Every finding on record at Bay Terrace Rehabilitation and Health Center

Based on record review and interview it was determined that for one (R83) out of three residents reviewed for abuse the facility failed to ensure immediate reporting of an allegation of abuse. Findings include: The facility policy on abuse last updated January 2026 indicated, Reporting of all alleged violations to the Administrator, state agency, adult protective services, and to all other required agencies (e.g. law enforcement when applicable) within specific time frames! a. Immediately but not later than two hours after the allegation is made.6/12/25 3:31AM - An incident note in R83's clinical record documented that R83 made an allegation of physical staff to resident abuse against E8 (CNA). 6/12/25 11:21 AM - The facility reported an allegation of staff to resident physical abuse involving R83 that allegedly occurred at 2:35 AM to the State Agency; an estimated nine hours after the allegation occurred. 4/23/26 11:06 AM - During an interview with E6 (RN) it was confirmed that R83's allegation of abuse was not immediately reported to the State Agency. E6 stated, When the [DON] came in, she told me I should have reported it right away and not waited for the day shift. 4/23/26 11:14 AM - During an interview, E2 (DON) confirmed the findings and that the facility verbally educated E6 (RN) on reporting time frames. 4/23/26 3:00 PM - Findings were reviewed with E1 (NHA), E2 (DON) and at the exit conference.

Based on record review and interview it was determined that for one (R83) out of three residents reviewed for abuse the facility failed to ensure residents were protected from further abuse when the facility failed to remove an employee from resident care immediately after an allegation of abuse. Findings include: The facility policy on abuse last updated January 2026 indicated, Protection of Resident. Room or staffing changes if necessary to protect residents from the alleged perpetrator. 6/12/25 11:21 AM - The facility reported an allegation of staff to resident physical abuse involving R83 and E8 (CNA). 4/23/26 9:26 AM - Review of E8's (CNA) timesheet revealed that after the allegation of physical abuse involving R83, E8 remained in the facility working with residents until 7:05 AM. 4/23/26 10:56 AM - During an interview, E7 (LPN) the nurse assigned to R83's unit at the time of the incident confirmed that E8 (CNA) remained caring for patients after R83 made an accusation of physical abuse against R83. E7 stated, She had dementia and a care plan for false accusations what she said didn't make sense, so we stopped him from caring for her room through the rest of the shift. 4/23/26 11:06 AM - During an interview, E6 (RN) confirmed that E8 (CNA) remained caring for residents after R83 made an allegation of physical abuse. E6 stated, I told [E8] to care for other patients E6 then explained that [E2 (DON)] verbally educated her that accused staff must be removed to protect all residents. 4/23/26 3:00 PM - Findings were reviewed with E1 (NHA), E2 (DON) and at the exit conference.

Based on observation, interview and record review, it was determined that for one (R10) out of seven residents reviewed for ADL (Activities of Daily Living), the facility failed to provide ADL care for dependent residents. Findings include:Review of R10's clinical record revealed:3/26/25 - R10 was admitted to the facility with a diagnosis of terminal prostate cancer and delirium.1/12/26 - A review of R10's care plan documented that the resident had a self-care deficit for ADLs. 3/24/26 - A quarterly MDS documented that the resident was dependent for personal hygiene.4/15/26 7:10 AM - A progress note documented that R10 was restless all night and was smearing his feces with his hands.4/20/26 9:45 AM - An observation of E5 (CNA) providing a bed bath to R10 revealed dark debris beneath three fingernails on the resident's left hand4/21/26 9:00 AM - An observation of R10's left hand had dark debris beneath three of his fingernails. 4/21/26 10:15 AM - During an interview, E5, CNA stated that during the resident's bed bath, she shaved the resident (R10) and washed his entire body. She confirmed that she did not check or clean the resident's fingernails during the bath and stated she would complete this task immediately. 4/21/26 10:20 AM - E4 (LPN) confirmed that R10's left hand had dark debris beneath three fingernails. E4 stated she has not seen a nail cleaning device available for use in a long time.4/21/26 10:20 AM - During an interview, E2 (DON) confirmed that the fingernails for R10 were not cleaned during the bath.4/23/263:00PM - Findings were reviewed with E1 (NHA), E2 (DON) and at the exit conference.

Based on record review and interview it was determined that for one (R85) out of three residents reviewed for hospitalization the facility failed to provide appropriate care and monitoring consistent with professional standards of practice. When the facility failed to monitor and restrict fluid intake for R85 admitted with active diagnosis of heart failure. Findings include:Review of R85's clinical record revealed:4/19/25 through 4/29/25 - R85 was hospitalized for multiple conditions, including heart failure. 4/29/25 - R85 was admitted to the facility with multiple diagnoses including congestive heart failure and kidney disease requiring dialysis.4/30/25 - An admission assessment completed by E11 (RN) documented that R85 had congestive heart failure.4/30/25 - R85's baseline care plan revealed that R85's diagnosis of congestive heart failure lacked interventions.5/1/25 - A nutrition assessment documented that R85 was receiving therapeutic, regular textured meal plan with 1500 mL fluid restriction . Will continue to monitor oral intake, weight, skin integrity, and labs as available for significant changes and reassess as needed. Review of R85's physicians orders and dietary intake lacked evidence of an order for fluid restriction.5/1/25 12:05 PM - A progress note in R85's clinical record written by E10 (MD) documented The patient remains generally weak and clinically deconditioned. The patient has multiple complex co morbidities to include heart failure placing the patient at high risk for re admission [to hospital] without proper care. The patient will require frequent clinical evaluations, neglecting regular monitoring and management may result in symptom exacerbation and re-hospitalization. Assessment/Plan strict intake and output's daily weights.5/5/25 - An admission MDS assessment documented that R85 was cognitively intact, experiencing shortness of breath and had an active diagnosis of heart failure. 5/5/25 - A physician's order was written for R85 be restricted to 1500ml of fluid per day at the request of R85's responsible party.5/6/25 11:15 AM - A nurses note in R85's clinical record documented that the resident was sent to the hospital from the dialysis center for chest pain and shortness of breath.4/23/26 1:41 PM - During an interview, E10 (MD) confirmed that R85 should have been placed on fluid restriction on admission. 4/23/26 1:48 PM - During an interview, E11 (RN) confirmed that residents admitted with congestive heart failure and on hemodialysis are usually placed on fluid restrictions. E11 was unable to recall why R85 was not placed on fluid restrictions on admission.4/23/26 1:54 PM - During an interview, E2 (DON) confirmed that R85 should have been placed on fluid restriction and monitoring prior to 5/5/26. E2 stated Most residents with congestive heart failure would have had a fluid order but [R85] did not have one. E2 then stated that an order for fluid restriction was written on 5/5/24 because It was just noticed. The fluid restriction was not in timely.4/23/26 3:00 PM - Findings were reviewed with E1 (NHA), E2 (DON) and at the exit conference.

Based on interview and record review, it was determined that for one (R72) out of five residents sampled for medication review, the facility failed to ensure that the residents were free from unnecessary meds when a Protonix order was used in excessive dose. Findings include: Review of R72's clinical record revealed:1/26/26 - R72 was admitted to the facility.1/27/26 - A physician's order for Protonix 40 mg give one by mouth two times a day for GERD (gastro-esophageal reflux disease). 2/22/26 - A physician's order for Protonix 40 mg give one tablet by mouth once daily for GERD. 3/30/26 - A Monthly Consultant Pharmacist Report documented two Protonix orders seen please clarify if both are current orders. Report was signed off and acknowledged by provider. 4/22/26 11:52 AM - During an interview, E10 (MD) confirmed the Consultant Pharmacist Report was reviewed and confirmed that the Protonix order daily was to be discontinued. 4/22/26 11:54 AM - During an interview, E3 (ADON) confirmed that R72 had two active Protonix orders from 2/22/26 to 3/30/26 when the second order was discontinued which totaled 37 additional doses. E3 stated that E2 (DON) or herself were responsible to review the monthly pharmacy reviews and implement any changes that were initiated by E10. 4/22/26 12:11 PM - During an interview, C1 (Pharmacy Technician) confirmed that R2 had two active Protonix orders on the aforementioned dates and that the pharmacy dispensed and delivered those medications to the facility. 4/22/26 12:45 PM - During an interview, E2 (DON) stated that the expectation was that E3 or herself would monitor the monthly pharmacy reviews and address any changes to be implemented. E2 stated that E3 runs a daily report to monitor all new prescription orders and that occasionally nurses on 11:00 PM to 7:00 AM shift will monitor them as well. E2 could not articulate how the how the discrepancy in the medication order was missed. 4/23/26 3:00 PM Findings were reviewed with E1 (NHA), E2 (DON) and at the exit conference.

