Every finding on record at Arroyo Vista Nursing Center

Based on observation, interview and record review, the facility failed to document nursing care in an accurate, concise manner when:1. Wound treatments were not documented for one of two residents (Resident 36); and,2. Skin observations were documented as being performed for one of two residents (Resident 60) with a condom catheter (a non-invasive device for males that looks like a condom, fits over the penis, and has a tube to drain urine into a collection bag), when no condom catheter was present, when reviewed for documentation.These failures had the potential for Resident 36 and Resident 60's clinical record to be incomplete and inaccurate. Findings:1. Resident 36 was admitted to the facility on [DATE], with diagnoses which included hepatic encephalopathy (a decline in brain function occurring in patients with advanced liver disease), per the facility's Face Sheet.Resident 36's clinical record was reviewed 1/27/26. According to the Physician's order dated 1/3/26:a. Cleanse right leg wound, apply Silvadene (a prescription topical cream used to prevent and treat infections), cover with pad and secure with Kerlix (a woven gauze) every day.b. Cleanse right heel, apply betadine, wrap with dry kerlix every day.c. Cleanse right ischium (hip bone), apply barrier cream every day.d. Cleanse left posterior heel, apply Santyl (a prescription topical ointment used to debride (remove) dead, damaged tissue from chronic wounds) and apply alginate (a medicate cream that promotes healing). Cover with dry dressing and kerlix wrap, every day.e. Cleanse right and left leg, apply Silvadene and cover with pad, secure with kerlix wrap, every day.f. Cleanse left plantar heel (inner heel) and apply Silvadene. Cover with pad and secure with kerlix wrap, every day.g. Cleanse right buttocks, apply hydrogel (a medicated cream that promotes healing). Cover with dry dressing, every day.h. Cleanse left heel, apply Santyl and alginate. Cover with foam dressing and change daily.A review of Resident 36's Treatment Administration Record (TAR), indicated no wound treatments were performed on 1/15/26.A review of Resident 36's Nursing Progress notes, indicated Resident 36 remained in the facility on 1/15/26.A review of the nursing schedule, dated 1/15/26, indicated the Infection Control Nurse (ICN) was the acting treatment nurse during the day shift (7 A.M.to 3:30 P.M.). An interview and record review was conducted with the ICN on 1/27/26 at 4:18 P.M. The ICN stated she filled- in for the treatment nurse 1/15/26, after the treatment nurse called in sick. The ICN reviewed Resident 36's TAR and stated she performed the wound treatments on 1/15/26, but did not them. The ICN stated she knows she performed all the wound treatments, because it took so long and she specifically recalls doing the treatments. The ICN stated by not documenting wound treatment, the reader would not know if the physician's order was followed. The ICN stated it was important to document all wound treatments, so everyone knows they were done. 2. Resident 60 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (abnormal blood sugar) type II (non-insulin dependent) with foot ulcer (wound), per the facility's Face Sheet. An interview was conducted with Resident 60 on 1/26/26 at 8:52 A.M., as he laid in bed. Resident 60 stated They took away my condom catheter and now I'm wet all the time, and the urine irritates my skin. Resident 60 could not recall if the condom catheter was removed at the hospital or when he arrived at the facility. Resident 60 asked if he could get a condom catheter again, because it really helped keep him dry and pain free. Resident 60's clinical record was reviewed on 1/28/26. According to the physician's order, dated 1/23/26, monitor skin surrounding condom catheter for skin integrity or any skin breakdown, every shift.According to Resident 60's TAR dated 1/23/26 through 1/28/26, the skin surrounding the condom catheter was checked 14 out of 14 times as being performed and skin intact.A wound treatment observation of Resident 60 was conducted on 1/28/26 at 2:04 P.M. with Licensed Nurse 1 (LN 1). During the wound treatment, Resident 60 was observed not having a condom catheter, and LN 1 did not inspect the skin surrounding his penis for irritation.An interview and record review was conducted with LN 1 on 2/28/26 at 2:35 P.M., after Resident 60's wound treatment. LN 1 confirmed it was her signature that signed off Resident 60's skin inspection around the condom for the past three days. LN 1 stated she never realized Resident 60 was supposed to have a condom catheter and she never actually performed a skin inspection. LN 1 stated she missed it completely. LN 1 stated the harm of not having a condom catheter as ordered by the physician, would be skin irritation and possibly moist skin associated damage. LN 1 stated by documenting a skin inspection, which was not actually done, was considered inaccurate documentation and false.An interview and record review was conducted with the ICN on 1/28/26 2:37 P.M., of Resident 60's TAR. The ICN reviewed Resident 60's admission assessment and stated the resident did not have a condom catheter on admission. The ICN stated she expected the admission nurse to capture the order for a catheter condom or to contact the physician when she did not see one. The ICN stated the condom catheter should have been captured to prevent pain and a decline in skin integrity. The ICN stated the nurses should not have been documenting the skin and condom catheter were intact, if they never checked it. An interview was conducted with the Director of Nursing (DON) on 1/29/26 at 1:01 P.M. The DON stated he expected resident medical records to be complete, accurate, and concise. The DON stated if wound treatments were not completed and condom catheters were not checked; the reader would not know what treatment was really being provided.According to the facility's policy, titled Charting and Documentation, undated, The resident's clinical record is a concise account of treatment, care, response to care, signs and symptoms and progress of the resident's condition.

Based on interview and record review the facility failed to ensure a resident was informed of the right to a bed hold when transferred to the hospital.As a result, one (56) of three discharged residents was not informed of the right to a 7 day bed hold.Findings:On 1/29/26 Resident 56's clinical record was reviewed. Resident 56 was admitted to the facility on [DATE] with diagnoses which included malignant carcinoma (a type of cancer) according to the facility face sheet. Resident 56's Brief Interview for Mental Status score (a mental assessment tool) dated 10/21/25 was 12 (which indicated some memory issues, but not severely impaired).A Change in Condition Evaluation indicated Resident 56 was transferred to the hospital on [DATE]. A nursing progress note dated 10/28/25 indicated, .Writer called (the hospital) and was notified that resident is being admitted . The Discharge Minimum Data Set (standardized health status assessment tool) dated 10/28/25 indicated, Return anticipated. There was no facility document to indicate Resident 56 was informed of the right to a bed hold. On 1/29/2026 at 9:25 A.M., the Admissions Coordinator (AC) was interviewed. The AC stated the facility attempted review bed hold paperwork with Resident 56 but she was always asleep or groggy so did not sign it. The AC stated it should have been documented that the resident knew about the bed hold.On 1/29/2026 at 9:29 A.M. the Social Services Director (SSD) was interviewed. SSD stated residents should have been told about the bed hold to ensure they know the bed will be held for them. The SSD stated the resident's bed is held for 7 days after transfer to the hospital.On 1/29/26 at 1P.M., the Director of Nursing was interviewed. DON stated all residents sent to the hospital should be given a bed hold. The DON stated it should have been communicated to Resident 56 that her bed would be held for 7 days. The DON acknowledged if Resident 56 was not able to review it at the facility, the documentation should have been sent to her at the hospital.According to the facility admission packet, If you must be transferred to an acute hospital.we will notify you or your representative that we are willing to hold your bed.According to the undated facility policy Bed Hold, Procedure: 1. The resident or the resident's representative shall be informed in writing of their right to exercise the bed hold provision in the event of a transfer from the facility to a general acute care hospital.Each notice shall include: the duration of the State bed-hold policy and/or of the facility policy that the resident's bed will be held for the duration of 7 days, during which time the resident is permitted to return and resume residence in the facility.In the event of an emergency transfer, the second notice will be provided within 24 hours.

Based on observation, interview, and record review, the facility failed to follow the physician's plan of care when a condom catheter (a non-invasive device for males that looks like a condom, fits over the penis, and has a tube to drain urine into a collection bag), was not applied for one of two residents (Resident 60), reviewed for plan of care.This failure had the potential for Resident 60 to experience increased pain and a decline in skin integrity.Findings:Resident 60 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (abnormal blood sugar) type II (non-insulin dependent) with foot ulcer (wound), per the facility's Face Sheet. An interview was conducted with Resident 60 on 1/26/26 at 8:52 A.M., as he laid in bed. Resident 60 stated, They took away my condom catheter and now I'm wet all the time, and the urine irritates my skin. Resident 60 could not recall if the condom catheter was removed at the hospital or when he arrived at the facility. Resident 60 asked if he could get the condom catheter back again, because it really helped keep him dry and pain free. Resident 60's clinical record was reviewed on 1/28/26. According to the physician's order, dated 1/23/26, monitor skin surrounding condom catheter for skin integrity or any skin breakdown, every shift.According to Resident 60's TAR dated 1/23/26 through 1/28/26, the skin surrounding the condom catheter was checked, for 14 out of 14 times opportunities as being performed and skin intact. A wound treatment observation of Resident 60 was conducted on 1/28/26 at 2:04 P.M. with Licensed Nurse 1 (LN 1). During the wound treatment, Resident 60 was observed without a condom catheter, and LN 1 did not inspect the skin surrounding his penis for skin irritation.An interview and record review was conducted with LN 1 on 2/28/26 at 2:35 P.M., after Resident 60's wound treatment. LN 1 confirmed it was her signature that signed off Resident 60's skin inspection around the condom for the past three days. LN 1 stated she never realized Resident 60 was supposed to have a condom catheter and she never actually performed a skin inspection. LN 1 stated she missed the physician's order completely. LN 1 stated the harm of not having a condom catheter as ordered by the physician, would be skin irritation and possibly moist skin associated damage. LN 1 stated by documenting something she was not doing, was considered inaccurate and false.An interview and record review was conducted with the ICN on 1/28/26 2:37 P.M., of Resident 60's TAR. The ICN reviewed Resident 60's admission assessment and stated the resident did not have a condom catheter on admission. The ICN stated she expected the admission nurse to capture the order for a catheter condom or to contact the physician when she did not see observed a condom catheter. The ICN stated the condom catheter should have been captured in order to prevent pain and a decline in skin integrity. The ICN stated the nurses should not have been documenting the skin and condom catheter were intact, if they never checked it. An interview was conducted with the Director of Nursing (DON) on 1/29/26 at 1:01 P.M. The DON stated he expected staff to be aware of the physician's orders and to contact the physician if clarification was needed. According to the facility's policy, titled Physician Orders, dated June 2024, .3. admission orders are reviewed with the physician on admission based on the discharge instructions from the discharging facility and are transcribed accordingly.

