Every finding on record at Allure of Walnut

Based on interview and record review, the facility failed to perform a PASARR (Pre-Admission Screening and Resident Review) rescreen after the emergence of a newly diagnosed severe mental illness for two of three residents (R4, R27) reviewed for PASARR screening, in the sample of 24. Findings include: The (undated) facility policy, Resident Assessment- Coordination with PASARR (Pre-Admission Screening and Resident Review) Program directs staff, This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability or a related condition receives care and services in the most integrated setting appropriate to their needs. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. 1. R4's (facility) Face Sheet documents that R4 was admitted to the facility on [DATE] with the following diagnosis: Bipolar Disorder (11/14/23). R4's Notice of PASARR, dated 7/21/20 documents, No Level II required- No Serious Mental Illness. On 4/22/25 at 10:00 A.M., V1/Administrator verified that R4 had not had a PASARR rescreen upon the emergence of a newly diagnosed severe mental illness. 34048 2. R27's current Face Sheet documents the following diagnosis: Insomnia, Delusional Disorder, Post-Traumatic Stress Disorder, Dementia, unspecified severity, with other Behavioral Disturbance, General Anxiety. R27's PASRR, Preadmission Screening and Resident Review, dated 8/28/23, documents that R27 does not show that she has a serious mental illness or an intellectual/developmental disability (IDD). You do not need more screening unless you have or may have a serious mental illness or an IDD and are experiencing a significant change in treatment needs. On 4/22/25 at 2:00pm, V1, Administrator, verified that R27 did not have a PASRR screening completed after R27 was diagnosed with a mental illness.

Based on interview and record review, the facility failed to ensure a PASARR (Preadmission Screening and Resident Review) Level II screening was completed for one of three residents (R31) reviewed for PASARR screenings in the sample of 24. Findings include: The facility's Resident Assessment- Coordination with PASARR (Preadmission Screening and Resident Review) policy documents the following: All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. This same policy documents, Positive Level I Screen- necessitates a PASARR Level II evaluation prior to admission. This policy also documents, The Level II resident review must be completed within 40 calendar days of admission. R31's medical record documents R31's current diagnoses to include: Psychotic Disorder with Hallucinations due to known Physiological Condition; Anxiety Disorder; and Major Depressive Disorder. R31's medical record documents the above diagnoses were present at the time of R31's admission to the facility on [DATE]. R31's Notice of PASARR (Pre-admission Screening and Resident Review) Level I Screen Outcome (dated 07/18/2) documents the following: PASARR Level I Determination: Refer for Level II Onsite. This same form also documents, Your health care professional and (local agency) completed a PASARR Level I screen for you. This screen shows you need a face-to-face Level II evaluation. PASARR Level I screens and Level II evaluations are required by Federal law. You need this evaluation because you may have serious mental illness or an intellectual/developmental disability. The purpose of this evaluation is to decide whether a nursing facility is able to meet your needs. A clinician working for (local agency) will complete the Level II evaluation with you on behalf of (State Agency). R31's medical record does not contain documentation of that a PASARR Level II screening was ever completed. On 04/23/25 at 09:45 AM, V1 (Administrator) confirmed that R31 has not received a Level II PASARR screening while he has resided at the facility.

Based on interview, observation and record review, the facility failed to ensure a pressure ulcer treatment was completed as ordered for one of two residents (R31) reviewed for pressure ulcers in the sample of 24. Findings include: The facility's Wound Treatment Management policy (dated 2024) documents the following; Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. R31's Wound Evaluation and Management Summary (dated 04/22/25) documents the following after V8 (Wound Physician) examined R31 on 04/22/25: Stage III pressure wound of the left sacrum full thickness. Surgical Excisional Debridement Procedure: The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, curette was used to surgically excise 3.70 square centimeters of devitalized tissue including slough, biofilm and non-viable subcutaneous level tissues were removed at a depth of 0.2 centimeters and healthy bleeding tissue was observed. This same form documents the following treatment orders: Discontinue: skin prep (skin protectant). Add: Leptospermum honey apply once daily and as needed if saturated, soiled or dislodged. Gauze island with border apply once daily and as needed if saturated, soiled or dislodged. On 04/23/25 at 01:00 PM, V6 (Registered Nurse) entered R31's room to provide cares to the pressure ulcer located on his sacrum. R31 was lying supine in bed, and V9 (Certified Nursing Assistant) was standing next to R31's bed. V9 indicated she would be providing positioning assistance to R31 during cares. V9 assisted R31 to roll onto his left side while V6 removed the current dressing he had in place. An oblong, open area measuring approximately 3.8 centimeters by 2.5 centimeters was present on R31's sacrum with small amount of scattered slough tissue present. V6 cleansed R31's sacral area and then applied skin prep to R31's recently debrided sacral pressure ulcer. Once R31's cares were completed, V6 and V9 assisted R31 to reposition in bed. On 04/23/25 at 01:12 PM, V6 stated she was not aware that R31 had a new treatment order for his sacral pressure ulcer. On 04/23/25 at 01:15 PM, V2 (Director of Nursing) verified that R31 did not receive the current physician-ordered treatment that was in place following the recent debridement of his sacral pressure ulcer. V2 stated, I'm going to be honest with you. The new order has not been processed yet and we do not have the (leptospermum honey) at the facility. It will have to be ordered. (R31) should not have applied skin prep to (R31's) pressure ulcer.

Based on interview, observation and record review, the facility failed to ensure a range of motion program was implemented for a resident with functional limitations for one of four residents (R31) reviewed for range of motion in the sample of 24. Findings include: R31's Medical Record documents R31's current diagnoses to include: Parkinson's Disease with Dyskinesia; Adult Failure to Thrive, and Chronic Pain. R31's Minimum Data Set Assessment (dated 03/13/25) documents the following in Section GG: R31 has impairment on both sides of his lower extremities. R31's Restorative Observations form (dated 03/13/25) documents the following: R31 has mild (75% of normal) state of mobility in his neck, left hip, right hip, left ankle, and left foot; R31 has moderate (50% of normal) state of mobility in his left knee, right knee, right ankle, and right foot. On 04/21/25 at 01:40 PM, R31 was sitting reclined in a high-back reclining chair in the hallway near his room with a fall alarm in place. R31 was wearing glasses and non-slip socks. A wheelchair cushion with a raised, padded section in the center that was separating R31's legs was in place. R31 stated facility staff do not encourage or assist him to complete any type of range of motion exercises. R31's medical record does not document any type range of motion program in place. On 04/23/25 at 03:25 PM, V2 (Director of Nursing) stated, (R31) does not have a range of motion plan in place and he should.