Based on interviews, record review, and review of other documentation as indicated, it was determined that for one (R2) out of three residents sampled for discharge, the facility failed to ensure durable medical equipment and home health services were in place prior to R2's discharge. R2 was discharged from the facility on 2/9/26 at 6:00 PM and transported home via medical transport services and assisted up the stairs to a three-story residence by transport, where no caregiver support was in the home. On 2/11/26, R2 was found in the home by the home health agency nurse in unsafe conditions. The facility's failure to confirm home health services and the availability of caregiver support to perform required care and assistance placed R2 in a situation with the potential for serious harm or injury. An immediate jeopardy (IJ) was identified starting on 2/9/26. Based on the facility's investigation, documented response, completion of in-service training, and staff interviews, the facility's date of abatement for the Immediate Jeopardy was determined to be 2/20/26. Findings include: A facility policy titled Transfer and Discharge (including AMA) dated 9/2025 documented A post discharge plan of care that is developed with the participation of the resident, and the resident's representative(s) which will assist the resident to adjust to his or her new living environment. Orientation for transfer or discharge must be provided and documented to ensure safe and orderly transfer or discharge from the facility in a form or manner that the resident can understand.Review of R2's clinical record revealed:1/16/26 - R2 was admitted to the facility with diagnoses including spinal stenosis, cervical disc disorder, muscle weakness, carpal tunnel syndrome and a recent post-fasciotomy to the right arm. 1/22/26 - A review of a five-day admission MDS assessment documented R2 was cognitively intact with a BIMS of 14/15. 2/9/26 2:21 PM - A progress note titled Late Entry for 2/11/26 authored by E3 (SW) documented [R2] will have a safe discharge home with services and supports in place to assist with continuity of care, person-centered goals and psychosocial well-being. Further review of the progress note revealed referrals for home health care, skilled nursing services and DME equipment were made. Additionally, the progress note documented family members were in attendance at the discharge care plan. R2's clinical record lacked evidence of confirmation by the facility that services were in place prior to R2's discharge from the facility. 2/9/26 7:43 PM - A progress note documented The resident has been discharged from the facility. Discharge paperwork was reviewed with the resident and the resident verbalized understanding. No further concerns were received the d/c (sic) paperwork was signed and a copy handed to the resident. Medications were called to the pharmacy and will be delivered at the resident's house. The resident left the unit with medical transportation at 6:00 PM with his personal belongings and received evening meds from the floor nurse.2/11/26 8:43 AM - A progress note titled Late Entry authored by E3 documented 5:13 PM, [E5 (HHA RN)] called to update E3 on the status of staffing resident with HHA (Home Health Aide). [E5] has been in touch with the VA (Veterans Administration) who is currently working on authorization for HHA (Home Health Agency Services). [E5] shared that he forgot to mention to [E3] that VA service required PCP (Primary Care Physician) script (sic). [E5] confirmed a nurse will visit [R2] tonight 2/11/26.2/11/26 2:40 PM - A review of a progress note for R2 revealed the facility reached out to [R2] to discuss discharge concerns. [R2] informed the facility the hospital bed had not been delivered until the morning of 2/10/26 and that therapy, RN and HHA had not shown up as of time of the call and had not heard anything from the VA. In addition, the progress note documented [E3] to follow up with [R2] after outreach to providers.2/17/26 2:23 PM - During an interview, E3 reported [R2's] significant other and stepchildren were visiting on the day of the resident's baseline care plan and reported they would be there to support [R2].2/19/25 9:25 AM - A telephone interview with the DME provider confirmed the hospital bed was ordered for R2 on 2/6/26 was not delivered until 2/10/26. 2/19/26 9:39 AM - A telephone interview with R2 revealed that the resident returned to the hospital. R2 stated, I live in a three-story home. I don't think that was fair the way they sent me home. I needed a caretaker. Nobody was home when I got there. I can't use my hands. I had to call my sister-in-law to help me get washed up and fix a meal so I had something to eat that night, and she moved some furniture around to make room for the bed that didn't come until the next day, but she couldn't stay long. R2 then stated, The nurse was supposed to be at my house but was not there until a couple of days after I was home.2/19/26 10:02 AM - During a phone interview FM1 (Significant Other) stated, [R2] lives alone, no one lives with [R2]. FM1 then stated, I have my own health issues I'm dealing with, I can't take care of [R2]. [R2] arrived home alone, nobody was with [R2].2/19/26 10:37 AM - A telephone interview with E5 revealed a referral was received for R2 2/6/26. E5 then stated, The nurse is in the home within 48 hours of discharge.2/19/26 12:05 PM - During an interview E4 (DOR) stated, I do believe that [R2] needed more assistance based on [R2's] difficulty with fine motor skills.2/19/26 1:13 PM - During an interview, E3 was asked, Did you inform the agency what date services for [R2] needed to start? E3 stated, No I always give them a discharge date , and they contact the resident to set up the date. E3 then stated, I was assuming [R2] was going to get a call from the agency and the VA. E3 confirmed, I did not call to confirm the delivery of the hospital bed prior to [R2's] discharge.2/19/26 1:51 PM - During an interview E1 (NHA) reported contacting [E5] to inquire about [R2] not getting services. E1 then stated, E5 reported the agency received a call from someone that [R2] didn't need their level of care. E1 then stated, I was under the impression that FM1 and the son were going to be at home with [R2] and that the agency would be providing [R2] support through the VA.2/19/26 2:06 PM - During a telephone interview E7 stated, The referral for [R2] was received on 2/6/26 with a discharge date of 2/9/26 and start of care was requested for 2/11/26. In addition, E7 stated, I was called about the condition of [R2] I advised [E6] to call APS (Adult Protective Services). E7 then reported receiving a call on 2/10/26 from a family member of [R2], and they reported the facility said [R2] would have twenty-four-hour care. E7 then reported I can't say how the facility translated the care to the family, but I told them We do not do private duty, and that [E5] had already reached out to the VA for additional support services. E7 reported R2 agreed to go back to the hospital. 2/20/26 9:12 AM - During a telephone interview E6 (HHA RN) reported arriving to R2's home between 7:40 PM - 7:50 PM on 2/11/26. E6 stated, [R2] was sitting on the couch wearing an undershirt, a pull-up brief, and socks. [R2] reported not eating in two days, and that a friend had come by and brought a cheeseburger, and that was all [R2] had eaten. E6 reported that the cheeseburger was half-eaten. E6 then stated, [R2] said there was no food in the house, and if there was [R2] said, 'I couldn't get up to fix it. In addition, E6 stated, [R2] said I can't open my medications, and I can't open bottles. E6 reported assisting R2 to use the urinal to urinate, and that [R2] could not grip anything with the right hand and [R2] didn't have the fine motor skills to open a bottle. E6 reported contacting E7 (Agency Director) and explained the unsafe conditions that R2 was found in. E6 then spoke to R2 and explained why R2 should not be home alone, and asked R2 to call 911. E6 reported waiting with R2 until emergency medical transport arrived to take the resident to the hospital for further evaluation. 2/20/26 10:11 AM - During another telephone interview FM1 stated, On the day [R2] was being discharged my son who lives in Chesapeake, Virginia brought me to the nursing home to give [R2] his house keys when [R2] got home the transport people helped him into the house. I did not go to [R2's] house my son drove me back to my house and then got in the car and drove back to Chesapeake, Virginia and no, my son did not go to [R2's] house.2/20/26 2:20 PM - An immediate jeopardy was identified. 2/20/26 - 2/24/26 - Through interviews and record reviews, the Surveyor confirmed the facility had regained compliance on 2/20/26. 2/20/26 - The facility identified residents affected or likely to be affected by an inappropriate discharge from the facility. Audits of discharge documentation related to home health services, appropriate caregiver/family support, and any necessary services to meet residents' care needs for the last 7 days were reviewed by the NHA in order to determine if any residents were affected. All discharges planned within the next 72 hours were reviewed by the Administrator, DON, Director of Social Services, and the Director of Rehabilitation to ensure home health services, appropriate care/giver/family support, and necessary services to meet the resident's care needs are in place before discharge. Actions to Prevent Occurrence/Reoccurrence: The facility took the following actions to prevent an adverse outcome from recurring. Root cause analysis was determined to be failure to have a robust discharge care plan meeting with the Interdisciplinary team, with the resident and resident representative.The procedure for safe and effective discharge planning was reviewed with the IDT.Discharge planning IDT will be re-educated on the policy and procedure to ensure sufficient preparation and orientation to ensure a safe discharge. Residents who are scheduled to be discharged within 14 days will be reviewed to ensure appropriate discharge planning is in place.Residents who are scheduled to be discharged in the next 14 days will be reviewed to ensure support for ADLs is in place, durable medical equipment is available prior to or on the discharge date , medications are available upon discharge, and identified needs/support are available.Two times a week, residents who are scheduled for discharge will be reviewed to ensure safe discharge is in place. Any issues identified will be addressed accordingly.Weekly, during utilization review, NHA/Designee will oversee discharge planning to ensure preparation and services are in place prior to discharge.2/20/26 - The facility's response initiated for R2's inappropriate discharge to home included audits, educational in-services to the IDT team and staff interviews with E1 (NHA), E2 (DON), E3, (SW), E4 (DOR), E8 (ADON) and E9 (RNAC) confirmed education received for a residents discharge from the facility to the community and or other facility transfers, the facility's date of abatement for the immediate jeopardy was determined on 2/20/26. 2/24/26 2:15 PM -Findings were reviewed with E1 (NHA), E2(DON), and E8 (ADON) at the exit conference.

