Every finding on record at Cascades at Riverwalk

Based on interview and record review, it was determined that the facility did not inform each resident periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility's per diem rate. Specifically, for 2 out of 3 sampled residents, 2 residents did not receive a Skilled Nursing Facility Beneficiary Notice of Non-coverage (SNF ABN) or a Notice of Medicare Non-Coverage (NOMNC) when one was due. Resident identifiers: 60 and 61.Findings included:Resident 60 was admitted to the facility on [DATE] with diagnoses which included myotonic muscular dystrophy, acute respiratory failure, and major depressive disorder.Resident 61 was admitted to the facility on [DATE] with diagnoses which included atherosclerotic heart disease, cervical disc disorder with radiculopathy, fusion of spine cervical region, polyneuropathy, dementia, and anxiety disorder.There were no NOMNC's located in resident 60 and 61's medical record. On 9/10/25 at 12:54 PM, an interview was conducted with the Administrator (ADM). The ADM stated the Resident Advocate should have provided a NOMNC to residents 60 and 61. The ADM stated they do not have to do those that often and only those two had to be completed over the last 6 months.

Based on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, food items in the reach-in refrigerator were not labeled, food in the walk-in refrigerator was not labeled and/or dated, and food in the walk-in freezer was open to air. Findings included:On 9/7/25 at 8:49 AM, an initial tour of the kitchen was conducted. In the reach-in refrigerator, 2 trays containing bowls of a white substance were covered with plastic wrap, but were not labeled or dated. In the walk-in refrigerator, a container of vanilla low-fat yogurt did not have an open date. During the observation, one of the dietary aides entered the walk-in refrigerator and returned a large container of mayonnaise to the shelf. It was approximately 3/4 empty. There was no open date on the lid. Also, a large plastic container of a red liquid was observed with no label or date on the container. In the walk-in freezer, a box of mixed vegetables was open to air, a box of frozen cookie dough was open to air, and a box of beef patties was open to air. On 9/10/25 at 1:50 PM, a follow up tour of the kitchen was conducted and an interview was conducted with the Dietary Manager (DM). The DM stated he received all the orders, checked the dates and ensured that food items were dated and put away. The DM stated that he provided education to the dietary staff once per month about important procedures in the kitchen. The DM stated the Registered Dietitian (RD) completed weekly audits of the kitchen to ensure it was clean, that food was properly stored and labeled and that the temperatures were correct. The DM stated his expectation of his staff when taking items from the refrigerator and freezer was that they return it and make sure it was labeled, dated and sealed to prevent spoilage. The DM stated that he checked to make sure food items were properly stored.

Based on observation, interview and record review it was determined, for 3 of 39 sampled residents, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, staff did not use personal protective equipment (PPE) when administering medications through a peripherally inserted central catheter (PICC) line, staff did not wear PPE when entering resident rooms with contact precautions and PPE was not worn in enhanced barrier precautions (EBP) rooms. Resident identifiers: 11, 41, 85 Findings include:1. On 9/9/25 at 8:15 AM, the west hallway morning medication pass was observed. Registered Nurse (RN) 1 was observed to enter the room of resident 11 with oral medications and exited without the medications. RN 1 stated she had administered the oral medications to resident 11. RN 1 was not observed to have donned gloves or a gown prior to entering the room. Resident 11's door was observed to have a contact precautions sign in place that required all who entered the room to wear at a minimum a gown and gloves. On 9/9/25 at 8:25 AM, RN 1 was observed to again enter the room of resident 11 with no PPE (personal protective equipment) in place and administer additional medications to resident 11. On 9/9/25 at 8:45 AM, RN 1 was observed to enter the room of resident 85. The door to resident 85's room was observed to have a contact precautions sign attached to the wall next to the door. RN 1 was observed to sit resident 85 up in bed, touch her mug, adjust her bedding and wiped the resident's mouth. RN 1 was not observed to don gloves or a gown prior to administering the resident's medications. RN 1 was then observed to exit the room, no hand hygiene was not used and RN 1 was observed to touch the mouse and the computer on the medication cart. At 8:55 AM RN 1 re-entered resident 85's room without donning any PPE. RN 1 was then observed to remove the cap from the gray line of the PICC and flush the line with Normal Saline and attached intravenous Daptomycin. RN 1 was then observed to remove the cap from the white line of the PICC, flush the line with Normal Saline and attached intravenous Tigecycline. RN 1 did not use gloves during the medication administration. On 9/9/25 at 8:56 AM, an interview was conducted with RN 1. RN 1 stated resident 85 was on contact precautions for per PICC line and the staff should all wear a gown and gloves when they provided cares for resident 85's PICC line. RN 85 stated she did not use any PPE when she administered the antibiotics and she should have worn at least gloves when she administered her medications. On 9/10/25 at 10:39 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the nurses were expected to follow physician orders and administer them as they were ordered, they were expected to contact the provider for clarification, if they had a question. The DON stated in regard to PICC lines the nurses were always supposed to use hand hygiene, wear appropriate PPE, flush to ensure patency, attached the appropriate antibiotic, disconnect and flush and attach a new cap. The DON stated if the resident had a PICC line the nurse were expected to wear a gown and gloves. The DON stated that the nurses were required to wear gloves and\ appropriate PPE if they were in a contact isolation room, doing cares or administering medications. 2. Resident 11 was admitted to the facility on [DATE] with diagnoses which included paraplegia, urinary tract infection, pressure ulcer stage 4 right and left buttock, methicillin-resistant staphylococcus aureus (MRSA) and sepsis. On 9/7/25 at approximately 9:30 AM, an observation was made of room [ROOM NUMBER] where resident 11 resided. There was a sign outside the room that revealed contact precautions and EBP. The contact precautions sign revealed Everyone must clean their hand, including before entering and when leaving the room. Providers and Staff must also put on gloves before room entry discard gloves before room exit. Put on gown before room entry discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use disposable equipment. Clean and disinfect reusable equipment before use on another person. On 9/7/25 at 10:11 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated resident 11 had EBP precautions because he had a wound and catheter. LPN 1 stated there was a contact precautions outside the room because the facility ran out of EBP signs. On 9/7/25 at 11:58 AM, an observation was made of room [ROOM NUMBER]. The Certified Nursing Assistant (CNA) coordinator was observed to enter room [ROOM NUMBER] with no PPE. The CNA coordinator was observed to take resident 11's meal in and put it on the overbed table with no PPE. Resident 11's medical record was reviewed on 9/7/25. A physician's order dated 8/15/25 revealed resident 11 was to have contact precautions and staff needed to put on gloves and gown before entering and discard before exiting. On 9/10/2025 at 2:08 PM, an interview was conducted with the DON. The DON stated if a resident was on contact isolation all staff members were required to wear a gown along with gloves, at the very least, when entering the resident's room. The DON stated anyone who broke the entry point of the room should have worn PPE and those residents on contact isolation should have a contact isolation sign outside of their door. The DON stated staff were made aware of those residents who were on isolation through report and on admission an assessment was completed to determine if they have anything contagious. The DON stated resident 11 had an active ESBL (Extended Spectrum Beta-Lactamases) infection in his urine that was being treated with intravenous Gentamycin and he was on contact precautions. The DON stated anyone who entered his room should have worn a gown and gloves regardless of why they were in the room, even if it was just to pass food trays. 3. Resident 41 was admitted to the facility on [DATE] with diagnoses that included non-intracerebral hemorrhage intraventricular, ankylosing spondylitis of multiple sites in the spine, apraxia, dysphagia, severe protein-calorie malnutrition, hemiplegia and hemiparesis. On 9/9/25 at 9:57 AM, an observation was made of Certified Nursing Assistant (CNA) 1. CNA 1 entered resident 41's room without donning personal protective equipment (PPE) to change his brief. CNA 1 awakened resident 41 and told him she was going to check his brief and change it. CNA 1 closed the curtain to provide privacy. CNA 1 was observed to be wearing a gown. On 9/9/25 at 10:02 AM, an interview was conducted with CNA 1 as she exited resident 41's room. CNA 1 stated resident 41 was totally dependent on staff for his care. CNA 1 stated resident 41 was a 1 person assist for brief changes. CNA 1 stated staff check resident 41's brief every hour, but change him every 2 hours if he did not need it sooner. CNA 1 stated resident 41 was not on any enhanced precautions. CNA 1 stated she had been working at the facility for about a week and asked about it when she started. CNA 1 stated she was told resident 41 was not on any enhanced precautions. When asked if she knew what enhanced barrier precautions were, CNA 1 glanced at the sign outside of resident 41's door and stated, yes. Resident 41's medical records were reviewed between 9/7/25 and 9/11/25. Resident 41's physician orders for enteral feedings. A review of resident 41's care plan revealed: [Resident 41] requires enhanced barrier precautions r/t [related to] feeding tube. With a goal of remaining free of transfer infection of an MDRO [multi-drug resistant organism]. The interventions were staff wearing gown and gloves per facility protocol for dressing, bathing, transferring, hygiene, changing linens, changing briefs, assisting with toileting, device care, feeding tube care, and wound care. On 9/9/25 at 10:45 AM, an interview was conducted with CNA 2 who stated enhanced barrier precautions were for residents who had a foley catheter, open wounds, were incontinent, etc. and she stated the staff were required to use PPE when having contact with the residents.

Based on interview and record review, the facility did not ensure that 1 of 39 sample residents who was continent of bladder on admission receives services and assistance to maintain continence. Specifically, one resident who was continent upon admission later became incontinent and was not on a toileting program. Resident identifier: 24. Findings include: Resident 24 was admitted to the facility on [DATE] which included hemiplegia, malignant neoplasm of brain, obesity, hyperlipidemia and mild cognitive impairment. An admission Minimum Data Set (MDS) dated [DATE] revealed resident 24 was always continent of bladder. Quarterly MDS's dated 2/22/24 through 7/3/25 revealed resident 24 was frequently incontinent of bladder and was not on a toileting program (TP). On 1/22/24, an admission Assessment was completed for resident 24. The assessment indicated that the resident was fully continent of urine. Review of resident 24's care plan revealed the following: a. On 1/25/24, the resident was documented as having an Activities of Daily Living (ADL) performance deficit related to incontinence. The care plan also revealed that the resident required up to partial/moderate assist of one staff with toileting. b. On 1/25/24, the resident was documented as being at risk for episodes of bowel [and] bladder incontinence [related to] impaired mobility, ADL's (sic) limitations, [Left] ankle weakness, diuretic use. The care plan revealed that the resident was using disposable briefs.c. On 11/26/24, resident 24 was documented to be using disposable briefs. The care plan did not indicate if a TP was in place for resident 24. Skilled Nursing notes for resident 24 from admission through 2/2/24 indicated that the resident was voiding independently but did require assistance with toilet use. On 2/3/24, staff began documenting in the skilled progress notes that the resident was incontinent of urine. Review of resident 24's progress notes revealed the following: On 1/22/24, the resident was documented as being continent of bladder. On 1/29/24, the resident was complaining of burning with urination and frequency. The physician was notified and ordered facility staff to push fluids and continue to monitor. On 2/3/24, The patient will call for the CNA (Certified Nursing Assistant) every 30 minutes to be transferred to the toilet starting at 1800 6:00 PM). The CNA has repeatedly tried to let the patient know that due to the shift change and the other patients she needs to care for as well that the transfer cannot happen at such a rate. The patient refuses a request to have a brief on so that if the toilet transfer cannot happen as fast as the resident needs to occur avoiding the wet clothes and linens. Once the patient falls asleep the call light is utilizedto (sic) transfer the patient to the toilet if needed has slowed to a manageable pace for the CNA.On 2/6/25, the resident was documented as continuing to have symptoms of a urinary tract infection. No documentation could be located that provided information regarding resident 24's change in continence status. In addition, no documentation could be located regarding the potential use of a TP to restore, if possible, the resident's urinary continence status. On 9/10/25 at 3:49 PM, an interview was conducted with CNA 3. CNA 3 stated that resident 24 was incontinent of urine and wore incontinence briefs. CNA 3 stated that resident 24 was not on a specific toileting program. On 9/10/25 at 3:27 PM, an interview was conducted with CNA 4. CNA 4 stated that resident 24 thinks she is continent but that the resident was actually incontinent of urine. CNA 4 stated that resident 24 was not on a specific toileting program. On 9/10/25 at 1:50 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that facility staff did not document if a resident was on a TP. The DON stated that staff were supposed to encourage continence by frequently offering to toilet residents. The DON stated that upon admission, a resident's urinary continence status was evaluated by a nurse. However, the DON stated he was unsure how the status was communicated to the CNAs. On 9/10/25 the facility policy regarding Urinary Incontinence was reviewed. The policy indicated that as part of the initial assessment, the physician will help identify individuals with impaired urinary continence. The policy also indicated that the physician would identify potentially treatable medical and psychiatric conditions related to urinary incontinence, order appropriate diagnostic tests and categorize the incontinence. The policy further indicated that facility staff would identify environmental interventions and assistive devices that facilitate toileting, and based on the assessment would provide scheduled toileting or other interventions to try to improve the individual;s continence status. [Note: It should be noted that the first provider note to be included in resident 24's medical record was not until 4/3/24 by a nurse practitioner, which was approximately 90 days after the resident was admitted . The nurse practitioner did not address resident 24's continence status. Additional progress notes after this date also did not address the resident's continence status per facility policy.]