Based on observation, interview, and record review ,the facility failed to ensure safe infection control practices were followed when a urinary catheter bag (a flexible tube inserted in order to drain urine from the bladder into an external collection bag), and its tubing was in contact with the floor for one of two residents (Resident 5) when reviewed for catheter care.This failure had the potential for Resident 5 to sustain a urinary tract infection from bacteria on the floor. Findings:Resident 5 was admitted to the facility on [DATE] with diagnoses which included need for personal assistance, per the facility's [NAME] Sheet.An observation was conducted of Resident 5 during initial tour on 1/26/26 at 9:30 A.M. Resident 5 was asleep in bed with a urinary collection bag clipped to the left side of the bedframe. The catheter collection bag and the tubing were both in contact with the floor. An observation and interview was conducted with certified nursing assistant 1 (CNA 1), of Resident 5 on 1/26/26 at 9:39 A.M. CNA 1 observed Resident 5's urinary collection bag and stated, the bag and tubing are in contact with the floor. CNA 1 stated the catheter on the floor was an infection control issue, and the resident was at risk for infection. Resident 5's medical record was reviewed on 1/26/26. According to the physician's order, dated 8/15/25, indwelling catheter to gravity drainage for diagnoses of urinary retention (the inability to empty the bladder on your own). An interview was conducted with the Infection Control Nurse (ICN) on 1/27/26 at 10:36 A.M. The ICN stated urinary collection bags and their tubing should never be in contact with the floor because bacteria could travel up the tubing into the resident, resulting in an infection.An interview was conducted with the Director of Nursing (DON) on 1/29/26 at 1:01 P.M. The DON stated urinary collection bags should never be on contact with the floor, because the floor contains bacteria and the resident could be at risk of an infection. According to the facility's policy, titled Infection Prevention and Control Program, undated, .The infection prevention and control program is comprehensive in that it addresses detection, prevention, and control of infections among residents.

Based on interview and record review, the facility failed to ensure one resident (Resident 1) was treated with dignity/respect when the facility denied Resident 1 re-entry following a return from being out on pass (OOP; also referred to as a day pass; physician ' s order that gives permission for a resident to leave the facility for a specified period of time). This failure had the potential to affect Resident 1 ' s physical and psychosocial well-being related to feeling betrayed and kicked out from his home. (Cross Reference F-553 and F-657) Findings: According to the facility ' s Admission Record, Resident 1 was admitted to the facility on [DATE], with diagnoses which included multiple fractures of the pelvis and right ribs. An interview was conducted with Resident 1 on 4/11/25 at 10:12 A.M. Resident 1 stated that he has always been allowed to leave on a day pass to spend time with friends. Resident 1 stated that on the early morning of 3/19/25, the facility would not allow him back inside, because it was after midnight and those were their rules. Resident 1 stated he was never informed that he would be locked out after midnight. Resident 1 stated he was finally allowed back into the building three hours later, after he called the police. Resident 1 stated he felt betrayed, as if the facility was trying to kick him out, because he had no other place to go. On 4/11/25, Resident 1 ' s medical record was reviewed. According to the physician ' s order, dated 9/30/24, Resident 1 was able to go Out on Pass. According to the quarterly Minimum Data Set (a clinical assessment tool), dated 2/13/25, Resident 1 had a cognitive score of 15, indicating cognition was intact. Per the Functional Abilities section, Resident 1 was independent for activities of daily living (eating, dressing, showering), and used a manual wheelchair to move around. According to the nurse ' s note dated 3/19/25 at 12:07 A.M., Licensed Nurse 2 (LN 2) documented, patient still not back from pass, Nurse Practitioner (NP) [name] aware, waiting for orders. Orders received from NP [name] that patient is now AMA (against medical advice; referring to when a patient leaves the facility against the recommendation of the physician or healthcare provider), not to allow him in the building and has to go to the emergency room . Called resident and left message through voicemail. According to the nurse ' s note dated 3/19/25 at 12:45 A.M., LN 2 documented patient came via private vehicle with a female driver. Patient was ambulating with a front wheel walker and informed about what NP [name] ordered. Patient wanted to talk to NP [name] but per NP [name], to call director of nursing (DON) per DON patient is now discharged , follow what NP [name] ordered and that patient needs to go to ER. Resident outside facility door and made aware. According to nurse ' s notes dated 3/19/25 at 2:28 A.M., Three police officers arrived and spoke to writer as well as patient. Per Officer 1, we have to let patient in due to civil matter, that there is no medical reason for patient to go to ER and that he ' s been living here for a period of time and has established residency. Officer 1 asked to speak with Administrator or DON, but no response from either one. Patient was let in back to his room and will talk to the DON or administrator in the am. According to the nurses ' s note dated 3/19/25 at 3:08 A.M., LN 2 documented Patient asked for pain meds and writer informed him that it will be clarified to DON if writer will be allowed to give his medication since he was AMA and was considered discharged .Patient then insist to have urine collected and send to lab .writer informed .no order, cannot be sent to lab. An interview was conducted with NP on 4/11/25 at 11:35 A.M. NP stated he was notified by the facility that it was after midnight and Resident 1 had not returned. NP instructed staff to consider the resident AMA and not to allow him back in. While on the phone with the facility, Resident 1 arrived and demanded to be let back in. NP instructed staff to consider Resident 1 discharged and to instruct him to go to the emergency room . NP stated he thought the OOP deadline was midnight, and that was the reason staff was instructed to deny the resident entry. NP stated since this event, he learned the deadline for AMA if leaving on OOP, was actually three days. The Administrator, DON, and Director of Staff Development were unavailable on 4/11/25 for an interview. According to the facility ' s policy titled Resident Rights and Responsibility, undated, .7. To assure that out residents, staff, and visitors are continually informed and aware of resident rights, grievance procedures, and responsibilities .

Based on interview and record review, the facility failed to ensure one resident (Resident 1) was included in his own person-centered planning of care related to Interdisciplinary Team meetings (IDT; head of department staff meet with the resident to discuss care or concerns/issues) after an incident when the facility refused Resident 1 entry back into the facility following an Out on Pass leave (OOP; physician ' s order that allowed the resident to leave the facility; usually for the day; also referred to as a day pass). This failure resulted in Resident 1 not being informed of the facility rules or expectations when leaving on and returning from, being OOP. In addition, this failure had the potential to result in an AMA (against medical advice)-triggered discharge, which had the potential to affect Resident 1 ' s physical and psychosocial well-being. (Cross-reference F-550 and F-657) Findings: According to the facility ' s Admission Record, Resident 1 was admitted to the facility on [DATE], with diagnoses which included multiple fractures of the pelvis and right ribs. An interview was conducted with Resident 1 on 4/11/25 at 10:12 A.M. Resident 1 stated that he has always been allowed to leave on a day pass to spend time with friends. Resident 1 stated that on 3/19/25, upon returning from being out on a day pass, the facility would not allow him back inside, because it was after midnight, and those were their rules. Resident 1 stated that he was never informed that he would be locked out from the facility after midnight. Resident 1 stated that his friend ' s car had broken down on the way back to the facility, which caused his delay in returning. Resident 1 stated that he was finally allowed back into the building three hours later, after he called the police. Resident 1 stated that he felt betrayed, because he had no other place to go, and felt the facility was trying to kick him out. On 4/11/25, Resident 1 ' s medical record was reviewed. According to the physician ' s order, dated 9/30/24, Resident 1 was able to go Out on Pass (OOP). According to the quarterly Minimum Data Set (a clinical assessment tool), dated 2/13/25, Resident 1 had a cognitive score of 15, indicating cognition was intact. Per the Functional Abilities section, Resident 1 was independent for activities of daily living (eating, dressing, showering), and used a manual wheelchair to move around. There was no documented evidence that an IDT was conducted after the 3/19/25 incident. The last documented IDT meeting for Resident 1 was dated 6/1/24. No other IDT or care conferences were documented. An interview and record review were conducted with the Social Service Director (SSD) on 4/11/25 at 11: 43 A.M. The SSD stated that she was on vacation when the 3/19/25 incident occurred and learned about it when she returned. The SSD stated that Resident 1 left the facility several times a month and there was never an issue. The SSD stated she scheduled the IDTs, which were required quarterly (every three [3] months), and if there were problems, such as a change of condition. The SSD stated that when she returned to the facility (from vacation), she was informed that an IDT was conducted after the OOP incident. The SSD reviewed Resident 1 ' s IDT log and could not locate an IDT for the March OOP incident. The SSD stated she could only locate one IDT which was dated June 2024. The SSD continued looking through Resident 1 ' s medical record and could not find any documented evidence that other IDTs were conducted. The SSD stated that if Resident 1 refused an IDT, it would be documented in the SSD notes. The SSD stated there was no documented evidence that IDTs were refused. The SSD continued, and stated that after IDTs were conducted, the resident ' s care plans were usually updated and revised to reflect the changes or improvement, and new goals and interventions would be applied. The SSD stated that since there were no documented IDTs for Resident 1, there was no collaborative review of the resident ' s care. The SSD stated this was considered a resident right to be involved in their planning and care, however there was no documented evidence that Resident 1 was involved. An interview was conducted with the Assistant Director of Nursing (ADON) on 4/11/25 at 12:10 P.M. The ADON stated IDTs were conducted for every resident quarterly and more often, if problems were identified, or a change of condition occurred. The ADON stated IDTs were important for the head of department staff to discuss issues and suggest solutions. The ADON stated when IDTs were completed, the resident ' s care plans were updated, so new goals and interventions could be listed, and staff were all aware of the changes. The ADON stated if IDTs were not conducted, there was no collaboration of care with the resident, so there was no meeting of the minds. An interview and record review were conducted with licensed nurse (LN) 1 on 4/11/25 at 12:46 P.M. LN 1 stated IDTs were important to address issues, such as weight loss, wounds, or behaviors. LN 1 stated she assumed an IDT was conducted after Resident 1 was denied entry, after leaving on a pass. LN 1 stated the IDT would address preventing this AMA-triggered discharge from occurring again, so Resident 1 would know the rules and expectations. LN 1 stated she was surprised if an IDT was not done, because this also triggered a change to the resident ' s care plan. LN 1 reviewed Resident 1 ' s record and acknowledged that Resident 1 was not included in an IDT for person-centered care planning after the OOP incident. The Administrator and Director Nursing were unavailable on 4/11/25 for an interview. According to the facility ' s policy, titled Comprehensive Person-Centered Care Planning, undated.4. The facility IDT will develop and implement a comprehensive person-centered care plan for each resident .will include the resident needs identified .and resident ' s goals and desired outcomes, preferences for future discharge .