Based on observation, interview, and record review it was determined that for three (R63, R53, and R59) out of three residents reviewed for pain, the facility failed to ensure that that adequate pain management was provided and pain assessments were not conducted with a consistent scale for pre and post pain assessments. Findings include: April 2002 - The pain management standards by the American Geriatrics Society included: appropriate assessment and management of pain; assessment in a way that facilitates regular reassessment and follow-up; same quantitative pain assessment scales should be used for initial and follow up assessment; set standards for monitoring and intervention; and collect data to monitor the effectiveness and appropriateness of pain management. November 2009 - The American Academy of Pain Medicine, Pharmacological Management of Persistent Pain in Older persons, stated to refer to the previous American Geriatrics Society for specific recommendations for pain assessment in older persons that remain relevant. 1. Review of R63's clinical record revealed: 9/23/24 - R63 was admitted to the facility with the diagnoses including chronic pain, venous insufficiency, and cellulitis. 9/25/24 - A care plan for R63 was initiated for pain related to chronic pain with the following interventions: administer analgesia per orders, monitor and document side effects from pain medication, monitor/record/report to nurse any signs and symptoms of pain to the nurse, and notify the physician if interventions are unsucessful or if current complaint is a significant change from resident's experience of pain. 9/27/24 - An admission MDS documented R63 was receiving scheduled pain medication, as needed pain medication, pain frequency is occasional, and level of 3/10 as highest pain level in the last 5 days. 11/12/24 - A physician's order for R63 documented Tramadol 50 mg give one tablet by mouth every six hours for moderate and severe pain as needed and give thirty minutes prior to wound care. 11/2024 - A review of the November MAR revealed that R63 received Tramadol one time out of the 18 ordered opportunities to be given. 12/2024 - A review of the December MAR revealed that R63 received Tramadol one time out of the 31 ordered opportunities to be given. 1/2025 - A review of the January MAR revealed that R63 received Tramadol zero times out of the 31 ordered opportunities to be given. 2/11/25 10:15 AM - An interview with R63 revealed that R63 was having bilateral lower leg pain at a score of 7-8 out of 10. R63 stated she had received Tylenol for pain and it was ineffective and she had told the doctor previously that Tylenol does not help her pain. 2/13/25 11:11 AM - An observation of R63's wound care treatment revealed that R63 stated she had pain of 5/10 prior to administration of the treatment. R63 confirmed she was a 10/10 during treatment and 10/10 after treatment. An observation of resident yelling out every time E20 (LPN) would touch an area on R63's left lower extremity. R63's bilateral lower extremities were covered in crusted scab like areas and when touched the crusted area would come off and revealed reddened tissue underneath. R63 stated that the liquid (acetic acid) that E20 was applying to her legs was burning and stinging when applied. 2/13/25 11:25 AM - An interview with E20 revealed that she administered Tylenol 650 mg to R63 despite the order in the EMR stated to give Tramadol (pain medication) 50 mg 30 minutes prior to wound care. 2/13/25 2:37 PM - An interview with E20 confirmed she only administers the Tramadol when R63 complains of moderate or severe pain. E20 confirmed that she usually gives R63 Tylenol prior to wound care and today she did because resident complained of 5/10 pain. 2/14/25 12:31 PM - An interview with E9 (MD) confirmed that the Tramadol was to be administered 30 minutes prior to R63 receiving wound care to control pain. E9 was unaware staff was not administering the Tramadol per order. 2/14/25 1:00 PM - An interview with R63 confirmed she received Tramadol per order and her legs are less painful today. 2/2025 - A review of the February MAR revealed that R63 received Tramadol four times out of the 13 opportunities to be given. The facility failed to administer pain medication prior to wound care treatment per physician's order. 2. Review of R53's clinical record revealed: 4/5/24 - R53 was admitted to the facility. 4/5/24 - A care plan was initiated and documented that R53 had pain related to generalized pain, diagnosis of pain in joints, right shoulder pain, and hemrorroid pain. Interventions included notify physician if interventions are unsuccessful and observe and report any changes in usual routine, sleep pattern, or if current pain complaint is a significant change from baseline. 4/18/24 - An admission MDS documented that R53 was on a scheduled pain regimen and had constant pain. 12/2024 - A review of R53's December MAR revealed that R53's pain was not being monitored every shift and PRN (as needed) medications were being administered with a numerical pre pain score and post score documented as ineffective, effective, and unchanged. R53 received four doses of Tylenol out of 30 potential opportunities with the incorrect pain scale used pre and post administration. 1/2025 - A review of R53's January MAR revealed that R53's pain was not being monitored every shift and PRN (as needed) medications were being administered with a numerical pre pain score and post score documented as ineffective, effective, and unchanged. R53 received four doses of Tylenol out of 30 potential opportunities with the incorrect pain scale used pre and post administration. 2/2025 - A review of R53's February MAR revealed that R53's pain was not being monitored every shift and PRN (as needed) medications were being administered with a numerical pre pain score and post score documented as ineffective, effective, and unchanged. R53 received one dose of Tylenol out of 30 potential opportunities with the incorrect pain scale used pre and post administration. 2/11/25 9:42 AM - An interview with R53 revealed that she is having left knee pain and Tylenol is not effective. 2/14/25 12:31 PM - An interview with E2 (DON) and E19 (Corporate) confirmed that R53's pain was not being monitored and the pain scale did not match pre and post assessment. The review of R53's medical record revealed that the facility failed to monitor pain with a consistent scale. 3. Review of R59's clinical record revealed: 12/23/23 - R59 was admitted to the facility. 1/8/24 - A review of the care plan lacked evidence of a pain care plan. 1/19/24 - An admission MDS documented that R59 was on a scheduled pain medication and did not have pain currently. 12/2024 - A review of R59's December MAR revealed that R59's pain was not being monitored every shift and PRN (as needed) medications were being administered with a numerical pre pain score and post score documented as ineffective, effective, and unchanged. R59 received four doses of Tylenol out of 30 potential opportunities with the incorrect pain scale used pre and post administration. 1/2025 - A review of R59's January MAR revealed that R59's pain was not being monitored every shift and PRN (as needed) medications were being administered with a numerical pre pain score and post score documented as ineffective, effective, and unchanged. R59 received one dose of Voltaten (topical pain cream) out of 30 potential opportunities with the incorrect pain scale used pre and post administration. 2/2025 - A review of R59's February MAR revealed that R59's pain was not being monitored every shift and PRN (as needed) medications were being administered with a numerical pre pain score and post score documented as ineffective, effective, and unchanged. R59 received two doses of Tylenol and five doses of Voltaren out of 30 potential opportunities with the incorrect pain scale used pre and post administration. 2/18/25 09:30 AM - An interview with R59 revealed she is having bilateral knee pain and Tylenol is not effective. 2/14/25 12:31 PM - An interview with E2 (DON) and E19 (Corporate) confirmed that R59's pain was not being monitored and the pain scale did not match pre and post assessment. The review of R59's medical record revealed that the facility failed to monitor pain with a consistent scale. 2/19/25 1:41 PM - Findings were reviewed during the exit conference with E1(NHA), and E2 (DON).

Based on observation and interview it was determined that the facility failed to ensure food was stored, prepared, and served in a manner that prevents food borne illness to the residents. Findings include: 1. 2/11/25 8:39 AM - During the initial tour of the kitchen the surveyor observed the following: - The hair on the front of E5's (FSS) head was unsecured by a hair net. - The hand washing sink located in the dish area was obstructed by a fan and the paper towel dispenser was empty. - The small refrigerator for milk storage contained an opened gallon of milk with an expiration date of 2/5/25. 38302 2. 2/17/25 10:06 AM - During a tour of the kitchen, food particles were splattered on the top and sides of the cooktop and oven. Food debris and other litter was on the kitchen floor, under the shelving, prep trables and oven. 2/17/25 11:05 AM - The underside of all of the shelves on the plastice shelving units in the walk-in refrigerator had numerous areas of small black circular staining, which appeared to be mold or mildew creating the potential for contamination of food items stored there. 2/17/25 11:40 AM - During a tour of the kitchen, the walk-in refrigerator contained a pan of sausage patties, which was not completely covered exposing it to contamination from dust and other debri 2/19/25 1:41 PM - Findings were reviewed during the exit conference with E1(NHA), and E2 (DON).

Based on observation and interview, it was determined that for two (R43 and R63) out of eighteen (18) residents in the investigative sample, the facility failed to ensure residents were treated with respect and dignity. Findings include: 1. Review of R43's clinical record revealed: 4/8/24 - R43 was admitted to the facility. 4/12/24 - An admission MDS documented R43 as cognitively intact with a BIMS score of 14. 2/11/25 10:31 AM - An observation of E20 (LPN) entering R43's room revealed that staff did not knock or request to enter. 2/13/25 11:01 AM - An observation of E12 (CNA) entering R43's room revealed that staff did not knock or request to enter. 2/13/25 11:10 AM - An interview with E12 confirmed that she entered R43's room without knocking or requesting to enter. 2. Review of R63's clinical record revealed: 9/23/24 - R63 was admitted to the facility. 9/27/24 - An admission MDS documented R63 as cognitively intact with a BIMS score of 15. 2/11/25 10:24 AM - An observation of E20 (LPN) entering R63's room revealed that staff did not knock or request to enter. 2/11/25 10:27 AM - An interview with E20 confirmed that she entered R63's room and did not knock or request to enter. 2/13/25 11:10 AM - An interview with E12 confirmed that she entered R43's room without knocking or requesting to enter. The facility failed to ensure that R43 and R63 were treated with respect and dignity. 2/19/25 1:41 PM - Findings were reviewed during the exit conference with E1(NHA), and E2 (DON).

Based on interview and record review, it was determined that for one (R43) out of one resident reviewed for personal funds, the facility failed to ensure that the resident received their quarterly personal funds statement. Findings include: The facility policy entitled; Transactions Involving Residents Funds last updated November 2024 indicated, Quarterly statements will be provided in writing to the resident or the resident's representative, at the end of the quarter and upon request. Review of R43's clinical record revealed: 4/8/24 - R43 was admitted to facility. 12/30/24 - A quarterly MDS assessment documented that R43 was cognitively intact. 6/24/24 - 9/30/24 - A review of R43's electronic record revealed that the quarterly statement was not provided. 2/11/25 10:34 AM - During an interview, R43 reported the facility manages R43's money and the resident has not received quarterly statements. 2/18/25 9:12 AM - During an interview E1 (NHA) confirmed R43 did not receive quarterly statements. 2/18/25 9:14 AM - During an interview E10 (Business Office Manager) confirmed R43 was not provided with quarterly statements. 2/19/25 1:41 PM - Findings were reviewed during the exit conference with E1 and E2 (DON).