Based on interview and record review the facility did not provide routine and emergency drugs and biologicals to 1 of 39 sample residents. Specifically, one resident did not have 6 medications available for administration on multiple occasions. Resident identifier: 5. Findings include:Resident 5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included pulmonary edema, chronic obstructive pulmonary disease, pulmonary hypertension, congestive heart failure, protein calorie malnutrition, chronic respiratory failure, osteoporosis, diabetes mellitus, and chronic kidney disease. Resident 5's medical record was reviewed between 9/7/25 through 9/10/25. Resident 5's May 2025 Medication Administration Record (MAR) was reviewed. The following medications were documented as not being administered per the physician's order: Lactobacillus Rhamnosus oral packet, one packet by mouth one time a day. The medication was not administered on 5/2/25 or 5/3/25. The medication was discontinued on 5/3/25. Lansoprazole oral suspension 3 milligrams (mg) per milliliter (ml), 10 ml by mouth one time a day. The medication was not administered on 5/2/25. The medication was discontinued 5/2/25. LidoPro External Patch 4-4-5 % (Methyl SalicylateLidocaine-Menthol), Apply to affected area topically one time a day in the morning. The medication was not administered on 5/2/25, 5/3/25, or 5/4/25. The medication was discontinued on 5/5/25. Pantoprazole Sodium Oral Packet 40 mg, 40 mg by mouth one time a day. The medication was not administered on 5/2/25.The medication was discontinued on 5/20/25. Advair HFA Inhalation Aerosol 230-21 microgram per actuation (MCG/ACT) 2 puffs inhaled orally two times a day. The medication was not administered on 5/1/25, 5/2/25, 5/3/25, 5/4/25, 5/5/25, 5/6/25, or 5/7/25.Vitron-C Oral Tablet 65-125 MG, one tablet by mouth two times a day. The medication was not administered on 5/2/25 and 5/3/25. The medication was discontinued on 5/3/25. Nursing progress notes were reviewed for the above listed dates. No documentation could be located to indicate why the above listed medications were not administered on the appropriate dates. On 9/10/25 at 1:50 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the pharmacy made deliveries to the facility multiple times a day. The DON also stated that the pharmacy was available to make stat or immediate medication deliveries as well. When asked about the medications that were not administered to resident 5 as documented on the May 2025 MAR, the DON stated that he did not know why the medications were not administered.

Based on record review and interview, the facility did not ensure that 1 of 39 sample residents' drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate drug therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued. Specifically, a resident received a medication used to treat hypotension outside of prescribed parameters. Resident identifier: 5. Findings include: Resident 5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included pulmonary edema, chronic obstructive pulmonary disease, pulmonary hypertension, congestive heart failure, protein calorie malnutrition, chronic respiratory failure, osteoporosis, diabetes mellitus, and chronic kidney disease. Resident 5's medical record was reviewed between 9/7/25 through 9/10/25. Resident 5 had a physician order dated 5/1/25 to administer Midodrine hydrochloride (HCl), 2.5 milligrams (mg) by mouth every 6 hours for systolic blood pressure (SBP) below 100. Resident 5's May 2025 Medication Administration Record (MAR) was reviewed. The following was documented: On 5/2/25 at 6:00 AM, the SBP was 100, however the medication was documented as administered.On 5/2/25 at 6:00 PM, no blood pressure (BP) was documented as having been obtained. On 5/3/25 at 6:00 AM, no BP was documented as having been obtained. On 5/3/25 at 12:00 PM, the SBP was 100, however the medication was documented as administered.On 5/3/25 at 6:00 PM, no BP was documented as having been obtained.On 5/4/25 at 6:00 AM, no BP was documented as having been obtained. On 5/5/25 at 12:00 AM, the SBP was 105, however the medication was documented as administered. On 5/5/25 at 6:00 AM, the SBP was 108, however the medication was documented as administered. On 5/6/25 at 12:00 PM, the SBP was 146, however the medication was documented as administered.On 5/7/25 at 6:00 AM, the SBP was 104, however the medication was documented as administered. On 5/8/25 at 12:00 AM, the SBP was 100, however the medication was documented as administered. On 5/8/25 at 6:00 AM, the SBP was 100, however the medication was documented as administered. On 5/8/28 at 6:00 PM, no BP was documented as having been obtained. On 5/9/25 at 12:00 PM, no BP was documented as having been obtained. On 5/10/25 at 6:00 AM, the SBP was 118, however the medication was documented as administered. On 5/10/25 at 12:00 PM, the SBP was 108, however the medication was documented as administered. On 5/11/25 at 6:00 PM, the SBP was 118, however the medication was documented as administered. On 5/12/25 at 12:00 AM, the SBP was 107, however the medication was documented as administered. [Note: It should be noted that for the above listed errors, multiple nurses administered the medication incorrectly per the staff initials listed on the MAR.] On 9/10/25 at 1:26 PM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that the electronic health record prompted staff to enter a blood pressure prior to documenting that the Midodrine was administered. The May 2025 MAR was reviewed with RN 2, and RN 2 confirmed that the medication was administered outside of prescribed parameters. On 9/10/25 at 1:50 PM, an interview was conducted with the Director of Nursing (DON). The DON reviewed the May 2025 and confirmed that the medication had been administered outside of prescribed parameters.

Based on observation, interview, and record review, the provider failed to ensure that the resident environment remained as free of accidents hazards as was possible. Specifically, a resident who was in the shower did not have access to a call light. Resident identifier: 3 In response to the incident involving Resident 3, the facility identified the quality deficiency and developed a corrective action plan. At the time of the complaint survey, it was determined that the facility had implemented corrective measures and met the requirements of F689. Due to the facility ' s corrective measures, the noncompliance was determined to be past noncompliance. The facility ' s corrective action plan, which was developed and implemented by April 9, 2025, included the following measures: a. Removing Certified Nursing Assistant (CNA) 1 from the facility staff. b. Adding a call light to Resident 3 ' s shower. c. Evaluating all current residents to ensure call lights were accessible in areas required based on their specific needs and care plans. d. Reeducating staff on Resident 3 ' s care preferences. Findings Include: The surveyor interviewed Resident 3 on May 22, 2025. Resident 3 stated that it was his preference to be helped into and out of the shower, but to complete his shower by himself. Resident 3 stated that CNAs would assist him into the shower, and then check in periodically to see if he needed assistance or was done and needed help out of the shower. Resident 3 stated that on March 4, 2025, CNA 1 recently helped him into the shower and then left. Resident 3 stated that he completed his shower and was calling out for assistance, but nobody was there to help. Resident 3 stated that he was unable to reach the call light from his position on the shower chair. Resident 3 stated that he used the shower head to hit the wall to signal for assistance. Resident 3 stated that a different CNA eventually came in and helped him back into his bed. Resident 3 stated that after the incident, staff had added an additional call light button in the shower. The surveyor observed Resident 3 ' s bathroom. The bathroom had a shower chair, and the bathroom call light was next to the toilet. The bathroom call light appeared to be out of reach from where the shower chair was placed. The licensor observed an additional, portable call light in the shower, within reach of where the shower chair was placed. The surveyor reviewed Resident 3 ' s medical records, and the following entries were observed: a. The Minimum Date Set from May 20, 2025 revealed that Resident 3 required a one person extensive assistance with transfers. The surveyor interviewed CNA 4 on May 22, 2025. CNA 4 stated that Resident 3 preferred to have assistance getting into the shower, and then to be left alone until he was ready to get out or if he needed assistance. CNA 4 stated that Resident 3 preferred for CNAs to wait outside the door until he was done. CNA 4 stated that Resident 3 often took long showers, sometimes exceeding an hour long, so CNAs would often complete other tasks while waiting for Resident 3 to finish his shower. CNA 4 stated that the CNAs would let Resident 3 know if they had to step away to help another resident. CNA 4 stated that she was aware of the incident where Resident 3 requested help and CNA 1 was unavailable. CNA 4 stated that a new call light button had been added to the bathroom shower so Resident 3 can easily call for help. The surveyor interviewed the Administrator (Admin) on May 22, 2025. The Admin stated that Resident 3 had requested that CNAs leave him in the shower and check on him periodically, because Resident 3 preferred to take long showers. The Admin stated that Resident 3 had filed a grievance regarding CNA 1 leaving him in the shower for too long, and Resident 3 did not have a way to signal for help. The Admin stated that he interviewed CNA 1 about the incident, and CNA 1 stated that another resident required help, and he was busy helping someone else. The Admin stated that a new call light was added to Resident 3 ' s shower. The Admin stated that CNA 1 no longer worked at the facility.

