Every finding on record at Autumn Leaves Nursing & Rehab Center, LLC

Based on interview and record review, the facility failed to implement a comprehensive person-centered care plan for 1 (Resident #27) of 40 sampled residents. The facility failed to monitor and document daily meal consumption for Resident #27, who had weight loss, as stated in the current plan of care. Findings: Review of an undated facility policy on 08/19/2025 at 2:14 p.m. titled, Comprehensive Resident Care Plans revealed the following in part.Purpose: The resident's comprehensive care plan will be developed utilizing the results of the comprehensive resident assessment instrument (RAI) plus information gained from resident and family interviews, care conferencing and health care professional data to determine daily care needs, ad to attain, or maintain, the resident's highest functional capacity. Review of Resident #27's medical record revealed an admission date of 10/02/2023, with diagnoses that included in part.Schizoaffective Disorder, Delusional Disorders, Moderate Protein-Calorie Malnutrition, and Generalized Anxiety Disorder. Review of Resident #27's active physician's orders revealed an order for high risk for malnutrition with a start date of 10/27/2023. Review of Resident #27's Annual MDS with an ARD of 07/21/2025 revealed a BIMS score of 14, which indicated intact cognition. Resident #27 was independent with eating and had weight loss of 5% or more in the last month or weight loss of 10% or more in the last 6 months. Review of Resident #27's current plan of care revealed the following in part.Initial Date: 10/30/2023-Focus: Potential for altered nutrition and dehydration related to Schizoaffective Disorder. Consumes less than 50% of meals. Has delusional thoughts of her food being poisoned. Interventions: Monitor percentage % of meal intake and offer alternate if 50% consumed. Review of Resident #27's medical record revealed the following Tasks for the CNAs to monitor/document meal consumption with each daily meal: Meal Intake-Breakfast 7:30 a.m., Meal Intake-Lunch 11:30 a.m., and Meal Intake-Dinner 5:00 p.m. Further review of the daily meal intake tasks from dates 08/01/2025- 08/19/2025 revealed the following: Breakfast: 16 days of no monitoring/documentation, Lunch: 15 days of no monitoring/documentation, and Dinner: 17 days of no monitoring/documentation. In an interview on 08/19/2025 at 4:29 p.m., Resident #27 revealed she did eat her meals, but had a poor appetite, and for today's lunch she ate less than 50% of her meal. Resident #27 stated she has had some weight loss lately. In an interview on 08/20/2025 at 9:47 a.m., S16 LPN revealed she was assigned to Resident #27 today and was familiar with her care. S16 LPN stated Resident #27's appetite varies and had declined due to recent delusional thoughts of people poisoning her food, in which she had a new diagnosis of Schizoaffective Disorder. S16 LPN stated that the CNAs were responsible for charting on all residents' daily meal consumption for each meal. In an interview and record review on 08/20/2025 at 12:34 p.m., S1 DON reviewed the 08/2025 meal intake tasks section for Resident #27 and confirmed the above findings. S1 DON confirmed that on several days in 08/2025 the CNAs did not monitor/document Resident #27's meal consumption as required with each meal, but should have. S1 DON confirmed Resident #27's plan of care was not implemented due to the CNAs failing to document meal consumption daily.

Based on record review, observation and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infection by failing to ensure the resident was placed on contact precautions in a timely manner for 1 (#4) resident out of 2 (#4 and #87) residents investigated for infection control.Findings:A review of the facility's undated infection control precautions (isolation) policy, revealed under the title of Procedure: Placement In Isolation: 1) If there is reason to believe that a resident has a communicable disease, the attending physician or alternate shall be notified immediately of such condition and permission requested to initiate the appropriate isolation precautions.On 08/18/2025 at 8:55 a.m., Resident #4 was out of the facility at the mental health intensive outpatient program until his anticipated return at 3:00 p.m. the same day. There were no transmission-based precautions noted in his electronic health record.On 08/18/2025 at 3:35 p.m., Resident #4 was interviewed after returning to the facility from the mental health day program. Resident #4 was observed to have an intravenous access secured to the inside of his lower right arm.On 08/19/2025 at 8:55 a.m., Resident #4 was observed in his room under contact precautions. S4LPN confirmed Resident #4 is now in isolation and on contact precautions due to the culture results dated 08/13/2025, of his urinalysis collected on 08/11/2025.Review of Resident #4's urine culture collected on 08/11/2025 and reported on 08/13/2025 revealed in part.Urine culture results: E. coli.consistent with a probable ESBL.multi-drug resistant organism.Review of Resident #4's physician orders revealed an order dated 08/18/2025 that read:Contact isolation d/t e. coli/ESBL in urine.On 08/19/2025 at 3:17 p.m., S2 ADON/IP confirmed that Resident #4 should have been placed on contact precautions on 08/13/2025 when the physician ordered an intravenous antibiotic for the resident's urinary tract infection, as identified by the culture results dated 08/13/2025, but was not.

Based on observation, interview and record review the facility failed to:1. Ensure nurse staffing data was displayed daily in a prominent location readily accessible to all residents, staff, and visitors for viewing;2. Ensure nurse staffing data requirements for all shifts were documented on the daily posting; and 3. Ensure nurse staffing data included the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift.This deficient practice had the potential to affect all 101 residents residing in the facility. Findings: Observation on 08/18/2025 at 2:06 p.m. of the facility entrance revealed no display of the nurse staffing posting. 1.Observation on 08/18/2025 at 2:08 p.m. revealed the facility nurse staffing posting was displayed at the end of 1 (Hall W) of 6 (Hall A, Hall B, Hall C, Hall D, Hall E, and Hall W) hallways at 1 (Nurse Station Y) of 2 (Nurse Station Y and Nurse Station Z) nurse's stations. Due to the staffing posting displayed only on Nurse Station Y's desk and at the end of Hall W, this made it difficult for all visitors, residents, and staff to access. 2. & 3.Review of the facility nurse staffing posting from dates 08/04/2025-08/17/2025 revealed no daily documentation of the nursing data for the evening shift (3:00 p.m.- 11:00 p.m.) or night shift (11:00 p.m.-7:00 a.m.) and no documentation of the actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care for all shifts. In an interview and record review on 08/18/2025 at 3:20 p.m., S1 DON revealed she was responsible for overseeing the ward clerk's completion of the nurse staffing forms for the facility. S1 DON confirmed the above findings. S1 DON revealed she was unaware the nurse staffing posting should include all shifts (day, evening and night) and this portion was not completed daily. S1 DON confirmed that the nurse staffing data did not include the actual hours worked for each shift and was unaware of this requirement. S1 DON revealed she was unaware the staffing data should had been posted in an area for all visitors, residents, and staff to access upon entering the facility. S1 DON confirmed the staffing data was only displayed at Nurse Station Y located at the end of Hall W. S1 DON confirmed that due to the current placement of the nurse staffing data, only one half of the facility could easily access the data.

Based on record review and interview, the facility failed to ensure a quarterly assessment was completed timely for 1 (Resident #12) of 2 (Resident #12 and Resident # 97) Residents reviewed for Resident Assessments. The total sample size was 40. Findings:Review of an undated facility policy on 08/19/2025 at 2:14 p.m. titled Resident Assessment Instrument (RAI) read in part. Quarterly review assessments will be completed no less than once every 92 days. Review of Resident #12's medical record revealed an admission date of 12/10/2024. Resident #12 had the following diagnoses that included in part . Idiopathic Gout, Urinary Tract Infection, Repeated Falls, Chronic Pain Syndrome, Dementia, Major Depressive Disorder, and Generalized Anxiety Disorder. Review of Resident #12's MDS assessments revealed a quarterly assessment was completed on 04/30/2025, with no MDS quarterly assessments completed and/or accepted since that time. Interview on 08/19/2025 at 2:50 p.m. with S3MDSLPN revealed a review of Resident #12's MDS assessments. S3MDSLPN confirmed that the last completed and/or accepted quarterly assessment for Resident #12 was on 04/30/2025, and a quarterly assessment had not been completed within 92 days since then, but should have.

Based on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards for 2 (Resident #31 and Resident #48) 2 Residents reviewed for respiratory care. The facility failed to:1. Ensure Resident #31 received oxygen therapy as ordered;2. Provided Resident #48, who required continuous oxygen therapy, with portable oxygen while out of her room.Findings:Review of an undated facility policy on 08/19/2025 at 2:14 p.m. titled “Oxygen Administration (Concentrator or Tank) read in part… If a resident is ambulatory and requires oxygen, portable oxygen tanks should be considered to avoid restricting the resident to his/her room. Resident #31 Review of Resident #31’s medical record revealed an admission date of 02/24/2022. Resident #31 had diagnoses that included in part… Hemiplegia and Hemiparesis following Cerebral Vascular Accident- affecting Left Non Dominant Side, Cough, Shortness of Breath, and Dependence on Supplemental Oxygen. Review of Resident #31’s Significant Change MDS with an ARD of 07/11/2025 revealed Resident #31 had a BIMS score of 04, indicating severe cognitive impairment. Review of Resident #31’s 08/2025 physician orders read in part… Oxygen at 4 Liters per nasal cannula continuously related to diagnosis of Respiratory Failure and Chronic Obstructive Pulmonary Disease. Every Shift. Order date: 07/01/2024 Observation on 08/18/2025 at 9:35 a.m. of Resident #31 revealed her oxygen was set at 2 Liters per nasal cannula. Observation on 08/19/2025 at 9:02 a.m. of Resident #31 revealed she received oxygen therapy and her oxygen was set at 2 Liters per nasal cannula. Observation on 08/19/2025 at 11:40 a.m. of Resident #31 revealed her oxygen continued at 2 Liters per nasal cannula. Observation on 08/19/2025 at 12:24 p.m. of Resident #31 revealed her oxygen continued at 2 Liters per nasal cannula. Observation on 08/20/2025 at 9:25 a.m. of Resident #31 revealed she received oxygen therapy and her oxygen was set at 1.5 Liters per nasal cannula. Interview on 08/20/2025 at 9:35 a.m. with S6LPN revealed Resident #31 was ordered oxygen therapy at 4 Liters per nasal cannula continuously. S6LPN stated Resident #31 did not tolerate being off of oxygen therapy well, and required the oxygen therapy continuously. S6LPN revealed Resident #31 at times removed the oxygen, and would become symptomatic within a few hours, so staff had to closely monitor her to ensure she kept the oxygen on. S6LPN revealed Resident #31 was bedbound and not capable of changing her oxygen settings. S6LPN stated staff was to ensure that the oxygen settings are correct and as ordered for Resident #31 each shift. Observation of Resident #31’s oxygen settings with S6LPN confirmed Resident #31 was set at 1.5 Liters. S6LPN confirmed 1.5 Liters was incorrect and the oxygen setting for Resident #31 should be at 4 Liters as ordered, but was not. Resident #48 Review of Resident #48’s medical record revealed an admit date of 03/29/2013 ….with diagnoses that included in part… …Chronic Obstructive Pulmonary Disease (Acute) Exacerbation, Vascular Dementia, mild, with agitation; Repeated Falls, Dependence on Supplemental Oxygen, Wheezing, Major Depressive Disorder, Recurrent, Severe with Psychotic Symptoms, Other Persistent Atrial Fibrillation, Schizoaffective Disorder, Depressive Type; Shortness of Breath, Other Specified Anxiety Disorders, Chronic Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure, and Non-ST Elevation (NSTEMI) Myocardial Infarction. Review of Resident #48’s Quarterly Minimum Data Set with an Assessment Reference Date of 05/15/2025 revealed a Brief Interview Mental Status of 11, which indicated moderate cognition. Further review of MDS (Minimum Data Set) revealed Resident #48 required supervision or touching assistance with bathing and transfers, and was independent with toileting, bed mobility, and eating. Review of Resident #48’s Care Plan initiated on 07/17/2024 and a review date of 11/24/2025 revealed the resident was care planned for Potential for impaired gas exchange secondary to Chronic Obstructive Pulmonary Disease. Refuses to wear oxygen at times. Interventions included in part… Oxygen at 2 liters per minute per nasal cannula continuous due to shortness of breath related to Chronic Obstructive Pulmonary Disease Change Oxygen tubing/humidifier bottle, clean filter every week when in use Notify MD with increased shortness of breath or change in conditionPortable oxygen 2 liters per nasal cannula on excursions Review of Resident #48’s current physician’s orders revealed: 09/27/2021-Oxygen at 2 liters per minute per nasal cannula. Continuous due to shortness of breath 02/07/2025 - Change oxygen tubing/humidifier bottle, clean filter every week when in use. An observation on 08/19/2025 at 8:55a.m. revealed Resident #48 asleep in bed with continuous Oxygen in progress at 2 liters per minute per nasal cannula. An observation on 08/19/2025 at 10:53a.m. revealed Resident #48 sitting in wheelchair in day room of Hall X without oxygen. Oxygen noted in room on and in progress still at 2 liters per minute with nasal cannula underneath bed covers. In an interview on 08/19/2025 at 2:36p.m., S13LPN confirmed Resident #48 does have an order for continuous oxygen but takes it off at times. S13LPN stated when she visibly sees resident with shortness of breath or anxiousness, she will bring her to her room and put her oxygen on. S13LPN said she didn't know of any reason why she couldn't have portable oxygen. In an interview on 08/19/2025 at 2:47 p.m., S1DON confirmed Resident #48 did have an order for continuous oxygen but takes if off at times. S1DON voiced there was no rule Hall X residents could not have portable oxygen tanks.

