Every finding on record at Center at Arrowhead, LLC

Based on observation, staff interviews and facility policy, the facility failed to maintain infection prevention and control when delivering meal trays, providing foley catheter care for one of one sampled resident's (#9), and failing to consistently implement tracking and trending of their infection prevent and control program. The deficient practice could result in transmission of infection within the facility. -Regarding delivering of meal trays: Observations were conducted on April 30, 2025 of a Certified Nursing Assistant (CNA/staff #200) delivering in-room lunch meal trays to four residents on enhanced barrier precautions (EBP). The following was observed: -The CNA entered the first room, moved items on the bedside table and placed a meal tray on a bedside table, and exited the room without sanitizing her hands. -The staff member picked up a meal tray from the dietary cart and entered a second room without sanitizing her hands prior to entering the room. The staff member placed the meal tray on the bedside table, repositioned items on the bedside table then exited the room without sanitizing her hands. -The CNA entered a third room, leaving the meal tray on the bedside table, without sanitizing her hands before entering or after exiting the room. -In a fourth room the staff member entered without sanitizing her hands, placed a meal tray on the bedside table, picked up a coffee cup off the tray, exited the room, filled the coffee cup from a carafe on the dietary meal cart, and re-entered the room with the coffee cup. The CNA exited the room without sanitizing her hands. -The staff member entered the first room, wiped the bedside table with paper towels and exited the room without sanitizing her hands before entering or after exiting. -The staff member re-entered the fourth room with another coffee cup and a styrofoam cup of ice, without sanitizing her hands when entering and exiting the room. -The CNA entered the first room without sanitizing her hands, assisted the resident with eating a bite of the food, then exited the room without sanitizing her hands. An Enhanced Barrier Precautions (EBP) sign that was posted outside of all the resident rooms the CNA entered during tray pass on April 30, 2025, revealed that everyone must: clean their hands, including before entering and when leaving the room. An interview was conducted on April 30, 2025 at 11:32 AM with a registry CNA (staff #200) who stated that she only needed to gown up when entering EBP rooms for catheter or foley care, but the facility policy was to follow the EBP sign instructions posted outside of the rooms. The CNA read an EBP sign posted outside of the doors stating everyone must clean their hands, including before entering and when leaving the room. The CNA stated that she did not sanitize her hands upon entering/exiting the resident rooms with EBP on the door when passing meal trays. An Interview was conducted on April 30, 2025 at 11:40 AM with a registry Licensed Practical Nurse (LPN/staff #201), who stated that residents requiring EBP precautions have a sign posted by their room. The LPN stated that when staff enter a room on EBP all staff should sanitize their hands when entering/exiting the rooms, and this included passing meal trays. An interview was conducted on April 30, 2025 at 11:44 AM with a CNA (staff #202), who stated that when entering or exiting resident rooms placed on EBP, all staff are required to sanitize their hands, including when they are passing meal trays. An interview was conducted on May 2, 2025 at 12:38 PM with the Interim Director of Nursing (DON/staff #63), who stated that staff should would wash or sanitize their hands before entering/exiting each resident's room, including residents placed on EBP. The DON also stated that this included when staff bring meal trays into resident rooms. She further stated that the meal tray observations for hand hygiene. DON stated that hand hygiene was important to maintain infection prevention/control and prevent the spread of germs and infections. -Regarding Enhanced Barrier Precautions (EBP) and hand hygiene during Foley catheter care: Findings include: Resident #9 was admitted to the facility on [DATE] with diagnoses that included: osteomyelitis of vertebra, acute kidney failure, and cognitive communication deficit. A care plan initiated on April 27, 2025, revealed that Resident #9 had a Foley catheter for acute retention and required catheter care as ordered by the physician and as needed. Review of a care plan initiated on March 26, 2025, revealed that Resident #9 required: EBP related to a Foley catheter and a Peripherally Inserted Central Catheter (PICC), a sign to be placed outside the resident's door, EBP per policy and staff to wear personal protective equipment (PPE) during high contact resident care. Review of an order summary revealed an order dated April 27, 2025. The order prescribed a Foley catheter and Foley catheter care to be performed every shift. The resident also had an order, dated April 27, 2025, for EBP with high contact care activities due to a Foley catheter every shift. During initial observations on April 29, 2025 at 8:35 AM, an EBP sign was observed outside Resident #9's room. The sign instructed all who entered the room to: -clean their hands before entering and when leaving the room, and to -wear gloves and a gown for the following high-contact resident care activities: dressing, bathing, changing linens, changing briefs, device care for urinary catheter, . A cart was observed outside of the resident's room that contained gowns and gloves. During that same observation, it was also noted that Resident #9 had a Foley catheter in place. A procedure for Foley catheter care was observed for Resident #9, on April 30, 2025 at 10:55 AM, with Registered Nurse (RN/staff #83). The RN was observed to sanitize her hands with alcohol-based hand rub (ABHR) before entering the resident's room. The RN was not observed to don a gown. The RN donned gloves and closed the door to the resident's room. The RN dipped a washcloth into soapy water and cleaned the resident's groin area. She doffed the gloves and donned a new pair of gloves. The RN was not observed to sanitize her hands between glove changes. The RN (staff #83) then dipped a new washcloth into the soapy water and cleaned the resident's genital area, including the catheter tubing. The RN doffed her gloves and donned new gloves. She was not observed to sanitize her hands between glove changes. The RN (staff #83) proceeded to clean the resident's buttocks, with a new washcloth, as the resident had had a bowel movement. She doffed the gloves and donned new gloves. The RN was not observed to sanitize her hands between glove changes. The RN (staff #83) then put a new brief on the resident and then discarded her supplies. The RN was then observed to wash her hands with soap and water. The RN was not observed to wear a gown throughout the procedure. An interview was conducted with the RN (staff #83) on April 30, 2025 at 11:10 AM. The RN acknowledged that she did not wear a gown and did not sanitize her hands between glove changes. She acknowledged that Resident #9 was on EBP and that she should have been wearing a gown during Foley catheter care and the brief change. She stated she did not wear a gown because she forgot that the resident was on EBP. She also stated she should have sanitized her hands before and after she donned and doffed gloves. She stated she did not sanitize her hands between gloves changes because she did not bring her own ABHR into the room. An interview was conducted with the Assistant Director of Nursing (ADON/staff #54) on May 1, 2025, at 11:35 AM. The ADON stated that for residents on EBP, the expectation was that staff would wear gowns and gloves when performing all cares except bedside meal or fluid delivery. She stated that RN (staff #83) should have worn a gown during Foley catheter care and the brief change for Resident #9. The ADON also stated that Staff #83 should have sanitized her hands between glove changes. Further the ADON stated the risk of not performing hand hygiene and not wearing proper EBP could be the spread of infection. An interview was conducted with the Interim Director of Nursing (DON/staff #93) on May 2, 2025 at 9:21 AM. The DON stated that if a resident was on EBP, staff would be expected to wash their hands and wear a gown and gloves while performing personal cares, according to the sign by their door. The DON acknowledged that RN (staff # 83) did not follow EBP and hand hygiene protocols when she performed Foley catheter care and a brief change on Resident #9. The DON stated the risk of not following EBP and hand hygiene protocols could be infections to both residents and staff. -Regarding the Infection Prevention and Control Program: Finding include: On May 1, 2025 at 11:35 AM, an interview was conducted with the Assistant Director of Nursing (ADON/staff #54) and the Regional Clinical Director (RCD/staff #205). The ADON and the RCD explained that the ADON was in the process of completing her training as the Infection Preventionist (IP). It was further explained that the previous IP (staff #69) was assisting the ADON with IP tasks approximately three to four hours per week. During the interview on May 1, 2025, the Infection Control Logs for January 2025 through April 2025 were reviewed with the RCD and the ADON. Information regarding infections were listed on the log. However, there was no evidence of trending the information found on the logs. Further, The RCD (staff #205) explained that the data found on the logs regarding infections had not been recorded in real time. She stated that the previous IP (staff #69) had been going back and filling in the logs after the fact. She confirmed that infections were not being tracked and trended from January 2025 through April 2025. The RCD then acknowledged that tracking and trending of infections was not occurring per company policy. The RCD further stated that the risk of not tracking and trending infections could be the spread of infection throughout the facility. A policy titled, Hand hygiene for Clinical Staff, effective date January 29, 2025, revealed that hand hygiene is the process of cleaning hands to remove dirt, organic matter or microorganisms. It includes both handwashing with soap and water and hand antisepsis using alcohol-based hand rub (ABHR). Clinical staff must perform hand hygiene in the following situations: - before patient contact (e.g., entering the room) -after touching surfaces or objects in the patient care area A policy titled, Enhanced Barrier Precautions (EBP), refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms. EBP are used in conjunction with standard precautions and expand the use of personal protective equipment (PPE) to donning of gown and gloves during high-contact resident care activities the provide opportunities for transfer of MDROs (multidrug-resistant organisms) to staff hands and clothing. A policy titled, Infection Prevention and Control Program, reviewed/revised March 14, 2024, revealed that hand hygiene should be performed in accordance with the facility's hand hygiene procedures. It also revealed that a system of surveillance was to be utilized to prevent, identify, report, investigate and control infectious and communicable diseases. A policy titled, Hand Washing, reviewed/revised March 14, 2024, revealed hands should be washed before donning disposable gloves and after gloves are removed.

Based on record review, staff interviews, policy review and Center for Disease Control (CDC) guidelines, the facility failed to consistently implement tracking and trending of their antibiotic stewardship program. The facility census was 79 residents. This deficient practice could result in improper antibiotic use and adverse outcomes to residents. Findings include: On May 1, 2025 at 11:35 AM, an interview was conducted with the Assistant Director of Nursing (ADON/staff #54) and the Regional Clinical Director (RCD/staff #205). The ADON and the RCD explained that the ADON was in the process of completing her training as the Infection Preventionist (IP). It was further explained that the previous IP (staff #69) was assisting the ADON with IP tasks approximately three to four hours per week. During the interview on May 1, 2025, the Infection Control Logs for January 2025 through April 2025 were reviewed with the RCD and the ADON. Resident names, types of infections and antibiotics used were listed on the log. However, there was no evidence of trending the information found on the logs. Further, The RCD (staff # 205) explained that the data found on the logs regarding antibiotic use had not been recorded in real time. She stated that the previous IP (staff #69) had been going back and filling in the logs after the fact. She confirmed that antibiotics were not being tracked and trended from January 2025 through April 2025. The RCD then acknowledged that tracking and trending of the antibiotic stewardship program was not occurring per company policy. The RCD explained that an integral part of the program was to track and trend the information. The RCD further stated that the risk of not implementing the antibiotic stewardship program could be that antibiotics are not used correctly. Review of the Infection Prevention and Control Program Policy, revised March 14, 2024, revealed that a system to monitor antibiotic use would be implemented and that the Infection Preventionist would oversee the program.