Based on interview and record review, the facility failed to ensure a care plan related to Out on Pass (OOP; also referred to as a day pass; a physician ' s order that allows the resident to leave the facility for an approved time period) was revised for one resident (Resident 1). This failure had the potential for staff and Resident 1 to be confused on the facility ' s rules when leaving on an Out on Pass. (Cross Reference F-550 and F-553) Findings: According to the facility ' s Admission Record, Resident 1 was admitted on [DATE], with diagnoses which included multiple fractures of the pelvis and right ribs. An interview was conducted with Resident 1 on 4/11/25 at 10:12 A.M. Resident 1 stated that he has always been allowed to leave on a day pass to spend time with friends. Resident 1 stated that on 3/18/25, the facility would not allow him back inside, because it was after midnight and those were their rules. Resident 1 stated that his friend ' s car had broken down on the way back to the facility, and he was never informed of a rule of that he would not be allowed back inside the facility, after midnight. Resident 1 stated he was finally allowed back into the building three hours later, after he called the police. Resident 1 stated he was never informed that he could only be gone (out on pass) for a certain number of hours or that he would be locked out after midnight. On 4/11/25, Resident 1 ' s medical record was reviewed. According to the physician ' s order, dated 9/30/24, Resident 1 was able to go Out on Pass. According to the quarterly Minimum Data Set (a clinical assessment tool), dated 2/13/25, Resident 1 had a cognitive score of 15, indicating cognition was intact. Per the Functional Abilities section, Resident 1 used a manual wheelchair to move around. There was no documented evidence that an Interdisciplinary Team Meeting (IDT- head of department staff and the resident meet to discuss incidences or concerns) was conducted after the 3/19/25 incident. The care plan titled, Elopement Risk related to not informing licensed nurses when going out on pass, and exceeding the required number of hours allowed, revised 1/16/25, listed the following interventions: .Licensed nurse will talk to resident when leaving the facility to wait for MD/NP approval of OOP. Licensed nurse will notify MD/NP if patient left the building without requesting OOP and exceeds the allowable amount of time. Licensed nurses/staff will call the patient before the fourth hour of being OOP to check the well-being of the patient and remind the patient of the time. An interview and record review was conducted with Licensed Nurse 1 (LN 1) on 4/11/25 at 12:10 P.M. LN 1 stated care plans were reviewed and revised regularly and especially after IDT meetings. LN 1 was aware of Resident 1 being refused entry last month (3/19/25) and stated she assumed an IDT was conducted and the OOP care plan was revised, based on the 3/18/25, incident alone. LN 1 reviewed Resident 1 ' s care plan, titled Elopement [NAME] and stated the last time the care plan was revised was 1/16/25. LN 1 stated that because the care plan was not updated, staff were unaware of what the rules were and if there really was a time limit for the resident returning to the facility. LN 1 stated that care plans were important for staff, so everyone knew what interventions to implement and what were being consistency applied. An interview was conducted with the Assistant Director of Nursing (ADON) on 4/11/25 at 1 P.M. The ADON acknowledged that Resident 1 ' s care plan should had been updated and revised, but was not. The ADON stated care plans were important for staff to identify issues and set interventions and expectations. The Administrator and Director of Nursing were unavailable for interview on 4/11/25. According to the facility ' s policy, titled Comprehensive Person-Centered Care Planning, undated, .^. The resident ' s comprehensive plan of care will be reviewed and/or revised by the IDT .

Based on interview and record review, the facility failed to ensure four of ten residents sampled for immunizations were offered the Covid-19 vaccine. This failure resulted in the potential for residents to be infected with or experience complications from Covid-19. Findings: According to the Admission Record, Resident 39 was admitted to the facility on [DATE]. A review of Resident 39's immunization indicated Resident 39 received the Covid-19 vaccination in 2021. There was no documentation that Resident 39 was offered, received, or declined the Covid-19 vaccine since admission. According the the Admission Record, Resident 201 was admitted to the facility on [DATE]. There was no documentation that Resident 201 was offered, received, or declined the Covid-19 vaccine since admission. According to the Admission Record, Resident 30 was admitted to the facility on [DATE]. According to the Immunization Record, Resident 30 received the Covid-19 booster shot in 2022. There was no documentation that Resident 30 was offered, received, or declined the Covid-19 vaccine since admission to the facility. According to the Admission Record, Resident 9 was admitted to the facility on [DATE]. A review of Resident 9's Immunization Record indicated Resident 9 received the Covid-19 booster shot in 2021. There was no documentation that Resident 30 was offered, received, or declined an updated Covid-19 vaccine since admission to the facility. On 10/10/24 at 8:49 A.M., a concurrent interview and record review for Residents 39, 201, 30, and 9 were conducted with the Infection Preventionist (IP). The IP stated the facility offered updated Covid-19 vaccinations to residents .every three to four months . The IP stated every resident's vaccination status (including refusals, declinations, or receipt of the Covid-19 vaccines) should be documented in the residents' electronic chart under Immunizations. The IP stated education provided to the resident regarding the Covid-19 vaccine should also be documented. On 10/10/24 at 3:45 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated it was important that residents are offered the Covid-19 vaccine. The DON stated it was important to offer vaccinations .even if it doesn't prevent .Covid, it will prevent an ill effect of the disease. Plus they're older and more susceptible . The DON stated it was his expectation for residents' Covid-19 vaccination status to be updated in the Immunization Record. A review of the facility's undated policy titled Vaccinations Policy indicated, It is the policy of this facility to offer and administer .Covid-19 immunizations to eligible residents .to minimize the risk of residents acquiring, transmitting, or experiencing complications from .Covid-19 by ensuring that each resident .has the opportunity to receive .the Covid-19 vaccine .Document that the resident either received .the Covid-19 immunization or did not receive the Covid-19 immunization .[in the ] electronic health record/immunization tab/progress notes .

Based on interview and record review, the facility failed to offer and/or provide education regarding the benefits and potential side effects of the pneumococcal (a type of bacterial lung infection) vaccine to four of ten residents (Residents 18, 71, 105, and 201) reviewed for immunizations. This failure posed the risk of the residents contracting pneumonia and its associated complications. Findings: 1. According to a review of Resident 18's Admission Record, the resident was over [AGE] years old. During a review of Resident 18's immunization record, there was no indication the resident was offered or received the pneumococcal vaccine. 2. According to a review of Resident 71's Admission Record, the resident was over [AGE] years of age. During a review of Resident 71's immunization record, there was no indication the resident was offered or received a pneumococcal vaccine. 3. According to a review of Resident 105's Admission Record, the resident was over [AGE] years old. During a review of Resident 105's immunization record, there was no indication the resident was offered or received a pneumococcal vaccine. 4. According to a review of Resident 201's Admission Record, the resident was over [AGE] years old. During a review of Resident 201's immunization record, there was no indication the resident was offered or received a pneumococcal vaccine. On 10/10/24 at 8:49 A.M. an interview was conducted with the Infection Preventionist (IP). The IP stated it was important to offer vaccines to residents aged 65 and older .to protect them, us or family members from different viruses .older people are more frail . The IP stated it was important give the pneumococcal vaccine to help residents stay healthy. On 10/10/24 at 3:45 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated his expectation was that staff offer the pneumococcal vaccine to eligible residents. The DON stated .[Residents] are more susceptible to pneumonia .its important to protect them . A review of the facility's undated policy titled Immunizations-Resident indicated, Receipt of vaccinations is essential to the health and well-being of long-term care residents .Pneumococcal pneumonia .is a common cause of hospitalization and death. People [AGE] years or older are two to three times more likely than the younger population to get pneumococcal infections . The policy also indicated, Information related to education provided regarding the benefits and risks of (the pneumococcal vaccine) and the administration or refusal of or medical contraindications to the vaccine will be documented in the resident's medical record .