Based on observation, record review, and interview the facility failed to ensure a resident's food and drink were palatable, attractive, and at a safe and appetizing temperature for 1 (#70) of 40 sampled residents. The facility failed to ensure Resident #70 received a meal tray which was served at an appropriate, appetizing temperature. Findings:Review of Resident #70's medical record revealed an admit date of 07/12/2024 .with diagnoses that included in part. Restlessness and Agitation, Vascular Dementia, moderate, with Agitation, Pain-Unspecified, Major Depressive Disorder, Recurrent, Severe With Psychotic Symptoms, Other Specified Anxiety Disorders, Other Schizophrenia, and Other Insomnia.Review of Resident #70's Quarterly MDS with an ARD of 07/17/2025 revealed a BIMS was not completed because resident was rarely/never understood. Further review of MDS revealed Resident #70 was dependent on staff assistance with bathing, toileting, eating, and bed mobility, and required substantial/maximal assistance with transfers. Observation of Meal Cart (#X) right outside of kitchen area on 08/19/2025 at 11:53 a.m. revealed 2 disposable lunch trays with meal tickets on each plate on top of cart.Observation on 08/19/2025 at 12:10 p.m. revealed S12 CNA left out of Hall X to go get the lunch meal cart for the Hall X.In an interview on 08/19/2025 at 12:21 p.m., S12 CNA said the Hall X lunch meal cart (#X) was just finished being prepared when she got there to pick it up from the kitchen. She said she had to pass a few trays out to the rooms right outside of Hall X before entering Hall X. Observation of Meal Cart (#X) on hallway right in front of Hall X on 08/19/2025 at 12:22 p.m. revealed 2 disposable lunch trays with meal tickets on each plate remained on top of cart.Observation of Meal Cart (#X) entering into Hall X on 08/19/2025 at 12:24 p.m. revealed 2 disposable lunch trays with meal tickets on each plate remained on top of the cartObservation on 08/19/2025 at 1:07 p. m. revealed Resident #70's lunch meal tray that had been sitting on top of meal cart in a disposable tray was bought into Resident #70's room by a CNA for him to be fed per staff.In an interview on 08/19/2025 at 1:08 p.m., S13 LPN confirmed that Resident #70's lunch meal tray that had been sitting on top of the lunch meal cart (#X) for over an hour was cold, and the staff should have heated it in the microwave before giving it to the resident, but did not.

Number of residents sampled: Number of residents cited: Based on interview and record review, the facility failed to ensure a Certified Nursing Assistant (CNA) received 12 hours of in-service training annually which included Dementia management and abuse prevention trainings for 1 (S11CNA) of 5 (S7CNA, S8CNA, S9CNA, S10CNA and S11CNA) CNAs' personnel files reviewed.Review of the facility assessment with review date of [DATE] revealed in part, Staff training/education and competencies: 3.3. Staff training/education and competencies necessary to provide the level and types of support and care needed for our resident population will be completed on hire and annually. Required in-service training for nurse aides. In-service training must: be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year. Include Dementia management training and resident abuse prevention training.Review of S11 CNA's personnel record revealed a hire date of [DATE] and no documentation that S11 CNA had received and/or completed the required yearly 12 hours of Dementia management training and abuse prevention training since upon hire.Interview on [DATE] at 3:25 p.m., with S5 HR for a review of S11 CNA's trainings revealed all required annual trainings had been expired and had a past due date. S5 HR confirmed that S11 CNA did not complete the required 12 hours of annual trainings to include dementia management and abuse prevention, but should have.

Based on observation and interview, the facility failed to maintain a safe, clean, comfortable and homelike environment for 1 (Resident #251) of 26 sampled residents by failing to ensure the resident and her room was free of odor. Findings: Review of Resident #251's medical record revealed an admitted [DATE] with diagnoses which included in part .Disorientation, Vascular Dementia, Type II Diabetes Mellitus, Major Depressive Disorder and Functional Diarrhea. Review of Resident #251's Quarterly MDS with an ARD of 02/26/2024 revealed she had a BIMS score of 6 (indicating severe cognitive impairment). The MDS revealed Resident #251 required partial/moderate assistance with dressing; supervision or touching assistance with personal hygiene; and independent with toileting. Observation on 05/06/2024 at 9:43 a.m. of Resident #251's room revealed a malodorous scent of onion was detected. Resident #251 was lying in bed, there were no visible signs of being soiled. Resident stated she did not feel well enough to talk at this time. Observation revealed Resident #251's bathroom had dirty clothes in a basket, and her room was filled with clothes thrown on the bed and chair. Upon exiting Resident #251's room the malodorous scent of onion was detected in the hallway. Interview on 05/06/2024 at 9:47 a.m. with S1 DON outside of Resident #251's room revealed the facility was aware of the malodorous scent in Resident #251's room and had discussed it the prior week. S1 DON stated it smelled like onions in Resident #251's room. S1 DON stated the scent may have been dirty clothes in Resident #251's bathroom. Interview on 05/06/2024 at 11:54 a.m. with S11 housekeeper revealed Resident #251's room had a malodorous scent and stated it may have been the dirty clothes in her bathroom. Interview on 05/07/2024 at 10:30 a.m. with S9 CNA revealed she provided care for Resident #251. S9 CNA revealed she had smelled a malodorous scent in Resident #251's room, which smelled like onions. S9 CNA stated Resident #251 hoarded dirty clothes in her room and bathroom. Interview on 05/07/2024 at 11:00 a.m. with S10 CNA revealed she provided care for Resident #251 and had smelled a malodorous scent in resident #251's room which smelled like onions. S10 CNA stated this scent was in Resident #251's room all the time. Interview on 05/08/2024 at 12:15 p.m. with S1 DON revealed Resident #251's room had been discussed in a meeting last week by administrative nurses and department heads due to the her room having a bad odor like onions. S1 DON acknowledged this had been on on-going problem with Resident #251.

Based on observation, record review, and interview the facility failed to ensure that Resident's comprehensive care plan was reviewed and revised by the interdisciplinary team composed of individuals who have knowledge of the Resident's needs for 3 (#21, #49, and #51) of 26 sampled Residents. Findings: Review of the facility's undated policy titled Care Plans: Initial and Comprehensive on 05/07/2024 at 3:43 p.m. revealed in part . A comprehensive care plan will be developed for each resident, according to the OBRA mandated dates. The comprehensive care plan will be revised as often as necessary to provide the information necessary to provide appropriate care and services for the resident. Review/Revise: After a MDS is completed, the Resident's plan of care will be completed or revised, if necessary. The care plan is to be reviewed at least quarterly, and revised as necessary to address the current needs of the resident. Updates: Any change that would require an alteration in the normal, daily care routine of the resident should be added or deleted from the present plan of care when indicated. Resident #49 Review of Resident #49's medical record revealed she was admitted to the facility on [DATE] and had diagnoses that included in part .Retention of urine, Cognitive Communication Deficit, and Vascular Dementia. Review of Resident #49's 05/2024 physician's orders revealed in part . 05/02/2024 Clindamycin Hcl (Antibiotic) 300mg- Administer 1 capsule every 6 hours for 10 days for prophylactic measures. 04/17/2024 Macrobid (Antibiotic) 100mg- Administer 1 capsule one time a day every day prophylactically. Review of Resident #49's current Comprehensive Plan of Care plan revealed no entry for use of Antibiotics. Interview on 05/06/2024 at 11:08 a.m. with Resident #49 revealed she had a history of UTI's and received antibiotics. Resident #49 was observed with a Foley catheter hanging on bedframe within a privacy bag. Interview on 05/07/2024 at 9:04 a.m. with S3 LPN revealed Resident#49 currently did not have a diagnosed UTI, but was recently prescribed antibiotics prophylactically as Resident #49 had chronic UTI's. Interview on 05/07/2024 at 2:29 p.m. with S4 LPN revealed she was the Care Plan Coordinator and was responsible for updating resident's comprehensive plan of care. S4 LPN confirmed Resident #49's care plan was not revised to include the use of antibiotics, but should have been. 39317 Resident #21 Review of the medical record revealed Resident #21 was admitted to the facility on [DATE] with diagnoses including Gastrostomy, GERD, and Vascular Dementia. Review of Resident #21's Physician's orders for the month of May 2024 revealed Continuous Jevity 1.2 at 25 ml per hour. Review of Resident #21's Comprehensive Care Plan with a target date of 07/19/2024 revealed in part .Potential for malnutrition and dehydration related to NPO status, receiving nutrition via peg tube. Goal: to maintain adequate nutritional status. Interventions included Jevity 1.2 at 30 ml/hr. Observation on 05/07/2024 at 1:16 p.m. revealed Resident #21 was resting in bed with the head elevated. She was receiving Jevity 1.2 at 25 ml/hr via pump. Interview on 05/08/2024 at 1:45 p.m. with S2 ADON revealed Resident #21 was previously receiving Jevity 1.2 at 30 ml/hr, but was not tolerating the feeding well. S2 ADON stated the physician changed the order to decrease the amount of Jevity the resident was receiving in March of 2024, from 30ml/hr to 25ml/hr. Interview on 05/08/2024 at 1:44 p.m. with S2 DON confirmed the physician changed the orders for the tube feeding in March of 2024. S2 DON confirmed the care plan should have been updated to reflect the new orders. Resident #51 Interview on 05/08/2024 at 8:40 a.m. with S3 LPN revealed Resident #51 is currently receiving Keflex 500 mg BID for a diagnoses of pneumonia. She stated Resident #51 began receiving the antibiotic on 05/02/2024. Review of Resident #51's Physicians orders dated 05/01/2024 revealed Cefalexin (Keflex) 500 mg BID for diagnosis of bibasilar pneumonia. Review of Resident #51's Comprehensive Care Plan revealed no entry for pneumonia or treatment with Cefalexin. Interview on 05/08/2024 at 2:08 p.m. with S4 LPN revealed she is the Care Plan Coordinator. S4 LPN stated she does not update care plans to reflect new orders for antibiotics, or for the treatment of pneumonia. Interview on 05/08/2024 at 2:16 p.m. with S2 DON confirmed Resident #51's Comprehensive Care Plan should have been updated to reflect the diagnoses of Pneumonia and the treatment with Cefalexin.

Based on observation and interview the facility failed to ensure that each Resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his quality of life for 1 (Resident #59) out of a total sample of 26 Residents by failing to ensure a resident did not wear eyeglasses in disrepair. Findings: Review of Resident #59's medical record revealed an admitted [DATE] with diagnoses which included in part .Type II Diabetes Mellitus, Pain Unspecified, Aphasia, Cognitive Communication Deficit, and Need for Assistance with Personal Care. Review of Resident #59's Quarterly MDS with an ARD of 03/27/2024 revealed he had a BIMS score of 15 (indicating intact cognition). The MDS revealed Resident #59 was independent with: eating, personal hygiene, toileting and dressing; required partial/moderate assistance with bathing. Observation and interview on 05/06/2024 at 9:30 a.m. revealed Resident #59 sitting on the side of his bed with a pair of eyeglasses on, which were crooked on his face. The left template of the eyeglasses were made of elastic. Resident #59 revealed the handle (template) of the eyeglasses were gone but he had made a handle by using the elastic off of face masks; which he had tied together to make a handle. Observation on 05/07/2024 at 11:03 a.m. revealed Resident #59 ambulating in the hallway from playing Bingo. Resident #59's eyeglasses observed in his shirt pocket. Resident #59 revealed no one had asked him if he wanted new eyeglasses, and stated if he could get a new pair that would be great. Observation and interview on 05/07/2024 at 11:10 a.m. of Resident #59 with S8 Social Service Director in attendance revealed Resident #59 wore eyeglasses. Observation at this time revealed Resident #59's left eyeglasses temple were missing. Resident #59 revealed he had made a left template out of elastic strings of face masks; and tied them together to hold his eyeglasses in place. S8 Social Service Director confirmed Resident #59's eyeglasses were in disrepair and he should not have been wearing them.