Based on observation, staff and resident interviews, and the facility policy and procedures, the facility failed to ensure that one resident (#86 ) was provided with appropriate sized briefs for incontinence care. The deficient practice could result in skin breakdown/injury. Findings include: Resident (#86) was admitted on [DATE] with diagnoses that included bilateral primary osteoarthritis of the knee, morbid (severe) obesity, right and left knee pain, and muscle weakness. The care plan dated March 30, 2025 revealed that the resident had bowel and bladder incontinence. The interventions included to check frequently and assist with toileting as needed. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 15 indicating she was cognitively intact. It also included that the resident is frequently incontinent of bladder and always incontinent of bowel. The resident was not on a toileting program. An interview was conducted on May 2, 2025 at 9:07 a.m. with the resident who stated that the adult briefs provided by the facility are too small and cuts into the creases where the brief lies between her legs, so she doesn't tape the brief closed. She stated that she keeps telling the certified nursing assistants (CNAs) that she needs a larger size and the CNAs tell her that they don't have a larger size. During the interview, blue/green colored briefs were observed on the dresser and the resident stated that they were not big enough for her. An interview was conducted on May 2, 2025 at 9:56 a.m. with (CNA/staff #205) who observed the blue/green briefs on the resident's counter and stated that they were a size 2 XL and based on the resident's size, he thought she needed the larger bariatric brief, 3 XL, which was a white brief. He stated that if the brief is too small, it can cause creases in the groin area and indentations across the abdomen. An interview was conducted on May 2, 2025 at 10:41 a.m. with the maintenance/housekeeping assistant (staff #206), he stated that the supply rooms on each floor are stocked daily and if a CNA asks for supplies, such as a specific size of brief, he will stock the supply room with the specific size. During the interview, it was observed that there were no 3 XL adult briefs in the supply room on the third floor where the resident's room is located. It was also observed that there were no 3 XL adult briefs in the supply room on the second floor where residents reside. An interview was conducted on May 2, 2025 at 11:09 a.m. with the interim Director of Nursing (DON/staff #93), who stated that she stocks the supply rooms on the second and third floors and it was her expectation that the CNAs tell her if they need adult briefs, so she can go and get some in the main supply room located on the first floor. She observed the blue/green briefs on the counter in the resident's room and stated that they were 2 XL. Then the DON assessed the resident and stated that the resident was wearing a 2 XL adult brief which was not the appropriate size and apologized to the resident. The DON went to the supply room on the third floor and stated that there were no briefs sized 3 XL stocked and this was the size the resident needed. She stated that when a brief is too small, there is a risk of the resident developing skin integrity issues. During an interview with (CNA/staff #72) conducted on May 2, 12:31 p.m., she stated that there are two tapes on each side of the brief and when she and a nurse changed the resident, she only fastened one tape on each side of the brief at the resident's request. She stated that the brief seemed snug and went to look for a larger size in the supply room, but there were no larger briefs and she thought the resident probably needed the bariatric brief 3 XL. She stated that when the brief is too small, there is a risk of it cutting into the skin and skin rash. The facility's policy, Incontinence Management Policy states that the purpose of incontinence care is to ensure that the residents who are incontinent receive care and services to prevent urinary tract infections, skin breakdown, and loss of dignity, in compliance with the Centers for Medicare and Medicaid Services (CMS) regulations and Arizona Department of Public Health.

Based on clinical record review, interviews, and facility documentation and policy, the facility failed to ensure that one resident (# 207) was administered medications in accordance with physician's orders. This deficient practice can result in diminished quality of life, and suboptimal clinical outcomes. Findings include: Resident #207 was admitted to the facility August 12, 2024 for a 5-day respite for hospice care with diagnoses that included Cerebrovascular disease, sequelae of cerebral infarction, hypertension, anxiety disorder, atrial fibrillation & depression. A hospice order summary dated August 12, 2024 revealed that the resident was prescribed Lactaid, Glucerna and sliding scale insulin instruction. Review of the August 2024 Medication Administration Record and the Treatment Administration Record revealed insulin was not administered and that fasting or random blood sugars were not completed during the 5-day respite period, that the resident was in the facility. A progress note dated August 12, 2024, indicated that medications to include medication administration times were reviewed with the resident and the resident's family. A progress note dated August 12, 2024, revealed a review of the medication reconciliation sheet dated August 12, 2024 that indicated that the resident's medications were reviewed by the pharmacist and physician's orders were clarified with the hospice agency. The sheet documented that the orders were transcribed and sent to the hospice pharmacy. According to the medication reconciliation sheet, there was no physician's order for insulin. A progress note dated August 14, 2024, the Resident reported to the night nurse that she was supposed to be get insulin. The nurse noted that there were no orders for insulin in the resident's record. The hospice agency was contacted, they stated they would investigate and report back. A progress note dated August 14, 2024, a review of the resident's admission Medication Review Report dated August 12, 2024 was completed and uploaded to the dashboard. An interview with a Registered Nurse (RN/Staff #93)/Interim Director of Nursing (DON) was conducted on May 1, 2025 at 12:24 PM. she is accompanied by RN Staff #207, Regional Clinical Director. Interim DON has been in position for 1 week. During the interview, staff #207 and #93 confirmed that upon review of resident #207's record, they were unable to locate an order for insulin or insulin administration documentation. Staff #207 stated that insulin was not administered to the resident. Furthermore, during review of the hospice order summary. Both staff members confirmed that the orders included Lactaid, Glucerna, and sliding scale instruction for insulin. However, the staff members noted that the hospice order summary was not uploaded into the resident's clinical record until October 10, 2024 which was after the resident's discharge. According to staff #207, the resident was not administered insulin during her stay. Additionally, staff #207 stated that this does not meet the facility expectations for quality of care. Furthermore, staff #93 noted that hospice is very particular and expects that their physician's orders are to be followed. Staff #93 indicated that the impact of not administering insulin is that it could lead to hyperglycemic events which could result in diabetic keto-acidosis (DKA) and possible diabetic coma. - An interview with a Registered Nurse (RN/staff #7) was conducted on May 1, 2025 at 1:00 PM. Staff #7 stated that for new admits, Medical Records/Admissions are responsible for inputting the resident's initial demographics into the system. The nurse is responsible for reviewing admission paperwork to verify for completion and accuracy. Reviewed documents are uploaded into the system for Provider and Pharmacy review, if discrepancies are noted, they may be addressed with the interdisciplinary team prior to the uploading the records to the electronic health record. Staff #7 advised that once medication reconciliation is completed, it is reviewed the resident and/or resident's family, they are asked to sign it, if it is accurate. The resident's hospice note dated August 13, 2025 was reviewed with staff #7. She stated that she would expect to see blood sugar levels to be completed three times a day if the resident had a diagnosis of diabetes, The RN did not feel comfortable answering further questions regarding medication errors or order completeness. The RN noted that the risk of not taking insulin could lead to Hyper glycemia, DKA or Diabetic Coma. Staff #7 said that she would report a medication error to the provider once it was found, in the event of any adverse reactions. She also noted that she would notify the DON and the resident's family. The medication discrepancy would also be documented in progress notes. An interview with a Licensed Practical Nurse (LPN/staff #54), interim Assistant Director of Nursing was conducted on May 1, 2025 at 2:09 PM. According to staff #54 hospice residents admitted to the facility usually comes from home. Therefore, the hospice facility provide the orders and the medication for the respite stay. According to staff #54's review of the hospice note dated August 12, 2024, per the orders the resident should have been glucose tested four times per day. Staff #54 mentioned that other than diabetes, insulin can also be used for weight loss or if the resident is on steroid therapy. Staff #54 confirmed that the resident did not receive insulin or blood sugar testing during his 5-day respite stay at the facility. The LPN stated that generally speaking this would be considered a medication error, the nurse who was admitting the resident would be responsible for reviewing/checking the incoming residents orders. The risk for the resident could be diabetic coma or ketoacidosis. -Policies Veritas-The Center for Policies and Procedures The facilities Medication Administration policy, issued July 1, 2017, revealed that medications must be administered in accordance with written orders. In addition, all current drugs and dosage schedules must be recorded on the patient's medication administration record (MAR and TAR as appropriate). The facilities Physicians Orders policy, issued: December 4, 2019, revealed that the center will transcribe the Physician's orders and treatments and will be consistent with principles of safe and effective order writing. Additionally, drug and biological orders will be recorded in the patient's medical record on the order sheet; such orders are reviewed monthly by a consultant pharmacist.

Based on observations and staff interviews, the facility failed to ensure the daily nurse staffing information was complete and accurate for actual hours worked for licensed and unlicensed direct care nursing staff. The deficient practice could result in residents, representatives, and visitors not being informed of accurate and current staffing information in the facility. Findings include: Review of the facility's daily nurse staffing forms for the dates of February 14, 2025 through February 18, 2025 and April 25, 2025 through April 27, 2025 revealed no evidence of actual hours worked by licensed and unlicensed staff. During an observation conducted on April 29, 2025 at 9:07 AM, the daily nurse staff posting form was displayed at the front information desk and form did not include the actual hours worked by licensed and unlicensed nursing staff. An interview was conducted with the Staffing Coordinator (staff # 73) on May 1, 2025 at 1:25 PM who stated that she is responsible for ensuring the daily nurse staffing information is accurate and posted. She stated that she had not been informed to include the actual hours worked on the daily nurse staff posting form. She further stated that she had, never been told that, but that she will update the form and include the actual hours worked going forward. She reviewed the daily nurse staff postings dated February 14, 2025 through February 18, 2025 and April 25 2025 through April 27, 2025 and stated that there was no evidence of the actual working hours worked by licensed and unlicensed nursing staff. An interview was conducted the with Director of Nursing (DON/staff #93) on May 2, 2025 at 12:52PM, who stated that it is staffing's responsibility to complete the staff postings. She further stated that the daily nurse staff posting should be accurate for each day. She reviewed the daily nurse staff postings dated February 14, 2025 through February 18, 2025 and April 25, 2025 through April 27, 2025 and stated that there was no evidence of actual hours worked by licensed and unlicensed nursing staff on the forms. She stated that she did not know the risk associated with including the actual hours worked on the forms. Review of the facility's policy regarding Posted Staffing Numbers revealed the daily posting is to include hours worked by the Registered Nurses, Licensed Practical Nurses, and Nursing Assistants for each shift.

Based on observation, clinical record review, staff interview, and facility policy, the facility failed to ensure medications were not left at the bedside for one of 16 sampled residents (#404). The deficient practice could result in medications not being administered correctly, or medications not taken as ordered by the provider. Findings include: Resident #404 was admitted on [DATE] with diagnoses that included fracture of fourth lumbar vertebra and subsequent encounter for fracture with routine healing. During an initial observation conducted on April 29, 2025 at 09:30 AM, of Resident #404's room, a tube of barrier cream and anti-fungal powder were observed on the resident's bedside table unattended. A second observation conducted on April 29, 2025 at 10:45 AM., revealed a tube of barrier cream and anti-fungal powder on the bedside table unattended. Review of physician orders revealed: barrier cream to coccyx and buttock area every shift and PRN dated February 22, 2025. Further review of physician orders revealed no evidence of an order for anti-fungal medications. 5-day Medicare Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. A care plan initiated on February 22, 2025 revealed no evidence of a focus or intervention regarding medication self-administration. Review of the clinical record from February 22, 2025 through May 1, 2025 revealed no evidence of a mediation self-administration assessment. Immediately after the 2nd observation an interview with Licensed Practical Nurse (LPN/staff #83) was conducted on April 29, 2025 at 10:47 AM. The LPN entered the resident's room and stated that a tube of barrier cream and anti-fungal powder were on the resident's bedside table. The LPN stated that she did not leave the moisture barrier cream at the bedside and that the tube is empty, and she was not sure why it was even in the resident's room. The LPN stated that the Resident's wife left the antifungal powder at the bedside and that the LPN has seen the Resident's wife use it, but thought that the wife took it home with her. The LPN stated that it was not appropriate for the medications to have been left at the bedside unattended. The LPN stated that when family brings in medications, they should give the medications to a nurse. The LPN further stated that the facility policy requires a provider order along with a completed medication self-administration assessment, prior to leaving medication/treatments at the bedside. The LPN removed both medications from the bedside table and placed them in a treatment cart, and notified the charge Registered Nurse (RN). In an interview conducted on May 2, 2025 at 10:31 AM, with LPN (staff #203) who stated that all medications, including topical treatments, are not to be left unattended at the resident's bedside table. She further stated that if a family member brings any medications into the facility, they would need to give the medications to a nurse to place in the treatment cart. The LPN stated that the risks of leaving medications unattended in a resident's room could result in medications not being administered correctly, or someone beside the resident could take the medication. In an interview, conducted on May 2, 2025 at 10:39 AM., with a Certified Nurse Assistant (CNA/staff #204) who stated he accesses the resident's barrier cream from the nurse and leaves the barrier cream in the resident's bedside drawer when he is done. An interview was conducted with the interim Director of Nursing (DON/staff #93) on May 2, 2025 at 01:16 PM, who stated that medications were not to be left unattended on the resident's bedside table, and if family members bring medications into the facility, nursing staff should be notified. The DON further stated that barrier cream is to be kept in the treatment cart, not on the resident's bedside table, or in a drawer. The DON stated that in order for a resident to self -administer medications, an order from the resident's provider, the resident's signature, and a medical self-administration assessment form are to be in the resident's clinical record. The DON reviewed the medical record and stated that there was no evidence of a self-administration assessment form. The DON stated that risk of a medication being left at the bedside without an assessment could result in the resident being injured. A policy titled, Medication Administration, revised August 8, 2022, revealed that medications are to be administered as prescribed by the attending physician. Only licensed medical and nursing personnel or other lawfully authorized staff members may prepare, administer, and record medications. Medications must be administered in accordance with the written orders of the attending physician. A policy titled, Self-administration of Medications, revised February 8, 2021, revealed that as part of their overall evaluation, the nursing staff will assess each resident's mental and physical abilities to determine whether self-administering medication is clinically appropriate for the resident. Self-administered medications mush be stored in a safe and secure place, which is not accessible by other patients. If safe storage is not possible in the resident's room, the medications of patients permitted to self-administer will be stored on a central medication cart or in the medication room. Nursing will transfer the unopened medication to the resident when the resident requests them. Staff shall identify and give to the Charge Nurse any medications found at the bedside that are not authorized for self-administration, for return to the family or responsible party.