Based on interview and record review, it was determined, for 1 of 43 sampled residents, that the facility did not ensure that a resident who was incontinent of bladder received the appropriate treatment and services to prevent urinary tract infections. Specifically, the facility bladder scanner was broken and a resident required bladder scans prior to being straight catheterized (cathed) to remove urine. The resident was transferred to the hospital and diagnosed with a urinary tract infection (UTI) and sepsis. Resident identifier: 77. Findings included: Resident 77 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included sepsis, diabetes mellitus, UTI, neuromuscular dysfunction of the bladder, anxiety, major depressive disorder, and gastrointestinal reflux disease. On 10/2/23 at 10:51 AM, an interview was conducted with resident 77. Resident 77 stated that he was unable to walk since he had back surgery a year ago. Resident 77 stated he thought staff were checking his catheter once a day but his bag was not always changed. Resident 77 stated the staff once emptied his catheter bag and there were 3000 milliliters. Resident 77 stated he had waited anywhere from 1 to 3 hours for a brief change. Resident 77 stated since he returned from the hospital staff were responding quicker. Resident 77 stated that he went to the hospital on a Sunday after he had slept all day. Resident 77 stated Registered Nurse (RN) 5 assessed him and asked if something was wrong. Resident 77 stated an ambulance took him to the hospital and he had a UTI and sepsis. Resident 77's medical record was reviewed 10/2/23 through 10/10/23. A significant change Minimum Data Set (MDS) assessment dated [DATE], revealed resident 77 had a Brief Interview of Mental Status score of 14 which indicated intact cognition. The MDS further revealed that resident 77 was always incontinent of bowel and bladder. Resident 77 was not on a toileting program. Resident 77 did not use appliances such as an indwelling catheter. A care plan dated 2/19/23 and revised on 6/1/23, revealed resident 77 was at risk for bowel and bladder incontinence and required assistance with toileting care related to decline in mobility, and diuretic use. The goal was that resident 77 remained free from skin breakdown due to incontinence and brief use through the review date. Interventions included clean peri-area with each incontinence episode, ensure resident 77 had unobstructed path to the bathroom, monitor for signs and symptoms of a UTI, and monitor for possible causes of incontinence. A care plan dated 8/22/23, revealed The resident has Indwelling Catheter: Neurogenic bladder. The goal revealed The resident will be/remain free from catheter-related trauma through review date. Interventions included Catheter: Foley catheter cares; Monitor for s/sx [signs and symptoms] of discomfort on urination and frequency and; Monitor/record/report to MD [medical doctor] for s/sx of UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp [temperature], Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. A physician's order dated 6/26/23 and discontinued on 8/3/23, revealed Bladder scan BID [twice daily] and straight cath if PVR [post volume residual] [greater than] 350ml [milliliters] two times a day. According to the Treatment Administration Record (TAR) for July 2023, for the order bladder scan BID and straight cath if PVR was greater than 350 ml twice daily, there were x's on 7/26/23 in the evening, 7/27/23, 7/28/23, 7/29/23, and 7/30/23. Nursing progress notes revealed the following entries: a. On 6/29/23 at 10:01 PM, the bladder scanner was not available. Resident 77 was voiding in his brief. b. On 7/1/23 at 10:12 PM, the bladder scanner was unavailable. c. On 7/4/23 at 1:01 AM, the bladder scanner was not working. d. On 7/6/23 at 1:07 AM, the bladder scanner was not functioning and resident was informing nursing if catheter was needed. e. On 7/7/23 at 1:24 AM, the bladder scanner was unavailable. f. On 7/7/23 at 5:43 PM, the bladder scanner was unavailable at this time, resident was voiding and staff assisting with brief changes, denied any bladder discomfort, abdominal soft, and non-distended. g. On 7/8/23 at 10:25 PM, the bladder scanner not available. h. On 7/10/23 at 5:38 AM, the bladder scanner was not available. i. On 7/14/23 at 1:08 AM, the reasoning documented for not having bladder scanned was Not available. j. On 7/14/23 at 9:24 PM, the bladder scanner was not available. k. On 7/15/23 at 8:59 PM, the bladder scanner was not available. l. On 7/16/23 at 10:11 AM, PVR unable to measure as resident was incontinent of urine. m. On 7/17/23 at 5:15 AM, the bladder scanner was unavailable. n. On 7/18/23 at 1:31 AM, no bladder scanner was available and resident denied need for straight cath at this time. o. On 7/21/23 at 1:51 AM, the reasoning documented for not having bladder scanned was Not available. p. On 7/21/23 at 7:25 PM, the reasoning documented for not having bladder scanned was Not available. q. On 7/23/23 at 4:26 AM, the reasoning documented for not having bladder scanned was Not available. r. On 7/23/23 at 12:30 PM, Resident refuses scan, reporting he doesn't feel like he needs it. Is having wet briefs. Bladder is not palpable above pubic bone and denies pain with palpation. s. On 7/27/23 at 6:31 AM, the bladder scanner was not available. t. On 7/27/23 at 10:04 PM, the reasoning documented for not having bladder scanned was Not available. u. On 7/28/23 at 9:36 AM, [Resident 77] requested straight cath, feeling like his bladder did not empty fully. Straight cath'd and 500ml was collected. v. On 7/29/23 1:31 PM, [Resident 77] requested straight catheterization. 500ml removed via cath. w. On 7/29/23 at 10:42 PM, the bladder scanner was not available. x. On 7/30/23 at 7:40 AM, Resident reporting a lot of back pain and bloating. Appears pale, temp 99.9 [Fahrenheit], unable to find appropriate words during our conversation and his glucose per fingerstick is 330. He reports his sugar was elevated over 300 yesterday as well. Abdomen appears large and per his usual, denies pain with palpation,, BS [blood sugar] +x4, denies bladder pain or burning with urination. LS [lung sounds] are difficult to assess as he cannot lean forward, reports too much back pain. Clear to auscultation anteriorly. HR [heart rate] WNL [within normal limits]. Denies any other symptoms. NP [Nurse Practitioner name removed] notified via secure [electronic medical record system] conversation. He does have a vape in his room with various 'JUICE' flavors. Requested resident not use this and it was moved off his bedside table and onto his dresser. y. On 7/30/23 at 6:35 PM, Resident with altered LOC [loss of consciousness],wakes up briefly when name is called and falls right back to sleep. Alert to name only. VS [vital signs] [blood pressure] 80/55, HR 136, Resp [respirations] 16,Temp 99.3 02 [oxygen] 80% on room air. NP [name removed] notified and new order to send him to hospital. 911 notified and EMS [emergency medical services] crew came to eval [evaluate]. Started an IO [Intraosseous] line to Left tibia as BP dropped to 55/30. Took patient to [local hospital] Called and left voicemail message with [name removed] asking for a return call to update on residents condition. A form titled Discharge Documentation from a local hospital with a visit dated of 7/30/23. Resident 77's discharge diagnosis was altermed mental status, actue kidney ijury, hyperglycemia, urinary tract infection, severe sepsis with spetic shock and weakness. On 10/10/23 at 11:41 AM, an interview was conducted with RN 5. RN 5 stated she was the nurse when resident 77 went to the hospital. RN 5 stated she noticed a change in resident 77 about 8:00 AM, and he progressively was worse throughout the day. RN 5 stated resident 77 was not himself. RN 5 stated he was sleepy, response time was lagged, and then as the day progressed, he became slower in his response time. RN 5 stated resident 77 was picking things out of the air that were not there. RN 5 stated his vital signs were wacky. RN 5 stated resident 77's blood pressure was low and pulse was high. RN 5 stated she called the physician and sent resident 77 to the emergency room . RN 5 stated resident 77 kept a vape pen in his room and it was on the bedside table. RN 5 stated resident 77 was not allowed to vape in his room. RN 5 stated that sometimes resident 77 got a glossy look when he vaped. RN 5 stated resident 77's eyes were blood shot and he was slow to respond, so she put the vape on his dresser out of his reach. RN 5 stated resident 77 had a neurogenic bladder from a spinal surgery. RN 5 stated when resident 77 was admitted to the facility staff had to straight cath him and perform bladder scans. RN 5 stated resident 77 had a superpubic catheter currently. On 10/10/23 at 12:38 PM, an interview was conducted with the Director of Nursing (DON). The DON stated catheter cares were completed daily but cleansing the catheter and emptying the urine from the catheter bag. The DON stated the recommendation for changing the catheter with a closed system was not every 30 days but as needed. The DON stated resident 77 was straight cathed at times when he needed it but she needed to review the physician's orders. On 10/10/23 at 2:06 PM, an interview was conducted with Unit Manager (UM) 1. UM 1 stated that tasks set up for nurses to monitor catheters daily and change the catheter out monthly. UM 1 stated the PVR was post volume residual. UM 1 stated resident 77 was having trouble voiding and was wet but did not complain of a full bladder. UM 1 stated she did not know what the X's and N/A's were for on the TAR in July 2023. UM 1 stated she did not understand the physician's order for the bladder scan twice daily and straight cath if PVR was greater than 350ml. UM 1 stated resident 77 was incontinent of bladder and bowel so there was no way to measure the PVR. UM 1 stated she did not know how nurses were completing the physician's order. On 10/10/23 at 2:58 PM, a follow-up interview was conducted with the DON. The DON stated resident 77 had a catheter inserted on 8/20/23. The DON stated that nurses stated resident 77 was afraid to get a UTI and wanted the catheter. The DON resident 77 had a physician's order for bladder scans from 2/6/23, and then decreased frequency on 6/26/23. The DON stated the bladder scanner was broken in July 2023. The DON stated nursing staff should have contacted the physician and determined what to do differently. The DON stated the she was off when the bladder scanner was broken. On 10/10/23 at 3:05 PM, an interview was conducted with Certified Nursing Assistant (CNA) 4. CNA 4 stated that resident 77 had a catheter. CNA 4 stated when providing catheter care she wiped the tubing around the tip of the penis and then wiped the tube. CNA 4 stated that she emptied the catheter bag every time she did catheter care. CNA 4 stated the catheter bag was changed weekly by the nurse. CNA 4 stated the signs and symptoms of urinary tract infections were agitation or not acting like themselves. On 10/10/23 at 4:03 PM, a follow-up interview was conducted with the DON. The DON stated the Administrator told her the bladder scanner was down for 10 days to 14 days. The DON stated she was not aware of other residents that required bladder scanning. The DON stated PVR was post volume residual and should be checked after a resident had voided. The DON stated with a resident being incontinent she was unsure how nurses would check PVR. The DON stated staff obtained bladder scans randomly and resident 77 complained of feeling like he had a full bladder when his scan showed 350 mls. The DON stated if resident 77 had more than 350 mls then nurses would straight cath.

Based on observation, interview and record review it was determined, for 14 of 43 sampled resident, that the facility did not provide food that was palatable, attractive, and at a safe and appetizing temperature. Specifically, residents complained of food quality, a test tray was bland and resident council minutes revealed complaints of food quality. Resident identifiers: 7, 12, 22, 25, 29, 30, 50, 56, 62, 72, 77, 82, 85 and 365. Findings include: 1. On 10/2/23 at 3:00 PM, an interview was conducted with resident 12. Resident 12 stated the food was not good. Resident 12 stated the pasta was soaked in water and then when served on the plate there was water all over the plate. Resident 12 stated she talked to the Dietary Manager (DM) and the DM had been really good to work with. 2. On 10/2/23 02:36 PM, an interview was conducted with resident 22. Resident 22 stated she was lactose intolerant and was served cheese, milk and dairy food. Resident 22 stated the mashed potatoes had milk and butter in them. Resident 22 stated her family provided her breakfast daily. Resident 22 stated there was food in the freezer, her closet, and her family brought in food. Resident 22 stated she had microwaved pudding one time. Resident 22 stated that staff heated up her tray one time and there was potato salad on the tray. Resident 22 stated the potato salad was served warm. 3. On 10/2/23 at 11:01 AM, an interview was conducted with resident 77. Resident 77 stated the food not was not good. Resident 77 stated he was served a plain hot dog with no fixing. Resident 77 stated he ordered bacon, sausage, eggs and hash brown for breakfast. Resident 77 stated the bacon was really hard and the food was cold most of the time. Resident 77 stated that the sandwiches were a small piece of meat, slice of cheese and lots of mayo. Resident 77 stated that beans did not taste good. Resident 77 stated that the french fries were soggy and cold, like they were not cooked all the way. 4. On 10/10/23 at 2:42 PM, an interview was conducted with resident 29. Resident 29 stated he was only getting snacks twice a week. Resident 29 stated the DM was ordering food one time per week and ran out of food. Resident 29 stated there were a lot of times that the 200 hallway was not served what was on the menus. Resident 29 stated the 200 hallway was served last. Resident 29 stated the food was warmer because they bought the metal inserts. Resident 29 stated last night they tried to make a quiche without the crust. Resident 29 stated it was really bland and was like a scrambled egg farm. 5. On 10/2/23 at 10:25 AM, an interview was conducted with resident 82. Resident 82 stated they were not a fan of the ground up food. Resident 82 stated that they received tube feeding by was able to eat some food by mouth and did not like the food. 6. On 10/2/23 at 1:28 PM, an interview was conducted with resident 30. Resident 30 stated the food sucks. Resident 30 stated he wanted a couple of eggs, sausage and bacon in a burrito. Resident 30 stated he received a tortilla without any fixing for the burrito. 7. On 10/2/23 at 11:30 AM, an interview was conducted with resident 25. Resident 25 stated that the food had not been appetizing. Resident 25 stated the food was not tasty and that the facility used a lot of chicken. 46232 8. On 10/2/23 at 2:08 PM, an interview was conducted with resident 7. Resident 7 stated the food had gotten better in the last 4 weeks. Resident 7 stated they were being served a lot of chicken since the facility ran out of other food. Resident 7 stated chicken was being served in different forms so residents would not catch on. 9. On 10/02/23 at 12:02 PM, an interview was conducted with resident 50. Resident 50 stated they were a vegetarian and had trouble with their meal since they didn't always get fruit or a yogurt with the meals. Resident 50 stated they were sick of eating the same thing every day. Resident 50 stated the meal either consisted of potatoes or gravy. 10. On 10/2/23 at 1:59 PM, an interview was conducted with resident 56. Resident 56 stated the food was bad and the flavor was horrible. 11. On 10/2/23 at 11:30 AM, an interview was conducted with resident 85. Resident 85 stated the only meal they liked was breakfast. Resident 85 stated the food lacked variety. Resident 85 stated were being served a lot of chicken at one point. Resident 85 stated they would much rather eat subway then eat the food at the facility. 47431 12. On 10/02/23 at 11:00 AM, an interview was conducted with resident 62. Resident 62 stated that last night he was served half a hot dog with no bun and about 6 tablespoons of soup. Resident 62 stated that the menu that had been provided to the residents was not matching with what was being served. Resident 62 stated that he circled the items he wanted with the menu that was provided to him and often he did not get what he had ordered. Resident 62 stated that the dinner portions were very small and did not include any fruits or vegetables. 13. On 10/02/23 at 10:50 AM, an interview was conducted with resident 72. Resident 72 stated the, Food is awful. Resident 72 stated the food did not taste good, last night he was served a boiled hot dog and that was it, no bun. 14. On 10/02/23 at 3:20 PM, an interview with resident 365 was conducted. Resident 365 stated she does not like the food, sometimes the food came to her cold or they were late. Resident 365 stated that she had circled her request meal items for the upcoming meal and some of the requested items were missing from her meal. A test tray was requested on 10/4/23 at 12:38 PM. The test tray was placed onto the 200 hallway meal cart at 12:40 PM. The last meal was served at 12:53 PM and the test tray was obtained. The following temperatures were obtained in degrees Fahrenheit: a. The meat loaf was 134 and was bland to the taste and tough to chew. b. The macaroni and cheese was 127 and was bland to the taste. There was no cheese flavor. c. The biscuit was 122 and was palatable. d. The apple pie was cool to the taste and was palatable. Resident council minutes were reviewed and revealed the following: a. On 4/24/23, dietary section revealed Always out of common items please order more of the common items at [sic] time. b. On 6/26/23, dietary section revealed Food is cold. We have to much chicken. The Resident Choice Meal of the month revealed Aren't choosing anything because it's been months since they go what they asked for. There was no response documented from the Dietary Manager. c. On 7/26/23, dietary section revealed Food is cold. We had to much chicken. The Resident Choice Meal of the month revealed Aren't choosing anything because it's been months since they go what they asked for. The DM's response was We will educate staff on serving food in a timely manor. d. On 8/28/23, dietary section revealed No diabetic snacks for residents who need it. No OJ, PB&J sandwiches or anything that will help bring up a BS [blood sugar]. Not following menu tickets. Food is still coming out cold. The DM's response was We will make sure that the snacks are being brought up and CNA [Certified Nursing Assistant] and nurses are aware when we bring them up. Are menus being fill out? We are working on getting trays out faster so food isn't so cold. e. On 9/25/23, dietary section revealed No diabetic snacks for residents who need it. No OJ, PB&J sandwiches or anything that will help bring up a BS [blood sugar]. Not following menu tickets. There was no response from the DM. On 10/10/23 at 4:52 PM, an interview was conducted with the Corporate Director of Nutrition Services (CDNS). CDNS stated she tried the meal and thought it was good.