Based on record review and interview the facility failed to ensure residents' drug regimens were free from unnecessary psychotropic medications for 3 (#71, #85, & #87) of 5 (#17, #71, #78, #85, & #87) residents reviewed for unnecessary medications. The facility failed to ensure: 1. A PRN order for a psychotropic drug was limited to 14 days for Resident #71. 2. A psychotropic medication was used only when there was an acceptable diagnosis documented in the clinical record for Residents #85 and #87. Findings: Review of the facility's undated policy titled Drug Regimen Review on 05/07/2024 at 3:43 p.m. revealed in part . Drug Regimen Review consists of a review and analysis of prescribed medication therapy and medication use review, using the Federal indicators. The Consultant Pharmacist reviews the medication regimen of each resident at least monthly. Findings and recommendations are reported to the Administrator, Director or Nursing, and the responsible physician. Procedure: The Consultant Pharmacist documents potential or actual medication therapy problems and communicates them to the responsible physician and the Director of Nursing. The Consultant Pharmacist drug regimen review is processed as follows: Drug Regimen Review recommendations to physician: 1.The notification/letter is provided by the Consultant Pharmacist and sent by facility to the responsible physician. 2. The notification/letter is filed in the residents' medical record for the responsible physician's review on his next visit to the facility if the irregularity/recommendation is not of a life-threatening nature. 3. The physician is asked to provide a written response to the irregularity/ recommendation. 4. A copy of the notification/ letter is kept in the facility until the physician's signed response is returned. 5. The DON or her designee takes action on the physician's signed response prior to being filed in the residents' medical record. Resident #71 Review of Resident #71's Medical Record revealed an admitted [DATE] with diagnoses that included in part .Neurocognitive Disorder with Lewy Bodies, Unspecified Dementia without Behavioral Disturbance, Aphasia, Cognitive Communication Deficit, Major Depressive Disorder, and Generalized Anxiety Disorder. Review of Resident #71's care plan with a start date of 03/28/2024 and a review date of 07/12/2024 revealed she had potential for adverse effects due to use of psychotropic medications. The care plan revealed Resident #71 Takes Lorazepam (Ativan) for Anxiety Disorder Interventions included administer medication as ordered and drug regimen review monthly and as needed. Review of Resident #71's current physician's orders revealed the following order: 04/16/2024: Ativan 2mg tablet- Administer 1 tablet orally as needed every 8 hours as needed for restlessness/agitation. Review of Resident #71's 04/2024 and 05/2024 EMARs revealed Resident #71 received Ativan 2mg tablet as needed on 04/18/2024, 05/04/2024, and 05/06/2024. Review of the Psychoactive Gradual Dose Reduction letter sent to Resident #71's physician by the pharmacist on 04/01/2024 revealed the pharmacist asked the physician to evaluate the resident prior to extending the order for psychotropic medication as PRN is limited to 14 days. The physician responded on 04/11/2024 to continue the current use of the listed medications with his rationale as In locked memory unit. No reduction. It was signed by S1 DON, also. Interview on 05/07/2024 at 2:17 p.m. with S5 LPN revealed psychotropic PRN's are ordered for 14 days unless the physician wants to order the medication for 30days with a valid reason. S5 LPN stated she was unsure why Ativan 2mg tablet- Administer 1 tablet orally as needed every 8 hours as needed for restlessness/agitation was ordered for longer than 14 days for Resident #71. Interview on 05/07/2024 at 2:25 p.m. with S1 DON revealed a review Resident #71's GDR dated 04/01/2024. S1 DON confirmed the PRN order for Ativan should have been discontinued after 14days, or the physician should have assessed Resident #71 and provided a rationale to continue the use, but had failed to do so. 38373 Resident #85 Review of Resident #85's medical record revealed an admitted [DATE] with diagnoses that included in part .Pneumonia, Cerebral Infarction, Aphasia, Type 2 Diabetes Mellitus, Dysphagia, Vascular Dementia, Major Depressive Disorder, and Shortness of Breath. Review of Resident #85's current physician's orders revealed the following order: 11/22/2023: Risperidone (Risperdal-an antipsychotic medication) 0.25 mg tablet-administer 1 tablet oral one time a day every day. Review of Resident #85's April 2024 and May 2024 MARs revealed Resident #85 received Risperidone 0.25 mg tablet by mouth every day with the diagnosis listed as Vascular Dementia. Review of Resident #85's care plan with a start date of 11/22/2023 and a review date of 07/25/2024 revealed the resident was care planned for potential for adverse effects due to use of psychotropic medications. The care plan revealed Resident #85 takes Lexapro for Depression and Risperidone for diagnosis of Dementia. Interventions included administer medication as ordered and drug regimen review monthly and as needed. Review of the Psychoactive Gradual Dose Reduction letter sent to Resident #85's physician by the pharmacist on 02/23/2024 revealed the pharmacist asked the physician to consider a GDR of Risperdal 0.25mg every day and to Please evaluate the use of Risperdal for the treatment of dementia as this is considered inappropriate according to the CMS interpretive guidelines. Please consider an alternative therapy. The physician responded on 04/29/2024 to continue the current use of the medication with his rationale as Hospice patient, well controlled on current regimen. It was signed by S1 DON, also. In an interview on 05/07/2024 at 3:20 p.m., S1 DON and S2 ADON acknowledged Resident #85 was prescribed Risperdal for Dementia and did not have an appropriate diagnosis for an antipsychotic medication documented in Resident #85's medical record. In an interview on 05/08/2024 at 9:23 a.m., S1 DON acknowledged she reviewed the GDR letter after the doctor completed it and did not follow up with the doctor when he did not follow the recommendations of the pharmacist for an alternative therapy for Risperdal. S2 DON stated she usually just goes along with whatever orders the doctor documents on the form. Resident #87 Review of Resident #87's medical record revealed an admitted [DATE] with diagnoses that included in part .Vitamin Deficiency, Hypothyroidism, Hyperlipidemia, Vascular Dementia, unspecified severity, with Agitation, Osteoarthritis, Repeated Falls, CKD, Alzheimer's disease with late onset, and Malignant Neoplasm of Prostate. Review of Resident #87's current physician's orders revealed the following: 12/14/2023: Seroquel (an antipsychotic medication) 50mg po daily at bedtime 11/29/2023: Abilify (an antipsychotic medication) 10mg po every day at bedtime 10/04/2023: Cymbalta (an antidepressant medication) 30mg po daily at bedtime Review of Resident #87's current care plan revealed the resident was care planned for the potential for adverse effects due to the use of psychotropic medication; Takes Abilify, Seroquel, and Cymbalta for diagnosis of Dementia with behaviors. Interventions listed included administer medications as ordered and drug regimen review monthly and prn. Review of April and May 2024 MARs for Resident #87 revealed the resident received Cymbalta for the diagnosis of Myalgia and received Seroquel and Abilify for the diagnosis of Vascular Dementia. Review of the Psychoactive Gradual Dose Reduction letter sent to Resident #87's physician by the pharmacist on 02/23/2024 revealed the pharmacist asked the physician to consider a gradual dose reduction of Abilify 10 mg po daily at bedtime, Seroquel 50 mg po daily at bedtime, and Cymbalta 30 mg po daily at bedtime. The pharmacist also requested the physician to please evaluate the use of Seroquel and Abilify for the treatment of Dementia as this is considered inappropriate according to the CMS interpretive guidelines. Please consider an alternative therapy. Resident #87's physician responded a dose reduction was not appropriate and to continue current use of above stated medication. The physician's rationale for continuance was documented as Hospice patient easily agitated-meds are effective. The form was signed by S1 DON and Resident #87's physician on 04/29/2024. In an interview on 05/07/2024 at 3:21 p.m., S2 ADON and S1 DON [NAME] acknowledged there were no appropriate diagnoses documented in Resident #87's medical record for the use of antipsychotics and Abilify and Seroquel were prescribed for the diagnoses of Dementia. In an interview on 05/08/2024 at 9:23 a.m., S1 DON who confirmed she does receive the pharmacist's GDR letter back for review after the physician signs it. S1 DON stated she did not follow up with the physician when he didn't consider an alternative therapy for the antipsychotic medications, as recommended by the pharmacist. S1 DON stated she usually just goes along with whatever the doctor documents on the form.

Based on observation, interview, and record review the facility failed to meet the nutritional needs of residents in accordance with established national guidelines. The facility failed to follow the menu in regard to portion size to ensure nutritional adequacy of the meal for 9 residents that received mechanically altered diets prepared by the facility kitchen. Findings: Review of the facility's policy titled: Preparation and Service of Pureed Diets read in part Procedure: 8. Pureed foods should be served with correct utensils. Serving sizes will depend upon the recipe used and are indicated on menu modifications when different from the regular portion. Review of the facility's approved 2023 Fall/Winter Menu revised on 10/2018 revealed on 05/06/2024 the facility was on week 2, day 2. Pureed lunch menu, in part, consisted of: Pureed Red beans and sausage 3/4 cup, pureed rice 1/2 cup, pureed mixed green 1/3 cup, pureed cornbread 1/4 cup, pureed bread pudding 1/2 cup, beverage of choice and water. Observation on 05/06/2024 at 11:45 a.m. revealed S7 Dietary Aide serving a pureed lunch tray with 4 oz scoop of rice, 4 oz scoop of greens and 4 oz scoop of pureed meat and beans. S7 Dietary Aide revealed she does not typically serve food and had not been trained on portion sizes. Interview on 05/06/2024 11:50 a.m. with S6 Dietary manager revealed the correct serving size for pureed beans and meat is 3/4 cup and the tray was only served 1/2 cup . S6 Dietary Manager stated she typically ensured the proper size scoops were being used but had not checked them prior to serving food today. S6 Dietary Manager confirmed residents being served mechanically altered diets were not given the proper portion sizes because the wrong scoop size was used and should not have been.

Based on record review and interview, the facility failed to implement a comprehensive person-centered care plan for 1 (#36) of 27 sampled Residents. The facility failed to obtain bloodwork as ordered by the Physician for Resident #36 in a timely manner. The total facility census was 98 residents. Findings: Resident #36 Review of Resident #36's medical record revealed diagnoses that included Chronic Kidney Disease, Stage IV, Osteomyelitis, Stage IV Sacral Pressure Ulcer, and Unspecified Protein-Calorie Malnutrition. Review of the MDS dated [DATE] revealed Resident #36 had a BIMS score of 12, which indicated moderately impaired cognition, and required extensive assistance by two persons with bed mobility and toilet use. Review of Resident #36's medical record revealed the following Physician's orders: 04/05/2023-Start Normal Saline at 60ml per hour x 2 liters 04/05/2023-Repeat BMP, Mg (magnesium level) after fluids complete Review of Resident #36's medical record revealed no laboratory results since 04/03/2023. In an interview on 04/12/2023 at 11:46 a.m., S1 DON confirmed the lab ordered by the Physician to be drawn after completion of IV fluids had not been drawn and acknowledged it should have been.

Based on observations, interviews and record review, the Facility failed to ensure that Residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The Facility failed to provide clean trimmed fingernails to dependent Residents for 1 (#300) of 1 Residents sampled for ADL's. Findings: Review of the Facility policy titled: Nail Management, revealed in part .Nail management is the regular care of the fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails. It includes cleansing, trimming, smoothing and cuticle care and is usually done during the bath. Residents with either Diabetes Mellitus will have nail care performed by a nurse or podiatrist. Review of Resident #300's clinical record reveal an admitted [DATE] with diagnoses which included: Other Reduced Mobility, Need for assistance with personal care, Age-related physical debility, Chronic Kidney Disease Stage 5, Dementia, Diabetes Mellitus, Cognitive Communication Deficit and Dependence on Renal Dialysis. Review of Resident #300's AM5 MDS with and ARD of 03/28/2023 revealed Resident #300 had a BIMS score of 99 (Resident was unable to complete the interview), required one person physical assist for bathing and one person extensive assist for personal hygiene. Review of Resident #300's care plan with an onset date of 03/22/2023 revealed a self-care ADL deficit: Resident will receive person-centered care; needs assist with bathing, hygiene, dressing and grooming related to Spondylosis, Glaucoma, Arteriosclerotic Heart Disease. Interventions included: Assist with hygiene, dressing and grooming x 1 staff; Fingernails cleaned and trimmed as needed. Observation and interview on 04/10/2023 at 10:36 a.m. revealed Resident #300 lying in bed with his clothes on, alert and verbal. Resident #300's fingernails noted to be approximately 1 and a half inches long and dirty with black debris underneath them. Resident #300 stated he would like for his fingernails to be cleaned /trimmed and was going to ask for some clippers. Interview on 04/11/2023 at 8:40 a.m. with S3 LPN revealed Resident #300 was out of the facility at dialysis. Observation and interview on 04/11/2023 at 1:53 p.m. revealed Resident #300 in bed, awake and alert. Resident #300 stated he had went to dialysis early that morning. Observation of Resident #300's fingernails revealed them to be approximately 1 and a half inches long and dirty with black debris underneath them. Resident #300 revealed he would have preferred to have his nails cleaned and trimmed before he went to dialysis earlier that morning. Observation and interview on 04/11/2023 at 2:00 p.m. of Resident #300 with S3 LPN in attendance revealed Resident #300 in bed with fingernails approximately 1 and a half inches long and dirty with black debris underneath them. S3 LPN confirmed Resident #300's fingernails were long and dirty and needed to be cleaned and trimmed. Interview on 04/12/2023 at 9:10 a.m. with S1 DON confirmed Resident #300 was a Diabetic and his fingernails should have been trimmed by a nurse.