Based on clinical record review, staff and resident interviews, facility documentation and policy review, the facility failed to ensure that an allegation of abuse for one resident (#6) was reported to the State Agency. The deficient practice places the resident at risk for continued abuse. Findings include: Resident #6 was admitted to the facility on [DATE], with diagnoses of acute respiratory failure with hypoxia, enterocolitis due to clostridium difficile, sepsis, depression and low back pain. A review of the Resident #6 admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderately impaired. In addition, Resident #6 mostly required assistance with everyday activities. A review of the care plan initiated on January 24, 2024 revealed a need assistance with transfers and toileting related to impaired mobility secondary to weakness and debility. The interventions included check frequently and assist with toileting as needed, keep call light within reach, and remind me to call for assistance. An interview was conducted with a Case Manager, (Staff #12), on February 13, 2024 at 11:55 AM. She stated that for an alleged abuse, they get information from the person reporting the abuse, and it gets elevated to the administrator. She further stated she has not received any information regarding Resident's #6 alleged abuse. She then stated that it might have been reported to the Assistant Director of Nursing (ADON/Staff #75) or the Director of Nursing (DON/Staff #65). On February 13, 2024 at 12:38 PM, an interview was conducted with ADON (Staff #75). Staff #75 stated that he was not aware or remembers any report of alleged abuse. He stated that allegations always go to the DON/Staff #65. On February 13, 2024 at 12:42 PM, an interview was conducted with DON (Staff #65) in her office. Staff #75 was also present. The DON stated that she does not have any recollection of a notification regarding an incident of alleged abuse of Resident #6. She further stated there was no mention to the physician, while she was looking at a 7-day look back at the physician progress notes. Staff #65 stated that she will be speaking to Resident #6 so she can interview resident, to obtain a description of the staff, and the timeframe so she can interview the staff. On February 13, 2024 at 12:57 PM, Staff #100, the Clinical Services Resource staff, stated that the DON was on vacation last week. She also stated that the alleged abuse came on a report last week. She stated that met with Resident #6 and that Resident #6 declined an interview at first and then stated the staff are good. She then stated that Resident #6 thinks one person yelled at her, but was unable to describe the staff who yelled at her. The resident stated the staff asked her why her call light was on and what she needed. On February 13, 2024 at 12:59 PM, an interview was conducted with the Administrator (Staff #10). he was informed of the allegation of abuse by Resident #6. He further stated all the managers conduct angel rounds every morning and if there is a concern, then they determine if it is grievance or not. There was rounding for all patients and there were no concerns identified on February 8. He stated he will provide copy of the angel rounds for that week. On February 14, 2024 at 9:59 AM, a document about the alleged abuse of Resident #6 was received from Administrator/Staff #10. The document was returned to Staff #10 because it does not match the Resident #6's name on the provided document about the alleged abuse. On February 14, 2024 at 11:36 AM, a follow up interview was conducted with Staff #100. She stated that she was rounding in the hallway, where the resident is and on February 5, 2025, and she stopped by Resident #6 room to check on her, and Resident #6 stated that she thinks someone came in her room and asked her why her call light was on. Staff #100 asked Resident #6 if she can describe the incident and resident said no, she could not. Staff #100 stopped by the resident room approximately 10:00 AM. Resident #6 stated to that she felt the staff was rude and yelled at her but was unable to recall the time and who or describe the person. Staff #100 apologized to Resident #6. She then asked if resident feels safe and Resident #6 stated she feel safe and everyone is nice to her. Staff #100 conducted an interview with the night shift and day shift staffs and interviewed patients and no one heard yelling. Staff #100 further stated that the resident was visited during angel round. She then stated that Resident #6 stated she does not have concerns or complaints. She further stated that after investigating, there was no evidence to substantiate. She further added, the resident denied any feelings of intimidation or feeling of being unsafe. She then stated that the process is to do immediate investigate and interview. There was nothing to report about this alleged abuse, resident has no complaints or concerns. She stated if no one has heard it, and they can not identify anything or anyone, and resident does not want anything further done about, so no report was required. On February 14, 2024 at 12:08 PM, received a four paged document titled Conclusion to Concern: abuse investigation interviews dated February 5, 2024 from Staff #100. On February 14, 2024 at 12:21 PM, Staff #100 stated that a customer service in-service was conducted on February 5, 2024 and Staff #100 provided a copy of the in-service sign in sheet. However further review of the facility's investigation revealed no evidence that the allegation of abuse was reported to the State Agency. Review of the facility policy titled, Abuse and Neglect Prohibition with a revised date of October 12, 2022 revealed that each resident has the right to be free from abuse. Any observations or allegations of abuse must be immediately reported to the Administrator. Reporting and Response section 1 (a) states, if the eventes that caused the allegation involved abuse or serious bodily harm, a report is made not later than 2 hours after the management becomes aware of the allegation.

Based on clinical record review, staff interviews, and facility policy and procedures, the facility failed to ensure one resident (#55) receive trimming of toe nails. The deficient practice could result in resident discomfort with pain and infection. Findings include: Resident # 55 was admitted to facility on January 9, 2024 with diagnosis included unspecified fracture of upper end of left humerus, subsequent encounter for fracture with routine healing, subsequent encounter, sepsis, unspecified organism, contusion of left elbow, subsequent encounter, essential (primary) hypertension, alcohol abuse, uncomplicated, gastro-esophageal reflux disease without esophagitis, muscle weakness (generalized), difficulty in walking, not elsewhere classified. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident is cognitively intact. The MDS also indicated that the resident was dependent on toileting and lower body dressing. Review of the care plan initiated on January 9, 2024 revealed that resident have actual/potential decline in his ability to perform his activities of daily living. Intervention included therapy evaluation and provide assistance as needed with grooming, bathing, and personal hygiene and per patient's preferences. Review of the resident task sheets for bath and nail care from January 16, 2024 to February 13, 2024 showed that resident is schedule for bathing every Tuesday and Friday. The following dates were reviewed for resident nail care: January 16, 2024: no nail care offered; January 19 - February 6, 2024: resident refused once and no follow up made on another shift; January 30 - February 13, 2024: no nail care offered or follow-up made on different shift Review of resident progress note on February 3, 2024 from Licensed Practical Nurse (LPN, staff # 106) revealed that patient had concerns about his toe nails not being cut. During an initial interview on February 12, 2024 at 12:15 a.m., resident stated that he wanted his nail to be clipped and staff ignores his request for podiatrist consult. An observation was made on resident toe nail on February 12, 2024 at 12:15 AM, both toe nails were big, thick and greenish in color. During an interview, resident stated that his toe nail is growing to his foot and his big nails hurt, he did not remember when was that last cut. An interview was conducted with certified nursing assistant (CNA, staff # 56) on February 14, 2024 at 9:57 AM, and she stated that by looking at the resident toe nails, she never asked him to cut his nails. She further stated that she notified the wound nurse couple weeks ago but did not follow-up. She also stated that she did not remember resident asking her to cut his toe nails. An interview was conducted with wound care nurse (staff # 54) on February 14, 2024 at 9:57 AM, and she stated that she is competent to do podiatry. She further stated that for non-diabetic residents' regular nurses provide cares and those with diabetes, she provides their care. She also stated that the resident is not diabetic and she is not sure whether he requested for nail care or not. An interview was conducted with Director of Nursing (staff # 65) on February 14, 2024 at 9:57 AM, she stated that if resident is diabetic then the nurse will provide nail care, if they are not diabetic then a CNA will do that. She further stated that facility does not have a podiatrist, if they need podiatrist then wound care nurses or doctor can do that. She also stated that if the nail is really thick then she does not recommend CNA to do that. About risk, she stated that it may cause infection and skin damage if nails were not cut. Review of facility policy on Activities of Daily Living (ADLs) revised on February 8, 2021, stated that patients shall receive assistance with activities of daily living every shift, as appropriate and ADLs include: bathing, grooming, dressing, eating, oral hygiene, ambulation, toilet activities and trimming of toe nails.