Based on observation and interview, it was determined that the facility did not ensure a clean and comfortable homelike environment. Specifically, walls with large white patches and not painted, privacy curtain dirty, wheelchair armrests are cracked and have duct tape on them, melted piece of carpet floor, and threshold missing and replaced with duct tape. Resident identifiers: 45 Findings include: 1. On 10/2/23 at 10:41 AM, an observation was made of white patches on painted accent wall in room [ROOM NUMBER]. 2. On 10/10/23 at 10:44 AM, an observation was made of the carpet on 100 Hall in front of room [ROOM NUMBER]. The carpet had black spots on it. 3. On 10/10/23 at 11:57 AM, an observation was made of white spots on painted accent wall in room [ROOM NUMBER]. 4. On 10/10/23 at 11:58 AM, an observation was made of carpet duct taped down on 200 hall in front of room [ROOM NUMBER] and 220. 5. On 10/10/23 at 12:02 PM, an observation of chipped paint on wall in room [ROOM NUMBER]. 6. On 10/10/23 at 3:30 PM, an observation was made of room [ROOM NUMBER]. There was a large piece of drywall that had been cut out of the wall and placed back in. The cut out piece had not been repaired and the cut lines were visible. 30563 7. On 10/2/23 at 218 PM, an observation and interview were conducted with resident 45. Resident 45's wheelchair was observed to have duct tape on the right arm rest. The left arm rest was observed to be cracked. Resident 45's privacy curtain was observed to have brown substance on it. Resident 45 stated she had asked staff about her privacy curtain and the staff stated to her that it could not be cleaned. Resident 45 stated that her bedspread was washed and came back with stains on it. Resident 45 stated it was driving her nuts to have a dirty privacy curtain and bedspread. On 10/10/23 at 2:30 PM, a follow-up observation and interview were conducted with resident 45. Resident 45 was observed to have duct tape on the right arm rest of her wheelchair and the left arm rest was cracked. Resident 45 stated she was getting a new wheelchair. Resident 45 stated she would like her arm rest fixed. Resident 45 stated her new wheelchair should have arrived like 2 months ago. Resident 45's privacy curtain was observed to have brown stains on it. Resident 45 stated her wheelchair and privacy curtain bugged her and drove her crazy every time she went in her room. Resident 45 stated she did not like dirty things. On 10/10/23 at 2:24 PM, an interview with Certified Nurse Assistant (CNA) 1 was conducted. CNA 1 stated when staff noticed or was made aware of a repair, a repair request was entered on the computer website, this also included any wheelchair repairs. CNA 1 stated they looked for the Maintenance Director (MD) and made him aware of any repair requested. On 10/10/23 at 4:20 PM, an interview was conducted with the MD. MD stated that he was notified of repairs on an application on his phone and by staff verbally telling him. MD stated that he had been working at the facility for about 14 months, slowly he had been patching and prepping the damaged walls for repainting. MD stated that it took time for all the wall preparation which included patching, floating, and matching the paint color, then painting the whole wall. MD stated he was responsible for all repairs in the facility and making wall repair was lower on the priority list. MD stated for the carpet repairs he had put in a request with the corporation to replace the carpet with vinyl flooring. MD stated in the meantime he had been looking for a low-profile threshold for the carpeting on the 200-floor hall. MD stated that the duct tape was there due to the bolts on the Hoyer-lift catching and snagging the carpet. MD stated that he completed minor repairs on wheelchairs. MD stated that resident 45 was ordered a new wheelchair from physical therapy so he had not done any repairs on the resident's current wheelchair.

Based on interview and record review, it was determined for 1 or 43 sampled residents that the facility did not ensure the comprehensive care plan included the services needed to achieve the highest practicable physical, mental and psychosocial well-being. Specifically, a resident with pressure ulcers did not have a care plan that addressed the specific pressure ulcers. Resident identifier: 71. Findings include: Resident 71 was admitted to the facility on [DATE] with diagnoses which included encephalopathy, type 2 diabetes mellitus, pressure ulcer of sacral region stage 4, pressure ulcer of right heel stage 3, pressure ulcer of left ankle stage 2. Resident 71's medical record was reviewed on 10/3/23. An admission Minimum Data Set (MDS) assessment dated [DATE], documented that resident 71 required two person physical assistance and was total dependence for bed mobility, toilet use, personal hygiene, dressing. In addition the MDS assessment documented that resident 71 was at risk of developing pressure ulcers and resident 71 had 1 stage 4 unhealed pressure ulcers on admission. A care plan dated 6/28/23 with a focus area [Resident 71] admitted with pressure injuries. Sacral stage 4. Intervention documented a. Implement weekly skin checks b. Implement wound care protocol c. Turn schedule frequently as tolerated while in bed d. Low-air-loss mattress [Note: the heel and ankle pressure ulcers were not addressed.] A care plan dated 6/28/23 with a focus area [Resident 71] has potential/actual impairment to skin integrity and is at risk for pressure injury r/t [related to] admitted with pressure injuries, decreased mobility, incontinence. Interventions documented: a. follow facility protocols for treatment of injury. b. pressure reducing Air mattress as ordered. On 7/1/23 a physician admission note documented resident 71 was discharged to the facility with diagnoses vascular dementia, sacral PU [pressure ulcer] stage IV [4] POA [present on admission], stage III [3] R [right] heel POA, stage II [2] L [left] ankle POA . On 8/21/23 a Nurse practitioner note documented resident 71 was discharged to the facility with diagnoses vascular dementia, sacral PU [pressure ulcer] stage IV [4] POA [present on admission], stage III [3] R [right] heel POA, stage II [2] L [left] ankle POA . On 9/29/23 at 7:00 AM a skin and wound note documented wound #2 right heel pressure stage 2 . no slough, no eschar. On 10/5/23 at 6:13 PM a skin and wound note documented the wound care team saw resident 71 wound 2 right heel pressure stage 2 . Wound 3 left heel pressure unstageable . On 7/3/23 an admission skin and weight review documented resident 71 current skin impairments: Sacral wound [with] wound vac. On 10/04/23 at 1:58 PM, an interview was conducted with the wound nurse (WN) 1. WN 1 stated that resident 71 was admitted to the facility with his sacral pressure injury. WN 1 stated that resident 71 developed his heel wound in the facility. WN 1 stated that she had been the facility wound nurse for about 4 weeks from today. On 10/10/23 at 8:07 AM, an observation of resident 71's wound care being preformed. WN 1 preformed the wound care. WN 1 stated that resident 71 was admitted with the sacral pressure ulcer and that he developed the right heel pressure ulcer in the facility. The right heel pressure ulcer was observed to have a saturated dressing, the wound was a dark brown and black color. WN 1 stated that the right heel was a stage 3 with necrotic tissue covering it. WN 1 provided wound care to resident 71's right heel. WN 1 turned resident 71 on his side revealing a bandage on his right hip. WN 1 stated that he had skin tears on each hip from shearing and being pulled up in bed frequently. WN 1 removed the right hip bandage the bandage had blood and drainage on the bandage. WN 1 stated that a layer of skin was missing from the tear. WN 1 turned resident on his other side revealing a bandage on resident 71's left hip. WN 1 stated that a layer of skin was torn on the left hip and was also a shearing wound. On 10/10/23 at 11:19 AM, a follow-up interview was conducted with the WN 1. WN 1 stated that if a resident had a pressure ulcer there should be a care plan detailing interventions. WN 1 stated that new wounds were discussed in the daily morning meeting and the Minimum Data Set coordinator (MDSC) would be the person to implement the care plan for wounds. On 10/10/23 at 11:51 AM, an interview was conducted with the Minimum Data Set Coordinator (MDSC). The MDSC stated that if a resident develops a pressure ulcer in the facility the wound nurse implemented a wound care plan. The MDSC stated that she will check to see if a wound was resolved and resolved the care plan but she stated she does not initiate the care plans. On 10/10/23 at 12:36 PM, an interview was conduced with the Director of Nursing (DON). The DON stated that if a wound care plan needed to be initiated the wound care nurse or the MDSC implemented the care plan. The DON stated that there have been a few different wound nurses in a short amount of time and that there must have been miscommunication on who was to initiated the care plans for wounds.