Based on observation and interview,it was determined that for one (R43) out of eighteen sampled residents, the facility failed to protect personal privacy. Findings include: Review of R43's clinical record revealed: 4/8/24 - R43 was admitted to the facility. 4/12/24 - An admission MDS documented R43 as cognitively intact with a BIMS score of 14. 2/11/25 10:33 AM - An interview with R43 revealed that R43 felt she was unable to have a private phone call in the facility due to not having a phone available to use in her room. R43 stated when she makes phone calls she uses the phone in the facility lobby. R43 stated that when she asked the facility advised her she could get a cell phone for personal use. 2/17/25 1:26 PM - An interview with E22 (Corporate Maintenance) confirmed that all resident rooms currently do not have phone access and the facility is running the phone lines today so the residents will have personal phones available to use in each room. 2/17/25 01:45 PM - An interview with E2 (DON) revealed that the facility has portable phones available for use that the residents can take back to the rooms and utilize. E2 also stated that the nursing supervisor has a phone that family members are given the number to call. 2/18/25 2:43 PM - An interview with R43 revealed that R43 was unaware of a portable phone to use for personal calls and staff had not offered the use of it to maintain privacy. 2/19/25 1:41 PM - Findings were reviewed during the exit conference with E1(NHA) and E2 (DON).

Based on record review and interview, it was determined that for one (R60) out of two residents reviewed for hospitalization the facility failed to notify the Ombudsman of the residents transfer to the hospital. Findings include: The facility policy on Transfer and Discharge last updated September 2024, indicated Emergency Transfers/Discharges - The Social Services Director, or designee, will provide copies of the notices for emergency transfers to the Ombudsman, but the may be sent when practicable, such as in a list of residents on a monthly basis. Review of R60's clinical record revealed: 9/17/24 - R60 was transferred from the facility to the hospital emergently. 2/17/25 1:36 PM - E1 (NHA) provided the September 2024 Ombudsman Notification List of residents transferred out of the facility. A review of the list lacked evidence of notice of R60's transfer. 2/17/25 1:35 PM - E1 confirmed the findings. 2/19/25 1:41 PM - Findings were reviewed during the exit conference with E1 and E2 (DON).

Based on interview and record review, it was determined that for two (R19 and R31) out of three residents reviewed for PASARR, the facility failed to ensure that a referral for PASARR screening was completed. Findings include: 1. Review of R19's clinical record revealed: 3/7/18 - R19 was admitted to the facility with the diagnoses including non-Alzheimer's dementia. 4/16/18 - A PASARR level I was submitted to the state PASARR authority and had no evidence of any serious mental illness noted. 12/23/24 - A quarterly MDS assessment documented that R19 had the following diagnoses: non Alzheimer's dementia and psychotic disorder. 2/17/25 3:21 PM - A phone interview with E23 (SW) confirmed that a PASARR update had not been submitted since March of 2021. E23 also confirmed that the PASARR system had an issue with the system having previous employee information in system and resulting in the facility being unable to submit updates. 2. Review of R31's clinical record revealed: 2/13/19 - R31 was admitted to the facility with diagnoses including psychotic disorder with behavioral disturbances and altered mental status. 4/21/21 - A review of R31's diagnoses list revealed a new diagnosis of major depressive disorder and delusional disorder were added. 9/16/21 - A psychology progress note documented that R19 had the following new diagnoses: mood disorder and delusional disorder. 10/1/22 - A review of R31's diagnoses list revealed a new diagnosis of unspecified dementia with other behavioral disturbances. 1/7/25 - A quarterly MDS assessment documented R19 had a diagnoses of a psychotic disorder, depression, mood disorder, and non Alzheimer's dementia. 2/17/25 3:21 PM - A phone interview with E23 (SW) confirmed that a PASARR update had not been submitted since March of 2021. E23 also confirmed that the PASARR system had an issue with the system having previous employee information in system and resulting in the facility being unable to submit updates. 2/19/25 1:41 PM - Findings were reviewed during the exit conference with E1(NHA) and E2 (DON).

Based on record review and interview it was determined that for one (R69) out of one reviewed for new admission, the facility failed to ensure that a baseline care plan was completed. Findings include: Record review for R69 revealed: 11/29/24 - R69 was admitted to the facility. 12/4/24 - A review of R69's clinical record revealed a lack of evidence of a baseline care plan. 2/17/25 12:57 PM - E1 (NHA) confirmed that there was no evidence that R69 had a base line care plan developed and that a summary of the plan was provided to the resident/ resident representative. 2/19/25 1:41 PM - Findings were reviewed during the exit conference with E1and E2 (DON).

Based on interview and record review, it was determined that for one (R63) out of eighteen residents in the investigative sample the facility failed to develop and implement a comprehensive resident centered care plan for an identified care area. Findings include: Cross refer F690 Review of R63's clinical record revealed: 9/23/24 - R63 was admitted to the facility. 9/23/24 - A care plan (last updated 1/6/25) was initiated for R63 and documented R63 had a self care defecit related to limited mobility with interventions including R63 was completely dependent on staff for toileting use and to encourage R63 to participate to the fullest extent possible with care. 9/27/24 - An admission MDS assessment documented R63 was dependent on staff for toileting. The MDS also documented R63 was always incontinent of bowel and bladder and was not on a toileting program. 12/27/24 - A quaterly MDS assessment documented R63 was dependent on staff for toileting. The MDS also documented R63 was always incontinent of bowel and frequently incontinent bladder and was not on a toileting program. The facility failed to develop and implement a comprehensive resident centered care plan related to R63's incontinence. 2/19/25 1:41 PM - Findings were reviewed during the exit conference with E1(NHA) and E2 (DON).

Based on record review and interview, it was determined for two (R22 and R63) out of eighteen residents in the investigative sample the facility failed to review and revise the care plan. Findings include: 1. Review of R22's clinical record revealed: 12/14/18 - R22 was admitted to the facility. 12/14/18 - A care plan documented that R22 had a self care deficit related to impaired mobility and cognitive defect with the following interventions: provide total assist with personal hygiene and dressing, provide a bed bath per RP (responsible party) and risk for falls in shower chair due to severe chorea. 2/19/25 10:30 AM - An interview with E3 (ADON) confirmed that R22 was unsafe to use shower chair or stretcher related to falls and that care plan was not updated to accurately reflect R22's current plan of care. 2. Review of R63's clinical record revealed: 9/23/24 - R63 was admitted to the facility. 9/25/24 - A care plan for R63 was initiated for pain related to chronic pain with the following interventions: administer analgesia per orders, monitor and document side effects from pain medication, monitor/record/report to nurse any signs and symptoms of pain to the nurse, and notify the physician if interventions are unsuccessful or if current complaint is a significant change from resident's experience of pain. 2/14/25 12:31 PM - An interview with E2 (DON) and E19 (Corporate) confirmed that R63's care plan lacked an acceptable level of pain and updated interventions related to non-pharmacological interventions. 2/19/25 1:41 PM - Findings were reviewed during the exit conference with E1(NHA) and E2 (DON).

Based on observation, interview and record review, it was determined that for three (R19, R22 and R55) out of five residents reviewed for ADL's, the facility failed to ensure ADL care was provided to dependent residents. Findings include: 1. Review of R55's clinical record revealed: 1/2/25 - R55 was admitted to the facility with multiple diagnoses including legal blindness. 1/3/25 - A baseline care plan documented that R55 had visual impairment and needed substantial maximum assistance with hygiene. 1/9/25 - An admission MDS assessment documented that R55's vision was severely impaired, and that the resident required partial moderate assistance to complete hygiene related ADL's such as shaving. 2/11/25 9:08 AM - During an interview R55 stated, I have a brand new razor and they have used it once. I can't see and need help to shave. R55 was observed with significant unkempt facial hair that he confirmed was not his preference. 2/14/25 10:48 AM - R55 was observed with unkempt facial hair. 2/14/25 1:11 PM - The surveyor accompanied E11 (CNA) to R55's room where R55 remained with unkempt facial hair. E11 confirmed that that she was aware of R55's visual impairment and did not offer to assist R55 with shaving/hygiene because This is a rehab floor so I assume they can all do that themselves. February 2025 - Review of the CNA task completion documented that hygiene, which includes shaving, was documented as completed and was inconsistent with observation of R55's unkempt facial hair. 46988 2. Review of R19's clinical record revealed: 3/7/18 - R19 was admitted to the facility. 3/7/18 - A care plan documented that R19 had a self care defect for related to impaired mobility and cognitive defect with the following interventions: provide total assist with with personal hygiene and dressing, provide tub bath/shower two times a week, and provide tub bath/ shower with total dependence. 12/27/24 - A quarterly assessment documented that R19 was dependent with one staff member for ADL's including showering and bathing. 1/2025 - A review of the January CNA documentation record revealed that R19 was receiving two showers a week on Sunday and Thursday. 2/2025 - A review of the February CNA documentation record revealed that R19 was receiving two showers a week on Sunday and Thursday. 2/13/25 11:34 AM - An observation of R19 with uncombed, unmanaged, greasy hair. 2/14/25 1:50 PM - An observation of R19 with uncombed, unmanaged, greasy hair. 2/17/25 9:35 AM - An observation of R19 with uncombed, unmanaged, greasy hair. 2/18/25 9:54 AM - An observation of R19 with uncombed, unmanaged, greasy hair. 2/19/25 9:30 AM - An observation of R19 with uncombed, unmanaged, greasy hair. 2/19/25 9:50 AM - An interview with E28 (CNA) confirmed that R19's shower's were signed off and confirmed the R19's hair did not appear clean. E28 stated that typically the floor has limited staff and it is difficult to complete twelve residents per CNA, especially on shower days. E28 stated a CNA can be scheduled to come in and assist with showers but they have not been in since previous week. 2/19/25 10:30 AM - An interview with E3 (ADON) confirmed that a CNA responsible for showers was not present on unit today and will review acuity for the unit to see if they can get more staff to assist the unit. The facility failed to assist a dependent resident with ADL care. 3. Review of R22's clinical record revealed: 12/14/18 - R22 was admitted to the facility. 12/14/18 - A care plan documented that R22 had a self care defect for related to impaired mobility and cognitive defect with the following interventions: provide total assist with with personal hygiene and dressing, provide a bed bath per RP (responsible party) and risk for falls in shower chair due to severe chorea. 1/3/25 - A CNA task for R19 was revised for bed baths on Tuesday's 3 to 11 and Friday's 7 to 3 and bed bath for all other days unless specified. 2/13/25 11:44 AM - An observation of R22 with uncombed, unmanaged, greasy hair. 2/14/25 1:40 PM - An observation of R22 with uncombed, unmanaged, greasy hair. 2/17/25 9:55 AM - An observation of R22 with uncombed, unmanaged, greasy hair. 2/18/25 10:07 AM - An observation of R22 with uncombed, unmanaged, greasy hair. 2/19/25 9:30 AM - An observation of R22 with uncombed, unmanaged, greasy hair. 2/19/25 9:50 AM - An interview with E28 (CNA) confirmed that R22's bath's were signed off and confirmed the R22's hair did not appear clean. E28 stated that typically the floor has limited staff and it is difficult to complete twelve residents per CNA, especially on shower days. E28 stated a CNA can be scheduled to come in and assist with showers but they have not been in since previous week. 2/19/25 10:30 AM - An interview with E3 (ADON) confirmed that a CNA responsible for showers was not present on unit today and will review acuity for the unit to see if they can get more staff to assist the unit. The facility failed to assist a dependent resident with ADL care. 2/19/25 1:41 PM - Findings were reviewed during the exit conference with E1(NHA), and E2 (DON).