Based on observation, interview and record review, the facility failed to ensure safe and sanitary conditions were maintained in the kitchen for food storage methods, according to standards of practice and facility policy when: 1. Multiple food items were not dated correctly. 2. The ice machine was observed to have black residue inside the ice bin and the water filter for the ice machine was 45 days past the due date to be changed. These failures had the potential for food contamination, which could result in food borne illnesses for all residents who consume food from the kitchen. The census was 42. Findings: 1. An initial kitchen tour with [NAME] (CK) 1 was conducted on [DATE] at 7:45 A.M. An open box of corn starch and an open box of rice cereal were not transferred to sealed containers and labeled with a use by date. An open bottle of imitation vanilla flavoring was not labeled with a use by date. Boxes of fountain juices were labeled with numbers 921 and 105 without indication of what the numbers meant. Bags of toasted oats cereal were labeled [DATE] without indication of what the date referred to. CK 1 stated the toasted oats cereal should have an R for received next to the date. CK 1 stated opened food items should be marked with OP to indicate an opened date and BY to indicate a used by date. On [DATE] at 11:55 A.M. an interview was conducted with the Certified Dietary Manager (CDM) who stated food items should be marked with the received date designated with the letter R, the opened date designated with the letters OP and the use by date designated with the letters BY. The Registered Dietitian (RD) stated, The contractor dates the boxes of drinks as received date. Staff should mark them with the open date. The vanilla should have been marked with the opened date and the use by date. The cereals should have been transferred to a container with a lid and labeled with the opened date and the use by date. On [DATE] a record review was conducted. Per an undated facility training document, titled Food and Nutrition Skills Check - Labeling and Dating of Foods indicated, All food items in the storeroom, refrigerator, and freezer need to be labeled and dated based on established procedures .The Use By date will be the absolute date in which the food must be consumed or discarded by the facility. Food delivered to the facility needs to be marked with a delivery or received date. The individual preparing/handling food shall be responsible for date marking at the time of processing and/or storage Food should be dated once opened with the date by which foods shall be consumed or discarded - Use By date Per a facility policy, dated 2023 and titled Labeling and Dating of Foods, Policy: All food items in the store room, refrigerator, and freezer need to be labeled and dated based on established procedures .Definitions: .DD = Delivery, or received date; OD = Open Date .UB = Use By Date Food delivered to facility needs to be marked with a delivery or received date The individual opening or preparing a food shall be responsible for date marking at the time of processing and/or storage 2. During an initial kitchen tour on [DATE] at 7:45 A.M., an observation of the ice machine was conducted with [NAME] (CK) 1. The interior of the machine had black residue along the top seam directly above the ice. Condensation from the area dripped directly onto the ice cubes below. CK 1 stated, That's mold. Patients might get sick. A concurrent record review of the ice machine cleaning log was conducted. CK 1 stated, The last time the ice machine was cleaned by the contractor was [DATE]. The last time it was cleaned by our maintenance was [DATE]. A filter between the water inlet at the wall and the connecting hose to the ice machine was dated [DATE]. On [DATE] at 11:55 A.M. an interview was conducted with the CDM, the RD and the Maintenance Director (MaintD). The MaintD stated, I service the machine monthly. Every time I clean and wipe there's something black that I find. The filter should be changed once per year. It was last changed on [DATE], it's late by one and a half months. The CDM stated he did not know about the filter. The RD stated, I was not aware of the expired filter. The substance in the ice machine is probably mold and the maintenance director should have made someone aware so we could find the root cause of the issue. The risk is food borne illness. On [DATE] at 9:25 A.M. an interview was conducted with the Contracted Technician (CT) for the ice machine. The CT stated a technician was responsible to check the filter to see if it was due to be changed. Per the CT, if the filter had been changed it was possible the ice machine would not have developed mold, as the filter had antimicrobial properties. On [DATE] a record review was conducted. A review of the contractor Service Work Order and Invoice dated [DATE] did not include change of the filter in the description of work done. A review of the Instruction Manual for Hoshizaki KM-520MAJ-E ice machine indicated Maintenance Schedule: .More frequent maintenance may be required depending on water quality, the appliance's environment, and local sanitation regulations Monthly: external water filters. A review of the facility policy titled Sanitation dated 2023 indicated, The FNS (Food Nutrition Services) Director is responsible for instructing employees in the fundamentals of sanitation in food service and for training employees to use appropriate techniques The Maintenance Department will assist Food and Nutrition Services as necessary in maintaining equipment .Ice which is used in connection with food or drink shall be from a sanitary source and shall be handled and dispensed in a sanitary manner.

Based on observation, interview and record review, the facility failed to implement infection control procedures when: 1. Continuous Positive Airway Pressure (CPAP- a device that delivers oxygen) machine mask and tubing were not stored in a sanitary manner. 2a. Enhanced Barrier Precautions (EBP- infection control procedures to lessen the risk of cross-contamination) were not implemented for three rooms and, 2b. Visitors were not educated regarding the need for hand hygiene. This failure had the potential for the spread of infection to other residents in the facility. Findings: 1. According to the Admission Record, Resident 28 was admitted to the facility on [DATE] with diagnoses that included obstructive sleep apnea (a condition in which breathing is interrupted during sleep). During a record review conducted on 10/7/24, the Minimum Data Set (MDS, an assessment tool) for Resident 28 indicated a Brief Interview for Mental Status (BIMS assessment tool) of 15 indicating intact cognition. On 10/7/24 at 8:59 A.M., a concurrent observation and interview was conducted with Resident 28. Resident 28's CPAP machine was observed on the resident's night stand. The CPAP mask, which would come in contact with the resident's face, was observed dangling from the night stand, uncovered and approximately an inch of an empty urinal. On 10/8/24 at 4:18 P.M., an interview was conducted with Resident 28. Resident 28 stated the CPAP machine was his personal one brought from home. Resident 28 stated I don't clean it here .nobody does. On 10/8/24 at 4:20 P.M. an interview was conducted with Licensed Nurse (LN) 2. LN 2 stated Resident 28's CPAP mask should be stored in a plastic bag. LN 2 stated if the mask was on the floor, .it can get dirty .it should be contained for infection control . On 10/10/24 at 3:45 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated it was his expectation for staff to clean CPAP machines after each use, and to store the mask in a plastic container. The DON stated, It is important to clean it every night to avoid growing microorganisms. It's wet, you don't want to inhale it. Respiratory infection can happen . A review of the facility's undated policy titled Care and Storage of Nebulizer/CPAP Equipment indicated, It is the policy of this facility to clean the .equipment after use . 2a. On 10/7/24 at 8 A.M., an observation was conducted. Three residents were identified with indwelling devices, such as a feeding tube and a catheter. Of the three, none had signage outside the door indicating EBP or isolation supplies. During an interview on 10/8/24 at 8:59 A.M. with LN 1, LN 1 stated residents with indwelling devices should be on EBP, .because of potential risk for infection to the patient. On 10/9/24 at 10:41 A.M., an interview was conducted with the Infection Preventionist (IP). The IP stated residents with devices should be on EBP, per Centers for Disease Control (CDC) guidelines. The IP stated residents on EBP should have a sign posted outside the room to indicate the precaution. The IP stated there should be a supply of Personal Protective Equipment (PPE-gowns, gloves, masks) available near residents' rooms. On 10/10/24 at 3:45 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated it was the responsibility of the IP to ensure residents who required EBP were placed on EBP precautions. The DON stated .EBP is important for patient safety, to prevent the patient from getting infection and to protect everyone else . 2b. Resident 16 was admitted to the facility on [DATE] with diagnoses to include end stage renal disease (irreversible kidney damage) and dependence on dialysis, per the facility's Admission Record. On 10/10/24 at 8:12 A.M., an observation of Resident 16's room was conducted. An orange sign was posted outside the room, indicating Resident 16 was in EBP, and, .EVERYONE MUST: Clean their hands, including before entering and when leaving the room . LN 13 was preparing medications outside of the room, and Certified Nursing Assistant (CNA) 11 was inside the room. On 10/10/24 at 8:15 A.M., an observation was conducted. Two visitors entered Resident 16's room without reading the sign or performing hand hygiene. On 10/10/24 at 8:16 A.M., an interview was conducted with LN 13. LN 13 stated Resident 16 was in EBP due to an indwelling device, which placed her at higher risk for infection. LN 13 stated she had not seen the visitors enter the room, but she should have stopped them and provided education regarding the need for hand hygiene. LN 13 stated it was important to educate visitors as it was intended to protect the resident from infection, but she had not done so. On 10/10/24 at 8:18 A.M., an interview was conducted with CNA 11. CNA 11 stated Resident 16 was in EBP due to her indwelling device. CNA 11 stated it was everyone's responsibility to educate visitors and staff regarding the importance of performing hand hygiene before entering the room. CNA 11 stated she had not informed the visitors to do so. CNA 11 stated not performing hand hygiene could cause the resident to get sick from infections. On 10/10/24 at 11:36 A.M., an interview was conducted with the DON. Per the DON, all staff should follow the instructions on the signs, and visitors must be educated to follow the facility guidelines. The DON stated, All staff is responsible for educating about this. A review of the facility's policy titled IPCP Standard and Transmission Based Precautions indicated, .It is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions .EBP .is indicated .for nursing home residents with .indwelling medical devices . 49330

Based on interview and record review, the facility failed to provide pain management for one of two residents (Resident 200) reviewed for pain management when pain medication was not administered per physician's order for severe pain. This failure had the potential to prevent Resident 200 from receiving adequate pain relief. Findings: According to the Admission Record, Resident 200 was admitted to the facility on [DATE] with diagnoses that included cancer and acute appendicitis (a condition in which the appendix becomes inflamed, causing pain). On 10/8/24 a review of Resident 200's Physician's Orders, dated 7/26/24, indicated to monitor pain level using the following pain scale: 0= No Pain, 1-3=Mild, 4-6= Moderate, 7-10= Severe. On 10/8/24 a review of Resident 200's Physician's Orders, dated 10/1/24 indicated Resident 200 had an order for Oxycodone HCl Oral Tablet 5 mg (milligrams) every four hours for moderate pain. Resident 200 had an order for Oxycodone HCl 10 mg every four hours for severe pain. A review of Resident 200's medication administration record indicated Resident 200 received Oxycodone 5 mg at the following dates and times: On 10/2/24 at 9:19 A.M. for 8 out of 10 pain level (severe). On 10/3/24 at 9:01 A.M. for 8 out of 10 pain level (severe). On 10/4/24 at 8:13 A.M. for 7 out of 10 pain level (severe). On 10/6/24 at 9:04 A.M. for 7 out of 10 pain level (severe). On 10/7/24 at 8:14 A.M. for 8 out of 10 pain level (severe). On 10/8/24 at 3:28 P.M. an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated she administered Oxycodone 5 mg to Resident 200 for 8 out of 10 pain on 10/2/24, 10/3/24, and 10/7/24. LN 1 stated she administered Oxycodone 5 mg, when she should have given Oxycodone 10 mg. LN 1 stated the physician's order was not followed for Resident 200. LN 1 stated it was important to follow the physician's order to ensure residents received adequate pain relief. On 10/10/24 at 3:45 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated his expectation was for Resident 200 to be given the appropriate dose of medication based on his pain scale. The DON stated Resident 200 was undermedicated for his pain level and, .the patient will still continue to have pain . A review of the facility's policy titled Pain Recognition and Management revised 12/23 indicated, It is the policy .to ensure that pain management is provided to residents who require such services .