Based on interview and record review it was determined, for 3 out of 43 sampled residents, that the facility did not ensure all alleged violations of abuse, neglect, exploitation or mistreatment were reported immediately, but no later than 2 hours after the allegation was made. Specifically, the facility did not report a allegations of abuse within 2 hours of the allegation. Resident identifiers: 12, 20 and 157. Findings include: 1. Resident 12 was 9/2/22 and readmitted on [DATE] with diagnoses which included spinal stenosis, pneumonia, diabetes mellitus, and fusion of spine. A form titled Exhibit 358 revealed that the facility reported to the State Survey Agency on 8/18/23 at 5:54 PM that on 7/24/23 at 12:17 PM resident 12 was found lying on her left side, with right arm underneath her. Resident 12 sustained a 2 inch jagged laceration to the left side of her forehead. Resident was sent to the hospital. Resident 12's medical record was reviewed 10/3/23 through 10/10/23. A nursing progress note dated 7/24/23 at 10:17 PM, Found resident lying on her left side, with right arm underneath her, head lying against the floor on left side of forehead with a puddle of blood visible under her. She is alert and oriented x4 [person, place, time, situation], PEARRLA [pupils, equal, round, reactive to light and accommodate] at this time, Immediate c-spine stabilization provided and resident rolled onto her back x3 staff while maintaining c-spine stabilization, with the help of an aide, a stack of moistened 4x4 gauze was placed over an approximate 2 inch jagged laceration to the left side of her forehead. She is able to move all extremities without reports of pain, no other obvious signs of injury observed. She denies pain to her neck but d/t [due to]recent C-spine fusion, C-spine stabilization completed as a precaution. 911 called by another nurse, awaiting EMS [emergency medical services] arrival. 2. Resident 12 was 9/2/22 and readmitted on [DATE] with diagnoses which included spinal stenosis, pneumonia, diabetes mellitus, and fusion of spine. Resident 20 was admitted to the facility on [DATE] with diagnoses which included multiple myeloma not having achieved remission, diabetes, anxiety disorder, and muscle spasms. A form titled exhibit 358 revealed that the facility reported to the State Survey Agency on 8/14/23 at 8:00 PM. A review of exhibit 358 revealed on 8/14/23 at 3:40 PM, resident 20 reported that resident 12 was threatening in her language to him saying she was going to beat him up. [Resident 12] stated that he does not feel safe. A nursing progress note for resident 20 was dated 8/17/23 at 4:45 PM, On 8/14/23 [resident 20] reported to me that another resident was bothering him verbally and it was making him feel unsafe. Today I followed up with him and he reported that he has not had any interactions with the other resident since and he is pleased that they have stopped bothering him. On 10/10/23 at 9:13 AM, an interview was conducted with the Administrator. The Administrator stated his understanding was to report falls with fracture and did not think to report resident 12's fall with a serious injury. The Administrator stated he reported the incident later. The Administrator stated the incident between resident 12 and resident 20 was not reported within 2 hours and he was not sure why it was reported after 2 hours. 45490 3. Resident 157 was admitted to the facility on [DATE] with diagnoses which included Chronic obstructive pulmonary disease, restless leg syndrome, weakness, and repeated falls. A form titled exhibit 358 revealed that the facility reported to the State Survey Agency on 7/13/23 at 9:50 PM, that resident 157 reported to the Director of Nursing (DON) that the NOC (nocturnal) shift aide, on 7/13/23 at 1:00 AM, had been rough with her while changing her brief and then after the brief change had been thrown into bed the night before. The resident alleged she had told the aide that she had hurt her and was told too bad. Resident 157 was assessed, and no injuries or signs of distress were noted, she reports feeling safe. The Aide had been suspended pending investigation. APS (adult protective services), Ombudsman, and provider were notified. The form titled exhibit 358 also revealed that the facility staff became aware of the incident and notified the administrator on 7/13/23 at 2:35 PM. [Note: The abuse allegation was reported more than 7 hours after staff became aware of the incident.] The policies and procedures for Abuse -Prohibiting was reviewed. Policy The Administrator will ensure that the residents residing in this facility will remain free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, neglect and misappropriation of resident property . Reporting Abuse Any person who suspects that abuse, neglect, or the misappropriation of property may have occurred must immediately report the alleged violation to their immediate supervisor or the Administrator of the facility, State Survey Agencies and Law Enforcement. Time Period for Reporting 1. Serious Bodily Injury - 2 Hour Limit: If the events that cause the reasonable suspicion result in serious bodily injury to a resident, the covered individual (owner, operator, employee, manager, agent, or contractor) shall report the suspicion immediately, to State Survey Agencies and Law Enforcement, but no later than 2 hours after forming the suspicion. 2. All others - Within 24 Hours: If the events that cause the reasonable suspicion do not result in serious bodily injury to a resident, the covered individual shall report the suspicion no later than 24 hours after forming the suspicion.

Based on observation, interview and record review it was determined, for 1 of 43 sampled residents, the facility did not provide each resident with food that accommodated resident allergies, intolerance's and preferences. Specifically, a resident with lactose intolerance was not provided food and a supplement that was lactose free. Resident identifier: 22. Findings include: Resident 22 was admitted to the facility on [DATE] with diagnoses which included muscle weakness, vitamin deficiency, rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems involvement, pain, and severe protein-calorie malnutrition. On 10/02/23 at 2:36 PM, an interview was conducted with resident 22. Resident 22 stated that she was lactose intolerant. Resident 22 stated that the facility served cheese, milk and dairy foods to her for meals. Resident 22 stated that she had mashed potatoes served to her with butter and milk in them. Resident 22 stated that her family usually provided her breakfast. Resident 22 stated that she also had food in the freezer and in her closet that she could eat. Resident 22 stated that she received a supplement that was not lactose free. On 10/10/23 at 1:20 PM, an observation was made of resident 22's lunch tray. Resident 22 was served a roll, margarine, cake with whipped topping, turkey and mashed potatoes. Resident 22's meal ticket revealed NO CHEESE, NO DAIRY (Lactose intolerant). Resident 22's medical record was reviewed 10/2/23 through 10/10/23. A physician's order dated 9/11/23 revealed Fortified diet Regular texture, Thin consistency. There was no lactose intolerance documented in resident 22's medical record. A physician's order dated 9/21/23 revealed House Supplement one time a day for Supplement 60 ML [milliliters] QD [daily]. A care plan dated 4/5/18 and revised on 5/15/23 revealed resident 22 had a nutritional problem or potential nutritional problem related to rheumatoid arthritis, variable meal intake, abnormal labs, selective food preferences, vitamin supplemented, palliative care, malnutrition, history of breast cancer. Resident 22 refuses all nutritional supplements. The goal was resident 22 will have no significant weight changes through review date. Interventions included resident 22 preferred to manage her own diet and supplements. Will refuse at times. In addition, provide, serve diet as ordered. Monitor intake and record every meal. A progress note dated 3/9/23 at 10:45 AM, . Pt [patient] refuse all supplements related to wound healing, pt teaching and ingredients read from prostat bottle shown to pt, on benefit of wound healing, asked pt about meeting w/ [with] staff and family on day shift yesterday about wound healing suppliments [sic] added to MAR [Medication Administration Record] pt states laughing 'I didn't meet with anyone yesterday please tell me who were all these people at this meeting'. Went to ask ADON [Assistant Director of Nursing] and upon return p [sic] states 'oh I think we're getting caught up on semantics I did meet with the wound care nurse [name removed] and my daughter was here but I thought suppliment [sic] meant the lactose free shake reminded her the vitamins are also suppliments [sic] for wound healing, pt refuse to take them states 'I wanna make sure none of the vitamins interrupt my other stuff first', agreed, reported to ADON. Personal belongings, water and call light within reach, encouraged to make needs known. On 10/05/23 10:13 AM, an interview was conducted with Dietary Aide (DA) 1. DA 1 stated Certified Nursing Assistants (CNA) staff notified the kitchen staff if there were allergies. DA 1 stated there were three to four residents that were lactose intolerant here. DA 1 stated the allergies were on each listed on the meal ticket. On 10/10/23 at 1:44 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident 77 refused the house shake because of the sugar in it. LPN 1 stated that resident 77 drank the strawberry banana flavor. LPN 1 stated she was not sure if the strawberry banana was lactose free. LPN 1 stated she offered the house supplement and any sugar-free supplements the nurses had. LPN 1 stated she did not have any strawberry banana flavored shakes. On 10/10/23 01:03 PM, an interview was conducted with the Assistant Dietary Manager (DM). The Assistant DM stated resident allergies and intolerance's were on the meal tickets. The Assistant DM stated resident 22 was a resident that had lactose intolerance. The Assistant DM stated supplements were administered by the nurses. The Assistant DM stated that the residents with lactose intolerance should have been provided a slice of bread that was lactose free instead of the roll. The Assistant DM stated the lactose intolerant residents had mashed potatoes were made without butter or milk. It should be noted that resident 22 had a roll on her tray. On 10/10/23 at 2:16 PM, an interview was conducted with Unit Manager (UM) 1. UM 1 stated the shakes were stored in the kitchen. UM 1 stated she was not aware of resident 22 complaining of getting lactose when she had an intolerant. On 10/10/23 at 4:30 PM, an observation was made of the house supplements. The supplements were not lactose free. On 10/10/23 at 5:04 PM, an interview was conducted with the Corporate Director of Nutrition Services (CDNS). The CDNS stated there have been times that the facility was unable to get supplements because of a supply chain shortage. The CDNS stated there was boost breeze or ensure clear that were lactose-free. The CDNS stated the strawberry banana house supplement was not lactose free.

Based on observation, interview and record review it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, there were soiled areas in the kitchen and the vents above the food preparation area had dust on them. Findings include: 1. On 10/2/23 at 9:48 AM, the following observations were made: a. The preparation fridge handles were soiled. b. There was a container with pineapple in it in the refrigerator with a broken lid on it. c. The vents above the dry storage area and preparation area were soiled with dust. d. There was a yellow pipe behind the range that was soiled with black substance. e. A table with bases and hot plates soiled with crumbs and debris. f. The area under the dirty dish area in the dish machine room was soiled with food splatter and debris. The shelves had chemicals stored on it. g. There was food splatter on the ceiling in the dish machine room. h. There was food debris on a cart that clean cups were placed on. The cups were placed with rims down and the cart with the food debris. 2. On 10/10/23 at 4:33 PM, a follow-up kitchen tour was conducted. The following observations were made: a. The vents over the dry storage and food preparation area had dust and debris. b. The handle to the preparation fridge were soiled. c. The yellow pipes behind the range were soiled. d. There was debris inside the plate warmer. e. The shelf under the soiled dishes had an orange and brown substance on it. On 10/10/23 at 4:52 PM, an interview was conducted with Corporate Director of Nutrition Services (CDNS). The CDNS stated maintenance cleaned the vents and she did not know how often. The CDNS stated she was not aware of the soiled areas. On 10/10/23 at approximately 5:00 PM, an interview was conducted with Maintenance Director. The Maintenance Director stated that he had everything cleaned in the kitchen a month ago. The Maintenance Director provided a copy of the cleaning and there was no information the ceiling was cleaned.

Based on interview and record review, the facility did not ensure for 1 of 43 sampled residents, that residents did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable; and the residents with pressure ulcers received necessary treatment and services. Specifically, a resident developed pressure ulcers during his stay and did not receive timely skin checks or wound treatments. Resident identifier: 71. Findings included: Resident 71 was admitted to the facility on [DATE] with diagnoses which included encephalopathy, type 2 diabetes mellitus, pressure ulcer of sacral region stage 4, pressure ulcer of right heel stage 3, and pressure ulcer of left ankle stage 2. Resident 71's medical record was reviewed on 10/3/23. An admission Minimum Data Set (MDS) assessment dated [DATE], documented that resident 71 required two person physical assistance and was total dependence for bed mobility, toilet use, personal hygiene, and dressing. In addition, the MDS assessment documented that resident 71 was at risk of developing pressure ulcers and resident 71 had one stage 4 unhealed pressure ulcer on admission. A care plan dated 6/28/23, with a focus area [Resident 71] admitted with pressure injuries. Sacral stage 4. Interventions documented: a. Implement weekly skin checks. b. Implement wound care protocol. c. Turn schedule frequently as tolerated while in bed. d. Low-air-loss mattress. [Note: The heel and ankle pressure ulcers were not addressed.] A care plan dated 6/28/23, with a focus area [Resident 71] has potential/actual impairment to skin integrity and is at risk for pressure injury r/t [related to] admitted with pressure injuries, decreased mobility, incontinence. Interventions documented: a. Follow facility protocols for treatment of injury. b. Pressure reducing air mattress as ordered. On 6/6/23, the hospital records documented a wound overview, resident 71's wound classified as a pressure injury was located on his right heel as a stage 3. The provider notes documented right heel stage 3 PI [pressure injury] fully epithelized. Left lateral ankle stage 2 PI fully epithelized. On 7/1/23, a physician admission note documented resident 71 was discharged to the facility with diagnoses vascular dementia, sacral PU [pressure ulcer] stage IV [4] POA [present on admission], stage III [3] R [right] heel POA, stage II [2] L [left] ankle POA . On 7/3/23, an admission skin and weight review documented resident 71 current skin impairments: Sacral wound [with] wound vac. On 8/21/23, a Nurse Practitioner note documented resident 71 was discharged to the facility with diagnoses vascular dementia, sacral PU stage IV POA, stage III R heel POA, stage II L ankle POA . On 9/27/23, a weekly skin review documented is there a new skin integrity problem? No. The skin review documented Open wound to sacrum. Two small openings left buttock below sacral wound. pressure to right heel. two pressure sores to top of right foot . On 9/29/23 at 7:00 AM, a skin and wound note documented wound #2 right heel pressure stage 2 3 x 2 x 0.2, actual area 6, actual volume 1.2 [measurement in centimeters], no slough, no eschar. On 10/1/23, an order documented wound #2 right heel pressure stage 2 clean with cleanser apply skin prep to peri wound apply medihoney secure bordered foam change daily and PRN [as needed]. On 10/5/23 at 6:13 PM, a skin and wound note documented the wound care team saw resident 71 wound 2 right heel pressure stage 2, 4 X 2 X 0.2 actual area 8 actual volume 1.6 [measurement in centimeters], Wound 3 left heel pressure unstageable . On 10/4/23 at 1:58 PM, an interview was conducted with the Wound Nurse (WN) 1. WN 1 stated that resident 71 admitted into the facility with his sacral pressure injury. WN 1 stated that resident 71 developed his heel wound in the facility. WN 1 stated that she had been the facility wound nurse for about four weeks. WN 1 stated that the wound nurse before her was in the facility for two week and the wound nurse before that was in the facility for just a few months. [Note: The first time resident 71's heel wound was documented was on 9/27/23, in a weekly skin assessment. The first time WN 1 documented on resident 71's wound was on 9/29/23.] On 10/10/23 at 8:07 AM, an observation of resident 71's wound care being preformed was conducted. WN 1 preformed the wound care. WN 1 stated that resident 71 was admitted with the sacral pressure ulcer and that he developed the right heel pressure ulcer in the facility. An observation of the right heel pressure ulcer revealed the dressing was saturated, the wound was a dark brown and black color. WN 1 stated that his right heel was a stage 3 with necrotic tissue covering it. WN 1 provided wound care to resident 71's right heel. WN 1 turned resident 71 on his side revealing a bandage on his right hip. WN 1 stated that he had skin tears on each hip from shearing and being pulled up in bed frequently. WN 1 removed the right hip bandage, the bandage had blood and drainage on the bandage. WN 1 stated that a layer of skin was missing from the tear. WN 1 turned resident 71 on his other side revealing a bandage on resident 71's left hip. WN 1 stated that a layer of skin was torn on the left hip and was also a shearing wound. [Note: There was no documentation found on resident 71's hip wounds or orders for wound care.] On 10/10/23 at 11:59 AM, an interview was conducted with Registered Nurse (RN) 4. RN 4 stated that the residents had scheduled skin check. RN 4 stated that skin checks included a head to toe assessment of the residents skin, she stated that if a resident had a new skin condition the process was to document the wound in an incident report, in the resident chart, inform the wound care nurse, the unit manager, and the provider. RN 4 stated she knew that resident 71 had pressure ulcers on his heels, she stated the interventions were to float his heels and dressing changes. RN 4 stated that she started working in the facility the second week of August 2023 and resident 71's heel ulcers were present when she started. When RN 4 was asked if an incident report was documented for resident 71's heel ulcers, RN 4 stated she was unable to locate an incident report for the wounds on his heel that developed in the facility. On 10/10/23 12:36 PM, an interview was conduced with the Director of Nursing (DON). The DON stated that if the staff identified a new wound on a resident the process would be to document the wound in a progress note, notify the wound care nurse and manager on the floor, and get orders from the provider. When asked about the wounds resident 71 acquired in the facility, the DON stated that she was unable to find documentation on resident 71 when the wound was first found and documentation on the wound.

