Every finding on record at Avantara Groton

Based on observation, interview, record review, and policy review, the provider failed to develop and implement a resident-centered baseline care plan within 48 hours of admission for four of five sampled residents (1, 3, 20, and 37) who were recently admitted .Findings include:1. Review of resident 3's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *His 11/19/25 Brief Interview of Mental Status (BIMS) assessment score was 13, which indicated his cognition was intact. *A 3/31/25 progress note stated, A copy of his admission summary note was provided to [the] resident. Baseline care plan was reviewed with [the] resident. Resident agrees and understands the baseline care plan. -The baseline care plan was reviewed with resident 3 three days after his admission to the facility. Review of resident 3's baseline care plan revealed focus areas of: *The new admission initial/interim care plan was initiated on 3/31/25. *Advanced directive (a document that expresses a person's health care wishes if they become unable to speak for themselves) status initiated on 3/31/25 identified the resident wished to be a full code. *Discharge potential and discharge planning initiated on 3/31/25 identified resident 3's discharge goal to return home after completion of therapy. *[Resident 3] require/s Enhanced Barrier Precautions [glove and gown use when providing contact care] related to: indwelling foley [urinary catheter] was initiated on 4/1/25. *[Resident 3] requires assistance with ADL's [activities of daily living] (bed mobility, transfers, dressing, walking, personal hygiene, eating and toileting) was initiated on 4/1/25. -Interventions within the resident ADL focus were, Assist resident with shower/bathing per schedule up to 2x/wk [two times per week]. [Resident 3] is able to voice preference of shower or tub bath initiated on 5/1/25. - Assist with application of appliances if needed (hearing aid, eyeglasses, dentures), Encourage participation in ADL's, Keep call lights within reach when in bedroom or bathroom, initiated on 3/28/25. -Provide DME [durable medical equipment] -wheelchair and walker initiated on 4/1/25. *[Resident 3] has an ADL Self Care Performance Deficit and Impaired Mobility initiated on 4/8/25. -Interventions within the focus areas were, BED MOBILITY -total assist of 1, TRANSFER: partial/moderate, WALKING: partial/moderate- very short distances occasionally, DRESSING: partial/moderate for upper body dressing. Total assist for lower body dressing/footwear, TOILET USE: total assist of 1, PERSONAL HYGIENE/ORAL CARE: partial/moderate assist of 1. -All the interventions for resident 3's ADL self-care performance deficit and impaired mobility which identified the assistance required to safely care for resident 3 were initiated on 4/8/25, 11 days after he was admitted . 2. Interview on 12/9/25 at 2:40 p.m. with resident 37 revealed he did not recall if a staff member talked to him about his plan of care on his admission. Review of resident 37's EMR revealed: *He was admitted on [DATE]. *His 12/2/25 BIMS assessment score was 14, which indicated his cognition was intact. *He did not have a progress note in his EMR that indicated his baseline care plan had been reviewed with him or a resident representative. Review of resident 37's baseline care plan revealed focus areas of: *The new admission initial/interim care plan was initiated on 11/14/25. *Advanced directive (a document that expresses a person's health care wishes if they become unable to speak for themselves) status identified resident wish to be a full DNR that was initiated on 11/18/25. *Discharge potential and discharge planning was initiated on 11/18/25 that identified resident 37's discharge goal to return home after the completion of therapy. *[Resident 37] require/s Enhanced Barrier Precautions related to: straight caths [catheterizations] TID [three times a day] & [and] PRN [as needed] was initiated on 11/19/25. *[Resident 37] requires assistance with ADL's [activities of daily living] (bed mobility, transfers, dressing, walking, personal hygiene, eating and toileting) was initiated on 11/14/25. -Interventions within the resident's ADL focus that were initiated on 11/14/25: -Assist [resident 37] with shower/bathing per schedule up to 2x/wk [two times per week]. [Resident 37] will voice preference of shower or tub bath. -Assist with application of appliances if needed. -Encourage participation in ADL's. -Keep call lights within reach when in bedroom or bathroom. -Provide DME -wheelchair and walker. -Skilled Rehabilitation Therapy evaluation and treatment as indicated initiated on 11/14/25. *[Resident 37] has an ADL Self Care Performance Deficit and Impaired Mobility was initiated on 11/25/25. -Interventions within the focus areas were, BED MOBILITY -supervision/touching assistance, TRANSFER: supervision/touching assistance, WALKING: supervision/touching assistance with FWW, DRESSING: Partial/moderate assist for upper body dressing. Total assist with lower body dressing/footwear, TOILET USE: partial/moderate assist, PERSONAL HYGIENE/ORAL CARE: partial/moderate assist. -All the interventions for resident 37's ADL self-care performance deficit and impaired mobility which identified the assistance required to safely care for resident 1 were initiated on 11/25/25, 11 days after he was admitted . *New admission care plan for the resident's preferred activities was initiated on 11/17/25. *Risk for fall was initiated on 11/19/25. 3. Interview on 12/9/25 at 4:00 p.m. with resident 1 revealed he: *Did not have any teeth but stated he was able to eat soft foods at home. *Had trouble chewing some foods since his admission to the facility because they were tough. *Would like to be involved in his discharge planning because he did not feel he was kept up to date on his goals and discharge information. Review of resident 1's EMR revealed: *He was admitted on [DATE]. *His 10/25/25 BIMS assessment score was 13, which indicated his cognition was intact. *His 10/17/25 admission summary note stated, He is WBAT [weight baring as tolerated] and wears O2 [oxygen] at 2 L/min [liters per minute] via nasal cannula.No dentures or hearing aides [aids]. No teeth. Fax sent to get orders for mech [mechanical] soft due to no teeth or dentures. *A 10/20/25 progress note stated, Presented baseline care plan to resident. Educated on what a care plan is and why it is used. No other questions at this time. -The baseline care plan was reviewed with resident 1 three days after his admission to the facility. Review of resident 1's baseline care plan revealed focus areas of: *The new admission initial/interim care plan was initiated on 10/20/25. *Advanced directive (a document that expresses a person's health care wishes if they become unable to speak for themselves) status was initiated on 10/20/25 that identified the resident's wish to be a DNR (do not resuscitate) code status. *Discharge potential and discharge planning identified resident 1's discharge goal to *** on 10/20/25. *[Resident 1] requires assistance with ADL's [activities of daily living] (bed mobility, transfers, dressing, walking, personal hygiene, eating and toileting) initiated on 10/17/25. -Interventions within the resident ADL focus that were initiated on 10/17/25 were: -Assist resident with shower/bathing per schedule up to 2x/wk [two times per week]. [Resident 1] is able to voice preference of shower or tub bath. -Encourage participation in ADL's. -Keep call lights within reach when in bedroom or bathroom. -Provide DME [durable medical equipment] -wheelchair and walker. -Skilled Rehabilitation Therapy evaluation and treatment as indicated initiated on 10/17/25. *[Resident 1] has an ADL Self Care Performance Deficit and Impaired Mobility initiated on 4/8/25. -Interventions within the focus areas were, BED MOBILITY -partial/moderate assist, TRANSFER: partial/moderate assist, WALKING: supervision/touching assistance with FWW [front wheeled walker], DRESSING: substantial/maximal assist for upper body dressing. Total assist with lower body dressing/footwear, TOILET USE: substantial/maximal assist, PERSONAL HYGIENE/ORAL CARE: partial/moderate assist. -All the interventions for resident 1's ADL self-care performance deficit and impaired mobility which identified the assistance required to safely care for resident 1 were initiated on 10/30/25, 13 days after he was admitted . **New admission care plan for the resident's preferred activities was initiated on 10/27/25. *Alteration in nutritional status interventions initiated on 10/17/25 were Monitor for signs and symptoms of dehydration and weight loss, Obtain weight as ordered, Offer extra fluids if not contraindicated, Provide assistance with meals if indicated, Provide diet and supplements as ordered, and Provide good oral hygiene. -The alteration in nutritional status interventions did not identify that resident 1 did not have teeth and an altered diet order had been requested. 4. Review of resident 20's EMR revealed: *She was admitted to the facility on [DATE]. *She did not have a documented intervention on her care plan until 11/14/25. *Her interventions for activities of daily living (ADL's) in her care plan included: -Assist with application of appliance if needed -Encourage participation in ADL's -Provide durable medical equipment [DME] if needed -Transfer: partial/moderate assist 5. Interview on 12/11/25 at 2:17 p.m. with certified nursing assistant (CNA) P revealed she: *Referred to a paper care plan for new admissions or if she did not know what cares a resident required. *Was also able to access a resident's care plan in the computer in the Kardex (a report of the resident's care needs and interventions). 6. Interview on 12/11/25 at 2:37 p.m. with licensed practical nurse (LPN) I revealed: *The paper care plan referred to by CNA P were printed from each resident's Kardex. *The information on the Kardex was based off each resident's care plan. *The nurse completed the baseline care plan during the admission process on the day the resident was admitted by selecting pre-scripted options on the admission assessment. *The boxes that the nurse checked on admission would then generate the baseline care plan. *Within the focus areas such as nutrition and activities of daily living (ADL) the interventions auto-populated to be the same for every resident. *LPN I verified that resident 1's discharge goal on his baseline care plan was *** and did not identify what resident 1's discharge goal was. 7. Interview on 12/11/25 at 3:13 p.m. with registered nurse [RN]/minimum data set [MDS] coordinator E revealed: *When a new resident arrives to the facility, the nurses fill out a UDA form [UDA or user-defined assessment, a series of questions related to the resident's care with options to choose from that apply to the resident]. -The assessment form has the same choices for every resident. *After the form is filled out by the nurse, she adds the resident's name and any information that those nurses may have missed. *Social services director (SSD)/interim administrator C fills in the rest of the admission form. *She stated that to her knowledge the activities department and dietary department do not document in the baseline care plan. *The assessment selections generate and create the care plan in the resident's electronic medical record [EMR]. *She would expect that each baseline care plan is resident-centered. *She agreed that the certified nursing assistants [CNAs] would not know how to care for a newly admitted resident if the care plan did not specify the type of transfer assistance the resident requires. *She expected base line care plans needed to be completed within 48 hours of admission. *SSD/interim administrator C would review the baseline care plan and provide a copy to the resident or resident representative within 72 hours of admission. *SSD/interim administrator C would document in a progress note in each resident's EMR that the baseline care plan was reviewed with the resident or the resident representative and a copy had been offered to them. 8. Interview on 12/11/25 at 4:04 p.m. with regional nurse consultant D revealed: *She agreed that the baseline care plan should be reviewed with the resident and documented that it was reviewed. *She would expect the baseline care plan to be resident-centered. *She expected the baseline care plan to be completed and reviewed with the resident or resident representative within 48 to 72 hours after the resident was admitted to the facility. *She expected the information in the baseline care plan to be accurate and provide a basis of information that would allow for the staff to provide safe resident-centered care. *She expected each resident to be involved in discharge planning, and the baseline care plan was to identify what the resident's discharge goals were. 9. Review of the providers May 2025 Care Plan policy revealed: *Individual, resident-centered care planning will be initiated upon admission and maintained by the interdisciplinary team throughout the resident's stay. *Each resident is an individual. The personal history, habits, likes and dislikes, life patterns and routines, and personality facets must be addressed in addition to medical/diagnosis-based care considerations. *Care planning is constantly in process; it begins the moment the resident is admitted to the facility and doesn't end until discharge or death. *The director of nursing [DON] will be responsible for holding the team accountable to initiating and completing the admission care plan within 48 hours and the long-term care plan by day 21 and updated as necessary thereafter. *Interventions act as the means to meet the individual's needs. The recipe for care requires active problem solving and creative thinking to attain, and clearly delineates who, what, where, when, and how the individual resident goals are being addressed and met. *Each staff member working with the individual resident is responsible to read, utilize and offer input to improve the care plan content ongoing. *A baseline care plan is started by nursing staff on the first day of admission to provide guidance to direct care givers as soon as possible after admission and completed no later than 48 hours after admission. Nursing, dietary, activities and social services staff complete formal assessments, interviews and observation and begin formulating the full care plan as soon after admission as possible. (These departments do have areas that need to be completed by the 48 hour deadline). *The areas that must be addressed in the baseline care plan include the minimum healthcare information necessary to properly care for a resident including but not limited to: initial goals based on admission orders, physician orders, dietary orders, therapy services, social services, PASARR recommendation, if applicable.

