Every finding on record at Archstone Care Center

Based on clinical record review, staff interviews, and review of policy, revealed the facility failed to ensure one resident (#98) received the necessary care and services post fall and that one resident's (#25) durable medical equipment was applied to prevent a reduction in mobility and contracture. The deficient practice could result in residents not receiving the treatment and care, based on their assessed needs, resulting in increased contracture and reduced mobility.Findings Include: -Regarding Resident #98: Resident #98 was admitted on [DATE] with diagnosis including periprosthetic fracture around the internal prosthetic right knee join, hypertension, type 2 diabetes mellitus, chronic kidney disease, acute kidney failure, nonrheumatic mitral valve insufficiency, muscle weakness, and difficulty walking. A review of the electronic health record revealed a fall risk assessment on March 21, 2022 with a score of 13, indicating that the resident was a low fall risk. A review of the care plan revealed a focus area dated March 21, 2022 noting that the resident was at risk for falls due to recent illness, deconditioning and new environment. Interventions included to attempt and anticipate the resident's needs, ensure that the call light is within reach and encourage use, educate resident/family/ caregivers about safety reminders and what to do if a fall occurs, physical therapy to evaluate and treat as ordered, review information on past falls to attempt to determine cause of falls, record possible root causes of falls, remove potential causes of falls and educate regarding causes of falls, as well as that the resident was a 2-person assist. A review of the annual MDS (minimum data set) dated March 25, 2024 revealed a BIMS (brief interview of mental status) score of 07 indicating that the resident was severely cognitively impaired. The MDS further revealed that there had been no documented falls since admission. Under functional abilities and goals, it was documented that the resident was 'dependent' on staff for toileting hygiene, chair to bed as well as tub to shower transfers, with 'dependent' identified as the helper doing all of the effort or the assistance of 2 or more helpers required for the activity. A review of the facility 5-day report noted an incident on April 29, 2024 at 4:55 AM, which documented that resident #98 had 'rolled' out of bed and started falling while staff #111, CNA (certified nursing assistant) assisted her to the floor. The documented interview with staff #111 noted that staff #111 was in the process of changing the resident's sheets and that the resident was unable to balance her legs and subsequently dropped both legs to the floor. It was further noted that the CNA held the resident by the shoulders and let her sit on the floor. Staff #111 then reported that he called a nurse and that after a physical 'checkup' the nurse assisted the CNA to put the resident back into bed. The 5-day report documented an interview with staff #52 CNA, who stated that when she observed the resident on April 29, 2024 at 8:30 AM, she was crying. The interview further revealed that the resident stated that she was crying because she had been dropped while a staff member was working with her and that the staff member tried to pick her up but couldn't, so he left to find someone else to assist. She then stated that the initial staff member and another staff member got her up and put her back into bed. Staff #52 stated that she pulled back the sheet and saw that the resident's left leg, from the knee up to the thigh, which looked swollen. Staff #52 stated that she reported this to the charge nurse, staff #84, LPN (licensed practical nurse) and the nurse (staff #84) stated that he would take care of it. The report further noted that staff #52 stated that at 9:30 AM on the same day, she reported to staff #74 ADON (assistant director of nursing) that the resident had not yet been 'checked on.' It was documented that the resident relayed to the ADON that when she fell she heard a crack that sounded like a stick breaking. The report further documented the resident was observed to be wet and staff #52 stated that she was 'afraid' to cause the resident further pain, as she was crying and begged not to be moved, but the CNA was instructed by the ADON to change the resident. Further documentation revealed that staff #52 had a conversation with staff #85, LPN (licensed practical nurse) the following day, April 30, 2024, to check on how the resident was doing and staff #85 reported that the resident had fallen out of bed and that no one had reported it. Staff #52 stated that she observed that the resident was still there and had not been treated. The report summary noted that the resident had a fall that resulted in an injury. Follow-up actions noted in the report included education of staff while providing care, proper documentation and communication with providers to ensure prompt care and a written warning to the staff #111, CNA for not following the care plan to ensure safe patient care. A review of the progress notes revealed a health status note dated April 29, 2024 at 7:22 PM noting that resident had complained of left knee pain from recent fall and was awaiting an x-ray which had not been completed yet. The note further revealed that the left knee appeared to be swollen, but no bruising or redness to the area. A review of the radiology report dated April 30, 2024 revealed a left femoral view documenting that resident #98 had a fracture of the distal femoral shaft with slight malalignment. A health status note on April 30, 2024 at 12:49 PM documented that an x-ray was conducted at 7:00 AM in the morning, which revealed that the resident had an acute femoral fracture and that an order was given to send the resident to the emergency room. The note further documented that transport arrived around 11:00 AM. An interview was conducted on January 15, 2026 at 2:40 PM with staff #102 LPN. Staff #102 stated that to ensure a resident's safety, transfers and brief changes should always be conducted as outlined in the resident's care plan, but if a fall occurs and the CNA is there or witnesses the fall, a nurse should be called to assess the resident and make sure that they are okay to be moved back into bed. The LPN further stated that if swelling to an extremity were present, she would call the doctor to see if the resident could be sent out for further assessment/ treatment. Staff #102 stated that she was familiar with resident #98 but was not on site when the fall occurred. She stated that she had heard that the resident was not sent to the hospital until a day or two later and stated that in her opinion, this was unacceptable. Staff #102 further stated that she had heard that the resident had been complaining of pain for a day or two prior to being sent to the hospital. Staff #102 stated that she knew who the CNA, involved with the fall, was and stated that she did not feel he had the skill set needed to be a CNA and that she didn't think he cared about the residents. A telephone call was placed on January 15, 2026 at 4:30 PM to staff #52, CNA. A message was left on the voicemail; however, no return call was received. A telephone call was placed on January 15, 2026 at 4:41 PM to staff #111, CNA. A message was left on the voicemail but no return call was received. The staff member was observed not to be on schedule during the duration of the survey. A telephone call was placed on January 15, 2026 at 4:43 PM to staff #11, CNA. A message was left on the voicemail requesting a call back. No return call was received. Additional calls were placed on January 16, 2026 at 8:45 AM and 9:00 AM to staff #111. Messages were left on the voicemail, but no return call received. A telephone call was placed on Januray 16, 2026 at 8:50 AM to staff # 45, RN (registered nurse). Message was left on the voicemail; however, the call was not returned. An interview was conducted on January 16, 2026 at 9:03 AM with staff #54 LPN. Staff #54 stated that if a fall occurred, a nurse would need to conduct an assessment to determine if there are any injuries, vitals would be taken and neuro-checks started if the fall was unwitnessed. The LPN stated that a CNA should never lift a resident back into bed, even if it was a witnessed fall, without the resident first being assessed by a nurse. Staff #54 further stated that the doctor would be contacted and notifications to family would take place, post fall. Staff #54 stated if the resident had pain in the arm(s) or leg(s) then range of motion should be established and that at times 911 may need to be called to assist with getting the resident up. Staff #54 stated that if the resident experienced a fall, had pain and needed an x-ray, this would be done the same day. Staff #54 stated that if the x-ray was not done the same day the risk could include increased pain and potential for embolism. Staff #54 stated that he did not recall resident #98. An interview was conducted on January 16, 2026 at 9:13 AM with staff, #98 CNA. Staff #98 stated that if a resident falls, he would first check that they are not injured and then call for help, but not leave the resident unattended in the room. Staff #98 stated that he would never attempt to get the resident back into bed until first having clearance from a nurse. He stated that if clearance was not obtained prior to moving the resident, it could result in further injury to the resident. Staff #98 further stated that if conducting a brief or sheet change, he would ensure that the resident is not too close to the edge, would use his body to block the resident, so they would not fall and ask for help if the resident was a 2-person assist. An interview was conducted on January 16, 2026 at 9:26 AM with staff #74 ADON (assistant director of nursing). Staff #74 stated that a resident's care plan is to be followed when providing care or treatment to a resident. She further stated that if a CNA observed a fall that they are expected to get help, and ensure that a nurse has assessed them before they can be moved. She further stated that the expectation would be that the doctor should be notified as well as their representative. Staff #74 further stated that pain or swelling should be relayed to the doctor and orders should be obtained to send the resident out if an injury was suspected. Staff #74 stated that a nurse is the doctor's eyes post fall, to relay if there is pain, swelling, redness, and different limb length, so the doctor can make an informed decision. Staff #74 stated that if some of the aforementioned were present or if there were other indicators of serious injury, a STAT x-ray would be ordered. Staff #74 stated that turn around for a STAT x-ray is generally 2-3 hours and that if it takes longer than that the resident should be sent out for evaluation and treatment. Staff #74 stated that it would never be okay for a resident to wait more than 24 hours to have an x-ray post fall, further more if a resident exhibits extreme pain stating that they do not want to be moved, they should be sent out. The ADON stated that the risk for not conducting a timely x-ray or sending a resident out, could include increased pain and a worsening condition. Staff #74 reviewed the 5-day report and stated that the dates did not seem appropriate and that the x-ray order should have been a STAT, not routine order. Staff #74 stated that the time it took for the resident to obtain an x-ray and be sent out did not meet her expectations. She further stated that the nurse on duty at the time of the incident should have followed up, prior to going off duty and ensured the appropriate notifications transpired. Staff #74 further stated that doctor and family were not notified at the time of the incident and notifications had not occurred until April 30, 2024 at 12:14 PM. She further stated that a lapse in notifying the doctor or family timely, as well as not following the care plan did not meet professional standards nor quality of care for the resident. She stated that if professional standards are not followed then the resident is at risk for injury or a delay in treatment. A follow-up interview was conducted on January 16, 2026 at 1:25 PM with staff #74 (ADON). The ADON stated that staff #111, CNA was 'written-up' for not following the care plan for resident #98, as the resident should have been a 2-person assist. A review of the policy titled Compliance Risks-Resident Quality fo Care and Quality of Life with a revision date of January 2025 revealed that residents are to be provided a safe, clean and comfortable environment that is free from accident hazards and adequately supervised and that nursing staff have the appropriate training and levels of competency to ensure resident safety. A review of the policy titled Request for Diagnostic Services revised April 2007 revealed that emergency requests must be labled stat' to assure that prompt action is taken. A review of the policy titled Change in a Resident's Condition or Status revised February 2021 revealed that the facility is to promptly notify the resident, his or her attending physician and the resident representative of changes in the resident's medical/ mental condition and/ or status. The policy further documented that unless otherwise instructed by the resident, a nurse will notify the resident's representative when the resident is involved in any accident or incident that results in injury. -Regarding Resident #25: Resident #25 was admitted to the facility on [DATE] with diagnosis that includes unspecified displaced fracture of surgical neck of right humerus, subsequent encounter for fracture with routine healing, Parkinson's disease without dyskinesia, without mention of fluctuations, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, difficulty in walking, not elsewhere classified, need for assistance with personal care. Review of the annual Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating severely impaired cognition. There were no indicators for behaviors. Further review of the MDS revealed impairment on one side of the upper extremity and no impairment to the lower extremity. Review of the Care Plan revealed a focus for right humeral neck fracture. Interventions include encouraged use of the affected limb as much as tolerated to help maintain the range of motion and maintain the resident's body alignment. Further review revealed that focus areas for Parkinson's disease interventions include monitoring for muscle cramps or rigidity, decline in range of motion, and skin breakdown. Review of the physician orders revealed active orders for Pressure Relief Ankle -Foot Orthosis (PRAFO) boots to be worn on the left lower extremity for proper positioning due to foot drop. To be worn all day with a skin check from staff or nursing on every shift for skin integrity, redness, or irritation. Nursing to don and doff left hand roll: On at all times except during meals, as the patient uses the right hand to help feed self. Left hand roll to decrease further risk for contractures and or proper hand positioning. Perform skin checks for redness or skin irritation, Ankle -Foot Orthosis (AFO) to the left lower extremity when the patient is up in a wheelchair (WC). Remove when returning to bed. An initial observation was made of resident #25 during initial screening on January 13, 2026, at 8:42 am. Resident #25 was observed in a hallway in front of a nurse's station. Resident #25 is non-verbal, noted left hand contracture, clenched inward towards the chest. No devices in the resident's palm. A dressing to the right side of the neck with date, the wheelchair was tilted, and both feet were turned inwards. An observation was conducted on January 15, 2026, at 9:28 am of resident #25. The resident was observed in a wheelchair. There was no administration of the PRAFO boot to the left lower extremity for positioning due to foot drop, no AFO to the left lower extremity, and no left-hand roll. The resident was observed sitting in the wheelchair with both feet in a padded device on the footrests. The left wrist was curled against the stomach with the left fist contacted against the middle of the chest. An observation was conducted on January 16, 2026, at 8:14 am on resident #25. The resident was in the dining room being assisted with her breakfast. The resident did not have on the physician-ordered PRAFO boot to the left lower extremity for positioning due to foot drop, no AFO to the left lower extremity, and no left-hand roll. An observation was conducted on January 16, 2026, at 9:29 am on resident #25. The resident was in activities. The resident did not have on the physician-ordered PRAFO boot to the left lower extremity for positioning due to foot drop, or the AFO to the left lower extremity, nor a left-hand roll. Review of the Medication and Treatment Administration Record (MAR/TAR) for January 2026 revealed AFO to the left lower extremity when the patient is up in WC. Remove when returning to bed. Every shift for the contracture of the ankle. Order Date September 14, 2025, at 5:51 pm; PRAFO boots to be worn on the lower left extremity for proper positioning due to the foot drop. To be worn all day with skin checks from the staff or nursing on every shift for skin integrity, redness, or irritation. Order Date July 8, 2025, at 10:00 pm; Nursing to don and off left-hand roll: On at all times except during meals as patient uses B hands to help feed self. Left hand roll to decrease further risk for contractures and or proper hand positioning. Perform skin checks for redness or skin. -Order Date July 8, 2025, at 9:57 pm. Further review of. The MAR/TAR for these orders revealed check marks on January 13 and January 14, 2026 at 6 AM and 6 PM-6 AM. Review of MAR and TAR for December 2025 revealed no documentation for the administration of the physician-ordered AFO, PROFO, or hand roll for resident #25. An interview was conducted with Licensed Practical Nurse (LPN/Staff #54) on January 16, 2026, at 9:31 am. Staff # stated that the PRAFO boot is to keep the feet straight and stated the AFO has contradicting orders. Staff #54 stated the purpose of the handroll is to stop the hand from contracting. Staff #54 conducted an observation of resident #25, noting the PRAFO, AFO, or the handroll for the left hand had been placed on the resident. Staff#54 stated the devices would be placed on the resident, but she would remove them, so they stopped placing them on her. Staff #54 declined to comment on why it was documented that the resident had the DME placed when it had not. Staff #54 stated that there is no documentation that the family was consulted or agreed that the boots and handroll were no longer feasible for the resident, and that he should have notified the physician. Staff #54 stated the boots were causing the resident's wounds on her legs, but there is no documentation to support this. Staff #54 stated that the risks with not documenting, not placing, or following physician orders for durable medical equipment place the resident at risk for further decline in functional ability, further contracture of the hand and further foot drop. Staff #54 stated he did not document that the resident did not tolerate the boot, and this was his mistake. An interview was conducted on January 16, 2026, at 10:30 am with Certified Nursing Assistant (CNA/Staff#61). Staff #61 stated she was that the resident was supposed to be wearing them since she had not for a while, but had not been informed to stop placing the resident's DME. Staff #61 stated the resident had not worn the boots for a while because they were hurting her legs, but she does have a foam cushion on her footrests to protect her legs. An interview was conducted with the Assistant Director of Nursing (ADON/Staff #74) on January 16, 2026, at 11:22 am. The ADON stated she expects staff to follow doctors' orders or notify if there is a concern. The ADON stated the restorative nursing assistant may have completed that documentation as to why the DME had not been placed and stated, I will have to check as see if there is RNA documentation and get back to you. The ADON stated that the risks of not following physicians' orders for DME can cause further contracture or a limited range of motion. The ADON did not provide any documentation regarding the residents' administration of DME. Review of the facility policy titled Assistive Device and Equipment states, our facility maintains and supervises the use of assistive devices and equipment for residents.1. Certain devices and equipment that assist with resident mobility, safety, and independence are provided for residents.