Based on interview, observation and record review, the facility failed to ensure tubing for an enteral tube feeding was dated, and items utilized during a tube feeding remained clean for one of two residents (R1) reviewed for tube feedings in the sample of 24. Findings include: The facility's Care and Treatment of Feeding Tubes policy (dated 2024) documents, It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. This policy also documents, Use of infection control precautions and related techniques to minimize the risk of contamination. R1's current Physician's Orders document the following nutritional order: Jevity (nutritional feeding) 1.2 kilocalories per milliliter give 85 milliliters per hour via gastrostomy tube in the evening. Run at 85 milliliters per hour for 16 hours and remove per schedule. R1's current Care Plan documents the following focus: (R1) requires a tube feeding related to dysphagia due to a stroke. She is NPO (nothing by mouth). She receives all of her nutrition and fluids via gastrostomy tube. On 04/21/25 at 08:55 AM, R1 was lying in bed with the head of her bed elevated approximately 45 degrees. A bottle of tube feeding and a tube feeding administration pump were both hanging on a nearby wheeled pole at R1's bedside. R1's bottle of tube feeding was connected to tubing that was in place through the tube feeding pump. R1's tube feeding pump was infusing her tube feeding at 85 milliliters per hour. R1's wheeled pole and the tube feeding pump contained multiple areas of a dried, light brown substance. V5 (Registered Nurse) verified R1's tube feeding pole and the administration pump contained areas of a dried, light brown substance at this time and stated, There are several areas of dried tube feeding on them (R1's wheeled pole and tube feeding pump). They both need to be cleaned. V5 then stated the tubing being utilized to administer R1's tube feeding should be dated with the date it began being used. V5 then located a label attached to the tube feeding tubing, and upon inspection, confirmed that it was blank and did not contain a date. V5 stated, The tubing should be dated and it is not.

Based on interview and record review the facility failed to implement specific PTSD/Post Traumatic Stress Disorder interventions for one of one (R27) residents reviewed for Post Traumatic Stress Disorder in a sample of 24. Findings include: The facility's Trauma Informed Care policy, undated, documents it is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally-competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatizing. This form documents that trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being. R27's current Face Sheet documents the following diagnosis: Insomnia, Delusional Disorder, Post-Traumatic Stress Disorder, Dementia, unspecified severity, with other Behavioral Disturbance, General Anxiety. R27's Trauma Informed Care Assessment, dated 8/30/23, documents PTSD (Post Traumatic Stress Disorder) Screen: Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example: a serious accident or fire, a fire, a physical or sexual assault or abuse, an earthquake or flood, a war, seeing someone be killed or seriously injured, having a loved one die through homicide or suicide. 1. Have you ever experienced this kind of event. The yes box is marked. This form documents that R27 has nightmares about the event(s) or thought about the events when you did not want to. R27's current care plan documents that R27 has a diagnosis of PTSD. R27's PTSD is nightmares. They're not necessarily the same dreams every night but she still has them. R27's care plan does not address the actual trauma or the possible triggers for R27's PTSD. On 4/23/25 at 12:30pm, V7, Minimum Data Set Coordinator, stated that she does not know exactly what R27's PTSD is. V7 verified that she does not know what R27's triggers are for her PTSD. V7 verified that V7's current care plan does not have specific goals and interventions concerning R27's PTSD triggers. V7 stated that even R27's family does not know what R27's PTSD is. On 4/24/25 at 12:15pm, V2, Director of Nursing, stated that she does not know what R27's PTSD is related to. V2 stated that it is thought to be because of her dreams.

Based on interview, observation, and record review, the facility failed to ensure Enhanced Barrier Precautions were implemented prior to administering cares for two of eight residents (R31 and R41) reviewed for Transmission Based Precautions in the sample of 24. Findings include: The facility's Enhanced Barrier Precautions policy (dated 2025) documents the following: It is the policy of this facility to implement Enhanced Barrier Precautions for the prevention of transmission of multi-resistant drug organisms. Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug resistant organisms that employs targeted gown and gloves use during high contact resident care activities. This policy also documents, High-contact resident care activities include: Dressing; Bathing, Transferring; Providing hygiene; Changing linens; Changing briefs or assisting with toileting; Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC (peripherally inserted central catheter) lines, midline catheters; Wound care: any skin opening requiring a dressing. 1. R31's Wound Evaluation and Management Summary (dated 04/22/25) documents R31 has a non-pressure wound on his left anterior leg. R31's current Physician's Orders document the following order: May use EBP (Enhanced Barrier Precautions) per policy as needed for indwelling medical devices, wounds, that require dressings, or infected or colonized with MDRO (Multidrug Resistant Organisms)/XDRO (Extensively Drug-Resistant Organisms). On 04/23/25 at 10:25 AM, a sign indicating Enhanced Barrier Precautions was posted on R31's door. V6 (Registered Nurse) entered R31's room to provide wound care to R31's left anterior leg wound. V6 washed her hands, applied gloves and approached R31, who was lying supine in a low bed. V6 removed R31's current dressing in place, and an oblong, open area measuring approximately 2.5 centimeters by 1.2 centimeters containing a small amount of slough tissue was present on R31's left anterior leg. V6 cleansed R31's wound, applied a collagen-based dressing, and covered the area with a border gauze dressing. V6 did not wear a gown while administering R31's cares. On 04/23/25 at 01:00 PM, V6 (Registered Nurse) stated Enhanced Barrier Precautions should be in place for R31, and verified she did not wear a gown while performing R31's wound care. 34048 2. R41's current Physician Order Sheet documents to use Enhanced Barrier Precautions per policy as needed for indwelling medical devices, wounds, that may require dressing, or infected or colonized with MDRO/XDRO (Multi-drug-Resistant Organisms/Extensively Drug Resistant Organisms). On 4/23/25 at 2:16pm, A sign indicating Enhanced Barrier Precaution was posted on R41's door. V6, Registered Nurse, entered R41's to perform gastrostomy tube care. V6 changed R41's gastrostomy tube insertion site care and flushed R41's gastrostomy tube with water as ordered. V6 performed hand hygiene during care. V6 did not donn a gown during cares. On 4/23/25 at 2:30pm, V6 verified that R41 is on EBP. V6 stated that she did not donn a gown during R41's care.