Based on observation, record review, and interview, the facility failed to ensure a Resident with pressure ulcers received the necessary treatment and services to promote healing for 1 (#36) of 3 (#36, #54, #77) Residents reviewed for pressure ulcers. The facility failed to provide the supplements to promote wound healing as ordered by the Physician for Resident #36. Findings: Resident #36 Review of Resident #36's medical record revealed diagnoses that included Chronic Kidney Disease, Stage IV, Osteomyelitis, Stage IV Sacral Pressure Ulcer, Unstageable Pressure Ulcer to Right Heel, Stasis Ulcers to Left Leg, and Unspecified Protein-Calorie Malnutrition. Review of the MDS dated [DATE] revealed Resident #36 had a BIMS score of 12, which indicated moderately impaired cognition, and required extensive assistance by two persons with bed mobility and toilet use. Review of Resident #36's Physician's orders revealed the following: 02/20/2023-Vitamin C 500 mg tablet oral two times a day every day (discontinued 03/21/2023) 02/20/2023-Multivitamin tablet oral one time a day every day (discontinued on 03/21/2023) 02/20/2023-Zinc amino acid chelate 50mg tablet oral one time a day every day (discontinued 03/21/2023) Observation of wound care on 04/11/2023 at 9:35 a.m. revealed Resident #36 had a large Stage IV pressure ulcer to the sacrum area, an unstageable pressure ulcer to his right heel, and two stasis ulcers to the left lower leg. Review of Resident #36's April 2023 Medication Administration Record revealed the Resident had not received any doses of Zinc, Vitamin C, or a Multivitamin. Review of the progress notes by the NP dated 03/22/2023 revealed the following Plan: Decubitus ulcer of sacral region, stage 4: continue vitamin C 500mg daily, continue Zinc 50mg daily, continue multivitamin 1 tablet daily. Review of the progress note by the facility NP dated 03/29/2023 revealed the following Plan: Decubitus ulcer of sacral region, Stage 4: Continue vitamin C 500mg daily continue zinc 50mg daily continue multivitamin 1 tablet daily In an interview on 04/12/2023 at 11:46 a.m., S1 DON acknowledged Resident #36 had not been receiving zinc, vitamin C, and a multivitamin daily. S1 DON acknowledged the orders were not reinstated after the Resident returned from a hospital stay and should have been.

Based on interview and record review the facility failed to ensure nutritionally compromised residents received a comprehensive nutritional assessment by the Registered Dietician to identify possible interventions to prevent continued weight loss for 2 (#36 and #60 ) of 2 residents sampled for nutrition in a total sample of 27 residents. Findings: Review of the facility Nutrition/Hydration Management Policy revealed in part . 2. New Admissions/Hospital Re-Admissions: C. All new admits or hospital re-admits will be added to the referral form for the RD consultant to assess at the next scheduled visit to the facility. Review of Resident #60's face sheet revealed she was admitted to the facility on [DATE]. She had diagnoses including Hemiplegia, Cognitive Communication Deficit, Hypertension, Protein Calorie Malnutrition, and Stage 4 Chronic Kidney Disease. Review of the Physicians orders revealed: House Supplement twice a day. Renal diet, no potatoes, tomatoes, oranges, or orange juice. Document percentage of intake. Review of the care plan revealed: Potential for malnutrition and dehydration related to history of hypertension, cerebrovascular accident. Goal: Will maintain adequate nutrition as evidenced by a stable weight. Interventions included: Refer to RD for assessment yearly and when needed. Review of Resident #60's weights revealed: 10/11/2022 - 202.9 10/17/2022 - 199.6 10/25/2022 - 201.3 11/02/2022 - 193.5 12/09/2022 - 191.3 01/04/2023 - 188.3 02/06/2023 - 186.5 03/13/2023 - 177.4 03/21/2023 - 175.9 03/28/2023 - 172.4 04/11/2023 - 171.8 Interview on 04/12/2023 at 8:20 a.m. with S1 DON revealed Resident #60 has lost 31 pounds in 6 months. S1 DON stated Resident #60 was transferred to the hospital on 03/03/2023. S1 DON stated Resident #60 was diagnosed with Acute Kidney Injury and Stage 3-4 Kidney Disease. S1 DON stated Resident #60 returned to the facility on [DATE] and had a new order for a renal diet. S1 DON stated the Resident #60 was not placed on the referral list given to the RD to be assessed during her rounds at the facility on 03/15/2023 and should have been. 38373 Review of Resident #36's medical record revealed diagnoses that included Chronic Kidney Disease, Stage IV, Osteomyelitis, Stage IV Sacral Pressure Ulcer, Unstageable Pressure Ulcer to Right Heel, Stasis Ulcers to Left Leg, Deaf, and Unspecified Protein-Calorie Malnutrition. Review of the MDS dated [DATE] revealed Resident #36 had a BIMS score of 12, which indicated moderately impaired cognition, and required extensive assistance by two persons with bed mobility and toilet use. Review of Resident #36's medical record revealed a significant weight loss of 16.79% over 6 months. Review of the weights revealed the following: 03/21/2023-170.4 lbs 03/28/2023--178.5 lbs 02/28/2023-179.4 lbs 12/19/2022-188.9 lbs 10/04/2022-204.8 lbs Review of the nurses' notes revealed an entry dated 02/27/2023 at 2:14 p.m. by the Dietary Manager that read: Resident receives a double meat or eggs, ice cream and apple sauce. Resident has no chewing/swallowing problem noted. Receives meals in room, he feeds self no food allergies known no food complaints since he came back from hospital, he eats less than 25% of meals, will refer to RD next visit and put on weekly weights; Height 63 inches and IBW 124, weight 186.6 on 2/20/23. By S4 Dietary Manager Review of Resident #36's current Physician's orders revealed the following order: 03/21/2023-Diet-Pureed with thickened liquids In an interview on 04/11/2023 at 12:20 p.m. S5 LPN confirmed she makes the referrals to the Registered Dietician based on weight loss. S5 LPN stated she refers everyone to RD with weight loss of greater than 5% in a month or 10% in 90 days. S5 LPN stated Resident #36 had not been referred because his weight loss was over a greater length of time than 90 days. S5 LPN stated Resident #36 was in the hospital on the days the RD was in the building. S5 LPN acknowledged Resident #36 was in the facility from 02/20/2023 until 03/09/2023 and from 03/21/2023 until the present date. S5 LPN acknowledged the RD could complete assessments remotely, also. Review of RD note dated 04/11/2023 by S6 RD revealed the following: Pt's nutrition provided with the regular diet with double meat or eggs. Potential for this diet is 2000 calories and 80 gram protein. This can satisfy patient's caloric nutritional requirement of 1650-1850 calories and 66-76 grams protein. Hydration can be met with 1925-2125 cc fluid sourced with diet and water pitcher in room. No chew/swal (chewing/swallowing) issues reported. Weight is 170# reflecting SWL that totals 16% over 6 months. IBW for height is 124#. Pt is 137% of the weight goal. BMI is 30 confirming wt well above DBW goal. Hx for independent feeding. WDS: unstageable area to the right heel, [NAME] to sacrum, venous ulcers to left lateral shin, improved and left calf, deteriorated in status. Communication with the written word related to deaf status. Continue the current diet effort and promote good response. Monitor weight and wound status. by S6 RD. During a telephone interview on 04/12/2023 at 10:30 a.m., S6 RD confirmed the Nursing Facility contacted her yesterday and she completed a RD assessment remotely. S6 RD stated she does assessments based on a list provided to her by the facility of resident who have triggered for a weight loss 5% in 30 days or 10% in 90 days. S6 RD stated she doesn't generally see everyone who returns from a hospital stay unless they have a diet change. S6 RD confirmed she was unaware Resident #36 was on a pureed diet and wasn't aware of any chewing or swallowing issues. S6 RD confirmed she did not make any recommendations for Resident #36 but would reevaluate the resident next week. In an interview on 04/12/2023 at 11:46 a.m. S1 DON acknowledged Resident #36 had significant weight loss, was not eating well, and had not been referred to the RD since 12/2022.

Based on observation, interview, and record review the Facility failed to provide respiratory care consistent with professional standards for 1(#43) of 2 (#43 and #67) Residents reviewed for respiratory care. The Facility failed to ensure respiratory equipment was properly labeled, and stored. Findings: Review of the Facility's Oxygen Administration (Concentrator or Tank) policy read in part . Humidifier bottles, cannulas and O2 tubing will be changed at least once weekly and dated. Concentrator filter should be cleaned weekly or as needed as well. When not in use, Cannula or mask should be placed in a plastic bag. Observation of Resident #43's room on 04/10/2023 at 9:30 a.m. revealed a nasal cannula draped over an oxygen concentrator at the end of Resident #43's bedside, open to air and undated. Observation of Resident #43's room on 04/11/2023 at 8:58 a.m. revealed the oxygen concentrator at the end of Resident #43's bed with nasal cannula attached and draped over the concentrator. The nasal cannula tubing was undated and open to air. Observation and interview with S2 LPN on 01/05/2022 at 2:40 p.m. revealed Resident #43's nasal cannula was draped over the oxygen concentrator undated and open to air. S3 LPN confirmed that the nasal cannula should have been stored in a plastic bag and dated and it was not.

Based on interview and record review the facility failed to develop and implement written standards, policies and procedures for a water management program, to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in the facility's water systems. This deficient practice had the potential to affect all residents who reside in the facility. The total resident census was 81. Findings: Review of a Boil Advisory Declaration Form for the municipality in which the facility is located, revealed a water main break occurred on 08/13/2022, and a Boil Advisory was issued for the area on 08/14/2022. The time of the water main that occurred on 08/13/2022 was not documented on the form. Interview with S2 TNA on 09/28/2022 at 1:40 p.m. revealed she worked on 8/13/2022 and 8/14/2022 when the last boil advisory was issued. S2 TNA stated she did know there was a boil advisory until the water at the facility was shut off. S2 TNA stated boil advisories for the city were usually discovered through social media. S2 TNA revealed the facility uses only bottled water when there were boil advisories; however, S2 TNA stated she had not received any training on a facility water management plan. Interview with S3 CNA on 09/28/2022 at 1:53 p.m. revealed she usually hears of a boil advisory on the radio, or when she is unable to get a fountain drink in town, because there is no ice. S3 CNA stated she reports any issues with water pressure at the facility to the Housekeeping Supervisor, and notifies the nurses. S3 CNA stated the facility uses only bottled water when there were boil advisories; however, S3 TNA stated she had not received any training on a facility water management plan. Interview with S4 Housekeeper on 09/28/2022 at 1:58 p.m. revealed when a boil advisory has been issued, as housekeeping staff, her duties are to watch residents and remind them not to drink water from the lavatory. S4 Housekeeper stated they are notified of boil advisories by the facility intercom system. S4 Housekeeper stated she had not received any training on a facility water management plan. Interview with S5 Dietary on 09/28/2022 at 2:40 p.m. revealed when a boil advisory has been issued, the facility announces it overhead and usually the water will be completely shut off. She stated they start using bottled water contained in jugs, and water is boiled to wash dishes or cook with. S5 Dietary stated she had not received any training on a facility water management plan. Interview with S6 Maintenance Supervisor on 09/26/2022 at 11:15 a.m. revealed the facility did not have a Water Management Program, and did not have any policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in the facility's water systems. Interview with S1 DON on 09/26/2022 at 1:45 p.m. revealed that a boil advisory had been put in place on 08/14/2022, for entities within the parish's city municipal water district. S1 DON revealed that staff and residents were informed of the boil advisory on 08/14/2022, and residents were given bottled water to drink and use for oral care. S1 DON revealed the facility did not have a water management program and/or policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogen the building water systems, and are currently establishing those policies and procedures.

Based on observation, record review and interview the facility failed to ensure their policy and procedures included a process for ensuring the implementation of additional precautions intended to mitigate the transmission and spread of COVID-19, for all staff who were not fully vaccinated for COVID-19. The facility failed to ensure unvaccinated employees wore an approved N95 mask or equivalent, or higher-level respirator for source control while in the facility. Findings: Review of the facility's COVID-19 Vaccine Policy and Procedures for Staff with last update date of 02/10/2022 revealed in part Staff who receive an exemption to the COVID-19 vaccine will be subject to additional precautions to migrate the transmission and spread of COVID-19, which include the following: 3. The staff member will wear a facemask at all times. The type of face mask worn will be determined by the facility's current COVID-19 status. 1. Review of the vaccination roster dated 04/04/2022 revealed that S4 LPN had a qualifying exemption. Interview with S4 LPN on 04/11/2022 at 8:15 a.m. revealed she had a qualifying exemption and had not received the COVID-19 vaccinations. She further revealed that she was not required to wear a N95 mask unless there were positive COVID-19 cases in the facility. 2. Review of the vaccination roster dated 04/04/2022 revealed that S5 facility staff had a qualifying exemption. Observation on 04/11/2022 at 8:25 a.m. revealed S5 facility staff was sitting at the front desk checking in and screening visitors. S5 facility staff was wearing a surgical mask face covering. Interview with S5 facility staff on 04/11/2022 at 8:26 a.m. revealed she had a qualifying exemption and had not received the COVID-19 vaccinations. She further revealed that she was not required to wear a N95 mask unless there were positive COVID-19 cases in the facility. 3. Review of the vaccination roster dated 04/04/2022 revealed that S6 CNA had a qualifying exemption. Observation on 04/11/2022 at 8:40 a.m. revealed S6 CNA was on the hall going in and out of rooms removing breakfast trays from residents' rooms. S6 CNA was wearing a surgical mask face covering. Interview with S6 CNA on 04/11/2022 at 8:40 a.m. revealed she had a qualifying exemption and had not received the COVID-19 vaccinations. She further revealed that she was not required to wear a N95 mask unless there were positive COVID-19 cases in the facility. 4. Review of the vaccination roster dated 04/04/2022 revealed that S7 therapy and S8 CNA had a qualifying exemption. Interview with S3 LPN on 04/11/2022 at 1:30 p.m. confirmed S7 therapy and S8 CNA were working and were wearing surgical masks, not N95 mask. S3 LPN revealed that she gave S7 therapy and S8 CNA a N95 mask and instructed them that they were required to wear it while in the facility. Further interview with S3 LPN revealed she was not aware that exempt staff were to wear a N95 mask, or equivalent face covering if there was no outbreak in the facility. S3 LPN revealed the parish was currently in the blue (low) rate according to the parish positivity rate, and the facility had no COVID positive resident's in the building.