Based on closed record review, observation of current practice, staff interviews, and facility documentation and policy review, the facility failed to ensure wound assessment was completed for one of 3 sampled residents (#1). The deficient practice could result in resident not receiving appropriate treatment and developing or worsening or wound. Findings include: Resident #1 was admitted on [DATE] with diagnoses of fractured left femur, essential hypertension, chronic obstructive pulmonary disease, diabetes mellitus type II, muscle weakness, and difficulty walking. The admission progress notes of July 7, 2023 revealed the resident arrived at the facility and had an immobilizer. The nursing comprehensive admission data collection tool dated July 7, 2023 revealed the resident had small surgical site pin hole in the left knee, 36 staples, minimal upper extremity bruising, bruising to the left thigh, and four sites of bruising on the left foot. Per the documentation Braden Scale score was 15, indicating the resident was low risk for pressure sore development. The physicians order dated July 7, 2023 included the following orders: -Wear immobilizer to left lower extremity when out of bed; -Monitor every shift for skin breakdown or complications, notify Medical Doctor (MD)/ and wound care if there are concerns; -Braden Scale every week on Friday night shift for routine screening y; -Skin prep to heels every shift for prophylaxis; -Weekly skin and foot evaluation every Friday night shift; -Barrier cream to coccyx/buttock/peri area/reddened area every shift and as needed for prevention; -Monitor incision to left knee/thigh every shift, report concerns to MD/Surgeon; and, -Wound care to the left knee: cleanse with normal saline (NS)/wound cleanser, pat dry, apply dry dressing or leave open to air (OTA) daily every night shift and as needed for wound care. The baseline care plan with effective date of July 7, 2023 included the resident was at risk for skin breakdown and had surgical wounds related to left lower femur fracture. Goals were that the skin will remain intact and surgical wound would heal without complications. Interventions included Braden scale every week and skin evaluation as ordered, skin treatment per physician orders, dressing changes per physician orders, follow up with surgeon as scheduled, and monitor incision daily and as needed. The baseline care plan did not include the presence of the knee immobilizer and interventions related to the use of the immobilizer. The daily skilled note dated July 8, 2023 revealed resident had surgical incision to the left lower extremity (LLE). The daily skilled note dated July 9, 2023 included the resident had LLE surgical site with staples and blister to the LLE. However, the note did not document the assessment of the blister to include the size, appearance, or specific location of the blister. Review of the physician admission history and physical dated July 10, 2023 revealed the resident required maximum assistance for all activities of daily living (ADLs); and that, the immobilizer was to be applied when out of bed. The daily skilled notes dated July 10 and 11, 2023 included the resident had LLE surgical site. The note did not mention the assessment or status of the blister that was previously identified. Review of the daily skilled note dated July 13, 2023 revealed the resident's brace was taken off while in bed and an intact blister to LLE was noted. Per the documentation, wound care order was added per protocol and the wound nurse and physician will be notified in the morning. The orders-administration note dated July 13, 2023 revealed a blister to LLE, wound care order added and the wound nurse and physician will be notified in morning. note did not document the assessment of the blister to include the size, appearance, or specific location of the blister. The physician order dated July 13, 2023 included to apply betadine-soaked gauze to LLE blister, cover with abdominal (ABD) pad, secure with kerlix and tape every day and night shift and as needed (PRN) for soiling or dislodgement. The physician progress note dated July 13, 2023 revealed that the extremities had no edema or varicosities noted and the left lower extremity immobilizer was noted. The daily skilled nursing note dated July 13, 2023 revealed the resident had LLE surgical site with staples and had blister to the LLE. There was no other information noted regarding the assessment or status of the the blister to include size, appearance, or specific location. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident had intact cognition. Per the assessment, the resident was at risk for pressure ulcers, had no unhealed pressure ulcers and had surgical wounds. It also included that the resident was receiving wound care and a pressure relieving device for the bed was coded. Further, the assessment included that skin condition was triggered for care planning. Review of the orders-administration note dated July 14, 2023 revealed the resident refused dressing to LLE blister. Per the documentation the resident stated that it burned and would not allow dressing to be placed. The skin evaluation dated July 14, 2023 included the resident had bilateral upper extremity scattered bruising, left thigh surgical site with staples, and LLE scattered bruising. The evaluation did not mention the assessment or status of the blister to the LLE that was previously identified. The Braden Scale dated July 14, 2023 revealed a score of 17 indicating the resident was low risk for pressure sore. Review of the appointment progress note dated July 18, 2023 revealed the resident went to an orthopedic appointment where the left leg staples were removed and the knee immobilizer was discontinued. The Braden score dated July 17, 19, and 21, 2023 continued to reveal a score of 17 indicating the resident continued to be low risk for pressure sore. The skin evaluation dated July 21, 2023 included that left thigh surgical site staples were removed and the site was healing well no signs or symptoms of infection. It also included that the resident had bilateral upper extremity scattered bruising and scattered bruising to the LLE. However, the documentation did not include assesment or status of the blister on the LLE. The physician's discharge order dated July 24, 2023 included revealed orders to discharge home on July 27, 2023 and wound care to LLE blister. Review of the TAR (treatment administration record) for July 2023 revealed that treatment was documented as administered to the LLE blister. However, despite documentation of a blister and treatment was provided, the clinical record revealed no evidence that the LLE blister was assessed to include size, appearance, or specific location. In an interview with the wound nurse (staff #84) conducted on September 19, 2023 at 2:00 p.m., the wound nurse stated that staff nurses were responsible for doing regular skin assessments and for notifying the wound nurse and the physician of any findings. She stated that once notified she would do a full head to toe assessment on all new admissions or a focused assessment if the resident had been at the facility for a while. The wound nurse said that upon completion of the assessment she would notify the physician, document her assessment and initiate a care plan. She stated that she would refer to the nursing staff simple wounds; and, she would follow the care of full thickness pressure injuries, and packed or complex wounds regularly at least weekly. Regarding resident #1, the wound nurse stated that she did not follow the resident's pressure injury because it was an intact blister with a simple treatment; and, there were no changes in the wound during the resident's stay. Further, the wound nurse stated that staff nurses should describe the wound and document in the daily skilled notes or weekly skin evaluations; and that, the description should include wound location, size and measurements, and a description of the wound bed and surrounding tissue. An interview with registered nurse (RN/staff #68) was conducted on September 20, 2023 at 11:15 a.m. The RN stated that she recalled admitting resident #1 to the facility; and that, the resident had no wounds to her leg with the exception of the surgical wounds on her knee and thigh. Further, the RN said the resident had a blister on her leg. The facility policy on Skin Evaluation/Braden Scale included that the facility will provide the necessary requirements to ensure that a patient receives the treatment and care in accordance with professional standards of practice. Review of the facility policy on Wound/Skin Management included that on admission, the wound care floor nursing must complete head to toe skin assessment and put findings in nursing comprehensive under skin integrity to include any open areas and location, reddened areas and location. The policy also included that the wound care floor nursing must complete 24-hour skin assessments and weekly skin assessments as ordered.

Based on clinical record review, review of hospital records, interviews, and policies, the facility failed to ensure one resident (#162) received appropriate catheter care and services. The sample size was one resident. The deficient practice could increase the risk for catheter-related injuries. Findings include: Resident #162 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, chronic obstructive pulmonary disease, and Benign Prostatic Hyperplasia (BPH). A urinary catheter care plan dated December 12, 2019 related to BPH with obstruction had a goal for no complications related to the catheter. An intervention included catheter care as ordered by the physician and as needed. A Nurse Practitioner (NP) progress note dated December 30, 2019 at 12:56 p.m. included that the resident's urinary catheter was patent and draining clear, light yellow urine. The note indicated that bladder training would be started that day to remove the catheter. A physician's order dated December 30, 2019 at 2:01 p.m. for bladder training for urinary catheter removal for 3 days was noted in the clinical record. Review of the December 30, 2019 through January 1, 2020 Treatment Administration Records (TAR) revealed bladder training had been completed as ordered. The clinical record did not include documentation related to the resident's urinary output during the bladder training. A physician's order to discontinue the urinary catheter was noted on January 3, 2020 at 12:43 a.m. An NP progress note dated January 3, 2020 at 9:56 a.m. included that the urinary catheter had been discontinued that day. The note indicated that the resident had not yet voided, but the catheter was just removed an hour prior to the visit, that the NP would follow up and nursing was monitoring as well. On January 4, 2020 at 5:17 a.m. a change of condition noted included that the urinary catheter had been reinserted on January 3, 2020 because the resident was only able to void a small amount of urine. At 5:00 a.m. on January 4, 2020, the catheter had drained 200 milliliters (ml) of urine with a moderate amount of hematuria, and a small amount of blood coming from the resident's penis was noted. The resident's vitals were within normal range. The resident denied pain. A message was left for the NP. On January 4, 2020, the NP's recommendation included to flush the urinary catheter with 100 ml sterile water or normal saline every shift for three days and as needed thereafter. Instructions included to monitor urine output every shift for three days, and keep the catheter in until the urology appointment. A nursing note, dated January 4, 2020 at 11:00 a.m., included that tea-colored urine was noted in the catheter bag, but no new output that shift. The note included that an attempt was made to flush the catheter per orders, but the nurse was unable to do this. The old catheter was removed, which was noted to have a blood clot in it. A new catheter was inserted which immediately returned another blood clot and nothing else. The resident's vitals were a bit elevated with blood pressure at 143/68 millimeters of mercury (mm/hg), temperature 99.5 degrees Farenheit (F), pulse 115 beats per minute (bpm) and respirations of 18 per minute. The note indicated that the NP was notified of the above and gave orders to attempt flushing again with several hundred mls. A nursing note dated January 4, 2020 at 12:00 p.m. revealed that there was an attempt to flush the new urinary catheter, which already seemed to have clotted as it was difficult to get saline in at first. The note included that the catheter was flushed with 350 ml of sterile saline, and returned about 30-35 ml of red drainage. The NP was notified and new orders were received to send the resident non-emergent to the emergency room (ER) for an abdominal ultrasound. This was set up for a pick up time of 1:30 p.m. The NP also gave an order to monitor the resident's vital signs every 30 minutes until pick up. On January 4, 2020 at 1:00 p.m. the resident's temp was 100.8 degrees F and the resident's pulse was 108 bpm. The note included that the resident had produced a large amount of emesis, light brown in color. The NP was notified and confirmed a 1:30 p.m. transport to the ER. Review of the TAR for January 4, 2022 revealed the resident's urine output for day shift was documented as 0 ml. Review of hospital records dated January 4, 2020 at 2:10 p.m. included the resident had a temperature of 100.8 degrees F and abdominal pain. Upon evaluation, it appeared the resident had a urinary catheter balloon inflated in the resident's urethra. The catheter was removed and replaced and there was release of urine from the bladder. A hospital progress note, dated January 5, 2020 at 9:25 a.m. included impressions of a Computerized Tomography (CT) scan of the resident's abdomen and pelvis. The findings revealed a urinary catheter balloon within the membranous urethra, a significantly extended urinary bladder, a Urinary Tract Infection (UTI), and sepsis. On November 8, 2022 at 1:27 p.m., an interview was conducted with a Registered Nurse (RN/staff #90). She stated that the process of inserting a urinary catheter included obtaining a provider's order, explaining the procedure to the resident, preparing the supplies in a sterile manner, cleaning the resident's peri area, dipping the end of the catheter tube into sterile lubricant, inserting the tube into the penis, and watching for a back flow of urine. She stated once she has urine back flow, she knows the end of the tube is in the bladder. She stated she will insert the tube approximately one inch further into the bladder, inflate the balloon, hang the bag, and monitor urine output. She stated that if she did not get urine back flow, she would remove the catheter and report this to the provider. An interview was conducted with the Director of Nursing (DON/staff #68) on November 9, 2022 at 9:43 a.m She stated that usually when a flash of urine occurs after urinary catheter insertion, the urine is draining correctly, and the resident does not complain of pain, it is ok. She stated that if the resident complains that it hurts, the catheter is probably not in the right spot. She stated that normal urine output is 30 ml per hour. She stated that urinary catheter insertion is reviewed during the annual skills training to ensure that nursing is aware of the process of insertion, and what to monitor for, including hematuria and 30 ml of urine per hour. She stated that her expectation is for nurses to have knowledge of how to insert a catheter, and the signs and symptoms of what to watch for so they know it is in the right place. The facility's urinary catheter policy, revised February 8, 2021, included that when possible, all urinary catheters should be removed prior to admission unless an appropriate diagnosis exists. Bladder training, if ordered by the physician, should begin prior to discontinuation of the catheter. Exceptions include: BPH, urethral obstruction with urinary retention, and as medically necessary for strict input/output monitoring. The policy included that if there is no urinary output in the next eight hours, then initiate either a bladder scan as ordered or begin straight cathing every 8 hours and as needed, documenting all input and output. The policy included to notify the DON with issues.

Based on clinical record review, interviews, and policy, the facility failed to ensure provision of Activities of Daily Living (ADL) care was provided to one resident (#112). The sample size was four residents. The deficient practice could result resident needs being unmet. Findings include: Resident #112 was admitted to the facility on [DATE] with diagnoses that included pressure ulcer, Alzheimer's disease, muscle weakness, and difficulty walking. Review of a nursing note dated September 8, 2021 included an admitting diagnosis of weakness and that the resident needed substantial/maximal assistance with toileting hygiene. The resident's ADL care plan dated September 7, 2021 revealed an actual/potential decline in ability to perform ADLs. Interventions included to provide assistance as needed with grooming, bathing, and personal hygiene and to assist with ADLs as needed. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 9 on the Brief Interview for Mental Status (BIMS) indicating the resident was moderately cognitively impaired. The resident received extensive assist with bed mobility. Review of the ADL documentation revealed no documentation that the resident received assistance with bed mobility on the night shift on September 11 and 12, 2021. The clinical record did not reveal any documentation to show that this care had been provided. Review of the clinical record revealed that the resident discharged from the facility on September 12, 2021. An interview was conducted on November 10, 2022 at 9:21 a.m. with a Certified Nursing Assistant (CNA/staff #6). She stated at the beginning of her shift she checks on all of her residents to see to their needs. She stated that she repositions the residents before breakfast. She stated she would chart the care she gives in the resident record and that all residents should have documentation of provision of ADL care to include repositioning for each shift. She stated if there was no documentation in the resident's record that the care was provided, there was no other way to show that the care was given. She stated if ADL care was not provided, the resident was at risk for bed sores and further decline and it could make the resident feel bad or fearful. An interview was conducted on November 10, 2022 at 9:38 a.m. with a Licensed Practical Nurse (LPN/staff #93). He stated that ADL care could be done by the nurse or the CNA and documented in the ADL documentation. He stated the documentation should show that the ADL care was provided each day/shift and as needed. He stated if the ADL care provision was not documented in the resident record there would be no way to show the care was given and the resident would be as risk for bed sores and could feel like they were not being taken care of. He stated repositioning should be done each shift and at least every two hours and that no area in the task documentation should be left blank. An interview was conducted on November 10, 2022 at 12:55 p.m. with the Director of Nursing (DON/staff #68). She stated she expected staff to provide ADL care to residents who need assistance. She stated the care provision should be documented in the task documentation. She stated bed mobility should be documented each shift. She stated if staff did not document in the resident record, there was no way to show the care was provided. She stated if the care was not provided the resident was at risk for skin breakdown and a decline in patient progression. She stated the task documentation should not be blank and that staff should code for level of assist, that the task did not occur, or the task was refused. Review of a facility policy for ADL and mobility care needs dated August 20, 2022 revealed that when providing care to the residents, promoting functional independence while maintaining patient safety is among the highest priorities for the facility. The residents often have frequent changes to their functional independence and care needs. The policy noted that it is in place in order to ensure direct care staff is aware of and able to immediately provide the care needs of the residents.