Based on observation, interview, and policy review, the provider failed to ensure standard infection control practices were followed by:*One of one certified nursing assistant (CNA) (L) performed hand hygiene while assisting residents during their dining experience.*One of one CNA (K) performed hand hygiene (handwashing) before putting on gloves and after removing his gloves.*One of one CNA (P) wore personal protective equipment (PPE) (such as a gown and gloves) while providing cares for a resident (4) on contact precautions (a gown and glove were to be worn anytime there was a risk of contact with a resident or objects he may have been in contact with).*Two of two CNAs (K and P) adequately cleaned and disinfected the shower room with a hospital grade disinfectant between residents' showers in two of two shower rooms. Findings include:1. Observation on 12/9/25 between 11:14 a.m. and 11:58 a.m. in the provider's dining room revealed: *Certified nurse assistant [CNA] L sat down at the dining table at 11:47 a.m. between residents 24 and 26. -She grabbed the front handrails of resident 24's wheelchair. She pulled the resident closer to the table. -She turned to resident 26 and pulled resident 26's wheelchair closer to the table. -She did not perform hand hygiene between touching both residents wheelchairs. Continued observation on 12/9/25 at 11:52 a.m. revealed: *CNA L was feeding resident 24 a bite of food. *She turned to resident 26 and provided that other resident a bite of food with the same hand. *She did not perform hand hygiene between feeding the residents with the same hand. 2. Observation on 12/11/25 at 9:52 a.m. of the 100-hall tub room revealed: *In the tub room was a spray bottle of Fabuloso 2x lavender bottle (a household cleaner) and a bottle of Medline Micro-Kill Q3 (a hospital grade disinfectant) on the shelf in the shower. -The Fabuloso was purple in color. *On the inside of the cover of the white laundry basket was a brown smear, and the interior seams of the laundry basket had a dense line of a brown substance on it. *The bucket for under the shower chair had a purple liquid in it. *The seat of the shower chair was wet. *The surrounding walls of the back portion of the shower area were dry. 3. Interview on 12/11/25 at 9:58 a.m. with CNA O revealed: *The Fabuloso 2X was used by the night staff to clean the floor of the tub room. *She used the Micro-Kill disinfectant to spray the shower after she finished showering a resident. She let the Micro-Kill sit on the surface until just before she showered another resident when she would rinse off the surfaces of the shower. 4. Observation and interview on 12/11/25 at 10:32 a.m. with CNA J in the 300-hall shower room revealed: *There were two shower rooms in the facility in the 100 and 300 hallways. *The 100-hall tub room had a bathtub and shower in it, but the 300-hallway shower room only had a shower. *The 300-hall shower room did not get used often. *There was a bottle labeled with the Fabuloso 2X label with a clear colored cloudy liquid. *There was not a bottle of Micro-Kill in the 300-shower room. 5. Interview on 12/11/25 at 12:09 p.m. with nurse consultant D revealed: *She had spoken with the administrator about the Micro-Kill and the Fabuloso 2X. *During the day the housekeeping staff were to use the Micro-Kill to clean the shower room and then use the Fabuloso 2X after, to make the room smell better. *The Micro-Kill was to be used on the shower chair and all the surfaces in the shower as it was a hospital grade disinfectant. *The Fabuloso was left in the shower room because at night the CNAs cleaned the resident wheelchairs with it and then washed the floors of the tub room after they cleaned the wheelchairs. 6. Observation on 12/11/25 at 1:51 p.m. of CNA P as she exited the 100-hall tub room revealed: *She was not wearing a gown or gloves. *She pushed resident 4 on a bath chair, down the hallway, and into his room. *After she pushed resident 4 into his room, she exited the room and put on a gown and gloves and reentered the room. *On the outside of resident 4's room was a sign that indicated he was on contact precautions. 7. Observation and interview on 12/11/25 at 2:00 p.m. with CNA K in the 100-hall tub room revealed: *There was a pair of gloves in the trash can but no gown. *Resident 4's medicated shampoo and a bottle of Baby Magic Wash labeled stock were on the half wall that divided the shower and the rest of the room. -The bottles had water droplets on them. *CNA K pushed the shower chair that was used by resident 4 into the tub room. *He was not wearing a gown or gloves when he entered the tub room. *He applied gloves without having performed hand hygiene. *He removed the bucket from under the shower chair, sprayed the shower chair with Fabuloso 2X and then rinsed it off with water. *Sprayed the shower chair with Micro-Kill and then rinsed it off with water. *He did not spray the surrounding walls or floor of the shower with either the Fabuloso or the Micro-Kill. *CNA K confirmed the shower chair was the one used by resident 4. *He picked up a blanket that had been lying on the tub and placed it in the hamper. *He removed his gloves and did not perform hand hygiene. *He stated the bucket under the shower chair was cleaned with Fabuloso spray and then sprayed with Micro-Kill. He would let the Micro-Kill sit for a little while to dry and if it was not dry, he would dry it off before it was used for another resident. *CNA K did not know if either the Fabuloso or the Micro-Kill had a contact time (the specific duration cleaning/disinfecting product must remain visibly wet on a surface to effectively kill germs, clean, or achieve its intended chemical action). *He picked up the bottle of resident 4's shampoo and the Baby Magic Wash and placed it in a cabinet beside other bottles of shampoos and body washes without cleaning the outside of the bottles. *CNA K exited the tub room and returned with resident 37 to give him a shower. 8. Interview on 12/11/25 at 2:13 p.m. with CNA P revealed: *To clean the shower, she sprayed the purple-colored cleanser on the shower chair and floor and let it sit for a couple minutes and then rinsed it off. *She stated the purple-colored cleaner had a three-minute contact time. *She did not know if the Micro-Kill had a contact time. *She verified she had not worn a gown while she showered resident 4. *She was aware she was supposed to wear a gown and gloves for resident 4's cares because he was on contact precautions. 9. Interview on 12/11/25 at 4:04 p.m. with nurse consultant D revealed: *She would expect all staff to perform hand hygiene per policy. This included when their hands or gloves were soiled, when switching between a dirty procedure and a clean procedure, between glove changes, after assisting one resident and before assisting another resident, and when assisting residents with eating. *She expected PPE to be worn while providing cares if a resident was on EBP or contact precautions. *She expected the tub and shower be cleaned with proper disinfectant between each resident's use. *She verified resident 4's medicated shampoo and the stock bottle of Baby Magic Wash should have been cleaned prior to placing them back in the cabinet because there was the potential for those bottles to have been contaminated with touch or splash due to the proximity to the location in which the resident would have sat while he took a shower. 10. Review of the providers May 2025 Hand Hygiene policy revealed: *Hand hygiene refers to a general term that applied to hand washing, antiseptic handwash, and ABHR [alcohol based hand rub]. *Employees must wash their hands for at least twenty (20) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions. before and after eating or handling food. *The preferred methos of hand hygiene is with ABHR for the following situations: -Before and after direct contact with residents -After contact with the resident's intact skin -After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident. Review of the provider's 1/26/25 Transmission Based Precautions policy revealed: *Facility will use contact precautions in addition to standard precautions for residents known or suspected to have a serious illness easily transmitted by direct resident contact or by contact with items in the resident's environment. *Hand hygiene should be completed prior to donning [putting on] and after removal of gloves. *Gloves should be worn when entering the room and while providing care for the resident. *Gloves should be changes when contaminated (e.g. handling fecal material and wound drainage). *Gloves should be removed before leaving the resident's room and hand hygiene should be performed immediately. *After glove removal and hand hygiene, hands should not touch potentially contaminated environmental surfaces or items. *A gown should be donned prior to entering the room or resident's cubicle. *The gown should be removed before leaving the resident's room. *TRANSPORTATION FOR MEDICALLY NECESSARY REASONS: -When the resident leaves the room, precautions should be maintained to minimize the risk of transmission of pathogens to others and contamination of surfaces or equipment. Review of the provider's 2/25/25 Cleaning and Disinfection of Equipment policy revealed: *Cleaning refers to removal of visible soil (e.g., organic and inorganic material) from objects and surfaces and is normally accomplished manually or mechanically using water with detergents or enzymatic products. *Disinfection: refers to thermal or chemical destruction of pathogenic and other types of microorganisms. *Device classification Noncritical (touches intact skin but not mucous membranes). *Devices (examples) Stethoscopes, tabletops, bedpans, etc. *Spaulding process classification Low-level disinfection. *Hospital disinfectant with label claim for HBV [hepatitis B virus] and HIV [human immunodeficiency virus]. Review of the 2022 Medline Micro-Kill Q3 manufacturer's instructions revealed: *Micro-Kill Q3 is a concentrated one-step disinfectant formulated for general hospital cleaning and the disinfection of hard, nonporous, non-food surfaces. *Three-minute contact time for many bacteria and viruses. Review of the Fabuloso manufacturer's information indicted it was a household cleaner that killed most viruses and bacteria but was not considered a hospital grade disinfectant because it was not indicated to kill HBV or HIV.

Based on observation, interview, record review, Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1 October 2025 review, the provider failed to ensure five of five sampled residents' (4, 7, 8, 19, and 37) Minimum Data Set (MDS) (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) assessments were accurately coded for the areas of weight loss, Pre-admission Screening and Resident Review (PASRR), insulin administration, and pneumococcal (pneumonia) vaccination status.Findings include:1. Interview on 12/9/25 at 4:10 p.m. with resident 8 revealed she had a history of trauma and was receiving counseling services. Review of resident 8's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her diagnoses included delusional disorder (a mental illness where a person holds strong, false beliefs despite evidence to the contrary), anxiety disorder (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability), post-traumatic stress disorder (PTSD) (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), and bipolar disorder (mental condition causing extreme shifts in mood, energy, and activity levels). *She had a level I (1) PASRR completed on 2/14/25 due to a change in her medications. -The Level I PASRR stated, Your Level I screen was submitted for a potential status change. It shows that you have evidence of serious mental illness or an intellectual/developmental disability (IDD). However, your condition does not require further PASRR evaluation at this time because your serious mental illness or IDD treatment needs have not significantly changed since your previous PASRR Level II evaluation. -The facility should mark yes for question A1500 on the MDS 'Is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or related condition?' *There was no Level II PASRR in resident 8's EMR. *Item A1500 in section A of her 9/19/25 comprehensive MDS assessment was coded No to the question Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? -Item A1500 in section A was coded No on resident 8's 4/28/22, 9/9/22, 6/20/23, 10/4/23, and 9/30/24 comprehensive MDS assessments. 2. Review of resident 4's EMR revealed: *He was admitted on [DATE]. *He had a diagnosis of diabetes (a condition involving disruptions in how the body regulates blood sugar). *His blood sugar levels were to be monitored every Monday, Wednesday, and Friday by the nursing staff. *A 11/23/24 physician's order for Trulicity [injectable medication for treating diabetes] Subcutaneous [under the skin in the fatty tissue layer] Solution Pen-Injector 0.75 MG [milligrams]/0.5ML [milliliter] (Dulaglutide) Inject 3 mg subcutaneously one time a day every Sat [Saturday]. *Item N0350A of section N of her 9/9/25 quarterly MDS assessment was coded as she had received insulin injections one times during the seven-day look-back period (the time period over which the resident's condition or status is captured by the MDS assessment) of that MDS. -Trulicity's medication classification was a glucagon-like peptide-1 (GLP-1) agonists, not an insulin. 3. Review of resident 37's EMR revealed: *He was admitted on [DATE]. *He had received a PCV13 (Pneumococcal Conjugate Vaccine) on 10/6/2020. *There was no documentation that he had received other pneumococcal vaccines in his EMR. *There was no documentation that resident 37 had been offered or refused his next dose of a pneumococcal vaccine. *Item O0300A of section O of his 12/2/25 comprehensive MDS assessment was coded as he was up to date on his pneumococcal vaccinations. 4. Review of the Center for Disease Control and Prevention's (CDC) Pneumococcal Vaccine Timing for Adults revealed if someone over the age of [AGE] years of age had received a PCV13 vaccine, it was recommended that a PCV20 or a PCV21 vaccination be administered after one year of having received the PCV13 for their pneumococcal vaccinations to be considered up to date. 5. Review of the Centers for Medicare and Medicaid Services' October 2023 Version 1.18.1 Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual regarding insulin coding in section N revealed: *Review the resident's medication administration records for the 7-day look-back period. *Determine if the resident received insulin injections during the look-back period. *Enter in Item N0350A, the number of days during the 7-day look-back period (or since admission/entry or reentry if less than 7 days) that insulin injections were received. 6. Interview on 12/10/25 at 3:35 p.m. with registered nurse (RN)/MDS coordinator E revealed: *She was RAC-CT (Resident Assessment Coordinator- Certified) credentialed, which meant she completed courses regarding accurate coding of MDS 3.0 assessment and care planning. *She was responsible for ensuring all the residents' MDS assessments were completed accurately. *After reviewing resident 8's level I PASRR RN/MDS coordinator E verified resident 8 had a level II PASRR. -After reviewing resident 8's MDS assessments she verified resident 8's PASRR level II was coded inaccurately on the MDS. -She thought she may have clicked on prior to use the prior MDS data instead of reviewing the resident's EMR for changes. *After review of resident 4's medication orders in his EMR, RN/MDS coordinator E verified he was not on insulin. -She verified his 9/9/25 MDS assessment was coded inaccurately. *RN/MDS coordinator E stated that the residents' immunization information in the MDS auto populates from the resident's EMR system (PCC), and she did not enter the information. *After review of resident 37's MDS assessment she stated there was a triangle located beside the yes to the question regarding whether the resident was up to date on his pneumococcal vaccine. -The triangle indicated she had manually entered the response to the question. *She did not recall why she manually entered that response. *She verified resident 37's 12/2/25 MDS assessment was coded inaccurately. 7. Interview on 12/11/25 at 4:33 p.m. with regional nurse consultant (RNC) D revealed: *It was her expectation that the MDS assessments were coded accurately. *She verified resident 8's MDS assessment related to her PASRR was not coded correctly, resident 4 was not on insulin, and resident 37's pneumococcal immunizations were not up to date. 8. Review of resident 19's EMR revealed: *Her admission date was 5/26/23. *Her 9/15/25 nurse progress weight change note included a weight warning that her weight was 93.4 pounds (lbs), and was a 5.9 percent (%) increase in one month. Her 11/17/25 MDS indicated she had a significant weight loss of 5% (percent) in 30 days or 10% in 180 days. *Her weight record documentation indicated that: -On 11/17/25 she weighed 93.2 lbs., and on 10/17/25 she weighed 90.2 lbs., a weight gain of 3 lbs., this was 3.3% in one month. -On 8/15/25 she weighed 90.8 lbs., a weight gain of 2.4 lbs., a 2.65% on 11/17/25. -On 5/12/25 she weighed 95.6 lbs., a weight loss of 2.4 lbs., a 2.51% on 11/17/25. -The resident did not have a documented significant weight loss of 5% (percent) in 30 days or 10% in 180 days. 9. Review of resident 7's EMR revealed: *Her admission date was 6/6/25. *Review of her 9/12/25 MDS indicated she had a significant weight loss. *Her weight record documentation indicated that: -On 8/11/25 she weighed 97.0 lbs., on 9/9/25 she weighed 102.4 lbs., a weight gain of 5.4 lbs. in one month -On 6/6/25 she weighed 98 lbs., and on 9/9/25 she weighed 102.4 lbs., a weight gain of 4.4 lbs. in 3 months. -The resident did not have a documented significant weight loss of 5% (percent) in 30 days or 10% in 180 days. 10. Review of the CMS Long-Term Care Facility RAI 3.0 User's Manual Version 1.20.1 October 2025 revealed section K Swallowing/Nutritional Status, page 4, definition for weight loss included: DEFINITIONS 5% WEIGHT LOSS IN 30 DAYS Start with the resident's weight closest to 30 days ago [from the ARD] and multiply it by .95 (or 95%). The resulting figure represents a 5% loss from the weight 30 days ago. If the resident's current weight is equal to or less than the resulting figure, the resident has lost weight. 11. Interview on 12/10/25 at 3:35 p.m. with RN/MDS coordinator E revealed: *Certified dietary manager (CDM) F was responsible for completing section K of the residents' MDS assessments. *She expected section K of the MDSs to be completed accurately. 12. Interview and record review on 12/10/25 at 4:01 p.m. with CDM F revealed: *She completed section K of the residents' MDS assessments. *She had limited training on how to complete the MDS. *She was aware there was an RAI manual but was not aware that there were instructions on how to complete section K of the MDS in that manual. *After review of resident 19's EMR and 11/17/25 MDS, CDM F confirmed she miscoded resident 19's weight as a significant weight loss on the MDS, and it should have been coded as a weight gain. -She indicated she used resident 19's weight report information and did not use 30 days from the ARD of 11/17/25 to calculate resident 19's weight gain or loss. *After review of resident 7's EMR and 9/12/25 MDS, she stated she marked the resident's weight loss in error on the MDS, and resident 7 had a weight gain. She was not sure why she coded that error. She confirmed 30 days from that MDS's ARD of 9/12/25 would have been 8/11/25, and resident 7 had weighed 97 lbs.

Based on observation, interview, record review, and policy review, the provider failed to ensure medications for four of four sampled residents (18, 20, 23, and 34) with physician's orders for antifungal powder were labeled and stored according to the provider's policy. Findings include:1. Observation in resident 23's bathroom on 12/9/25 at 10:20 a.m. revealed:*One open bottle of Miconazole 2% powder (a medicated powder used to prevent fungal growth on skin) on the shelf. The bottle had resident 23's first name and last initial handwritten on it. There was no pharmacy label on that bottle.*The bathroom is shared between four residents. 2. Observation and interview on 12/10/25 at 2:42 p.m. with resident 18 in her room revealed:*She had an open bottle of miconazole powder in the drawer of her nightstand. This did not have a resident name handwritten on it or a pharmacy label on it.*The CNAs put that powder on her when she used the bathroom. 3. Interview on 12/10/25 at 2:57 p.m. with CNA M revealed:*The nurses get creams and powders out of the medication room if a resident needed them.*They are typically stored in the resident's bathroom.*They had a daily huddle meeting and the CNAs were told to apply creams from the nurses in those meetings.*She tries to be proactive and would apply creams and powders to the residents to prevent moisture in the resident's skin folds.*She did not document that in the residents' MAR. *She stated that sometimes the nurses would ask the CNAs to apply topical creams and powders. Sometimes the CNAs would apply those items and then tell the nurse they applied them. 4. Interview on 12/11/25 at 4:15 p.m. with regional nurse consultant D revealed:*She agreed that having multiple bottles in the residents' shared bathroom created the potential for not using the correct individual residents' products. *She agreed that the individual that applied the medicated powder should be the individual to document it in the resident's MAR.*She stated that the nurses should not be documenting in the MAR that they gave a medication if they did not administer it or after they instructed the CNA to apply it. 5. Review of resident 18, 20, 23, and 34's EMR revealed:*The physician's order for the Miconazole 2% powder had instructions to apply to intertriginous [areas where skin rubs together and the friction creates moisture and fungal growth] areas two times per day.*Resident 18, 29, 23, and 34 did not have physician's orders to self-administer the Miconazole 2% powder. Review of the provider's January 2018 Medication Storage in the Facility policy revealed:*Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) [are] permitted access to medications.*Medications labeled for individual residents are stored separately from floor stock medications when not in the medication cart.