Based on Interview and Record review, the facility failed to prevent an incident of resident to resident physical abuse, re-assess resident's risk for abuse and revise abuse care plans after founded physical abuse occurred for two of three residents (R1, R2) reviewed for abuse in the sample of three. Findings include: The facility's Abuse, Neglect and Exploitation policy, dated 8/2024, documents It is the policy of this facility to provide protections for health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Physical Abuse includes but it not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. This same policy also documents The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. The facility's Care Plan Revisions upon Status Change policy, dated 8/2024, documents The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. The care plan will be updated with the new or modified interventions. Staff involved in the care of the resident will report resident response to new or modified interventions. Care plans will be modified as needed by the MDS (Minimum Data Set) Coordinator or other designated staff member. The Unit Manager or other designated staff member will communicate care plan interventions to all staff involved in the resident's care. The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs. The facility's Abuse Investigation, dated 2/15/25, documents on 2/15/25 between 5:15 PM and 5:30 PM, R2 was slapped on her facial cheek by R1 in the facility's common area day room. This investigation documents V4 (Registered Nurse) was witness to the incident and that the abuse was investigated to be substantiated, without injury to either resident. R1's current Care Plan dated, 2/20/25, documents (R1) has a behavior problem in related to her diagnosis of dementia with behavioral disturbances. She can be uncooperative with care. She may attempt to hit staff or refuse to transfer/refuse care. She may become angry, anxious and agitated. This plan of care has an intervention added on 2/15/25 of If (R1) becomes aggressive with another resident, separate them immediately. This same Care Plan documents a plan of care initiated on 12/4/23 of (R1) is at a low risk for abuse, neglect, exploitation, trauma as noted from Abuse screening related to dementia and anxiety. Intervention: (Facility) Abuse/Neglect/Trauma assessment quarterly or prn (as needed). This plan of cares most recent revision is dated 12/19/24. R2's current Care Plan, dated 2/20/25, documents (R2) has impaired cognitive function. She usually scores in range of moderate cognitive impairment on BIMS (Brief Interview for Mental Status). She has moderate hearing impairment which may affect her cognitive function. (R2) is also easily distracted and can have delusional thinking at times. She also has a diagnosis of dementia. This plan has an intervention added on 2/15/25 of If (R2) becomes aggressive with another resident, separate them immediately. This same Care Plan documents a plan of care initiated on 12/4/23 of (R2) is at a low risk for abuse, neglect, exploitation, trauma as noted from Abuse screening related to dementia, attention and concentration deficit. Intervention: (Facility) Abuse/Neglect/Trauma assessment quarterly or prn (as needed). This plan of cares most recent revision is dated 12/24/24. On 3/7/25 at 12:15 PM, V5 (Registered Nurse/ MDS coordinator) confirmed she did not update the Abuse Care Plans for R1 and R2. V5 stated I added an intervention to their behavior Care Plans that if they are aggressive, to remove them from other resident contact. V5 confirmed that both R1 and R2 are still Care Planned as being at a low risk for abuse. On 3/7/25 at 12:25 PM, V6 (Social Service Director) confirmed she is the person who does Abuse risk assessments and created the Abuse Care Plans for R1 and R2. V6 stated I only update the Abuse specific Care Plan with a re-assessment, either quarterly or on an MDS significant change review. That is when I would complete a new Abuse risk assessment. I guess (V5) would be the one who updates the care plans with new interventions in between that time. V6 confirmed she has not done a new risk assessment for Abuse and has not made any revisions to the Abuse risk care plans for R1 and R2 since the 2/15/25 physical abuse occurred. On 3/7/25 at 1:25 PM, V4 (Registered Nurse) confirmed she was working on 2/15/25 and was witness to a physical altercation between R1 and R2. V4 stated I was the nurse that was present when the altercation took place. The residents were in the day room, which is where the television is. I was at the nurses station and I heard (R2) say Stop that. I looked and could see that (R1) was fiddling with (R2's) wheelchair and (R2) said Stop that again and tried to swat (R1's) hand away. I got up from the desk and I saw (R1) slap (R2) on the face, due to the disagreement. (R2) did say her cheek hurt. (R1) likes to fiddle with stuff and we try to keep her busy and monitored. (R1) just needs closer supervision when around other residents.

Based on record review and interview, the facility failed to identify the indication for the prolonged duration of use for 1 of 1 (R22) resident with a prescribed antibiotic maintenance dose in a sample of 12 residents. Findings include: On 11/24/22, R22's Physician ordered an Antibiotic for maintenance dose for a history of frequent of Urinary Tract Infections with no stop date. On 2/22/24, R22's Careplan documents (R22) has developed a UTI (Urinary Tract Infection). Doctor ordered no stop date and would like R22 to be on a maintenance dose of Antibiotic therapy. On 8/21/23, R22's Physician ordered an Antibiotic for treatment of a Urinary Tract Infection for 7 days. On 5/7/24, R22's Physician ordered an Antibiotic for treatment of a Urinary Tract Infection for 10 days. On 5/22/24 at 11:45 AM, V3 (Infection Control Preventionist) stated I don't know why R22 is on it (maintenance Antibiotic). It (maintenance Antibiotic) hasn't stopped R22 from getting UTI's.

Based on observation, interview and record review, the facility failed to administer medications as ordered by the physician for three residents (R4, R27 and R31) on the sample of 10 residents reviewed for medication pass. This failure resulted in four medication errors out of thirty- one opportunities for error, for a 21.9% medication error rate. FINDINGS INCLUDE: The facility policy, Medication Administration, dated (7/1/23) directs staff, 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, in a manner to prevent contamination or infection. Ensure the six rights of medication administration are followed: right resident, right drug, right dosage, right route, right time and right documentation. 1. R4's current Physician Order Sheet, dated May 2024 includes the following medications: Baclofen 10 MG (1/2 tab) one tablet twice daily; Eliquis 5 MG one tab twice daily; Glucophage 500 MG one tablet two times daily with food; Tylenol 500 MG one tablet two times daily; Lyrica 100 MG one capsule each evening and Carboxymethylcellulose Sodium Solution instill two drops in both eyes two times daily. On 5/20/24 at 3:46 PM, V4/Licensed Practical Nurse (LPN) prepared to administer medications for R4. V4/LPN administered one each of Baclofen, Eliquis, Glucophage, Tylenol and Lyrica to R4. V4/LPN then administered one drop of Carboxymethylcellulose Sodium Solution into both of R4's eyes. Upon exit from R4's room, V4/LPN confirmed the instructions on the bubble pack for Glucophage included the following instructions: Take with food. V4/LPN also confirmed that R4 should have received two drops of Carboxymethylcellulose in each eye. 2. R27's current Physician Order Sheet, dated May 2024 includes the following medications: Tylenol 325 MG two tablets twice daily; Allopurinol 100 MG one tablet twice daily; Aspirin 81 MG one tablet daily; Diltiazem ER 240 MG one capsule daily; Vasotec 20 MG one tablet daily; Glipizide 5 MG one tablet daily; Potassium Chloride ER (Extended Release) 10 MEQ (Milliequivalents) one tablet two times daily and Olopatadine HCL (Hydrochloride) 0.2% two drops to both eyes in the morning. On 5/21/24 at 7:56 AM, V5/Registered Nurse (RN) prepared to administer medications for R27. V5/RN administered one each of Alopurinol, Aspirin, Diltiazem, Vasotec, Glipizide, Potassium Chloride and two tablets of Tylenol. V5/RN then administered one drop of Olopatadine HCL (Hydrochloride) into both of R27's eyes. Upon returning to the medication cart, V5/RN confirmed that R27 should have received two drops of Olopatadine HCL in each eye. 3. R31's current Physician Order Sheet, dated May 2024 includes the following medications: Cranberry Capsule 200 MG one capsule twice daily; Potassium Chloride Extended Release 20 MEQ (Milliequivalents) one tablet two times daily; Sucralfate 1 GM (Gram) one tablet before meals and at bedtime, take 2 hours before or 2 hours after other medications. On 5/20/24 at 3:30 PM, V4/Licensed Practical Nurse prepared to administer medications for R31. V4/LPN administered one capsule of Cranberry 200 MG, and one tablet each of Potassium Chloride 20 MEQ and one capsule Sucralfate 1GM. Upon exit from R31's room, V4/LPN confirmed the instructions on the bubble pack for Sucralfate included the following instructions: Take two hours before or two hours after other medications.