Based on facility documentation, interviews, and policy, the facility failed to ensure residents and/or their representatives/family were notified of a confirmed case of COVID-19 within the required timeframe. The facility census was 46 residents. The deficient practice could result in residents and/or their representatives being unaware of the COVID-19 status in the facility. Findings include: Review of facility documentation revealed that one resident had tested positive for COVID-19 on November 5, 2022. Her symptoms included fatigue and a cough. The resident was put on quarantine on the same date. An interview was conducted with the representative of resident #29 on November 7, 2022 at 12:13 p.m. She stated that she have not been notified that any residents in the facility have COVID-19. In an interview with a family member of resident #165 on November 7, 2022 at 2:45 p.m., she said that the resident had received a phone call that morning to notify him that there was an active COVID-19 case in the building. During an interview with the representative of resident #21 on November 8, 2022 at 10:51 a.m., she stated that she received notice on November 7, 2022 that there was one resident who had COVID-19 in the building. An interview was conducted on November 10, 2022 at 10:24 a.m. with the Director of Nursing (DON/staff #68). She stated that one resident had tested positive for COVID-19 on November 5, 2022. She stated that a subsequent Polymerase Chain Reaction (PCR) test was conducted, the resident was moved to a hallway where there were no other residents, and increased vitals and monitoring was implemented. She stated that the resident's family was notified. On November 10, 2022 at 10:56 a.m., an interview was conducted with the Executive Director (ED/staff #145). He stated there was a timeframe for reporting COVID-19 to the residents and/or representatives. He stated that his policy stated notification should occur within 24 hours. The facility policy titled Notification of Patients, Families, Staff of Positive COVID-19, dated March 23, 2020, included that it is facility policy to ensure patients, families, and staff are kept safe and informed of positive COVID-19 test results. The policy indicated the facility is committed to keeping everyone safe and informed, and that they are following local and federal guidelines, including notification of the diagnosis of COVID-19 case(s) within 24 hours of receiving the report and notification of a cluster of three or more patients or staff with new onset of respiratory symptoms that occur within 72 hours.

Based on clinical record review, interviews, and policies, the facility failed to ensure one resident (#113) was provided pressure ulcer care and assessment per physician's orders. The sample size was two residents. The deficient practice could result in delayed wound healing. Findings include: Resident #113 was admitted to the facility on [DATE] with diagnoses that included osteomyelitis of the left ankle and foot, status post-surgical amputation, gangrene, peripheral vascular disease, and type two diabetes mellitus. The resident's skin care plan, dated July 18, 2021, revealed a potential for skin breakdown due to decreased mobility. The interventions included conducting a Braden scale every week, skin evaluation as ordered, and dressing changes/treatments per physician's orders. Review of a wound care evaluation dated July 20, 2021 included the resident was admitted with an unstageable left heel pressure ulcer which measured 0.8 centimeters (cm) long by 0.9 cm wide. The wound bed was noted to contain eschar. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] included the resident scored 15 on the Brief Interview for Mental Status (BIMS) indicating intact cognition. The assessment included the resident had an unstageable pressure ulcer that was present on admission with pressure ulcer care and application of dressings to feet. Review of the July 2021 physician's orders revealed the following orders: -July 17 - barrier cream coccyx/buttock/peri area for prevention every shift and as needed. -July 17 - Braden scale each week -July 20 - paint the left heel pressure injury with betadine, apply foam dressing to bilateral heels for offloading three times per week and as needed. -July 27 - cleanse the left heel wound with Normal Saline (NS), pat dry, apply iodosorb, cover with dry dressing three times per week and as needed. -July 29 - weekly skin and foot evaluation -July 31 - wound care to be completed prior to the resident going to dialysis. Review of the July 2021 Treatment Administration Record (TAR) revealed the following: -No documentation that the pressure ulcer care to the left heel was completed on July 24 and 29. -No documentation that the barrier cream was applied to the coccyx/buttock/peri area on day shift for July 24 or 26. -No documentation that the skin prep was applied to the heels on day shift on July 24 or 26. -No documentation that the Braden scale was completed on July 26. -No documentation that the weekly skin and foot evaluation was completed on July 26. The clinical record revealed no documentation that these missing treatments/assessments were provided to the resident. A physician's order dated August 4, 2021 noted to cleanse the left heel wound with NS, pat dry, apply iodosorb, cover with dry dressing three times per week an as needed on the night shift on Sunday and the day shift on Tuesday and Thursday. Review of the August 2021 TAR revealed no documentation that the pressure ulcer care to the left heel was completed as scheduled on July 12. Also noted, the TAR only included that the wound care should be provided on Tuesdays and Thursdays, so wound care was not provided on August 8 or 15. The clinical record revealed no documentation that the these treatments were provided to the resident. The resident discharged from the facility on August 25, 2021. An interview was conducted on November 10, 2022 at 9:48 a.m. with a Licensed Practical Nurse (LPN/staff #93). He stated he was expected to follow the physician's orders as written. He stated that if he had a question about the orders he would talk to the provider. He stated he would sign the TAR when wound care was provided. He stated the TAR should not be blank for scheduled care. He stated if there was no documentation that the care was given, the facility would not be able to show that the care was provided. He stated if the care was not done as ordered there was a risk for the wound to get worse, larger, and/or infected. He stated the Braden and weekly skin and foot evaluation should be done and documented as completed on the TAR. He stated if the Braden was not completed, staff would be unable to determine the resident's pressure ulcer development risk. He stated the documentation should be completed on the TAR, even if the care was documented elsewhere in the record. He stated the care should be done and documented before or after dialysis if it was scheduled at the time the resident was at dialysis. An interview was conducted on November 10, 2022 at 1:04 p.m. with the Director of Nursing (DON/staff #68). She stated she expected staff to follow the physician's orders as written and to document the provision of care on the TAR. She stated if the TAR was blank for a scheduled treatment it would mean that the care was not provided. She stated there would be a risk for infection and decline in a wound if the treatments were not provided. She stated if the weekly skin assessment and/or the Braden assessment were not done there was a risk for skin breakdown and missed opportunities to identify skin concerns early on and provide preventative measures. She stated wound care/assessments that were scheduled on dialysis days should be done before or after dialysis. She stated the facility had identified a concern with documentation in the administration records and had created a plan of correction. Review of the facility's pressure ulcer policy, dated September 14, 2018, revealed that the facility will provide the necessary requirements to ensure a resident receives treatment and care in accordance with professional standards of practice. The policy included that the physician will authorize pertinent orders related to wound treatments. Review of a facility policy for skin evaluation, dated August 15, 2022, revealed that the facility will provide the necessary requirements to ensure that a resident receives the treatment and care in accordance with professional standards of practice. The policy included that the nurse will follow treatment orders as prescribed.

Based on clinical record review, interviews, and policy, the facility failed to ensure one resident (#113) was provided wound care and treatment per physician's orders. The sample size was two residents. The deficient practice could result in delayed wound healing. Findings include: Resident #113 was admitted to the facility on [DATE] with diagnoses that included osteomyelitis left ankle and foot, status post-surgical amputation, gangrene, peripheral vascular disease, and type two diabetes mellitus. Review of a nursing note dated July 18, 2021 included that the resident had a left great toe amputation. The resident's skin care plan, dated July 18, 2021, revealed the resident had a surgical wound related to a left toe amputation. The interventions included dressing changes per physician's orders and to monitor the incision daily and as needed. A wound care consultation dated July 20, 2021 included that the resident had a left great toe amputation with a surgical incision. The wound had wet eschar along the incision line. The consultation noted that sutures remained intact and there was moderate serous exudate. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] included the resident scored 15 on the Brief Interview for Mental Status (BIMS) indicating intact cognition. The assessment included the resident had a surgical wound with surgical wound care and application of dressings to feet. The July 2021 physician's orders revealed the following orders: -July 17 - to monitor the left toe every shift and report concerns to doctor/surgeon. -July 20 - cleanse the surgical wound to the left great toe with Normal Saline (NS), pat dry, apply silver alginate, cover with dry gauze and secure with kerlix, and tape three times per week (Tuesdays, Thursdays, and Saturdays) on day shift and as needed. This order changed on July 27 to apply iodosorb instead of silver alginate and to use an ACE wrap instead of tape. The rest of the order remained the same. -July 31 - wound care to be completed prior to the resident going to dialysis every Saturday. Review of the July 2021 Treatment Administration Record (TAR) revealed no documentation that the left toe was monitored on the day shift for July 24 and 26 and no documentation that the surgical wound care to the left great toe was completed on July 24 or 29. The clinical record revealed no documentation that wound care or wound monitoring were provided on these dates. The physician's order for the toe wound changed on August 4, 2021 and included to cleanse the surgical wound to the left great toe with NS, pat dry, apply iodosorb to wound bed, cover with calcium alginate, cover with dry gauze, secure with kerlix and ACE wrap three times per week (day shift on Tuesday and Thursday and night shift on Sunday). The August 2021 TAR revealed no documentation that wound care was provided to the left great toe on August 12. Also noted, the TAR only included that the wound care should be provided on Tuesdays and Thursdays, so wound care was not provided on August 8 or 15. The physician's order for the toe wound changed on August 18, 2022 to cleanse left great toe with NS, pat dry, apply medihoney to wound followed by calcium alginate, cover with dressing, secure with kerlix and ACE wrap two times per week (day shift Tuesdays and Fridays) and as needed. The August 2021 TAR revealed no documentation that wound care was provided on August 24. Also noted, the TAR only included that the wound care should be provided on Tuesdays, so wound care was not provided on August 20. The clinical record revealed no documentation that wound care or wound monitoring were provided on these dates. Review of the clinical record revealed that the resident discharged from the facility on August 25, 2021. An interview was conducted on November 10, 2022 at 9:48 a.m. with a Licensed Practical Nurse (LPN/staff #93). He stated he was expected to follow the physician's orders as written. He stated that if he had a question about the orders he would talk to the provider. He stated he would sign on the TAR when a treatment was given. He stated the TAR should not be blank for scheduled care. He stated if there was no documentation that the care was given, the facility would not be able to show that the care was provided. He stated if wound care was not done as ordered there was a risk for the wound to get worse, larger, and/or infected. He stated the care should be done and documented before or after dialysis if it was scheduled at the time the resident was at dialysis. An interview was conducted on November 10, 2022 at 1:04 p.m. with the Director of Nursing (DON/staff #68). She stated she expected staff to follow the physician's orders as written and to document the provision of care on the TAR. She stated if the TAR was blank for a scheduled treatment if would mean that the care was not provided. She stated there would be a risk for infection and decline in a wound if the treatments were not provided. She stated wound care/assessments that were scheduled on dialysis days should be done before or after dialysis. She stated the facility had identified a concern with documentation in the administration records and had created a plan of correction. Review of a facility policy for skin evaluation, dated August 15, 2022, revealed that the facility will provide the necessary requirements to ensure that a resident receives the treatment and care in accordance with professional standards of practice. The policy included that the nurse will follow treatment orders as prescribed.