Based on interview, record review, and policy review, the provider failed to ensure the code status (emergent treatment a person wishes to receive if their heart or breathing would stop) for three of three sampled residents (1, 23, and 37) was currently and accurately documented in the residents' electronic medical records.Findings include:1. Interview on [DATE] at 2:54 p.m. with resident 37 revealed: *The staff had spoken with him when he was admitted about his wishes if his heart were to stop (advanced directives or code status). *He told them he wanted a do not resuscitate (DNR) (no cardiopulmonary resuscitation [CPR] or other heroic measures would be started if his heart or breathing stopped) code status. Review of resident 37's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *His Brief Interview of Mental Status (BIMS) assessment score was 14, which indicated his cognition was intact. *The advanced directives area in the EMR banner (a resident information area on the EMR screen) was blank. *His physician's orders did not include his advanced directives wishes. *His [DATE] admission progress note did not indicate what his resuscitation wishes were. *His EMR documentation did not include his DNR wishes. *His [DATE] care plan indicated on [DATE] his wishes were to be a DNR. *His EMR included his signed advanced directives to initiate CPR, from his previous [DATE] admission to the facility. 2. Review of resident 1' EMR revealed: *He was admitted on [DATE]. *His [DATE] admission progress notes indicated he was a full code [to start CPR if his heart or respirations stop] at this time per wife *On [DATE] resident 1's representative signed a form that indicated a DNR code status. -The physician signed that form on [DATE]. *There was a [DATE] DNR physician's order. 3. Interview on [DATE] at 2:17 p.m. with licensed practical nurse (LPN) I revealed: *A resident's code status could be found under the miscellaneous tab in the resident's EMR, and on the EMR banner. Residents with full code statuses were to have a red dot near their door. *Residents usually were admitted from the hospital with a physician's order that indicated their code status. *Residents are to be asked upon admission what their code status wishes were. *The resident's code status would be updated on the EMR banner by the nurses or medical records person once the order was received from the physician. *If the code status was not documented in the physician orders or on the EMR banner, it could be in the admission progress notes. 4. Interview on [DATE] at 4:27 p.m. with regional nurse consultant D revealed: *The resident's advanced directive was to be entered onto the resident's EMR banner and the physician's orders immediately upon admission to the facility. *She explained she would not wait for a physician's signature on the resident's advanced directive before entering them into the resident's EMR, because the advanced directives were to be based on a resident's wishes not the formality of a physician signature. *She agreed that the time lapse between the resident representative's designating resident 1 as a DNR code status and the physician's signature had the potential for resident 1's advanced directive wishes to not have been followed. *She verified that resident 37 did not have his current advanced directives in his EMR or on his EMR banner. 5. Review of resident 23's EMR revealed: *She was admitted to the facility on [DATE] from the hospital. *Her hospital discharge paperwork included resuscitation status: full resuscitation [fullc code]. *Her EMR banner stated, Advance Directives: DNR [do not resuscitate]. *There was no signed document in her EMR that stated her code status wishes. *Social services director/interim administrator C completed her admission assessments on [DATE]. The note stated DNR code status remains. *Resident 23 confirmed wishes to be DNR status on [DATE]. 6. Interview on [DATE] at 11:10 a.m. with LPN [licensed practical nurse) H revealed: *The facility does not use paper charts. All documents are uploaded to the resident's electronic chart. 7. Interview on [DATE] at 9:29 a.m. with certified nursing assistant (CNA) T revealed: *A resident had a full code status if they had a red dot next to their name on the sign by the door to their room. *The staff could also look at the banner in the resident's EMR to quickly see their code status. 8. Interview on [DATE] at 2:55 p.m. with LPN I revealed: *The nurses were to ask the resident their code status wishes when the resident admitted to the facility. *The signed form was to be sent to medical records staff to scan into the resident's EMR. *The EMR banner was to be updated with the resident's code status by the nurses. *The nurses were to document the resident's choice is for code status in the admission progress note. 9. Interview on [DATE] at 3:13 p.m. with registered nurse (RN)/ minimum data set (MDS) coordinator E revealed: *When a resident admitted to the facility, social services director/interim administrator C was responsible for speaking with the resident about their code status wishes, putting their choice in the resident's care plan, and sending the document to the provider to sign. *Social services director/interim administrator C was not available for interview at the time of the survey. 10. Interview on [DATE] at 7:56 a.m. with regional nurse consultant D revealed that she could not find any signed document in resident 23's EMR regarding her code status. 11. Further interview on [DATE] at 4:38 p.m. with regional nurse consultant D revealed: *She expected the resident's code status to be updated on admission to the facility. *She expected the EMR code status banner and the physician's order to be accurate. *She agreed that the resident's wishes should be updated regardless of having a physician's signature on the document. *She agreed that there was a risk for not following the resident's wishes if the code status was not updated immediately. 12. Review of the provider's [DATE] Advanced Directives policy revealed that: *Each resident was to choose their advance directives on admission. *An advance directive form shall be completed with the resident and/or legal representative to verify treatment options as well as code status. *If the resident is unable or chooses not to initiate any type of advance directive, it is the policy of this facility for the resident to be a full code and to receive appropriate life sustaining treatment interventions such as CPR. *The resident's choice of code status will be added to the physician order sheet. *The resident's advance directive and treatment options/refusals will be documented in the medical record, as well as, care planned during the admission process.

Based on observation, interview, and policy review, the provider failed to ensure food safety standards were followed by three of three employees (certified nursing assistant (L), guest services aide (GSA)/cook R, and cook Q), completed proper hand hygiene during one of one meal service. Findings include: Based on observation, interview, and policy review, the provider failed to ensure three of three employees (certified nursing assistant (L), guest services aide (GSA)/cook R, and cook Q), completed proper hand hygiene during one of one meal service. Findings include: 1. Observation on 12/9/25 between 11:14 a.m. and 11:58 a.m. in the provider's dining room revealed: *Resident 7 was one of the first to arrive in the dining room at 11:19 a.m. She was the second to last resident to be served lunch at 11:58 a.m. *Certified nurse assistant [CNA] L sat down at the dining table at 11:47 a.m. between residents 24 and 26. -She grabbed the front handrails of resident 24's wheelchair. She pulled the resident closer to the table. -She turned to resident 26 and pulled resident 26's wheelchair closer to the table. -She did not perform hand hygiene between touching both residents' wheelchairs. Continued observation on 12/9/25 at 11:52 a.m. revealed: *CNA L was feeding resident 24 a bite of food. *She turned to resident 26 and provided that resident a bite of food with the same hand. *She did not perform hand hygiene between feeding the residents with the same hand. 2. Review of the providers' May 2025 Hand Hygiene policy revealed: *Hand hygiene refers to a general term that applied to hand washing, antiseptic handwash, and ABHR [alcohol based hand rub]. *Employees must wash their hands for at least twenty (20) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions. before and after eating or handling food. *The preferred methos of hand hygiene is with ABHR for the following situations: -Before and after direct contact with residents -After contact with the resident's intact skin -After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident. 3. Observation and interview on 12/9/25 at 11:30 a.m. of meal service revealed: *Guest Services Aide (GSA)/cook R was wearing one-use gloves. -With those gloves, she served chicken teriyaki, fried rice, broccoli, and egg rolls with different utensils. -She then picked up a slice of bread with a pair of tongs and placed it on the plate next to the above food items. -With those same gloved hands, she took a lid off a pan that was in the steam table, took a cheeseburger on a bun that was wrapped in tinfoil from that pan, removed the tinfoil, picked up the cheeseburger bun with the same gloves on, and placed it on a plate. -GSC/cook R completed this routine two more times. -GSC/Cook R confirmed she had used tongs for bread, but not for the cheeseburger in a bun. *She agreed she had potentially contaminated her one-use gloves by touching utensils, tinfoil, and a pan lid before touching the cheeseburger bun. 4. Observation and interview on 12/9/25 at 11:43 a.m. with cook Q revealed: *She had on a one-use glove on one hand, there was no glove on her other hand. *She took a bag of hot dog buns, opened it with both hands, reached into the bag, and took out a hot dog bun with her gloved hand. *Cook Q confirmed she was not aware of all the locations the hotdog bun bag had been before she opened it. -She agreed she had potentially contaminated her one-use gloved hand by touching the hot dog bag, opening it with both hands, and then touching a hot dog bun with her gloved hand. 5. Review of the provider's 2020 Handwashing and Glove Use policy revealed: *Policy: Guidelines for handwashing and glove use to promote safe and sanitary conditions throughout the Food and Nutrition Services Department must be followed. *Gloves: -Gloves may be used for one task only. -It is important to remember that gloves can often give a false sense of security and can carry germs the same as our hands. 6. Interview on 12/11/2025 at 12:14 p.m. with certified dietary manager (CDM) F revealed: *Ready-to-eat food, such as buns, should not be touched with potentially contaminated gloves or ungloved hands. *The provider's process was to use gloves for one task only. *She confirmed GSA/cook R and cook Q had not followed the provider's policy for glove use. 7. Interview on 12/11/25 at 2:34 p.m. with regional nurse consultant (RNC) D stated that she expected staff members to avoid touching food with gloved or ungloved hands that could be potentially contaminated.

Based on observation, interview, and policy review, the provider failed to ensure two of two sampled residents (19 and 35), who received an altered texture therapeutic diet of pureed food, received the required nutritional value and the required amount of pureed food served to them. Findings include: 1. Observation and interview on 12/9/25 at 11:10 a.m. with cook Q revealed that pureed broccoli was prepared with water. [NAME] Q stated the cooks were trained that pureeing broccoli with water was appropriate. She reported that she often used water to puree vegetables and used broth as the liquid to puree other foods. [NAME] Q agreed that using water to puree vegetables would reduce the nutritional value of the vegetables. Observation on 12/9/25 at 11:43 a.m. of cook R in the kitchen revealed cook R dished the pureed food items by pouring the food from a pan without using a scoop to measure the amounts of those foods. Review of resident 19's electronic medical record (EMR) revealed a physician-ordered diet of puree texture. Review of resident 35's EMR revealed a physician-ordered diet of puree texture. Interview on 12/11/2025 at 12:14 p.m. with certified dietary manager (CDM) F regarding pureed food revealed:*The proper serving of pureed foods included the use of the correct-sized scoop according to what was listed on the menu spreadsheet, and pureed foods were not to be poured from a pan without measuring.*There was a color-coded instruction sheet posted in the kitchen that indicated the scoop size to be used when serving foods.*Foods were to be pureed with a liquid that contained nutritional value.-Water had no nutritional value and should not be used to puree food. Review of the provider's 2020 Pureed Food Preparation policy revealed:*Pureed foods will be prepared using standardized recipes to ensure quality, flavor, palatability, and maximum nutritive value.*Recipes will not use water to thin pureed foods. Only broth, milk, juice, gravy, margarine or another appropriate condiment that preserves flavor shall be used.*Serve with appropriate scoop number or divide equally to provide an equal number of portions. All the pureed food must be used in order to deliver the correct nutrient density to each resident. Review of the provider's 2020 Menu Diet Spreadsheets/Portion Serving Communication Tool revealed:*Diet spreadsheets are based on the planned menu and reflect serving portions for regular and therapeutic diet orders offered in the community.*Diet spreadsheets are dated for each day of the menu cycle and are reviewed and approved by the registered dietitian. Interview on 12/11/25 at 2:34 p.m. with regional nurse consultant D regarding serving of pureed food revealed:*A scoop was to be used for measuring the amount of pureed food to be provided to each resident on a therapeutic pureed diet.*Water had no nutritional value.*She confirmed the provider's policies regarding Pureed Food Preparation and Menu Diet Spreadsheets/Portion Serving Communication were not followed by cooks Q and R.

Based on observation, interview, and record review, the provider failed to ensure two of two sampled residents (1 and 17) who used side rails (bars attached to the bed) had documented alternatives attempted prior to the implementation of using those side rails and the risks and benefits of using those side rails were reviewed with the resident or the resident's representative.Findings include:1. Observation and interview on 12/09/25 at 9:35 a.m. of resident 17's room revealed:*There were two quarter-length side rails in the up position at the head of her bed.*She used the side rails to change position herself in bed and to help transfer herself in and out of bed.Review of resident 17's electronic medical record (EMR) revealed:*She was admitted on [DATE].*Her 10/21/25 Brief Interview of Mental Status (BIMS) assessment score of 15, indicated her cognition was intact.*A 10/15/25 physician's order for, Enabler bars [side rails] in [on] both sides of [her] bed to help [her] with repositioning.*Her 10/15/25 Side rail/Other Device Evaluation assessment indicated she requested the side rail, so that she is able to reposition self [herself] and also [to] help staff.-The check box in front of the Select any/all alternatives that have been attempted was Other and within the Specify other alterative(s) Enabler bars on both sides of bed was documented as the intervention attempted prior to the installation of the side rails.-The assessment did not include if any alternatives were attempted prior to the implementation of those side rails.-Resident 17 gave consent for the installation of the side rails on 10/15/25 at 3:45 p.m.-There was no documentation of what the risks and benefits of the side were or if the risk and benefits were reviewed with resident 17 prior to her consent for the installation of the side rails.2. Observation on 12/9/25 at 4:00 p.m. of resident 1's room revealed two quarter-length side rails in the up position at the head of his bed.Review of resident 1's EMR revealed:*He was admitted on [DATE]*His 10/25/25 BIMS assessment score was 13, which indicated his cognition was intact.*A 10/20/25 physician's order for, Bilateral enabler bars on the bed to help with repositioning for [the] resident.*His 10/17/25 Side rail/Other Device Evaluation assessment indicated he requested the side rail, so that he is able to reposition [himself] when in bed.-The check box in front of the Select any/all alternatives that have been attempted was Other and within the Specify other alterative(s) enabler bars was documented as the intervention attempted prior to the installation of the side rails.-The assessment did not include if any alternatives were attempted prior to the implementation of the side rails.-Resident 1's resident representative gave consent for the installation of the side rail on 10/17/25 at 1:00 p.m.-There was no documentation of what the risks and benefits of the side were or if the risks and benefits were reviewed with resident 1 or his representative prior to his representative giving consent for the installation of those side rails.3. Interview on 12/10/25 at 2:46 p.m. with licensed practical nurse (LPN) I revealed:*If a resident would request side rails, or if a staff member would think a resident would benefit from a side rail the nurse would request a physician's order for the use of a side rail.*When the physician's order for the side rail was received the nurse would complete the Side rail/Other Device Evaluation assessment.*A request would then be made for maintenance to install the side rails on the resident's bed.*The interdisciplinary team (IDT) would discuss the potential for the installation of side rails on a resident's bed and determine if there was an alternative that could be attempted before the side rails were implemented.*Therapy was involved with some residents when a side rail was requested or recommended.*Not all residents who requested a side rail or were suggested to use a side rail by a staff member, had alternatives attempted prior to the installation of the side rail*LPN I stated the nurses would obtain consent from the resident or the resident's representative when completing the Side rail/Other Device Evaluation assessment.*She verified the resident's risks and benefits for the use of a side rail was not included in the Side rail/Other Device Evaluation assessment.4. Interview on 12/11/25 at 4:21 p.m. with regional nurse consultant D revealed:*The provider did not have a policy related to the side rails if the side rails were not determined to be a restraint.*She stated the resident or resident's representative would give consent for the use of the side rails and the review of the risks versus benefits of the side rails would be part of the consent process.*She did not know if the provider attempted any alternatives prior to the installation of the side rails or where that would have been documented.