Based on clinical record reviews, staff interviews, facility documentation, policy and procedures, the facility failed to ensure that one resident (#98) received adequate supervision and assistance to mitigate falls and to abide by professional standards regarding post fall protocol. The universe was 81 and the sample size was 22. The deficient practice could contribute to resident injuries and delay in treatment/ notifications. Findings include:Resident #98 was admitted on [DATE] with diagnosis including periprosthetic fracture around the internal prosthetic right knee join, hypertension, type 2 diabetes mellitus, chronic kidney disease, acute kidney failure, nonrheumatic mitral valve insufficiency, muscle weakness, and difficulty walking.A review of the annual MDS (minimum data set) dated March 25, 2024 revealed a BIMS (brief interview of mental status) score of 07 indicating that the resident was severely cognitively impaired. The MDS further revealed that there had been no documented falls since admission. Under functional abilities and goals, it was documented that the resident was 'dependent' on staff for toileting hygiene, chair to bed as well as tub to shower transfers, with 'dependent' identified as the helper doing all of the effort or the assistance of 2 or more helpers required for the activity.A review of the electronic health record revealed a fall risk assessment on March 21, 2022 with a score of 13, indicating that the resident was a low fall risk. A review of the care plan revealed a focus area dated March 21, 2022 noting that the resident was at risk for falls due to recent illness, deconditioning and new environment. Interventions included to attempt and anticipate the resident's needs, ensure that the call light is within reach and encourage use, educate resident/family/ caregivers about safety reminders and what to do if a fall occurs, physical therapy to evaluate and treat as ordered, review information on past falls to attempt to determine cause of falls, record possible root causes of falls, remove potential causes of falls and educate regarding causes of falls, as well as that the resident was a 2-person assist.A review of the facility 5-day report noted an incident on April 29, 2024 at 4:55 AM, which documented that resident #98 had 'rolled' out of bed and started falling while staff #111, CNA (certified nursing assistant, ) assisted her to the floor. The documented interview with staff #111 noted that staff #111 was in the process of changing the resident's sheets and that the resident was unable to balance her legs and subsequently dropped both legs to the floor. It was further noted that the CNA held the resident by the shoulders and let her sit on the floor. Staff #111 then reported that he called a nurse and that after a physical 'checkup' the nurse assisted the CNA to put the resident back into bed.The 5-day report documented an interview with staff #52 CNA, who stated that when she observed the resident on April 29, 2024 at 8:30 AM, she was crying. The interview further revealed that the resident stated that she was crying because she had been dropped while a staff member was working with her and that the staff member tried to pick her up but couldn't, so he left to find someone else to assist. She then stated that the initial staff member and another staff member got her up and put her back into bed. Staff #52 stated that she pulled back the sheet and saw that the resident's left leg, from the knee up to the thigh, which looked swollen. Staff #52 stated that she reported this to the charge nurse, staff #84, LPN (licensed practical nurse) and the nurse (staff #84) stated that he would take care of it. The report further noted that staff #52 stated that at 9:30 AM on the same day, she reported to staff #74 ADON (assistant director of nursing) that the resident had not yet been 'checked on.' It was documented that the resident relayed to the ADON that when she fell she heard a crack that sounded like a stick breaking. The report further documented the resident was observed to be wet and staff #52 stated that she was 'afraid' to cause the resident further pain, as she was crying and begged not to be moved, but the CNA was instructed by the ADON to change the resident. Further documentation revealed that staff #52 had a conversation with staff #85, LPN (licensed practical nurse) the following day, April 30, 2024, to check on how the resident was doing and staff #85 reported that the resident had fallen out of bed and that no one had reported it. Staff #52 stated that she observed that the resident was still there and had not been treated. The report summary noted that the resident had a fall that resulted in an injury. Follow-up actions noted in the report included education of staff while providing care, proper documentation and communication with providers to ensure prompt care and a written warning to the staff #111, CNA for not following the care plan to ensure safe patient care.A review of the progress notes revealed a health status note dated April 29, 2024 at 7:22 PM noting that resident had complained of left knee pain from recent fall and was awaiting an x-ray which had not been completed yet. The note further revealed that the left knee appeared to be swollen, but no bruising or redness to the area.A review of the Fall Review note dated April 30, 2024 at 12:14 AM revealed that the family, doctor and DON (director of nursing) were notified; however, there was no evidence in the progress notes of prior notifications at the time of the incident.A review of the radiology report dated April 30, 2024 revealed a left femoral view documenting that resident #98 had a fracture of the distal femoral shaft with slight malalignment.A health status note on April 30, 2024 at 12:49 PM documented that an x-ray was conducted at 7:00 AM in the morning, which revealed that the resident had an acute femoral fracture and that an order was given to send the resident to the emergency room. The note further documented that transport arrived around 11:00 AM.An interview was conducted on January 15, 2026 at 2:40 PM with staff #102 LPN. Staff #102 stated that to ensure a resident's safety, transfers and brief changes should always be conducted as outlined in the resident's care plan, but if a fall occurs and the CNA is there or witnesses the fall, a nurse should be called to assess the resident and make sure that they are okay to be moved back into bed. The LPN further stated that if swelling to an extremity were present, she would call the doctor to see if the resident could be sent out for further assessment/ treatment. Staff #102 stated that she was familiar with resident #98 but was not on site when the fall occurred. She stated that she had heard that the resident was not sent to the hospital until a day or two later and stated that in her opinion, this was unacceptable. Staff #102 further stated that she had heard that the resident had been complaining of pain for a day or two prior to being sent to the hospital. Staff #102 stated that she knew who the CNA, involved with the fall, was and stated that she did not feel he had the skill set needed to be a CNA and that she didn't think he cared about the residents.A telephone call was placed on January 15, 2026 at 4:30 PM to staff #52, CNA. A message was left on the voicemail; however, no return call was received.A telephone call was placed on January 15, 2026 at 4:41 PM to staff #111, CNA. A message was left on the voicemail but no return call was received. The staff member was observed not to be on schedule during the duration of the survey.A telephone call was placed on January 15, 2026 at 4:43 PM to staff #11, CNA. A message was left on the voicemail requesting a call back. No return call was received.Additional calls were placed on January 16, 2026 to staff #111. Messages were left on the voicemail, but no return calls received.A telephone call was placed on Januray 16, 2026 at 8:50 AM to staff # 45, RN (registered nurse). Message was left on the voicemail; however, the call was not returned.An interview was conducted on January 16, 2026 at 9:03 AM with staff #54 LPN. Staff #54 stated that if a fall occurred, a nurse would need to conduct an assessment to determine if there are any injuries, vitals would be taken and neuro-checks started if the fall was unwitnessed. The LPN stated that a CNA should never lift a resident back into bed, even if it was a witnessed fall, without the resident first being assessed by a nurse. Staff #54 further stated that the doctor would be contacted and notifications to family would take place, post fall. Staff #54 stated if the resident had pain in the arm(s) or leg(s) then range of motion should be established and that at times 911 may need to be called to assist with getting the resident up. Staff #54 stated that if the resident experienced a fall, had pain and needed an x-ray, this would be done the same day. Staff #54 stated that if the x-ray was not done the same day the risk could include increased pain and potential for embolism. Staff #54 stated that he did not recall resident #98.An interview was conducted on January 16, 2026 at 9:13 AM with staff, #98 CNA. Staff #98 stated that if a resident falls, he would first check that they are not injured and then call for help, but not leave the resident unattended in the room. Staff #98 stated that he would never attempt to get the resident back into bed until first having clearance from a nurse. He stated that if clearance was not obtained prior to moving the resident, it could result in further injury to the resident. Staff #98 further stated that if conducting a brief or sheet change, he would ensure that the resident is not too close to the edge, would use his body to block the resident, so they would not fall and ask for help if the resident was a 2-person assist.An interview was conducted on January 16, 2026 at 9:26 AM with staff #74 ADON (assistant director of nursing). Staff #74 stated that a resident's care plan is to be followed when providing care or treatment to a resident. She further stated that if a CNA observed a fall that they are expected to get help, and ensure that a nurse has assessed them before they can be moved. She further stated that the expectation would be that the doctor should be notified as well as their representative. Staff #74 further stated that pain or swelling should be relayed to the doctor and orders should be obtained to send the resident out if an injury was suspected. Staff #74 stated that a nurse is the doctor's eyes post fall, to relay if there is pain, swelling, redness, and different limb length, so the doctor can make an informed decision. Staff #74 stated that if some of the aforementioned were present or if there were other indicators of serious injury, a STAT x-ray would be ordered. Staff #74 stated that turn around for a STAT x-ray is generally 2-3 hours and that if it takes longer than that the resident should be sent out for evaluation and treatment. Staff #74 stated that it would never be okay for a resident to wait more than 24 hours to have an x-ray post fall, further more if a resident exhibits extreme pain stating that they do not want to be moved, they should be sent out. The ADON stated that the risk for not conducting a timely x-ray or sending a resident out, could include increased pain and a worsening condition. Staff #74 reviewed the 5-day report and stated that the dates did not seem appropriate and that the x-ray order should have been a STAT, not routine order. Staff #74 stated that the time it took for the resident to obtain an x-ray and be sent out did not meet her expectations. She further stated that the nurse on duty at the time of the incident should have followed up, prior to going off duty and ensured the appropriate notifications transpired. Staff #74 further stated that doctor and family were not notified at the time of the incident and notifications had not occurred until April 30, 2024 at 12:14 PM. She further stated that a lapse in notifying the doctor or family timely, as well as not following the care plan did not meet professional standards nor quality of care for the resident. She stated that if professional standards are not followed then the resident is at risk for injury or a delay in treatment.A follow-up interview was conducted on January 16, 2026 at 1:25 PM with staff #74 (ADON). The ADON stated that staff #111, CNA was 'written-up' for not following the care plan for resident #98, as the resident should have been a 2-person assist.A review of the policy titled Compliance Risks-Resident Quality of Care and Quality of Life with a revision date of January 2025 revealed that residents are to be provided a safe, clean and comfortable environment that is free from accident hazards and adequately supervised and that nursing staff have the appropriate training and levels of competency to ensure resident safety.A review of the policy titled Care Plans-Baseline with a revision date of March 2022, revealed that the care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality of care.A review of the policy titled Care Plans, Comprehensive Person-Centered with a review date of March 2022, revealed that the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Furthermore, the policy documented that the care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem area and their causes and relevant clinical decision making.A review of the policy titled Change in a Resident's Condition or Status revised February 2021 revealed that the facility is to promptly notify the resident, his or her attending physician and the resident representative of changes in the resident's medical/ mental condition and/ or status. The policy further documented that unless otherwise instructed by the resident, a nurse will notify the resident's representative when the resident is involved in any accident or incident that results in injury.

Based on observations, staff interviews, and the facility policy and procedures, the facility failed to ensure a resident (#48) did not have medications at bedside without the presence of an assessment and orders and failed to ensure treatment cart with prescriptions treatments was locked. The deficient practice could lead to medication interactions, inaccurate dosing and others having unrestricted access to medications. The universe was 81. The sample size was 22. Findings include: -Regarding Resident #48 Resident #48 was admitted on [DATE] with diagnosis including the presence of a right artificial hip joint, atrial fibrillation, hypertension, need for assistance with personal care, encephalopathy, urinary tract infection and hypertensive heart disease. An observation was conducted on January 13, 2026 at 8:57 AM in the room of resident #48. The observation revealed Equate Nasal Spray and Dermal Wound Cleanser on the bedside table. A review of the MDS (minimum data set) dated November 30, 2025 revealed a BIMS (brief interview of mental status) score of 11, indicating that the resident had moderate cognitive impairment. A review of the physician orders revealed an order for Fluticasone Furoate nasal suspension, 1 spray in each nostril every 24 hours as needed for allergies. However, there was no evidence in the physician orders for Equate Nasal Spray or it's equivalent or for the dermal wound cleanser. Furthermore, physician's orders revealed no evidence of an order for medication self-administration. A review of the electronic health record revealed no evidence that the resident was assessed for self-administration of medications. A review of the care plan revealed that the resident was at risk for impaired skin integrity and had a documented right lateral skin tear. The documented interventions included that medications are to be administered as ordered and to monitor/ document for side effects and effectiveness. The care plan further noted that the resident had impaired cognitive function/ dementia or impaired thought processes. An interview was conducted on January 13, 2026 at 9:05 AM with staff #61, CNA (certified nursing assistant). Staff #61 stated that a medication is any prescribed or over the counter treatment. Staff #61 stated that nasal spray would be a medication but was unsure if dermal wound cleanser would be classified as a medication. Staff #61 stated that medications should not be at the resident's bedside and that the risk could include a resident using the medication inappropriately. An interview was conducted on January 13, 2026 at 9:08 AM with staff #84, LPN (licensed practical nurse). Staff #84 stated that both equate nasal spray and dermal wound cleaners would be considered medications and these should not be at bedside. Staff #84 removed both medications from the resident's bedside table. Staff #84 stated that the risk could include another resident picking the medications up and using them. A follow-up interview with staff #84, LPN was conducted on January 13, 2026 at 10:08 AM. The LPN stated that a resident would have to be assessed for the ability to self-administer medications and an order would be put in place. Staff #84 stated that the resident would then be reassessed every 6 months, or sooner if warranted such as a change in condition, to ensure that they are still safely able to self-administer medications. Staff #84 stated that he checks the resident rooms for medications during medication administration. An interview was conducted January 16, 2026 at 10:00 AM with staff #74 ADON (assistant director of nursing). The ADON stated that medications are to be administered as ordered and that a resident would need to be assessed to be able to self-administer medications. She stated that risk for medications at bedside without an assessment could include inaccurate dosing, use of a medication outside of the intended use, and someone else accessing the medication. Regarding unlocked treatment cart: An observation was conducted on January 15, 2026 at 8:13 a.m. and revealed that a cart was unlocked, facing away from the nurses' station. Staff, residents and visitors were walking past the cart. An interview was conducted with licensed practical nurse (LPN) Staff #38 on January 15, 2026 at 8:14 a.m. and revealed the cart was a treatment cart with supplies. Staff #38 opened the treatment cart and prescription treatments were in the cart. The cart is supposed to be locked. A resident could get in the cart. An interview was conducted with assistant director of nursing (ADON) Staff #74 on January 15, 2026 at 10:31 a.m. and revealed that nurses have a key to the medication cart they are assigned to. There are 4 medication carts and 2 treatment carts. One of the treatment carts has a code that is needed to open and access the contents of the cart. The other treatment cart is opened by a key. The wound nurse has the key for the cart. When the wound nurse is not at the facility the key is kept in the wound office and the staff can get the key from the wound office. The residents could get into the cart and the medications in it. An observation was conducted on January 16, 2026 at 3:06 p.m. and revealed a nurse standing at a medication cart and a resident sitting in a wheel chair behind the nurse. The nurse secured the computer screen and walked around the outside of the nurse's station, into a room and the door closed after the nurse. The medication cart was not secured. The nurse opened the door and came out of the room, around the nurse's station and back to the medication cart. An interview was conducted with LPN Staff #102 on January 16, 2026 at 3:07 p.m. and revealed that the cart was left unsecured but that the staff went over there, pointing to the other side of the station. The risk for not having the medication cart secured is that someone could grab something. Review of the facility policy titled, Storage of Medications version 1.3 revealed that in section 6.0, compartments (including carts) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. A review of the policy titled Administering Medications, revised April 2019 noted that medications are to be administered in a safe and timely manner, and as prescribed. The policy further noted that residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely.

Based on observations, staff interviews, and policy, the facility failed to ensure that garbage and refuse were maintained properly.Findings include:During a walkthrough of the kitchen conducted on January 14, 2026, at 12:04 PM with Diet Technician/staff # 40, an observation was conducted of the facility dumpster area. Observed were two soiled gloves under the garbage receptacle, and trash debris was observed surrounding the outside perimeter. The lid to the garbage receptacle was open with a large number of flies. The lower left exterior of the receptacle had a rusted area approximately 6-7 inches in length that was dripping a liquid substance, milky in color that had formed a small puddle beneath the garbage receptacle with flies. The substance had a strong rancid odor. Also observed a Home Depot bucket filled with empty soda cans, empty food bags, and other garbage. There were multiple flies observed inside the bucket. An interview was immediately conducted on January 14, 2026, at 12:22 PM with Diet Technician/staff # 40, who stated the refuse area is maintained by the maintenance department, but it is expected that anyone disposing of garbage ensure that the lid is closed at all times. Staff #40 stated she was unaware of what the substance was leaking from the garbage receptacle. Staff #40 stated the risk of having the garbage receptacle lid open and having an unclean area surrounding it as it can attract vermin and pests. An interview was conducted on January 16, 2026, at 12:39 PM with Dietary Supervisor (Staff # 101). Staff # 101 stated that the cleaning of the garbage receptacle area is a collaborative effort of keeping the area clean, but is unaware of who is responsible for maintaining the area. Staff # 101 stated that the risks of not maintaining a clean perimeter, having an open garbage receptacle lid, and leakage from the garbage receptacle are the attraction of pests to the area. Review of the facility policy titled Waste Disposal revised January 2012 states all infectious and regulated waste shall be handled and disposed of in its appropriate manner.

Based on documentation, staff and resident interviews, and policy and procedures the facility failed to ensure that one resident (#1) received adequate supervision and care, during perineal care, to prevent accidents. The deficient practice could result in resident injuries. Findings include: Resident #1 was most recently admitted on [DATE] with diagnosis including: encephalopathy, extended spectrum beta lactamase resistance, unspecified fracture of the right ilium, subsequent encounter for fracture with routine healing, acute kidney failure, anemia in chronic kidney disease, acute embolism and thrombosis of unspecified deep veins of right lower extremity, type 2 diabetes, non-pressure chronic ulcer of other part of right lower leg with unspecified severity, muscle weakness, need for assistance with personal care, polyneuropathy, pressure ulcers of left heel-unstageable, chronic pain syndrome, retention of urine, chronic kidney disease stage 2, poly-osteoarthritis, essential hypertension, diastolic congestive heart failure, and morbid obesity. It was noted that the resident was discharged to the hospital on January 04, 2024. A review of the admission MDS (minimum data set) dated December 20, 2023 revealed a BIMS (brief interview of mental status) score of 10, indicating moderate cognitive impairment. The MDS further revealed that the resident had no noted behaviors, was totally dependent for toileting needs and personal hygiene. It was further noted that the resident had falls in the last 2-6 months prior to admission. A review of the care plan revealed a focus area for falls initiated on September 27, 2023, noting that the resident was at risk for falls. Interventions included to anticipate and meet the resident's needs, placing the call light within reach and educating on use thereof and safety, encouraging good footwear usage, following facility fall protocol and reviewing past falls to determine root cause. The care plan noted to assist with ADL's (activities of daily living) as needed but did not specify a 2-person assist. A review of the facility's fall assessment dated [DATE]. 2024 revealed that the resident was a moderate fall risk. It further noted that the bed was placed in the lowest position, that call light and water were in place and within reach. A review of the progress notes revealed that the resident had a witnessed fall on January 4, 2024. A, post fall, nursing assessment revealed no outwardly noted injuries and that the appropriate notifications transpired. The incident note in the progress notes further stated that that the CNA (certified nursing assistant) was performing peri care on the resident and proceeded to turn the resident to the left when the resident rolled out of bed and landed on her knees. It was noted that the resident did not hit her head and had been assessed for injuries. Notes stated that the resident was alert and oriented. It was documented that the physician and POA (power of attorney) were notified and that x-rays had been ordered. However, x-rays not able to be completed at the facility; therefore, the resident was sent to the hospital, per the progress notes. A review of the fall and fall prevention training documentation, revealed that a training was conducted on April 16, 2023; however, there was no evidence that staff #87 had participated in the training. Hospital records were requested, but had not been received. An interview was conducted on October 9, 2024 at 11:50 A.M. with staff #64 RN (registered nurse). Staff #64 stated that she recalled the incident of when resident #1 had rolled off the bed, but had not observed it. She stated that a post-fall incident assessment had been conducted and that notifications had transpired. She stated that she had later assisted with calling the hospital as the resident had been yelling out in pain. Staff #64 stated that she recalled having had peri care training and fall prevention training when she had initially started as a CNA in November of 2017 and a few thereafter but was unable to recall if she had either training last year. An interview was conducted on October 9, 2024 at 12:15 A.M with staff #106, DON (director of nursing), who provided fall and fall prevention in-service documentation. When asked about missing signatures on the sign-off, she stated that either staff did not attend or forgot to sign-off. She stated that oversight of the training documentation, at the time, was conducted by another staff member who is no longer at the facility. She stated that the risk would include staff not having received the necessary training. She further stated that she is now tracking all training and verify for completeness as well as conducting audits to ensure and verify understanding of the required trainings. Another interview was conducted with staff #106 DON regarding skills training for staff #87. Staff #106 stated that no skills training or annual performance review was conducted for staff #87 in 2023. A further review of the staff file revealed that although there was no evidence of an annual performance review a skills checklist was evident with a completion date of December 5, 2023; however individual topics did not denote a completion date-only the overall date was indicated. A subsequent interview was conducted on January 4, 2024 at 1:48 P.M. with staff #106 DON (director of nursing). Staff #106 stated that peri-care for a resident with a diagnosis of morbid obesity should always be a 2-person assist; however resident #1 was noted to have only been assisted by 1 CNA on January 4, 2024. She further stated that resident #1 was designated as a Hoyer lift transfer and therefore should have been a 2-person assist for peri care. She stated that the risk for not utilizing 2-staff members for peri care could include potential injuries or falls. Staff #106 further stated that fall management training is conducted annually. However, in reviewing the documentation of training, was unable to initially find documentation for fall management training in 2023. When the sign-off documentation was found it did not contain signatures or sign-off documentation for staff #87. Staff #106 stated that the risk for incomplete training could include not knowing about a change of condition and when to refer forward to therapy when that does happen. She stated that a change of condition might also be the cause a fall and without fall management training might not be recognized by staff. She further stated that her expectation was that policy was followed at all times when providing resident care and the risk for not doing so could result in resident injury. A telephonic interview was conducted on October 9, 2024 at 2:33 P.M. with staff #87 CNA. Staff #87 stated that on January 4, 2024 she had been performing peri care on resident #1. She stated that the resident was in bed on her left side and she was standing behind her on the other side of the bed. She stated that she made sure that the resident was secure. She stated that the resident's legs were stacked above each other, when the right leg slipped and dropped. She stated that the resident had her enabler bars in place and she was still behind her, when the resident's lower half of the body slipped from the bed, but upper half of the body remained on the bed. She stated that the resident landed on her knees and that she called out for help. Staff #87 stated that that the criteria for assisting residents with a diagnosis of morbid obesity includes having 2 -staff present if you can, but thought it was okay to do it by herself. She stated that in hind-sight having had another person there to assist would have been helpful, but stated that she couldn't find anyone. When asked if there were staffing concerns that day, she stated that she thought they were fully staffed that day with 3 CNA on that unit and a ratio of 10-13 residents. Staff # 87 stated that she did not recall having received fall management or peri care training when she started, but did recall having received a fall risk training in 2023; however, review of the training sign-off revealed no evidence of her presence in the training. Staff # 87 further stated that she had not had a skills assessment since starting at the facility in March of 2023; however, the personnel file did indicate the evidence of skills training dated December 5, 2023. A review of the facility policy entitled Peri care with a review date of February 2018 revealed that the resident should have their knees bent and feet flat on the mattress; however, when peri-care was provided to resident #1, the resident was reported to have been positioned on her left side and not with feet flat on the mattress, the resident fell and was subsequently transferred to the hospital. The policy entitled In-service Training, All Staff, revised August 2022 revealed that all staff must participate in initial orientation and annual in-service training.