Based on record review and interview, the facility failed to identify, track, monitor and analyze for trends in data for 2 of 2 (R3, R22) in a sample of 12 residents. Findings include: The Infection Prevention and Control Policy and Procedure policy, dated 7/28/21, documents an Infection Criteria Checklist includes the date the infection was first suspected, evidence the infection was or was not present upon admission, what infection is present, testing, treatment, outcome and follow-up. The Infection Prevention and Control Monthly Log will be completed and used to track infections in the facility and noting trends that may be present. R3's Physician's Orders dated 4/4/24, 4/10/24 and 4/18/24 documents an Antibiotic was ordered for treatment of a Urinary Tract Infection. The Infection Prevention and Control Monthly Log dated April 2024 lacked documentation of R3's Urinary Tract Infection and the other required data. R22's Physician's Orders dated 11/22/23 documents an Antibiotic was ordered for an Upper Respiratory Infection. The Infection Prevention and Control Monthly Log dated November 2023 lacked documentation of R22's Upper Respiratory Infection and the other required data. On 5/22/24 at 12:30 PM, V3 (Infection Control Preventionist) reviewed the November 2023 and April 2024 Infection Prevention and Control Monthly Logs and stated R3 and R22's infections were not documented on the log and should have been. V3 stated I must have just over looked them (R3 and R22's infections).

Based on interview and record review the facility failed to revise the care plan to to include preference to exclude specific staff from providing care for one (R2) of two residents reviewed for care plans. Findings include: On 8/2/23 at 1:10 pm, R2 stated that V4, CNA is always in a hurry to get to the next resident We don't see eye to eye. R2 stated that V4 was changing him in the sit to stand lift and was trying to balance on his bad foot and bad hip/leg. R2 stated V4 doesn't clean him well, just wipes with dry paper. R2 stated that he told them he didn't want V4 as a caregiver again and it was ok for 2-3 days, then V4 answered my light and came in to help me go to the bathroom. On 8/3/23 at 12:15 pm, V2 DON (Director of Nursing) stated R2 did notify her that he did not want V4 to provide care. V2 stated they should have updated R2's care plan with R2's request. Current care plan did not include any documentation that R2 did not want V4 providing his care.

Based on observation, interview and record review the facility failed to identify an appropriate indication for administration of an antipsychotic medication for two residents with a diagnosis of Dementia (R31, R42) of three residents reviewed for unnecessary antipsychotic medications in the sample of 18. Findings include: Facility Policy/Psychotropic Medication dated/revised 11/28/17 documents: These medications are to be given to treat a specific condition/medical symptom that is diagnosed and documented in the medical record. Specific condition/medical symptoms alone are not enough to justify pharmalogical use. An evaluation must be done to determine other possible physical, mental, behavioral, psychosocial needs. Additionally, antipsychotic medication may be indicated for use if: Behavioral symptoms present a danger to the resident or others; Expressions or indications of distress that are significant distress to the resident. 1) Physician's Order Summary Report indicates R31 was admitted to the facility 12/31/19 with diagnoses that include Chronic Post Traumatic Stress Disorder, Unspecified Dementia - Unspecified Severity with Other Behavioral Disturbance, Moderate Recurrent Major Depressive Disorder, Adjustment Disorder with Depressed Mood, Unspecified Macular Degeneration. Report indicates Seroquel (antipsychotic) 25mg (milligrams) at bedtime related to Chronic Post-Traumatic Stress Disorder was initially ordered on 1/19/23. MAR (Medication Administration Record) indicates R31 continued to receive Seroquel through 3/15/23. Pre Admission Screening dated 1/4/20 indicates R31 was admitted without mental illness or developmental disability. Antipsychotic Medication Consent indicates consent was received to administer Seroquel 25mg for Post-Traumatic Stress Disorder on 1/18/23. Consent indicates medication is used to treat specific conditions, such as Schizophrenia, Delusional Disorder, Schizoaffective Disorder, Acute Psychotic Episodes, Atypical Psychosis, Tourette's Disorder, Huntington's Chorea, Psychotic Mood Disorder, Manic Behavior. Behavior Note dated 1/31/2023 at 7:29pm indicates peer talking on her cell phone propelling herself down the hallway when above resident R31 started yelling at peer and grabbed the arm of the wheelchair and stopped peer from going on any further - yelling at peer that she should not be talking on the phone and continued to yell at peer. Staff separated R31 from peer, then R31 again wheeled toward peer and grabbed the wheel of her wheelchair and prevented peer from going any further - again residents separated with R31 brought to day room completely away from peer. Behavior Note dated 2/14/23 at 8:57pm indicates R31 was agitated and rude to peer. Note indicates R31 and peer separated No further behaviors noted. Behavior Note dated 3/9/23 at 6:34pm indicates R31 agitated with staff, threatening to hit nurse because no one was helping her; told nurse and another staff to stop talking and take care of her. Note indicates R31 did go to her room, put on call light and was pleasant as shift progressed. CNA (Certified Nurse Assistant) Behavior Monitoring and Interventions Report dated 1/1/23 to 3/15/23 indicates R31 had the following behaviors: 3/9/23 threatening others. No other behaviors identified between 1/1/23 and 3/15/23. Current Comprehensive assessment dated [DATE] indicates R31 had no hallucinations, delusions, wandering or behavior symptoms and behavior is Improved. Current Care Plan indicates R31 has a behavior problem related to diagnosis of dementia; R31 can curse, yell, push and have repetitive movements. Care Plan indicates R31 can be rude and verbally abusive to staff, residents and visitors; can be difficult to redirect. Current Care Plan also indicates R31 receives an antipsychotic for her PTSD (Post Traumatic Stress Disorder) related to tragically losing a son within the last couple of years that R31 witnessed. Care Plan indicates R31 thinks about her son and the accident throughout the day and is angry at GOD for letting this happen. Psych Services Note dated 1/18/23 and 3/15/23 indicate R31 has no Abnormal/Psychotic/Perceptual Disturbances. Note indicates Behavior is Within Normal Limits. On 3/16/23 at 1:00pm V5, MDS (Minimum Data Set) Coordinator stated R31 didn't talk about losing her son unless she was asked about it directly. V5 stated that she questioned the psychiatric services order for Seroquel for R31 but She's the physician and felt she couldn't question the order for the antipsychotic medication any further. V5 stated that they now have orders to reduce and then discontinue the Seroquel. 41869 2) R42's medical record documents R42 admitted to the facility on [DATE]. R42's medical record dated 1/6/23 documents a diagnosis of unspecified dementia, unspecified severity with agitation. R42's physician visit with V9, Medical Doctor (MD), dated 12/28/22 documents Primary Diagnosis: Severe dementia without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety, unspecified dementia type. R42's medical record does not include a diagnosis of psychosis prior to 1/18/23. R42's behavior tracking dated 1/7/23 at 7:31 PM documents Behaviors: noted agitation and hitting staff in the dining room. verbally threatening others. redirected. reassured. one on one. calmed down. seems to dislike crowds of people. will talk to self. very confused. orientated only to self. R42's behavior tracking dated 1/8/23 at 6:06 PM documents Behaviors: Wandering: exit seeking. verbally abusive to staff. redirected. reassured. R42's progress notes dated 1/9/23 at 8:47 PM documents Resident alert and oriented to person, expressed agitation and wandering this evening, along with exit seeking and hitting CNA (Certified Nursing Assistant). Resident was unable to be redirected. Resident thought that staff were wearing masks to hide something. Resident has hallucinations and carried on conversations with those hallucinations. R42's progress notes dated 1/10/23 at 8:18 PM documents Resident alert and oriented to person, wandering halls, and having hallucinations. Resident will talk to hallucinations as if real, no pain or shortness of breath noted at this time, will continue to monitor. R42's physician order dated 1/10/23 by V9, MD, documents Haloperidol (Haldol) Tablet 5.0 milligrams (mg). Give 5.0 mg by mouth every 24 hours as needed for agitation and restlessness. R42's physician order sheet dated 1/10/23 and ordered by V9, MD, documents Haloperidol Tablet 5.0 mg. Give 5.0 mg by mouth every 24 hours as needed for agitation and restlessness. R42's antipsychotic consent form dated 1/10/23 documents Haloperidol 5.0 mg every 24 hours as needed for agitation and restlessness. R42's medication administration record dated January 2023 documents R42 received Haldol 5.0 mg on 1/12/23 and 1/13/23. R42's medical record documents R42's initial psychiatric assessment by V7, Psychiatric Nurse Practitioner (NP), was conducted on 1/18/23. On 03/15/23 at 11:04 AM, V6, Medical Director, stated I've never seen anyone develop psychosis late in life. You don't develop psychosis at [AGE] years old outside of drug induced psychosis which he (R42)doesn't have. He shouldn't have the unspecified psychosis not due to a substance or known physiological condition diagnosis. I agree with what you're saying, (R42) has no history of psychosis and all of his behaviors can be associated with dementia. So I agree with you that his symptoms and behaviors can be from dementia. On 3/17/23 at 9:50 AM, V8, Regional Nurse Consultant, verified R42 did not have a diagnosis of psychosis prior to being administered an antipsychotic medication and stated The order came from his outside personal physician (V9, MD). It didn't come from the medical director (V6, MD) or our psychiatric provider (V7, NP). (V7, NP) didn't evaluate (R42) until 1/18/23. What happened is that the nurse called his personal physician due to his behaviors and they ordered the Haldol and no one questioned the order. No, they didn't try any other medications for his behaviors prior to giving him the Haldol.