Based on record review and interview, the facility failed to immediately notify a resident's representative for 1 (#51) of 27 sampled residents when there was a significant change in the resident's psychosocial status which required a transfer to an inpatient psychiatric facility. Findings: Review of a significant change MDS assessment for Resident #51 dated 03/01/2022 revealed he had a BIMS score of 8 which indicated Moderately impaired cognitive skills. Interview with resident #51 on 04/11/2022 at 11:00 a.m. revealed he thought he went to the doctor on Monday to check his ear. When asked if he had been in the hospital recently, he could not remember. He stated all the staff treated him well, and he got along with all of the staff. He had no complaints. Review of a Progress Note dated 03/17/2022 revealed S9 LPN documented: at approximately 9:45 a.m., she was preparing to administer medications per the resident's PEG tube. She spoke to the resident, and he spoke back. As she was checking to see if the tube was in place, the resident punched her in the forehead and left a knot. The resident was very combative at that time. S2 DON was notified. Review of a Progress Note dated 03/18/2022 at 10 a.m. revealed S2 DON documented a late entry. She documented S9 LPN reported to her, on 03/17/2022, that she was hit in the forehead by Resident #51 while she was attempting to administer his medications via PEG tube. The resident's physician and the Social Worker were notified in an attempt to have the resident transferred to a behavior facility for evaluation. Further review of a Progress Note dated 03/17/2022 at 2:00 p.m. revealed the facility received a call from the behavior facility instructing them to transport the resident to the ER and they would admit the resident from the ER into the behavior facility. Documentation revealed he was prepared and transported via the facility van to the ER. His vital signs were not obtained prior to transport due to his combative behaviors. review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Progress Notes dated 03/17/2022 and 03/18/2022 revealed there was no documentation the resident's family was notified of his combative behaviors and his transfer to the behavior facility. Interview with S2 DON on 04/11/2022 at 1:00 p.m. revealed she stated the facility had no documentation the family was notified of the resident's change in behavior and his transfer to the behavior facility. She stated she did not notify the family. She stated she did not know if S9 LPN notified the family or not. An attempt was made at that time to interview S9 LPN by telephone with S2 DON. S9 LPN did not answer the phone, and no message could be left. S2 DON stated S9 LPN should have documented in the Progress Notes if she notified the family, and she confirmed there was no documentation the family was notified. Telephone interview conducted with the resident's son on 04/07/2022 at 4:15 p.m. revealed the son stated he was not notified when the resident was sent to the behavior facility on 03/17/2022. Telephone interview with the resident's sister on 04/10/2022 at 6:00 p.m. revealed she was not notified when the resident was admitted to the behavior facility on 03/17/2022. She stated she called the facility one day (could not remember the date) to check on her brother. The staff who answered the phone told her he was not there, and he had been admitted to a behavior facility. She told the staff no one notified her of his transfer. She stated the staff looked in his record and told her there was no documentation that any of the resident's family was notified regarding the transfer.

Based on record review and interview the facility failed to immediately consult with the resident's physician when a family member noticed and complained to S3 LPN TReatment Nurse that the resident's foot wound had a foul odor, for 1(#2) of 3 (#2, #3, #4) sampled residents reviewed with wounds in a total sampled of 5 (#1, #2, #3, #4, #5) residents. According to the Resident Census and Conditions of Residents form the facility's census was 110. This failed practice resulted in actual harm for resident #2. Resident #2 was diagnosed with [REDACTED]. The S3 LPN Treatment Nurse who was wound care certified assessed and provided daily wound care to resident #2. The resident's daughter informed S3 LPN Treatment Nurse on 4/9/15 the resident's wound had a foul odor and S3 LPN Treatment Nurse did not consult with the Facility Nurse Practitioner at that time. It was not until the Physician called the facility on 4/14/15, asking the facility's Nurse Practitioner to assess the resident's right foot wound, that S3 LPN Treatment Nurse observed a change in wound status and faxed her assessment of the change to the resident's physician. Findings: Review of resident #2's face sheet revealed an admitted [DATE] with [DIAGNOSES REDACTED]. Review of the Wound Assessment Reports documented by S3 LPN Treatment Nurse and dated 2/2/15, 2/9/15, 2/16/15, 2/23/15, 3/2/15, 3/9/15, 3/13/15, 3/20/15, 3/27/15, 4/3/15, 4/10/15 and 4/14/15, revealed documentation that either the S2 NP or Physician was notified of the resident's wound status. Additionally, the Wound Assessment Report dated 4/10/15 read that the wound status had improved. Review of the resident's clinical record revealed the doctor's office contacted the nursing facility on 4/14/15 requesting resident's #2's foot be assessed by the S2 NP as a result of the resident's daughters calling the office and requesting the doctor go to the facility and assess the wound. The S3 Treatment Nurse assessed the wound and faxed the assessment to the doctor because S2 NP was not at the facility at that time. Review of the Wound Assessment documented on the fax cover sheet dated 4/14/15 and documented by S3 LPN/Treatment Nurse revealed the wound to medial aspect, metatarsal head right great toe measures 4 cm x 4 cm x UTD. The wound bed was 60% eschar with 40% granulation tissue to center of the wound bed. No odor. Moderate amount of purulent sanguineous drainage. Wound edges irregular, Peri-wound bright pink. Have been using Santyl as enzymatic debridement. The resident is very combative during ADL care and dressing changes. The report revealed the resident has been observed kicking and fighting staff multiple times, and swinging feet and tapping them together while up in chair causing injury to area. Have spoken to both daughters multiple times but they were never happy, nor do I feel like they even understand. Review of the NP's progress notes dated 4/15/15 (no time specified) documented it was noticed that the resident's wound had changed. The notes further revealed the resident's wound to her first metatarsal joint now has purulent drainage and first toe had discoloration. The notes read that the resident had increased agitation and had been banging her feet together causing more trauma to the area. Further review of the notes revealed the right first metatarsal joint red, open, and an increase in drainage was observed. Interview on 5/6/15 at 10:30 a.m. with the resident's daughter revealed that after she returned from vacation on April 8, 2015, she was told by S3 Treatment Nurse that the resident's foot was improving. The resident's daughter stated she assisted a CNA with changing the resident on April 8 or 9, and noticed that the resident had a bad smell to her foot and the foot was bleeding. Interview on 5/6/2015 at 11:30 a.m. with S3 Treatment Nurse revealed that she was made aware of the resident's right metatarsal wound on 2/2/15. S3 Treatment Nurse also stated she was wound certified and attended a class on pressure ulcers, and she determined that the resident's wound was an Arterial Ulcer by the placement of the wound, size of the wound and appearance of the wound. S3 Treatment Nurse revealed the RN did not have to sign her assessments because the wound was not a pressure ulcer, and only pressure ulcers needed a RN to assess and sign behind her. S3 Treatment Nurse also stated that if she saw a change in resident's #2's wound during her daily dressing change, she would document the change on a departmental note and notify the doctor. S3 Treatment nurse stated the doctor was called when a wound first occurred, and if 1/10 of a change in the wound size was observed. S3 Treatment Nurse stated her last assessment documented before the resident was sent to the hospital was on 4/14/15. S3 Treatment Nurse stated on 4/15/15 she and the NP looked at the resident's wound and noticed purulent drainage with discoloration to the surrounding area and the right great toe. She also revealed when the resident was sent to the Speciality hospital on [DATE], the right outer metatarsal area was draining purulent draining and the area surrounding it was blacken. She also stated the top of the resident's great toe was black. Interview on 5/6/2015 at 12:53 p.m. with S2 NP revealed she assessed the resident's foot on 4/15/15 and found the foot to have an odor with purulent drainage, so she called and informed the doctor. S2 NP also stated the resident only had the opened area on the side of the right toe and the area around it was darken, but the other skin was intact. Interview on 5/6/15 at 4:15 p.m. with the resident's daughter revealed that on 4/8/15 she went in the resident's room and smelled an odor. The resident's daughter stated her sister told her earlier that day that the resident had an odor that was coming from her foot wound, so she went in the resident's room to see. Further interview with the resident's daughter on the above date and time revealed she visited the resident's room again on 4/9/15, smelled the odor again and noticed the resident had increased bleeding to her right foot with an odor. The daughter stated she called the doctor's office on 4/9/15 and left a message with the secretary for the doctor to call her, but he didn't. The daughter also stated on 4/11/15 she went into the resident's room and held the resident's foot up while S11 RN change the resident's dressing. She stated she observed the resident's foot to have a hole in it with blood coming out of the hole, and the wound had a bad smell to it. The daughter stated she observed S11 RN to squeeze the resident's foot and more blood came out. Interview on 5/7/15 at 11:10 a.m. with S11 RN revealed that she was the weekend RN and dressed resident #2's wound to her right foot. She stated on the weekend of 4/11/15 she did the resident's wound care and the resident's daughter assisted. S11 RN stated she talked with the daughter regarding concerns she (the daughter) had that the resident's wound was getting worse. S11 RN stated she told the resident's daughter that she did not see any improvement in the wound, but also did not see that the wound had gotten worse. S11 RN stated that the wound was not healing. Interview on 5/7/15 at 12:15 p.m. with S4 LPN revealed that she received a call from the doctor's office on 4/14/15 (during the morning, unknown exact time) and the clerk stated the resident's daughters kept calling them to have the doctor come out to assess the resident's foot. S4 LPN stated the clerk told her that the doctor wanted the S2 NP to assess the resident for him. S4 LPN stated the NP was not at the facility at that time, so S3 Treatment Nurse assessed the resident and faxed her assessment to the doctor. S4 LPN stated she did not document the call or write it on a physician's orders [REDACTED]. Interview on 5/7/15 at 3:00 p.m. with S3 LPN Treatment Nurse revealed the doctor's office had called the facility on 4/14/15 and asked S4 LPN to please send the NP to assess the resident's wound, because the family had called their office multiple times. S3 LPN Treatment Nurse stated the S2 NP was not at the facility, so she assessed the resident's wound and faxed her findings to the doctor. S3 LPN Treatment Nurse stated she never smelled any odor from the resident's wound, but the wound measurements had increased in size to 4cm x 4cm with necrotic or dry dark blood around the open area. S3 LPN Treatment Nurse stated she observed the wound to have sanguineous purulent drainage, and there was no discoloration to any part of the resident's foot. S3 LPN Treatment Nurse stated she dressed the resident's wound daily, and dressed her wound on 4/13/15 at the normal time (2:00 p.m.). S3 LPN Treatment Nurse stated the resident's wound on 4/13/15 did not look like her assessment on 4/14/15. S3 LPN Treatment Nurse confirmed the resident was admitted to the Specialty hospital on [DATE] as a result of digression of the wound. Telephone interview on 5/11/15 at 11:38 a.m. with the resident's doctor revealed that he remembered the resident's family had called his office days before 4/14/15 regarding concerns of their mother's foot and wanting him to go and look at the mother's foot. The doctor stated that they (resident's daughters) were directed to voiced their concerns with the staff at the nursing facility because the facility had a full time NP. The resident's doctor also stated that if the facility's NP had assessed the resident, she would have contacted him if needed. Interview on 5/11/15 at 11:55 a.m. with the resident's daughter revealed that she was visiting her mother at the facility on 4/9/15 and asked the S3 LPN Treatment Nurse to take the resident's dressings off so she could look at the wound. The daughter stated the S3 LPN Treatment Nurse took off the dressing and she (daughter) saw that the wound was bleeding red blood and it smelled stinky. She also stated the resident's great toe was black and voiced her concerns to the S3 LPN Treatment Nurse, and the S3 LPN Treatment Nurse told her that the wound was alright and was looking good. The daughter stated she asked the S3 LPN Treatment Nurse how could the wound be alright if it was stinky and bleeding. Interview on 5/12/15 at 9:50 a.m. with S1 DON revealed that she did not have a policy specific to Arterial Ulcers, but the Arterial Ulcers were included with the policy for Ulcer Management. Further interview with S1 DON revealed that the policy for MD notification, change in condition, and assessments were included within the Ulcer Management Policy. Interview on 5/12/15 at 10:15 p.m. with S3 LPN Treatment Nurse revealed the last follow up assessment done by S2 NP prior to the 4/15/15 assessment, was on 3/25/15. S3 LPN Treatment Nurse confirmed that staff at the doctor's office called the nursing facility and asked to have the S2 NP assess the resident's wound because the resident's daughters had called the office multiple times prior. Further interview with S3 LPN Treatment Nurse revealed that she saw no change in the resident's wound that warranted notifying S2 NP prior to 4/14/15, to assess the resident's wound. S3 LPN Treatment Nurse stated it was not until the physician's office called on 4/14/15 to have the S2 NP assess the resident's wound for him that she observed a change in the resident's wound status. Review of the facility's policy on Ulcer Management included the following under the section for Arterial Ulcer: The ulcers will be treated according to physician's orders [REDACTED].