Based on personnel record reviews, staff interviews, and policy and procedures, the facility failed to ensure that one out of two Certified Nursing Assistants, (CNA/#106), sampled received in-services and training for at least 12 hours per year. The deficient practice failed to ensure the continuing competence of the CNA. Based on personnel record reviews, staff interviews, and policy and procedures, the facility failed to ensure that one out of two Registered Nurses (RN/#33) sampled received in-services and training for at least 12 hours per year. The deficient practice failed to ensure the continuing competence of the RN. Findings include: Review of the personnel file for CNA, (staff #106), revealed a hire date of October 11, 2022. Further review of the training from October 2022 to October 2023, revealed no evidence of in-service training for Communication and Dementia. The review did reveal completed in-service training for Abuse and Neglect and Resident Rights. Review of the personnel file for RN, (staff #33), revealed a hire date of October 7, 2022. Further review of the training from October 2022 to October 2023 revealed no training had been completed. An interview was conducted on October 12, 2023 at 09:35 AM, with Director of Nursing, (DON staff #12). He stated that orientation and training for skills is provided upon hire. He also stated that in-services are provided monthly at staff meetings and that CNA (staff #106), did not have documentation that dementia training was completed since hire date. He did provide an in-service sign in sheet dated February 12, 2023, with CNA (staff #106) signature, but the in-service was for Abuse, Neglect, Misappropriation of Property, Elder Justice and Resident Rights. He stated he did not have documentation for any dementia in-service training for her. An interview was conducted on October 12, 2023 with DON (staff #12). He stated an employee audit revealed RN (staff #33), had not completed training, TB testing or fingerprint clearance. He stated he had a phone conversation with her on October 11, 2023. He stated she refused to obtain her fingerprint clearance card. As a direct result of this refusal, her employment was terminated on October 11, 2023. Review of the facility's Sufficient and Competent Nurse Staffing revealed licensed nurses and nursing assistants are trained and monitored by nursing leadership to ensure programming for staff training results in nursing competency and gaps in education are identified and addressed. Skills in the following areas but not limited to: Resident Rights, Behavioral Health, Psychosocial Care, Dementia Care, Person Centered Care, Communication, Basic Nursing Skills, Basic Restorative Services, Skin and Wound Care, Medication Management, Pain Management, Infection Control, Identification of Changes in Condition, and Cultural Competency.

Based on closed clinical record review, facility documents, staff interviews, and facility policies and procedures, the facility failed to provide documentation of notification to the receiving provider (emergency room ) of the reason for the transfer, provide accurate transfer documentation, or follow the facility transfer process for one resident (#168). The deficient practice could result in discharge/transfer requirements not being met. Findings include: Resident #168 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged on [DATE] for not being COVID-19 vaccinated. Review of the medical record revealed no evidence of the specific needs that could not be met, the attempts the facility made to meet the resident's needs, or the specific services the new facility would provide to meet the resident's needs. Review of the facility admission booklet revealed no documentation that the facility did not accept resident's unless they had received the COVID-19 vaccination. Review of progress notes did not reveal any evidence the resident and or the resident's spouse had been notified of the facility requirement to be COVID-19 vaccinated prior to admission to the facility. Further review of progress notes did not reveal evidence the admissions staff had confirmed the resident's vaccination status through use of the state vaccine database (ASIIS), or contacting the family for a copy of the vaccination card. There was no documentation in the medical record of advanced notice due to this being a facility-initiated discharge, to the resident or resident representative. Review of the medical record revealed no discharge summary form was completed/provided to the receiving facility or to the resident/family. Review of the medical record revealed a Transfer/Discharge Report dated December 21, 2022 at 2:21 PM, with no documentation as to the reason for the transfer, personal effects sent with the resident, medications or history of the resident's stay. Documentation revealed that the resident was transferred to a different hospital at discharge from the hospital she had originally been admitted from. The report did not contain documentation that a copy was provided to the family or resident at the time of discharge. Review of the medical record revealed no evidence the receiving provider (emergency room ) had been notified of the reason for the transfer. Review of the physician's order revealed no discharge order prior to discharge. Review of the medical record revealed no evidence the resident had been offered a COVID-19 vaccination when admitted to the facility. Review of progress notes revealed the resident's spouse had been notified of the transfer to the emergency roiagnom on [DATE]. Review of the discharge summary note by a case manager dated December 21, 2021 revealed the facility had been informed in writing that the resident had been vaccinated for COVID-19, but the resident stated that she was not vaccinated after discharge. It further stated that per protocol the resident was discharged . Review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted on August 23, 2022 at 11:15 AM with the Director of Admissions (staff #3), who stated that the facility is requiring that all new residents be vaccinated prior to admission. She stated that the process to confirm vaccination includes checking the state vaccine database (ASIIS), and contacting the family to ask for a copy of the vaccination card. She stated that this process would be completed prior to admission to the facility. She further stated that the hospital will try to see if the resident or family have easy access to the vaccination card, if not, the facility admissions staff would contact the family. The Admissions Director stated the vaccination card would be scanned into the medical record. She stated the first thing that is discussed with the resident and/or family is the admission information, including the need to be vaccinated prior to admission. She reviewed the medical for Resident #168, and stated that there was no documentation that the resident or the resident's family had been informed of the facility policy to be COVID-19 vaccinated prior to admission. She further stated that there was no documentation that they had confirmed the resident's vaccination status in the ASIIS database, or requested a copy of the vaccination card prior to admission. The Director of Admissions stated that the discharge staff at the hospital had told them the resident was vaccinated, but they did not check the ASIIS database, or ask the family directly about her vaccination status. She stated that this did not meet the facility admissions protocol. The Admissions Director stated that the admission forms/consents had not been signed at the time of admission. Staff #3 stated that she contacted the case manager at the hospital to let her know that there was an error in communication and that they were sending the resident back. However, review of the medical record revealed that the resident was transferred to a different hospital than the one the resident had been admitted from. She further stated that when a resident is discharged to the hospital the transfer summary paperwork is completed by the nurse. During an interview with the Administrator (staff #40) on August 23, 2022 at 11:25 AM, he stated that the current new patient handout/booklet was revised about two to three years ago and the only addition in the past year has been a letter regarding use of extension cords and candles. An interview was conducted on August 24, 2022 at 10:22 AM with an LPN (staff #58), who stated that a transfer/discharge summary should be completed at the time of discharge/transfer. She also stated that they would call the receiving facility and notify them of the reason for the transfer, then document the call in the medical record. She further stated that upon admission they test residents for COVID-19. She reviewed the medical record and stated that there was a progress note for the discharge summary, that the documentation stated that the resident was discharged related to COVID-19 vaccination status. She reviewed the medical record and stated that she did not see any documentation that the receiving hospital had been given a report. She further stated that she was the nurse that attended the resident's discharge, and she was not sure why the resident was sent back to the hospital. The LPN stated that the risk of not reporting the reason for the transfer to the hospital could result in the hospital not knowing why they are receiving the resident. An interview was conducted with the Director of Nursing (DON/staff #13) on August 24, 2022 at 2:56 PM, who stated that when they receive an admission referral they would find out if the patient is vaccinated, or the reason why if they are not. He reviewed the medical record and stated the facility did not follow the process for resident #168. He further stated the resident should not have been admitted to the facility without admissions confirming the vaccination card or checking the ASIIS system. The DON also stated that he would have kept the patient, as they currently have an unvaccinated resident residing in the facility. He reviewed the vaccine policy, and stated that it speaks to residents receiving the COVID-19 vaccine in the facility. He stated that they have no policy that states residents are required to be vaccinated prior to admission. The DON further stated that when a discharge/transfer is not emergent, the nurse would be expected to call the receiving facility and give a report, and document the call. He reviewed the medical record and stated that there was no documentation in the progress notes that the receiving facility had been notified of the reason for the transfer. He further stated that this did not meet the discharge policy. The DON stated the risk could result in the hospital being unable to care for the resident, and family would not know where the resident was transferred to. He stated that he did not see documentation that a COVID test had been done on admission, or orders for isolation. The DON reviewed the facility policy on discharges and stated the resident was not discharged following the facility policy, and this did not meet his expectations. An interview was conducted on August 25, 2022 at 9:09 AM with a Licensed Practical Nurse (LPN/staff #50), who stated that the discharge process included a physician order, and discharge summary. He further stated that the emergency room would be notified and it should be documented in the medical record. The LPN stated that they do vaccinate residents at the facility for COVID-19 and provide COVID-19 testing. Another interview was conducted on August 25, 2022 at 9:13 AM with the DON (staff #13), who stated that he could not speak to how the discharge benefited the resident's welfare, but that hospitals have more capabilities to prevent spread of infection. He also stated that there was no documentation in the medical record that a COVID-19 vaccination was offered to the resident, or of any reason why the facility could not meet the resident's needs. The DON stated that there was no documentation in the medical record that the resident was involved in the discharge, that the necessary healthcare information was shared with the emergency room , or that a discharge summary had been completed. He further stated that the facility policy is to obtain a physician order prior to transfer to the emergency room . He reviewed the medical record and stated that there was no documentation that a physician order had been obtained prior to discharge. He also stated that it is the facility policy for the attending physician to dictate a discharge note, and that he did not see one documented in the medical record. The DON stated that this did not meet the facility discharge policy. An interview was conducted on August 28, 2022 at 2:57 PM with the Infection Preventionist (IP/staff #55) in conjunction with the DON, who stated that it is the Administrator's preference that residents are admitted on ly if they are vaccinated. She also stated that new admissions are tested for COVID-19 when they are admitted . She further stated that when they realized the resident was not vaccinated, they should have offered to administer the COVID-19 vaccination and allowed the resident the right to refuse. She reviewed the line list and stated the facility was not in an outbreak status at the time of the resident's admission. The facility policy titled, Admission Criteria, included that prior to admission, the resident or representative is informed of any service limitation or special characteristics of the facility. It also stated that the facility admits only residents whose medical and nursing care needs can be met. The facility policy titled, Transfer or Discharge Documentation, included that when a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider. When a resident is transferred from the facility, the following information will be documented in the medical record: a) When a resident is transferred or discharged because his or her needs cannot be met at the facility, documentation will include: -the specific resident needs that cannot be met; -this facility's attempt to meet those needs; and -the receiving facility's services that are available to meet those needs. b) that an appropriate notice was provided to the resident and/or legal representative; c) the date/time of the transfer or discharge; d) the new location of the resident; e) the mode of transportation; f) A summary of the resident's overall medical, physical, and mental condition; g) Disposition of personal effects; h) Disposition of medications; Should a resident be discharged of any reason, the following information will be communicated to the receiving facility or provider: a) The basis for the transfer or discharge; b) If the resident is being transferred or discharged because his or her needs cannot be met at the facility, documentation will include: -The specific resident needs that cannot be met; -This facility's attempt to meet those needs; and -the receiving facility's services that are available to meet those needs. c) All special instructions or precautions for ongoing care, as appropriate; Review of the facility policy titled, Vaccination of Residents, included all residents will be offered vaccinations that aid in preventing infectious diseases. All new residents shall be assessed for current vaccination status upon admission. The resident or the resident's legal representative may refuse vaccines for any reasons.

Based on clinical record review, observations, staff interviews, and policy review, the facility failed to consistently implement care planned interventions for application of a hand roll to decrease risk for further hand contracture prevention for one resident (#7). The sample size was 2. The deficient practice could result in care plan interventions not being followed for residents with contractures. Findings include: Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of orders revealed: -Nursing to don/doff the patient to wear left hand roll all day, seven times a week as tolerated to decrease risk for further hand contracture and maintain skin integrity. Started October 24, 2018 and discontinued on October 26, 2018. Review of the medical record revealed no documentation that a hand roll had been applied after January 21, 2021. Review of the care plan revealed: - A focus on limited physical mobility related to weakness, history of cardiovascular accident ([CONDITION(S)]) with left sided [CONDITION(S)], [CONDITION(S)], initiated on May 19, 2015 with interventions that included a hand roll to left hand, initiated on January 25, 2021. - A focus on ADL (activity of daily living) self-care performance deficit related to [CONDITION(S)] with extensive residual deficits, requires total support with interventions initiated on January 17, 2019 included: hand roll to left hand as ordered, initiated on April 27, 2021, and hand roll to left hand related contracture prevention initiated on January 25, 2021. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], included a staff assessment for Cognitive Skills for Daily Decision-Making that indicated the resident was severely impaired. The assessment included an impairment of the upper extremity (shoulder, elbow, wrist, hand). Review of current physician orders revealed no orders for use of hand roll to the left hand, however nurse practitioner notes document to use hand roll to the left hand. Review of Nurse Practitioner progress notes dated July 14, 2022 and August 15, 17, 19, 2022, included documentation of contracture left hand, apply left hand roll every day. Observations conducted on the following dates revealed the resident lying in bed with no hand roll observed in the left hand: -August 08, 2022 at 11:36 AM -August 23, 2022 at 10:29 AM and 3:27 PM An interview was conducted on August 24, 2022 at 10:22 AM with a Licensed Practical Nurse (LPN/staff #58), who stated that she is familiar with the resident's care and that the resident has contractures. She also stated that the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The LPN stated that documentation of hand roll application would be on the treatment administration record (TAR). She reviewed the medical record and stated that there was no documentation in the TAR that a hand roll had been applied. She also reviewed the care plan and stated that there is an intervention that stated to use a hand roll to the left hand. She stated the only documentation that she could see in the medical record that the hand roll was applied was on January 21, 2021. She stated that this did not meet the facility expectation for following care planned interventions. An interview was conducted on August 24, 2022 at 11:56 AM with a Certified Nursing Assistant (CNA/staff #51), who stated that she was familiar with the resident, and that she did not place a hand roll in the resident's left hand. She further stated that sometimes she will place it on for 2 hours, then remove. An interview was conducted on August 24, 2022 at 2:16 PM with the Director of Nursing (DON/staff #13), who stated that the hand roll for contracture prevention should be continuous, and should be documented in the tasks section of the medical record. He also stated that interventions in the care plan should be implemented. He reviewed the medical record and stated that there was no documentation that the hand roll had been applied. The DON reviewed the care plan and stated that the hand roll was documented in interventions and should be placed on the resident. He also stated that the risk of not following the care plan could result in and crease of contractures. The DON further stated that the expectation is to follow the care planned interventions, and that this did not meet his expectations. Review of the facility policy titled, Comprehensive Person-Centered Care Plans, included that a comprehensive care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on observation, staff interview, and policy review, the facility failed to ensure medications were secured and not left unattended on top of the medication cart. The deficient practice could result in misappropriation of medications. Findings include: A medication administration observation was conducted on August 23, 2022 at 7:35 AM with a Registered Nurse (RN/staff #49). During the observation at 7:39 AM, a staff member came up to the nurse and said he was needed on station 1. The RN locked the medication cart, and was observed to walk down the hall away from the medication cart. At that time, it was observed that a vial of [MEDICATION(S)] 2 grams, two 0.9% sodium chloride injections, and a 10 ml (milliliter) bag of sodium chloride were on top of the medication cart when the RN left the unit. The RN returned at 7:41 AM and continued medication administration. The RN moved the medication cart to the doorway of the next room and prepared medications by placing them in a medication cup on top of the cart. Leaving the medication cup with the medications, and the intravenous medications on top of the cart, the RN picked up a blood pressure cuff and entered a resident's room. The RN was observed to be across the room with his back turned away from the medication cart. After completing the blood pressure check, the RN was observed to walk back across the room, sanitize his hands, pick up the medication cup that was on the top of the medication cart, re-enter the room and administer the medications. The [MEDICATION(S)], sodium chloride syringes and sodium chloride were observed to be on top of the medication cart during the administration of the other medications. An interview was conducted on August 23, 2022 at 8:15 AM with an RN (staff #49), who stated that it is the facility policy to not leave any medications unattended. He stated that he did leave the medications, syringes, and sodium chloride on top of the medication cart, unattended when he left the unit, and during medication administration. He stated that this did not meet the facility policy for medication administration. An interview was conducted on August 24, 2022 at 10:22 AM with a Licensed Practical Nurse (LPN/staff #58), who stated that the facility policy includes not leaving any medications or anything unattended on top of the medication carts. She also stated that all medications and any saline products should be kept in the drawer. The LPN further stated that it is not following the facility process to leave IV mediation and sodium chloride on the cart unattended. She stated that the risk could result in another resident taking the medication. An interview was conducted on August 24, 2022 at 1:46 PM with the Director of Nursing (DON/staff #13), who stated that it is not following the facility process to leave medications unattended on top of the medication carts. The DON stated that they should be locked up in the cart. He stated that the risk could result in a resident taking the medication or the vials being switched. Review of the facility policy titled, Administering Medications, revealed medications shall be administered in a safe and timely manner. During the administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse. No medications are kept on top of the cart.