Based on observation, interview and record review, the facility failed to implement care plans for two of 42 residents for: 1. Dialysis (a process to remove waste products from the blood stream, Resident 16) and, 2. Substance use disorder and nicotine dependence (Resident 151). As a result, Resident 16 and Resident 151's care needs, goals and interventions were not addressed or communicated to staff members for continuity of care. Cross reference: F698 Findings: 1. Resident 16 was admitted to the facility on [DATE] with diagnoses to include end stage renal disease (irreversible kidney damage) and dependence on dialysis, per the facility's Admission Record. On 10/7/24 at 9:30 A.M., a concurrent observation and interview was conducted with Resident 16. Resident 16 was in bed, with a dialysis access site visible on her left upper arm. Resident 16 stated she went for dialysis on Mondays, Wednesdays and Fridays. Per Resident 16, she returned to the facility around 3 P.M. after dialysis was completed. On 10/10/24 at 8:10 A.M., a concurrent interview and observation of Resident 16 was conducted in her room. Resident 16 was sitting in bed, with her dialysis access site visible on her left arm. Resident 16 stated she had gone to dialysis the previous day and returned as usual around 3 P.M. Per Resident 16, a Licensed Nurse (LN) had removed the dialysis dressing from her access site a few minutes earlier. Resident 16 stated the dressing was often removed the morning after dialysis. On 10/10/24 at 8:29 A.M., a concurrent interview and record review was conducted with LN 12. LN 12 stated she had just removed the dressing from Resident 16's dialysis access site. LN 12 stated the dressing should have been removed four to six hours after Resident 16 returned from dialysis the previous day, somewhere between 7 P.M. and 9 P.M. LN 12 stated at that time, the P.M. shift nurse should have assessed the site for bleeding or signs of infection, which was a part of the after-dialysis assessment. LN 12 stated leaving the dressing on the dialysis site could cause pressure on the site and could cause problems with future dialysis treatments. LN 12 stated a care plan was used to communicate the specific care needs for each resident, so a care plan for dialysis would be important for Resident 16. LN 12 was unable to locate a care plan for dialysis in Resident 16's medical record. On 10/10/24, a record review was conducted. According to the Minimum Data Set (MDS, an assessment tool), dated 9/3/24, Resident 16's Brief Interview of Mental Status (BIMS) score was 15, indicating intact cognition. According to Resident 16's physician's orders, dated 9/12/24, dialysis treatments were scheduled every Monday, Wednesday and Friday. The physician's orders indicated to remove the dialysis dressing four to six hours after the dialysis treatment, and to inform the physician of any changes to the dialysis access site. No care plan for dialysis was identified for Resident 16. On 10/10/24 at 11:36 A.M., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated the nurses needed to assess the dialysis access site upon return from dialysis and when removing the dressing. Per the DON, one of the places LNs could look for guidelines to care and treatment was the care plan. The DON stated a care plan would be important for every diagnosis Resident 16 had, as the care plan was a guide to the caregivers and provided goals and interventions to meet the goals. The DON was unable to locate a care plan related to dialysis for Resident 16. On 10/10/24 at 4:37 P.M., a concurrent interview and record review was conducted with LN 11. LN 11 stated she had been assigned to Resident 16 the previous day during her shift of 3-11 P.M. LN 11 stated she had forgotten to remove the dialysis dressing from Resident 16's arm. LN 11 stated she had assessed the site with the dressing on but had not returned to remove the dressing or view the site for signs of infection. Per LN 11, the care plan could be a useful tool for communicating dialysis needs between shifts and caregivers. LN 11 was unable to locate a care plan for dialysis in Resident 16's medical records. Per an undated facility policy, titled Comprehensive Person-Centered Care Planning, It is the policy of this facility .shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs .includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care . 2.Resident 151 was admitted to the facility on [DATE] with diagnoses that included substance use disorder per the facility Admission Record. A review of the skilled nursing referral intake summary form dated 9/18/24 indicated Resident 151 had a current history of substance use disorder, and nicotine dependency which was treated at the hospital with a nicotine patch. On 10/09/24 at 3:26 P.M. an interview and concurrent record review were conducted with the Director of Nursing (DON). The DON stated, The care plan for polysubstance abuse (use of more than one substance) has interventions like avoid rearranging the furniture that are not related to the diagnosis. The nurse could have written specific interventions. The care plan for psychosocial wellbeing could have been more specific. A review of the undated facility policy titled Comprehensive Person-Centered Care Planning indicated, .includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care .The care plan will include the minimum healthcare information necessary to properly care for a resident .

Based on observation, interview and record review, the facility failed to remove the dressing from a dialysis (treatment to remove waste from the body) access site for one of one residents reviewed for dialysis care (Resident 16). This failure had the potential to result in damage to the dialysis access site. Findings: Resident 16 was admitted to the facility on [DATE] with diagnoses to include end stage renal disease (irreversible kidney damage) and dependence on dialysis, per the facility's Admission Record. On 10/7/24 at 9:30 A.M., a concurrent observation and interview was conducted with Resident 16. Resident 16 was in bed, with a dialysis access site visible on her left upper arm. Resident 16 stated she went for dialysis on Mondays, Wednesdays and Fridays. Per Resident 16, she returned to the facility around 3 P.M. after dialysis was completed. On 10/10/24 at 8:10 A.M., a concurrent interview and observation of Resident 16 was conducted in her room. Resident 16 was sitting in bed, with her dialysis access site visible on her left arm. Resident 16 stated she had gone to dialysis the previous day and returned as usual around 3 P.M. Per Resident 16, a Licensed Nurse (LN) had removed the dialysis dressing from her access site a few minutes earlier. Resident 16 stated the dressing was often removed the morning after dialysis. On 10/10/24 at 8:29 A.M., an interview was conducted with LN 12. LN 12 stated she had just removed the dressing from Resident 16's dialysis access site. LN 12 stated the dressing should have been removed four to six hours after Resident 16 returned from dialysis the previous day, somewhere between 7 P.M. and 9 P.M. LN 12 stated at that time, the P.M. shift nurse should have assessed the site for bleeding or signs of infection, which was a part of the after-dialysis assessment. LN 12 stated leaving the dressing on the dialysis site could cause pressure on the site and could cause problems with future dialysis treatments. On 10/10/24, a record review was conducted. According to the Minimum Data Set (MDS, an assessment tool), dated 9/3/24, Resident 16's Brief Interview of Mental Status (BIMS) score was 15, indicating intact cognition. According to Resident 16's physician's orders, dated 9/12/24, dialysis treatments were scheduled every Monday, Wednesday and Friday. The physician's orders indicated to remove the dialysis dressing four to six hours after the dialysis treatment, and to inform the physician of any changes to the dialysis access site. According to the Medication Administration Record (MAR), LN 11 documented she had removed the dialysis dressing on 10/9/24, during the P.M. shift (3-11 P.M.). According to the Facility/Dialysis Center Nursing Communication Record, dated 10/9/24 with no time indicated, LN 11 documented the dialysis dressing was in place, had no bleeding, and had no signs or symptoms of infection at the dialysis access site. On 10/10/24 at 11:15 A.M., an interview was conducted with LN 13. LN 13 stated she was assigned to Resident 16 and was familiar with her care. LN 13 stated she had given report to LN 11, regarding Resident 16's dialysis treatment and return to the facility. LN 13 stated it was the responsibility of the P.M. nurse to assess the dialysis site and remove the dressing four to six hours after return from dialysis. LN 13 stated it was necessary to remove the dressing to check for bleeding, and to assess the site for any damage or bleeding. LN 13 stated failing to complete the assessment could cause damage to the dialysis access site. On 10/10/24 at 11:36 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated the nurses needed to assess the dialysis access site upon return from dialysis and when removing the dressing. Per the DON, the expectation was for all nurses to follow the physician's orders to keep the residents safe. On 10/10/24 at 4:37 P.M., an interview was conducted with LN 11. LN 11 stated she had been assigned to Resident 16 the previous day during her P.M. shift of 3-11 P.M. LN 11 stated she had forgotten to remove the dialysis dressing from Resident 16's arm. LN 11 stated she had assessed the site with the dressing on but had not returned to remove the dressing or view the site for signs of infection. LN 11 could not explain why she had documented she completed the dressing removal in the MAR. Per LN 11, failing to remove the dressing could cause infection or compress the dialysis access site. Per a facility policy, revised December 2023 and titled Dialysis (Renal), Pre-and Post-Care, It is the policy of this facility to .Assess and maintain patency of renal dialysis access .Post-Dialysis Care: 1. Dialysis access should be assessed upon return to the facility for .any unusual redness or swelling. 2. Post dialysis .access care as ordered .Documentation: Documentation related to .post-dialysis care will be placed in the clinical record and include .assessment of renal dialysis access site .