Based on interview and record review it was determined that for two (R43 and R63) out of two residents reviewed for general care and services, the facility failed to ensure treatment and care in accordance with professional standards of practice and physician orders. Findings include: 1. Review of R43's clinical record revealed: 4/8/24 - R43 was admitted to the facility with diagnoses including but not limited to constipation. 12/30/24 - A quarterly MDS assessment documented that R43 has a diagnosis of constipation unspecified. 1/2/25 - A review of physician's orders revealed the following orders: -Milk of Magnesia (MOM) give 30 mL every seventy two hours as needed for constipation if no bowel movement (BM) after three days. -Bisacodyl suppository 10 mg insert one suppository rectally as needed for constipation daily if no results from MOM. -Fleet enema insert one dose rectally every twenty four hours as needed if no BM in three days. 1/21/25 to 2/10/25 - Review of the CNA documentation sheet revealed that the facility failed to ensure that physician's orders were implemented when R43 failed to have bowel activity for nine (9) shifts on the following dates: - 2/10/25 ending on 7 AM to 3 PM shift - total of 12 shifts. 2/18/25 12:40 PM - An interview with E16 (LPN) revealed that the bowel protocol is initiated by the 7 AM to 3 PM shift after review of the facilities BM report and the supervisor will notify nurses who is on the list to have protocol initiated. 7 AM to 3 PM will document medication in the electronic medical record (EMR) and verbally notify the next shift regarding results of protocol. E16 confirmed that R43 had 12 shifts with no BM and protocol was initiated. 2. Review of R63's clinical record: 9/23/24 - R63 was admitted to the facility with the following diagnoses but not limited to venous insufficiency and local infection of the skin and subcutaneous tissue. 12/17/24 - A physician's order documented acetic acid irrigation solution use one application every day shift for open areas to R63's left lower leg: cleanse left lower leg with acetic acid and apply bacitracin and abdominal pad daily and as needed. Order was discontinued 1/20/25. 1/17/25 - A physician's order documented to R63's left leg dressing apply bacitracin (antibiotic ointment) then non-adherent dressing, wrap with ACE bandage. 2/11/25 - A physician's order documented to cleanse R63's left leg with soap and water then apply dermaseptin infused kling and wrap legs daily and as needed. 2/13/25 11:25 AM - An observation of wound care to R63's lower extremities revealed that E20 (LPN) administered acetic acid irrigation solution to R63's lower left leg and applied bacitracin ointment to open areas post irrigation solution. 2/13/25 2:37 PM - An interview with E20 confirmed that the current physician's order in the system was not the same as the treatment administered at 11:25 AM. E20 stated she was given a verbal order by E9 (Physician) this morning and to change the treatment. Facility documentation did not reflect this change in treatment orders. 2/14/25 12:31 PM - An interview with E9 confirmed that the treatment order in the EMR was not the current order for R63's current plan of care. The facility failed to follow a physician's order. 2/19/25 1:41 PM - Findings were reviewed during the exit conference with E1(NHA), and E2 (DON).

Based on observation and interview, it was determined that for one (R31) out of two residents reviewed for positioning and mobility, the facility failed to apply an ordered splint device. Findings include: Review of R31's clinical record revealed: 2/13/19 - R31 was admitted to the facility with diagonoses to including hemipleglia and hemiparesis following a cerebral vascular accident. 2/13/19 - A care plan was initiated for R31 documented actual contractures related to decreased mobility with the following interventions: left and right hand/wrist orthotic on each shift, maintain joints and body in a neutral body position at all times, and passive range of motion as tolerated. 6/26/24 - A physician's order for R31 documented apply right hand/wrist orthortic on every shift and remove for range of motion (ROM), hygiene, and routine skin checks every two hours. 12/12/24 - A physician's order for R31 documented apply left hand soft resting hand splint to be on in morning and remove in evening. 1/7/25 - A quarterly MDS assessment documented that R31 had impairments bilaterally to upper extremities and dependent of one staff for ADL's. 2/13/25 9:02 AM - An observation of R31 with bilateral contractures to bilateral upper extremities and no splints noted in place. 2/13/25 11:00 AM - An observation of R31 with bilateral splints noted but not in proper placement for intended function. 2/18/25 9:40 AM - An observation of R31 with bilateral contractures to bilateral upper extremities and no splints noted in place. 2/18/25 11:40 AM - An observation of R31 with bilateral contractures to bilateral upper extremities and no splints noted in place. 2/18/25 11:41 AM - An interview with E12 (CNA) confirmed that R31 wears bilateral hand splints and stated they are applied in the morning and removed in the evening. E12 confirmed that the CNA is responsible to check for placement of the splint during the day and adjust if moved out of place. E12 confirmed that R31's bilateral hand splints were not placed properly at time of observation. 2/19/25 9:27 AM - An observation of R31 with bilateral contractures to bilateral upper extremities and no splints noted in place. 2/19/25 10:45 AM - An interview with E26 (CNA) confirmed that R31 did not have splints on and stated that another staff member told her R31's bilateral splint order was discontinued. 2/19/25 10:52 AM - An interview with E27 (COTA) confirmed that R31's bilateral splint order was not discontinued. 2/19/25 10:59 AM - An interview with E16 (LPN) confirmed that R31 still had an active order in the EMR (electronic medical record) for bilateral splints and stated that she will ensure they get placed on R31. 2/19/25 1:41 PM - Findings were reviewed during the exit conference with E1(NHA), and E2 (DON).

Based on interview and record review it was determined that for two (R53 and R63) out of two residents reviewed for bowel and bladder, the facility failed to provide services to maintain or restore bowel and bladder continence. Findings include: 1. Review of R53's clinical record revealed: 4/5/24 - R53 was admitted to the facility. 4/5/24 - A care plan was initiated for bladder incontinence related to occasionally incontinent with the following interventions: apply barrier cream with each incontinent episode, change clothing with each incontinent episode, and check resident every two hours for incontinence and provide care. 10/9/24 - A quarterly MDS assessment documented that R53 required supervision of one for toileting. The MDS also documented that R53 had a BIMS score of 5 indicating cognitive decline and was occasionally incontinent of bladder, always continent of bowel, and was not indicated for a toileting program. 10/2024 - A review of the October CNA documentation record revealed that R53 was incontinent of urine 14 times out of 95 opportunities and incontinent of bowel 14 out of 96 opportunities. 11/4/24 - A bowel and bladder assessment documented R53 was incontinent of urine and continent of bowel. The assessment also documented that R53 was aware of urges for toileting and required assistance of one for toileting. 11/2024 - A review of the November CNA documentation record revealed that R53 was incontinent of urine 40 out of 93 opportunities and incontinent of bowel seven times out of 91 opportunities. 11/15/24 - A significant change MDS assessment documented that R53 required supervision of one for toileting. The MDS also documented that R53 was frequently incontinent of bladder, occasionally incontinent of bowel, and was not indicated for a toileting program. 12/2024 - A review of the December CNA documentation record revealed that R53 was incontinent of urine 62 times out of 101 opportunities and incontinent of bowel 11 times out of 96 opportunities. 1/2025 - A review of the January CNA documentation record revealed that R53 was incontinent of urine 79 times out of 102 opportunities and incontinent of bowel 13 times out of 98 opportunities. 2/2025 - A review of the February CNA documentation record revealed that R53 was incontinent of urine 42 out of 49 opportunities and incontinent of bowel four times out of 55 opportunities. 2/8/25 12:45 PM - An interview with E25 (CNA) confirmed that R53 was an assist of one staff for toileting and that R53 can tell staff that she has to use the bathroom. E25 stated that she does not recall resident being on a toileting program. The facility lacked evidence that they attempted to restore bowel and bladder function for R53. 2. Review of R63's clinical record revealed: 9/23/24 - R63 was admitted to the facility. 9/27/24 - An admission MDS assessment documented R63 is dependent on staff for toileting. The MDS also documented R63 was always incontinent of bowel and bladder and was not on a toileting program. 11/2024 - A review of the November CNA documentation record revealed that R63 was continent of urine four times out of 96 opportunities and continent of bowel six times out of 96 opportunities. 12/2024 - A review of the December CNA documentation record revealed that R63 was continent of urine two times out of 105 opportunities and continent of bowel two times out of 98 opportunities. 12/27/24 - An quaterly MDS assessment documented R63 is dependent on staff for toileting. The MDS also documented R63 was always incontinent of bowel and and frequently incontinent bladder and was not on a toileting program. 12/30/24 - A bowel and bladder assessment documented R63 was total incontinence of urine and total incontinence of bowel. The assessment also documented that R63 was unaware of urges for toileting and required complete dependence of one for toileting. 1/2025 - A review of the January CNA documentation record revealed that R63 was continent of urine zero times out of 101 opportunities and continent of bowel zero times out of 98 opportunities. 2/11/25 10:20 AM - An interview with R63 revealed that R63 was using a bed pan prior to admission to the facility and R63 stated she requested to use one and has not received one. 2/18/25 11:30 AM - An interview with E12 (CNA) confirmed that R63 is dependent for care and R63 is able to verbalize when she needs to use the bathroom. E12 stated that R63 does not use a bed pan and has not been on a toileting program that she can recall. The facility lacked evidence that they attempted to restore bowel and bladder function for R63. 2/19/25 1:41 PM - Findings were reviewed during the exit conference with E1(NHA), and E2 (DON).