Based on observation, staff interviews, facility documentation, and policy review, the facility failed to ensure a blood pressure cuff designated for multi-resident use was properly cleaned and disinfected between resident use. The deficient practice increases the risk for transmission of infection. Findings include: An observation was conducted on August 23, 2022 at 7:35 AM with a Registered Nurse (RN/staff #49) using a blood pressure cuff to perform a blood pressure check on a resident. When the test was completed, staff #49 placed the blood pressure cuff on top of the medication cart, without sanitizing it. At 7:45 the RN was then observed to remove the blood pressure cuff from the top of the medication cart, and proceeded to perform a blood pressure test on another resident. When the test was completed, he was observed to bring the blood pressure cuff out of the resident's room and place it on top of the medication cart without sanitizing the cuff. At 8:07 AM, the RN was observed to enter another resident room taking the blood pressure cuff from the top of the medication cart. He was observed to complete the test and place the cuff on top of the medication cart, he did not sanitize the cuff at that time. During an interview conducted with staff #49 on August 23, 2022 at 8:15 AM, he stated that the blood pressure cuff is his own, and all staff have their own blood pressure cuffs. He also stated that according to the facility policy a blood pressure cuff does not need to be disinfected between resident use unless the resident is on isolation precautions. The RN stated that he did not sanitize the blood pressure cuff between resident use during the medication administration observation. He stated that the risk of not sanitizing between resident use could result in transmission of infection. An interview was conducted on August 24, 2022 at 10:22 AM with a Licensed Practical Nurse (LPN/staff #58), who stated that all nursing staff have their own equipment, including blood pressure cuffs. She stated that the facility process is to disinfect/sanitize the equipment after use on each resident. She further stated that would include all residents, not just those on contact/isolation precautions. The LPN stated the risk of not sanitizing equipment between residents could result in the equipment carrying germs from one resident to another. An interview was conducted on August 24, 2022 at 12:16 PM with the Assistant Director of Nursing, and Infection Preventionist (ADON-IP/staff #5), who stated that she instructs all staff to sanitize blood pressure cuffs after every resident use, for all residents. An interview was conducted on August 24, 2022 at 1:46 PM with the Director of Nursing (DON/staff #13), who stated that blood pressure cuffs are multi-resident use, and should be sanitized between each resident use. He also stated that the nurses have their own blood pressure cuffs, and he would expect those to be sanitized as well. The DON stated the risk of not sanitizing between each resident could result in spreading infection from resident to resident or resident to visitor, or resident to a staff member. Review of the facility policy titled, Cleaning and Disinfection of Resident-Care and Equipment, included that Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC (Centers for Disease Control and Prevention) recommendations for disinfection and the OSHA (Occupational Safety and Health Administration) Bloodborne Pathogens Standard. Reusable items are cleaned and disinfected between residents. Durable medical equipment (DME) equipment must be cleaned and disinfected before reuse by another resident.

Based on employee record reviews, facility documentation, staff interview, and facility policy and procedures, the facility failed to conduct COVID-19 testing based on the frequency set forth by state and federal guidelines for one staff (#1). The deficient practice could result in the spread of the COVID-19 virus. Findings include: Review of facility documentation revealed the facility was on outbreak status from June 17, 2022 thru August 11, 2022 and required COVID-19 testing 2 times per week. Review of the facility's July 2022 testing log indicated that employee #1 was COVID-19 tested on [DATE] and 26, and the results were negative. However, on July 29, the test came back positive. The time Card for July 2022 revealed staff #1 worked at the facility on July 6, 7, 8, 9, 10, 11, 12, 13, 14, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, and 28. Comparison of the test dates and Time Card revealed that staff #1 worked on every week in July but was not tested for COVID-19 for the first two weeks of July and was only tested on ce during the week of July 17 thru July 22, 2022. An interview was conducted on August 23, 2022 at 11:44 a.m. with the Infection Preventionist (staff #55). Staff #55 stated all staff are tested during a COVID outbreak. Staff #55 stated that during an outbreak, staff are tested every 3-7 days for 14 days. She said that staff knew when they needed to be tested . During an interview with staff #1 conducted on August 23, 2022 at 2:05 p.m., she stated that the only time she was off for the month of July was after she tested positive for COVID. Staff #1 also said that she only recalled being tested on ce or twice in the month of July while the facility was in outbreak. An interview was conducted on August 25, 2022 at 2:19 p.m. with the Director of Nursing (DON/staff # 13). Staff #13 said that during COVID outbreak, all staff are tested regardless of vaccination status. He included the facility was in outbreak from June 17 thru August 11, 2022. The facility's policy titled Coronavirus Disease (COVID-19) - Testing Staff revised 2021, revealed [CONDITION(S)] testing of all staff regardless of vaccination status is conducted if there is an outbreak in the facility. If additional cases are identified, testing will continue every 3-7 days until there are no new cases for 14 days.

Based on observations, resident and staff interviews, and review of facility documentation and policy, the facility failed to maintain an effective pest control program to ensure the facility was free from insects. The deficient practice could result in ongoing insect problems. Findings include: Review of a pest control services invoice from an outside exterminator from June 15, 2022 through August 17, 2022 included: - June 15: interior, exterior, back wall and sidewall pest control for scorpions, cockroaches, spiders and crickets - July 14: interior, exterior, back wall and sidewall pest control for scorpions, cockroaches, spiders and crickets - August 17: interior, exterior, back wall and sidewall pest control for scorpions, cockroaches, spiders and crickets Review of the facility's work order request log regarding pest control for 2022 revealed the following: - January 9, 2022: report of ants on the dresser located in a resident's room - February 3, 2022: report of roaches on curtain located in a resident's room - February 12, 2022: report of cockroaches located in a resident's room - May 3, 2022: report of beetle or roach on the bed and on the floor located in a resident's room - August 3, 2022: report of big bugs in a resident's room - August 7, 2022: report of ants on side table located in a resident's room During an observation conducted on August 22, 2022 at 8:49 a.m., two cockroaches were observed in the hallway by rooms 156 and 157. One roach was dead, while the other one was alive scooting around. Staff members kept walking through the hall and passed by the insects and did not seem to notice the pests on the floor. One staff member was wiping the walls by the dead cockroach and did not seem to notice the pest. The pests were observed on the floor until about 9:39 a.m. On August 23, 2022 at 8:30 a.m., a cockroach was observed coming out of a resident room into the unit 2 hallway. An interview was conducted on August 24, 2022 at 1:17 p.m. with a resident who said that they have roaches bad in the facility. An interview was conducted on August 24, 2022 at 1:55 p.m. with the maintenance director (staff #39) who stated he schedules pest control weekly on Wednesdays. He stated once a month on one of those Wednesdays, the facility is sprayed for pests. Staff #39 stated that to his knowledge, the facility does not have a pest issue. He stated the exterminator sprays both the outside and the inside of the facility. Staff #39 verified with the exterminator during a call that the pest control service targets ants, roaches, cricket and any insects. He stated that whenever there is an issue, it is reported via an online work order system available for staff to fill out for requests. He stated alternatively, staff can come to the maintenance office to inform them of pest control issues. Staff #39 admitted that he is aware that there are sewage roaches and sometimes they come into the facility. He stated they try to keep water flowing in the rooms that are not in use to prevent the sewage roaches from coming in. He stated they do this by keeping p-traps water flowing and flushing. Staff #39 said that staff is supposed to inform maintenance of pest sightings/issues. An interview with a housekeeping (staff #38) conducted on August 25, 2022 at 10:16 a.m., who stated roaches seem to pop out in the facility. She stated mostly, they come out after the exterminator sprays the facility. Staff #38 stated that the last couple of times the exterminator sprayed, shortly thereafter, the roaches came out. Staff #38 stated staff are supposed to inform maintenance of pest sightings/issues. She said reporting can be done via the computer or by speaking directly with maintenance staff. She said she has reported roach sightings once or twice. Staff #38 stated the last report she made was about a month ago and was done verbally. An interview with a certified nursing assistant (CNA/staff #64) was conducted on August 25, 2022 at 10:38 a.m. Staff #64 said that she has seen pests such as scorpion, roaches and ants in the facility. She said right outside the building there are a lot of roaches. She said that sometimes they are told to put a work order in; other times, just tell maintenance directly. Staff #64 stated they have been instructed to inform maintenance of resident's concern regarding pests. She stated that last night one of her residents informed her about ants and showed her where it was in the room. She reported the ant sighting verbally. Continued review of the pest work order log did not render a match for the insect sighting that staff #64 reported. A follow up interview with the maintenance director (staff #39) was conducted on August 25, 2022 at 11:42 a.m. Staff #39 stated that if pest control issues were reported verbally, then there would be no documentation regarding the work order. He said he does reiterate to staff to request a work order via the computer but when staff is busy it does not happen. He said the maintenance staff are also busy so they are not able to generate the work order in the computer for verbal requests. Staff #39 also stated that no one informed him about roaches on Monday. The facility's pest control policy, revised May 2008, revealed the facility shall maintain an effective pest control program. The policy stated maintenance service assists in providing pest control services.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#55) and/or their representative was informed of the risks and benefits of psychoactive medications prior to administration. The census was 55. The deficient practice could result in residents and/or the residents' representative not being aware of the risks and benefits of psychoactive medications. Findings include: Resident #55 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 5, which indicated severe cognitive impairment. The assessment included the resident received antidepressant and antipsychotic medications during the 7-day look back period. Regarding [MEDICATION NAME] Review of the clinical record revealed a physician order dated February 11, 2021 for [MEDICATION NAME] (antidepressant) 20 milligrams (mg) one tablet by mouth one time a day for depression as evidenced by sad affect. A care plan initiated February 15, 2021 revealed the resident used antidepressant medication related to depression. Interventions included educating the resident/family/caregivers about risks, benefits, and the side effects and/or toxic symptoms; and administering antidepressant medications as ordered by the physician. Review of the Medication Administration Records (MARs) for February 2021 and March 2021 revealed the resident was administered [MEDICATION NAME] as ordered. A review of the [MEDICAL CONDITION] Medication Use Consent form for [MEDICATION NAME] revealed a date of February 23, 2021 by one of the signatures on the form (signature of person presenting the form). The other signature on the form did not have a date. No other evidence was provided to indicate the resident/representative was informed of the risks and benefits of [MEDICATION NAME] before February 23, 2021. Regarding [MEDICATION NAME] Review of the clinical record revealed a physician order dated February 11, 2021 for [MEDICATION NAME] (anti-psychotic) 25 mg one tablet by mouth at bedtime for agitation. Review of the nursing communication note dated February 11, 2021 revealed the resident's representative was notified of the resident's behavior of slapping self but refused consent for [MEDICATION NAME]. The note also revealed the resident representative wanted to be notified of any other outbursts and that the resident representative may consent then. The note included the resident's representative consented to a psych consult. A physician progress notes [REDACTED]. The note included the resident representative was now agreeable as the resident was agitated intermittently and harmful to self. Review of the MARs for February 2021 and March 2021 revealed [MEDICATION NAME] was not administered as ordered to the resident until February 16, 2021. However, no documented evidence was provided that the resident representative was informed of the risks and benefits of [MEDICATION NAME]. A consent for [MEDICATION NAME] with the date February 16, 2021 was provided. However, no physician order was found for [MEDICATION NAME]. The care plan initiated February 18, 2021 revealed the resident used antipsychotic medication related to behavior management. Interventions included administering [MEDICAL CONDITION] medications as ordered by the physician and discussing with the physician and family regarding ongoing need for use of medication. An interview was conducted on March 3, 2021 at 1:18 PM with a Licensed Practical Nurse (LPN/staff #1). The LPN stated the process is to obtain informed consent before administering a [MEDICAL CONDITION] medication. The LPN stated [MEDICAL CONDITION] medications are not administered without consent. Staff #1 stated that if the resident is unable to give consent, verbal consent is obtained from the resident's representative and that two nurses will sign the consent form. Staff #1 stated that if the resident or resident's representative refused to consent, the nurses will call the physician and the order would be discontinued. The LPN further stated that if the resident or their representative decides later to consent, the physician would be contacted to obtain an order for [REDACTED].>In an interview conducted with the Assistant Director of Nursing (ADON/staff #27) on March 4, 2021 at 10:02 AM, the ADON stated her expectation is for the nurse to obtain consent for a [MEDICAL CONDITION] medication prior to administering the medication. The ADON stated if the resident is cognitively impaired, the nurse would contact the resident representative to obtain verbal consent and two nurses would sign the consent form. The ADON also stated staff #88 signed the consent form for resident #55. An interview was conducted with the LPN (staff #88) on March 4, 2021 at 12:37 PM. The LPN stated that after a resident has been admitted , she and the ADON will conduct a chart check the next day to ensure all consents have been obtained. The LPN also stated that she conducts weekly chart checks. Staff #88 stated that the signed consents are sent to medical records. The LPN stated that if she finds a consent has not been obtained, she will print out the consent and give it to the nurse to obtain before administering the medications. Staff #88 stated the resident representative is contacted to obtain verbal consent for a [MEDICAL CONDITION] medication if the resident is unable to give consent. The LPN agreed that she signed the consent for [MEDICATION NAME] on February 23, 2021 for resident #55. The LPN could not say why the [MEDICATION NAME] consent was missing for resident #55. During an interview conducted with the Director of Nursing (DON/staff #26) on March 4, 2021 at 12:48 PM, the DON stated all residents' documents including [MEDICAL CONDITION] medication consents are sent to medical record. The DON stated medical record then scans the residents' documents into the residents' electronic record under miscellaneous. She stated her expectation is for the nurses to obtain consent for a [MEDICAL CONDITION] medication prior to administration. The facility's Antipsychotic Medication Use policy revised December 2016 did not include informing residents and/or their representative of the risks and benefits of antipsychotic medications.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#60) and the resident representative was provided the opportunity to participate in the care planning process and one resident's (#43) care plan was revised. The deficient practice could result in residents and their representatives not participating in the care planning process and care plans not being revised. Findings include: -Resident #60 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's care plan history revealed care plan meetings occurred on September 29, 2020, October 3, 2020, and December 28, 2020. Review of the clinical record did not reveal a care plan meeting invitation informing the resident/representative a care plan meeting was scheduled September 29, 2020, October 3, 2020, and December 28, 2020. Review of the progress notes, including the Care Conference Notes, did not reveal documentation regarding the care plan meetings or who attended the meetings. An interview was conducted on March 4, 2021 at 12:04 p.m. with the MDS (Minimum Data Set) Coordinator (staff #73), who stated it was her responsibility to document who attended the Care Plan Meetings in the Care Conference Notes. Staff #73 stated she would not have completed documentation for the Care Plan Meetings on September 29, 2020, October 3, 2020, and December 28, 2020 because she did not start working for the facility until January 4, 2021. She reviewed the care plans and the Care Conference Notes and stated there was no documentation regarding those care plan meetings, but that she would continue to look. An interview was conducted on March 4, 2021 at 12:32 p.m. with the Social Services Director (SSD/staff #72), who stated that she was responsible for sending an invitation to the resident's representative when a care plan meeting is scheduled. Staff #72 stated that she mails the invitation to the representative and gives an invitation to the resident. Staff #72 also stated that she informs the resident verbally of the date and time of the meeting. The SSD stated that when the meeting occurs, the names of everyone attending are documented in the Care Conference Note. During the interview, the SSD reviewed her notes and stated the care plan meetings occurred on September 30, 2020, October 7, 2020, and December 30, 2020. Staff #72 stated that she did not have a copy of the invitation letters for those dates and did not document in the progress notes that the resident or representative were invited to the care plan meetings. She reviewed the Care Conference Notes and could not find any documentation regarding who attended the meetings and was not able to remember if the resident or representative attended. During an interview conducted with staff #73 on March 4, 2021 at 1: 14 p.m., the MDS Coordinator stated that she could not find any documentation regarding the care plan meetings or who attended. An interview was conducted on March 4, 2021 at 1:20 p.m. with the Director of Nursing (DON/staff #26), who stated that the resident is notified about a Care Plan Meeting verbally and it should probably be documented in the progress notes. The DON said the Conference Care Meeting, including who attended is documented in the Conference Care Notes. The facility's Comprehensive Assessment and the Care Delivery Process policy revised December 2016 revealed assessment and information collection included resident and family interview. -Resident #43 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the care plan initiated May 26, 2017 and revised April 6, 2020 revealed resident #43 had senile dementia, which was showing signs of progression as evidenced by inability to find his room on occasion. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed a score of 2 on the Brief Interview for Mental Status (BIMS) indicating the resident had severe cognitive impairment. Review of the clinical record revealed an alert note dated December 16, 2020 that stated the resident was found outside siting on a bench next to the front door. The resident stated he was looking for his truck. The alert note dated December 18, 2020 revealed that a wander guard was put on the resident's ankle. Continued review of the clinical record revealed the resident was on alert charting for elopement risk until December 19, 2020. A physician's orders [REDACTED]. Another physician's orders [REDACTED]. However, further review of the clinical record revealed the care plan had not been revised to include the resident's elopement and the placement of the wander guard. An interview was conducted on March 4, 2021 at 10:02 am with a Certified Nursing Assistant (CNA/staff #56), who stated she was familiar with the resident and his care. Staff #56 stated the resident is ambulatory in his wheelchair and enjoys taking himself around the building during the day. The CNA stated the resident enjoys his routine which included going to the main dining room for meals. Staff #56 stated the resident had difficulty with the changes to his routine due to COVID-19 restrictions and would not follow the guidelines to remain in his room. Staff #56 stated she was aware that resident #43 was an elopement risk because she knew he had a wander guard on. She stated she did not know if the wander guard was in the resident's care plan, since the nurse is the one who completes and updates the care plan. An interview was conducted on March 4, 2021 at 11:00 am with a Licensed Practical Nurse (LPN/staff #86), who stated she was familiar with the resident and his care. The LPN stated the resident wore a wander guard because he liked to try and get out of the building on occasion. Staff #86 stated the resident had been better about it recently, but that the resident used to try and open the doors to get out of the facility often. Staff #86 stated the admission nurse initiates the care plans for residents and the care plan should include everything the staff needs to be aware of about the resident. The LPN stated the care plan is updated whenever there is a new issue or a problem with the resident, or when there are new treatments or medications. Staff #86 stated resident #43's care plan should include that he wanders and that he wears a wander guard. An interview was conducted on March 4, 2021 at 11:30 am with the Director of Nursing (DON/staff #26). She stated the care planning process begins at admission with the admitting nurse initiating the care plan. Staff #26 stated the MDS coordinator updates the care plans as needed, with input from other staff. The DON stated that a resident's care plan should be updated with any changes or issues. She stated the care plan is discussed regularly in care plan meetings and updated as needed after the meetings. Regarding resident #43, the DON stated she did not consider the incident on December 16 to be an elopement since the resident did not leave the facility grounds and was located just outside the front door. The DON also stated she would expect the resident's care plan to be updated with the new information following the placement of the wander guard. The facility's policy titled Wandering and Elopements, revised March 2019, stated if a resident is identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.