Based on record review and interview the facility failed to ensure residents received services that meet professional standards of quality for 1(#2) of 3 (#2, #3, #4) sampled residents reviewed with wounds in a total sampled of 5 (#1, #2, #3, #4, #5) residents. According to the Resident Census and Conditions of Residents form the facility's census was 110. The facility failed to: 1. ensure the RN supervised the assessment and treatment/care received by resident #2 once treatment of [REDACTED]. This failed practice resulted in actual harm for resident #2. Resident #2 was diagnosed with [REDACTED]. The S3 LPN Treatment Nurse who was wound care certified assessed and provided daily wound care to resident #2. According to interviews of S3 Treatment Nurse, S1 DON and S2 NP, the S3 LPN Treatment Nurse did not receive supervision and/or oversight of a resident with an Arterial Ulcer unless she requested the S1 DON or the S2 NP to assess. The Specialty Hospital assessed the resident's right foot wound on 4/16/15 with the following findings: Stage 4 with bone exposed, and necrotic tissue with brown thick foul smelling drainage. The resident had a right BKA on 4/29/15 at another hospital. Findings: Review of the La. Revised Statue 46, Part XLVII, Subpart 2, Chapter 37 Nursing Practice; 3703 Definition of Terms Applying to Nursing Practice; A. Terms applying to nursing Practice; a. reads: Delegation Nursing Interventions reads: reflected under Delegating Nursing Interventions entrusting the performance of selected nursing tasks by the registered nurse to other competent nursing personnel in selected situations. The registered nurse retains the accountability for the total nursing care of the individual. The registered nurse is responsible for an accountable to each consumer of nursing care for the quality of nursing care he or she receives, regardless of whether the care is provided solely by the registered nurse or by the registered nurse in conjunction with other licensed or unlicensed assistive personnel. a. the registered nurse shall assess the patient care situation which encompasses the stability of the clinical environment and the clinical acuity of the patient, including the overall complexity of the patient's health care problems. This assessment shall be utilized to assist in determining which tasks may be delegated and the amount of supervision which will be required. Review of resident #2's face sheet revealed an admitted [DATE] with [DIAGNOSES REDACTED]. Review of the weekly Wound Assessment Reports completed by S3 LPN Treatment Nurse and dated 2/2/15, 2/9/15, 2/16/15, 2/23/15, 3/2/15, 3/9/15, 3/13/15, 3/20/15, 3/27/15, 4/3/15, 4/10/15 and 4/14/15, reflected there was no RN signature on the above dated Wound Assessment Reports to ensure accuracy of the assessments of resident #2's right foot arterial wound performed by S3 LPN Treatment Nurse, or documentation in resident #2's clinical record to reflect the RN assessed resident #2's Arterial Ulcer status on the above dates. Review of the resident's clinical record revealed the doctor's office contacted the nursing facility on 4/14/15 requesting resident's #2's foot be assessed by the S2 NP as a result of the resident's daughters calling the office and requesting the doctor go to the facility and assess the wound. The S3 LPN Treatment Nurse assessed the wound and faxed the assessment to the doctor because S2 NP was not at the facility at that time. Review of the wound assessment documented on the fax cover sheet dated 4/14/15 and documented by S3 LPN/Treatment Nurse revealed the wound to medial aspect, metatarsal head right great toe measures 4 cm x 4 cm x UTD. The wound bed was 60% eschar with 40% granulation tissue to center of the wound bed. No odor. Moderate amount of purulent sanguineous drainage. Wound edges irregular, Peri-wound bright pink. Have been using Santyl as enzymatic debridement. The resident is very combative during ADL care and dressing changes. The report revealed the resident has been observed kicking and fighting staff multiple times, and swinging feet and tapping them together while up in chair causing injury to area. Have spoken to both daughters multiple times but they were never happy, nor do I feel like they even understand. Review of the S2 NP's progress notes dated 4/15/15 (no time specified) documented it was noticed that the resident's wound had changed. The notes further revealed the resident's wound to her first metatarsal joint now has purulent drainage and first toe had discoloration. The notes read that the resident had increased agitation and had been banging her feet together causing more trauma to the area. Further review of the notes revealed the right first metatarsal joint red, open, and an increase in drainage was observed. Interview on 5/6/15 at 10:30 a.m. with the resident's daughter revealed that after she returned from vacation on April 8, 2015, she was told by S3 LPN Treatment Nurse that the resident's foot was improving. The resident's daughter stated she assisted a CNA with changing the resident on April 8 or 9, and noticed that the resident had a bad smell to her foot and the foot was bleeding. Interview on 5/6/2015 at 11:30 a.m. with S3 LPN Treatment Nurse revealed that she was made aware of the resident's right metatarsal wound on 2/2/15. S3 LPN Treatment Nurse also stated she was wound certified and attended a class on pressure ulcers, and she determined that the resident's wound was an Arterial Ulcer by the placement of the wound, size of the wound and appearance of the wound. S3 LPN Treatment Nurse revealed the RN did not have to sign her assessments because the wound was not a pressure ulcer, and only pressure ulcers needed a RN to assess and sign behind her. S3 LPN Treatment Nurse also stated that if she saw a change in resident's #2's wound during her daily dressing change, she would document the change on a departmental note and notify the doctor. S3 LPN Treatment nurse stated the doctor was called when a wound first occurred, and if 1/10 of a change in the wound size was observed. S3 LPN Treatment Nurse stated her last assessment documented before the resident was sent to the hospital was on 4/14/15. S3 LPN Treatment Nurse stated on 4/15/15 she and the S2 NP looked at the resident's wound and noticed purulent drainage with discoloration to the surrounding area and the right great toe. She also revealed when the resident was sent to the Speciality hospital on [DATE], the right outer metatarsal area was draining purulent draining and the area surrounding it was blacken. She also stated the top of the resident's great toe was black. Interview on 5/6/2015 at 12:53 p.m. with S2 NP revealed she assessed the resident' foot on 4/15/15 and found the foot to have an odor with purulent drainage, so she called and informed the doctor. S2 NP also stated the resident only had the opened area on the side of the right toe and the area around it was darken, but the other skin was intact. Interview on 5/6/15 at 3:00 p.m. with S2 NP revealed that she did not supervise S3 LPN Treatment Nurse. Interview on 5/6/15 at 4:15 p.m. with the resident's daughter revealed that on 4/8/15 she returned to work and went in the resident's room and smelled an odor. The daughter stated her sister told her earlier that day that the resident had an odor that was coming from her foot wound, so she went in the resident's room to see. Further interview the resident's daughter on the above date and time revealed she visited the resident's room again on 4/9/15, smelled the odor again and noticed the resident had increased bleeding to her right foot with an odor. The resident's daughter stated she called the doctor's office on 4/9/15 and left a message with the secretary for the doctor to call her, but he didn't. She also stated that on 4/11/15 she went into the resident's room and held the resident's foot up while S11 RN change the resident's dressing. She stated she observed the resident's foot to have a hole in it with blood coming out of the hole, and the wound had a bad smell to it. She further stated she observed S11 RN to squeeze the resident's foot and more blood came out. Interview on 5/7/15 at 11:10 a.m. with S11 RN revealed that she was the weekend RN and dressed resident #2's wound to her right foot. She stated on the weekend of 4/11/15 she did the resident's wound care and the resident's daughter assisted. S11 RN stated she talked with the daughter regarding concerns she (the daughter) had that the resident's wound was getting worse. S11 RN stated she told the resident's daughter that she did not see any improvement in the wound, but also did not see that the wound had gotten worse. S11 RN stated that the wound was not healing. Interview on 5/7/15 at 12:15 p.m. with S4 LPN revealed that she received a call from the doctor's office on 4/14/15 (during the morning, unknown exact time) and the clerk stated the resident's daughters kept calling them to have the doctor come out to assess the resident's foot. S4 LPN stated the clerk told her that the doctor wanted the S2 NP to assess the resident for him. S4 LPN stated the NP was not at the facility at that time, so S3 LPN Treatment Nurse assessed the resident and faxed her assessment to the doctor. S4 LPN stated she did not document the call or write it on a physician's orders [REDACTED]. Interview on 5/7/15 at 3:00 p.m. with S3 LPN Treatment Nurse revealed the doctor's office had called the facility on 4/14/15 and asked S4 LPN to please send the S2 NP to assess the resident's wound, because the family had called their office multiple times. S3 LPN Treatment Nurse stated the S2 NP was not at the facility, so she assessed the resident's wound and faxed her findings to the doctor. S3 LPN Treatment Nurse stated she never smelled any odor from the resident's wound, but the wound measurements had increased in size to 4cm x 4cm with necrotic or dry dark blood around the open area. S3 LPN Treatment Nurse stated she observed the wound to have sanguineous purulent drainage, and there was no discoloration to any part of the resident's foot. S3 LPN Treatment Nurse stated she dressed the resident's wound daily, and dressed her wound on 4/13/15 at the normal time (2:00 p.m.). S3 LPN Treatment Nurse stated the resident's wound on 4/13/15 did not look like her assessment on 4/14/15. S3 LPN Treatment Nurse confirmed the resident was admitted to the Specialty hospital on [DATE] as a result of digression of the wound. Telephone interview on 5/11/15 at 11:38 a.m. with the resident's doctor revealed that he remembered the resident's family had called his office days before 4/14/15 regarding concerns of their mother's foot and wanting him to go and look at the mother's foot. The doctor stated that they (resident's daughters) were directed to voiced their concerns with the staff at the nursing facility because the facility had a full time NP. The resident's doctor also stated that if the facility's NP had assessed the resident, she would have contacted him if needed. Interview on 5/11/15 at 11:55 a.m. with the resident's daughter revealed that she was visiting her mother at the facility on 4/9/15 and asked the S3 LPN Treatment Nurse to take the resident's dressings off so she could look at the wound. The daughter stated the S3 LPN Treatment Nurse took off the dressing and she (daughter) saw that the wound was bleeding red blood and it smelled stinky. She also stated the resident's great toe was black and voiced her concerns to the S3 LPN Treatment Nurse, and the S3 LPN Treatment Nurse told her that the wound was alright and was looking good. The daughter stated she asked the S3 LPN Treatment Nurse how could the wound be alright if it was stinky and bleeding. Interview on 5/12/15 at 9:50 a.m. with S1 DON revealed that she monitored S3 LPN Treatment Nurse by going to look at the resident's wound herself, or if the S3 LPN Treatment Nurse wanted her to look at something she wound let her know. S1 DON also revealed that she did not have a policy specific to Arterial Ulcers, but the Arterial Ulcers were included with the policy for Ulcer Management. Further interview with S1 DON revealed that the policy for MD notification, change in condition, and assessments were included within the Ulcer Management Policy. However, in a prior interview with S3 LPN Treatment Nurse on 5/6/15 at 11:30 a.m. revealed the RN did not have to sign her assessment because the wound was not a pressure ulcer, and only pressure ulcers needed a RN to assess and sign behind her. Interview on 5/12/15 at 10:15 p.m. with S3 LPN Treatment Nurse revealed the last follow up assessment done by S2 NP prior to the 4/15/15 assessment, was on 3/25/15. S3 LPN Treatment Nurse confirmed that staff at the doctor's office called the nursing facility and ask to have the S2 NP assess the resident's wound because the resident's daughters had called the office multiple times prior. Further interview with S3 LPN Treatment Nurse revealed that she saw no change in the resident's wound that warranted notifying S2 NP prior to 4/14/15, to assess the resident's wound. S3 LPN Treatment Nurse stated it was not until the physician's office called on 4/14/15 to have the S2 NP assess the resident's wound for him that she observed a change in the resident's wound status. Review of the facility's policy on Ulcer Management included the following under the section for Arterial Ulcer: The Arterial Ulcer is characteristically painful, and the wound bed is frequently dry and pale with minimal or no exudate. The affected foot may exhibit diminished or absent pedal pulse, coolness to touch, decreased pain when hanging down (dependent) or increased pain when elevated, blanching upon elevation delayed capillary fill time, hair loss on top of the foot and toes, toenail thickening. Further review of the policy reflected Vascular insufficiency/ischemia (venous stasis and arterial ischemic ulcers) and neuropath ulcers are all directly related to a disease process. The ulcers will be treated according to physician's orders [REDACTED]. The Policy gave no directive for RN supervision or assessment for resident's with Arterial Ulcers.