Based on observation, interview and record review, the facility failed to perform gastrostomy tube care using aseptic technique for one of one residents (R29), reviewed for gastrostomy tubes, in a sample of 20. FINDINGS INCLUDE: The facility policy, Enteral Tube (gastrostomy/ [DEVICE]) Exit Site Care, dated (revised) 11/2016 directs staff, A resident with an enteral tube will receive daily care to prevent infection. Newly established sites or sites with current infections that require specialized nursing care will be cared for by licensed nursing staff. R29's current Physician order [REDACTED]. This same form contains the following physician orders: Cleanse G tube site daily. Mix [MEDICATION NAME] Cream 1% (topical antimicrobial ointment) and [MEDICATION NAME] Cream 0.1% (corticosteroid ointment) and put around site. Cover with drawtex secure with tape on dressing, not on site. On 3/23/21 at 10:10 A.M., V4/Licensed Practical Nurse (LPN) prepared to perform wound care to R29's [DEVICE] exit site. V4/LPN applied gloves, squirted a dollop of [MEDICATION NAME] Cream into a plastic medication cup, then added a dollop of [MEDICATION NAME] Cream into the same cup and mixed them together with a cotton-tipped applicator. V4/LPN entered R29's room and without cleansing the top of or placing a clean barrier onto the top, placed the medication cup, bottle of wound cleanser and handful of loose gauze pads directly onto the top of (R29)'s over-the-bed table. At that time, V4/LPN reached into her uniform top pocket, removed bandage scissors and without cleaning them, placed them on the over bed table. V4/LPN saturated multiple gauze pads with wound cleanser, placed them on top of the table and using one at a time, cleansed R29's enteral site. The stoma site was fiery red with thick green/gray exudate present. The surrounding skin was excoriated with areas of maceration present. V4/LPN picked up the uncleansed bandage scissors and cut half-way up the middle of a gauze pad, positioned it around R29's stoma site and taped it into place. V4/LPN removed her gloves, performed hand hygiene, picked up the bandage scissors, dropped them in her pocket and left the room. On 3/24/2021 at 1:30 P.M., V2/Director of Nurses stated, (R29) has an on-going infection of the [DEVICE] site. I would expect staff that were performing wound care for (R29) to cleanse any equipment being used to cut gauze sponges and to use a barrier to create a clean field, before setting dressing supplies down. We are trying diligently to get this infection cleared up.

Based on observation, interview, and record review, the facility failed to implement an intervention to prevent range of motion (ROM) limitations for one of two residents (R23) reviewed for limited ROM in the sample of 20. Findings include: The facility's Contracture Prevention Program, dated 1/15/11, documents, Objective: To maintain residents at the highest level of physical functioning possible. The plan of care established by physical therapy or nursing when a contracture is present or the resident is at risk for developing a contracture may include goals, positioning aids, treatment plans and potential for improvement. Those individuals having limited range of motion and fair to good potential for resolution may be placed in a therapy or restorative/rehabilitation program. R23's Contracture Risk Evaluation, dated 1/4/21, documents, R23 has contractures. R23 has limitations in shoulder extension/abduction due to stiffness, holds his hands tightly closed, able to open, limited extension of fingers/thumb. R23 has limited right wrist movement. R23's MDS (Minimum Data Set) Assessment, dated 1/6/21, documents in Section G Functional Status that R23 has function limitations in range of motion in R23's bilateral upper and lower extremity. R23's Care plan, dated 9/18/20, documents, R23 is at risk for ADL (Activities of Daily Living) Self Care Performance Deficit related to Dementia, Alzheimer's. Range of Motion limitations to bilateral shoulders and hands. Intervention: Rolled wash cloth in each hand daily. R23's Bedside Kardex (CNA plan of care), dated 3/24/21, documents, Resident care: Rolled wash cloth in each hand daily. On 03/22/21 at 11:48 AM, R23 was sitting up in high back reclining wheelchair. R23 had ROM limitations/contractures to R23's bilateral hands. R23 did not have splint device or wash clothes in his hands. On 03/23/21 at 09:56 AM, R23 alert sitting up in high back reclining wheelchair. R23 did not have any splint device or wash clothes in his hands. V9 (CNA-Certified Nursing Assistant) confirmed that R23 did not have wash clothes in his hands. On 03/24/21 at 10:53 AM, V6 (CNA) stated that R23 is to have wash clothes in both of his hands. R23 was sitting up in the main sitting area in a recliner. R23 did not have any wash clothes in his hands. V6 confirmed that wash clothes were not in R23's hands. On 3/24/21 at 1:00 PM, V10 (Restorative Nurse) stated, R23 has ROM limitations in his bilateral hands and shoulders. To help with the contractures in his hands staff should be putting wash clothes in both of his hands during the day.