Based on observation, personnel record review, staff interviews, and policy and procedures and the Centers for Disease Control and Prevention (CDC), the facility failed to ensure one staff (#12) maintained infection control standards regarding hand hygiene and one staff member (#18) had evidence of freedom from infectious [MEDICAL CONDITION] on or before the staff member began providing services. The deficient practice could result in the spread of infection. Findings include: -On March 1, 2021 at 10:58 a.m., a Certified Nursing Assistant (CNA/staff #12) was observed putting two white plastic bags on the floor by the air conditioner in a resident's room. The CNA removed her gloves and picked the bags up, one in each hand. The resident asked the CNA to lower her mobile tray. The CNA was observed to hold both bags in her left hand, while she adjusted the resident's mobile tray with her right hand. The CNA was not observed to perform hand hygiene or disinfect the resident's tray. Following this observation, an interview was conducted with staff #12. The CNA stated one bag contained a soiled brief and the other bag contained dirty washcloths. The CNA said she should have sanitized her hands before touching the resident's mobile tray to keep the tray from being contaminated. Staff #12 stated she was trained to sanitize her hands after doffing her gloves to prevent cross contamination. An interview was conducted with the Infection Control Preventionist (ICP/staff #88) and the Assistant Director of Nursing (ADON/staff #27) on March 4, 2021 at 8:56 a.m. The ADON stated staff should put a soiled brief in a garbage can that is lined with a plastic bag, remove gloves, and sanitize their hands. Staff #27 stated that if she saw a staff member touching the bags and then the resident's mobile tray, she would retrain the staff because the staff would be handling dirty bags and then touching a clean tray. The facility's policy, How to Safely Remove Personal Protective Equipment (PPE), stated the outside of the glove is contaminated and to wash hands or use an alcohol-based hand sanitizer after removing all PPE. The CDC Hand Hygiene in Healthcare Settings for Healthcare Providers included hand hygiene is clinically indicated immediately after glove removal and after contact with contaminated surfaces. -Staff #18, a registered nurse, was hired at the facility on January 10, 2020. A review of staff #18's personnel file on March 3, 2021 revealed no documented evidence that staff #18 was free from infectious [MEDICAL CONDITION]. Review of the facility's [MEDICATION NAME] skin test sheet for staff #18 revealed the test was given on January 14, 2020 in staff #18's left forearm. There was no documented result from the test. An interview was conducted on March 4, 2021 at 11:30 am with the Director of Nursing (DON/staff #26), who stated all staff are tested for [MEDICAL CONDITION] annually. She stated the facility provides the test onsite. The DON stated the facility used to have a staff member who reviewed all of the employee [MEDICAL CONDITION] tests, but that staff member was no longer employed with the facility. The DON stated that the managers are now supposed to review the [MEDICAL CONDITION] tests for their employees. After reviewing staff #18's [MEDICAL CONDITION] skin test, the DON stated there should be a result documented for the test. The facility's policy Employee Screening for [MEDICAL CONDITION], revised August 2019, included all employees are screened for latent [MEDICAL CONDITION] infection (LTBI) and active [MEDICAL CONDITION] (TB) disease, using [MEDICATION NAME] skin test (TST) or interferon gamma release assay (IGRA) and symptom screening prior to beginning employment.

Based on observations, staff interviews, and policy review, the facility failed to ensure one resident's (#40) bathroom sink was in working order. The deficient practice could result in residents' bathroom sinks not being in working order. Findings include: Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] revealed a score of 10 on the Brief Interview for Mental Status (BIMS) indicating the resident had moderately impaired cognition. An observation of resident #40's bathroom sink was conducted on March 1, 2021 at 9:55 am. The sink was observed full to the top with water. The resident stated the sink had been like that for a couple of months. The resident stated she had reported it to her Certified Nursing Assistant (CNA) and to her nurse. On March 2, 2021 at 10:20 am, another observation was conducted of resident #40's bathroom sink. The sink was observed three quarters full of water. The water was observed to be a milky color. The bottom of the sink was not visible through the water. Following this observation an interview was conducted with resident #40, who stated maintenance had come to look at the sink but did not fix the sink. She said the maintenance man spoke in Spanish and she was not able to understand him. The resident said her CNA had plunged the sink the day prior since it looked like it was going to overflow. Resident #40 stated she has had to brush her teeth in a basin at her bed since she was not able to use the clogged bathroom sink. The resident stated she has also had to wash her face and have personal care provided in bed due to the lack of a working sink. The resident stated she would prefer to do these activities in the bathroom at the sink. An interview was conducted on March 2, 2021 at 11:02 am with the maintenance manager (staff #78). Staff #78 stated all maintenance work in the building should be submitted on a work order, and that the work orders are picked up daily. He stated he receives 1-3 work orders a day and that he triages them to respond to the most important ones first. Staff #78 stated he does not keep work orders for the previous month and was unable to say if a work order had been submitted for resident #40's bathroom sink. Staff #78 stated he was not aware of any ongoing issues in the building. On March 2, 2021 at 11:47 am, an interview was conducted with a CNA (staff #8) who stated she was aware of the problem with resident 40's sink. The CNA said the sink had been clogged and not draining properly for a couple months. Staff #8 stated several work orders had been filled out and that she verbally informed staff #78 about the issue the day before. Staff #8 further stated staff #78 told her he would get to it when he had time. On March 2, 2021 at 12:23 pm, an interview was conducted with a Licensed Practical Nurse (LPN/staff #84) who stated work orders are submitted to maintenance through the drop box at the nurse's station. The LPN said that maintenance does not always respond to work orders immediately and sometimes she has made multiple work orders for the same issue. During an observation conducted of resident 40's bathroom sink with staff #78 on March 2, 2021 at 12:40 pm, staff #78 stated all plumbing in the building was expected to be in proper working order. Staff #78 stated he was aware of the problem with resident 40's sink. The maintenance manager stated there were two sinks in the facility that were having a problem and that the other sink was determined to be more of an emergency situation. Staff #78 stated he thought the issue with resident #40's sink was a problem with the pipes on the roof but that after investigating, that was not the problem. Staff #78 said the bathroom sink in resident 40's room needed to be re-piped and that the work would be completed that day. An interview was conducted with the facility administrator (staff #36) on March 2, 2021 at 12:47 pm. The administrator stated that he expects staff to fill out a work order for any work that needs to be done in the facility. The administrator stated the maintenance manager and assistant complete a lot of work on the building. Staff #36 stated maintenance does a lot of work that there were no work orders for as well. Staff #36 stated he was not aware of the problem with resident 40's sink. The administrator stated he would expect the staff to come to him if there was a work order that was not responded to. The facility's Work Orders policy revised April 2010, stated that in order to establish a priority of maintenance service, work orders must be filled out and forwarded to the maintenance director. The policy also included work orders are picked up daily and emergency requests will be given priority in making necessary repairs.

Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure a comprehensive care plan was developed for one resident (#39) regarding [MEDICAL CONDITION]. The facility census was 55. The deficient practice could result in care issues not being addressed in residents' plan of care. Findings include: Resident #39 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident had intact cognition. The MDS assessment also included the resident had a [DIAGNOSES REDACTED]. Review of a SBAR (Situation, Background, Assessment, Recommendation) note dated February 23, 2021 at 2:59 am revealed the resident has [MEDICAL CONDITION] disorder, shaking temp 97.8 gen hives. A nursing note dated February 23, 2021 at 3:33 am revealed the resident was taken to the hospital at 3:30 am. A nurse note dated February 28, 2021 revealed the resident was readmitted to the facility on [DATE] at 7:00 pm. Review of physician orders [REDACTED]. A physician skin/wound note dated March 1, 2021 at 10:24 am stated the resident was recently hospitalized for [REDACTED]. However, review of the resident's care plans did not reveal a care plan for [MEDICAL CONDITION]. An interview was conducted with resident #39 on March 4, 2021 at 10:29 am. The resident stated that in February of 2021 she was sent to the hospital for [MEDICAL CONDITION], but that she had a [MEDICAL CONDITION] as well. The resident stated that she does not remember much of the [MEDICAL CONDITION], but that she had a loss of control and was shaking. An interview was conducted with the Registered Nurse (RN/staff #16) on March 4, 2021 at 10:51 am, who stated that he assisted the resident during her [MEDICAL CONDITION], but was not aware that the resident lost control or consciousness. The RN said that he was not aware the resident has a [DIAGNOSES REDACTED]. During an interview conducted with the Licensed Practical Nurse supervisor (LPN/staff #88) on March 4, 2021 at 11:01 am., staff #88 stated that she was aware that the resident had a [DIAGNOSES REDACTED].#88 also stated that she was not aware there was no care plan to monitor for [MEDICAL CONDITION] and that the nurse should be monitoring for [MEDICAL CONDITION]. An interview was conducted on March 4, 2021 at 11:21 am with the Director of Nursing (DON/staff #26). Staff #26 stated that she was not aware the resident had a [DIAGNOSES REDACTED]. The DON said that she was not aware resident #39 reported loss of control and was not sure if the resident had an actual [MEDICAL CONDITION]. The DON stated that the process of initiating a care plan starts with the MDS Coordinator. The DON said the care plan is then reviewed by nursing and the interdisciplinary team. The DON further stated that she did not know why resident #39 did not have a care plan for [MEDICAL CONDITION]. Staff #26 said the MDS Coordinator was new to the facility. An interview was conducted with the MDS Coordinator (staff #73) on March 4, 2021 at 11:29 am. Staff #73 stated the resident's needs are evaluated on admission and a care plan is initiated at that time. The Coordinator further stated that she was aware the resident had [MEDICAL CONDITION] and should have a care plan to monitor for [MEDICAL CONDITION]. Staff #73 stated it must have been an oversight. Review of the facility's policy regarding assessments and care planning revised December 2016 included comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions. The policy stated to define conditions and problems that are causing or could cause other problems. Define current treatments and services; link with problems/diagnoses. The policy also included assessments (baseline, comprehensive, MDS, etc.) are used to develop, review and revise the resident's comprehensive care plan.

Based on clinical record review, resident and staff interviews, facility documentation and policy review, the facility failed to ensure one resident (#25) received consistent showers. The deficient practice could result in residents not consistently receiving showers. The resident census was 55. Findings include: Resident #25 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview Mental Status score of 11, indicating the resident was moderately impaired. The MDS assessment also included the resident required one-person physical assist in part of bathing activity. The resident's care plan for Activities of Daily Living included for showering/bathing and a sponge bath when a full bath or shower cannot be tolerated. Review of the Skin Monitoring: Comprehensive CNA Shower Review forms revealed the resident was scheduled for a shower on Tuesdays and Saturdays. There were no shower forms to confirm the resident received a shower on Saturday, January 2, 2021, Tuesday, January 12, 2020, and Saturday, January 30, 2021. An interview was conducted on March 1, 2021 at 12:10 p.m. with resident #25, who stated that he is supposed to get a shower on Tuesdays and Saturdays. The resident stated that when there are not enough staff, he does not receive a shower. An interview was conducted on March 3, 2021 at 2:54 p.m. with a Certified Nursing Assistant (CNA/staff #45), who stated residents are showered twice a week and there is a set schedule for resident showers. The CNA stated that he documents showers, refusals, or if the resident was not present for the shower on the Skin Monitoring: Comprehensive CNA Shower Review forms. Staff #45 stated the forms are then reviewed by a nurse. The CNA also stated that the facility was short staffed and the resident may not have gotten a shower. In an interview conducted with the Infection Control Preventionist (ICP/staff #88) and the Assistant Director of Nursing (ADON/staff #27) on March 4, 2021 at 8:56 a.m., the ADON stated every resident is provided a shower two times a week and all the information pertaining to the shower is documented on the Skin Monitoring: Comprehensive CNA Shower Review form. The ICP said that if a resident refused a shower or was not present for a shower, it would be documented on the shower form. The ADON and the ICP stated that there should be a shower form completed for each resident two times a week and a nurse must review the forms and sign off on them. In an interview conducted with the Director of Nursing (DON/staff #26) on March 4, 2021 at 10:39 a.m., the DON stated the facility does not have a shower policy, but that it is standard practice for each resident to be given a shower/bed bath two times a week. The DON also said if a resident refused a shower, it is her expectation that the nurse would talk to the resident and encourage the resident to take a shower. The DON said if the resident still refused, the nurse should document the refusal on the Skin Monitoring: Comprehensive CNA Shower Review form. The facility's Supporting Activities of Daily Living (ADL) revised March 18, 2018 included appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene. The policy did not include providing the residents showers twice a week.

Based on observation, clinical record review, staff interviews, and policy review, the facility failed to ensure bilateral heel pressure ulcer treatment was administered as ordered by the physician for one resident (#55). The deficient practice could result in residents receiving treatments not ordered by the physician. Findings include: Resident #55 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's care plan initiated March 2, 2021 revealed the resident had pressure ulcers to the heels and metatarsals. The goal was that the resident's pressure ulcer will show signs of healing and remain free from infection. Interventions included administering treatments as ordered and monitoring for effectiveness. Review of the physician orders [REDACTED]. -an order dated March 2, 2021 to apply skin prep to the right heel every night shift for wound care -an order dated March 3, 2021 to cleanse the left heel with normal saline, apply Medi honey to wound bed and cover with protective dressing every night shift for left heel treatment until the Santyl is available. An interview was conducted with the Nurse Practitioner (NP) on March 3, 2021 at 1:43 PM, after the NP had assessed resident #55 wounds. The NP stated the daily treatment recommended for the right heel was skin prep and leave open to air. The NP stated the daily treatment for [REDACTED]. A wound treatment observation was conducted on March 3, 2021 at 1:50 PM. The Assistant Director of Nursing (ADON/staff #27) was observed to cleanse the left heel with normal saline, applied skin prep and leave the left heel open to air. The ADON was then observed to cleanse the right heel with normal saline, apply Medi honey with a cotton tipped applicator, place a gauze on the right heel and covered it with an island dressing and date the dressing March 3, 2021. A nursing Daily Wound Data Collection form dated March 3, 2021 revealed skin prep was applied to the right heel and the right heel was left open to air. A nursing Daily Wound Data Collection form dated March 3, 2021 revealed the left heel was cleansed with normal saline, pea sized Medi honey was applied to the wound bed and a protective dressing was applied. Review of the NP Wound Progress Note dated March 3, 2021 revealed the right heel wound was a deep tissue pressure injury persistent non-blanchable deep red, maroon or purple discoloration pressure ulcer. Measurements were 1.4 centimeters (cm) length x 3 cm width, with an area of 3.299 square cm. No drainage was noted and the wound bed had 76-100% [MEDICATION NAME]. The note included the dressing/recommendation for the right heel included skin prep and open to air daily. Continued review of the NP note dated March 3, 2021 revealed the left heel wound was a stage 3 pressure injury pressure ulcer with measurements 0.5 cm length x 1 cm width x 0.1 cm depth, with an area of 0.393 square cm and a volume of 0.039 cubic cm. A small amount of serous drainage was noted and the wound bed had 76-100% pink granulation. The note also revealed the dressing/recommendation for the left heel included medical grade honey, cover with dry protective dressing daily. An interview was conducted on March 4, 2021 at 10:02 AM with the ADON (staff #27). The ADON stated daily assessments of wounds are done by the nurses and that she reviews the Daily Wound Data Collection forms and weekly reviews the wound treatment to see if the wound is improving or not. The ADON stated the NP assess resident wounds weekly and new treatment orders are implemented as soon as possible. Staff #27 stated resident #55 wounds included a right heel wound and a left heel wound. The ADON further stated the treatment ordered for the right heel wound was skin prep and the treatment ordered to the left heel was Medi honey and cover with protective dressing. Another wound observation conducted with the ADON on March 4, 2021 at 10:15 AM, revealed resident #55 right heel and left heel were covered with a dressing. On March 4, 2021 at 10:31 AM, wound documents including orders, progress notes and weekly wound treatment order sheets were reviewed with the ADON. The ADON was unable to provide any documentation that reflected change in wound care for the right heel and left heel for resident #55. Following this review at 10:35 AM., the ADON agreed she applied Medi honey to the right heel and skin prep to the left heel. She stated that as the right heel is macerated, Medi honey was needed for the right heel. She stated the left heel was only baggy, red and not open, therefore she applied skin prep to the left heel. The ADON further stated the NP gave her a verbal order to apply skin prep to the left heel and Medi-honey to the right heel. The ADON stated the current order was a mistake and that she would verify the order with the NP or physician and update the order in the resident's clinical record. An interview was conducted with the Director of Nursing (DON/staff #26) on March 4, 2021 at 12:48 PM. The DON stated the nurses should follow the physician order [REDACTED]. A review of the physician order [REDACTED]. The facility's policy titled Medication and Treatment Order revised July 2016 revealed orders for medications and treatments will be consistent with principles of safe and effective order writing. The policy revealed verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include the prescriber's last name, credentials, and the date and time of the order. The policy further revealed verbal orders must be signed by the prescriber at his or her next visit. Review of the facility's Pressure Ulcers/Skin breakdown - Clinical Protocol revised April 2018 revealed the physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressing (occlusive, absorptive, etc.), and application of topical agents. The policy further stated that during the resident visits, the physician will evaluate and document the progress of wound-healing- especially for those with complicated, extensive, or poorly healing wounds.

Based on observations, clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#410) had an order for [REDACTED]. Findings include: Resident #410 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On March 2, 2021 at 3:12 p.m., an interview was conducted with a Certified Nursing Assistant (CNA/staff #45) in the resident's room. During this time, the resident was observed receiving oxygen via nasal cannula at 2 liters per minute. The oxygen tubing was dated February 27, 2021. Staff #45 stated that the nurses take care of the oxygen. On March 3, 2021 at approximately 9:30 a.m., the resident was observed sleeping in the bed receiving oxygen via nasal cannula at 2 liters per minute. However, review of the clinical record did not reveal an order for [REDACTED]. An interview was conducted on March 3, 2021 at 9:32 a.m. with a Licensed Practical Nurse (LPN/staff #1), who stated a physician's order is needed before administering medications or a treatment to a resident. The LPN stated she knew resident #410 was receiving oxygen because she placed the oxygen on the resident that morning. After reviewing resident #410's orders, the LPN stated the order for oxygen was discontinued on February 24, 2021 because the resident was sent out to the hospital. The LPN stated that she would contact the Physician's Assistant. An interview was conducted on March 3, 2021 at 10:05 a.m. with the Director of Nursing (DON/staff #26), who stated that the expectation is that the nurses ensure the right medication/treatment is given to the right person based on the physician orders. The DON stated that if there is no order, the nurses should contact the physician. The DON also stated that if the resident is sent to the hospital and returns, the nurse is supposed to review the orders and confirm the orders with the doctor, the Assistant Director of Nursing is supposed to check the orders, and the nurse administering medications/treatments should be checking the order and the Medication Administration Record. The facility's Oxygen Administration policy stated the purpose of the procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.