Based on record review and interview the facility failed to ensure residents attain or maintain the highest practicable physical, mental and psychosocial well-being for 1(#2) of 3 (#2, #3, #4) sampled residents reviewed with wounds in a total sampled of 5 (#1, #2, #3, #4, #5) residents. According to the Resident Census and Conditions of Residents forn the facility's census was 110. The facility failed to: 1. ensure that the RN supervised the assessment and care received by resident #2 once treatment of [REDACTED]. 2. ensure that resident #2 was assessed for pain when she was observed banging her feet together. 3. notify the physician when the family member voiced a concern to the LPN Treatment Nurse, that the resident's wound was bleeding and had a foul odor on 4/8/15 and 4/9/15. This failed practice resulted in actual harm for resident #2. Resident #2 was diagnosed with [REDACTED]. The S3 LPN Treatment Nurse who was wound care certified assessed and provided daily wound care to resident #2. According to interviews of S3 Treatment Nurse, S1 DON and S2 NP, the S3 LPN Treatment Nurse did not receive supervision and/or oversight of a resident with an Arterial Ulcer unless she requested the S1 DON or the S2 NP to assess. The Specialty Hospital assessed the resident's right foot wound on 4/16/15 with the following findings: Stage 4 with bone exposed, and necrotic tissue with brown thick foul smelling drainage. The resident had a right BKA on 4/29/15 at another hospital. Findings: Review of resident #2's face sheet revealed an admitted [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE] revealed the resident was cognitively unable to complete the interview. Review of the care plan with a goal date of 5/3/15 revealed a problem of Physical Mobility impaired r/t Arthritis, uses a wheelchair as main source of locomotion. Approaches included to administer pain medication as ordered, OT and PT to screen quarterly and as needed, turning and repositioning program: resident is to be turned and repositioned every 2 hours and as needed, ½ side rails up times two while in bed for bed mobility due to decreased physical mobility secondary to [MEDICAL CONDITION], monitor every 30 minutes, released every 2 hours times 10 minutes for range of motion and repositioning. Further review of the care plan with a goal date of 5/3/15 revealed a problem of skin integrity impaired with a potential impaired skin integrity related to incontinence, and is at risk for pressure ulcers. [DIAGNOSES REDACTED]. Approaches included: pressure reducing mattress to bed, report any red or open areas, and pressure reducing cushion to wheelchair at all times with turning and repositioning program. The resident was to be turn and repositioned every 2 hours and as needed. Heel protectors to bilateral heels while in bed for pressure reduction and preventive measures. Review of the Wound Assessment Report dated 2/2/15 and documented by S3 LPN Treatment Nurse revealed the resident's wound was an Arterial Ulcer to the right great toe; Medial Metatarsal Head Right Great Toe. The wound had small serious drainage, infection present, with increased pain with [DIAGNOSES REDACTED]. The wound bed had 20% slough with 80% granulation tissue. The measurements were length 0.30 cm, width 0.30 cm and depth 0.10 cm. The wound border was well defined with normal healthy skin. The Dorsalis Pedis and the Posterior Tibial pulses were Palpable/weak. The Capillary refill was less than 3 seconds and the affected extremity was normal skin, warm/dry to touch, with normal elasticity. The S2 NP and Responsible Party (RP) were notified. Review of the S3 Treatment Nurse's documentation read cleanse Arterial Wound to Medial Aspect Metatarsal Head Right Great Toe with wound cleanser, 4 x 4, dry well, apply small amount of [MEDICATION NAME] ointment to wound bed and cover with bordered foam dressing daily until healed. Review of the S2 NP's progress notes dated 2/3/15 revealed under Chief Complaint: Right Great Metatarsal Wound. The resident was an [AGE] year old female with a history of Alzheimer, [MEDICAL CONDITION], and [MEDICAL CONDITION]. It was noted that the resident had a sore red area on her first metatarsal joint. Upon examining, the area was red and somewhat soft underneath. It was very sore to touch. Under the section for Skin/Breast, it was documented that the right first metatarsal joint, red, swollen, serosang drainage. The Plan read: will continue current medication and add [MEDICATION NAME] 100 mg (antibiotic) by mouth twice daily for 7 days. Will continue to monitor this area and have a daily dressing change with the wound nurse Review of the S2 NP's progress notes dated 2/4/15 revealed the resident developed an abscess on her right first metatarsal. She was started on [MEDICATION NAME] and daily dressing changes. Today it is not as sore, minimum drainage, no redness or swelling. Further review of the progress notes read the right metatarsal joint, red, swollen and serosang drainage. Will continue current medication, will monitor for osteo[DIAGNOSES REDACTED], will continue to monitor rash, almost healed. Review of the S2 NP's progress notes dated 2/6/15 revealed the resident had developed an abscess on her right great first metatarsal. It was healing well. Minimum drainage, no fever, or chills. Further review under the section of Skin/Breast reflected right first metatarsal joint, red, swollen, serosang drainage. Review of the Wound Assessment Report dated 2/9/15 and documented by S3 LPN Treatment Nurse revealed Arterial Ulcer to the right great toe. The wound status was improved, no drainage, no infection, 100% slough, and the surrounding tissue was red and indurated with less than 3 seconds capillary refill. The measurements were length 0.50 cm, width 0.50 cm, and depth 0.0 cm. The wound edges were well defined and indurated. The Dorsalis Pedis and the Posterior Tibial were palpable/weak. The affected extremity had normal skin color and warm to touch. The S2 NP and RP were notified. The report read to cleanse Arterial Wound to Medial Aspect Metatarsal Head Right Great Toe with wound cleanser, 4 x 4, dry well, and apply small amount of [MEDICATION NAME] ointment to wound bed and cover with bordered foam dressing daily until healed. Review of the S2 NP's progress notes dated 2/10/15 revealed the resident had developed an abscess to right first metatarsal joint. She responded well to antibiotics. The wound has no redness or swelling, minimum drainage. Review of the S2 NP's progress notes dated 2/13/2015 revealed the resident developed an abscess on first metatarsal joint. It was improved. No drainage, redness or swelling. Review of the Wound Assessment Report dated 2/16/15 and documented by S3 LPN Treatment Nurse revealed Arterial Ulcer to the Right Great Toe. The report also revealed the wound status deteriorated, no drainage, no infection, 100% slough, the surrounding tissue was red and indurated with less than 3 seconds capillary refill. The measurements were length 0.50 cm, width 0.50 cm, and depth 0.0 cm. The wound edges were well defined and indurated. The Dorsalis Pedis and the Posterior Tibial were palpable/weak. The affected extremity had normal skin color and was warm to the touch. The doctor and RP were notified. The report read to cleanse Arterial Wound to Medial Aspect Metatarsal Head Right Great Toe with wound cleanser, 4 x 4, dry well, apply small amount of [MEDICATION NAME] ointment to wound bed and cover with bordered foam dressing daily until healed. Review of the Wound Assessment Report dated 2/23/15 and documented by S3 LPN Treatment Nurse reflected Arterial Ulcer to the right great toe. The report revealed the wound status was deteriorated, no drainage, no infection, 100% slough, and the surrounding tissue was red and indurated with less than 3 seconds capillary refill. The measurements were length 1.00 cm, width 1.50 cm, and depth 0.0 cm. The wound edges were well defined and indurated. The Dorsalis Pedis and the Posterior Tibial pulses were palpable/weak. The affected extremity had normal skin color, and was warm to the touch. The doctor and RP were notified. The report also read to cleanse Arterial wound to Medial Aspect Metatarsal Head Right Great Toe with wound cleanser, 4 x 4, dry well, apply small amount of [MEDICATION NAME] ointment to wound bed and cover with bordered foam dressing daily until healed. Review of the Wound Assessment Report dated 3/2/15 and documented by S3 LPN Treatment Nurse revealed Arterial Ulcer to the right great toe. The report reveaeld the wound status was deteriorated, no drainage, no infection, 100% slough. The surrounding tissue was normal with less than 3 seconds capillary refill. The measurements were length 1.50 cm, width 1.50 cm, and depth 0.0 cm. The wound edges were well defined and indurated. The Dorsalis Pedis and the Posterior Tibial pulses were palpable/weak. The affected extremity had normal skin color and was warm to the touch. The doctor and RP were notified. The report also revealed the depth to the wound was unable to determine due to wound bed 100% light yellow adherent slough, the doctor was notified of a decline with request for change in treatment orders, awaiting response. Further documentation revealed to cleanse Arterial Wound to Medial Aspect Metatarsal Head Right Great Toe with wound cleanser, 4 x 4, dry well, apply small amount of [MEDICATION NAME] ointment to wound bed and cover with bordered foam dressing daily until healed. Review of the S2 NP's progress notes dated 3/4/15 read the resident had developed an abscess on her right great toe joint. It is healing well, no drainage or foul odor. No fevers or chills. Review of the Wound Assessment Report dated 3/9/15 and documented by S3 LPN Treatment Nurse revealed Arterial Ulcer to the right great toe. The above report revealed the wound status was improved, no drainage, no infection, 95% slough and 5% granulation, the surrounding tissue was normal with less than 3 seconds capillary refill. The measurements were length 1.50 cm, width 1.20 cm, and depth 0.0 cm. The wound edges were well defined and indurated. The Dorsalis Pedis was palpable/weak and the Posterior Tibial were palpable/weak. The affected extremity had normal skin color and was warm to the touch. The report revealed the doctor and RP were notified. Further review of the report revealed the depth of the wound was undetermined related to slough to wound bed, the resident was resisting care during treatment, becomes physically abusive and attempting to kick and slap this LPN. Further documentation revealed that it required the assistance of 2 CNAs to provide treatment to keep the resident from injuring self or staff. The family was aware of the resident's behavior. All treatment and preventive measures were continued. The report revealed a new treatment order dated 3/4/15 to cleanse Arterial Wound to Medial Aspect Metatarsal Head right great toe with wound cleanser, 4 x 4, dry well apply Santyl and Hydrogel gauze (cut) to wound bed, cover with bordered foam dressing daily til healed. Review of the Wound Assessment Report dated 3/13/15 and documented by S3 LPN Treatment Nurse revealed Arterial Ulcer to the right great toe. The wound status revealed unchanged, no drainage, no infection, 90% slough and 10% granulation, the surrounding tissue was normal with less than 3 seconds capillary refill. The measurements were length 1.20 cm, width 1.80 cm, and depth 0.0 cm. The wound edges were well defined and indurated. The Dorsalis Pedis and the Posterior Tibial pulses were palpable/weak. The affected extremity had normal skin color and was warm to the touch. The doctor and RP were notified. The report read to cleanse Arterial Wound to Medial Aspect Metatarsal Head right great toe with wound cleanser and 4 x 4, dry well, apply Santyl and Hydrogel gauze (cut) to wound bed, cover with bordered foam dressing daily til healed. Review of the Wound Assessment Report dated 3/20/15 and documented by S3 LPN Treatment Nurse revealed Arterial Ulcer to the right great toe. The wound status reflected improved, no drainage, no infection, 60% slough and 40% granulation, the surrounding tissue was normal with less than 3 seconds capillary refill. The measurements were length 1.00 cm, width 0.50 cm, and depth 0.0 cm. The wound edges were well defined and indurated. The Dorsalis Pedis and the Posterior Tibial pulses were palpable/strong. The affected extremity was normal skin color, warm to touch. The doctor and RP were notified. The report revealed the depth of the wound was unable to determine related to 60% of slough to wound bed. Documentation on the report read to cleanse Arterial Wound to Medial Aspect Metatarsal Head right great toe with wound cleanser and 4 x 4, dry well, apply Santyl and Hydrogel gauze (cut) to wound bed, cover with bordered foam dressing daily til healed. Review of the S2 NP's progress notes dated 3/25/15 revealed the resident's right great toe joint wound is healing, no drainage or odor, is taking more time to heal likely due to decrease perfusion. Review of the Wound Assessment Report dated 3/27/15 and documented by S3 LPN Treatment Nurse revealed Arterial Ulcer to the right great toe. The wound status reflected improved, no drainage, no infection, 60% slough and 40% granulation tissue, the surrounding tissue was normal with less than 3 seconds capillary refill. The measurements were length 1.00 cm, width 0.50 cm, and depth 0.0 cm. The wound edges were well defined and indurated. The Dorsalis Pedis and the Posterior Tibial pulses were palpable/strong. The affected extremity had normal skin color and warm to touch. The doctor and RP was notified. Further review of the report read to cleanse Arterial Wound to Medial Aspect Metatarsal Head right great toe with wound cleanser and 4 x 4, dry well, apply Santyl and Hydrogel gauze (cut) to wound bed, cover with bordered foam dressing daily til healed. Review of the Wound Assessment Report dated 4/3/15 and documented by S3 LPN Treatment Nurse revealed Arterial Ulcer to the right great toe. The wound status read improved, no drainage, no infection, 60% slough and 40% granulation tissue, the surrounding tissue was normal with less than 3 seconds capillary refill. The measurements were length 1.50 cm, width 1.50 cm, and depth 0.0 cm. The wound edges were well defined and indurated. The Dorsalis Pedis and the Posterior Tibial pulses were palpable/strong. The affected extremity had normal skin color and was warm to the touch. The doctor and RP was notified. The report read to cleanse Arterial Wound to Medial Aspect Metatarsal Head right great toe with wound cleanser and 4 x 4, dry well, apply Santyl and Hydrogel gauze (cut) to wound bed, cover with bordered foam dressing daily til healed. Review of the Wound Assessment Report dated 4/10/15 and documented by S3 LPN Treatment Nurse revealed Arterial Ulcer to the right great toe. The wound status reflected improved, no drainage, no infection, 40% slough and 60% granulation tissue, the surrounding tissue was normal with less than 3 seconds capillary refill. The measurements were length 1.50 cm, width 1.50 cm, and depth 0.10 cm. The wound edges was well defined and indurated. The Dorsalis Pedis and the Posterior Tibial pulses were palpable/strong. The affected extremity had normal skin color and was warm to the touch. The doctor and RP was notified. The report read to cleanse Arterial Wound to Medial Aspect Metatarsal Head right great toe with wound cleanser, 4 x 4, dry well, apply Santyl and Hydrogel gauze (cut) to wound bed, cover with bordered foam dressing daily til healed. Review of the Wound Assessment documented on the fax cover sheet dated 4/14/15 and documented by S3 LPN Treatment Nurse revealed the wound to medial aspect, metatarsal