Based on interview and record review, the facility failed to provide emergency treatment during an episode of respiratory distress, for one of three residents (R1), reviewed for emergency treatment, in a sample of three. This failure resulted in R1 experiencing prolonged respiratory distress. FINDINGS INCLUDE: R1's facility Admission Record documents that R1 was admitted to the facility on [DATE]. R1's (State) Department of Public Health Uniform Practitioner Order For Life-Sustaining Treatment (POLST) Form, signed By R1's Health Care Power Of Attorney on 10/5/17 documents, If patient has no pulse and is not breathing, Do Not Attempt Resuscitation. This same form continues, If a patient is found with a pulse and is breathing, Comfort-Focused Treatment: Primary goal of maximizing comfort. Relieve pain and suffering through the use of medication by any route as needed; use oxygen, suctioning and manual treatment of [REDACTED]. R1's Progress Notes, dated 8/22/19 at 2356 (11:56 P.M.) and signed by V3/Registered Nurse (RN), documents, On initial rounds, found (R1) with head of bed elevated and having difficulty breathing. Lung sounds with audible gurgling sounds. BP (blood pressure) 90/52 (normal 120/80), Pulse 110 (normal range 60-100), R (respirations) 22 (normal range 16-20) and oxygen saturation 82% (normal 100%). 9-1-1 called to transport (R1) to (local hospital). Unable to reach PO[NAME] Report called to ER (emergency room ). DON (V2/Director of Nurses) also notified. R1's Prehospital Care Report, dated 8/22/19 at 2351 (11:51 P.M.), documents, (V6/V8-Emergency Medical Technicians) EMTs arrived to (the facility) with (V4 and V5/Certified Nursing Assistants) CNAs sitting on chairs looking at their phones. (V6 and V8/EMTs) had to ask which room we were going to and (V4 and V5/CNAs) took us to (V3/RN), who was with (R1). (V6 and V8/EMTs) asked (V3/RN) what was going on and (V3/RN) stated that it was not good. (V3/RN) gave no other info (information) on the patient and stated (V3/RN) had found (R1) like this 15 minutes ago. (V6 and V8/EMTs) tried to talk to (R1) but got no response from (R1). (R1) was breathing and had gurgling noises on inhale and exhale. (V8/EMT) tried to open (R1's) mouth and it was not able to be opened with (V8's) fingers. (R1) was very diaphoretic. (V6 and V8/EMTs) decided to load (R1) and finish assessment in the ambulance. When we got (R1) in the ambulance we checked all vitals (vital signs). We called for an ALS (Advanced Life Support) Intercept as soon as we got in the ambulance. (V8/EMT) got a bite stick and pried open (R1's) mouth open the best (V8/EMT) could and saw fluid in (R1's) throat. We grabbed the suction equipment and suctioned (R1's) mouth and throat clean as best we could. We placed (R1) on a non-rebreather at that time because (R1's) O2 (oxygen) was at 82%. The suctioning improved (R1's) breathing and the O2 came up. We met with ALS Intercept and I was able to get (R1's) dentures out and then we suctioned one more time. About a minute later, (R1's) breathing was much better and O2 came up to the mid 90's. At that time when ALS arrived we transferred (R1) to (local hospital). R1's Progress Notes, dated 8/23/19 at 1603 (4:03 P.M.), documents, (R1) returned to facility at 1020 (10:20 [NAME]M.) by ambulance. (R1) is unresponsive. Hospice came to admit this afternoon. R1's Progress Notes, dated 8/23/19 at 2346 (11:46 P.M.), documents, (R1) congested. Too many secretions. [MEDICATION NAME] ([MEDICATION NAME]) given X 3 (three times) this shift. Oral care given. Family at bedside. 7:15 (P.M.) called to room by family. 7:20 P.M. No B/P or pulse. Physician notified. (Local) County Coroner notified. Funeral Home here to take body. V1/Administrator and V2/Director of Nurses notified of death. On 9/4/19 at 1:10 P.M., V3/Registered Nurse (RN) stated, I came into work the night of 8/22/19 for the 11:00 PM to 7:00 AM shift. I don't remember who gave me report that night. There was no mention of anything being wrong with (R1). I was headed down the hallway around 11:30 PM to give medications to another resident and I heard this awful sound. It sounded like someone was gurgling. I finished giving the medicine and then went to investigate. I turned the light on in (R1)'s room. It was where the gurgling was coming from. (R1)'s skin color was gray, (R1) was non-responsive. ((R1) was having problems breathing. I checked (R1)'s vital signs, I can't remember what they were. I went back to the Nurse's Station and checked (R1)'s chart to see if (R1) was Hospice. (R1) wasn't. I called (R1)'s doctor to get an order to send (R1) to the ER. I called 9-1-1, went to the front door to unlock it and made copies of (R1)'s chart papers that needed to go to the hospital with (R1). I had two CNAs with me, (V5) was one and I can't remember who the second one was. I don't remember if I started oxygen or not. I did not suction (R1). The ambulance got here around midnight and (R1) left the building around 12:05 AM. On 9/4/19 at 2:46 P.M., V4/Certified Nursing Assistant (CNA) stated, I had worked second shift on 8/22/19 and ended up staying over and working part of third shift. (R1) was my resident for all of second shift. (R1) was the same all shift. (R1) was alert, (R1) ate (R1)'s supper fine, (R1) was talkative. I put (R1) to bed around 8:00 PM and put the head of (R1)'s bed up, like (R1) wants. We checked on (R1) around 10:30, (R1) was sleeping, but (R1) was wet so we changed (R1). (R1)'s skin color was pink, (R1) was breathing easily and (R1) responded to us. It was like an hour later, 11:30 PM when I went into (R1)'s room because they said (R1) was having trouble breathing. At that time (R1)'s mouth was wide open, (R1) was gurgling and (R1) didn't respond to us. (V3/RN) called the ambulance at some point. I don't know what time it was. No one suctioned (R1) or started oxygen on (R1). On 9/4/19 at 2:00 P.M., V6/Emergency Medical Technician (EMT) stated,I was the other EMT that responded to the Call from the facility on 8/22/19. The call came in to us at 11:51 PM. We arrived at the facility at 12:03 AM and was with the patient at 12:04 PM. When we arrived (R1) was blue, very diaphoretic, gurgling loudly and unresponsive. We asked the (V3/RN) what was wrong with (R1) and (R1) said (R1) didn't know. (R1) told us they found (R1) 15 minutes before and (R1) was gurgling. We asked (V3/RN) if she had suctioned (R1) or started oxygen on (R1) and (V3/RN) said she had not. We checked (R1)'s vitals and got (R1) in the ambulance. I called for a Paramedic Intercept and (V8/EMT) got a bite stick in (R1)'s mouth, suctioned (R1) and started oxygen on (R1) because (R1)'s oxygen level was only 82%. After I did that, (R1)'s oxygen came up. We met with the ALS Intercept and we were able to get (R1)'s dentures out, and suctioned (R1) one more time. At that time (R1)'s oxygen level came up to the mid 90's. We arrived at the (local hospital) and they took over care of the resident. On 9/5/19 at 9:04 [NAME]M., V5/Certified Nursing Assistant (CNA) stated, I worked night shift the night (R1) got sent to the hospital. When I came in, I did rounds on the hallway and (R1) was fine. It was probably 10:15 to 10:30, I went into (R1)'s room and raised the head of (R1)'s bed up. It was a while later, maybe an hour, I was walking down the hall, (V3/RN) was in a room with another resident, and I heard a sound coming from (R1)'s room. When I went in there, (R1) was gurgling loudly. My first thought was that (R1) needed suctioned. That we needed to suction that out of (R1)'s throat. (R1) wasn't responsive at all. (R1)'s mouth was open. I ran into the room where (V3/RN) was at. (V3/RN) went into (R1)'s room and said she need to call an ambulance. (V3/RN) didn't start any oxygen. (V3/RN) mentioned something about a suction machine. (V3/RN) wanted to know if we had one and where it was kept. I told (V3/RN) I had never seen one. (V3/RN) never suctioned (R1). The ambulance showed up a little while later. On 9/5/19 at 11:55 [NAME]M., V2/Director of Nurses verified that if a resident has an airway obstruction, manifested by labored respirations with gurgling, she would expect nursing staff to suction a resident and start oxygen. At that same time, V2/DON verified that V3/RN had not suctioned R1 or started oxygen for R1 when R1 was found non-responsive, gurgling and with labored respirations on 8/22/19.