Based on record review and interview, it was determined for one (R1) out of three residents reviewed for hospitalization, the facility failed to provide services to maintain R1's bowel function. The facility's failure to initiate the bowel protocol resulted in harm to R1 as it resulted in R1 undergoing a fecal disimpaction procedure during his 11/23/24 hospitalization. Additionally, the facility failed to obtain ordered blood work, to provide neb treatment due to machine not available and failed to obtain peripheral access for intravenous fluid infusion and supplemental oxygen order. Findings include: Cross refer F561 and F677. Review of R1's clinical record revealed: 8/14/15 - R1 was admitted to the facility with diagnoses, including but not limited to, diabetes, stroke with left-sided weakness, constipation, dementia and PEG feeding tube in-situ. a. The facility's Bowel Protocol- Laxative: Milk of Magnesia 30 cc after 3rd day without BM (bowel movement) (3-11) (signifies given on the 3 PM to 11 PM shift) - if no BM, then bisacodyl suppository (7-3) (signifies 7 AM to 3 PM shift) - if no BM, then fleets enema (3-11) (signifies 3 PM to 11 PM shift) 2/1/18 - R1 was ordered senna syrup (a medication used to treat constipation) 8.8. mg/5 ml - give 10 ml via PEG tube two times a day related to constipation. 1/31/21 - R1 was started on Lactulose solution (a medication used to treat constipation by increasing water absorption and pressure in the colon) 20 gm/30 ml- give 30 ml via PEG two times a day for ileus (a partial or complete non-mechanical blockage of the intestine). It should be noted that R1 was ordered to be administered the two above- mentioned laxative medications twice a day every day as part of his routine medications. 11/19/24 9:54 PM - E6 (CNA) documented in R1's electronic medical record (EMR) that R1 was incontinent of a large, putty-like stool. Review of R1's EMR progress notes revealed no documentation by nursing or the providers regarding R1's lack of bowel movement from 11/19/24 night shift to 11/23/24 evening shift. Any notes during this time period lacked evidence of assessment of R1's abdomen and documentation of bowel sounds. Review of R1's EMR revealed no additional bowel/laxative medication was ordered after nine shifts (3 days) with no documentation of R1 having a bowel movement. 11/22/24 12:51 PM - E7 (NP) documented in R1's EMR progress notes, XXX[AGE] year old male with pmhx (past medical history) of CVA ( cerebral vascular accident/stroke) with hemiplegia and dependent for all ADLs (activities of daily living) .Notified this morning that patient is hypoxic, tachypneic, rhonchorus (sic) and febrile . Physical exam: Gastrointestinal: soft: positive; Tender: negative; Distended; negative; Dysphagia; positive; Bowel sounds Present: X 4 Quadrants; PEG tube; positive . This note lacked evidence of any documentation regarding R1's lack of bowel movement in three days or any interventions to alleviate his constipation. R1's last documented bowel movement (BM) was 11/19/24 at 9:54 PM. From 11/19/24 at 9:54 PM until 11/23/24 at 6:24 PM ,which was a total of eleven and a half shifts, R1 did not have a bowel movement. 11/23/24 6:24 PM - [Ambulance transport] Emergency medical technicians (EMTs) arrived at the facility to transport R1 to the hospital for respiratory distress. 11/24/24 2:02 AM - C1 (hospital emergency room physician) documented in R1's Hospitalist History and Physical Note, .Physical Exam- Abdominal: General: Abdomen is flat. Tenderness: There is generalized abdominal tenderness . 11/24/24 5:28 PM - C3 (hospital general surgery resident/MD) documented in R1's medical record, .diagnostic workup for his sepsis shows large fecal stool burden in rectum, general surgery consulted for fecal disimpaction .Physical Exam- Abdomen: mildly distended .CT of abdomen and pelvis .There is moderate fecal retention, especially within the rectum, which is distended up to 8 cm (centimeters) .will evaluate patient at bedside and perform digital rectal exam and fecal disimpaction. Will also order soap suds enema. After his disimpaction, recommend resident be placed on a bowel regimen . C2 (hospital general surgeon attending/MD) documented in R1's medical record a consult note, [AGE] year old male bedbound, previous stroke, contractures, PEG tube dependent for feeding, suprapubic cystostomy catheter in place, admitted for urosepsis. General surgery consulted for fecal (stool) disimpaction (a procedure to remove trapped stool from the rectum). Will perform a fecal disimpaction at bedside. Continue enemas. Review of R1's EMR CNA (certified nurses aide) tasks revealed various CNAs documented, DN- No bowel movement from Tuesday, 11/19/24 night shift to Saturday, 11/23/24 day shift. This confirmed that R1 went a total of eleven 8-hour shifts without having a bowel movement. 12/2/24 2:45 PM - During an interview with E2 (DON) and E4 (RCC), E2 reiterated the facility's bowel protocol for when a resident goes three days without a bowel movement. We run the report from the EMR. It is called a complex alert documentation report. Usually it is the day shift supervisor who runs the report. Then we discuss the residents on the BM list at the morning clinical meeting. Then an order is entered to start the protocol with milk of magnesia to be given on evening shift (3-11 PM) as a one-time order so it flags red in the MAR for the nurse to administer and sign off the medication. The facility was unable to provide evidence of the complex alert documentation report for 11/22/24 and 11/23/24 when requested. The facility was unable to provide evidence of the one-time order for milk of magnesia for R1 that was to be entered on 11/23/24 and administered on 11/23/24 evening shift. It should be noted that, per the facility's protocol, day three (9 shifts) without a bowel movement for R1 would flag in the report system on Friday, 11/22/24 after evening shift. The first complex alert documentation report that would reflect this information was Saturday, 11/23/24. There were no morning clinical meetings on weekends and therefore no complex alert documentation report. b. The facility's Oxygen Administration Policy: .Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control .8. Staff shall notify the physician of any changes in the resident's condition, including changes in vital signs, oxygen concentrations, or evidence of complications associated with the use of oxygen. Revised 5/2024 11/22/24 Friday 10:29 AM - E15 (LPN) documented in R1's Electronic medical record (EMR), .On assessment @approx. (sic) 0830, resident appear (sic) to be struggling to breathe, lung sounds assessed resident has coarse and crackling lung sounds. O2 (oxygen) assessed, resident at 77 %, O2 @2L (liters) applied, rose to 93% via NC (nasal cannula), B/P (blood pressure) - 133/81, HR (heart rate) 120 (normal adult heart rate is 60 to 100 beats per minute), Temp 98.9, 42 breaths per minute (normal adult respiratory rate is 12 to 20 per minute). On-call NP contacted with no answer, [E16] (MD) contacted with no answer, NP later called back with N. O (new order) ceftriaxone (antibiotic) 1 gm, guaifenesin liquid (cough medicine) 100 mg/5 ml, CBC w/diff (blood work- complete blood count with differential), BMP (blood work- basic metabolic panel). [E16] applied to N.O. for Xray. Resident emergency contact #1 contacted to make aware of the resident condition. 11/22/24 Friday 12:51 PM - E7 (NP) documented in R1's EMR progress notes, XXX[AGE] year old male with pmhx (past medical history) of CVA with hemiplegia and dependent for all ADLs . Notified this morning that patient is hypoxic, tachypneic, rhonchorus (sic) and febrile . Plan: Ceftriaxone 1 gm IM (intramuscular) q (every) 24 hours X (times) 5 days, Normal saline @ 50 ml/hr for 3 days. Antitussive, antipyretics as needed, suction q 2 hours . 11/22/24 - E7 (NP) ordered in R1's EMR, .BMP one time only for febrile illness .CBC with Diff one time only for febrile illness . flu, COVID, RSV one time only for viral panel swab .please place peripheral IV, if unable to obtain, consider external IV team to come and place midline .vital signs q shift x 3 days .Ipratropium-Albuterol solution (inhaled bronchodilator medication) 0.5-2.5 (3) mg/ 3 ml - 1 dose inhale orally four times a day for congestion; Start date - 11/23/2024 0000 .Sodium chloride solution 0.9% - use 50 ml/hr intravenously x 24 hours for IV infusion for hydration X 3 days. 11/22/24 Friday 2:13 PM - E15 (LPN) documented in R1's EMR, Nurses Note -NP notified and confirmed N.O . Use 50 ml/hr intravenously X 24 hours for IV infusion for hydration for 3 days. Please place peripheral IV (intravenous access). Flu, COVID, RSV (respiratory syncytial virus) (swabs). Vital signs q shift for 3 days. BMP, CBC with diff, Chest X-ray- crackles heard during assessment. Resident RP (representative) made aware of all N.O, is ok with treating resident in house. 11/22/24 Friday 7:35 PM - E11 (RN supervisor) documented in R1's EMR, Nurses note - NP called for update on patient. Gave her the vitals, pts (sic) heart rate is 110, orders received, informed her that his labs will not be drawn until 7:00 AM 11-23-24, she verbalized understanding. 11/22/24 Friday 8:10 PM - E11 documented in R1's EMR, Nurses note - Called [facility contracted laboratory] lab to get STAT labs ordered, left message on voice mail, will pass on in report. 11/22/24 Friday 9:21 PM - E11 documented in R1's EMR, Administration note - Sodium chloride solution 0.9% use 50 ml/hr intravenously x 24 hours for IV infusion for hydration for 3 days, no IV access. 11/23/24 Saturday 11:34 AM - E11 documented in R1's EMR, Nurses note - call placed to [medical practice] awaiting call back, can't get IV in patient. 11/23/24 Saturday 1:05 PM - E11 documented in R1's EMR, Nurse note - spoke to NP [E17] informed her pts. (sic) vitals, breathing at a rate of 28 on 5 liters nasal cannula, expiratory wheezes, 112/72, 107, 98.3. Unable to get IV access several attempts, facility does not have outside company to insert IV venous access. Phlebotomist unable to draw labs . Review of R1's clinical records lacked evidence of the facility's plan for obtaining peripheral access after several failed attempts and having no external company to come insert a midline. 11/23/24 Saturday 2:00 PM - E11 documented in R1's EMR, Nurses note - spoke with NP [E17] she reordered labs, station called the lab. I was informed unable to send phlebotomist out until Monday. Review of R1's clinical records lacked evidence of the facility's plan for obtaining STAT labs in a timely fashion after [laboratory] was unable to obtain the lab draw and allegedly informed the facility of a delay in another attempt until Monday, 11/24/24, which was close to seventy-two hours after the STAT labs were ordered. 11/23/24 Saturday 3:36 PM - E15 (LPN) documented in R1's EMR, Orders administration note - Ipratropium- Albuterol solution 1 dose inhaled orally four times a day for congestion . Machine not available per supervisor. Review of R1's clinical record lacked evidence of the facility's plan for the administration of the ipratropium- albuterol medication in light of the lack of a nebulizer machine availability. This medication was ordered to start on 11/23/24 at 0000 (midnight) so R5 missed four doses of the medication by the time R5 was sent to the hospital. Review of R1'S clinical record revealed a lack of any documented vital signs or nurses notes for the entire 11/22/24 night shift (from 11 PM on 11/22/24 to 7 AM 11/23/24). There were vitals signs documented for day and evening shifts on 11/22/24 and day and evening shifts on 11/23/24. 11/23/24 Saturday 6:26 PM - From R1's [Emergency transport company] Prehospital Care Report, the emergency medical technicians (EMTs) arrived in R1's room and increased his supplemental oxygen to 6 L NC. 11/23/24 Saturday 6:59 PM - R1 arrived at [hospital] emergency room. 11/23/24 Saturday 7:09 PM - E18 (RN) documented in R1's EMR, Nurses note - With the resident's spouse agreement and provider, sent to ED (emergency room) for increased respiratory distress and lethargy. Spouse disallowed labs work pending until Monday. Resident sent to ED for further evaluation and treatment. 11/24/24 Sunday 2:02 AM - C1 (hospital ER physician) documented in R1 's hospital EMR, Hospitalist History and Physical- In the ED, patient meets sepsis criteria with fever, tachypnea, tachycardia .labs 11/23/24 7:07 PM- WBC (white blood count) 13.8 (normal range 4.5-11.0), glucose 1359 (normal range 70-140), BUN 190 (normal range 7-20), creatinine 4.3 ( normal range 0.7-1.3), sodium 153 (normal range 137-145) and potassium 5.9 (normal range 3.5-5.1) .Plan: 1. Admit to ICU ( intensive care unit), consult critical care team. Manage hyperglycemia with insulin drip. Received IV sepsis bolus . 11/27/24 8:28 AM - During a telephone interview, C5 (laboratory supervisor) stated, For STAT labs, we come out our next availability. We have a phlebotomist available on weekends from 5 AM to 12 noon. It is limited .[laboratory] lab did have staff available on Sunday 11/24/24 to draw lab work. 11/27/24 9:44 AM - During an interview, E15 (LPN) stated, A guy from [laboratory] lab did come out on Saturday to draw labs. I think his name was [C7] and he was unsuccessful at getting the labs. 11/27/24 9:59 AM - During a telephone interview, C6 (lab personnel) confirmed that their company has a lab tech named [C7], who was sent to [facility] on Saturday morning to obtain labs. C6 also stated, No on came out on Friday (11/22/24) after the morning run . During weekdays, if a STAT lab order is called in prior to 3 PM, we have the availability to send a phlebotomist out that day. If the order comes in after 3 PM, the STAT lab order is added to the next morning's lab run . There were STAT labs called in on Saturday (11/23/24). There was a message on the voicemail. I was here on Saturday and checked the answering machine. [C7] came to the facility on Saturday 11/23/24 for the STAT labs. I am not seeing any labs in the system for [R1] on that day, probably put in as a UTL (unable to obtain). Of note, the order for the STAT was documented by E15 (LPN) on Friday 11/22/24 at 2:13 PM. 11/27/24 12:11 PM - During an interview, E2 (DON) confirmed that R1's EMR orders did not have an order entered for supplemental oxygen on 11/22/24 or 11/23/24. E2 also confirmed that the facility was not able to provide evidence of R1's STAT lab results as the lab was not successful at obtaining the ordered lab work. E2 also stated, We don't have the swabs results (flu, COVID, RSV). E2 confirmed the facility had the ability to perform a COVID swab in house. The facility failed to enter a supplemental oxygen order from its initiation during R1's respiratory crisis on 11/22/24 at 10:29 AM until R1's transfer to the hospital thirty-two hours later. During these thirty-two hours, R1's supplemental oxygen was titrated from 2L NC to 5L NC. 12/2/24 3:10 PM - The findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), E4 (RCC) and E5 (RDO) at the exit conference.