Based on clinical records, family and staff interviews, and facility policies and procedures, the facility failed to perform Quality Control (QC) for one resident's (#1) blood glucose monitor. The deficient practice could result in inaccurate blood glucose results. Findings include: Resident #1 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan initiated on May 18, 2022 for fluctuating blood glucose levels included a goal that the resident would have no complications related to hypo/[CONDITION(S)]. The interventions for this care plan included monitor blood sugars per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] An Admission Minimum Data Set (MDS) assessment dated [DATE] included that resident #1 had a Brief Interview for Mental Status (BIMS) score of 12 indicating mild cognitive impairment. The assessment included that resident #1 required extensive 1 or more person assistance for bed mobility, transfers, toilet use, and personal hygiene. The assessment included that the resident required limited assistance with dressing and that the resident was able to move on and off the unit with supervision. The assessment included that the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the clinical record revealed the following provider orders: -Insulin [MEDICATION(S)] Solution 100 UNIT/ML Inject 20 unit subcutaneously at bedtime for DM -[MEDICATION(S)] Tablet Give 1000 mg by mouth two times a day for DM -[MEDICATION(S)] (0.25 or 0.5 MG/DOSE) Solution Peninjector 2 MG/1.5ML ([MEDICATION(S)](0.25 or 0.5 MG/DOS)) Inject 0.25 mg subcutaneously in the morning every Fri for DM Review of the clinical record revealed no order for glucose monitoring. A review of the clinical record revealed that resident #1 had blood sugar results documented 66 times from May 19 through June 12, 2022. Review of the Glucometer Check Logs was conducted on June 13, 2022 for the medication cart on 3 C, the medication cart for resident #1's room. During that review there was no documented Quality Control performed for the glucometer for resident #1. During an interview conducted on June 13, 2022 at 1:30 pm with a Licensed Practical Nurse (LPN/staff #7), staff #7 stated she had conducted the QC on the glucometer for resident #1 but did not fill out a log sheet for it. Staff #7 stated she was sure it was either on June 10 or June 11, 2022. Another Review of the Glucometer Check Logs was conducted on June 14, 2022 for the medication cart on 3 C. Review of the Glucometer Check Log for resident #1 revealed the a Licensed Practical Nurse (LPN/staff #7) completed a initial calibration of the glucometer on June 13, 2022. The log included that the glucometer passed the initial calibration. A review of the User Instruction Manual for the glucometer revealed that it is the manufacturer's recommendation that it is recommended to perform a Control Solution Test when you open a new bottle of test strips, to ensure the meter and test strips are working correctly as a system, and to check technique. A facility policy titled Glucometer Cleaning included that the facility uses the glucometer per the manufacturer's recommendations and that all glucometers are single patient use. The procedure for the policy included that prior to using the glucometer for the first time you must check Hi/Low controls. The policy included that it is not required to check the controls nightly and the only time it would be required to check the controls after the first time is if the machine is dropped.

Based on clinical record review, staff interviews, observations, and review of facility policies and procedures, the facility failed to ensure that one resident (#1) had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Resident #1 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission Minimum Data Set (MDS) assessment dated [DATE] included that resident #1 had a Brief Interview for Mental Status (BIMS) score of 12 indicating mild cognitive impairment. The assessment included that resident #1 required extensive 1 or more person assistance for bed mobility, transfers, toilet use, and personal hygiene. The assessment included that the resident required limited assistance with dressing and that the resident was able to move on and off the unit with supervision. The assessment included that the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the assessment dated [DATE] did not include any documentation of resident #1 using oxygen. A review of the clinical record revealed the following provider orders: -Incentive Spirometer: 10 breaths Q2 (every 2) hours while awake. Monitor QShift (every shift) > (more than) 15 minutes, document pre/post RR (respiration rate), LS (Lung Sounds) and record total minutes, every shift for Lung Expansion for 8 Days every shift for Post Incentive Spirometer - Record Total minutes of therapy for 8 Days -Incentive Spirometer: 10 breaths Q2 hours while awake. Monitor QShift >15minutes, document pre/post RR, LS and record total minutes, every shift for Lung Expansion for 8 Days every shift for Pre incentive spirometer for 8 Days -Shortness of breath while lying flat. Document Yes or No (Y/N) Lay the head of the bed flat with patient in it and document Y for any of the following sx: -Increased respiratory rate - Pursed lip breathing - Prolonged expiratory phase - Audible respirations - Gasping for air at rest - Interrupted speech pattern (only able to say a few words before taking a breath) - Use of shoulder and other accessory muscles to breathe every shift for 7 Days. Review of the clinical record did not reveal documentation of an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the clinical record revealed that resident #1 was on oxygen via nasal cannula on June 6 at 4:05 pm, June 7 at 8:57 pm, and June 9, 2022 at 1:59 pm. Review of the progress notes, Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation conducted on June 13, 2022 at 1:10 pm of resident #1's room, there was a nasal cannula attached to wall oxygen at 2 LPM. The nasal cannula was wrapped around the bed rail on the left side of the bed. During an interview conducted on June 13, 2022 at 1:10 pm with resident #1, he stated that he uses oxygen when he is short of breath. Resident #1 stated he can put it on himself when he needs it and it is usually next to him in bed. During an observation of medication administration conducted on June 14, 2022 at 8:05 am, resident #1 still had his oxygen tubing wrapped around the bed rail on the left side. During an interview conducted on June 14, 2022 at 8:15 am, resident #1 stated that he takes the oxygen off when he goes to the restroom. Resident #1 stated he has not worn his oxygen since the day before because it was tangled up and he could not get it free. During that interview conducted on June 14, 2022 at 8:15 am with a Licensed Practical Nurse (LPN/staff #15) performing the medication administration, staff #15 stated that she did not know what the order was for resident #1 to receive oxygen. Staff #15 stated it is possible it is a PRN (as needed) order for shortness of breath. During an observation conducted on June 14, 2022 at 8:15 am, staff #15 placed the oxygen on resident #1 at 2 LPM via nasal cannula. An interview was conducted on June 14, 2022 at 1:43 pm with the Director of Nursing (DON/staff #66). The DON stated that medications and oxygen should be provided as ordered by a provider. The DON stated that provider orders are needed for oxygen administration and monitoring. A facility policy titled Physicians Orders included that the facility will transcribe physicians orders for medications and treatments and will be consistent with principles of safe and effective order writing. Drug and biological orders will be recorded in a patient's medical record orders sheet.

Based on observations, staff interviews and review of policy and procedures, the facility failed to ensure staff followed infection control standards related to putting on and wearing PPE (personal protective equipment), and the facility failed to ensure infection control measures were initiated for one resident (#1) being testing for Clostridioides difficile (C-Diff). The deficient practice could result in transmission of infection. Findings include: Regarding staff PPE: An observation was conducted on June 13, 2022 at 1:30 pm of the third floor nursing station. During the observation, a Licensed Practical Nurse (LPN/staff #7) and Registered Nurse (RN/staff #1) were both wearing a face mask below the level of the nose, exposing part of their faces. During another observation conducted on June 14, 2022 at 8:00 am, a Certified Nursing Assistant (CNA) donned a gown and gloves to enter resident #1's room with a meal tray. The gown was not tied at the back leaving the CNA exposed in close proximity to the resident. The CNA also was not wearing shoe covers. An observation was conducted on June 14, 2022 at 8:50 am of the third floor nursing station. During the observation, an RN (staff #1) was again wearing his mask below the level of his nose exposing his face. An interview was conducted on June 14, 2022 at 11:41 am with the Infection Preventionist (staff #22). Staff #22 stated that all staff in the building should mostly be wearing N95 masks and those masks should cover the nose and mouth. Staff #22 stated that staff entering a C-Diff isolation room should wear a mask, gown, gloves, and shoe covers. Regarding infection control measures for C-Diff Resident #1 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a laboratory report for a stool sample was collected for C. difficile on May 27, 2022 at 8:06 pm revealed the sample was received on May 28, 2022 at 11:23 am. The result was positive and reported to the facility on [DATE] at 4:10 pm. A clinical record review revealed a provider order dated May 31, 2022 to place resident #1 on strict transmission based precautions related to C-Diff. During an interview conducted on June 13, 2022 at 1:10 pm with resident #1, the resident stated that he was not placed on isolation until May 31, 2022. Resident #1 stated that the staff member that obtained the stool sample on May 28, 2022 stated that because it did not smell like C-Diff she felt like it would not be positive. During an interview conducted on June 14, 2022 at 12:41 pm with a Certified Nursing Assistant (CNA/staff #33), staff #33 stated that as soon as a resident is thought to have C-Diff they are placed on isolation. An interview was conducted on June 14, 2022 at 1:02 pm with a Registered Nurse (RN/staff #49). Staff #49 stated that when a resident has loose stools a sample is collected and the resident is placed on isolation right away. Staff #49 stated that the order for the lab test on the stool sample is usually ordered STAT. An interview was conducted on June 14, 2022 at 1:43 pm with the Director of Nursing (DON/staff #66). The DON stated that when a sample is collected to rule out C-Diff, the resident is placed on isolation precautions. The DON stated that if the resident is having loose stools and it smells like C-Diff the resident resident would be suspected of having it. A facility policy titled Infection Prevention, Control & Immunizations included that the staff, employees, consultants, contractors, volunteers, and others who provide services and care to the patient's on the behalf of the patients. Staff will use standard precautions including appropriate PPE equipment. Appropriate PPE is to be worn for infection/illnesses and staff will implement appropriate transmission based precautions. A facility policy titled C Diff Policy included that the facility is dedicated to providing the best care possible to patients who entrust their care to us. All employees must do everything possible to keep infection down. Any patient will loose stool or diarrhea should have a stool sample sent to detect C. diff. antigen. If positive the patient should be placed in strict isolation immediately and treatment should be initiated.