Based on observations, clinical record reviews, staff interviews, and review of policy and procedures, the facility failed to ensure the residents' environment was free of accident hazards, by failing to ensure safe water temperatures were maintained in multiple residents' bathrooms and in two shower rooms. As a result, the Condition of Immediate Jeopardy and Substandard Quality of Care were identified. Findings include: At 2:30 p.m. on October 3, 2016, the Condition of Immediate Jeopardy and Substandard Quality of Care were identified. The Director of Nursing (DON/staff #74) and the Assistant Director of Nursing (ADON/staff #73) were informed of the facility's failure to maintain safe water temperatures in multiple residents' bathrooms and in two shower rooms. Observations revealed the water temperatures in ten resident bathrooms (in which 15 residents resided) and two shower room sinks were found to have hot water temperatures between 120.3 and 135 degrees Fahrenheit (F.) The Director of Nursing presented a plan of correction at 4:20 p.m. on October 3, 2016. The Director of Nursing was informed at 4:45 p.m. that the plan of correction needed additional information regarding the monitoring of the hot water temperatures, and a plan for in-servicing staff regarding the risks of hot water temperatures and how and when to report hot water temperatures. A revised plan of correction was received at 5:45 p.m. on October 3, 2016. The plan of correction included that a plumber was immediately contacted and the mixing value was dialed down to decrease the water temperature, and that the dial thermometer and the mixing valve gauge were replaced. The Director of Nursing was notified that the plan of correction was accepted at 6:00 p.m. on October 3, 2016. Multiple observations were conducted on October 3 and 4, 2016, of the facility implementing their plan of correction, which included staff in-services, the facility's monitoring and documentation of water temperatures in resident rooms and shower rooms. and the use of new thermometers by maintenance staff. Surveyors also retested the water temperatures and were found to be within acceptable ranges. As a result of the facility implementing their plan of correction, the Condition of Immediate Jeopardy was abated at 9:45 a.m. on October 4, 2016. -During random observations conducted at 10:15 a.m. on October 3, 2016, the hot water temperature in resident room #129 was 130 degrees F. and in room #130 the water temperature was 129 degrees F. Due to the elevated temperatures, 10 additional resident rooms were checked on multiple hallways and revealed the following: Room #'s Temperatures #105 134 degrees F #106 134 degrees F #150 124 degrees F #151 123 degrees F #153 127 degrees F #160 126 degrees F The water temperatures in 4 other rooms were checked and ranged from 115 to 120 degrees F. Review of the facility's Water Temperature Weekly Logs for October 3, 2016 revealed the water temperatures in two resident bathrooms and two shower rooms were documented at 119 degrees F. The log also included that on October 3, the water temperature of the hot water heaters (#'s 1, 2, and 3) all read 143 degrees F. During an interview conducted at 11:40 a.m. on October 3, 2016, the Maintenance Supervisor (staff #117) stated that a maintenance staff member (staff #118) checked the water temperatures the morning of October 3, and no problems were identified. When asked when the last time the thermometer was calibrated, staff #117 stated that he was unsure. He stated that he did not know how to calibrate the thermometer, therefore; he takes the thermometer to the Dietary Manager to have the thermometer calibrated. He further stated that he believed he had the thermometer calibrated approximately a month ago by the Dietary Manager. Following this interview, the Maintenance Supervisor was observed in the kitchen with the dietary manager (staff #103) calibrating the thermometer used by maintenance staff. The thermometer calibrated at 32 degrees F., by using a cup of ice with a small amount of water. No adjustment was needed to this thermometer. The surveyor's digital thermometer was also checked and registered at 32 degrees F. An interview was conducted at 11:55 a.m. on October 3, 2106 with staff #118, with staff #117 present. Staff #118 stated the rooms he had checked and recorded on the Water Temperature Weekly Logs on the morning of October 3, were rooms #106 and #163. At this time, along with staff #117 and #118, the water temperatures were checked using the surveyor's digital thermometer and the maintenance staff's thermometer in two resident bathrooms and two shower room sinks and revealed the following: Room Maintenance Thermometer Digital Thermometer #106 120 degrees F. 134 degrees F. Station 1 shower room 119 degrees F. 132 degrees F. #163 115 degrees F. 127 degrees F. Station 2 shower room 113 degrees F. 120 degrees F. During an interview conducted at 12:30 p.m. on October 3, 2016, staff #117 stated that he obtained a second thermometer from the kitchen which was also calibrated to 32 degree F. He said they rechecked the same two resident bathrooms (#s 106 and 163) and found that the temperatures read the same as those found on the digital thermometer. He stated that the thermometer used by the maintenance staff member was not working properly. -Resident #44 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status score of 3, which indicated that the resident had severe cognitive impairment. Observations on October 3, 2016 revealed that this resident resided in one of the rooms with the elevated water temperatures. During an interview conducted with a Licensed Practical Nurse (LPN/staff #26) at 2:20 p.m. on October 4, 2016, the LPN stated that resident #44 was confused and wanders around the facility. -Resident #41 was readmitted on [DATE], with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] included that the resident required limited assistance of one person with locomotion on and off the unit and that the resident utilized a wheelchair. According to a care plan, the resident required limited assistance of one staff with personal hygiene and oral care. The care plan further included that the resident had impaired cognitive function, due to dementia. Multiple observations were made during the survey of the resident self propelling herself throughout the facility. An observation on October 3, 2016 at 10 a.m., revealed that this resident resided in one of the rooms with the elevated water temperatures. An interview was conducted with staff a LPN (staff #26) on October 4, 2016 at 11:12 a.m. Staff #26 stated that the resident had the ability to self propel in her wheelchair and could wash her hands by herself. She also stated that the resident was usually confused. -Resident #100 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A MDS quarterly assessment dated [DATE] identified that the resident had a BIMS score of 9, which indicated the resident had moderate cognitive impairment. An observation on October 3, 2016 revealed that this resident resided in one of the rooms with the elevated water temperatures. In an interview with resident #100 on October 3, 2016 at 11:37 a.m., the resident stated that she uses the sink in her bathroom. At this time, the resident was observed sitting in a wheelchair and she was able to move around in her room. Review of the policy regarding the Safety of Water Temperatures revealed Tap water in the facility shall be kept within a temperature range to prevent scalding of residents. The policy also included Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 120 degrees F ., or the maximum allowable temperatures per state regulation. According to the Federal regulation under F323, Table 1., the time required for a 3rd degree burn to occur is 1 min at 127 degrees F; 15 seconds at 133 degrees F; 5 seconds at 140 degrees F. and 2 seconds at 147 degrees F. The regulation also included that a safe water temperature was 100 degrees F. and that burns can occur even at temperatures below those identified in the table, depending on an individuals condition and the length of exposure.

Based on clinical and hospital record reviews, staff interviews, and review of facility documentation and policy, the facility failed to ensure that the appropriate amount of oxygen was administered using a non re-breather mask for one resident (#42) who was hospitalized , with a [DIAGNOSES REDACTED]. Findings include: Resident #42 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's prehospital medical care directive revealed he would refuse any resuscitation measures in the event of cardiac or respiratory arrest. There was no documentation in his clinical record stating that he did not want to go to the hospital in case of an emergency. According to the resident's quarterly Minimum Data Set (MDS) assessment from [DATE], the resident scored a 13 on the Brief Interview for Mental Status (BIMS), which indicated he was cognitively intact. Clinical record documentation included for oxygen 2L via nasal cannula as needed and to check O2 sats every shift. physician's orders [REDACTED]. Review of the care plan addressing respiratory status dated [DATE], revealed that staff were to monitor for signs and symptoms of acute respiratory insufficiency, which included: restlessness, shortness of breath (SOB) at rest, cyanosis, and somnolence. Also noted was an intervention for oxygen settings: 02 via (specify: nasal prongs/mask) and to specify frequency. However, the route or the frequency was not listed. According to nursing notes from April and May of 2014, the resident had high ammonia levels and increased confusion. A nurses note dated [DATE] documented that the resident's O2 sat on room air was 83%. The resident was placed on O2 at 2L and sats increased to 97%. The note included the resident also had a cough and that an SVN treatment was effective. Further review of the clinical record revealed there was no mention of the resident potentially being a candidate to receive hospice services. Review of the Situation Background Assessment Recommendation (SBAR) communication form and progress note from the early morning of [DATE], revealed that the resident had SOB, difficulty breathing, decline in oxygen saturation, and decreased consciousness. It was documented that at 2:45 a.m., the resident was found "gasping for air, breathing labored and oxygen sat was only 63% on 2L." The resident's oxygen was increased to 4 liters (L), which increased his O2 sat to 90%. The resident's head of the bed was elevated and the nasal cannula was exchanged for a face mask. A Small Volume Nebulizer (SVN) treatment was also administered to the resident, however; "the treatment was not effective." The physician was notified of the resident's condition. At 3:45 a.m. the resident's O2 sat was 92% and at 4:33 a.m., his O2 sat was 90% on 4L via mask. Further review of the clinical record revealed there was no documentation that the physician called back and there were no new orders obtained at this time. Review of the SBAR communication form and progress note from the day shift on [DATE], revealed that the resident was unresponsive and had a slightly elevated temperature. His O2 sat at 6:40 a.m. was 92%. The note revealed that the physician was notified at 7:45 a.m. of the resident's condition and orders were received. The note also included that the resident remained unresponsive to verbal and painful stimuli. physician's orders [REDACTED]. The orders also included for hospice to evaluate and treat, if the family agreed. The [MEDICATION NAME] was discontinued later that morning and and orders received for intravenous fluids at the rate of 100 milliliters an hour times 2 L. Documentation included that the labs were drawn at 8:55 a.m. physician progress notes [REDACTED]. The resident was tachypneic (breathing rapidly) and minimally responsive. That morning the resident was still difficult to arouse and his O2 sat was 94% on 4L of O2 via a mask. The physician documented that the resident had acute respiratory insufficiency and an acute change in mental status. Review of an order administration note from [DATE], revealed that at 1:24 p.m., medication was unable to be given, due to the resident not responding. According to the lab results, the resident's white blood cell count was 27.0 (normal range 4XXX,[DATE].0) and his carbon [MEDICATION NAME] level was 35 (normal range ,[DATE]). The chest x-ray results showed that the resident had bilateral pneumonia. It was documented on both the lab results and chest x-ray results that the physician was notified at 2:30 p.m. Further review of the order administration notes revealed that at 3:16 p.m., the resident was not taking anything orally. A health status note from that afternoon revealed that the resident continued to be unresponsive and the family decided for the resident to be transferred to the hospital. Paramedics arrived to the facility at 4:30 p.m. According to the facility's investigative documentation, it was noted that when the paramedics arrived, the resident was only on 4L of O2 via a non re-breather mask, when the resident should have been receiving over 10L of O2 with that type of mask. Hospital records revealed that the resident's O2 sats were in the low 90's when the paramedics arrived. Upon arrival to the Emergency Department, the resident was found to be significantly hypercarbic. At 4:50 p.m., the resident's O2 increased to 100% on 15L via a non-rebreather mask. Per the hospital documentation, at 6:04 p.m. on [DATE], the resident's Arterial Blood Gases (ABGs) were drawn. The following are the results with the normal ranges in parentheses per the hospital: Arterial blood pH was 7.17 (7XXX,[DATE].45) Partial pressure of carbon [MEDICATION NAME] (pCO2) was 113 (,[DATE]) Partial pressure of oxygen (pO2) was 229 (,[DATE]) [MEDICATION NAME] (HCO3) was 39.7 (,[DATE]) The resident's pH, pCO2, and HCO3 were all documented as being critical lab values. According to the hospital History and Physical, it was determined that the resident had hypercarbic [MEDICAL CONDITION] and severe respiratory acidosis. He was admitted to the step-down unit of the intensive care unit. During an interview conducted on [DATE] at 1:55 p.m., Licensed Practical Nurse (staff #1) who worked the day shift on [DATE], stated that it was reported to her by the night shift that resident #42 had "taken a turn for the worse" during the night and was nonresponsive. She stated that the physician had been called, but the night nurse was still waiting for a response. She said that the night nurses started the resident on 4L of oxygen by a mask. After report, she said she went in to see the resident and he was still unresponsive and had on oxygen by a non-rebreather mask. She reported that she called the physician to give him an update and he gave orders, and then saw the resident around 8:30 a.m. - 9:00 a.m. She stated that the physician wanted her to talk to the family about Hospice, because the resident's condition was poor. She reported that throughout the shift she was monitoring the O2 sats and vital signs. She reported that the resident was pretty stable throughout the afternoon with O2 sats between ,[DATE]%. When asked where she documented the O2 sats, she stated she was writing it on her report sheet. She reported that she did not get to charting until the end of the shift and stated "I know I didn't do the documentation I should have done." She stated the lab results came back in the afternoon and that the physician did not want to be called with the results, until both the lab and x-ray results were received. Staff #1 stated that she was not aware that there needed to be at least 10L of O2 for a non re-breather mask. When asked if the physician was aware that the resident was receiving 4L on a non-re-breather mask, she responded "yes." According to Staff #1's report sheet on [DATE] at 7:45 a.m., the resident's O2 sat was 91%, at 11:30 a.m. it was 89%, at 2:30 p.m. it was 90%, and at 3:00 p.m. it was 91%. An interview was conducted with a random LPN on [DATE], who stated that the non re-breather mask is only to be used in emergencies and that they have to call the physician and get an order for [REDACTED]. During an interview conducted on [DATE] at 3:00 p.m., the Director of Nursing (DON) stated that the physician was aware the resident was on a non re-breather. She reported that the nurses should have asked if they had questions about the non re-breather masks. The DON further stated that her expectation would be for nurses to use their judgment, until they hear from the physician. Once the physician is contacted, she stated that they should obtain orders for the oxygen. The Assistant Director of Nursing (ADON) was also present for this interview and stated they do not recall any in-services that were done regarding the use of non re-breathers. The DON stated that she knew the nurses needed to be educated on the non re-breather masks, because of this situation and that the nurses have now been in-serviced. The resident's physician was interviewed on [DATE] at 9:33 a.m. At that time he stated he was called early morning on [DATE]th. It was reported to him that the resident was having difficulty breathing and the nurses were giving him several breathing treatments that were not working. He reported that he had called the nurse back 5 minutes after she called him just after 3:00 a.m., (although there is no documentation of this or any new orders). He stated that he gave orders for an x-ray, routine labs, and to titrate oxygen. However; these orders were dated at 8 a.m. He said that he did not specify how much oxygen the nurses were to give at that time. He stated the nurse mentioned to him that the resident was DNR (Do Not Resuscitate). He reported that later he was told that the resident was still unresponsive; therefore, he came in to see him. The physician stated that the resident was lying in bed, was not as responsive as he would normally be. He reported that he examined him, tried to arouse him, but was not fully arousable. He stated that the resident had never had an exacerbation of [MEDICAL CONDITION] since his admission and that he had "never seen him this bad." At that point, he stated he thought it was a good time to talk to the resident's family about Hospice. When asked about this resident prior to [DATE]th, the physician stated that he was still strong and "was full of life." He reported that the resident was normally arousable and could speak, but was confused. He reported that he came in to see the resident and remembered that he was on a non-rebreather mask; however, did not know how much oxygen he was getting. When the physician clarified what was in his progress note from [DATE]th, he admitted that he had documented that the resident was on 4L of O2 via the non re-breather mask. When asked how many liters a resident should be on with a non re-breather mask he stated 10L. He stated at the time he received the lab and chest x-ray results, he ordered an oral antibiotic thinking the resident should have been responsive by that point. The physician stated that was when he was told the resident was not taking anything by mouth and was still unresponsive. When asking about the resident again and what time frame he would send a resident in that condition to the hospital, he again stated that the resident was DNR. He further stated that if the resident were a full code he would have sent the resident out immediately. He reported that since the resident was DNR, they wanted to find out from the family how aggressive with treatment they wanted them to be. He reported that it is not routine to use the non re-breather mask and that an O2 sat of 90% on a non re-breather mask would be appropriate. During an interview conducted on [DATE] at 11:20 a.m., LPN (staff #2) who worked the night shift on [DATE], stated that she was not resident #42's nurse that night, but his nurse (staff #3) came and got her to help. She reported that when she first observed the resident his fingers were blue, he already had oxygen on, and he was slow to respond. She mentioned that they thought he needed a mask, because he was mouth breathing. She stated that she was the one who put the non re-breather mask on at 4 or 5L of O2 and his O2 sats went up, but the resident was still unresponsive. The physician was called and texted. She reported that she had never been trained on the use of a non re-breather mask, prior to that morning. She stated that she was told by the DON that the oxygen should have been set between ,[DATE]L for a non re-breather mask. An interview was conducted on [DATE] at 11:53 a.m., with staff #3 (RN who was the resident's nurse on the night shift on [DATE]). She reported that at about 3:00 a.m., an aide called her into the resident's room, because his O2 sat was 63% when his vital signs were being taken. She stated that she sat him up and that he had 2L of O2 on via a nasal cannula. She stated that she called the physician, but could not get a response from him, so she bumped up the O2 to 4L. She stated that she told another nurse and the other nurse thought he needed a mask and put one on him and his O2 sat went up to 94%. She stated that she did not know it was a non re-breather mask that the other nurse put on the resident. She said that she had no training on the non re-breather masks, prior to that incident. She reported that there is a standing order to keep O2 sats above 92%. She stated that as of shift change, which is 6:00 a.m., she had not heard back from the physician. When asked if he called her back 5 minutes after she called him, she again stated that she had not heard from him. During an interview conducted on [DATE] at 1:05 p.m., a random LPN was asked what she would do if her resident had a low oxygen saturation. Her response was that she would assess the resident, listen to the lungs, and notify the physician and medical response. She stated that code status would play a part. She reported that she would administer a SVN treatment and if that was not effective and the physician did not respond back, she would call emergency response. The LPN stated that if a resident is in distress, you have to help them even if they are a DNR. She stated that ,[DATE]L of O2 needs to be used, with a non re-breather mask. A follow up interview was conducted on [DATE], with the DON. She stated that if the nurses are not hearing back from a physician, she would expect them to call another physician to get orders. She also mentioned that there are policies and procedures at the nursing stations for nurses to review should they have a question. Review of the facility's policy on orders for oxygen usage revealed "the use of oxygen shall be prescribed by physician to maintain a respiratory condition, to treat and improve an exacerbation of medical condition or to initiate treatment based on a change in medical condition." It further included that with a change of condition and when the O2 sat is below 90% on room air, oxygen is to be administered via nasal cannula at 2L. The physician is to be contacted for further orders. According to the manufacturer's instructions for the non re-breather mask, the oxygen flow rate should be set according to a physician's prescription. The facility's policy and procedure on non re-breather oxygen masks documented "the set-up and operation of the non re-breathing masks (NRB's) will be the responsibility of the Registered Nurses with Administrative approval...care must be taken to set flow rates sufficient to keep the reservoir bag inflated at all times. Failure to do so will lead to deceased FiO2's and increased CO2." The policy further included that the NRB's should be checked regularly for proper flow rates, should only be used in emergency situations and the flow rate for non re-breathers was ,[DATE]L. Also, included as part of the procedure was to check for a complete physician's orders [REDACTED]. Review of the 2011 Administering Emergency Oxygen fact sheet from The American National Red Cross online resources, revealed that "the pulse oximeter reading never should be used to withhold oxygen from a victim who appears to be in respiratory distress or when it is the standard of care to apply oxygen despite good pulse oximetry readings..." The fact sheet also documented that an oxygen saturation level between 86 to 90% on a non re-breather mask would be considered moderate [MEDICAL CONDITION].