Based on observation, interview and record review, the facility failed to provide services for substance use disorder (a disease that affects a person's inability to control the use of a legal or illegal drug or medicine) and nicotine dependency (a state of physical or psychological habit) to one resident, Resident 151. As a result, Resident 151 had the potential to experience cravings. Findings: Resident 151 was admitted to the facility on [DATE] with diagnoses that included psychoactive substance use (an impaired ability to control substance-taking behavior). On 10/7/24 a record review was conducted. The Facility Assessment 2024 indicated the facility could provide services for residents with Mental health: active or current substance use disorder. The skilled nursing referral intake summary form dated 9/18/24 indicated Resident 151 had a current history of substance use disorder and cigarette use. The document indicated Resident 151 was receiving a nicotine patch prior to admission to the facility. The facility history and physical written by Medical Doctor (MD) 1 dated 9/20/24 did not indicate a history of nicotine use or substance use disorder. Resident 151's physician's orders, dated 9/20/24, indicated psychiatry and psychology to evaluate and treat. On 10/8/24 at 3:30 P.M. an interview was conducted with Resident 151 and the Social Services Director (SSD). Resident 151 stated, No one has offered nicotine gum or patches. I can't get the smokes. The SSD stated the resident had used substances prior to admission to the facility. The SSD stated, I didn't offer him any resources for Narcotics Anonymous (a support group for people who are recovering from substance use disorder) while in the facility. There have been no psychology or psychiatry visits. I haven't offered anything since he has been here. I have not had a conversation with him to see if he's having cravings. On 10/9/24 at 3:26 P.M. an interview and concurrent record review were conducted with the Director of Nursing (DON). The DON stated the doctor's history and physical did not include nicotine or substance use. Per the DON, the doctor should have reviewed the hospital paperwork so that the facility could treat his current problems. The DON stated the facility should have asked the patient if he still used substances or smoked and there was no admission smoking assessment for Resident 151. The DON stated the facility had not provided interventions to address nicotine use or substance use disorder. A review of the job description for Social Services Manager, dated 11/30/21 and signed by the SSD indicated, The primary purpose of your job position is to . assure that the medically related emotional and social needs of the resident are met/ maintained on an individual basis .Refer resident/families to appropriate social service agencies when the facility does not provide the services or needs of the resident. A review of the facility policy titled Behavioral Health Services revised 12/2023 indicated, It is the policy of this facility to provide residents with necessary behavioral health care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being .which includes the prevention and treatment of mental and substance use disorders

Based on observation, interview and record review, the facility failed to ensure a medication was given as ordered by the physician for one of 14 sampled residents (Resident 106). This failure had the potential to affect the health and well-being of Resident 106. Findings: Resident 106 was admitted to the facility on [DATE] with diagnoses to include knee replacement surgery, per the facility's Admission Record. On 10/7/24 at 8:53 A.M., a concurrent observation and interview was conducted with Resident 106. Resident 106 was sitting on the bed, with her legs extended out in front of her. Two white patches were located on each side of her left knee. The patches were approximately five inches by four inches in size, and did not have any writing on them. Resident 106 stated the patches were for pain, as she had surgery about two weeks ago. Resident 106 stated she did not have another medication for pain, but the patches worked to control her pain, especially when the nurse first applied them each day. Per Resident 106, the pain patches were from the previous day in the morning, and she had not received new patches yet that day. Resident 106 stated she usually removed the patches each morning when the nurse came in to place new patches on her knee. On 10/9/24 at 10:25 A.M., a concurrent interview and observation of wound care was conducted with Resident 106 and Licensed Nurse (LN) 12. LN 12 removed the bandage on Resident 106's left knee, exposing one pain patch with no date or time written on it. Resident 106 stated the pain patch had been applied the previous day after Physical Therapy, at approximately 10:30 A.M. LN 12 removed the pain patch, and stated the LN from the previous evening shift should have removed the patch. On 10/10/24, a record review was conducted. A physician's order, dated 9/25/24, indicated Resident 106 was to have a Lidocaine External Patch 4% (a pain patch applied to skin) applied to the left leg once a day for pain, with the patch to be applied at 9 A.M., then removed at 9 P.M. Manufacturer's instructions on the Lidocaine patch packaging indicated the patch was to be applied, .up to 12 hours within a 24 hour period . On 10/10/24 at 8:05 A.M., an interview was conducted with LN 12. LN 12 stated the pain patch should have been removed 12 hours after being applied, as the manufacturer recommended. LN 12 stated the pain patch had cardiac (heart) effects, so writing the date and time applied was important, as was removing them as scheduled. LN 12 stated she had removed the patch during wound care on 10/9/24, approximately 12 hours late. On 10/10/24 at 10:55 A.M., an interview was conducted with the Director of Nursing (DON). Per the DON, the Lidocaine patches were to be applied per physician's orders and manufacturer's recommendations. The DON stated LNs were supposed to write the date and time the patches were applied, and not doing so could cause the patient to not receive adequate medication or cause complications to their medical care. On 10/10/24 at 4:30 P.M., an interview was conducted with LN 11. LN 11 stated she had been assigned to Resident 106 several previous shifts, including evenings (approximately 3-11 P.M.) for the last two days. LN 11 stated it was her responsibility to remove the Lidocaine patches during her shift, around 9 P.M. LN 11 stated she must have forgotten to do so. Per LN 11, failing to remove the Lidocaine patches could cause the medication to be less effective. Per an undated facility policy, titled Medication Administration and Storage, It is the policy of this facility to accurately prepare, administer and document medications .2. Review and verify MD orders . Per an undated facility policy, titled Six Rights of Medication Administration, It is the policy of this facility to ensure that the six rights of medication administration are followed in order to ensure safety and accuracy of administration .2. Right Time - Medications are administered within prescribed time frames .

Based on observation, interview and record review, the facility failed to ensure the medication error rate was less than five percent. The facility's mediation error rate was 7.14%. Two medication errors were observed, a total of 28 opportunities, during the medication administration process for two of three randomly observed residents (Residents 1, 31, and 104). As a result, the facility could not ensure medications were correctly administered to all residents. Findings: 1. On 10/9/24 at 8:17 A.M., a concurrent observation of medication administration, record review and interview with Licensed Nurse (LN) 13 was conducted. LN 13 prepared medications for Resident 31. LN 13 mixed Effer-K (a potassium supplement) with five ounces of water. The package instructions indicated to mix the Effer-K with 2-3 ounces of water. When prompted, LN 13 discarded the incorrectly mixed medication and remade the medication. LN 13 stated she should have followed the instructions on the packaging. Per LN 13, mixing the medication with the wrong amount of water could cause the medication to be less effective. On 10/9/24 at 5:12 P.M., a concurrent interview and record review was conducted with LN 13. LN 13 stated different brands of each medication could be in the medication cart, so it was important to follow the manufacturers instructions on the packaging. 2. On 10/9/24 at 8:46 A.M., LN 13 prepared and administered medication for Resident 104. LN 13 counted 10 medications, with a total of 11 capsules and tablets provided to Resident 104. On 10/9/24 at 3 P.M., a record review was conducted. Resident 104 had a physician's order for a multivitamin to be administered at 9 A.M., for a total of 12 tablets which should have been administered. On 10/9/24 at 5:12 P.M., a concurrent interview and record review was conducted with LN 13. LN 13 stated it was important to follow the physician's orders as the resident may need each medication for a medical condition. On 10/10/24 at 10:46 A.M., an interview was conducted with the Director of Nursing (DON). Per the DON, it was the facility's standard to follow the package instructions on all medications. The DON stated not mixing the medication correctly might affect the way the medication worked. The DON also stated the nurses should strictly follow the physician's orders, ensuring all medications were administered. Per an undated facility policy, titled Medication Administration and Storage, It is the policy of this facility to accurately prepare, administer and document medications . Per an undated facility policy, titled Six Rights of Medication Administration, It is the policy of this facility to ensure that the six rights of medication administration are followed in order to ensure safety and accuracy of administration .3. Right Medication .4. Right Dose .

Based on observation, interview and record review, the facility failed to provide residents safety when a resident (Resident 1) eloped from an unsecured exit. As a result, Resident 1 had a successful elopement (leaving the facility unsafely or unescorted), was found on the street by an officer and was returned back to the facility with no injury. This had the potential for residents with cognitive impairment (poor insight) to elope from the facility. In addition, this had the potential for unrestricted and unsafe access to the facility by persons without a need to be on the facility's property. Findings: On 9/07/23 the Department of Public Health received a Facility Report Incident (FRI) of an elopement by Resident 1 on 9/02/23. A review of Resident 1's facility record on 9/02/23 at 5:02 P.M. indicated .found wheelchair outside the facility .that [Resident 1] is not in his room .was nowhere to be found .cops arrived .bystander called the cops that they seen a man walking in his diaper and a gown . On 9/18/23 at 10:40 A.M., a concurrent observation and interview was conducted with the Director of Nursing (DON). Resident 1's room was observed leading outside to the back patio near an unsecured metal-fence type gate. The DON stated this gate was not secured and was used for residents' cigarette smoking breaks. The DON stated Resident 1 used this gate to exit the facility. On 9/18/23 at 10:43 A.M., an interview was conducted with Resident 1. Resident 1 stated when he first got to the facility he attempted to elope. Resident 1 stated he was about four blocks away from the facility and he realized he was just wearing a gown, briefs and socks. Resident 1 stated he asked someone to call for help and then the police arrived to help him and took him back to the facility. Resident 1 stated he used the exit where residents' cigarette smoking breaks occurred. On 9/18/23 at 10:56 A.M. an interview was conducted with LN 1. LN 1 stated staff looked for Resident 1 for about an hour and then staff were informed Resident 1 was escorted back to the facility by the police. 9/18/23 at 11:21 A.M., an interview was conducted with CNA 1. CNA 1 stated during the PM staff shift change, she found an empty wheelchair parked on the sidewalk nearby where the facility's residents' cigarette smoking breaks occurred.

