from the physician ' s office from a nurse. The nurse reported the physician ' s response as follows: " yes, the physician stated the decubitus ulcer was preventable if appropriate treatments and interventions were utilized (by the facility). " In an early phone with the nurse at the physician ' s office, she relayed on 3/15/13 at 10:50 a.m., the physician stated the decubitus ulcer contributed to the resident ' s death but was not the primary cause of death. A Certificate of Death dated 2/20/13 indicated the resident passed away related to multi-action failure, end stage [MEDICAL CONDITION], tobacco use and a sacral decubitus ulcer with the significant conditions contributing to the death [MEDICAL CONDITION] and the sacral pressure ulcer. During an interview 3/13/13 at 3 p.m., the DON confirmed the resident as admitted to the facility with an open area on his/her coccyx with a treatment order for an application of a Meplix dressing. The DON confirmed the facility failed to appropriate obtain a supply of the Meplix dressing and that the nurses failed to remove and assess the open area on the resident's coccyx and that she would have expected them to do so. 2. According to an MDS assessment dated [DATE] Resident #2 had [DIAGNOSES REDACTED]. The MDS assessment indicated the resident had short and long term memory deficits, severely impaired cognitive skills, dependent on staff with personal hygiene and toilet use, always incontinent of his/her bowels and bladder and with one stage 2 pressure ulcer. A Care Plan dated 1/11/13 indicated the resident had a problem with potential for and/or actual changes in skin integrity related to incontinence. The approaches included the following: a. Assess the skin condition. b. Treatment as ordered to the coccyx. c. Notify the physician PRN. d. Make sure briefs are not to tight. e. Make sure briefs were applied properly. A TAR dated 3/1/13 through 3/31/13 indicated the resident had an order dated 12/28/12 for an application of zinc oxide 20 % ointment to the open area on his/her coccyx BID. The form indicated the treatment as applied 3/1/13 through 3/14/13 but discontinued after the 6 a.m.- 2 p.m. shift on the 14th. An observation 3/13/13 at 1:25 p.m. revealed Staff A, LPN had measured an open area on the resident's right middle buttock at 0.5 cm x 0.9 cm with redness surrounding the area and then applied zinc oxide ointment. There had been no open area present on the resident's coccyx area. Review of a Weekly Pressure Ulcer Progress Report initiated 12/28/12 indicated the area on the resident's coccyx area as resolved on 2/18/13 and 2/25/13. During an interview 3/14/13 at 11:10 a.m., the DON confirmed the area on the resident's coccyx had been resolved on 2/25/13 but the staff proceeded to treat and document the ulcered area on the resident's right buttock as if it was the coccyx ulcer and utilized the same pressure form and treatment. The DON confirmed the staff failed to realize they were required to discontinue the order for the coccyx and receive a new physician's order [REDACTED]. A Nursing Policy Book revised 9/05 indicated one of the general guidelines for wound care as an evaluation that all preventative measures were in place or whether new interventions would have been beneficial to the resident. The Nursing Policy Book indicated prevention as key with a directive that all residents required a head-to toe assessment upon admit (and re-admit) and the documentation would have reflected the head to toe assessment had been completed which would have included the heels and coccyx areas. The DON would have been expected to review the assessment within 24 hours and look for areas of concern that may have required follow up (i.e., a 1 cm red area on the coccyx or a spongy heel noted would have been documentation the DON would have followed up on in observation of the area) During an interview 3/14/13 at approximately 12 p.m., the DON confirmed the nursing staff required continued education related to the facilities wound care protocol.