Based on observation, interview, record review, and policy review, the provider failed to ensure their policy was followed for:*Medication administration documentation for four of four sampled residents (18, 20, 23, and 34) with physician's orders for antifungal powder according to the provider's policy.*Implemented for one of one resident (5) who had physician-ordered speech services. Findings include: 1. Observation in resident 23's bathroom on 12/9/25 at 10:20 a.m. revealed: *One open bottle of Miconazole 2% powder (a medicated powder used to prevent fungal growth on skin) on the shelf. The bottle had resident 23's first name and last initial handwritten on it. There was no pharmacy label on that bottle. *This bathroom was shared between 4 residents. 2. Observation and interview on 12/10/25 at 2:42 p.m. with resident 18 in her room revealed: *She had an open bottle of miconazole powder in the drawer of her nightstand. This did not have a resident name handwritten on it or a pharmacy label on it. *The CNA's would put that powder on her when she used the bathroom. 3. Interview on 12/10/25 at 2:57 p.m. with CNA M revealed: *The nurses get creams and powders out of the medication room if a resident needed them. *They had a daily huddle meeting and the CNA's were told to apply creams from the nurses in those meetings. *She tried to be proactive and would apply creams and powders to the residents to prevent moisture in the resident's skin folds. *She did not document that that in the residents' medication administration records (MAR). *She stated that sometimes the nurses would ask the CNAs to apply topical creams and powders. Sometimes the CNAs will apply those items and then tell the nurse they applied them. 4. Interview on 12/11/25 at 4:15 p.m. with regional nurse consultant D revealed: *She agreed that the individual who applied the medicated powder should be the individual to document it in the resident's MAR. *She agreed that having multiple bottles in the residents' shared bathroom created the potential for not using the correct individual residents' products. *She stated that the nurses should not be documenting in the MAR that they gave a medication if they did not administer it or after they instructed a CNA to apply it. 5. Review of resident 18, 20, 23, and 34's EMR revealed: *The physician's order for the Miconazole 2% powder had instructions to apply to intertriginous [areas where skin rubs together and the friction creates moisture and fungal growth] areas two times per day. *Residents 18, 29, 23, and 34 did not have physician's orders to self-administer the Miconazole 2% powder. 6. Review of the provider's 5/20/22 CNA job description revealed the CNAs were expected to: *performs various tasks assigned by the floor nurse. *completes medical records documenting care provided. 7. Review of the provider's December 2019 Medication Administration – General Guidelines policy revealed: *Medications are prepared only by licensed nursing, medical, pharmacy, or other personnel authorized by state laws and regulations to prepare and administer medications. *The person who prepares the dose for administration is the person who administers the dose. *Residents can self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. *The individual who administers the medication dose records the administration on the resident's MAR/eMAR directly after the medication is given. 8. Observation and interview on 12/9/25 at 9:24 a.m. with resident 5 in his room revealed: *His clothes appeared to be too big for him. *He was hard of hearing and did not respond to questions. *He looked at his watch, said it was 9:30, and then stated, I don't know but think it is night. 9. Review of resident 5's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *His 10/7/25 Brief Interview of Mental Status assessment score was a 4, which indicated his cognition was severely impaired. *His diagnoses included: Alzheimer's disease (a progressive and irreversible brain disorder that affects memory, thinking, social abilities, and body functions), dysphagia (difficulty or discomfort in swallowing food or liquids, potentially leading to serious complications like aspiration pneumonia), protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), and need for assistance with personal cares. *He was hospitalized from [DATE] to 4/7/25 for aspiration pneumonia (an upper respiratory infection). *There was a 4/7/25 physician order for speech therapy services. 10. Interview on 12/10/25 at 11:36 a.m. with regional nurse consultant (RNC) D regarding resident 5's 4/7/25 physician-ordered speech therapy, revealed that there were no documented speech therapy evaluations or treatments for resident 5. 11. Follow-up interview on 12/10/2025 at 1:50 p.m. with RNC D regarding resident 5's 4/7/25 physician-ordered speech therapy revealed that she had visited with the provider's therapy department, and resident 5 had not received speech therapy services. 12. Review of the provider's 11/18/25 Following Physician Orders revealed All physician orders should be followed as written. The prescriber should be contacted if any order is not clear/understood. The physician should be notified when an order is not followed for any reason (omission, medication not in stock, repeated resident refusals for medication/treatments, etc.). 13. Interview and review of the providers' above policy regarding following the physician's orders on 12/11/25 at 1:41 p.m. with RNC D revealed that the staff did not follow that policy related to resident 5's 4/7/25 physician's order for speech therapy.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, interview, and document review, the provider failed to ensure one of one resident's (1) right to refuse a vaccination was honored. Failure to do so resulted in the resident receiving the vaccine and voicing feelings of frustration as she was not able to make her own decision. This citation is considered past non-compliance based on review of the corrective actions the provider implemented immediately following the incident. Findings include: 1. Review of the provider's 10/22/24 SD DOH FRI and resident 1's electronic medical record revealed: *There was a COVID-19 vaccination clinic at the facility on 10/22/24. *Licensed practical nurse (LPN) D told resident 1 that you can't refuse it when she referenced the COVID-19 vaccine. *The resident was upset and asked, 'I can't even make my own decisions?' *The resident was given the vaccine after voicing that she did not want the vaccine. *Resident 1's power of attorney (POA) declined the COVID-19 vaccine on 9/11/24. *LPN D misread the vaccine declination form and mistakenly thought that resident 1's POA consented for resident 1 to receive the COVID-19 vaccine. *Facility staff were re-educated on resident rights. 2. Interview on 11/26/24 at 1:18 p.m. with resident 1 revealed: *When asked if staff allow her to make choices about her life that matter to her, she stated, You have to do what they say. *She was able to recall the incident with the COVID-19 vaccine and expressed her frustration verbally by saying, I felt like I couldn't make any decisions for myself, and physically by grimacing. *She said that LPN D insisted on giving her the vaccine, stating that her family wanted her to receive the vaccine. 3. Interview on 11/26/24 at 2:12 p.m. with LPN D revealed: *To prepare for the vaccination clinic, she printed a resident list and marked which residents had a vaccination consent form on file. *She misread resident 1's form and mistakenly thought that the resident's POA had consented for her to receive the COVID-19 vaccine. *She confirmed that resident 1 verbalized that she did not want the vaccine. *She told the resident that her family wanted her to receive the vaccine. *Resident 1 brought herself to the vaccine station and received the COVID-19 vaccine. *After it was discovered that resident 1 received the unwanted vaccine, she received verbal education about resident rights and double-checking orders and consent forms if a resident refused. *She was also assigned additional online education about resident rights and their abuse/neglect policy. 4. Interview on 11/26/24 at 2:43 p.m. with social services designee C revealed: *She noticed that resident 1 was upset and asked what was going on. *The resident told her about having received the COVID-19 vaccination when she did not want to. *She immediately informed director of nursing (DON) B about the situation. *They contacted resident 1's POA to explain the situation and the POA verbalized acceptance that she had received the vaccine. *She worked with DON B to conduct a facility-wide audit to determine if there were any other vaccination errors. -They did not find any other errors. *All staff were assigned additional online training about resident rights and the abuse/neglect policy. *Resident 1 had not verbalized any further frustrations regarding the incident. 5. Interviews with other residents throughout the survey revealed no other concerns regarding resident rights and choices. 6. Interviews with other staff members throughout the survey revealed appropriate follow-up actions about resident refusals and resident rights were completed. 7. Interview on 11/26/24 at around 3:30 p.m. with administrator A and DON B revealed: *An investigation was initiated immediately to determine the extent of the situation. *LPN D was suspended pending the investigation. *No other vaccination errors were identified. *They determined that LPN D made a medication error. *LPN D, along with all staff, were re-educated about resident rights and how to respond to a resident if they refuse a service. 8. Review of staff training records revealed all staff were assigned and re-educated about resident rights and the provider's abuse/neglect policy. 9. The provider's implemented actions to ensure the deficient practice does not reoccur was confirmed on 11/26/24 after record review revealed the facility had followed their quality assurance process, education was provided to all staff about resident rights, and interviews revealed staff understood the education provided regarding those topics. Based on the above information, non-compliance at F578 was discovered on 10/22/24, and based on the provider's implemented corrective actions for the deficient practice confirmed on 11/26/24, the non-compliance is considered past non-compliance.

A. Based on observation, interview, and policy review, the provider failed to ensure one of one registered nurse (RN) unit manager C had performed glove changes during a dressing change for one of one sampled resident (15). Findings include: 1. 0bservation on 7/30/24 at 9:16 a.m. of RN unit manager C performing a dressing change with resident 15 revealed: *She applied PPE (personal protective equipment). *She wheeled a tray into the room and laid a barrier down for the dressing supplies. *She placed the dressing supply container on a pillow in the resident's wheelchair. *She lowered the blinds in the resident's room. *With those same gloved hands she: -Adjusted the tray. -Lowered resident 15's shorts and brief. -Retrieved her walkie from her pocket and used it. -Assisted resident 15 to the bathroom with his shorts and brief half way down. -Pulled his walker from out in front of him. -Retrieved a garbage bag. -Removed the resident's soiled shorts and brief. -Retrieved her walkie and used it again. -Removed the resident's socks. -Used a peri wipe to clean feces from his legs. -She removed those gloves and performed hand hygiene. *She applied a new pair of gloves and retrieved a clean brief and a pair of the resident's shorts. *With those same gloved hands she assisted him with a new pair of gripper socks and provided peri care. *She removed her gloves and performed hand hygiene and put on a new pair of gloves. *With those gloved hands she: -Used wound cleanser and cleaned the wound with gauze. -Opened the collagen packet, and applied ointment to the resident's wound bed. -Removed her gloves, performed hand hygiene and applied a new pair of gloves. *She poured collagen onto her gloved hand and applied it to the wound. *She asked for assistance to retrieve a sharpie marker from her pocket and used it to date the dressing. *She applied skin prep around the wound, applied the dressing to resident 15's coccyx, and removed his soiled shorts. *She removed those gloves and performed hand hygiene. *She applied a new pair of gloves and with those gloved hands she: -Assisted with dressing the resident with a new pair of shorts. -Cleaned the feces off of the floor and removed the garbage from her tray. -Continued to clean the feces off of the floor. -Removed the garbage bags and dirty laundry bag. -Replaced the garbage bags in the two garbage bins. -Opened the resident's blinds. *She removed her gown and gloves and performed hand hygiene. *She retrieved the resident's dressing supplies from the tray and placed them in the garbage, and removed her gloves. *She performed hand hygiene and applyied a new pair of gloves. *Used sani-wipes to clean her dressing tray. *She then removed those gloves and without washing her hands she, replaced the dressing supply container back into the medication cart without sanitizing it. Interview on 7/31/24 at 2:41 p.m. with RN unit manager C regarding the above dressing change revealed: *She agreed that she had missed some opportunities when she should have changed her gloves or washed her hands. *She agreed her pocket was not a clean area for her marker to have been placed and then used. *She agreed she had performed unclean tasks and then opened the resident's blinds with soiled gloves or washed hands. *She agreed she had not sanitized the resident's dressing box before she returned it to the medication cart. Interview on 7/31/24 at 3:30 p.m. with director of nursing (DON) B and regional nurse consultant H regarding the observed dressing change revealed: *They agreed that RN unit manager C should have changed her gloves when going from a dirty task to a clean task. *They agreed that RN unit manager C should have sanitized resident 15's dressing container prior to putting it back in the medication cart. Review of the provider's February 2024 Hand Hygiene Policy revealed: *Before moving from a contaminated body site to a clean body site during resident care, (e.g., after cleaning perineal area and prior to proceeding to another area of body or dressing resident. Gloves should be removed, hand hygiene performed and new pair of gloves applied). 49958 B. Based on observation, interview, and policy review the provider failed to ensure: *One of nine sampled residents (11) had been placed on enhanced barrier precautions (EBP). Findings include: 1.Observation and interview on 7/29/24 at 4:24 p.m. with resident 11 revealed: *She had returned from the hospital a few days ago after a surgical procedure for a wound on her left leg. *There was a wound vacuum (a device that removes pressure and fluid from a wound) on the arm of her recliner and attached to her left lower leg., *There had not been any signage on the door that indicated she was on EBP. Observation on 7/30/24 at 11:45 a.m. with resident 11 revealed: *The director of rehabilitation (DOR) G was standing in resident 11's bathroom doorway when the surveyor entered the room. -She was not wearing a gown or gloves. -She stated she was assisting the resident with toileting and asked the surveyor to come back in a few minutes. Interview on 7/30/24 at 1:25 p.m. with resident 11 revealed staff does not wear a gown when providing any of her care, however, they wore gloves for personal private area care. Observation and interview on 7/31/24 at 8:44 a.m. with DOR G revealed: *She was in resident 11's room. -Resident 11's room had a sign on the door that indicated EBP were to be followed and a cart outside that room contained gowns and gloves. *She stated, Gowns and gloves are needed if we are doing ADL [activities of daily living] tasks; like if she needs toileting. *She confirmed that she had worked on toileting with resident 11 on 7/30/24 and that the sign indicating EBP and the cart with gowns and gloves had not been there at that time. *She did not know when EBP had started for resident 11. Interview on 7/31/24 at 2:58 p.m. with director of nursing (DON) B: revealed: *Resident 11 was readmitted to the facility on [DATE] with a wound vacuum device to her left lower leg. *She expected that all residents with a wound would be on EBP. Review of the provider's June 21, 2024 Enhanced Barrier Precautions policy revealed Enhanced Barrier Precautions (EBP) should be used for all residents with wounds or indwelling devices. 50916 C. Based on observation, interview, and policy review, the provider failed to ensure appropriate glove use, hand hygiene, and catheter care technique had been performed during one of one sampled resident's (27) foley catheter care by one of one certified nursing assistant (CNA) D. Findings include: 1.Observation and interview on 7/31/24 at 1:52 p.m. with resident 27 during his foley catheter care revealed CNA D: *Did not perform hand hygiene before she put on personal protective equipment (PPE) for resident 27 who was on enhanced barrier precautions (EBP). *She did not change gloves or wash her hands after she emptied the foley catheter and began his catheter care. *She cleaned the resident's groin area first and ended at the catheter insertion site with that same towel. *She placed the unclean, wet towel on a dry towel, which she then used to dry the resident. *She did not change her gloves or wash her hands before, during, or after she provided catheter cares for the resident. *When asked about hand hygiene and changing gloves during resident cares, CNA D stated if she already had been wearing gloves, she would have performed all of cares for the resident and she would only have changed them if she was going to help another resident with their cares. Interview on 7/31/24 at 3:23 p.m. with registered nurse unit manager F revealed: *The CNA should have washed her hands before she applied PPE, after she emptied the foley catheter, and whenever she would have gone from soiled to clean items. *The CNA should have cleaned from the catheter insertion site and worked outward to not introduce bacteria to the opening. *She stated the groin should have been cleaned last. *She would have expected staff to have used clean wipes or towels after each time the area was wiped. Review of the provider's revised February 20, 2024, Hand Hygiene policy revealed: *Hand hygiene with alcohol-based hand rub must be done: -7) b. When entering and leaving a Resident care area/room. - c. Before donning and after removing gloves. - g.after cleaning perineal area and prior to proceeding to another area of body or dressing resident. Gloves should be removed, hand hygiene performed, and new pair of gloves applied. - h. After contact with residents' intact skin. - k. After contact with body fluids .

Based on observation, manufacturers' instructions review, and policy review the provider failed to ensure two of two randomly observed residents' (21 and 26) insulin had been administered according to the instructions for use by one of one registered nurse (RN) F. Those observations created a medication error rate of 9.68%. Findings include: 1.Observation on 7/30/24 at 7:59 a.m. with RN F during resident 21's Aspart and Degludec insulin administration revealed: *She had not primed the Aspart insulin pen needle prior to setting the dose of insulin. *She had not primed the Degludec insulin pen needle prior to setting the dose of insulin. *She administered the insulin to resident 21. 2.Observation on 7/30/24 at 10:57 a.m. with RN F during resident 26's Lispro insulin administration revealed: *She had not primed the Lispro insulin pen needle prior to setting the dose of of insulin. *She administered the insulin to resident 26. Review of the 2020 Insulin Lispro Injection KwikPen manufacturer's instructions for Use obtained from the Lispro Injection KwikPen box on 7/30/24 revealed: *Prime before each injection. *If you do not prime before each injection, you may get too much or too little insulin. *Instructions to prime insulin pen: -The dose knob should be set to two units. -While holding the pen with the needle pointing up, tap the cartridge to move the bubbles to the top. -Push the dose knob until 0 is seen in the dose window. -Insulin should be seen at the tip of the needle. -If insulin is not there, then repeat priming steps. Review of the provider's revised January 2018 Specific Medication Administration Procedure policy revealed: *For pen devices, dial dose as instructed by pen manufacturer. *There was no mention of specific use for insulin pen devices.