Based on resident, family and staff interviews, clinical record review, facility documentation, and policy and procedures, the facility failed to implement their policy regarding reporting allegations of abuse for two of two sampled residents (#19 and #309); conducting a thorough investigation for an allegation of abuse for one of two sampled residents (#19); and providing training on abuse, neglect, exploitation and misappropriation of property for one staff (#170). The deficient practice can result in an allegation of abuse not being reported and investigated on; and staff not being educated regarding, neglect, exploitation and misappropriation of resident property. Findings include: -Resident #19 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Regarding reporting and thorough investigation The facility investigative report dated June 25, 2021 included that the date and time of the staff to resident abuse incident was documented as June 20, 2021 at 1:00 a.m. According to the report, resident #19 reported that the night shift nurse (staff #170) attempted to give all the resident medications together in one cup in one swallow. The resident told staff #170 that he could not take all the pills at one time. Staff #170 then put the pills in applesauce and attempted to give the pills to the resident. Staff #170 told the resident that she was not going to wait for him to take the medications one at a time. Staff #170 continued on with giving the resident all the medications. The resident attempted to stop staff #170 with his hand and tried to push her hand away. According to the report, staff #170 strongly grabbed the resident's hand and when the resident attempted to remove her grasp from his arm, staff #170 grabbed the resident's other arm, and crossed and restrained both arms. According to the report, staff #170 was an agency nurse and was removed from scheduled shifts. The investigative report included an interview was conducted with the resident on June 23, 2021. According to the documentation, the resident reported that he was lying asleep when a lady (staff) with a cup full of pills came into his room. He told the staff that he takes his pills individually but the staff told the resident that he was going to take them this way (all together) damn it. The resident reported that the staff told him to take your damn pills; and, grabbed the spoon with all the pills on it and tried to push it into his mouth. The documentation also included the staff told the resident here you're going to take this or else. The resident responded by saying or else what? The staff told the resident, or else shove down your throat. The investigative report revealed no evidence of any interviews conducted with the alleged perpetrator, staff (#170), witnesses and others who might have knowledge of the allegation. The investigative report included that the incident was reported to the police, APS (Adult Protective Services), Ombudsman and the State Agency (SA). However, per the documentation, the incident was not reported to the SA and APS until June 23, 2021 at 9:30 a.m. (3 days after the incident). Regarding training on abuse for staff #170 Review of the personnel file for staff #170, licensed practical nurse, revealed staff #170 received training in Prophecy Health: Predicting Employee Success on May 4, 2021. The documentation revealed the following breakdown of topics taken: age-specific patient care, chronic conditions, communication, emergencies, infection control, medications, nursing care and safety. However, further review of the personnel file revealed no evidence that staff #170 had received training on abuse, neglect, exploitation and misappropriation of resident property. An interview was conducted with a registered nurse (RN/staff #93) on July 22, 2021 at 10:41 a.m. The RN stated that when any incidents such as a resident touched inappropriately by a resident/staff or allegations of abuse is reported to her, she will report it to the DON (Director of Nursing) immediately. She stated that she will report any incident even if the information comes from a resident who is cognitively impaired. She said that after the incident is reported, the facility investigation will begin. The RN stated that staff will ensure that the resident is safe and have no contact with the alleged aggressor; and if the incident involved a staff member, the staff will be sent home. During an interview conducted on July 23, 2021 at 12:03 p.m. with the Executive Director (ED/staff #88), he stated that when he started at the facility he started implementing a self-report form that consisted of 4 components that included to whom the facility needed to report an incident to such as the police, APS, SA and Ombudsman. The ED stated he will report incidents such as injury of unknown origin, abuse, and missing resident. The ED further stated abuse is reported within 2 hours. However, he stated it is his standard to report any incident within 2 hours because it is easy for him to remember. The ED stated that when investigating allegations of injury of unknown origin, abuse, missing residents, he will interview individuals who may have witnessed the incident, alleged aggressor, and at least 5 residents within the vicinity where the incident occurred. He stated that he will then meet with the DON to finalize the facility's investigative summary. Regarding the facility investigation of the incident with resident #19 and staff #170 on June 20, 2021, the ED stated that he was unable to contact the alleged staff (#170) and that he was just able to speak with the agency/registry staff #170 worked for. He stated that staff #170 did not return his call. The ED stated that he will check to see if he has a record of all the interviews with other staff and other residents that was conducted. The ED was not able to provide evidence of interviews with other staff and other residents conducted during their investigation of the incident. Regarding training of staff #170, the ED stated that the agency/registry where staff #170 was contracted from did not get back with him with evidence of training on abuse, neglect, exploitation and misappropriation of resident property for staff #170. -Resident #309 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 07/19/21 at 09:30 AM, an interview was conducted with the resident. The resident stated that she had a concern. The resident stated that recently during the night she had awakened to use the bedside commode. The resident stated that after she had finished, she returned to bed and was sitting on the side of the bed. She stated it was 4:00 AM and it was dark in her room. The resident stated the night nurse came into her room and touched the skin under her breasts and told her it was a tissue check. The resident stated that it upset her. The resident stated that she did not think a tissue check should be conducted at 4:00 AM in the dark. The resident stated it was not right and that she did not think it was a tissue check or that it was an appropriate time for this exam. The resident stated that she reported the incident to her family and to the Executive Director (ED/staff #88). The resident stated her family told her to speak to someone at the facility. The resident stated that she spoke to the ED the same day and that the ED stated that he did not think it was wrong and that nothing was wrong. A review of the State Agency (SA) database on 07/19/2021 at 10:12 AM revealed the incident had not been reported to the SA. Review of the clinical record revealed a Case Management (CM) note dated 07/16/2021 at 7:25 PM signed by Social Services (SS/staff #72). The note included the resident's family left a message that resident #309 would like to speak to the staff as soon as possible or that the staff could text the family member. The note also included the family member stated they were told the staff would be working on Saturday, July 17, 2021 and that this was very important. The note stated the CM spoke to the resident and that the family member's voicemail was full. The note also stated that the resident was told CM would be in tomorrow to see the resident. A Case Management note dated 7/17/2021 at 1:24 PM signed by staff #72 stated CM met with the resident and had a long conversation and that the resident felt better after talking. The note included the CM had messaged the ED (staff #88) and that the ED spoke to the resident. On 7/19/2021 at 10:35 AM, an interview was conducted with the ED (staff #88) who stated that he had spoken to the resident about the incident on Saturday, 07/17/2021. The ED stated that he believed that a skin check had been done on the resident. Staff #88 stated there may have been a lack of communication about the procedure between the nurse and the resident as the nurse speaks English as a second language. The ED also stated resident #309 is not a fan of this nurse. Another interview was conducted with the ED on 07/23/21 at 12:03 PM. The ED stated that he initiated a form when he first started working at the facility that states who the facility needs to report abuse allegations to: Police Department, Adult Protective Services, Arizona Department of Health Services and the Ombudsman. He stated abuse must be reported within 2 hours. The ED stated that it is his standard to report any incident within 2 hours because it is easy for him to remember. The ED stated that he did not report the incident with resident #309 because he viewed it as a customer service issue. He stated that he knew the resident had a skin check performed. The ED stated the resident did report the nurse touched her skin under her breast but did not report the incident as abuse. He stated that he explained to the resident why the nurse had to do a skin assessment. The ED also stated the resident stated that she thought it was a weird policy on skin assessment and that the policy should be changed. The facility's policy on Abuse and Neglect Prohibition included that each resident has the right to be free from abuse, neglect, mistreatment, injuries of unknown origin, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Any observations or allegations of abuse, neglect or mistreatment must be immediately reported to the Administrator. The policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. The policy also defined willful as the individual must have acted deliberately not that the individual must have intended to inflict injury or harm. The facility procedure on abuse included screening, training, prevention, identification, protection, investigation and reporting and response. The facility will conduct a timely investigation of any alleged abuse/neglect, exploitation, mistreatment, injuries of unknown origin, or misappropriation of resident property in accordance with State law. An employee alleged to be involved in an instance(s) of abuse and/or neglect will be interviewed and suspended immediately, and will not be permitted to return to work unless and until such allegations of abuse/neglect are unsubstantiated. Further review of the policy revealed that the facility will report all allegations and substantiated occurrences of abuse, neglect, exploitation, mistreatment, including injuries of unknown origin and misappropriation of property to the administrator, State Survey Agency, law enforcement officials and Adult Protective Services (where the state law provides jurisdiction in long-term care facilities) in accordance with Federal and State law through established procedures. Timeline for reporting is as follows: -If the events that cause the allegation involve abuse or result in serious bodily injury, a report is made not later than 2 hours after the management staff becomes aware of the allegation; or, -If the events that cause the allegation do not involve abuse and do not result in serious bodily injury, a report is made not later than 24 hours after the management staff becomes aware of the allegation. The policy also included that the facility will train each employee on abuse and neglect during orientation, annually, and more often as determined by the facility.

Based on resident, resident representative, and staff interviews and facility documentation, the facility failed to ensure there was sufficient nursing staff to meet the needs of residents. This deficient practice resulted in residents' needs not being met. The census was 80. Findings include: During the initial phase of the survey, 11 out of 25 residents and one resident representative identified concerns of not having enough staff. Residents reported they waited up to 2 hours for call lights to be answered. Residents stated they did not receive assistance with getting to the bathroom timely which resulted in the residents urinating in their beds or recliners. A resident reported an ice pack melted and leaked water onto the resident bed and gown. This resident stated a CNA (Certified Nursing Assistant) stated to the resident that there was not enough staff to assist with changing the resident gown or sheets. The CNA provided two towels and instructed the resident to place one towel over the resident in place of a gown, and the other towel underneath the resident as a barrier between the resident and the wet sheet. Another resident stated the resident central line dressing was not changed for 11 days and that a nurse and CNA had told the resident there was not enough staff to change the dressing. A resident representative stated a request was made for the resident be provided with a shower on July 16, 2021, July 17, 2021, and July 18, 2021. The representative stated staff said to the representative that the showers would be provided; however, the resident did not receive a shower on any of these days. The representative stated a staff member stated to the resident representative that the facility was not able to provide the resident with a shower due to the lack of staff. The residents interviewed stated that there were fewer staff working in the facility on the weekends and at night. Review of the Facility Assessment updated May 11, 2021, stated the average daily census ranges from 65-75 residents. The assessment stated the approximate number of admissions and discharges on a monthly basis is 22-28 on weekdays, and on the weekends 3-6 resident admissions and 4-5 resident discharges. The Facility Assessment revealed the facility's general approach to ensure sufficient staffing to meet the needs of residents included scheduling 5-8 certified nursing assistant staff members per shift. The Facility Assessment also included the total average hours needed for licensed nurses to provide direct care is 140 hours a day, and the total average hours needed for nurse aides to provide care is 120 hours per day. Review of the nursing staff information postings and staff schedules revealed the following: On June 20, 2021, the facility census was 49 and the actual hours worked was 108 hours for licensed nurses and 112 hours for nurse aides. The staffing schedule for this date included a CNA walked off the job. On July 4, 2021, the facility census was 55, with 21 residents on the second floor, and 34 residents on the third floor. The nurse staff posting information and schedule for that day indicated the actual hours worked was 108 hours for licensed nurses and 120 hours for nurse aides. Review of the payroll records revealed only 84 hours worked by nurses and 72 hours worked by nurse aides on July 4, 2021. On July 16, 2021, the facility census was 82, with 34 residents on the second floor and 48 residents on the third floor. The nurse staff posting information and schedule for that day indicated the actual hours worked was 132 hours for licensed nurse and 120 hours for nurse aides. Review of the payroll records revealed only 104 hours worked by nurses and 92 hours worked by nurse aides on July 16, 2021. The payroll records also included only 2 nurse aides worked on the evening shift, indicating there was only 1 aide per floor. On July 17, 2021, the facility census was 82, with 34 residents on the second floor and 48 residents on the third floor. The nurse staff posting information and schedule for that day indicated the actual hours worked was 96 hours for licensed nurses and 82.5 hours for nurse aides. Review of the payroll records revealed only 48 hours worked by nurses and 72 hours worked by nurse aides for July 17, 2021. The payroll records also included only 1 nurse aid worked the evening shift, and 2 nurse aides worked the night shift. These records included only 1 nurse was working in the facility on the night shift for this date. On July 18, 2021, the facility census was 81, with 34 residents on the second floor and 47 residents on the third floor. The nurse staff posting information and schedule for that day indicated the actual hours worked was 58.5 hours for licensed nurses and 88.5 hours for nurse aides. Review of the payroll records revealed 72 hours worked by nurses and 80 hours worked by nurse aides for July 18, 2021. The payroll records also included only two nurse aides working on the evening shift. An interview was conducted on July 21, 2021 with a CNA who was working on the third floor. At the time of the interview, there were 3 nurses and 5 CNAs working on the third floor. The CNA interviewed stated this was not the normal staffing level for this floor on this shift. The CNA stated there are three halls on this floor and sometimes there is a CNA working each hall; however, there have been multiple times when this CNA is the only CNA working the entire floor. The CNA stated that, at times, it is only the CNA and one nurse working on the floor. The CNA stated the CNA has been responsible for providing care for over 30 residents during these shifts. The CNA stated sometimes care is not provided to residents due to the lack of staff. The CNA stated residents are not able to be turned and repositioned every two hours and residents are not able to be assisted in the bathroom. This CNA stated it was possible for accidents to occur with residents due to the lack of staff. The CNA stated a concern is that a resident might fall and injure themselves and there would not be enough staff to respond. An interview was conducted on July 23, 2021 at 10:37 am with the Executive Director (ED/staff #88) and the staffing coordinator (staff #22). The staffing coordinator stated she has worked in her current position since May 2021. Both agreed that the facility is staffed based on the census. They stated the goal is to have 6 nurses and 8 CNAs working on each shift. The ED stated staffing has been a challenge recently and the facility has struggled to maintain the staffing level. He stated weekend shifts are difficult to staff. He stated he was not aware of any care that was not provided to the residents. During this interview, the nurse staff posting information from the previous weekend was reviewed with the ED and staffing coordinator. The staffing coordinator stated the staff schedules listed the staff who were scheduled to work and if the name is crossed off, it means that person did not work that shift. She stated that notes of NCNS written next to the staff member's name indicated that person was a no call no show for the shift. While reviewing this information, the ED and staffing coordinator stated the facility struggled with staffing due to the COVID-19 pandemic and staff leaving the industry. The ED stated the management team has tried multiple interventions to address the staffing issue, but the facility's staffing levels remain the same. A policy request was made on July 22, 2021 at 8:50 am for any policies addressing staffing, staff postings, and sufficient staffing at the facility. At 1:57 pm on July 22, 2021, a corporate nurse informed the survey team that the facility did not have any polices related to that request.