Based on open and closed record reviews, staff interviews and a review of other facility documents, it was determined that the facility failed to ensure two (R66 and R63) out of 23 sampled residents received adequate assistance and/or supervision to prevent accidents. R66 was not transferred properly in accordance with assessed needs and the plan of care. R66 was transferred using the Hoyer lift and assist of one instead of two staff, the Hoyer lift tilted, the resident was lowered to the floor, and sustained multiple fractures requiring treatment and hospitalization . This deficiency is past noncompliance and was corrected on 2/18/16. For R63, the resident was left unattended on the toilet, stood up which resulted in a fall with no injuries. This deficiency is also past noncompliance and was corrected on 9/21/16. Findings included: 1. Review of R66's clinical record revealed: The quarterly Minimum Data Set ((MDS) dated [DATE] reflected that the resident was moderately cognitively impaired. The quarterly MDS completed on 12/18/15 reflected that the resident was totally dependent on staff and required two plus persons physical assist for transfers. Additionally, the MDS documented that the resident had memory problems. R66's Plan of Care (initiated 5/22/15) with updates on 12/30/15 and 2/13/16 showed the following: Problem/Need - related to bruising, aspirin therapy, and bruises Approaches included but were not limited to: 2 assist for transfers & mechanical lift, monitor resident for safety in geri-chair/wheelchair/merry walker, and provide regular assessment Facility Investigation Report completed on 2/13/16 at 6:40 AM: Documented that R66 was being transferred from the bed to the geri-chair using a mechanical lift and assist of one staff person. According to the report the lift tilted and R66 had to be lowered to the floor by E9 (CNA) who then called for help. Based on the report document there were no injuries identified. Additionally the report had a question which read how do you believe this type of fall might be prevented in the future with this resident? E9 wrote that he/she believed the lift pad was too big to try a smaller lift pad and to make sure there is another CNA in the room with me, if the CNA is busy call the nurse on duty. Nurses Notes dated 2/13/16 at 7:10 AM - Resident was lowered to the floor due to the mechanical lift tilted on the floor. There were no signs and symptoms of pain or discomfort noted. The incident report was faxed to the physician on the 7 AM to 3 PM shift and the family was notified. No injuries noted. Nurses Note dated 2/13/16 at 1:00 PM - R66 evaluated because CNA reported R66 moaning and grimacing as if in pain. Assessment revealed a scrape to the middle of the back 8.5 inches long and red in color. During movement R66 in pain left shoulder, upper arm, and elbow. Given Tylenol 650 milligrams (mg) per order and an order was obtained for an x-ray to be done right away. Additional nurses notes on 2/13/16 - mobile x-ray results reported to the physician. Received an order to send the resident to the hospital. R66 transported by way of ambulance (911) to the emergency room . Initial x-ray report dated 2/13/16 showed a fracture (broken bone) of the neck of the bone of the upper arm. A written statement dated 2/14/16 by E10 (RN) documented that E9 requested help with R66 who had been lowered to the floor. E10 assessed R66 and noted a red mark on R66's middle to lower back area. E9 stated at that time that the mark was there earlier in the shift and he/she had not had an opportunity to report it to the nurse. Notifications were made to the nursing supervisor, to the physician/nurse practitioner, and others regarding the incident. emergency room record dated 2/13/16 at 6:22 PM revealed the following: R66 complained of pain by grimace to the right and left arm and the right leg. Resident has advanced Dementia and communicates only in one word responses. Received morphine sulfate (narcotic) and other pain medication while in the emergency room . admitted to the Intensive Care Unit. R66 had unspecified fall and findings included fractures of the right and left upper arm and other injuries including a nontraumatic brain bleed. A late entry facility nurses note dated 2/14/16 at 7:15 am - documented that E9 stated R66 had a red mark on the back during care at 6:00 AM prior to the incident of 2/13/16 at approximately 6:40 AM. A facility statement dated 2/16/16 from E11 (RN- Nursing Supervisor) reflected the following: E11 was the 3-11 nursing supervisor on 2/13/16 and received the xray results for R66. E11 placed a call to the physician and received an order to send R66 to the emergency room for evaluation. E11 notified the nurse on call by telephone and called R66's responsible party. At approximately 5:35 PM, 911 was called. R66 was alert and had been fed her dinner by staff. R66 was not in any distress or discomfort, R66 denied pain or discomfort in the presence of them (911). 11/30/16 at 9:51 AM the surveyor interviewed E1 (NHA). E1 indicated that the facility generally suspends staff involved in significant incidents and that E9 did transfer the resident by himself. E1 stated that the facility's handbook lists infractions that may result in dismissal or being fired. The surveyor discussed general findings with E1. During an interview with the surveyor on 11/29/16 3:53 PM, E2 (DON) confirmed that E9 was suspended after the investigation and staff were all inserviced on the use of the mechanical lift and the need to have the assist of two staff at all times. E9 was removed from the schedule and from payroll. E2 further stated that nursing does periodic checks to verify that a two person assist is used when staff transfer a resident using the mechanical lift. The surveyor reviewed current nurse verification audit sheets from 11/26/16, 11/28/16 and 11/30/16 which showed that two person transfers were being done by staff. During an interview on 12/1/16 at 9:23 AM with the surveyor, E8 (LPN) stated that he/she was the nurse on R66's unit on the dayshift of 12/13/16. E8 gave R66 morning medications while he/she was up in the geri-chair. No problems were noted at that time. Staff went to put resident back to bed later in the day and informed E8 that R66 was moaning and grimacing. R66 was reassessed, nursing supervisor notified, and physician notified. Received orders for an xray and resident received Tylenol for pain which was effective. Resident was sent out 911 later when the xray showed an arm fracture. The facility implemented the following plan of correction: a. an investigation was initiated on 2/13/16 b. all staff were reinserviced on the use of the mechanical lift and/or the stand up lift and the need to transfer with the assist of two staff (2/15/16 and 2/16/16) c. E9 was suspended on 2/18/16 upon completion of the investigation and has been removed from the payroll d. periodic verification audits are completed by nurses on the units to ensure staff use the mechanical lift and stand up lift properly with assist of two 2. Review of R63's current clinical record revealed: 9/6/16 - Admission to the facility from home with multiple [DIAGNOSES REDACTED]. 9/9/16 - Care Plan problem for ADLs (updated 11/2/16) related to cognitive deficits documented the approach of extensive assist with personal hygiene and dressing. 9/9/16 - Care plan included the problem for potential for falls related to adamant desire to transfer without assistance. 9/17/16 (2:30 PM) - Nursing Note recorded R63 was taken to bathroom. CNA left her on the commode to get a washcloth. When CNA returned, res (resident) was standing near her w/c (wheelchair) and door, started to fall down on her buttocks. Unable to prevent the fall. No signs of injuries. Denied any pain or discomfort. Did not hit head. Faxed to MD (Medical Doctor), RP (Responsible Party), spouse, notified. 9/21/16 - Admission MDS Assessment documented the resident had severe cognitive impairment and required extensive assistance with one person for toileting. During an interview with E2 (DON) and E5 (RNAC) on 12/1/16 at 10:25 AM to discuss leaving residents alone on the toilet E2 stated if the toileting/incontinence care plan indicated the resident needed assistance, then that person would not be left alone. When the surveyor showed E2 the progress note where CNA left resident alone on the toilet and stood up and fell without injury, E2 stated E7 (CNA who left resident unattended on the toilet) was no longer employed by the facility since s/he (CNA) called out and did not work any more shifts at the facility. The DON said since the information was on the assignment sheet that's why the CNA was written up. If it wasn't then s/he would not have known and would not be at fault. During an interview with E5 on 12/1/16 at 10:40 AM to review the ADL care plan that documented R63's need for extensive assistance, E5 said so that means she should not be left alone on the toilet. 12/1/16 - Review of an undated CNA assignment sheet included the following for R63: fall risk; 2 person transfer; total assist with ADLs; toilet every 2 hours incontinent. 12/1/16 (12:10 PM) - E2 gave the surveyor a copy of E7's Employee Disciplinary Warning (written by E3 (ADON) on 9/20/16) and explained that E7 was a new CNA who was hired the month before the incident. E2 explained that the CNAs signature/date on the written warning was from when E7 picked up her final paycheck from the facility on 9/21/16. The facility implemented the following plan of correction: a. an investigation was initiated on 9/17/16. b. E7 was inserviced on providing proper supervision when toileting a resident. c. E7 called out and never returned to work at the facility. d. E7 received a written warning dated 9/20/16 and signed by the CNA on 9/21/16 when picking up a paycheck at the facility. The above findings were reviewed with E1 and E2 at the exit conference on 12/2/16 at 1:30 PM.