Based on record review, interview, observation, and policy review, the provider failed to ensure resident care plans were revised to reflect the current enhanced barrier precautions (EBP) need for three of eight sampled residents (11, 15, and 32) who required EBP. Findings include: 1. Review of resident 11's Skin Alteration Evaluation completed on 7/22/24 revealed resident 11 had a pressure ulcer (damaged skin and tissue caused by sustained pressure) to her left calf. Review of resident 11's care plan revealed: *[Resident 11] has an actual impairment to skin integrity due to left calf hematoma and pressure ulcer. *It had not been revised to indicate the need for EBP. Interview on 7/31/24 at 2:58 p.m. with director of nursing (DON) B: revealed: *Resident 11 was readmitted to the facility on [DATE] with a wound vacuum (a device that removes pressure and fluid from a wound) to her left lower leg. *She expected that all residents with a wound would be on EBP. *She would have updated a care plan at the resident care conferences or whenever something changed. *She confirmed that resident 11's care plan had not been updated to reflect EBP. Review of the provider's August 23, 2023 Advanced Care Planning policy revealed it was a process used to identify and update the residence preferences regarding care and treatment . 50935 2. Observation on 7/29/24 at 4:19 p.m. of residents 15 and 32's doors revealed they had Enhanced Barrier Precautions (EBP) signs hung on their doors with drawered bins of PPE available outside of those resident's rooms. Review of resident 32's care plan revealed: *The resident had an indwelling foley catheter. *Her care plan did not indicate the need for Enhanced Barrier Precautions (EBP). Review of resident 15's care plan revealed: *The resident had an open wound to his coccyx region. *His care plan did not indicate the need for EBP. Interview on 7/31/24 at 2:27 p.m. with registered nurse (RN) unit manager C revealed: *She believed EBP would have been indicated in the resident's care plans. *She and DON B were responsible for updating resident's care plans. Interview on 7/31/24 at 3:00 p.m. with DON B revealed: *Residents 15 and 32 should have EBP included in their care plans. *Verified EBP had not been revised on their care plans. Review of the provider's September 2019 Care Plan policy revealed: *Data/Problems/Needs/Concerns are a culmination of resident social and medical history, assessment results and interpretation, ancillary service tracking, pattern identification, and personal information forming the foundation of the care plan. The care plan is broken down into separate focus areas: Psycho-Social, Quality of Life, Comfort/Pain/Sleep, Death & Dying, Behavior, Communication, Nutritional Status, Bowel & Bladder Function, Hygiene ADL's/Skin, Safety/Vulnerability, Mobility/Fall Prevention, Medications and Special Attention for Other Physical Conditions. *Care plans should be updated between care conferences to reflect current care needs of the individual resident as changes occur.

Based on observation, interview, record review, and policy review, the provider failed to dispose of expired medications in one of one Nexsys automated dispensing cabinet (ADC). Findings include: 1. Observation and Interview on 4/12/23 at 3:36 p.m. with director of nursing B during an inspection of the medication room revealed: *She was on the phone with the provider's contracted pharmacy to clarify the process for how she would remove expired medications from the Nexsys ADC. *On 3/31/23, the pharmacy had emailed her a list of expired medications in the Nexsys ADC. *Medications she should have removed from the Nexsys ADC included the following: -Prednisone 5 milligrams (mg) 20 tablets expired on 1/31/23. -Acyclovir 400 mg 10 tablets expired on 3/31/23. -Amoxicillin/Clavulanic Acid 875/125 mg 12 tablets expired on 12/31/22. -Simvastatin 10 mg 10 tablets expired on 3/31/23. -Risperidone 1 mg 14 tablets expired on 1/31/23. -Meclizine 12.5 mg 8 tablets expired on 10/31/22. -Olanzapine 5 mg 3 tablets expired on 3/31/23. -Memantine 5 mg 10 tablets expired on 3/31/23. -Phytonadione 5 mg 2 tablets expired on 2/28/23. -Celecoxib 100 mg 8 tablets expired on 10/31/22. -Scopolamine 1 mg transdermal 2 patches expired 3/23. -Piperacillin/Tazobactam 2.25 gram (gm) 4 vials expired 11/2022. -Meropenem 500 mg 5 vials expired 2/23. -Ampicillin/Sulbactam 1.5 gm 4 vials expired 2/23. -Hydrocodone/Acetaminophen 7.5/325 mg 10 tablets expired 3/2023. Review of the provider's undated Medication Destruction For Non-Controlled and Controlled Medications policies revealed: *Unused, unwanted and non-returnable medications should be removed from their storage area and secured until destroyed. *There was no documentation in the policy regarding when an audit of the Nexsys ADC should have been completed. *There was no procedure in the policy for ensuring medications were removed by the expiration date. 48058

Based on interview, record review, and policy review, the provider failed to ensure three of three newly admitted sampled residents (228, 229, and 230) had a baseline care plan that had been established and reviewed with the resident, their representative, or their responsible family member. Findings include: 1. Review of residents 228, 229, and 230 revealed no baseline care plan. There was no documentation that the resident, their representative, or their responsible family member and received the baseline care plan. Interview on 4/13/23 at 11:15 a.m. with SSD F revealed she was not aware of any baseline care plan requirement. She only provided a copy of the comprehensive care plan to the resident and/or representative at the care conference meetings. Interview on 4/13/23 at 11:30 a.m. with licensed practical nurse H revealed: *When a resident was admitted the nurse completed the initial assessment. *She had not completed a baseline care plan to give to the resident, their representative, and/or their responsible family member Interview 4/13/23 at 3:30 p.m. with emergency permit holder A revealed no baseline care plans had been completed for residents 228, 229, and 230. Interview on 4/14/23 at 8:00 a.m. with director of nursing (DON) B revealed she thought social services director (SSD) F completed the baseline care plan for a newly admitted resident. She would have then presented it to the resident, their representative, or their responsible family member for their review. Review of the provider's September 2019 Care Planning policy revealed the DON was responsible for holding the team accountable to initiate and complete the admission care plan within 48 hours.

Based on record review and interview, the provider failed to ensure Minimum Data Set (MDS) assessments for 5 of 13 sampled residents (4, 5, 9, 13, and 17) were completed in a timely manner. Findings include: 1. Review of Section C. Cognitive Patterns in the significant change in status MDS, with an assessment reference date (ARD) of 12/27/22 in resident 4's electronic medical record (EMR) revealed: *Item C0100 Should Brief Interview for Mental Status [BIMS] be conducted? was coded as Yes. *The interview items C0200 to C0400 were coded as Not assessed. *Section C was signed by social services director (SSD) F on 12/29/22. Review of the user-defined assessments (UDA) that supported the coding on the MDS in resident'4 EMR revealed the social services UDA for the 12/27/22 MDS had not been completed. Review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, dated October 2019, revealed: *On page 2-9, the ARD refers to the last day of the observation (or 'look back') period that the assessment covers for the resident. *On page C-2, the BIMS interview is conducted during the look-back period of the ARD and if the interview was not conducted within the look-back period (preferably the day before or the day of) .the standard 'no information' code (a dash) was entered in the interview items. 2. Review of Section F. Preferences for Routine and Activities in the annual MDS with an ARD of 9/14/22 in resident 5's EMR revealed: *Item F0300, Should Interview for Daily and Activity Preferences be conducted? was coded as Not assessed. *All the interview items in F0400 and F0500 were coded as Not assessed. *Item F0700, Should the Staff Assessment for Daily and Activity Preferences be conducted? was coded as Not assessed. *All the items in F0800 were marked with a dash, which was appropriate if staff were unable to determine the responses. *Section F was signed by Registered Nurse - Clinical Care Coordinator (RN - CCC) M on 9/29/22, 16 days after the start date of 9/14/22. Review of the CMS RAI 3.0 User's Manual, Version 1.17.1, dated October 2019, revealed: *On page 2-19, an annual MDS was required to be completed no later than 14 calendar days after the ARD. *On page F-2, the is conducted during the look-back period of the ARD and if the interview was not conducted within the look-back period .the standard 'no information' code (a dash) was entered in the interview items. Review of UDAs in resident 5's EMR revealed no activity evaluation had been completed for the 9/14/22 MDS, and the most recent activity evaluation was dated 9/22/21. Interview on 4/13/23 at 3:01 p.m. with director of nursing (DON) B revealed: *Activity director (AD) L confirmed she had missed completing her activity evaluation UDA. *AD L had started in her position in April 2022. Review of Section C. Cognitive Patterns in the 12/15/22 and 3/17/23 quarterly MDS assessments for resident 5 revealed: *Items C0100 Should Brief Interview for Mental Status [BIMS] be conducted? in both MDSs were as Yes. *The interview items in C0200 to C0400 were in both MDSs were coded as Not assessed. *Both MDSs were signed by SSD F. 3. Review of Section F. Preferences for Routine and Activities in the annual MDS with an ARD of 6/28/22 in resident 9's EMR revealed: *Item F0300, Should Interview for Daily and Activity Preferences be conducted? was coded as Yes. *All the interview items in F0400 and F0500 were coded as Not assessed. *Those items were signed by RN - CCC N on 7/6/22. Review of UDAs in resident 9's EMR revealed the activity evaluation for the 6/28/22 MDS had not been completed. 4. Review of Section C. Cognitive Patterns for the quarterly MDS with an ARD of 4/21/22 in resident 17's EMR revealed: *Item C0100 Should Brief Interview for Mental Status [BIMS] be conducted? was coded as Yes. *The interview items in C0200 to C0400 were coded as Not assessed. *Item C0600, Should the Staff Assessment for Mental Status be conducted? was coded as Not assessed. *Items in C0700 through C1000 and C1310 were coded as Not assessed. *Section C was signed by SSD F on 4/28/22. 26632 5. Review of Section C. Cognitive Patterns for the 2/19/23 quarterly MDS for resident 13 revealed: *Item C0100 Should Brief Interview for Mental Status [BIMS] be conducted? was coded as Yes. *The interview items in C0200 to C0400 were coded as Not assessed. *Item C0600, Should the Staff Assessment for Mental Status be conducted? was coded as Yes. *Section C was signed by SSD F on 2/20/23. Interview on 4/13/23 at 10:30 a.m. with SSD F revealed: *She was not able to complete the BIMS within the required MDS time frame so she had to code the interview items with dashes. *Section C BIMS items were to have been completed by 2/19/23. *She agreed the answers for Section C did not accurately reflect resident 13's cognitive status. *She had not discussed her inability to complete this section with the MDS coordinator.

Based on interview, medical record review, and document review, the provider failed to notify two of thirteen sampled residents (12 and 20) of a room and/or roommate change. Findings include: 1. Interview on 4/12/23 at 2:57 p.m. with resident 20 regarding her room and roommate revealed she: *Said there was kind of a ruckus when staff started to rearrange residents into new rooms. *Used to have a bedroom to herself. *Indicated staff had not informed her of the room change or that she was getting a roommate prior to moving her to another room. 2. Interview on 4/12/23 at 4:01 p.m. with resident 12 regarding his room and roommate revealed he: *Said staff had not given him a choice about having a roommate. *Said, They just [NAME] it on me. *Was very upset and said that his roommate had the bigger half of the room. *Experienced increased anxiety about having a roommate because of the following: -His roommate would put items in the walking space, making him feel trapped. -He was worried that his roommate might sift through his personal belongings. -Since his roommate moved in, there was not enough room to have his bed, his electric scooter, and his recliner. He had to get rid of his recliner. -He worried about having a bathroom accident if his roommate was using the bathroom at the time he needed to use the bathroom. 3. Interview on 4/13/23 at 9:19 a.m. with social services director (SSD) F regarding the recent room reassignments revealed: *They had started to move residents around about two months ago due to renovations. *She said she had conversations with both residents and their families about the upcoming room reassignments about a week prior to moving the resident. -At that time, she also informed the residents about their new roommates and would introduce the residents to each other. *She confirmed there was no documentation indicating the residents and family members had been informed about the room reassignments. 4. Interview on 4/13/23 at 10:46 a.m. with director of nursing (DON) B regarding resident room and roommate changes revealed: *They considered a resident's personality and similar likes/dislikes when making roommate assignments. *Due to remodeling on the 200-hallway, she and her staff rearranged room assignments and congregated the residents on the 100- and 300-hallways. *They started moving residents around in January. *The new roommate assignments coincided with their new staffing models. *They were working on gathering documentation for resident 12 to have his own room due to his increased anxiety and social isolation since getting a roommate. *She confirmed that if SSD F could not find documentation indicating the residents and family members had been informed about the room reassignments, then there was likely no such documentation. Interview on 4/14/23 at 11:04 a.m. with DON B about a room change notification policy revealed: *They had no formal room change policy or procedure. *She provided a Notification of Room Change form. -She said that was the form they should have been using for each resident room change. -She confirmed they had not been using the form. 5. Review of resident 20's medical record revealed: *She was moved from a private room to a semi-private room on 2/9/23. *There was no documentation indicating that she had been informed of the room and roommate change prior to 2/9/23. 6. Review of resident 12's medical record revealed: *He was admitted on [DATE] and had been staying in the same room. *There was no documentation indicating that he had been informed of the roommate change. 7. Review of the provider's Notification of Room Change form revealed: *There was space for a staff person to check Yes or No, and write the date that the resident had been notified, and that the resident's representative had been notified. *There was space for the resident to check Yes or No to the following statement: I voluntarily agree to move to room [blank space]. -Underneath, there was a statement that read, You may have the right to appeal the decision to transfer you to another room. If you have any questions about this transfer or would like help to appeal, contact the staff representative whose signature appears below or [your] State Long Term Agency or your State Ombudsman at the phone number listed below.