Based on observation, interview and record review it was determined, for 1 of 43 sampled residents, the facility did not provide the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for residents who were unable to carry out the activities of daily living. Specifically, a resident was not showered twice weekly according to his preferences. Resident identifier: 77. Findings include: Resident 77 was admitted to the facility on [DATE] with diagnoses which included sepsis, diabetes mellitus, urinary tract infection, hereditary and idiopathic, spinal stenosis, generalized anxiety, and major depressive disorder. On 10/2/23 at 11:05 AM, an interview was conducted with resident 77. Resident 77 was observed to be laying in bed. Resident 77 stated he sometimes only received a bed bath once a week. Resident 77 stated that he would like at least 2 bed baths per week. Resident 77 stated there were not enough staff to provide a bed bath twice a week. Resident 77's medical record was reviewed 10/2/23 through 10/10/23. A significant change Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 14 which revealed resident 77 was cognitively intact. The MDS further revealed that resident 77 was totally dependent and required 1 person physical assistance for bathing. A care plan dated 2/6/23 and revised on 6/1/23 revealed [Resident 77] has an ADL [activities of daily living] self-care performance deficit r/t [related to] after care of arthrodesis, intestinal obstruction, obesity, spinal stenosis, myelopathy, DM [diabetes mellitus] w/ [with] neuropathy, saddle embolus of pulmonary artery, neurogenic bladder, thoracic/lumbosacral . incontinence, psychotropic use, weakness & impaired balance/mobility. The goal was resident 77 would improve current level of function through the review date. Interventions included to monitor/document/report as needed any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. An additional intervention included to praise all efforts of self care. Certified Nursing Assistant (CNA) documentation in the tasks section of resident 77's medical record revealed that resident 77 received a bed bath on 9/9/23, 9/16/23, and 9/28/23. Resident 77 was provided 3 showers from 9/5/23 through 10/2/23. A binder titled Shower Sheets located at the nurses station was reviewed. There were no shower sheets for resident 77 for October 2023 in the binder. On 10/5/23 at 9:41 AM, an interview was conducted with CNA 3. CNA 3 stated at the start of her shift she checked the shower sheet book to see which residents needed a shower during her shift. CNA 3 stated she was usually assigned 4 resident to bath each day and was able to finished the showers. CNA 3 stated she had not bathed resident 77 because she had not been his CNA on a shower day. On 10/10/23 at 2:02 PM, an interview was conducted with Unit Manager (UM) 1. UM 1 stated that residents were scheduled according to their room number. UM 1 stated residents were scheduled to shower 2 to 3 times per week. UM 1 stated resident 77 should be getting bathed 2 times per week. UM 1 stated resident 77 was scheduled to be showered Wednesday and Saturday. UM 1 stated resident 77 was having a hard time getting out of bed. UM 1 stated the CNA completed a shower sheet after the resident had been showered. UM 1 stated was informed that resident 77 had 3 showers documented in the last 30 days. UM 1 stated That's interesting. UM 1 stated staff offered bed baths if a resident refused to get out of bed. UM 1 stated if a resident wanted more than 2 showers per week, the staff tried to accommodate that. UM 1 stated that if a resident was extra soiled then they received another bath that week but usually baths were not scheduled for 3 times per week. On 10/10/23 at 3:02 PM, an interview was conducted with CNA 4. CNA 4 stated there was a list of resident that needed a shower during her shift at the nurses station. CNA 4 stated all residents were showered twice a week. CNA 4 stated bed baths were done if the resident was unable to get out of bed or specifically asked. CNA 4 stated resident 77 had not refused being bathed. CNA 4 stated resident 77 was not usually in the section she cared for. CNA 4 stated resident 77 usually had bed baths. CNA 4 stated if a resident refused then she tried her best to convince the resident to take a shower. CNA 4 stated then she informed the nurse to talk to the resident. On 10/10/23 at 4:01 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that she noticed resident 77 was only getting showers weekly but the CNA tasks were populated to be daily. The DON stated that if there was a blank section, then the CNA's did not document. The DON stated she was not sure why resident 77 was not bathed twice a week.

Based on observation, interview, and record review it was determined, for 2 out of 43 sampled residents, that the facility did not ensure that the interdisciplinary team had determined that the resident's right to self administer medications was clinically appropriate. Specifically, a resident was observed to have medications on the bedside table in a medication cup and another resident was not evaluated to determine if they were safe to self administer medications. Resident identifiers: 9 and 47. Findings included: 1. Resident 9 was admitted to the facility on [DATE] with diagnoses which included paraplegia, cirrhosis of liver, portal hypertension, chronic respiratory failure, ascites, pressure-induced deep tissue damage, stage 2 pressure ulcer, stage 4 pressure ulcer of sacral region, hypertension, hepatic encephalopathy, pressure ulcer of right buttock stage 3, anxiety disorder, and neuromuscular dysfunction of bladder. On [DATE] at 9:59 AM, an observation was made of resident 9's room. There were four medications observed in the medication cup on the bedside table. Resident 9 was interviewed and stated there were a lot more pills in the medication cup earlier but he was waiting for his breakfast to digest before he took the rest of the pills. Resident 9 stated that he did not understand why the staff brought the medications with breakfast. Resident 9 stated it was very rare that the nurse watched him take his medications. Resident 9's medical record was reviewed on [DATE]. No documentation could be located indicating that resident 9 had been evaluated to safely self administer medications. An admission Minimum Data Set (MDS) assessment dated [DATE], documented that resident 9 had a Brief Interview for Mental Status (BIMS) score of 15. A BIMS score of 13 to 15 indicated intact cognition. The Resident Rights policy within the admission agreement signed by resident 9 documented . 30. To self-administer drugs if the interdisciplinary team has determined the practice is safe. On [DATE] at 8:17 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated a resident would need to be alert and oriented in order to self administer their medications. RN 1 stated she had never had a resident request to administer their own medications. RN 1 stated she would care plan that the resident wanted to self administer medications. On [DATE] at 8:39 AM, an interview was conducted with RN 2. RN 2 stated there would need to be a physician's order if a resident requested to administer their own medications. RN 2 stated that he would ensure the resident was safe to administer their own medications. RN 2 stated that no resident on his floor self administered medications. RN 2 stated he had a resident that was training to self administer their insulin but that resident had failed. 30563 2. Resident 47 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dysphagia, ataxia, chronic pulmonary embolism, paralysis of vocal cords, gastro-esophageal reflux disease, and hemiplegia and hemiparesis. On [DATE] at 1:44 PM, an interview and observation was conducted with resident 47. Resident 47 was observed to have over the counter medications on his bedside table. Resident 47 stated he had Zegerid for night time, Nexium for the morning and Vitamin B complex. Resident 47 stated he had the medication because he needed them for his stomach. Resident 47's medical record was reviewed [DATE] through [DATE]. A quarterly MDS dated [DATE] revealed resident 47 had BIMS score of 13 out of 15 which revealed he was cognitively intact. Resident 47's care plans were reviewed and there was no information regarding self administration of medications. There was no self administration assessment located in resident 47's medical record. There was no physician's order located for resident to self administer medications. On [DATE] at 6:40 PM a nursing progress note revealed, Patient bought himself some Nexium to try so he has a back-up in case Omeprazole is not available again. This RN gave Nexium to him this morning, patient tolerated well. He would like to try it again tonight and make a decision as to how well or if it works. Will continue to monitor and assess. On [DATE] at 1:50 PM, an interview was conducted with RN 3. RN 3 stated that there were no residents that administered their own medications on her hallway. On [DATE] at 10:13 AM, an interview was conducted with the DON. The DON stated residents were unable to keep medications at their bedside. The DON stated there might be a medication that they can leave at bedside for residents after an assessment was completed, a physician's order was obtained and a care plan was completed. The DON stated resident 47 did not keep medications at his bedside. On [DATE] at 11:25 AM, an observation was conducted of resident 47's room with the DON. There were B complex vitamins, Omeprazol, Nexium medication bottle on resident 47's observed on the bedside table. The DON stated she was not aware that resident 47 had medications at bedside. On [DATE] at approximately 10:00 AM, a follow up interview was conducted with the DON. The DON stated that resident 47 had the medications just in case the facility ran out of them. The DON stated resident 47 told her he had not taken any of the medications. The facility policy for Self-Administration of Medications documented, Policy heading Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Policy Interpretation and Implementation 1. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. 2. The IDT considers the following factors when determining whether self-administration of medications is safe and appropriate for the resident: a. The medication is appropriate for self-administration; b. The resident is able to read and understand medication labels; c. The resident can follow directions and tell time to know when to take the medication; d. The resident comprehends the medication's purpose, proper dosage, timing, signs of side effects and when to report these to the staff; e. The resident has the physical capacity to open medication bottles, remove medications from a container and to ingest and swallow (or otherwise administer) the medication; and f. The resident is able to safely and securely store the medication. 3. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. The decision that a resident can safely self-administer medications is reassessed periodically based on changes in the resident's medical and/or decision-making status. 4. If the team determines that a resident cannot safely self-administer medications, the nursing staff administer the resident's medications. The IDT evaluates options which allow residents to safely participate in the medication administration process if they wish to do so. 5. Residents who are identified as being able to self-administer medications are asked whether they wish to do so. 6. For self-administering residents, the nursing staff determines who is responsible (the resident or the nursing staff) for documenting that medications are taken. 7. If the resident is able and willing to take responsibility for documenting self-administration of medications, the resident is instructed on how to complete a record indicating the administration of the medication. 8. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer are stored on a central medication cart or in the medication room. A licensed nurse transfers the unopened medication to the resident when the resident requests them. 9. Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party. 10. The facility reorders self-administered medications in the same manner as other medications. 11. The nursing staff routinely checks self-administered medications and removes expired, discontinued, or recalled medications. 12. Nursing staff reviews the self-administered medication record for each nursing shift, and transfers pertinent information to the medication administration record (MAR) kept at the nursing station, appropriately noting that the doses were self-administered.