head right great toe measures 4 cm x 4 cm x UTD. The wound bed was 60% eschar with 40% granulation tissue to center of the wound bed. No odor. Moderate amount of purulent sanguineous drainage. Wound edges irregular, Peri-wound bright pink. Have been using Santyl as enzymatic debridement. The resident is very combative during ADL care and dressing changes. The report revealed the resident has been observed kicking and fighting staff multiple times, and swinging feet and tapping them together while up in chair causing injury to area. Have spoken to both daughters multiple times but they were never happy, nor do I feel like they even understand. Review of a Departmental Note dated 4/14/15 at 10:20 p.m. with entry timed for 9:30 p.m. by S9 LPN revealed she received a new order from the doctor, C&S to wound on right foot and send to the medical center. The notes further revealed to change [MEDICATION NAME] to QOD X 2 weeks then d/c., [MEDICATION NAME] 0.5mg Q 6 hours prn for agitation and 1 mg po Q HS. Review of the S2 NP's progress notes dated 4/15/15 (no time specified) revealed it was noticed that the resident's wound had changed. The notes further revealed the resident's wound to her first metatarsal joint now has purulent drainage and first toe had discoloration. The notes read that the resident had increased agitation and had been banging her feet together causing more trauma to the area. Further review of the notes revealed the right first metatarsal joint red, open, increase in drainage. Review of the physician's orders [REDACTED]. Review of the Nurse Liaison assessment report dated 4/15/15 (with no time documented) revealed a Black Female with wound to right great toe that continues to decline, despite wound care efforts. The patient now has purulent drainage with bogginess around wound, and a culture was done yesterday. However, interview on 5/11/15 at 2:54 p.m. with the Nurse Liaison revealed she was sent to the facility by the doctor to assess the resident's right foot wound. The Nurse Liaison stated she arrived at the nursing facility at 4:30 p.m. on 4/15/15. The Nurse Liaison also stated there was a push to assess the resident and submit the findings, so she did not assess the resident's right foot. The Nurse Liaison stated her assessment on 4/5/15 of the resident's right foot wound was taken from information given to her by the S3 LPN Treatment Nurse. The Nurse Liaison stated she never saw the resident's wound. Review of a Departmental Note dated 4/15/15 at 5:16 p.m. and documented by S9 LPN revealed the resident was transferred to Specialty Hospital per Specialty Transportation. Further review of the notes revealed the resident's daughter was notified by phone. Review of the lab's wound culture report dated 4/15/15 revealed a moderate growth of Proteus Mirabilis, Moderate growth of Staphylococcus Aureus (MRSA) and a Heavy growth of Corynebacterium species. Review of the Specialty Hospital Progress notes dated 4/15/15 at 5:05 p.m. revealed the resident was admitted via wheelchair/van. The notes further revealed that the dressing to the right foot was bleeding through and was reinforced at that time. Review of the physician's report at the Specialty Hospital dated 4/16/15 revealed the resident was a new admit yesterday for wounds. She came from the nursing facility. The report read that the resident's wounds were going to be examined in detail by the wound care nurse, consultant physician, and decided if IV antibiotics were necessary. Review of the Specialty Hospital's Wound care Specialist's Initial Report dated 4/16/15 revealed Stage 4 to the resident's right great toe. The wound measured 2 x 1 with necrotic eschar, and measured 3.5 x 3.5 periwound; large amount of thick brown serious drainage. Culture was obtained, positive pedal pulse and no [MEDICAL CONDITION]. Review of the physician's orders [REDACTED]. Review of the Consultant Physician's Wound Care Clinic Report at the Specialty Hospital , with a dictated date of 4/22/15 revealed the resident's extremities show a right great toe that is dry gangrene more proximal. She has purulent drainage. She had suspected deep tissue injury to the lateral aspect of her right foot. Her left foot is unremarkable except for ganglion cyst on the dorsum aspect of the foot. The above Consultant Physician's Assessment /Plan revealed [AGE] year old female with gangrene to her right great toe. At this point obviously she will require amputation. The report read that unfortunately I don't know if this should be a forefoot or a BKA. I have no way of knowing where she is going to heal this. She will need further workup with this regard and I will arrange this, hopefully through a hospital in another city. Further review of the Specialty Hospital's Physician's Progress Notes dated 4/30/15 revealed the resident was referred to and sent out to another hospital on [DATE]. The referral was from the Consultant Physician on our behalf (Speciality Hospital), to the other hospital because of this gangrenous right Great Toe. The resident has had a wound since February. The report further read that the resident arrived at the other hospital, and was assessed and determined that a right above-knee amputation was appropriate and this was undertaken. Interview on 5/6/15 at 10:30 a.m. with the resident's daughters revealed they were first informed in February 2015 by a CNA that the resident had an issue with her right foot. The daughter stated S3 LPN Treatment Nurse did not let them know that the resident's foot was getting worse. The resident's daughter stated S11 RN (weekend RN) suggested to her that the resident should see a foot doctor on March 28, 2015. The daughter stated she asked S3 LPN Treatment Nurse to send her mother to a foot doctor, but S3 LPN Treatment Nurse stated that the foot doctor could not do anything different than what they (facility) were already doing. The daughter stated that after she returned from vacation on April 8, 2015, she was told by S3 LPN Treatment Nurse that the resident's foot was improving. The daughter stated she assisted a CNA with changing the resident on April 8 or 9, and noticed that the resident had a bad smell to her foot and the foot was bleeding. Another daughter stated that she called the doctor's office on April 8th and 9th and ask the secretary to ask the doctor to come and look at the resident's foot. She stated the secretary told her the doctor would call her back, but no one returned her call from the doctor's office. Interview on 5/6/2015 at 11:30 a.m. with S3 LPN Treatment Nurse revealed that she was made aware of the resident's right metatarsal wound on 2/2/15. S3 LPN Treatment Nurse stated she did not remember who made her aware, but when she assessed the resident's wound on her right metatarsal foot, she saw that it was an Arterial Ulcer. S3 LPN Treatment Nurse also stated she was wound certified and attended a class on pressure ulcers, and she determined that the resident's wound was an Arterial Ulcer by the placement of the wound, size of the wound and appearance of the wound. She stated the S2 NP also assessed the wound that day and agreed with her. S3 LPN Treatment Nurse revealed the RN did not have to sign her assessments because the wound was not a pressure ulcer, and only pressure ulcers needed a RN to assess and sign behind her. S3 LPN Treatment Nurse stated that she notified the resident's daughter because the daughter worked at the facility and she talked with her often. S3 LPN Treatment Nurse also stated the resident's other daughter would call every day, and she spoke with her on the phone. S3 LPN Treatment Nurse stated the resident's other daughter would ask how her mother was doing and how her mother's toe was doing. Further interview with S3 LPN Treatment Nurse revealed body audits and wound assessment were done weekly. She stated that she only documented findings once a week on the wound assessment form. S3 LPN Treatment Nurse stated the body Audits were done along with the weekly wound assessments. S3 LPN Treatment Nurse also stated that if she saw a change in resident's #2's wound during her daily dressing change, she would document the change on a departmental note and notify the doctor. S3 LPN Treatment nurse stated the doctor was called when a wound first occurred, and if 1/10 of a change in the wound size was observed. S3 LPN Treatment Nurse stated the treatment at first to resident' #2's wound was to apply [MEDICATION NAME] to the area. But later she noticed the wound bed was not improving, so she notified the doctor and the treatment was changed. S3 LPN Treatment Nurse stated her last assessment documented before the resident was sent to the hospital was on 4/14/15. She stated the resident's daughter was complaining that the resident's wound was bleeding, so she contacted the doctor on 4/14/15 and he ordered a wound culture. She stated the resident clicks her feet together often and she believed that caused the wound to bleed. S3 LPN Treatment Nurse also stated the doctor ordered a wound culture on 4/14/15, but it was not collected until the next day on 4/15/15 when she came to work. S3 LPN Treatment Nurse stated she wanted to collect all C&S on wounds, because she knew how to do it right, and would see that it was done correctly. S3 LPN Treatment Nurse also stated the doctor ordered a change in the resident's [MEDICATION NAME] and also ordered prn [MEDICATION NAME] because the resident was agitated. S3 LPN Treatment Nurse stated on 4/15/15 she and the S2 NP looked at the resident's wound and noticed purulent drainage with discoloration to the surrounding area and the right great toe. She also revealed when the resident was sent to the Speciality hospital on [DATE], the right outer metatarsal area was draining purulent draining and the area surrounding it was blacken. She also stated the top of the resident's great toe was black. Review of the resident's clinical record revealed the doctor's office contacted the nursing facility on 4/14/15 requesting resident's #2's foot be assessed by the S2 NP as a result of the resident's daughters calling the office and requesting the doctor go to the facility and assess the wound. The S3 LPN Treatment Nurse assessed the wound and faxed the assessment to the doctor. The doctor orders dated 4/14/15 included the wound culture. Interview on 5/6/2015 at 12:53 p.m. with S2 NP revealed she was first made aware of the resident's right foot wound on February 3, 2015. S2 NP stated she assessed the area and found the resident's right inner side of the great toe was soft and tender to touch, and noted the skin around the area was dark tone, but intact. S2 NP stated she did not know if that was the skin's original dark color or not. She stated the resident was started on [MEDICATION NAME] (antibiotic). S2 NP stated she talked with the resident's daughters, and told her the resident did not have good profusion and had diminished pulse to the right foot, and explained to the resident's daughters that bad profusion could cause that kind of wound. S2 NP stated she observed that the wound was closed and the skin was intact, and that after starting the resident on the [MEDICATION NAME], the wound opened up and begin to drain, and that was the intent for the medication. S2 NP revealed that she assessed the resident's foot on 4/15/15 and found the foot to have an odor with purulent drainage, so she called and informed the doctor. S2 NP stated she saw the resident banging her feet together that day (4/15/15), and staff stated the resident bang her feet like that. S2 NP stated the resident did not have her heel protectors on at that time, and did not know if the resident was banging her feet because it hurt or that was a habit. S2 NP also stated the resident only had the opened area on the side of the right toe and the area around it was darken, but the other skin was intact. Interview on 5/6/15 at 1:16 p.m. with S6 CNA revealed in February 2015 she noticed the resident had a black scab on the side of her right great toe. S6 CNA stated that sometime in February 2015 (unknown date), the black scab had opened. S6 CNA also stated when the resident was sent to the hospital on [DATE], she noticed the resident's foot looked worse because it had pus draining from it. S6 CNA revealed the wound was smelling and bleeding on occasion. Interview on 5/6/15 at 3:00 p.m. with S2 NP revealed that she did not supervise S3 LPN Treatment Nurse. Interview on 5/6/15 at 4:15 p.m. with the resident's daughter revealed that on 4/8/15 she returned to work and went in the resident's room and smelled an odor. The daughter stated her sister told her earlier that day that the resident had an odor that was coming from her foot wound, so she went in the resident's room to see. The daughter stated she thought the resident had a bowel movement because of the foul smell, but noticed blood on the resident's sheet, saw blood coming from the resident's wound, and also noticed the smell was coming from the resident's foot wound. The daughter stated her sister called the doctor's office on 4/8/15 to let him know that he needed to check the resident's foot. Further interview of the resident's daughter on the above date and time revealed she visited the resident's room again on 4/9/15, smelled the odor again and noticed the resident had increased bleeding to her right foot with an odor. The daughter stated she called the doctor's office on 4/9/15 and left a message with the secretary for the doctor to call her, but he didn't. The daughter also stated on 4/11/15 she went into the resident's room and held the resident's foot up while S11 RN change the resident's dressing. She stated she observed the resident's foot to have a hole in it with blood coming out of the hole, and the wound had a bad smell to it. The daughter stated she observed S11 RN to squeeze the resident's foot and more blood came out. The resident's daughter stated that the resident did bang her feet together, but there was never a wedge or pillow between her legs, and she did not have her heel protectors on at times. Interview on 5/7/15 at 11:10 a.m. with S11 RN revealed that she was the weekend RN and dressed resident #2's wound to her right foot. She stated on the weekend of 4/11/15 she did the resident's wound care and the resident's daughter assisted. S11 RN stated she talked with the daughter regarding concerns she (daughter) had that the resident's wound was getting worse. S11 RN stated she told the resident's daughter that she did not see any improvement in the wound, but also did not see that the wound had gotten worse. S11 RN stated that the wound was not healing. She stated she could not remember if the wound had an odor and did not remember what the wound bed looked like. S11 RN stated she did remember that the wound had blood in it, but that was what they wanted to see for perfusion purposes. S11 RN also stated the resident's surrounding skin was darker, but it had been that way for a while. S11 RN stated she did not do pedal pulses on the resident, because that was not part of the dressing change. She stated sometimes the dressing came off because the resident was thrashing around. S11 RN revealed that she did not tell the resident's daughter that the resident needed to see a foot doctor, but told her that is was her right to request a second opinion, and for her to talk to the resident's doctor. S11 RN stated the wound had some unhealthy tissue and the resident's foot felt a little cool. She also stated that the resident wore heel protectors and socks. Interview on 5/7/15 at 12:15 p.m. with S4 LPN revealed that she received a call from the doctor's office on 4/14/15 (during the morning, unknown exact time) and the clerk stated the resident's daughters kept calling them to have the doctor