Based on interview and record review, the provider failed to provide appropriate follow-up interventions for one of one sampled residents (20) who had made suicidal ideations. Findings include: 1. Interview on 4/12/23 at 2:57 p.m. with resident 20 regarding her room and roommate revealed: *She was quite upset when she had to move rooms and get a roommate. *She had not liked her roommate at first but had since warmed up to her. 2. Review of resident 20's medical record progress notes revealed a Health Status Note from 2/12/23 that read the following: *As [resident 20's] daughter [daughter's name] was leaving, she informed writer that [resident 20] asked to leave some pills for her so she could end her roommate situation faster. [Resident's daughter] stated she told [resident 20] that her comment was inappropriate and she shouldn't talk like that. 3. Interview on 4/13/23 at 9:19 a.m. with social services director (SSD) F regarding resident 20 revealed: *She learned of resident 20's comments the next day on 2/13/23. *She could not remember if resident 20 was making comments about taking the pills herself or giving the pills to her roommate. *When she interviewed resident 20 on 2/13/23, she said that resident 20 did not have any specific plan. *Resident 20 had again expressed to her that she was upset about having a roommate. *SSD F said that she offered counseling services to resident 20, but the resident declined. *She confirmed she had not documented any of her follow-up interventions, such as her discussion with resident 20 on 2/13/23, offering counseling services, or any conversations with her family members. *There had been no other incidences regarding resident 20. *She was unable to determine if any interventions had been initiated on 2/12/23 when resident 20 had made those comments, such as separating the resident and her roommate, informing the director of nursing or her physician, putting resident 20 of 15-minute checks, or taking her to a safe room. 4. Interview on 4/13/23 at 9:44 a.m. with licensed practical nurse H regarding resident 20's comments revealed she: *Remembered that resident 20 was very upset about having to move rooms and move in with a roommate. *Was not aware of the comments that resident 20 had made on 2/12/23. 5. Phone interview on 4/13/23 at 10:24 a.m. with resident 20's daughter regarding comments her mother had made on 2/12/23 revealed she: *Confirmed that resident 20 had a change in behavior and was very upset about having to change rooms and move in with a roommate. *Visited resident 20 more often than usual during that time due to her change in behavior. *Clarified that resident 20 asked for pills to end her own life, not to give the pills to her roommate. -Resident 20 had been through a tough couple of years with several of her close family members passing away and had made statements of wanting to die so she could be with her loved ones again. *Was not aware if the provider contacted resident 20's physician to inform him of her comments. 6. Interview on 4/13/23 at 10:46 a.m. with director of nursing (DON) B regarding resident 20's comments revealed: *Resident 20 had made those comments on a Sunday. *She had not been made aware of those comments until the following day. *She said resident 20's comments would have been considered suicidal ideation. *If a resident made comments of suicidal ideation, she expected staff to notify her, the administrator, the assistant DON, the resident's physician, and the resident's representatives. -She confirmed that none of those steps had been completed. *She expected staff to follow-up with the resident to ask them what they meant by their comments, if they had an active plan or intent, and place the resident on 15-minute checks. -If the resident expressed that they had a plan, she would have expected staff to either move them to a safer area or obtain physician orders to send the resident to a mental health unit. *She could not determine if the staff had provided any interventions for resident 20 after she had made the suicidal ideation comments due to the lack of documentation. *Resident 20 had an increase in behaviors such as crying, yelling at staff and her roommate, and isolating herself after they had moved her to a new room with a roommate on 2/9/23. *She confirmed that resident 20's physician had not been contacted about her behaviors until 3/1/23 when they requested an increase for her duloxetine (a medication used to treat depression and anxiety) due to her behaviors. 7. Interview on 4/13/23 at 3:35 p.m. with regional nurse consultant D about the provider's policy on self-harm and suicidal ideation revealed: *They had no policy on resident self-harm or suicidal ideation. -They recently drafted a policy, but it had not been approved yet. *She agreed that resident 20's statements would have been suicidal ideation. *She would have expected the nurse on staff that day to follow-up immediately, assess the resident, and notify the DON and the resident's physician for further orders. 8. Interview on 4/13/23 at 3:37 p.m. with emergency permit holder A regarding policies and procedures revealed: *They had no policies or procedures for the following: -Documentation standards. -Standard of practice reference guide for social services. -Resident self-harm prevention or suicidal ideation. 9. Review of resident 20's medical record revealed: *There was a Behavior Note from 2/9/23 that read: -Behavior: Resident crying about her room change. States she doesn't care for her new [roommate]. States she feels as if she has to 'babysit' her. States [she is] afraid she'll fall because she doesn't call for help during transfers. Refuses to let anyone hang up her pictures and refusing to get into her bed. 'I'll just sleep in my recliner.' -Non Pharmacological Interventions: Reassurance provided. Called her daughter and gave her an update earlier and asked if she could talk to [resident 20]. Daughter talked to her for appx 15 min. -Summary/Outcomes: Continues to be upset but no longer crying. Will continue to monitor. *There was a Social Service Note from 2/10/23 that read: -[CNA's name] stated when he'd left the room and gone into another room he heard yelling coming from [resident 20's] room. When [CNA names] returned to the room they found [resident 20's] roommate going through the mail on her bed. [Resident 20] was screaming and yelling at her roommate telling her that wasn't her mail. Her roommate was telling her that she just wanted to check it. At one point [resident 20's] roommate became upset and threw her mail on the floor and then kicked it multiple times until it was under the bed. [CNA name] also reported [resident 20's] roommate appeared confused and was trying to get into [resident 20's] bed at one point instead of getting into her own. Writer directed [CNA names] to let both [resident 20] and her roommate know they can not be touching each other's things. *There was a Behavior Note from 2/11/23 that read: -Behavior: CNA informed writer that when she walked by [resident 20's] room. [resident 20] was yelling at roommate for being on her side of the room. Roommate was trying to cross the room to use the bathroom but had got her wheelchair stuck on the bed frame. -Non Pharmacological Interventions: CNA helped roommate across the room to the bathroom. *The daily skilled nursing assessments from 2/12/23 to 2/14/23 indicated that no behavioral problems were noted. *Her care plan had a section addressing her mental health which included: -The focus area read [Resident 20] is receiving anti-depressant medication. [History] of depression, which was initiated on 1/5/22 and revised on 3/14/22. -The goal read [Resident 20] will have intended effect of the medication through next review, which was initiated on 1/5/22, revised on 7/11/22, and had a target date of 1/6/23. -The interventions read: --Administer the medications as ordered. --Keep call light within reach. --Monitor for side effects and report to physician: Antidepressant-Sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia, muscle tremor, agitation, headache, skin rash, photo sensitivity and excess weight gain. --Monitor labs as ordered by [medical doctor]. --Provide Medications as ordered by physician and evaluate for effectiveness. Utilize [Patient Health Questionnaire]-9 scale and notify [primary care provider] [for] scores of 10 or more. 10. Review of the provider's December 2019 Notification of Change of Condition policy revealed: *Policy Statement -The facility will provide care to residents and provide notification of resident change in status. *Procedures -1. The facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is: --b. A significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); --c. A need to alter treatment significantly (i.e., a need to discontinue an existing form on treatment due to adverse consequences, or to commence a new form of treatment) .

Based on interview, record review, and policy review, the provider failed to support the sleep schedule for one of nine residents (5) interviewed. Findings include: 1. Resident 5 stated during an interview on 4/12/23 at 9:42 a.m. that the staff sometimes wake her up to give me my pills at 5:00 a.m. Interview on 4/13/23 at 9:49 a.m. with certified nursing assistant (CNA) J revealed: *She assists resident 5 to get dressed sometime between 6:00 a.m. and 6:30 a.m. *Sometimes she was awake and sometimes she was not awake but she doesn't seem to mind getting awakened. *Resident 5 had previously told CNA J that she had gotten awakened at 5:00 a.m. for her medication. Review of the electronic medical record for resident 5 revealed: *The following care plan focuses and interventions had not addressed her sleep schedule: -Physical functioning deficit, initiated on 1/13/20 and revised on 9/29/22, indicated that the resident required extensive assist and a stand-up mechanical lift to transfer from bed and limited assist of one staff person to get dressed, initiated on 10/5/21 and revised on 1/14/23. -At risk for fluctuating blood sugars, initiated on 1/2/20 and revised on 10/5/21, with an intervention to administer oral glycemic medications as ordered, initiated on 1/2/20 and revised on 4/3/20. *The Brief Interview for Mental Status (BIMS) score was 15 on the 9/14/22 annual Minimum Data Set assessment, which reflected resident 5's cognition was intact. *The April 2023 medication administration record noted the following orders scheduled at 6:00 a.m.: -Semaglutide Tablet 7 MG [milligrams], 1 tablet by mouth one time a day, related to diabetes mellitus, start date 6/24/22. -Farxiga Tablet 10 MG, 1 tablet by mouth in the morning, related to diabetes mellitus, start date 2/16/22. -Weekly skin assessment every day shift every Friday, start date 1/3/20. -Check daily BP [blood pressure] every day shift for 1 week, start date 4/7/23. Interview on 4/13/23 at 10:55 a.m. with licensed practical nurse (LPN) H revealed her shift started at 6:00 a.m., and the night nurse or medication assistant administers medications scheduled at 6:00 a.m. Interview on 4/13/23 at 10:57 a.m. with qualified medication aide (QMA) K revealed her shift started at 6:00 a.m., and she gave resident 5 her medications in the dining room with breakfast, but she received two pills before her shift started. Interview on 4/13/23 at 11:43 a.m. with director of nursing B, emergency permit holder A, and administrator E revealed: *They agreed that residents should not have been awakened for medications. *The DON confirmed resident 5 usually woke up daily sometime between 6:00 a.m. and 6:30 a.m., and there would be time for those medications to be administered before breakfast. Review of the provider policy, Resident Dignity and Privacy, with a creation date of September 2019 revealed: *It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity. *The resident's former lifestyle and personal choices will be considered when providing care and services to meet the resident's needs and preferences.

Based on observation, interviews, record review, and policy review, the provider failed to provide care in a considerate manner for two of thirteen (10 and 17) sampled residents. Findings include: 1. Observation on 4/13/23 at 10:31 a.m. revealed: *Certified nursing assistant (CNA) G pulled resident 10 backwards on a shower chair with her feet dragging on the floor through the hallway towards the spa. *Resident 10 was holding the strap of a small clutch bag between her teeth. Interview on 4/13/23 at 10:35 a.m. with CNA G after resident 10 was positioned in the spa room revealed: *That was the way she always transported resident 10 for her bath. *She had brought resident 10's wheelchair to the spa room before transporting her to the spa room on the shower chair. *If resident 10 was transported to the spa room in her wheelchair, she would have completed an additional transfer using the mechanical lift and the sling in the spa room into the shower chair. *She had not considered dignity or safety as concerns when pulling her backward. Interview on 4/13/23 at 11:05 a.m. with resident 10 revealed she: *Needed more hands so she could hold onto her clutch bag while being transported. *Had not offered a comment on being pulled backward but stated a compliment for how the staff had taken care of her. Review of resident 10's electronic medical record (EMR) revealed: *She had been a resident since 8/3/19. *Her diagnoses included post-polio syndrome, muscle wasting and atrophy, and pain in both shoulders. *Her care plan for physical functioning deficit related to self-care and mobility impairments directed interventions for: -Total assistance of two [persons] with full lift for transferring between surfaces, initiated on 9/23/19 and revised on 5/9/22. -Independent with electric scooter [wheelchair] for locomotion [moving between locations], initiated on 9/23/19 and revised on 10/27/22. -Total dependence with bathing; staff assists as needed, initiated on 2/5/20 and revised on 10/27/22. *The care plan had not specified how staff would assist the resident to the spa room. *The 1/12/23 Minimum Data Set (MDS) coded: -A score of 13 for the Brief Interview for Mental Status (BIMS), which reflected resident 10's cognition was intact. -Transferring was totally dependent on two persons providing physical assistance between surfaces. -Locomotion as supervision for self-performance with one person's physical assistance. Interview on 4/13/23 at 11:43 a.m. with administrator (ADM) E, emergency permit holder (EPH) A, and director of nursing (DON) B revealed CNA G transporting resident 10 backward in the shower chair was a concern related to both dignity and safety. Interview on 4/13/23 at 2:30 p.m. with ADM A revealed: *The provider's policy on dignity was the only policy that had addressed the observed concern regarding CNA G with resident 10. *They had no policy regarding safe locomotion while transporting residents. *How residents were moved between locations safely should have been addressed in the resident's care plan. Review of the provider's policy, Resident Dignity and Privacy, created in September 2019, revealed: *It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity, as well as, care for each resident in a manner and in an environment, that maintains resident privacy. *The guidelines to be followed included, The resident's former lifestyle and personal choices will be considered when providing care and services to meet the resident's needs and preferences. *There was no guideline regarding transporting residents to the spa room. 2. Observation on 4/13/23 at 10:00 a.m. revealed: *Certified occupational therapy assistant (COTA) I walked with resident 17 in the hallway. *COTA I supported resident 17's left arm with her left hand, and held onto a gait belt around resident 17's waist with her right hand. *As they neared a medication cart parked along the wall, resident 17 reached out her right hand towards a computer mouse setting on the top of the cart. *COTA I said in a firm tone with increased volume, No, No, No, and then reached behind resident 17s right arm to move it away from the mouse. Interview on 4/13/23 at 10:30 a.m. with COTA I, after continued observation of her interaction with resident 17, revealed: *Resident 17 often reached out for things and needed physical prompts or cues to perform physical actions. *Resident 17 vocalized with huffs and puffs in response to some conversations, and very seldom spoke words. *COTA I had not offered a comment about the way she said No to resident 17. Review of resident 17's EMR revealed: *Her admitted was 4/24/19. *Her diagnoses included Alzheimer's Disease and dementia with anxiety disorder. *Her care plan noted focus areas for: -Dependent on staff for emotional, intellectual, physical and social stimulation, initiated on 5/7/19 and revised on 5/10/22, with interventions for all staff to converse with [resident 17] while providing care, initiated on 5/7/19 and revised on 5/18/21. -Difficult or troubled past and parents were mentally/emotionally abusive as well as physical abuse from her brother, initiated on 10/1/20 and revised on 11/19/21, with interventions to observe [resident 17] for signs of fear and insecurity during delivery of care .Help her feel safe, initiated on 10/1/20 and revised on 5/18/21. -Impaired thought processes and intermittent communication issues, initiated on 4/28/22 and revised on 4/12/23, with interventions to cue, redirect and supervise her as needed, initiated on 10/31/19 and revised on 11/19/21. *The 1/24/23 MDS coded: -A score of 00 for the BIMS, which reflected resident 17's cognition was severely impaired. -Mood and behavior sections as no symptoms occurred. -Walking in the room as guided maneuvering with one-person physical assistance. -Walking in the corridor as only occurred once or twice. -Transferring as totally dependent with two persons providing physical assistance between surfaces. -Locomotion as supervision for self-performance with one person's physical assistance. Interview on 4/13/23 at 10:40 a.m. with licensed practical nurse (LPN) H confirmed: *Resident 17 said a few more words than she used to but usually responded with a [NAME] or puff. *Resident 17 did reach out and was distracted by things around her. She used to walk into other residents' rooms and take things. *LPN H was sitting at the nurse's desk when COTA I walked with resident 17 by the medication cart parked in the hallway. *She observed COTA I move resident 17's arm by reaching behind her arm and moving it away from the computer mouse. *COTA I should not have spoken to resident 17 with the tone of voice she used but LPN H felt COTA I had not intended it to be disrespectful. Interview on 4/13/23 at 11:43 a.m. with ADM E, EPH A, and DON B confirmed COTA I's tone of voice could be defined as disrespectful and they would follow-up with her about that. Interview on 4/13/23 at 4:30 p.m. with ADM E revealed they had no policy related to dementia care and approaches for effective communication.

Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (16) who had developed a pressure ulcer while in the facility had: *Family and physician notified of the new pressure ulcer. *Obtained physician orders for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] *Interventions for prevention of the pressure ulcer updated in his care plan. *Weekly skin assessments and wound assessments completed. *Monthly pressure ulcer risk assessments completed. Findings include: 1. Observation on 11/2/21 at 11:38 a.m. of resident 16 seated in his wheelchair in the dining room getting assistance from certified nursing assistant (CNA) I to eat his meal. *Resident had a sheepskin padding between his high-back wheelchair and behind his upper back. Interview on 11/2/21 at 2:35 p.m. with CNA M regarding resident 16 revealed: *He was dependent on staff and a total lift during cares. *He had been unable to communicate except to mumble. *He was repositioned about every two hours and checked on often by staff. *The CNAs had not been required to chart or document when they repositioned residents. Observation and interview on 11/2/21 at 4:03 p.m. with CNA I assisting registered nurse (RN) J to complete a dressing change for resident 16 revealed: *The resident had been seated in his recliner. *RN J brought dressing supplies into the resident's room and completed the dressing change. *CNA I had assisted him to lean forward and back against the back of his recliner when the dressing had been changed. -She stated she had not been working when the wound was discovered and was not sure when that had been. *RN J stated: -The wound had recently been discovered. -She was unsure what date that had been. -There had been a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] *The pressure ulcer was unstageable due to the eschar covering the area. *She placed a clean dressing dated 11/2/21 onto the wound and lowered his shirt. *CNA I leaned the resident back into position in his recliner. Review of resident 1's medical record revealed: *He had admitted on [DATE]. *His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Dementia with Lewy bodies. -Anxiety disorder. -[CONDITION(S)]. -[CONDITION(S)]. -Right shoulder pain. -Cognitive communication deficit. *A 10/5/21 note in charting that identifies a pressure ulcer on his left shoulder blade on 10/5/21. *No note that his physician or family had been notified of the new pressure ulcer. *A 10/28/21 fax to his physician requesting: -[Resident name] has an unstageable pressure ulcer to his left scapula. Measures 4 cm X 3 cm. Per wound care recommendations may we have orders to apply hydrogel to wound bed, cover with border dressing, change once daily? Will follow up with wound care next week. *No physician orders had been obtained regarding how to treat the pressure ulcer until a phone order had been obtained on 11/2/21, almost a month after the pressure ulcer had been discovered. Review of resident 16's 9/8/21 quarterly minimum data set (MDS) assessment revealed: *He was at risk for pressure injury. *Needed extensive physical assistance of two or more staff for bed mobility. *Was totally dependent on two or more staff for transfer. *Was not able to walk. *Interventions included a pressure reducing device for his chair and bed. *Repositioning/turning program had been marked as not used. A review of resident 16's 1/4/21, 3/21/21, and 9/7/21 Braden Scale for predicting pressure sore risk assessments revealed he had been at high risk for developing pressure ulcers. *There had not been assessments completed for February, April, May, June, July, August, or October of 2021. Review of resident 16's weekly skin evaluations revealed: *His 9/26/21 evaluation had noted no skin alterations. *His 10/10/21 evaluation noted a wound to his left shoulder. *An evaluation had not been completed on 9/12/21 and 10/3/21. Review of resident 16's 10/13/21, 10/20/21, and 10/27/21 weekly skin alteration assessments revealed: *An assessment had not been completed the week of 10/5/21 when the pressure ulcer had been discovered. *His 10/13/21 assessment indicated an area 4 centimeters (cm) X 3 cm that was unstageable. -50% granulated, 50% necrotic, regular/well defined margins, surrounding edges intact and no drainage present. -Note: Resident has an unstageable pressure ulcer to his left scapula. Area measures at 4 cm X 3 cm. Area covered with protective dressing and resident respositioned frequently *His 10/20/21 assessment had no changes. -Note: Resident has an unstageable pressure ulcer to his left scapula. Area measure at 4 cm X 3 cm. Area covered with protective dressing and resident repositioned frequently. Area is showing improvement. *His 10/27/21 assessment indicated no changes. -Note: Will be seen by wound care on 10/28/21. Review of resident 16's 6/23/21 revised care plan revealed: *resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . *Interventions: -Apply barrier cream PRN (as needed) after incontinent episode, and dry peri area; initiated 12/23/20. -Apply ointments/medications and change dressings per MD order, initiated 3/26/21. -Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short; initiated 12/12/18. -Anticipate and meet needs, change resident when needed and be sure to dry perineum to prevent break down; no initiation date. -Apply barrier cream as needed to prevent skin impairment; initiated 8/20/20. -Has fluctuating air mattress on his bed; initiated 2/4/19 and revised on 7/6/19. -Wear protective boots at all times; initiated 12/12/18. *A handwritten entry initiated on 10/27/21: -Actual skin impairment. Unstageable pressure ulcer to left scapula. *There was no mention of: -A cushion to be placed in his wheelchair. -A repositioning schedule. Interview on 11/4/21 at 8:28 a.m. with director of nursing (DON) B regarding resident 16 revealed: *She agreed that there had not been a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] *She could not remember if notification had been made to the physician or family when the pressure ulcer had been discovered but it should have been in charting if it was done. *Weekly skin assessments were to be completed by nursing staff. *CNAs were to check for any skin issues during resident bathing and report concerns to the nurses. *She stated she: -Had not been aware there were missing Braden assessments, weekly skin evaluations or weekly skin alteration assessments. -Agreed if those documents were not in the charting it had not happened. -Had been responsible for completing the weekly skin alteration assessments. -Confirmed there had been a delay in getting the resident assessed, added interventions in place and getting a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] -When there had been no response from the physician there should have been follow-up. *The care plan should have been updated as soon as possible once the interventions had been added for the resident. Review of the provider's revised April 2021 Skin Program Policy revealed: *Risk assessments [Braden or PUSH] will be completed with admission/readmission weekly for four weeks, and then monthly thereafter. *When a pressure injury, bruise, or skin tear is noted, a Skin Evaluation UDA [user defined assessment] should be completed, and the injury entered into Risk Management in [Name of computer program]. These areas will be monitored on Treatment Administration Record [TAR] until healed. Following identification of a skin issue, the Skin Alteration Evaluation UDA will be competed weekly until resolved. *Nursing personnel will develop a plan of care with interventions consistent with resident and family preferences, goals and abilities, to create an environment to the resident's adherence to the pressure injury prevention/treatment plan. POC [plan of care] to include: Impaired mobility, pressure relief, nutritional status and interventions, incontinence, skin conditions, treatment, pain, infection, education of resident and family, possible causes for pressure injury and what interventions have been put into place to prevent. Skin checks to be completed at least weekly by a licensed nurse. *Routine skin checks will be completed weekly and recorded on the Skin Evaluation UDA.