Based on observations, clinical record reviews, staff interviews and review of facility policy and procedures, the facility failed to provide the necessary care and services to ensure that five residents (#s 42, 110, 111, 154 and 183) did not develop pressure sores. Findings include: -Resident #183 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the closed clinical record revealed a Braden Scale dated March 27, 2012, which indicated the resident was at risk for developing pressure ulcers, with a score of 17. A comprehensive care plan was developed that addressed the resident's multiple pressure ulcers. Interventions included anti-pressure mattress on bed, treatments as ordered by the physician, reposition at least every two hours, measure and record size of wound every week, and use positioning devices to keep bony prominence's from direct contact. The nursing Admission Evaluation dated March 27, 2012, documented the resident had multiple pressure ulcers. Admission physician orders included for weekly skin assessments to be done. Review of the Weekly Body Audits (skin assessments) from April 2, 2012, through April 19, 2012, revealed documentation of a right heel pressure ulcer. The next weekly skin assessment was not completed until May 24, 2012. There was no documentation of any skin breakdown to the right lateral ankle. The next weekly skin assessment was completed on June 6, 2012. There was no documentation of any skin breakdown to the right lateral ankle. A physician's order dated June 8, 2012, included for Santyl and daily dressing changes to the right ankle. However, further review of the clinical record revealed there was no documentation of any thorough wound assessment of the right ankle. The resident was first seen by the facility's wound physician on June 12, 2012. Documentation included the resident had a stage 4 pressure ulcer to the right lateral ankle that measured 2 cm (centimeters) length by 2 cm width x 0.4 cm in depth. The wound was described as having moderate serosanguineous drainage, with 76 to 100 percent slough and 1-25 percent pink granulation within the wound bed. Also documented was that the plan was to float the heels. Wound physician's notes dated June 13, 2012, included the right lateral ankle was surgically debrided and for Santyl dressing to wound bed and cover with a dry protective dressing, and to float heels in bed. Wound physician's notes dated June 19, documented a stage 4 pressure ulcer to the right lateral ankle. The wound measured 2 cm length x 1.8 cm width x 0.4 cm depth, with 26-50 percent slough and 51-75 percent pink granulation and that there was no change in the wound progression. The note included for Calcium Alginate and cover with a dry protective dressing daily and to float heels in bed. The wound physician continued to follow the resident regarding the right ankle wound weekly with a plan to float heels. Wound notes dated July 4, 2012, included the right lateral ankle wound measured 1.8 cm length x 1.8 cm width x 0.3 cm depth and that muscle was exposed. The plan was to continue with the Calginate dressing and to float heels in bed. The wound physician continued to follow the resident weekly for the right ankle pressure ulcer from July 6 through July 26, with a plan to float heels in bed. Wound physician notes dated August 2, 2012, included the stage 4 right lateral ankle pressure ulcer measured 1.7 cm length x 2 cm width x 0.4 cm depth, with moderate amount of serosanguineous drainage noted. There was 1-25 percent slough and 76-100 percent pink granulation within the wound bed and that the wound was deteriorating. The plan was to obtain an MRI of the right ankle for osteo[DIAGNOSES REDACTED]. Despite the repeated notations regarding the need to float the heels in the wound physician progress notes [REDACTED]. In addition, the pressure ulcer care plan was not revised to reflect a stage 4 pressure ulcer to the right lateral ankle, nor any additional measures implemented. Review of the wound physician note dated August 6, 2012, revealed that the right lateral ankle measured 2.2 cm length x 2 cm width x 0.4 cm depth, with a moderate amount of serosaguineous drainage noted. The note included there was 1-25 percent slough and 76-100 percent pink granulation within the wound bed and that the wound was deteriorating. A physician's order dated August 6, 2012, included to send the resident to the emergency room to evaluate decreased responsiveness, low grade fever, [MEDICAL CONDITION] in parenthesis was written "sepsis." Review of the documents obtained from the hospital dated August 6, 2012, revealed the resident was admitted to the hospital's intensive care unit with a [DIAGNOSES REDACTED]. Review of a hospital orthopedic consult dated August 6, 2012, revealed that the right lateral ankle wound was assessed as being roughly 5 cm x 4 cm and actively draining purulent material and that the biggest concern was that the infection in the leg was the same in the blood and that possibly the resident will have to undergo a below-knee amputation on the right lower leg. An interview was conducted on April 18, 2013, with a CNA (certified nursing assistant) who cared for the resident when she was in the building. She said that the resident was an extensive assist for turning or transfer. She said the resident preferred to lay on her right side more to watch TV and to perform her own oral care. She said that when she cared for the resident she was turned every two hours, but admitted that the facility does not have any place to chart this documentation. An interview was conducted with a RN (registered nurse) on April 18, 2013, who acknowledged that she had cared for the resident. She stated that when a wound first appears, she would do a full assessment of the wound including measurements and then ask the resident's physician if they want to consult with the wound physician. She stated that when the wound appeared on the right ankle, the wound doctor was consulted. She also stated they would turn the resident per facility policy and told the resident why she needed to be turned, but that she never documented in writing the possible problems that could occur. She further stated that they never care planned the resident for resistance to turning or refusing to be turned. Review of the resident's clinical record revealed no documented evidence that a care plan was developed regarding any non compliant behaviors regarding resistance to turning. -Resident #42 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the comprehensive care plan last updated on July 7, 2011, revealed a problem area for the potential of skin breakdown, due to fragile skin and limited mobility. The approaches included to "Monitor skin Q (every) shift for s/sx (signs and symptoms) of potential skin breakdown (e.g. redness/discoloration or open areas). Alert charge nurse if observed for notification of physician as needed for tx orders. Complete and document weekly skin assessments." Review of the clinical record revealed that on December 10, 2012, the resident ran over a drawer in her room while driving her electric wheelchair and sustained a fracture to the right leg and was sent to the hospital. The resident returned to the facility and according to the Daily Skilled Nurse's Notes dated December 13, 2012, the resident went out for an orthopedic appointment and returned to the facility with a thigh high cast on the right leg. A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident was at risk for the development of pressure ulcers. Review of the Weekly Body Audit sheet for January 7, 2013, revealed the resident had a cast on the right leg and had no pressure ulcers. On January 14, 2013, the documentation also included the resident had no pressure ulcers. On January 17, 2013, the Nurse's Notes documented the resident went to an orthopedic appointment and the cast was removed and a splint was in place. Further review of the clinical record revealed there was no documentation on January 17, of any thorough skin assessment being completed regarding the condition of the resident's right foot/heel area, despite having the cast removed. There were also no physician orders regarding if the splint was to be removed to check for any skin breakdown. In addition, the care plans were not updated to reflect that the cast had been removed, and that a splint was now being utilized, nor were there any interventions added to prevent skin breakdown. Daily Skilled Nurse's Notes for January 20, 2013, included the skin was within normal limits on the day and night shifts. Review of the Weekly Body Audit sheet dated January 28, 2013 (11 days after the cast was removed), revealed the resident had a quarter size blackened area that was "caused by cast" on the right heel. The assessment also revealed decubitus "0." Continued review of the clinical record revealed there was no thorough wound assessment of the pressure ulcer to the right heel that was done on January 28, which included measurements, nor any description of the surrounding skin. There was also no documentation that the physician was notified of the right heel pressure ulcer at this time. Further review of the skin care plan revealed no evidence that the care plan was updated to reflect a right heel pressure ulcer, nor any new interventions. A review of the Nurse's Note dated February 5, 2013, revealed a right heel "callused" area and "parts of callus were open". The note included heel cup and waffle boot to the right heel and would notify on coming nurse to update the physician in the morning. However, there was no documented evidence that the physician was notified on February 5, 2013. A review of the physician's progress notes dated February 11, 2013, revealed that the resident's cast was removed and the resident had a blackened right heel and a boot was ordered for "off loading." A review of the physician's orders dated February 11, 2013, revealed for the in house wound doctor to assess the resident's right heel and for [MEDICATION NAME] 100 milligrams (mg) by mouth twice a day for two weeks for a wound infection. The orders also included to discontinue the current treatment to the right heel and ace wraps (although there was no previous order that could be located for this treatment). New orders included to cleanse the wound with wound cleanser, apply santyl, cover with a non adherent dressing and change daily for a deep tissue injury. From January 28, when the pressure ulcer was first identified through February 11, there was no documentation of any thorough assessments completed of the right heel pressure ulcer. On February 12, 2013, the resident was seen by the wound physician. According to the wound physician's note, the right heel now presented as an unstageable pressure ulcer, with necrotic tissue (wound bed was 76-100 percent eschar), measurements were 1.3 centimeters (cm) length x 2 cm width, and no drainage noted. The recommendation was for a foam dressing, skin prep and cover with a dry protective dressing twice daily and to float heels in bed. The notes further documented will keep eschar intact unless evidence of excessive drainage/infection and to follow up in two weeks. On March 6, 2013, the wound physician's note documented a necrotic unstageable pressure ulcer to the right heel. Debridement was performed and post measurements were 0.8 cm length x 1.5 cm width x 0.3 cm depth. The resident continued to be followed by the wound physician. During the survey, a wound observation of the resident's right heel was unable to be obtained. -Resident #110 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the closed clinical record revealed the resident had a history of [REDACTED]. According to the Braden Scale for predicting pressure ulcer risk dated October 23, 2012, the resident was identified to be at risk for developing pressure ulcers. Review of the Initial Interim Care Plans dated October 23, 2012, revealed that no care plan was initiated upon admission to address the identified concern of the resident being at risk for developing pressure ulcers. Review of the Nursing Admission Evaluation dated October 23, 2012, revealed the resident had a history of [REDACTED]. Admission physician orders included for weekly skin assessments to be done every Tuesday morning. A review of the Daily Skilled Nurse's Notes from October 23 through 30, 2012, revealed the resident's skin was within normal limits. The admission MDS assessment dated [DATE], documented the resident required limited assistance of one person for bed mobility, transfers and personal hygiene. The MDS also revealed that the resident had no pressure ulcers. A care plan for at risk for skin breakdown due to a history of pressure ulcers was developed on November 7, 2012. Approaches included to turn and reposition every two hours, use positional devices such as pillow and foam wedges to keep bony prominence's from direct contact with one another, and monitoring skin every shift for signs and symptoms of potential skin breakdown. Further review of the closed clinical record revealed that there was no evidence that weekly thorough skin assessments were completed between October 24, and December 15, 2012. A Nurse's Note dated December 15, 2012, now documented that the resident reported to the nurse that "he feels something sticky on his heels and he said that the sheet feels wet. Upon assessment of res's (resident's) heels R (right) heel very scaly (sic) dry skin. L (left) heel with serous drainage approx 7.5 cm in diameter, visible area darken (necrotic area approx 2.5 x 3.5 cm wound area yellow and white around edge, texture soft, mushy and sticky..." There was no documentation that the physician was notified on December 15, and there were no physician's orders for treatment until 2 days later on December 17. Physician's orders dated December 17, 2012, included to cleanse the left heel with wound cleanser, apply santyl, cover with 4 x 4 and wrap with Kerlix twice a day. Review of the wound physician's progress note dated December 19, 2012, revealed that wound on the resident's left heel was an unstageable pressure ulcer that measured 4 cm length x 5.5 cm width. The wound bed was 1-25% eschar, 1-2% slough and 26-50% pink granulation. The wound was debrided and post measurements were 4 cm x 5.5 cm x 0.2 cm. The plan was for nickel thick santyl to be applied to the wound bed, cover with a dry protective dressing daily, and to float the heels in bed. From December 24, 2012 through February 7, 2013, the wound physician continued to see the resident for the left heel pressure ulcer. According to the wound physician's progress note dated January 16, 2013, the left heel pressure ulcer was documented as a stage 3 and measured 2.9 cm length x 4.3 cm width x 0.2 cm depth. The wound bed was 76-100 percent pink granulation with a small amount of serous drainage noted. Review of the discharge summary revealed that the resident was discharged to a residential care setting on January 23, 2013, with orders for continued treatment to the left heel pressure ulcer. During an interview conducted at 11:15 a.m. on April 17, 2013, an MDS staff member/registered nurse (RN) stated that upon admission, an interim care plan should have been developed to address the resident's risk for skin breakdown. During an interview conducted at 4:00 p.m. on April 17, 2013, the Director of Nursing (DON) stated that she recalled that the resident was noncompliant with his care. She also stated that if a resident was noncompliant nursing should have documented the resident's behavior and would expect a care plan to have been developed to address the behavior. The DON stated that the nurses were to assess resident's skin weekly. The facility was unable to provide a care plan related to the resident's non compliance. During an interview conducted at 9:05 a.m. on April 18, 2013, a RN stated that weekly skin assessments were suppose to be completed weekly and documented on the Weekly Body Audit sheet. -Resident #111 was admitted to the facility originally on March 28, 2012. The resident went out of the facility to the hospital on June 6, 2012, and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed admission orders [REDACTED]. Review of the April 2012 weekly skin assessments revealed the resident's skin was intact. A comprehensive care plan dated April 10, 2012 identified the resident was at risk for impairment of skin integrity, due to incontinence and dependence on staff for ADL's (Activities of Daily Living). The goal was for the skin to remain intact on the sacral and peri-area during the next 90 days. Interventions included that the skin would be monitored, treatment given as ordered, assessment and evaluation of pruritis (itching) or discomfort including onset, causative factors and relief measures, and apply moisturizing lotion. According to the weekly skin assessments for May 5, 14, and 21, 2012, revealed the resident's skin remained intact. On May 28, 2012, the skin assessment indicated that the resident had a rash and abrasions on the center of his buttocks, however, there was no description of the condition of the skin. Further review of the clinical record revealed there was no documentation the physician was notified. The next skin assessment was completed on June 5, 2012, which indicated the resident had two open areas on the buttocks. The right buttocks wound measured 1 cm x (under) 1 cm with granulation tissue, scant drainage, and surrounding skin was intact. The left buttocks wound measured 2.2 cm x 0.6 cm x 0.1 cm depth. The wound bed contained granulation tissue with scant drainage and surrounding skin was intact. Further documented was that the wounds were worse and "alldress" wound dressings were applied. Review of the skin integrity care plan revealed it was not updated to reflect the new open areas. The resident was discharged to the hospital on June 6, 2012, for aspiration pneumonia and returned to the facility on [DATE]. Admission physician's orders dated June 9, 2012, included to cleanse open areas on the coccyx with soap and water and apply [MEDICATION NAME] every shift and as needed for incontinence. The orders also included for weekly skin assessments to be done. Continued review of the clinical record revealed there was no documented evidence that thorough wound assessments and a description of the wound bed characteristics was done upon readmission regarding the right and left buttocks open areas. An interim care plan dated June 9, 2012, documented the resident was at risk for impairment of skin integrity due to incontinence. However, there were no goals or interventions that were marked as being implemented, nor did it include the two open areas to the buttocks. A physician's order dated June 11, 2012, included to please have patient seen by the wound doctor on next visit. A daily skilled nursing note dated June 12, 2012, documented "pressure ulcer coccyx." There was no documentation of the size of the pressure ulcer (s) the stage or any wound characteristics, such as a description of the wound bed or the condition of the surrounding skin, or if any drainage was present. Physician orders dated June 12, 2012, included for [MEDICATION NAME] and a dry dressing to the right and left buttocks for excoriation daily and as needed. Review of the June 2012 TAR revealed the wound treatment was initiated on June 13, however, the wound treatment was not done on June 14. Review of the daily skilled nursing notes dated June 13, 14, 15, and 16, 2012, all documented that the resident's skin was within normal limits. Nursing notes dated June 17, 2012, documented that the resident's skin was within normal limits, however, it was also documented that the dressings were dry and intact to the buttocks. Review of the weekly body audit dated June 18, 2012, revealed there were two decubitus ulcers to the coccyx. The wound assessment did not include measurements or wound characteristics. On June 21, 2012, the physician changed the wound treatment to [MEDICATION NAME] to open areas on the right and left buttocks and change every three days and as needed if soiled. Review of the comprehensive skin care plan updated on June 21, included the resident had open areas to the right and left buttocks. The goal was that the wounds would be healed by August 1, 2012. Interventions included application of [MEDICATION NAME] to the open areas as ordered and to change the dressing every three days. Continued review of the clinical record revealed there was no thorough pressure ulcer assessments completed of the right and left buttocks open areas from the time of admission through June 27. The resident was seen by the wound physician on June 28, 2012, which was seventeen days after it was originally ordered on June 11. The wound on the left buttocks measured 0.6 cm x 0.4 cm x 0.1 cm in depth. The wound bed was described as having 1-25 percent slough and 76-100 percent pink granulation. The note documented the wound was debrided and a new treatment order for hydrogel and a dry protective dressing daily was included. There was no mention of a wound on the right buttock area. The wound physician notes dated July 5, 2012, documented "Buttock wound" as a chief complaint. The note documented a left buttocks wound was debrided and post measurements were 0.4 cm x 0.5 cm x 0.2 cm depth. Treatment included for Calcium Alginate and cover with a dry protective dressing daily. There was no documentation regarding any right buttocks wound. The resident was seen next on July 10, by the wound physician. Review of the wound physician note under the section for location, it was documented "right and left buttock." However, the note only addressed a wound to the left buttocks, which was described as having slough and pink granulation tissue. The wound was debrided and measured 0.2 cm x 0.3 cm x 0.2 cm. An incontinence care plan updated on July 10, 2012, included that the resident was at risk for impairment of skin integrity due to incontinence. It further indicated that the resident was dependent on staff for ADL's. Interventions included monitoring and recording skin condition each shift and with incontinence care for redness/discoloration/open areas, and to complete and document weekly skin assessments. Physician orders dated July 17, included for [MEDICATION NAME] cream to buttocks wound daily and as needed. The next wound physician visit was July 19, 2012. The note documented the left buttock wound measured 2.5 cm x 0.9 cm x 0.1 cm depth with sero-sanguineous drainage, and 1-25% slough and 76-100% pink granulation and that the wound was deteriorating. Plan was for [MEDICATION NAME] and a dry protective dressing daily and as needed. The notes did not address a right buttock wound. Review of the wound physician's progress note dated July 26, 2012, revealed the resident had a wound located on the left buttocks that measured 4 cm x 1 cm x 0.1 cm and that the wound was deteriorating with purple/maroon discoloration. Physician's orders included for [MEDICATION NAME] and meplix tape to coccyx area daily and as needed. The wound physician note dated July 30, 2012, included the wound on the left buttock measured 6 cm x 2.1 cm x 0.1 cm. Documented was that there was 1-25% slough and 51-75% pink granulation and that the wound was deteriorating. Treatment included for the use of [MEDICATION NAME] daily and as needed. There was no documentation regarding the right buttock wound. The resident was seen again on August 1, 2012 by the wound physician. The note included that the wound presents as a stage 3 pressure ulcer located on the coccyx and measures 6 cm x 3.5 cm x 0.3 cm depth. The wound was described as having a small amount of serous drainage and had 1-25% slough and 51-75% pink granulation, and that the wound was deteriorating. The plan was for a change in wound treatment. Physician's orders for August 1, 2012, included to cleanse buttocks wound with normal saline, pat dry and apply [MEDICATION NAME] dressing twice a day and as needed when soiled. Another physician's order dated August 6, 2012, included "Stage 3 coccyx santyl and dressing each day and as needed if dressing is soiled." Review of the wound physician's note dated August 8, 2012, revealed a coccyx wound presented as a stage 3 pressure ulcer and measured 6 cm x 3.5 cm x 0.2 cm. The wound was described as having 1-25% slough and 51-75% pink granulation. Review of the nutrition at risk review/minutes documented that on September 9, 2012, the resident had a stage three pressure ulcer to the coccyx. The resident continued to be seen by the wound physician and the wounds eventually healed by October 1, 2012. The resident was discharged to the hospital on January 17, 2013, and was readmitted again on January 23, 2013. Physician's orders dated January 23, 2013, included for weekly skin assessments to be done each week. Review of the Braden Scale that was completed upon readmission indicated the resident was a high risk for developing pressure sores. An interim care plan dated January 23, 2013, included the resident was at risk for skin breakdown related to incontinence and immobility. However, there were no goals or interventions documented that were to be implemented. Review of the clinical record revealed the resident's skin was intact upon readmission to the facility. Review of the February 2013 weekly skin assessments revealed the resident's skin was intact. On March 11, 2013, documentation on the weekly skin assessment showed that there was a small open area on the resident's coccyx. The assessment did not include any measurements or wound characteristics. A wound physician's note dated March 11, 2013, included the resident had a stage 3 pressure ulcer to the coccyx. The note did not include any measurements, nor a description of the wound charateristics. The note also documented coccyx wound, with a duration of "several weeks." However, further review of the clinical record revealed no documentation that the resident had a puressure ulcer to the coccyx prior to March 11. There was also no documentation of any wound treatment orders for the pressure ulcer to the coccyx at this time. Physician orders dated March 24, 2013, included for the resident to have caloseptine applied to the buttock area every shift and as needed. A care plan updated on April 11, 2013, identified the resident was at risk for impairment of skin integrity due to incontinence and dependence on staff for ADL's. The goal was for the skin in the sacral and peri-area to remain intact during the next 90 days. Approaches included treatment as ordered, pat skin dry and apply moisturizing lotion. The care plan did not include any open areas to the coccyx area. Review of an incontinence care plan updated April 11, 2013, revealed a problem of bowel and bladder incontinence, due to [MEDICAL CONDITION] left [MEDICAL CONDITION] and that the resident was dependent on staff for all ADL's. The goal was to be clean, dry and free of odor during the next 90 days. Interventions included to check for incontinence every two hours and as needed, to monitor and record skin condition every shift and with incontinence care for redness/discoloration/open areas, if observed notify physician for treatment orders and to complete and document weekly skin assessments. The care plan did not reflect any open areas to the coccyx area. Continued review of the clinical record revealed no weekly thorough wound assessments of the coccyx area were completed from March 11, 2013 through April 17, 2013. Review of the care planning documentation dated April 17, 2013, revealed the resident's skin was intact and that the pressure ulcer was healed. However, a wound observation was conducted on April 17, 2013 at 10:30 a.m. with the resident's nurse. The right buttock was observed to have several small open areas that were purple/maroon. No measurements were taken. An interview was conducted with the resident's nurse on April 17, 2013. She stated that the skin was open. She stated that she depends on her CNA's to let her know if there is a problem with a resident's skin and would then assess the area. The nurse stated that wound assessments were completed on Mondays. She further stated she was responsible for 22 residents and did not have time to do daily skin checks. During an interview with the assistant director of nursing (ADON) on April 17, 2013, she stated that she did not know why the care plan referred to checking the skin every shift as the CNAs do not document or record skin conditions and are not able to assess skin. She further stated that the nurses should have documented weekly skin assessments which include measurements and a description of the wound bed. An interview was conducted with the director of nursing on April 17, 2013. The DON stated that standing interim care orders are used when a new resident is admitted to the facility and include an order for [REDACTED]. -Resident #154 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the closed clinical record revealed an admission nursing assessment dated [DATE], that included the resident did not have any areas of skin breakdown. A Braden Scale for predicting pressure sore risk indicated the resident was at risk for pressure sore development. Review of the interim care plans dated November 17, 2012, revealed no care planned had been developed regarding being at risk for skin breakdown, nor any interventions implemented. Review of the weekly body audit dated November 26, 2012, revealed no problem areas had been identified with the resident's skin. Review of the admission MDS assessment dated [DATE], included in Section M (skin) that the resident was at risk for pressure ulcers. The documentation showed that the resident did not have any pressure ulcers on admission to the facility. Review of the MDS care area assessment dated [DATE], revealed that pressure ulcers had triggered and a care plan had been developed. Review of the comprehensive care plan dated November 30, 2012, revealed a plan in place for the risk of skin impairment due to incontinence. The goal included that the resident's skin would remain intact skin in the sacral and peri-area. Interventions included treatment as ordered, monitoring and recording response and notifying physician if discomfort persists or worsened. Review of the weekly skin audit dated December 3, 2012, revealed there were no decubitus ulcers identified. A care plan conference was completed on the resident on December 5, 2012. Documentation included the resident's skin was intact and that the resident was incontinent of bowel and bladder and required total care. The note also documented for frequent skin checks. Review of the nurses notes dated December 8, 2012, documented the resident had a reddened area to his right hip and that the resident kept laying on his left side. No measurements were documented. Physician orders dated December 9, 2012, now included for an Alternating Air Pressure Mattress. Nurses notes dated December 13, 2012, documented the righ