Based on interview and record review, the facility failed to ensure one of two sampled residents ( Resident 1) received the correct medications on discharge. This failure resulted in Resident 1 taking medications which were intended for another resident. Findings: On 5/31/23 an unannounced visit with the facility was conducted . Resident 1 was admitted to the facility on [DATE] with diagnoses which included hip surgery, per the facility's Admission Record. Resident 1 was discharged to home on 4/28/23 ,per the Discharge Summary and Post Discharge Plan of Care. On 5/31/23 at 10 A.M., a joint interview with the Administrator (ADM) and Assistant Director of Nursing ( ADON) was conducted. The ADM stated , on 5/1/23 , Resident 1's wife informed the facility that Resident 1 received incorrect medications upon discharged . The ADM further stated that Resident 1's wife administered the following incorrect medications; Gabapentin 300 mg (control seizures and relieve nerve pain ), Fluoxetine 10 mg ( treat depression) , and Plavix 75 mg (blood thinner medicine to prevent heart attack) to Resident 1 on the morning of 4/29/23 . On 5/31/23 at 10:33 A.M., an interview with LN ( licensed nurse)1 was conducted. LN 1 stated during discharged ,the LN would print the current medications, document the resident medications in the form titled, Continuing of Care medication List . The LN would review the medication list with the actual medications present to the resident or responsible party upon discharge. The resident and two LNs would sign the form. On 5/31/23 at 11: 10 A.M., an interview with the ADM was conducted. The ADM stated , the LN should have followed the procedure when discharging resident. ADM stated LN should have checked the medications against the medication list with the resident and another LN. On 5/31/23 at 11:15 A.M., an interview with the ADON was conducted. The ADON stated , the licensed nurse (LN) would review the resident discharge medication orders and compare the list to the bubble pack medications that would be send out to the residents. The ADON further stated that LNs should follow the procedures to ensure correct medications were send out to residents upon discharged . On 6/20/23 at 6:17 P.M., an interview with LN 2 was conducted. LN 2 stated that she was the LN assigned to Resident 1 on discharged . LN 2 stated that she reviewed the medication list with Resident 1 during the morning medication pass. LN 2 stated that the form was signed without the medications present. She stated that she pulled Resident 1 medications in the medication cart drawer , placed it in the container and gave to Resident 1 and his wife without checking the medication list upon discharge. LN 2 stated that she made a mistake of not following the proper procedure when discharging Resident 1's medications . A review of Resident 1's medication discharge order list , indicated no written order for Gabapentin 300 mg (control seizures and relieve nerve pain ), Fluoxetine 10 mg ( treat depression) , and Plavix 75 mg (blood thinner medicine to prevent heart attack). During a review of the Consultant Pharmacist's Medication Regimen Review , dated 5/4/2023, indicated Resident 1 received the following wrong medications; Gabapentin 300 mg (control seizures and relieve nerve pain ), Fluoxetine 10 mg ( treat depression) , and Plavix 75 mg (blood thinner medicine to prevent heart attack) . Per the agency's policy and procedure titled, Admission, Transfer and Discharge Rights, revised 6/2021, . the discharge process should effectively transition them to post discharge care .3a. Facility staff shall provide preparation .to help ensure safe transition will occur .

Based on observation, interviews and document reviews, the facility failed to ensure recipes were followed and appropriate measuring tools were used during pureed food production for seven residents. As a result, the residents were at risk of not receiving adequate nutrition, which could further compromised their health status. Findings: On 4/12/23 at 11:15 A.M., an observation and document review was conducted with Cook (CK) 1. 1. CK 1 prepared seven servings of pureed brown rice. CK 1 added regular chicken broth into the brown rice in the food processor. A recipe for pureed starch (rice, pasta, potatoes) listed warm milk as the liquid. CK 1 then added food thickener, using a standard household spoon to measure and mix. 2. CK 1 prepared seven servings of pureed vegetables. CK 1 added regular chicken broth into the vegetables in the food processor. A recipe for pureed vegetables listed low sodium broth as the liquid. CK 1 then added food thickener, using a standard household spoon to measure and mix. 3. CK 1 prepared seven servings of pureed chicken. CK 1 added regular chicken broth into the chicken in the food processor. A recipe for pureed meats listed low sodium broth as the liquid. CK 1 then added food thickener, using a standard household spoon to measure and mix. On 4/12/23 at 11:30 A.M., an interview was conducted with the Dietary Services Supervisor (DSS) and CK 1. Per the DSS, the recipes should be followed to ensure the nutritional adequacy of the foods. The DSS stated low sodium chicken broth should have been used as called for in the recipes. CK 1 stated she had measuring tools available, such as scoops and measuring spoons but did not use them to add in the thickener. Per a facility policy, dated 2018 and titled Food Preparation, .1. The facility will use approved recipes .2. Recipes are specific as to portion yield, method of preparation, amounts of ingredients .portion control equipment must be used. A variety of portion control equipment should be available and utilized by employees .

Based on interview and record review, the facility failed to provide a safe discharge for one of two sampled residents (Resident 1), when the facility did not communicate with or properly prepare Resident 1's caregiver for the discharge needs of Resident 1. As a result, Resident 1 was discharged home and did not receive the assistance needed to perform his activities of daily living (routine activities people do, such as feeding, bathing, dressing, and grooming). Resident 1 was found in pain and was taken to the hospital where he was diagnosed with weakness and tachycardia (fast heart rate) related to dehydration (a harmful reduction in the amount of water in the body). Findings: A review of Resident 1's medical record was conducted. Resident 1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1's facesheet also indicated Resident 1 was his own responsible party. A review of Resident 1's Minimum Data Set (MDS -assessment tool), dated 5/4/2020, indicated Resident 1 had a Brief Interview for Mental Status (BIMS - a screening to identify a person's mental status) score of 15 (cognitively intact). Per the same MDS, Resident 1 needed extensive assistance with two-person physical assist for bed mobility and toileting. A review of Resident 1's Activities of Daily Living (ADL) sheet, dated 7/14/2020-7/27/2020 (week before discharge), was conducted. The document indicated on 7/24/20, 7/25/20 and 7/26/20, Resident 1 was not transferred out from the bed. The record also indicated on 7/27/20 (day of discharge), Resident 1 required extensive assistance & two-person physical assist with transfer. A review of Resident 1's Discharge Summary and Post Discharge Plan of Care, dated 7/27/2020 (day of discharge from facility) indicated Resident 1 was non- ambulatory (unable to walk) and required extensive assistance (someone to provide weight bearing support for the resident) when preforming activities of daily living (care such as feeding, bathing, dressing and grooming). The document indicated Resident 1 was discharged on [DATE] and was transported home by family. The document also indicated that home health would follow up with Resident 1. On 10/26/2020 at 3:55 P.M., a telephone interview was conducted with Resident 1's Friend 1 (FR 1). FR 1 stated Friend 2 (FR 2) picked-up Resident 1 by the facility curbside the day the resident was discharged from the facility on 7/27/2020 and brought the resident home to his apartment. FR 1 stated FR 2 asked him (FR 1) to come to the apartment to help transfer Resident 1 to the couch because FR 2 could not transfer the resident alone. FR 1 stated he found Resident 1 the next day in the same position on the couch and he had not moved for over 24 hours. On 11/5/2020 at 1:25 P.M., a telephone interview was conducted with the Resident 1's Friend 1 (FR 1). FR 1 stated when he went to Resident 1's apartment the day after the resident was discharged from the facility, Resident 1 was in a lot of pain, and was physically unable to get up to get himself anything to drink or use the toilet. FR 1 stated Resident 1 had not moved for over 24 hours and could not reach his cell phone to call for assistance. On 11/16/20 at 3:40 P.M., a telephone interview was conducted with Resident 1. Resident 1 stated the facility told him on admission that they could help him walk again after he completed the physical therapy at the facility. Resident 1 stated the facility did not do what they promised because he still could not ambulate when the facility discharged him to his apartment. Resident 1 stated he was independent before he was admitted to the facility. Resident 1 stated he cooked for himself and managed all his self-care needs. Resident 1 stated he never told the facility that his daughter was his full-time caregiver because his daughter was a single parent and took care of her mother fulltime. On 12/11/2020 at 1:15 P.M., a telephone interview was conducted with Resident 1's family member (FM 1). FM 1 stated she was her father's part time care giver prior to him being admitted to the facility. FM 1 stated her role as her father's caregiver before he went to the facility was helping him grocery shop, get him to doctors' appointments and other needs he could not do for himself around the apartment. FM 1 stated before her father was admitted to the facility, he took care of his bathroom needs, used a cane, transferred himself to his wheelchair and cooked for himself. FM 1 stated her father was unable to ambulate or move himself back into his wheelchair from the couch when her brother and FR 1 found Resident 1 in his apartment the day after his discharge from the facility. FM 1 stated she went over to Resident 1's apartment to help transfer the resident. FM 1 stated she attempted to help Resident 1 to bathroom from the couch but could not because Resident 1 required more assistance than she anticipated. FM 1 stated her father was too weak. FM 1 stated she was able to help Resident 1 without difficulty by herself prior to his admission to the facility. FM 1 stated they called an ambulance for her father because he was weak, in a lot of pain and unable to do anything for himself. FM 1 stated no one called her from the facility or homecare agency to discuss Resident 1's discharge needs before or after Resident 1's discharge from the facility on 7/27/2020. A record review was conducted of Resident 1's acute care hospital record titled ED to Hosp-discharge date d 7/29/2020. The record indicated Resident 1's chief complaint on admission to the emergency department via ambulance was weakness and pain. The record indicated that Resident 1 was [CONDITION(S)] (fast heart rate) on arrival due to mild dehydration (reduction of the amount of fluid in the body). The record indicated that Resident 1 could not return home because he was not safe to take care of himself and did not have a caregiver at home full time. The record indicated Resident 1 was admitted to the hospital until placement could be arranged for Resident 1 to be transferred to a skilled facility where he could obtain the level of care, he required post discharge. A record review of the home health agency document titled Communication Log was conducted. The document indicated the following: -07/27: Patient referral was received over the weekend from (name of facility), patient will discharge home today from facility. Received telephone call from (name of facility and social worker name) who let me know patient primary contact. Called patient daughter as requested by facility with no answer received, unable to leave voicemail. Called secondary number who belongs to patient who stated he has a wound on his tailbone and nurses at the facility did not put a patch to cover for the reason he was rushing to leave the facility. Appointment is scheduled for tomorrow in the morning, patient will require in home MSW for IHSS. -07/28: Patient did not answer clinicians phone calls, per RN patient phone line was marked busy all day. Patient was called to reschedule with no answer received, left voicemail. -07/29: Patient was called with no answer received, left voicemail. Called patient daughter with no answer received, unable to leave voicemail. -07/30: Called patient and daughter to reschedule soc with no answer received, unable to leave voicemail. -07/31: Received telephone call from business owner (name of business owner) last night stating patient was taken to hospital because he was not seen On 1/22/2021 at 10:00 A.M., an interview and concurrent document review was conducted with the facility's Case Manager/Social Service (CM/SS). The CM/SS stated she did not typically call a resident's caregiver to coordinate discharge needs if the resident was alert. The CM/SS stated if she felt a resident was not alert or had cognitive issues, she would call the resident's caregiver to discuss the resident's discharge needs. The CM/SS stated, when asked how she decided when to call or not to call a resident's caregiver to coordinate discharge needs, I go by my gut feeling. The CM/SS stated she did all the discharge arrangements herself and the facility's IDT did not complete the task. The CM/SS was asked if she would follow up with a caregiver if the resident needed extensive care and the CM/SS stated, Some occasions I check and some I don't. The CM/SS stated, I probably should call on everyone. The CM/SS stated she should have followed up on everyone to make sure the caregivers were ready and knew the status of the residents' discharge needs. The CM/SS stated she spoke to Resident 1's daughter/caregiver one time when she came to visit the resident at the facility and the daughter confirmed that she was the caregiver for Resident 1. The CM/SS stated she did not attempt to call Resident 1's daughter/caregiver to coordinate the resident's discharge or discuss the discharge needs of Resident 1. The CM/SS stated she should have called Resident 1's daughter/caregiver and that it was a bad judgment on my part. The CM/SS stated she should have checked to see if Resident 1's caregiver could handle his care since Resident 1 was very different from his baseline. The CM/SS reviewed the facility's policy titled Discharge Planning Process, dated 11/2016, and stated, I did not follow d and e. The facility's policy indicated, d. Involve the interdisciplinary team (IDT) in the ongoing process of developing the discharge plan. The IDT shall include; the resident's attending physician, a registered nurse and nurse's aide with responsibility for the resident, a staff member from food and nutrition services, the resident and the resident's representative (to the extent possible). e. Consider caregiver/support person availability and the resident's or caregiver's/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs.