Based on interview, record review, and policy review, the provider failed to ensure professional standards had been followed for documentation of assessments and appropriate care and treatment for one of one sampled resident (1) who had a surgical wound. Findings include: 1. Review of resident 1's medical record revealed: *She had been admitted on [DATE] from the hospital after a spinal fusion surgery on 9/29/20. *She had [DIAGNOSES REDACTED].>-Fusion of spine, lumbar region. -Diabetes mellitus type 2. -Other signs and symptoms involving cognitive functions and awareness. -Difficulty in walking. Review of resident 1's 10/4/20 discharge orders from the hospital regarding her spinal fusion surgery included: *Special Instructions and Treatments: -TLSO ([MEDICATION NAME], lumbar, sacral orthosis) brace needs to fit with the brace crease in lower brace is between hip and ribs-must wear at all times for 6 wks (weeks) then must wear only when up. -Ankle pumps every 30 minutes while awake. -NO NSAIDS (non-steroidal, anti-[MEDICAL CONDITION] drugs) for cervical fusions and lumbar fusions. This includes [MEDICATION NAME]. -CMS (circulation, motion, and sensation) CHECKS Q2H (every two hours) X (times) 24H THEN Q4H & PRN (as needed). -ICE TO OP (operation) SITE. -PORT. (portable) I.S. (incentive spirometer) Q1H W/A (while awake) *Additional Instructions: -Activity: Ambulation encouraged. -Add'l (additional) Activity Info: --1. The patient (resident) will wear a TLSO brace full-time for 6 weeks and then a second 6 weeks when out of bed. --2. The patient (resident) will avoid all tobacco and anti-[MEDICAL CONDITION] products for a full 6 months postoperatively. --3. Routine core strengthening exercise to begin at approximately 8 weeks postop (post operatively). --4. No lifting greater than 10 pounds. --5. No work below waist level. -Diet: Cardiac/Heart Healthy. -Discharge Wound Care: Keep clean/dry. Change dressing (change dressing on post op day number 7 to dry gauze.) Change daily thereafter. Do not allow incision to get wet with bathing. Monitor incision for signs and symptoms of infection daily and if these occur, promptly contact (surgeons name). Review of resident 1's 10/4/20 hospital discharge documentation revealed: *Surgical incision: -Was located on her back. -Was not observable due to a dressing. -Dressing had a small amount of yellow drainage with no odor present. *Left flank blister: -Blister noted to left flank with surrounding redness/irritation. Barrier cream applied, cloth barrier applied between brace and skin, brace lowered. -Was intact, red, and dry. -Had no drainage. Review of resident 1's skin evaluations revealed on: *The 10/4/20 admission assessment skin section indicated: -Her skin appeared to be normal. -Her skin turgor was elastic. -She had a mid back surgical incision. -She had no vascular access placement. -Her Braden Scale skin evaluation score was eleven that indicated high risk for impaired skin integrity. *The 10/12/20 skin evaluation indicated: -Her skin appeared to be normal. -Her skin turgor was normal. -She did not have any alteration in her skin integrity. -Her Braden score was thirteen that indicated high risk for impaired skin integrity. *The 10/19/20 skin evaluation indicated: -Her skin appeared to be normal. -Her skin turgor was normal. -She had a surgical incision to her lower back. -Her Braden score was thirteen that indicated high risk for impaired skin integrity. *The 10/26/20 skin evaluation indicated: -Her skin appeared to be normal. -Her skin turgor was normal. -She had a surgical incision to her lower back left side. -Her Braden score was sixteen that indicated high risk for impaired skin integrity. *There was no documentation that described anything about the surgical incision. *There was no documentation regarding the blister on her left flank. Review of resident 1's daily nursing evaluations from 10/5/20 through 10/28/20 revealed: *Evaluations completed on 10/5/20, 10/6/20, 10/7/20, 10/8/20, 10/10/20, 10/11/20, 10/12/20, 10/14/20, 10/15/20, 10/16/20, 10/17/20, 10/19/20, 10/21/20, 10/22/20, 10/23/20, 10/24/20, and 10/25/20 did not include any information about her surgical incision, dressing changes, or the blister to her left flank. *Evaluations had not been completed on 10/9/20, 10/13/20, 10/18/20, and 10/20/20. *The evaluation on 10/26/20 indicated a wound that required a dressing change. Description of the wound was documented as Surgical incision serous bloody drainage. *The evaluation on 10/27/20 indicated a wound that required a dressing change. Description of the wound was documented as Incision to lower back draining clear fluid, foul smelling. Review of resident 1's October 2020 medication and treatment administration records revealed: *From 10/11/20 through 10/23/20: Wound Care: Keep clean/dry. Change dressing (change dressing on post op day number 7 to dry gauze. Change daily thereafter. Do not allow incision to get wet with bathing. Monitor incision for signs and symptoms of infection daily and if these occur, promptly contact (surgeons name). *Only the above days had been initialed indicating that had been done. Review of resident 1's interdisciplinary progress notes revealed:*On 10/5/20 at 12:48 a.m.: Unable to assess surgical incision at this time. Order received not to remove [MEDICATION NAME] dressing for 7 days and do not get incision wet. *On 10/11/20 at 5:27 a.m.: Changed resident's surgical dressing with dry gauze per order. Incision is intact with no redness, swelling or drainage present. Nursing will continue to monitor. *On 10/11/20 at 5:20 p.m.: c/o (complained of) much itching in her lower back, gauze dry and intact. *On 10/23/20 at 4:08 a.m.: Faxed (fax) sent to Dr. (name) requesting an order to DC (discontinue) IS (incentive spirometer) q1h, CMS checks and dressing change to wound at the back of her neck as it is closed with no redness or drainage noted. Her surgical incision was located on her lumbar region. *On 10/24/20 at 3:02 a.m.: Received fax back from Dr. stating yes to D/C request. *On 10/28/20 at 9:20 a.m.: Call to Dr. (doctor) regarding change of status, unable to feed self and hold head up. Order to send to (hospital name) Emergency Department for evaluation. Husband (name) notified of pending transfer daughter (name) also notified. *On 10/28/20 at 12:30 p.m. Call from (hospital name) ER (emergency room ) will be admitted to Post surgical incision infection. Review of resident 1's hospital documentation on 10/28/20 revealed: -10/28/20 emergency room visit notes: --Pt. (resident) complaint from nurse triage: Pt. was dx (diagnosed ) with UTI (urinary tract infection) yesterday, staff report change in baseline mental status in the past 24 hours. Had back surgery in the beginning of October and has been itching at incision site per nursing home staff. --Presenting symptoms: [AGE] year-old female was transferred from nursing home because of fever and lethargy in appearance. She was diagnosed having positive UTI yesterday. And the staff at nursing home reporting that she seems has declining mental status. Additionally she has a fever. She had a spinal operation end of last month. It seems patient reported some itching over the operation site. There is no wound checked by the staff at nursing home. --Skin Details: Over lumbar spine area there is a separation of recent operation wound. Positive yellowish and clear drainage coming from the deep side of the operation wound. Surrounding skin has positive [DIAGNOSES REDACTED]tous changes with increasing local temperature, consistent with infected surgical wound. -Her 10/28/20 hospital admission [DIAGNOSES REDACTED].>-[MEDICAL CONDITION] with acute [MEDICAL CONDITION] on admission, likely related to bacteremia, lumbar surgical site infection. Staphylococcus aureus bacteremia/MRSA ([MEDICAL CONDITION]), follow-up blood cultures obtained on October 31 and negative. Lumbar surgical site infection, with gross purulence deep to fascia, status [REDACTED]. Acute [MEDICAL CONDITION], suspected toxic metabolic, improved. Unlike meningitis. Review of resident 1's 11/5/20 provider's readmission documentation revealed: *11/5/20: admission nursing assessment revealed her skin appearance was normal, her skin turgor was elastic, and she had a vascular access. *There were no descriptions of the post surgical site infection to her lumbar area. *There were no descriptions of what type of vascular access she had, where it was located, site assessment. Review of resident 1's following interdisciplinary progress notes revealed: *On 11/6/20 at 2:41 a.m.: Resident remains in isolation room .trunk brace in position. PICC (Peripherally inserted central catheter) line in right arm. -On 11/6/20 at 7:41 p.m.: Rewrapped right arm with ace wrap to protect picc line from being pulled on. -On 11/7/20 at 1:30 p.m.: a note that described her increased lethargy, inability to follow directions. inability to support herself when sitting up, had to be fed her breakfast. Physical therapy had reported her having some symptoms possibly consistent with a stroke. Neurochecks had been done initially and her PCP (Primary Care Physician) had been notified by fax. Her dressing to her lower back was weeping and was reinforced by 4 x 4 gauze. -On 11/8/20 at 12:48 a.m.: Resident spinal dressing leaking, reinforced with gauze and tape. -On 11/8/20 at 2:00 p.m.: Dressing to her lower back have been reinforced with 4x4 as lower half have started to come off. -On 11/9/20 at 9:38 a.m.: Arousal is diminished unable to follow cues. Grimacing noted but denies pain. Unable to focus on tasks. Left arm is pulled into body and hard to move. cognition diminished. Dr. (name) updated on condition order to send to emergency room for evaluation. -No documentation had been completed of when she had left for the emergency department, when she returned, or if there were new physician orders. -On 11/11/20 at 11:46 p.m.: a note that the PICC line in the left anticubital had been pulled out. The on call physician was notified and asked for the information to be faxed to his office, and it would be evaluated. Review of resident 1's daily nursing evaluations after her facility readmission on 11/5/20 revealed: *No evaluation had been completed on 11/6/20 or 11/10/20. *On 11/7/20 it had been documented she received intravenous (IV) [MEDICATION NAME] daily. -There was no assessment of her PICC line or the wound dressing. *On 11/8/20 it had been documented she had a wound that required a dressing change. The description of the wound was dressing reinforces with 4x4. She continued to receive IV [MEDICATION NAME] daily. *On 11/9/20 it had been documented she had a surgical wound. Surgical incision sutures and staples intact with red/orange drainage foul smelling. Cleansed and covered with ABD (abdominal) pad. She continued on the IV [MEDICATION NAME]. Interview on 11/13/20 at 10:00 a.m. with director of nursing (DON) C revealed resident 1 had been readmitted to the hospital again on 11/11/20 for increased confusion, [MEDICAL CONDITION], and her PICC line had been pulled out. Review of resident 1's physician notification faxs revealed her PCP had been notified on: *10/17/20 at 2:23 a.m. that she had been lowered to the floor by staff without any injury. Her PCP responded back with a check mark on 10/19/20 at 1:13 p.m. *10/18/20 at 3:30 p.m. she had been trying to walk without assistance in her room and fell on her stomach. No injuries were noted. Her PCP responded back with a check mark on 10/19/20 at 1:13 p.m. *The neurosurgeon had not been notified of those falls. Interview on 11/13/20 at 3:30 p.m. with administrator A and DON C confirmed the documentation did not show what nursing care had been given to resident 1 for her surgical wound. DON C agreed she had been notified by the hospital of resident 1's infection to her surgical wound. She had not yet followed-up on that information. DON C stated the reference for professional standards was from a Lippincott nursing manual. Review of the provider's September 2019 Skin Program policy revealed: *A baseline assessment of the resident's skin status would be completed upon admission/readmission by the completion of the nursing admission/readmission user defined assessment examination. That would have included a physical exam of the resident's skin, a risk assessment using a risk assessment tool, and a comprehensive assessment of the resident's history and physical condition. A plan of care would have been put in place for residents that were identified with actual skin breakdown or at-risk for skin breakdown. *A comprehensive wound assessment would have been completed if there was a pressure injury. *There was no process for surgical incisions. Review of Sandra M. Nettina, Lippincott Manual of Nursing Practice, 11th Ed., 2019, p.15, revealed: *Common departures from the standards of nursing care included the failure to assess the resident properly, follow physician orders, follow appropriate nursing measures, communicate information about the resident, adhere to facility policy or procedure, and document appropriate information in the medical record.

Based on interview, record review, and policy review, the provider failed to appropriately assess, document, treat, and provide notification to the physicians for one of one sampled resident (1) who had a surgical incision and falls. Findings include: 1. Review of resident 1's medical record revealed: *No comprehensive or ongoing assessments had been conducted for her lumbar surgical incision. *There was no documentation when her surgical incision had shown signs of infection. *There had been no communication with her physician or the surgeon regarding the surgical incision. *Her surgeon had not been informed when she had sustained two falls. Review of the provider's revised 5/15/19 Abuse and Neglect policy revealed: *Neglect was the failure to provide necessary and adequate care. *Neglect was the failure to care for a person in a manner, that would avoid harm and pain or the failure to react to a situation that might be harmful. *Staff should have been aware of the service the resident required but failed to provide that service. Refer to F656, finding 1, and F658.