Based on clinical record reviews, staff interviews and policy review, the facility failed to provide the necessary care and services to prevent one resident (#110) from developing two incontinence ulcers, and failed to ensure pre and post [MEDICAL TREATMENT] assessments were consistently completed for five residents (#s 34, 63, 89, 96, and 188). Findings include: Issue regarding incontinence ulcers: -Resident #110 was admitted to the facility for long term care on October 23, 2012, with [DIAGNOSES REDACTED]. Review of the closed clinical record revealed a Braden Scale for predicting pressure ulcer risk dated October 23, 2012, which documented the resident was at risk and had a history of [REDACTED]. Review of the interim care plans dated October 23, 2012, revealed that no skin care plan was initiated upon admission, nor any interventions to prevent skin breakdown. A Urinary Continence Evaluation dated October 23, 2012, documented the resident had a [MEDICATION NAME]. According to the physician admission orders [REDACTED]. A review of the Nursing Admission Evaluation dated October 23, 2012, revealed no documentation of any skin breakdown to the resident's buttocks area. The Daily Skilled Nurse's Notes from October 23 through 30, 2012, documented the resident had a [MEDICATION NAME] and was incontinent at times of bowel. Documentation on these notes included that a box was checked, that indicated the resident's skin was within normal limits. Further review of the closed clinical record revealed there was no evidence that any thorough skin assessments were completed since admission. A Nurse's Note dated November 2, 2012, now documented the physician was notified regarding skin breakdown to the resident's buttocks. A physician's orders [REDACTED]. There was no clinical record documentation of any thorough assessment of the two buttocks wounds that was completed at this time. An admission Minimum Data Set (MDS) assessment dated [DATE], assessed that the resident required limited assistance of one person for bed mobility, transfers, toileting and personal hygiene. The MDS assessment also revealed that the resident was free of moisture associated skin damage and that the resident was occasionally incontinent of bowel and had a [MEDICATION NAME]. The resident was seen by the wound physician on November 5, 2012. The note documented the resident had incontinence wounds on the left and right superior buttock. The right superior buttock wound measured 7 cm (centimeter) length x 6 cm width, with a scant amount of serous drainage noted, the wound bed was 1-25 percent [MEDICATION NAME] and 51-75 percent slough. The left buttocks wound measured 12 cm length x 7 cm width, with scant amount of serous drainage, the wound bed was 1-25 percent [MEDICATION NAME] and 51-75 percent slough. The active problems included bilateral buttock wounds and incontinence. The note further documented the resident had [MEDICAL CONDITION] nine years and the resident stated that he "gets buttock wounds all the time" and that he does not feel when he has a bowel movement and believes that is the root cause. physician's orders [REDACTED]. A care plan was finally developed on November 7, 2012, for "At Risk For Skin Breakdown D/T (due to) History of Pressure Ulcers." The goal was to have no recurrence of skin breakdown. Approaches included to turn and reposition every two hours, keep skin clean and dry, keep bed linens clean, dry, and wrinkle free every shift, and to monitor skin every shift for signs and symptoms of potential skin breakdown. However, the care plan was not revised to include that the resident had two incontinent wounds to the buttocks, nor were there any additional measures to prevent further skin breakdown. Review of an Initial Team Meeting note dated November 14, 2012, revealed documentation that the resident was usually continent of bowel and bladder, and skin was intact. From November 14, through January 16, 2013, the resident was seen by the wound physician. A Wound physician progress notes [REDACTED]. The left superior buttock wound measured 7 cm length x 6 cm width, with a small amount of serous drainage, the wound bed was 1-25 percent [MEDICATION NAME], 1-25 percent slough and 26-50 percent pink granulation. Continued review of the clinical record revealed the resident was discharged on [DATE], with orders for ongoing treatment of [REDACTED]. During an interview conducted at 11:15 a.m. on April 17, 2013, an MDS staff member/registered nurse (RN) stated that upon admission an interim care plan should have been developed to address the resident's high risk for skin breakdown. During an interview conducted at 4:00 p.m. on April 17, 2013, the Director of Nursing (DON) stated that she recalled that the resident was noncompliant with his care and that if a resident was noncompliant, nursing should have documented the resident's behavior. She further stated that if a resident was noncompliant she would expect a care plan to have been developed to address the resident's behavior. The DON also stated that the nurses were to assess resident's skin weekly. The facility was unable to provide a care plan related to the resident's non compliance. During an interview conducted at 9:05 a.m. on April 18, 2013, a RN stated that weekly skin assessments were suppose to be completed weekly and documented on the Weekly Body Audit sheet. Issue regarding [MEDICAL TREATMENT]: -Resident #34 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's clinical record included a physician's orders [REDACTED]. Further review of the clinical record revealed that from February 26, 2013, through April 15, 2013, the facility only completed pre and post [MEDICAL TREATMENT] assessments of the resident only two out of 21 times on the days the resident went to [MEDICAL TREATMENT]. An interview was conducted with an LPN (licensed practical nurse) on April 18, 2013. The LPN stated that pre and post assessments should be done every day the resident went to [MEDICAL TREATMENT]. The LPN stated that the pre and post assessments should be documented and placed in the resident's clinical record. The LPN further stated that she could not find evidence that pre and post assessments were done every time the resident went to [MEDICAL TREATMENT]. -Resident #96 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed that the resident went to the [MEDICAL TREATMENT] center on Monday, Wednesday, and Friday for [MEDICAL TREATMENT]. From March 25, 2013 until April 17, 2013, the resident's clinical record revealed that pre and post [MEDICAL TREATMENT] assessments of the resident were only completed four of the 11 times on the days the resident went to [MEDICAL TREATMENT]. An interview was conducted with an LPN on April 18, 2013. The LPN stated that when a resident went to [MEDICAL TREATMENT], it was her responsibility to complete pre and post assessments and check the access site. An interview was conducted with the DON on April 18, 2013. The DON stated that the facility had a form which should be completed before the resident went to [MEDICAL TREATMENT] and upon returning from [MEDICAL TREATMENT], which included taking the resident's vital signs. -Resident #188 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed that the facility transfers the resident to a [MEDICAL TREATMENT] center every Monday, Wednesday and Friday for [MEDICAL TREATMENT]. The documentation included the resident had a central line port that was used for [MEDICAL TREATMENT]. Further review of the clinical record revealed that pre and post [MEDICAL TREATMENT] assessments were only completed four out of seven times when the resident went to [MEDICAL TREATMENT]. A facility run sheet from the [MEDICAL TREATMENT] center was reviewed, which documented the care of the resident following [MEDICAL TREATMENT]. It included the access site was to be observed every 30 minutes for the first four hours after returning. Further review of the clinical record revealed no documented evidence that the resident's access site was consistently assessed after returning to the facility. An interview was conducted on April 19, 2013, with a RN caring for the resident. She stated that vital signs should be done before and after [MEDICAL TREATMENT] upon returning to the facility and should be done twice at varying times. She said she checks the access site at this time to verify that it is intact and no bleeding exists. She said that she has not been following the recommendation of the [MEDICAL TREATMENT] center to check the access site every 30 minutes for four hours. -Resident #63 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the resident's clinical record revealed the resident receives [MEDICAL TREATMENT] three times a week on Tuesday, Thursday and Saturday. The documentation included the resident had a left upper arm fistula, as an access cite for [MEDICAL TREATMENT]. Further review of the clinical record revealed that pre and post [MEDICAL TREATMENT] assessments were not consistently done and/or thoroughly completed for multiple days in April 2013. During an interview conducted on April 18, 2013 at 10:00 a.m., a LPN stated the pre and post [MEDICAL TREATMENT] assessments include vital signs, checking the shunt site for thrill and bruit, bleeding, signs of infection and mental status. The LPN stated that this should be done every day a resident has [MEDICAL TREATMENT]. During an interview conducted on April 18, 2013 at 10:45 a.m., the DON stated that pre and post assessments should be done on the [MEDICAL TREATMENT] Assessment Sheet and needs to include vital signs, checking the [MEDICAL TREATMENT] site for bleeding, checking for thrill and bruit and for infection. -Resident #89 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the clinical record revealed the resident was receiving [MEDICAL TREATMENT] on Tuesday, Thursday and Saturday. According to a [MEDICAL TREATMENT] care plan dated January 6, 2013, the facility [MEDICAL TREATMENT] protocol should be followed. Continued review of clinical record revealed there were multiple days in March and April 2013, that pre and post [MEDICAL TREATMENT] assessments were not completed. In an interview conducted on April 18, 2013 at 10:00 a.m., a LPN stated that the [MEDICAL TREATMENT] protocol refers to taking the resident's pre and post [MEDICAL TREATMENT] vital signs, checking the catheter site, doing an assessment of the resident and after the initial post [MEDICAL TREATMENT] vital signs, doing another set of vital signs in four hours. The LPN stated that this should be done every day the resident has [MEDICAL TREATMENT]. During an interview conducted on April 18, 2013 at 10:45 a.m., the DON stated that pre and post assessments were to be done on the [MEDICAL TREATMENT] Assessment Sheet and that this assessment needed to include vital signs, checking the [MEDICAL TREATMENT] site for bleeding, checking for thrill and bruit and for infection. A review of the facility's policy regarding Care of the [MEDICAL TREATMENT] Patient documented that prior to going to [MEDICAL TREATMENT], staff were to use the [MEDICAL TREATMENT] Assessment Sheet to fill in the pre-assessment portion before the resident leaves the building. The policy also included that when the patient returns, the same sheet should be used to fill in the post-assessment on the bottom of the form. The policy further documented that all [MEDICAL TREATMENT] patients should be assessed for symptoms of [MEDICAL CONDITION], lung crackles, hypertension, mental status, and access device assessments.

Based on clinical record reviews, staff interviews, and review of facility policies and procedures, the facility failed to provide adequate supervision to one resident (#189), in order to prevent injury to another resident (#117). The sample size was one. Findings include: Resident #117 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed Nurse's Notes dated September 26, 2012, that documented "...LPN came to my office and said that (resident's name) had something wrong with her right leg. We went into the room together and (resident's name) was lying on her left side with her legs bent at the knees. I slipped my hands under her right leg and attempted to lift it, but she screamed out in pain. The leg was swollen and red-looking at the knee. I told (nurse's name) we would need an x-ray so we should send her to the hospital..." physician's orders [REDACTED]." A Resident Transfer Form dated September 26, 2012, documented "X-ray completed 9/26/12 - results state oblique fracture involving proximal tibia with mild displacement...Order received from doctor...to sent to emergency room for evaluation of fracture..." There was no further documentation in the resident's clinical record as to how the fracture occurred. An interview was conducted with a LPN (licensed practical nurse) on April 17, 2013. The LPN stated that the resident's roommate (resident #189) was very hateful and admitted that she hit resident #117 on September 26. The LPN stated that resident #189 thought it was funny and laughed about it. An interview was conducted with the DON (director of nursing) on April 17, 2013. The DON stated the LPN reported to her that resident #189 had told her that she had a cane and was swinging it and was threatening to hit resident #117, as well as other residents. The DON stated that she wondered if this was how the resident's leg was fractured, because of how much her roommate (resident #189) did not like her because she talked all the time. The clinical record of resident #189 was reviewed. The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. Further review of the clinical record revealed there was no documentation regarding the concern that resident #189 was hateful and did not like her roommate, resident #117. There was no documentation that any increased supervision was provided to resident #189, nor any interventions implemented that addressed the fact that resident #189 disliked her roommate. Another interview was conducted with the DON on April 17, 2013. The DON stated that after resident #189 made the threat to hit her roommate and other resident's with her cane, resident #189 only came out of her room with a family member, although there was no documentation in the clinical record. The facility was unable to provide any investigation that was conducted by the facility regarding this incident, nor documentation of any interventions that were implemented to ensure residents were protected from resident #189. A review of the facility's policy on Supervision of Combative Residents documented, "Staff will use appropriate, to the individual situation, alternative measures to manage target behaviors. This will be documented on resident's care plan."