Based on observation, interview, and record review, it was determined that for 1 of 43 sampled residents, the facility did not ensure a resident receiving enteral feeding received appropriate care and services to prevent complications of enteral feeding. Specifically a resident's feeding tube bag had not been changed for 3 days. Resident identifier: 98 Findings Included: Resident 98 was admitted to the facility 7/12/23 with the following diagnosis that included dysphagia, aphasia, type 2 diabetes mellitus, hemiplegia, hemiparesis, and vascular dementia. On 10/2/23 at 2:12 PM, an observation was made of resident 98's feeding tube setup. A 1000 milliliter (ml) feeding bag was observed with the date of 9/29/23 and time of 1:54 PM. Resident 98's medical record was reviewed on 10/3/23. A physician enteral feed order with a start date of 9/11/23 documented one time a day for enteral care: Change syringe daily, feed supplies, and cylinder. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) for the months of September and October were reviewed and documented the daily enteral care order was documented as done for the days of 9/29/23, 9/30/23 and 10/1/23. The order stated that cylinder, syringe and enteral feed supplies needed to be changed once a day. On 10/5/23 at 9:33 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated the process for resident with feeding tubes was to change the feeding bag, piston and beakers daily to prevent any kind of bacterial growth or infection. LPN 1 stated nursing staff labeled the feeding bag with the date it was changed. LPN 1 stated nursing staff documented in the resident MAR/TAR once the enteral care had been completed it. On 10/5/23 at 9:53 AM. an interview was conducted with LPN 2. LPN 2 stated that tube feed supplies were changed every 24 hours. LPN 2 stated when nursing staff changed a feeding bag they wrote the date, time and type of formula on the bag. LPN 2 stated the feeding formula was only good for a certain amount of time after it was not sealed and if the formula sat there long enough, it was gross and moldy and it would be a possible mode of infection for the resident. On 10/5/23 at 10:24 AM, an interview was conducted with Unit Manager (UM) 1. UM 1 stated the nurses were suppose to change all the tube feed supplies out daily. UM 1 stated the feeding bags were labeled with the date they were last changed. UM 1 stated the biggest risk of not changing the supplies daily was the feeding formula clogged because it was thick. On 10/10/23 at 11:48 AM, an interview was conducted with Registered Nurse (RN) 5. RN 5 stated when a resident was on tube feeds, their head of the bed need to be up at least at 30 to 40 degree angle. RN 5 stated nursing staff monitored gastric residuals, output and if a resident was tolerating the feed. RN 5 stated nursing staff changed the feeding bags, water bags, graduated colander and syringe every 24 hours. RN 5 stated the TAR notified the nurses when the tube feeding supplies needed to changed. RN 5 stated she was unsure why resident 98's feeding bag was not changed during the weekend. RN 5 stated nothing would happen to the resident if a feeding bag was not changed daily other than a possibility for bacteria to grow in the formula. RN 5 stated she worked on 10/1/23 and thought she had changed the bag. On 10/10/23 at 12:36 PM, an interview was conducted with the Director of Nursing (DON). The DON stated tube feeding bags and water syringes were changed daily and dated. The DON stated the bags should not have been used from 9/29/23 until 10/2/23. 30563

Based on interview and record the review it was determined, for 1 of 43 sampled residents, that the facility did not ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, a resident with documented pain had received pain medication recommendations from the pain clinic that were not implemented. Resident identifier: 160. Findings included: Resident 160 was admitted to the facility on [DATE] with diagnoses which included non-pressure chronic ulcer of unspecified part of left lower leg limited to breakdown of skin, methicillin susceptible staphylococcus aureus infection, major depressive disorder, resistance to multiple antimicrobial drugs, carrier of infections with a predominantly sexual mode of transmission, pain, chronic pain, and long term use of antibiotics. Resident 160's medical record was reviewed on 10/10/23. An admission Minimum Data Set (MDS) assessment dated [DATE], documented that resident 160 had a Brief Interview for Mental Status (BIMS) score of 15. A BIMS score of 13 to 15 indicated intact cognition. In addition, the MDS assessment documented that resident 160 had been on scheduled pain medications and had received as need (PRN) pain medications. A pain assessment interview was conducted. The Pain Assessment Interview documented that the resident had pain and the frequency was documented as frequently. Resident 160's pain intensity on a numeric rating scale of 00 to 10 was documented as a 7. Resident 160's pain made it hard to sleep at night and limited day to day activities. A care plan Focus initiated on 1/19/23, documented [Resident 160] has/ is at risk for pain r/t [related to] osteomyelitits. A care plan Goal documented The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. The interventions included: a. Monitor/record/report to nurse loss of appetite, refusal to eat and weight loss. b. Notify physician if interventions were unsuccessful or if current complaint was a significant change from residents past experience of pain. c. Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease range of motion, withdrawal or resistance to care. The Order Summary Report was reviewed and the following medications for pain were scheduled: a. On 1/19/23, a physician's order documented Morphine Sulfate Oral Tablet 30 MG [milligrams] (Morphine Sulfate) Give 1 tablet by mouth every 8 hours for pain. b. On 1/20/23, a physician's order documented Meloxicam Oral Tablet 15 MG (Meloxicam) Give 1 tablet by mouth one time a day for pain. c. On 1/30/23, a physician's order documented Lidocaine External Cream 5 % (Lidocaine) Apply to [sic] during dressing changes topically one time a day every Mon [Monday], Wed [Wednesday], Fri [Friday] for cream to be applied during dressing changes. The January and February 2023 Medication Administration Record (MAR) was reviewed. On 1/19/23, a physician's order documented Dilaudid Oral Tablet 4 MG (Hydromorphone HCl [hydrochloride]) Give 1 tablet by mouth every 6 hours as needed for prior to wound care. Resident 160 received Dilaudid on the following dates. a. On 1/20/23 at 12:14 PM, a pain score of 8 was documented. Complains of foot pain. b. On 1/21/23 at 4:17 PM, a pain score of 8 was documented. Post wound care. c. On 1/23/23 at 10:47 PM, a pain score of 6 was documented. Leg pain. d. On 1/24/23 at 11:15 AM, a pain score of 3 was documented. e. On 1/25/23 at 12:54 PM, a pain score of 8 was documented. f. On 1/26/23 at 8:50 AM, a pain score of 7 was documented. g. On 1/26/23 at 3:16 PM, a pain score of 8 was documented. h. On 1/27/23 at 12:58 PM, a pain score of 5 was documented. i. On 1/28/23 at 4:33 PM, a pain score of 8 was documented. Complains of pain left lower extremity. j. On 1/31/23 at 6:46 PM, a pain score of 5 was documented. Leg pain. k. On 2/1/23 at 10:15 PM, a pain score of 6 was documented. Leg pain. l. On 2/3/23 at 3:50 PM, a pain score of 6 was documented. m. On 2/4/23 at 11:16 AM, a pain score of 5 was documented. n. On 2/6/23 at 11:26 AM, a pain score of 4 was documented. o. On 2/8/23 at 3:59 PM, a pain score of 8 was documented. p. On 2/8/23 at 10:08 PM, a pain score of 7 was documented. Leg pain. q. On 2/9/23 at 10:41 AM, a pain score of 9 was documented. The January and February 2023 MAR was reviewed. On 1/19/23, a physician's order documented oxyCODONE HCl Oral Tablet 20 MG (Oxycodone HCl) Give 1 tablet by mouth every 4 hours as needed for pain. a. Out of 74 opportunities in January 2023 resident 160 requested Oxycodone on 37 occasions. The documented average pain score was a 6 out of 10. On one occasion the medication was documented ineffective. b. Out of 85 opportunities in February 2023 resident 160 requested Oxycodone on 51 occasions. The documented average pain score was a 6 out of 10. On two occasions the medication was documented ineffective. On 1/26/23 at 5:09 PM, a Nurses Note documented Note Text: Resident returned from pain clinic reports having more pain will follow-up n [sic] 6-8 weeks. Also reports dizziness over last few days, questioned whether it was related to meropenum. The Physician Communication Form from the pain clinic dated 1/26/23, documented She is doing better with infection but her pain she reports is getting a little worse with medication not being given timely. We would request Oxycodone Q [every] 4 hrs [hours] +- (plus or minus) 1 hr [hour], Morphine Q8hrs +- 1 hr, Dilaudid up to 3 per day PM severe uncontrolled pain. The form was signed by a physician. [Note: The Oxycodone and Dilaudid administration orders were not updated.] On 2/5/23 at 3:26 PM, a Nurses Note documented Resident was very aggressive with me demanding more pain pills. I explained to her that per doctor's orders, she can't have Dilaudid unless it's a wound care day, which was yesterday, and she was still demanding it. She told me to bring all her pill bottles in to her room because she knew how she needed to take it. I explained that I won't be doing that, and we can only administer per doctors orders that may have changed from her home orders. I then left the room as she would not stop arguing with me. She received an oxycontin at 1520 [3:20 PM] and is due for her scheduled morphine at 1600 [4:00 PM]. No other pain medications ordered or given at this time. On 10/10/23 at 2:26 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that she had just called the pain clinic and the pain clinic stated that resident 160 had received a prescription for pain medications on 1/4/23, prior to admission to the facility. The DON stated that resident 160 had not received any new scripts. The DON stated the pain clinic did not write a script for the recommendations on 1/26/23. The DON stated the facility staff should have followed up with the pain clinic regarding the recommendations but there were no progress notes. The DON stated if a resident was going to a pain clinic the providers at the facility would not write a script to prevent confusion. The facility policy for Pain Assessment and Management documented, Purpose The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. General Guidelines 1. The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. 2. 'Pain management' is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. . Implementing Pain Management Strategies . 22. The following are considered when establishing the medication regimen: a. Starting with lower doses and titrating upward as necessary; tt. [sic] Administering medications around the clock rather than PRN; uu. Combining long-acting medications with PRNs for breakthrough pain; vv. Combining non-narcotic analgesics with narcotic (opioid) analgesics; and ww. Reducing or preventing anticipated adverse consequences of medications (e.g., bowel regimen to preventing constipation related to opioid analgesics). 23. The medication regimen is implemented as ordered. Results of the interventions are documented and communicated directly to the provider when appropriate. Ongoing communication between the prescriber and the staff is necessary for the optimal and judicious use of pain medications. Monitoring and Modifying Approaches . 27. Contact the prescriber immediately if the resident's pain or medication side effects are not adequately controlled. 28. If pain has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated. 29. If there is a pattern (time of day or day of the week) that the resident reports or appears to be in increased pain, consider the possibility of drug diversion and communicate the pattern to the nursing supervisor. . Reporting Report the following information to the physician or practitioner: 1. Significant changes in the level of the resident's pain; 32. [sic] Adverse effects from pain medications, such as gastrointestinal bleeding from nonsteroidal antiinflammatory drugs (NSAIDs), anorexia, confusion, lethargy, severe constipation, or ileus related to opioids; 33. Medication side effects that are not adequately controlled; and/or 34. Prolonged, unrelieved pain despite care plan interventions.

Based on interview and record review it was determined, for 1 of 43 sampled residents, that the facility did not ensure that residents who received psychotropic drugs were not given these drugs unless the medication was to treat a specific condition as diagnosed and documented in the clinical record. Specifically, the facility continued to administer psychotropic medications after the recommendation to discontinued the psychotropic medications. Resident identifier 96. Findings include: Resident 96 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, unsteadying on feet, anxiety disorder, type 2 diabetes mellitus with diabetic chronic kidney disease, insomnia, and cerebral edema. Resident 96's medical record was reviewed 10/3/23 through 10/10/23. A physician's order revealed orders dated 9/19/23 for the following: a. Lamotrigine Oral Tablet 25 milligrams (MG) to be given two times a day for anticonvulsant. b. Trazodone Oral Tablet 50 MG to be given 0.5 tablet one time a day for insomnia. A Psychotropic Medication Review form for resident 96 dated 9/2023 recommended to have Trazodone 25 mg once daily (QD) and Lamotrigine 25 mg twice a day (BID) discontinued. The physician signed the form on 9/21/23. A note under physician signature stated, MD [medical doctor] signature signifies agreement with recommended changes unless otherwise noted. A Psychotropic Progress Note dated 9/21/23 at 3:52 PM stated, Attendees: DON [Director of Nursing], MDS [Minimum Data Set], RN [Registered Nurse], RA [Resident Advocate], MD, Pharmacist. Psychotropic Review completed. Recommendation to discontinue trazodone and lamotrigine. Next review in 30 days. Care plan reviewed. The Medication Administration Record (MAR) revealed the following: a. Lamotrigine was given twice a day on 9/22/23, 9/23/23, 9/24/25, 9/25/23, 9/26/23, 9/27/23, 9/28/23, 9/30/23, 10/1/23, 10/2/23. b. Lamotrigine was given once a day on 9/29/23 and 10/3/23. c. Trazodone was given once a day on 9/22/23, 9/23/23, 9/24/25, 9/25/23, 9/26/23, 9/27/23, 9/28/23, 9/30/23, 10/1/23, 10/2/23. On 10/10/23 at 2:25 PM an interview with Assistant Director of Nursing (ADON) 1 was conducted. ADON 1 stated that she attended the psychotropic medication review meetings. ADON 1 stated if the physician agreed to any recommendations for medication changes, she contacted the family of the resident for their consent. ADON 1 stated if the resident's family was in agreement with the medication changes she the order was updated in the medical record. ADON 1 stated if the family did not agree with the medication changes she contacted the physician for further instructions. ADON 1 stated it was resident 96's family that was requesting her lamotrigine and trazodone to be discontinued. ADON 1 stated that the order to discontinue the lamotrigine and trazodone must have been missed. On 10/10/23 at 1:38 PM an interview with the DON was conducted. The DON stated during the medication review the recommendations were presented and the physician was consulted. The DON Stated the physician then signed approved recommendations. The DON stated the signed recommendation were then given to nurse manager to put in the new order. The DON stated the nurse manager was the ADON on the floor the resident resides on. The DON stated the orders should have been put in the same day the physician was consulted.