Based on observation, interview, and record review, the facility failed to ensure food and fluids were stored and labeled with dates, and failed to ensure the staff covered hair in a sanitary manner while in the kitchen. These failures have the potential to affect all 49 residents at the facility. Findings include: 1. The facility's Food Labeling and Dating Policy, dated 6/2018, documents Labeling and dating food is important to assure foods are used in a timely manner. 1. Proper food labeling includes: Name of product, date stored and in some cases, the time of the day. 2. The food must be labeled and dated if it is removed from its original container. On 5/21/19 at 9:55am, a large bag of frozen french toast sticks in the pantry freezer, a large flat box of frozen biscuits in the kitchen freezer, and a pitcher of lemonade juice on the dining room counter were not dated or labeled. At that same time, V6, Dietary Manager, stated that the frozen items (french toast sticks and biscuits) should not have been in the freezers without labels and dates. V6 also confirmed that the pitcher of lemonade would have been given to the residents, and should have been labeled and dated. V6 stated, I don't know when the lemonade was made. 2. The facility's Hair Restraints Policy (undated) documents, Employees shall use effective hair restraints such as hats, hair coverings or nets, beard restraints and clothing that cover body hair that are designed and worn to effectively keep their hair from contacting exposed food, and clean equipment. The facility's Hair Restraints Policy (undated) also documents, Anyone entering a kitchen or serving area will have their hair restrained and/or a beard guard. This will be worn throughout the time in the kitchen and when handling food. On 5/21/19 at 10:15am, V12, Dishwasher, washed dishes in the kitchen and did not have his facial hair covered. V6 Dietary Manager stated, We have not required the staff to cover their facial hair in the past. On 5/21/19 at 11:50am, V13, Physical Therapy Assistant, entered the kitchen to get his food tray from the area in front of the holding serving table. V13 did not have his head or facial hair covered. At that time, V6, Dietary Manager, confirmed that the area in front of the holding service table was part of the kitchen. V6 stated, Yes, we allow staff to go to just that little area of the kitchen without having to put on hair restraints; they do not go behind the holding service table. The Resident Census and Conditions of Residents form dated 5/21/19, documents 49 residents currently reside in the facility.

Based on observation, interview, and record review, the facility failed to develop comprehensive care plans to address a wound caused by a migrating cochlear implant and a shearing wound for one resident (R4), and failed to address a wheelchair seatbelt for one (R34) of 18 residents reviewed for care plans in the sample of 34. Findings include: 1) R4's Physicians Order Sheet dated (MONTH) 2019, indicates apply [MEDICATION NAME] to area behind (R4) right ear daily for preventative measures. On 5/22/19 at 12:52pm, R4 was noted to have a scabbed over area behind right upper ear. At that time V10, LPN (Licensed Practical Nurse), stated that R4 has a cochlear implant migrating out/through skin above/behind his ear. R4's physician progress notes [REDACTED]. No care plan was developed until 5/23/19, with date of 5/17/19 indicating treatment order for wound. On 5/24/19 at 12:30pm, V2, DON (Director of Nursing), acknowledged a care plan should have been developed for the migrating implant. R4's Initial Physician Wound Notes, dated 4/29/19, indicate sacral shear wound of one day duration, measured 1.8cm x 0.6cm with light drainage. R4's Wound Evaluation and Management Summary/Physician Wound Notes, dated 5/20/19, indicate R4 with a sacral shear wound with moderate serous drainage of at least 20 days duration. This note further indicates Wound size 2.2cm (centimeter) x 1.3cm x (not measurable). This note also indicates peri wound excoriation, and that the wound had deteriorated. R4's Wound Evaluation and Management Summary/Physician Wound Notes, dated 5/23/19, indicate R4 has a sacral shear wound with heavy serous drainage, measures 2.1cm x 3.2cm, and that the wound has deteriorated. On 5/23/19 at 3:20pm, V10, LPN, stated that the care plan should include the cause of shearing and interventions to prevent it from occurring again. 2. On 5/21/19, at 12:00pm, R34 sat in a wheelchair with a seat belt secured around R34's waist. R34's clinical record documents R34 as being cognitively intact with [DIAGNOSES REDACTED]. R34's current care plan does not include R34 is to wear a self-releasing belt while sitting in a wheelchair. On 05/24/19, at 11:15am, V2 Director of Nursing/DON stated that R34's seat belt is not a restraint. The seatbelt is for (R34's) own safety. (R34) prefers it and can buckle it himself. It should be included on (R34's) care plan.