Based on observation, record review, interview, and policy review, the provider failed to assess, notify the physician, change treatment, follow physician's orders [REDACTED]. Findings include: 1. Review of resident 2's medical record revealed: *She had been hospitalized from [DATE] through 12/14/16. *Admission paperwork from the local hospital dated 12/9/16 stated she had been taken to the hospital due to [MEDICAL CONDITION] and a cough. *The examination (exam) of her back completed on admission to the hospital stated Stage II decubital (pressure) ulcers of sacrum and coccyx with additional surrounding skin shearing an (and) stage I decubiti in encompassing distribution around the stage II ulcers. See media or photo file. -The pressure ulcer had been present upon admission to the hospital and had not been acquired at the hospital. *The 12/14/16 interagency transfer orders from the hospital to the nursing facility revealed an order for [REDACTED]. Review of resident 2's December 2016 Medication Administration Record [REDACTED]. Review of resident 2's 5/13/16 significant change Minimum Data Set (MDS) assessment revealed: *She had a Brief Interview for Mental Status (BIMS) score of eleven. -A score of eight to twelve meant her cognition was moderately impaired. *She required extensive assistance from one staff person to transfer between surfaces and go to the bathroom. *She had been at risk for developing pressure ulcers. *She had not had any unhealed pressure ulcers. *The only intervention checked had been Pressure reducing device for bed. Review of resident 2's 12/16/16 MDS assessment revealed: *Her BIMS score had been an eleven indicating the same as above. *She now required extensive assistance from two staff persons to transfer between surfaces. *She required extensive assistance from one staff person to go to the bathroom. *She had been at risk for developing pressure ulcers. *She had one stage two pressure ulcer. -It had been present upon admission or re-entry. *The interventions checked were: -Pressure reducing device for chair. -Pressure reducing device for bed. -Turning/repositioning program. -Nutrition and hydration interventions. -Pressure ulcer care. Review of resident 2's 3/24/17 MDS assessment revealed: *Her BIMS score had been a nine indicating her cognition was moderately impaired. *She required extensive assistance from one staff person to transfer between surfaces and go to the bathroom. *She had been at risk for developing pressure ulcers. *She had one stage two pressure ulcer. -It had not been present upon admission or re-entry. *The interventions checked were: -Pressure reducing device for chair. -Pressure reducing device for bed. -Nutrition and hydration interventions. Observation on 4/11/17 at 8:55 a.m. of resident 2 revealed she had been in her room sitting in her wheelchair watching television (TV). Interview on 4/11/17 at 8:55 a.m. with certified nursing assistant (CNA) E regarding resident 2 revealed: *She had asked her if she wanted to sit in her recliner or bed, but she stated no because she could not get up then. *She would ask the resident if she wanted to lay down and leave it up to her, unless it was a nurses order to lay her down. Observation on 4/11/17 at 10:00 a.m. and at 11:00 a.m. of resident 2 revealed at 10:00 a.m. she had been sitting in her wheelchair participating in the activity in the living room. At 11:00 a.m. she had been in her wheelchair in her room. Staff had come in to assist her to the bathroom. Interview on 4/11/17 at 2:30 p.m. with the interim director of nursing (DON) regarding resident 2 revealed: *She had a stage two pressure ulcer on her bottom. *She was not aware of the timeline of the pressure ulcer and stated she would have to look through the chart. *Her pressure ulcer was healing as of this week. *She was not aware if the pressure ulcer had been acquired from the resident's last hospital stay or if it had been acquired at the facility. *She was asked at that time to provide the information regarding the timeline of when the pressure ulcer had developed, what treatments had been used, when they had notified the physician, why they had not followed the hospital discharge orders for the wound care, and what interventions had been attempted. Observation and interview on 4/11/17 at 4:15 p.m. with resident 2 revealed: *She had been sitting in her wheelchair watching TV. *She was friendly and answered questions appropriately. *She had a fall where she had dislocated her shoulder a while ago. *The staff were treating the pressure ulcer on her bottom. Interview and record review on 4/11/17 at 4:50 p.m. with the interim DON and the MDS coordinator regarding resident 2 revealed: *The MDS coordinator had offered to review the progress notes with this surveyor to determine the time line for the development of the pressure ulcer. *She stated the resident had a fall in May 2016 where she had dislocated her right shoulder. -She stated That caused her to decline and then at one point she stopped walking. --She had been ambulatory up until that decline. *Per the nursing progress note review: -The resident had not stopped walking until 8/4/16. -On 6/7/16 the resident had complained of soreness to the sacral area, redness noted. -There had been no documentation regarding being blanchable or not. --Both the interim DON and the MDS coordinator agreed that could have been the start of a stage one pressure ulcer. The wound data flow sheet should have been initiated. --The pressure ulcer had been acquired at the facility and not in the hospital. -On 6/18/16 there was an open area to her right buttock measuring 1 cm L (length) x (by) 1 cm W (width) x 0.2 cm W. --They stated the 0.2 should have been D (depth) not width. --There was no documentation in that note regarding the staging. *She had a hospital stay from 8/11/16 through 8/15/16 [MEDICAL CONDITION]. *She had inpatient surgery on 8/19/16 and returned on 8/20/16. *She had been hospitalized again from 12/9/16 through 12/14/16. *They were asked at that time to provide the wound evaluation flow sheets for as long as the pressure ulcers had been present, information regarding what treatments had been used, when they had notified the physician, if and when the pressure ulcer had healed, documentation they had followed the 12/14/16 hospital discharge orders for the wound care, and what interventions had been attempted. Review of resident 2's medical record revealed there had been no Braden assessments completed from 5/13/16 through 3/24/17 regarding if she was at risk for developing pressure ulcers. Review of resident 2's 6/18/16 immediate plan of care for pressure ulcer care revealed: *The pressure ulcer site had been the right inner buttock. *There had been no measurements or staging documented. *The interventions had been: -Turning/repositioning every two hours. -Daily skin inspection during care/bathing. *Hand written in were: -Apply [MEDICATION NAME] cream. -Encourage to sleep on her bed to remove pressure on buttocks. -Educated on consequences of non-repositioning often. -Cushion applied on recliner. *Interventions continued were: -Use mild cleansing agent and warm water to cleanse skin whenever soiled - do not use hot water. -Do not massage over bony prominence. -Maintain head of bed in lowest position consistent with resident condition and comfort. Review of resident 2's Weekly Skin Review assessments from 6/22/16 through 4/10/17 revealed: *On 6/22/16: 1. Right inner buttock open sore measures 1 cm x 1.5 cm x 0.2 cm. [MEDICATION NAME] cream applied. 2. Right upper buttock 3 cm x 3 cm bruised. *There had been no other documentation regarding if the area was new and if those were the initial measurements of the pressure ulcer. *The form stated: If skin alteration identified, validate that the Wound Evaluation Flow Sheet is in place. *On 6/29/16: A stage two open area on the right buttock. -It had measured 0.8 cm x 1.2 cm x. 0.2 cm. -[MEDICATION NAME] cream had been applied. *On 7/5/16: A stage two pre-existing pressure ulcer to the coccyx. -It had measured 1 cm x 1 cm x 0.2 cm. -It was whitish in color, clean, intact margins. -[MEDICATION NAME] was applied two times daily. -She was being reminded to take pressure off buttocks whenever possible. *On 7/6/16: Pre-existing open area measuring 0.5 cm diameter to buttocks, getting [MEDICATION NAME] to area. -There had been no documentation regarding staging. -The nurse had signed the assessment on 9/6/16. *On 7/13/16: A pressure ulcer to coccyx. -[MEDICATION NAME] cream was being applied to area. -Reminded her to reposition and shift weight off of area of concern. -There had been no measurements or documentation of staging. *On 7/19/16: Pre-existing open sore to right buttock. -Measurements were 0.4 cm x 0.4 cm x 0.1 cm. -[MEDICATION NAME] cream applied two times per day. -There had been no signature regarding who had completed the assessment. *On 7/27/16: Pre-existing open sore. -The location had not been documented. -Measurements were 0.4 cm x 0.4 cm x 0.1 cm. -[MEDICATION NAME] cream applied two times per day. *On 8/2/16: Pre-existing open sore to right inner buttock. -Measurements were 0.4 cm x 0.3 cm x 0.1 cm. -[MEDICATION NAME] cream applied two times per day. -There had been no other documentation regarding that pressure ulcer. -The nurse had signed the assessment on 8/3/16. *On 8/9/16: Pre-existing open area to buttocks. -Measurements were 0.4 cm x 0.3 cm x 0.1 cm. -[MEDICATION NAME] cream applied two times per day. -The nurse had signed the assessment on 8/10/16. *On 8/16/16: Pre-existing open area to buttocks. -Measurements were 0.4 cm x 0.3 cm x 0.1 cm. -[MEDICATION NAME] cream applied two times per day. -The nurse had signed the assessment on 8/17/16. *On 8/23/16: Pre-existing open area to buttocks. -Measurements were 0.5 cm x 0.5 cm x 0.1 cm. -[MEDICATION NAME] cream applied two times per day. -The nurse had signed the assessment on 8/25/16. *On 8/30/16: Pre-existing open area measuring 0.5 cm diameter to buttocks, getting [MEDICATION NAME] to area. -There had been no documentation regarding staging. -The nurse had signed the assessment on 8/31/16. *On 9/6/16: Pre-existing open area measuring 0.5 cm diameter to buttocks, getting [MEDICATION NAME] to area. -There had been no documentation regarding staging or coloration. *On 9/14/16 it had not addressed the pressure ulcer. *On 9/20/16 it had not addressed the pressure ulcer. *On 9/28/16: Open are on buttock continues to heal. -Resident repositioned every two hours. -[MEDICATION NAME] applied with every toileting episode. *On 10/5/16: Three open areas. -The open area to the right buttock measured 1.5 cm x 2.5 cm x 0.2 cm. -The open area to the left buttock measured 0.5 cm x 0.5 cm x 0.2 cm. -The open area to the sacrum measured 1.0 cm x 0.2 cm x 0.1 cm. -[MEDICATION NAME] applied with every toileting episode. -Resident repositioned every two hours. -There had been no documentation of staging. *On 10/12/16: Pre-existing open sore to buttocks area. -There had been no measurements and no mention of the three pressure ulcers mentioned the week before. -[MEDICATION NAME] cream applied two times per day. -Repositioned every two hours. *On 10/19/16: Pre-existing open sore to buttocks area. -There had been no measurements and no mention of the three pressure ulcers mentioned on 10/5/16. -[MEDICATION NAME] cream applied two times per day. -Repositioned every two hours. -There had been no documentation of staging. -The nurse had signed the assessment on 10/20/16. *On 10/26/16: Continues to have open areas to buttock region. -[MEDICATION NAME] cream applied two times per day. -Redistribution mattress. -Repositioned every two hours. -There had been no documentation of staging. -The nurse had signed the assessment on 10/27/16. *On 11/2/16 the assessment had not been completed. *On 11/14/16: Pre-existing open area to sacrum (4 cm x 0.5 cm) and right buttock (1 cm x 0.5 cm x 0.2 cm). -There had been no other documentation regarding those pressure ulcers including the staging. *On 11/30/16: Small open area to sacrum. -[MEDICATION NAME] cream applied. -There had been no documentation regarding measurements or staging. *On 12/7/16: Open area to sacrum. -[MEDICATION NAME] cream applied. -There had been no documentation regarding measurements or staging. *On 12/20/16: Pre-existing open areas to both buttocks area. -Repositioned every two hours. -There had been no documentation regarding measurements or staging. *On 1/31/17: She had two open areas. -One on her Upper coccyx measuring 0.5 L x 0.5 W x 0.01 D. -One to her Lower coccyx measuring 0.5 L x 0.5 W x 0.01 D. -[MEDICATION NAME] cream applied. -Repositioned every two hours. -There had been no documentation regarding staging. *On 2/15/17: Pre-existing open sore to coccyx. -It had been healing. -[MEDICATION NAME] cream had been applied. -There had been no documentation regarding staging or measurements. *On 2/22/17: She had a small open area to her coccyx. -It had been healing. -[MEDICATION NAME] cream had been applied. -There had been no documentation regarding staging or measurements. *On 3/1/17: She had a small open area to her coccyx. -[MEDICATION NAME] cream had been applied. -There had been no documentation regarding staging or measurements. *On 3/8/17: She had redness to her coccyx and buttocks. -[MEDICATION NAME] cream had been applied. -There had been no documentation regarding staging or measurements. *On 3/15/17: She had redness to her coccyx. -There had been no documentation regarding staging or measurements. *On 3/22/17: She had an open area to her coccyx measuring 1.5 cm length x 0.5 cm width x 0.02 cm depth. -[MEDICATION NAME] cream had been applied. *On 3/29/17: She had redness and an open area to her coccyx. -There had been no documentation regarding staging or measurements. -[MEDICATION NAME] cream had been applied. *On 4/5/17: She had an open area to her coccyx measuring 1.5 cm x 0.5 cm x 0.02 cm. -[MEDICATION NAME] cream had been applied two times per day. *On 4/10/17: She had an open area to her coccyx measuring 1 cm x 0.5 cm x 0.1 cm. -The wound bed was pink with no drainage noted. Review of resident 2's medical record revealed there had been no documentation of weekly skin assessments for the weeks of 12/26/16, 1/2/17, 1/9/17, 1/16/17, 1/23/17, and 2/6/17. Review of resident 2's 6/22/16 and 6/30/16 Weekly Care Management Meeting Note assessment revealed they had not identified wound care/skin integrity as a new or existing problem. Review of resident 2's medical record and the information provided by the interim DON and the MDS coordinator regarding resident 2 revealed: *There was no documentation of wound evaluation flow sheets from 6/18/16 through 12/18/16. -The first one had begun on 12/19/16. *The physician had been notified on 6/20/16 regarding the stage two pressure ulcer. -That had been two days after the stage two pressure ulcer had developed. -There had been no notification regarding the redness on 6/7/16. -They asked if they could use [MEDICATION NAME] cream, and the physician had agreed. *The 7/22/16 and 1/10/17 certified nurse practioner notes had not addressed the pressure ulcer. *There was no other documentation her physician had been notified after 6/20/16 even though the pressure ulcer had remained until April 2017. *There had been no change in treatment from 6/18/16 through 4/10/17. Review of resident 2's 3/20/17 care plan revealed: *A focus area for At risk for wt (weight) changes, abnormal labs, dehydration, skin concerns related to hx (history) of dementia, [MEDICAL CONDITION]. PU (pressure ulcer) on buttocks. *The interventions were: -Regular diet. Nutritional supplement tid (three times per day) all meals to promote wound healing. May ask for jello for hs (bedtime) snack. Makes meal choices using selective menu. -That intervention had been initiated on 3/21/17. Review of resident 2's care plan used through 3/19/17 revealed pressure ulcers had not been addressed. Interview on 4/12/17 at 9:35 a.m. with the dietary manager regarding resident 2 revealed: *She had been in her position since January 2017. *Resident 2 received a regular diet. *She received the supplement three times a day, but that had been implemented prior to her starting work at the facility. *Nursing staff had documented in the MAR indicated [REDACTED]. *There were no new interventions implemented. Interview on 4/12/17 at 9:45 a.m. with CNA F regarding resident 2 revealed when they documented if repositioning had been done it was not documented every two hours. It was only documented once per shift. Interview on 4/12/17 at 10:00 a.m. with the interim DON regarding resident 2 revealed they had no other documentation than what had already been provided to this surveyor. She was unable to answer why the physician had not been notified, why treatment had not changed, or why interventions were not listed on the care plan. She agreed the weekly skin review assessments had not been complete. Review of the provider's 2/3/16 Clinical Health Status Change of Condition Guideline revealed the electronic record should have had documentation the physician notification had occurred in a timely manner. Review of the provider's 7/1/13 Risk Assessment Scale and Documentation policy revealed: *The wound care coordinator should have completed a Braden Scale assessment upon admission, quarterly, or with a significant change. *The licensed nurse should have entered a program of prevention in the care plan. Review of the provider's 7/1/13 Monitoring and Staging policy revealed: *Residents were to have received appropriate treatment until healed. *A licensed nurse should have assessed the pressure ulcer weekly and should have kept the physician informed of progress with prescribed treatments. *Daily documentation should have reflected if dressing was intact, drainage noted, pain associated with the wound, any odor, and condition of surrounding skin that was visible around the dressing. *They should have initiated appropriate treatment for [REDACTED]. *Staff should have evaluated the effect of the treatment weekly and revised as needed. *If there had been no improvement review steps 4 through 7 of the policy before changing treatment. *They should have re-assessed appropriateness of treatment and changed as improvement occurred or per physician order. *The wound coordinator or licensed nurse should have documented progress of wound healing weekly. *Documentation should have included: -Length, width, and depth. -Location of any tunneling. -Condition of wound.