Based on interview and record review it was determined that for 1 of 39 sample residents the facility did not ensure that a resident receives care, consistent with professional standards of practice to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable. Specifically 1 resident developed an in-house pressure ulcer, and did not have documented interventions until 6 days after the discovery of the wound. During this 6 days documentation showed worsening of the pressure ulcer. Resident identifier: 130. Findings include: Resident 130 was admitted to facility 8/28/19 with [DIAGNOSES REDACTED]. Resident 130's medical record was reviewed on 10/8/19. Resident 130's admission assessment dated [DATE] revealed resident 130 was admitted with an open area to her coccyx, and was determined to be at moderate risk for pressure ulcers per the Braden Scale. Resident 130 developed an in house pressure ulcer that was noted in the medical record on 9/4/19 to the right buttocks. Resident 130 was admitted with an open area to her coccyx, and developed and in house pressure ulcer to the right buttocks on 9/4/19. No goals or interventions regarding either open area were entered into the resident's careplan until 9/18/19. It should be noted that resident 130 was discharged on [DATE]. A medical record review of facility progress notes, weekly skin assessments and daily skilled notes revealed the following: a. A progress note dated 8/31/19 stated Wound care provided to buttocks. (Note: Per the physician orders, no orders were in place at that time for any wound care. In addition, the note did not clarify what wound care had been provided.) b. A daily skilled assessment dated [DATE] revealed the following in the skin/wound section: Resident has treatable wounds. Coccyx. Wound care provided. Dressing changed as per treatment orders. (Note: Per the physician orders, no orders were in place at that time for any wound care.) c. A progress note dated 9/1/19 stated Patient (pt) stated pain in her buttocks and her hip . Wound care provided to buttocks per day shift . (Note: Per the physician orders, no orders were in place at that time for any wound care.) d. A daily skilled assessment dated [DATE] revealed the following in the skin/wound section: No new changes to skin integrity noted. Resident has treatable wounds. Surgical to right hip. Dressing change note required. CDI (clean, dry, intact). e. A daily skilled assessment dated [DATE] revealed the following in the skin/wound section: No new changes to skin integrity noted. Resident has treatable wounds. Surgical to right hip. Dressing change note required. CDI. f. A weekly skin assessment dated [DATE] documented, buttocks red open area. (Note: The skin assessment did not document a measurement or any other specific information about the wound.) g. A wound weekly assessment progress note dated 9/4/19 at 9:56 AM stated, Floor staff notified unit manager (UM) and regional nurse of new open sore to pt's (patient's) right buttock. UM and regional nurse in to assess. House nurse practitioner (NP) notified of new Stage II pressure injury to right buttock. Wound Location: Right buttock. Measurements. Length, Width, Depth: 6x3x0.1 centimeters (cm). Tunneling, Undermining: N/A (not applicable). Wound Bed description: Shiny, pink, very superficial. Full thickness wounds only; Precent (sic) granulation (and) percent non-viable Tissue (slough/escar): N/[NAME] Drainage (Type, Amount): Scant serous drainage. Description of peri wound: Blanchable redness. Odor (after cleansing): N/[NAME] Pain/Interventions: See orders. Current Treatment and Interventions in place. Barrier Cream every (Q) shift and as needed (PRN). Assist with frequent repositioning. Comments (if not improving after two weeks, notify MD (and) consider modifying treatment/interventions): Registered Dietician (RD) notified and will review. (Note: There was no physician order for [REDACTED]. h. A daily skilled assessment dated [DATE] at 1:19 PM revealed the following in the skin/wound section: No new changes to skin integrity noted. Resident has treatable wounds. Surgical to right hip. Dressing change note required. CDI. i. A progress note dated 9/5/19 stated Wound care provided to buttocks. j. A daily skilled assessment dated [DATE] revealed the following in the skin/wound section: No new changes to skin integrity noted. Resident has treatable wounds. Surgical incision on left hip. Pressure injury on buttocks. Wound care provided. k. A daily skilled assessment dated [DATE] revealed the following in the skin/wound section: No new changes to skin integrity noted. Resident has treatable wounds. Surgical to right hip. Dressing change not required. CDI. l. A weekly skin assessment dated [DATE] at 10:43 AM revealed no skin impairments. m. A daily skilled assessment dated [DATE] revealed the following in the skin/wound section, No new changes to skin integrity noted. Resident has treatable wounds. Surgical to right hip. Dressing change not required. CDI. n. A daily skilled assessment dated [DATE] revealed the following in the skin/wound section: No new changes to skin integrity noted. Resident has treatable wounds. Surgical to right hip. Dressing change not required. o. A progress note dated 9/9/19 stated pt stated pain in her buttocks when crean (sic) was applied. Wound care provided to buttocks by dayshift. p. A daily skilled assessment dated [DATE] revealed the following in the skin/wound section: No new changes to skin integrity noted. Resident has treatable wounds. Coccyx. Wound care provided. Dressing changed as per treatment orders. q. A wound weekly assessment progress note dated 9/10/19 at 10:22 PM revealed: Late Entry: Wound Type FA (facility acquired) Stage II pressure injury. Wound Location: right buttock. Measurements: Length, Width, Depth: 6x6x0.2cm. Tunneling, Undermining. N/[NAME] Wound bed Description: Red, Shiny. Full thickness wounds only: precent (sic) Granulation (and) Percent Non- Viable Tissue (slough/eschar): N/[NAME] Drainage: Scant, serous drainage. Description of peri wound: Induration noted to superior border, [DIAGNOSES REDACTED] noted to periwound. Odor after cleansing: N/[NAME] Pain/Interventions. See orders, encourage frequent repositioning- pt often refuses repositioning d/t (due to) feeling uncomfortable when on attempting (sic) to offload pressure to site. Staff has switched out LAL (low air loss) mattress x2 (twice) to try and make patient more comfortable. Current Treatment & Interventions in Place: [MEDICATION NAME] and silicone bordered foam, LAL mattress, pressure reducing pad to wheelchair, prostat, MVI (multivitamin). Comments (if not improving after 2 weeks notify MD (and) consider modifying treatment/interventions): Wound NP notified of decline and will see patient later this week. House NP also notified. Pt's INR (international normalized ratio) has been elevated and may have been contributing factor to decline in wound. (Note: From 9/4/19 to 9/10/19 the pressure ulcer to the resident's right buttocks worsened.) r. A daily skilled assessment dated [DATE] revealed the following in the skin/wound section: No new changes to skin integrity noted. Resident has treatable wounds. Coccyx. s. A progress note dated 9/11/19 stated pt has a surgical incision on her left hip and buttocks. Pt has been educated on the importance of offloading her weight off her buttocks. Pt was helped with position changes. Pt was helped with position changes. t. A daily skilled assessment dated [DATE] revealed the following in the skin/wound section: No new changes to skin integrity noted. Resident has treatable wounds. Left hip surgical incision and buttocks. Dressing changed as per treatment orders. u. A progress note dated 9/12/19 stated The wound on her coccyx was weepy and red with a large area of necrotic appearing tissue that had a very fowl (sic) odor. Wound care done as ordered. Unit manager, DON (Director of Nursing), and on call notified. v. A wound weekly assessment progress note dated 9/13/19 revealed the following; Wound Type: Unstageable Pressure injury. Wound Location: left buttocks and sacrum. Measurements: Length, Width, Depth: 6x8cmx unable to determine (UTD). Tunneling, undermining: N/[NAME] wound bed description: Necrotic tissue with areas of granular tissue. Full thickness wounds only; Precent (sic) Granulation (and) Percent Non- Viable Tissue (slough/eschar): 50% black eschar, 50% yellow slough. Drainage: Moderate serous sanguineous drainage. Description of Peri-Wound: Blanchable redness. Odor (after cleansing): Foul odor. Pain/Interventions: See current orders. Assist with frequent repositioning. Current Treament (and) Interventions in Place: Educating pt about importance of frequent repositioning. Santyl (and) [MEDICATION NAME] and hydrogel covered with foam dressing. Low air loss mattress and pressure reducing pad to wheelchair, comments (if not improving after two weeks, notify MD and consider modifying treatment/interventions): NP in to assess and gave new orders. NP plans to debride wound next week. w. A progress note dated 9/13/19 stated Correction: Wound location to right buttock extending to sacrum. x. A progress note dated 9/16/19 revealed UM in to assess pt's wound with floor nurse. Wound appears to have had a significant decline. Necrotic tissue noted to wound base. Tunneling noted at 12:00. Unable to assess whether bone is exposed. Low air loss mattress in place and functioning properly. Mattress was switched out earlier today d/t function alarm. Notified house NP and wound NP. Wound NP advised that she would recommend sending pt to ED (emergency department) however, to have UM discuss goals of care with pt . After discussion with pt, pt elected to go to (name of local hospital) for further treatment. On 10/10/19 an interview was conducted via telephone with resident 130. Resident 130 stated that she was admitted to the hospital and required surger to repair the pressure ulcer. Resident record review of physician orders was conducted 10/8/19 and revealed the following: a. An order dated 9/10/19 Stage II Pressure injury to Right Buttock: Cleanse with wound cleanser. Pat dry. Apply [MEDICATION NAME] to wound bed and cover with silicone bordered foam. Change daily and PRN b. An order dated 9/10/19 Encourage frequent repositioning and offloading to right buttock. c. An order dated 9/10/19 Pressure reducing pad to wheelchair. d. An order dated 9/10/19 Low Air Low Mattress. e. An order dated 9/13/19 : Stage II Pressure Injury to Right Buttock: Cleanse with wound cleanser, pat dry, apply Santyl, [MEDICATION NAME] and hydrogel with a foam dressing QD. An interview was conducted on 10/9/19 with registered nurse (RN) 2 at 2:55 PM. RN 2 stated that she was working as a Unit Manager on the floor where resident 130 resided. RN 2 stated that when resident 130 was admitted , the resident had an open area to her coccyx. RN 2 stated that resident 130 then developed a stage II pressure ulcer to her buttocks, which was a different wound than resident 130 had upon admission. RN 2 stated that she assessed the buttock wound for resident 130 on 9/4/19 when it was identified, and that at that time it was a superficial stage 2. RN 2 stated that she was not aware if resident 130 had a pressure ulcer on her buttocks prior to 9/4/19. RN 2 confirmed that the resident obtained the pressure ulcer to her buttocks at the facility, and stated that at the time resident 130 obtained the pressure sore, the facility was short staffed with regard to nurse management. RN 2 stated that there was not a DON or wound nurse at that time, and she was unable to keep up with her work load. RN 2 confirmed that facility staff did not identify resident 130's pressure ulcer on the buttocks until it was 6x3 cm. RN 2 stated that when the pressure injury was identified that treatment was continued with barrier cream because it was superficial. RN 2 stated that floor staff knew when and who to apply barrier cream to because there was a physician order for [REDACTED]. RN 2 did not know why the order for barrier cream was not implemented in the physician orders before 9/4/19 or after 9/4/19.