Based on observation, record review and interview it was determined that for one (R58) out of 37 sampled residents the facility failed to ensure an avoidable pressure ulcer did not develop. R58 entered the facility without skin breakdown and was assessed as at risk for pressure ulcer development. The facility failed to ensure approaches were put in place to relieve pressure to the resident's heels resulting in the development of an unstageable pressure ulcer. Findings include: R58 was admitted to the facility on [DATE] from another long term care facility with [DIAGNOSES REDACTED]. R58's Nurses' Admission Record dated 4/27/12 documented that there was no skin break down. The admission Minimum Data Set (MDS) assessment dated [DATE] documented that R58 was severely cognitively impaired, required extensive assistance with bed mobility, transfer and walking, was at risk for pressure ulcers but did not currently have a pressure ulcer and a pressure device(mattress) was used in the bed. The Braden Scale for prediction of pressure sore risk dated 4/30/12 scored a 16 indicating the resident was at risk for pressure ulcer development. This tool recommended the approaches of; frequent turning, maximal remobilization, protect heels, manage moisture, nutrition and friction and shear, pressure reduction support surface if bed or chair bound. The Wound Ostomy and Continence Nurses Society Guidelines for Prevention and Management of Pressure Ulcers 2003 documents; Long-term care: Residents usually develop pressure ulcers within the first 4 weeks of admission (Bergstrom & Braden, 1992) and under recommended interventions "relieve pressure under heels by using pillows or other devices". The resident's care plan dated 5/3/12 for prevention of pressure ulcers with a goal of skin will remain intact contained the following approaches; check skin every two hours, turn and reposition every two hours, moisture barrier after each incontinent episode, cushion in wheelchair and heel protectors in bed. Review of the treatment record for April 2012 and May 2012 revealed that heel protectors were not added as an approach until 5/29/12 after the resident developed a pressure ulcer to the heel. The approach of floating the heels was not added until an order was obtained on 5/22/13. A "Resident Weekly Body Check" conducted on 5/26/12 documented R58 had non-[MEDICAL CONDITION] to the lower extremities but no issues to the heels were noted. A nurse's note dated 5/28/12 and timed 7:10 PM documented "after CNA helped resident to bed noted some drainage from R (right) heel and reported to charge (sic nurse) appeared resident had a blood blister to right heel which was popped but no noted open area. SO (standing order) of [MEDICATION NAME] to broken blister right heel initiated". A note dated 5/29/12 at 7:10 AM documented "nursing measure initiated for heel protectors on both heels". Review of the Wound Assessment and Documentation Progress report for 5/29/12 documented a right heel pressure wound that measured 6 centimeters (cm) by 5 cm that was red and pink in color with necrotic (death of cells through injury or disease) and granulation tissue (new connective tissue with tiny blood vessels that form on a wound during the healing process), serous (clear yellow) drainage and staff were unable to stage the wound. Review of this report documented that the wound remained unstageable until 8/3/12 when it was determined to be a stage III ( Full thickness tissue loss but bone, tendon or muscle is not exposed.) pressure ulcer now measuring 2 cm by 1.9 cm. The heel wound was noted to be healed on 11/2/12. Review of the physician progress notes [REDACTED]. R58 was observed; 5/20/13 at 10:30 AM, 1:10 PM, 2:45 PM, 3:50 PM; 5/21/13 9:10 AM, 9:50 AM,10:40 AM, 11:00 AM, 3:15 PM; and 5/22/13 8:55 AM and 10:05 in bed with blue soft heel protectors on and no suspension of the heels. On 5/22/13 the facility obtained a physician's orders [REDACTED]. An interview on 5/22/12 with E1 Administrator, E2 Assistant Administrator, E3 Director of Nursing (DON) and E4 Assistant Director of Nursing (ADON) revealed that when R58 transferred from an out of state nursing home to the facility she was in declining health and the family wanted her to be closer to them. E4 stated that it has been the facility's experience that when a resident is transferred to a new facility they will sometimes decline. E4 also stated that although the heel protectors were not on the treatment record she was sure that they were in use since admission. E1 stated that all of their mattresses have level 1 surfaces (pressure reducing). E3 confirmed that suspending of the heels was not an approach that was in use for R58. There was no explanation as to why the wound was not identified until it was unstageable with necrotic tissue.