Based on interview and record review, the facility failed to provide the necessary care to prevent the development of pressure injury (localized damage to skin and/or underlying so tissue usually over a bony area) for one of three residents (Resident 1). The licensed nurses (LNs) did not remove Resident 1's medical device and perform skin checks as ordered by the physician. As a result, Resident 1 developed a painful pressure injury and underwent wound surgery. Findings: Resident 1 was admitted to the facility on [DATE] after Open Reduction and Internal Fixation (repair of broken bone) of the right femur fracture (broken upper leg bone) per History and Physical (H&P), dated 2/10/20. A review of Resident 1's Discharge Summary, dated 11/6/2020, indicated the facility discharged Resident 1 to the hospital on [DATE]. A review of Resident 1's Minimum Data Set (MDS-assessment tool), dated 2/8/20, indicated Resident 1's BIMS (Brief Interview for Mental Status - use to evaluate a person's mental status) score was 12 (on a scale of 00 to 15, 12 is moderate impairment). A review of Resident 1's (Braden Scale for Predicting Pressure Sore Risk - a tool used to measure a person's risk for developing pressure ulcer) assessment, dated 2/6/20, indicated Resident 1 was at low risk for developing pressure ulcers. A review of Resident 1's Order Summary Report (admission orders [REDACTED]. A review of Resident 1's Care plan with initiation date of 2/13/20 indicated, Monitor skin integrity to right immobilizer and notify the nurse. A review of Resident 1's Treatment Administration Record (TAR) for February and March 2020 indicated, Keep Knee immobilizer on at all times every shift Check skin integrity. The documentations from 2/8/20 P.M. shift through 3/4/20 A.M. shift indicated the licensed nurses (LNs) checked Resident 1's skin integrity. On 10/27/20 at 12:17 P.M., an interview with LN 3 was conducted. LN 3 stated she was one of the nurses that documented on Resident 1's TAR related to skin integrity checks. LN 3 stated Resident 1's TAR documentation meant that she checked the skin not covered by the knee immobilizer. LN 3 stated she did not check the skin covered by the immobilizer because she did not think she could remove Resident 1's immobilizer. LN 3 stated she did not clarify with the physician the removal of the immobilizer in order to conduct a skin integrity check. LN 3 further stated she should have clarified the order with the physician. On 10/30/20 at 7:30 A.M., a telephone interview with LN 4 was conducted. LN 4 stated he was one of the nurses that documented on Resident 1's TAR related to skin integrity checks. LN 4 stated Resident 1's TAR documentation meant that he only checked the surrounding and exposed skin and did not check the skin covered by the knee immobilizer. LN 4 stated he did not clarify with the physician the removal of the immobilizer to perform skin status check. LN 4 further stated he should have clarified the order with the physician. A review of wound care consultation note, dated 3/5/20, indicated, Resident 1 had a f/u (follow up) with her surgeon and a medical device pressure injury was noted on the RLE (right lower extremity) where her immobilizer was. A review of Resident 1's LN Skin Pressure Ulcer Weekly note, dated 3/5/20, indicated the resident's pressure ulcer on the right lateral calf was unstageable (full thickness tissue loss, base of the wound is covered by slough/eschar (dead tissue)). Per the same note, Resident 1's pressure ulcer had a measurement of 4.5 centimeter (cm) (length) x 3.0 cm (width) x 0.1 cm (depth). A review of Resident 1's IDT (interdisciplinary team) note, dated 3/6/20, indicated orthopedic physician (Specialized in skeleton and associated structures) found wound on the RLE during Resident 1's appointment on 3/5/2020. On 10/27/20 at 11:42 A.M., an interview with the Director of Staff Development (DSD) was conducted. The DSD stated the orthopedic physician found Resident 1's knee immobilizer related pressure injury during the resident's appointment on 3/5/2020. The DSD stated nurses could have taken off the knee immobilizer to check the skin, but nurses misunderstood the knee immobilizer order. On 11/20/20 at 9:58 A.M., a telephone interview with the Orthopedic surgeon was conducted. The surgeon stated the intent of his order was for the nurses to remove the knee immobilizer in order for Resident 1's leg to decompress (remove pressure), and for the nurses to check the resident's skin for reddened areas. The surgeon stated the nurses should have clarified the order, if the order was unclear. A review of Resident 1's LN Skin Pressure Injury Weekly note, dated 3/12/20 and 3/19/20, indicated Resident 1 was experiencing moderate pain related to the resident's right lateral calf wound. A review of Resident 1's Wound Consult note, dated 3/31/20, indicated a chief complaint of right lower extremity wound with Patient (PT) is having increased pain in the wound, which has increasing DTI (Deep tissue injury, pressure related skin injury) surrounding it. A review of Resident 1's Wound Consult note, dated 4/7/20, indicated chief complaint of right lower extremity wound with PT has had increased pain and deterioration (decline) of wound. The note further indicated debridement (procedure for treating a wound in the skin) to level of muscle/tendon performed today under local anesthesia . A review of Resident 1's LN Skin Pressure Injury Weekly note, dated 5/21/20 and 6/25/20, indicated Resident 1 was experiencing pain related to right lateral calf wound. On 12/1/20 at 3:12 P.M., a telephone interview with the wound care physician was conducted. The physician stated removing the knee immobilizer to check the resident's skin was very important. The physician stated any skin breakdown could develop as early as one to two hours. The physician stated Resident 1 verbalized pain on her right leg wound. A review of Resident 1's LN Skin Pressure Injury Weekly note, dated 4/2/20, indicated the right lateral calf pressure ulcer's measurement was 8.3 centimeter (cm) (length) x 6.0 cm (width) x 0.3 cm (depth). A review of Resident 1's LN Skin Pressure Injury Weekly note, dated 6/4/20, indicated the right lateral calf pressure ulcer's measurements was 14 centimeter (cm) (length) x 8.1 cm (width) x 0.2 cm (depth). A review of Resident 1's LN Skin Pressure Injury Weekly note, dated 8/13/20, indicated the right lateral calf pressure ulcer's measurement was 16.5 centimeter (cm) (length) x 7.0 cm (width) x 0.2 cm (depth). A review of Resident 1's Medication reconciliation discharge orders, dated 7/22/20, indicated wound vac (vacuum assisted closure wound therapy to help wounds heal) on the right leg was ordered and applied to Resident 1. A review of Resident 1's Clinical Record (physician progress notes [REDACTED]. The document indicated Resident 1 underwent debridement (cleaning of the wound bed and removing of dead tissue) of the right leg wound and skin graft reconstruction (surgical procedure that involves removing skin from one area of the body and moving it to a different area of the body) on 8/31/2020. On 12/10/20 at 10:05 A.M., a telephone interview with the DSD and the Interim DON (IDON) was conducted. The DSD stated the nurses should have removed Resident 1's knee immobilizer in order to check the skin under the immobilizer. The DSD also stated removing the knee immobilizer, to check the resident's skin, was important to prevent skin breakdown from developing. The IDON agreed with the DSD's statement. A review of the facility's policy and procedure titled Skin Care, dated June 2016, indicated, It is the policy of this facility that: 1. A resident who enters the facility without pressure injury does not develop pressure injury unless the individual's clinical condition or other factors demonstrate that a developed pressure injury was unavoidable . The policy also indicated, . Prevention: In order to prevent the development of skin breakdown or prevent existing pressure injuries from worsening, nursing staff shall implement the following approaches as appropriate and consistent with the resident's care plan: a. Stabilize, reduce or remove any existing any (sic) underlying risks. B. Monitor impact of interventions . The policy indicated, Monitoring: a. Daily via medication administration and treatment administration records. Confirm all orders have been implemented as ordered.