Based on observation, interview, and record review, the facility failed to follow their wound policy, failed to identify and stage a pressure injury, and failed to implement interventions to address shearing for one resident (R4) of five residents reviewed for pressure injury in the sample of 34 residents. Findings include: Facility Policy/Wound and Ulcer Policy and Procedure dated (YEAR) indicates: A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. Pressure ulcers are classified according to the amount of visible tissue loss using the international NPUAP/EPUAP (National Pressure Ulcer Advisory Panel/European Pressure Ulcer Advisory Panel) Pressure Ulcer Classification System. The classification of pressure ulcers is called staging. Pressure Ulcer - Stage 2 Stage 2 - Partial thickness skin loss of dermis presenting as a shallow open ulcer with a red-pink wound bed (without bruising or slough), or as an intact or open/ruptured serum-filled blister. Stage 3 - Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through underlying tissue. Slough may be present but does not obscure depth of tissue loss. Equipment, Prevention and Treatment Resources; Shearing - Maintain head of bed at least 30 degrees or less; may use draw sheet for repositioning. Skin Risk assessment dated [DATE] and 5/10/19, indicates R4 is High Risk for pressure injury. Initial Physician Wound Notes dated 4/29/19, indicates sacral shear wound of one day duration measured 1.8cm x 0.6cm with light drainage. Wound Evaluation and Management Summary/Physician Wound Notes dated 5/20/19, indicates R4 with a sacral shear wound with moderate serous drainage of at least 20 days duration. Note further indicates Wound size 2.2cm (centimeter) x 1.3cm x (not measurable). Note indicates peri wound excoriation, and that the wound had deteriorated. On 5/22/19 at 12:32pm, V10, LPN (Licensed Practical Nurse), changed R4's sacral wound dressing. R4's sacral wound had 4 open areas with surrounding dark pink skin. Largest open area was oval shaped with slough covering wound bed located over coccyx inside gluteal cleft. To the left of coccyx wound was a shallow ulcer, also with thin layer of scattered slough. Two superficial, less ulcerated linear/oval open areas were noted below and on either side of the coccyx wounds. V10 stated that V11, Wound Physician, ordered an anti-fungal to be applied to the surrounding areas excluding the center coccyx wound, which was treated with Calcium Alginate (absorptive wound dressing). On 5/23/19 at 2:51pm, R4's sacral wounds were assessed by V10, LPN, and V11, Wound Physician. At that time, V11 acknowledged that the left sacral wound adjacent to the center wound had coalesced with slough covering the entire wound bed. V11 attempted to scrape off slough/film from the wound, but the layer was adherent to the wound. V11 stated that he did observe wound to left of center wound on 5/20, which was not coalesced (merged together) at that time, but was now like one wound. MD stated that wounds are from shearing and moisture, stating, I'm not ready to say from pressure. If the wounds were Stage 2 or 3, would consider pressure. Both V10 and V11 were unable to state what is causing shearing and that the lower two areas are redness/irritation, Part of peri-wound excoriation, but the center wound is an ulcer. V11 stated that the wound had deteriorated. Wound Evaluation and Management Summary/Physician Wound Notes dated 5/23/19, indicates R4 has a sacral shear wound with heavy serous drainage, measures 2.1cm x 3.2cm, and that the wound has deteriorated. On 5/24/19 at 12:30pm V2, DON (Director of Nursing), acknowledged that all of the open areas should be included in the assessment, and the cause of the shearing should have been identified. Care Plan identified shear as the cause of R4's sacral wound, however no interventions were implemented to address shearing as the cause.

Based on observation, interview, and record review, the facility failed to ensure controlled medications were disposed of according to the facility policy for one resident (R36) of eight residents reviewed for medication administration. Findings include: The facility policy Medication Disposal, dated ,[DATE], documents Unused, unneeded, or expired prescription drugs which are not being returned to the pharmacy for destruction should be taken out of their containers and mixed with an undesirable substance such as used coffee grounds or kitty litter, and put in impermeable, non-descript containers such as empty cans or sealable bags, and disposed of with other garbage. R36's Medication Administration Record/MAR, dated (MONTH) 2019, documents an order for [REDACTED]. On [DATE] at 9:30am, during medication administration, V14 Licensed Practical Nurse/LPN, split R36's Klonopin 0.5mg tablet in half, then tossed one half tablet into the sharps container located on the medication cart. On [DATE] at 2:15pm, V14/LPN stated, I should have crushed it (R36's Klonopin) and mixed it with water then threw it in the kitty litter.

Based on interview and record review, the facility failed to apply and monitor moist hot packs in a manner to prevent the development of a burn for one of one resident (R1) who receive hot packs in the sample of 15. This failure resulted in R1 sustaining a two centimeter full thickness burn which required two months to heal. Findings include: Nurses notes dated 02/27/12 (no time documented) state that a CNA was showering R1 and noted a red broken blister area on R1's right shoulder. This circular area measured 2 centimeters. Nurses notes state that R1 said "Therapy got that too hot, after they put a hot pack on me Sat. (Saturday)" The facility's Occurrence Report dated 02/27/12 and investigation dated 02/28/12 completed by E2 stated that "Upon conclusion of all interviews, including the resident." (R1) "received a 2 cm. burn on her right shoulder from a hot pack placed on her Rt. (right) shoulder by therapy." This investigation includes documentation of an interview with E16 (Occupational Therapist), who stated that she had treated R1 on 02/24/12 after lunch and placed hot packs from the hydrocolator on R1's right shoulder. E16's statement documents that after 5 minutes into the treatment R1 stated that "this is getting hot." E16's statement documents that she removed the towel and the hot pack and placed a second towel down and replaced the pack. E16's statement says that when E16 removed the final hot pack, she (E16) noticed an area of redness and moisture like water on R1's skin. E16's statement continues stating, "maybe I didn't drain all the water off, I'm not sure why it got so hot." The facility's inservice information dated 02/29/12, states when applying moist heat packs to apply 4-6 layers of towels or 2 layers of commercial towels. physician's orders [REDACTED]. The facility's Wound Care Plan Treatment Plan dated 02/27/12 documents R1's wound type as a burn on right shoulder, measuring 2 by 2 cm. The Patient Wound Care Order Sheet dated 03/01/2012 by the consulting wound nurse states that R1's burn wound is a full thickness wound and has increased to 2 by 2.5 cm. This documentation states that R1's wound bed is light brown/grey thin eschar, with thin fragile pink peri-wound tissue. The Patient Wound Care Order Sheet dated 04/02/12 by the consulting wound nurse states that R1's burn is 100% yellow brown slough with thin pink fragile peri-wound tissue with a light purple discoloration 2 cm. perimeter. This form documents that the treatment for [REDACTED]. The April 2012 Treatment Administration Record documents that R1's burn was healed and treatment discontinued on 04/23/12. On 05/23/12 at 9:20 a.m., E2 confirmed that she had completed an investigation of R1's burn and determined that the cause of R1's burn was from the application of the hot packs.