Based on observation, resident and staff interviews, clinical record review, and facility policies review, the facility failed to ensure one sampled resident's (#58) [CONDITION(S)] to the right lower extremity with pain was acted upon timely. The deficient practice could result in negative resident outcomes. Findings include: Resident #58 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nurse admission note dated July 4, 2021 at 6:00 pm revealed the resident was admitted via stretcher for [CONDITION(S)] and was alert and oriented x 4 (person, place, time, and situation). The note included the there were therapy orders for physical therapy (PT) and occupational therapy (OT). A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a skin/wound note dated July 8, 2021 at 12:38 pm stated the resident's skin was clean, dry, and intact with no open areas. The note also stated that the resident had healed surgical incisions to the right hip. The note did not include any documentation regarding [CONDITION(S)]. Review of the daily skilled note dated July 9, 2021 included the resident's skin was dry and slightly flaky, otherwise intact. The admission Minimum Data Set (MDS) assessment dated [DATE] included the resident scored 15 on the Brief Interview for Mental Status, indicating the resident was cognitively intact. A daily nurse's note dated July 10, 2021 at 4:20 pm included the resident complained of increased pain to the right hip and thigh and the nurse observed the area to be swollen, but there was no difference in color or temperature from the resident's other leg. This note included the writer of the note notified the physician. The daily nurse's note dated July 10, 2021 at 5:51 pm stated the provider was notified of the resident's vital signs which included a temperature of 100.2 degrees Fahrenheit (F) and that the provider ordered Tylenol Extra Strength (ES) tablet 500 mg every 6 hours as needed for fever greater than 100.0 degrees F. The note did not include any information regarding the resident's [CONDITION(S)] to the right lower extremity. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The PT summary of daily skilled services for July 12, 2021 included the resident is unable to gait train due to right knee pain. It also includes the resident rated the pain at 8 out of 10 and that the resident was premedicated for pain. A case management note dated July 13, 2021 at 2:04 pm stated the resident was notified that the discharge date is July 21, 2021 due to benefits exhaust. The note also stated the resident did not understand and that she needed more time. The note included it was explained to the resident and that the resident stated that she would be going to a family member's home and not into Long Term Placement. The PT summary of daily skilled services for July 15, 2021 included the resident declined gait training and out of bed transfers stating right lower extremity swelling and discomfort. Review of the MAR for July 2021 revealed the resident was medicated with [MEDICATION(S)]-Acetaminophen at 9:21 am and at 8:25 pm on July 15 for a pain level of 7 and that the medication was effective. The OT summary of daily skilled services for July 16, 2021 included a complexity/ barrier that impacted the session was swelling of unknown origin to the right lower extremity. It also included nursing was made aware and the resident requested to see a physician. A skin evaluation dated July 16, 2021 was reviewed on July 20, 2021 and did not include the resident's right lower extremity [CONDITION(S)]. However, when this skin evaluation was reviewed again on July 21, 2021, it included the resident had right lower extremity [CONDITION(S)] that had been reported to the MD (medical doctor). Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The PT summary of daily skilled services for July 18, 2021 included the resident declined to sit out of bed or transfer and that the resident informed the physical therapist that something was wrong with her right leg. The note included that nursing staff was aware. The OT summary of daily skilled services for July 19, 2021 included the resident continued to complain of swelling to the right lower extremity and that nursing was made aware. The PT summary of daily skilled services for July 19, 2021 included the resident declined gait training and the resident stated she had increased soreness in her right thigh. Review of the MAR for July 2021 included the resident was medicated with [MEDICATION(S)]-Acetaminophen on July 19 at 1:15 am and 8:31 am for a pain level of 7, at 3:06 pm for a pain level of 6, and at 11:25 pm for a pain level of 8 and that each time the medication was effective. A physician's progress note dated July 19, 2021 stated the physician was back after vacation and a covering physician had seen the resident in the past week. The note also stated the resident was complaining of right-sided thigh pain that had been present for approximately a week. The note included the physician was ordering imaging of the right thigh. Review of the resident's clinical record revealed no physician's notes from the covering physician referenced in the July 19, 2021 physician's note. Review of a daily nursing note dated July 19, 2021 at 5:14 pm stated the pt (resident) to follow up with CT scan related to right thigh swelling from past surgery per resident. MD rec to have CT scan outpatient, pt is scheduled to DC on Wed. The note also stated the scheduler was notified to assist in scheduling the appointment. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record did not reveal any further documentation regarding the resident's lower right extremity [CONDITION(S)]. The discharge MDS assessment dated [DATE] revealed the resident was discharged on [DATE] to the community (private home). An observation of the resident was conducted on July 19, 2021 at 12:50 pm. The resident was in bed with her legs elevated. The resident's right knee and thigh were observed to be swollen and appeared larger than the resident's left knee and thigh. Resident #58 stated her right knee and thigh caused her pain and she was not able to participate in therapy. The resident stated she informed the staff at the facility, and she believed a physician told her it must have been twisted. The resident stated she has not received an exam or imaging of her right knee and thigh since she informed the facility staff of the issue. Resident #58 stated she will be discharging soon, and she expects she will have to go straight to the emergency room to have her right knee examined. An interview was conducted on July 22, 2021 at 10:35 am with a Registered Nurse (RN/staff #135) who stated she was familiar with resident #58's condition and care. Staff #135 stated she completes a full assessment on each resident daily and documents this assessment in the daily nursing note. Staff #135 stated she is checking on the residents regularly and looking for any change in condition, the placement of catheters and other tubing, and ensuring the resident's care is consistent with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she would notice if a resident had any swelling that was new or worsening, and that she would inform the physician if she had noticed that in any of her residents. Staff #135 stated she would document the contact in a nursing note and would also document any follow up from the physician, also in a nursing note. During this interview, staff #135 stated she was aware of the swelling in resident #58's right knee and thigh. Staff #135 stated the resident had a surgical procedure done earlier in the year to her right knee and staff #135 believed this accounted for some of the pain and discomfort that the resident had been experiencing. Staff #135 stated she did not know for sure what the origin of the swelling in resident #58's leg was. Staff #135 said she believed the physician had examined the resident's leg and had ordered a scan, but it was not scheduled by the facility since the resident was discharged . Staff #135 stated she was not able to tell from the resident's medical record if a physician had examined the resident's leg prior to July 19, 2021. An interview was conducted with a Physical Therapist (PT/ staff #105) on July 22, 2021 at 11:20 am. Staff #105 stated he had provided physical therapy to resident #58, and was familiar with her condition. He stated he had never experienced the resident being unable to participate in therapy while he was scheduled. Staff #105 stated he was aware that the resident had been unable to participate in therapy with other therapists and that the resident had concerns about her right leg. He stated the nursing staff was aware of the issue, but he did not know if the nursing staff had contacted the physician or of a physician had seen the resident to address the issue. An interview was conducted on July 22, 2021 at 11:27 am with the Director of Nursing (DON/staff # 57). The DON stated her expectation is that nurses assess the resident and document the assessment daily in the daily skilled nursing note. She stated any pertinent information about the resident's care and condition are included in that note and that it should be accurate to the resident's condition at that time. The DON stated if the resident is complaining of pain or has any skin issues or new [CONDITION(S)], the nurse can include it in the daily skilled note or a separate change in condition note. The DON said she would expect all of the nurse's information and any follow up that was needed to be included in either note. The DON stated the physician's will document their notes in a physician's progress note. She stated there is one physician who documents on paper and those notes are scanned into the resident's record. She stated she did not believe there were any notes to be scanned in at that time. Resident #58's record was reviewed at this time with the DON. The DON stated there should have been additional notes to follow up on the July 10, 2021 nursing note that resident #58 had pain and swelling. The DON said she would expect to see a note with the physician's response, as well as any orders that the physician might have given. The DON was not able to locate any additional notes regarding the resident's right leg until the July 19, 2021 physician's note. The DON stated there was a physician in the facility covering for the physician who was on vacation, but she was not able to locate any notes to indicate that physician had seen resident #58. The DON acknowledged that the resident was not able to participate in therapy due to the pain and swelling in her right leg, and stated she was not able to find any follow up documentation regarding the resident request to therapy to see a physician on July 16, 2021. The resident's skin evaluation from July 16, 2021 was reviewed with the DON at this time. The DON agreed there was a discrepancy between the documentation provided to the surveyor and the documentation that was in the resident's record. The DON stated the document in the resident's record had not been locked until July 21, 2021 and could have been edited at any time before it was locked. She stated she expects documentation to be completed and locked at the time of the evaluation, and that it was not the facility's practice to edit skin evaluations 5 days after the evaluation was completed. The facility's policy titled [MEDICATION(S)] Policy and Procedures was issued on February 1, 2018 and updated on February 8, 2021. The policy included it is the responsibility of the individual staff member who heard the complaint to follow up and make sure some intervention is initiated. A policy request was made on July 22, 2021 at 8:50 am for policies related to skin assessments. The facility provided an untitled document outlining wound care and skin assessment procedures. This document included 24-hour skin assessments and weekly skin assessments are to be completed as ordered. It also included any reddened areas or anything suspicious should be documented. A policy request was made on July 22, 2021 at 8:50 am for any policies addressing physician notification. At 1:57 pm on July 22, 2021, a corporate nurse informed the survey team that the facility did not have any polices related to that request.

Based on observations, clinical record reviews, staff interviews, and review of policy and procedures, the facility failed to provide the necessary care and services for one resident (#76) with pressure sores. The facility also failed to ensure that one resident (#378) received the necessary care and services for existing pressure sores and to prevent additional pressure sores from developing. Findings include: -Resident #76 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Regarding the right and left heel pressure ulcers and the left 5th metatarsal pressure ulcer: admission orders [REDACTED]. A care plan dated October 26, 2016 identified that the resident was at risk for skin breakdown, related to decreased mobility and pressure ulcers. The care plan identified that the resident had a sacrum pressure ulcer, and pressure ulcers to the right and left heel and a DTI (deep tissue injury) to the left 5th metatarsal. The goals included that the resident would not have any avoidable pressure ulcers and that pressure ulcers will show signs of healing. Interventions included for a foot assessment weekly, skin prep to bilateral heels, a pressure reducing mattress, frequent repositioning and to report any changes to the physician. Despite documentation on the care plan of pressure ulcers to the right and left heels and to the left 5th metatarsal, there were no treatment orders obtained upon admission. A Wound Consult note dated November 1, 2016 included the resident had a coccyx pressure ulcer, however, there was no mention of any wounds to the right and left heels or to the left 5th metatarsal. Under plan, the documentation included the following: prafo boots on for 2 hours, then remove for 2-4 hours, turn every 2 hours, and for an alternating pressure mattress. Further review of the clinical record revealed there was no physician's order for the prafo boots, nor documentation that they were being applied or removed, per the above wound consult note. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Review of the functional status section revealed the resident required extensive assistance of one or two staff for activities of daily living. The MDS also included the resident had two unstageable pressure ulcers, which were present upon admission. A Wound Consult note dated November 10, 2016 included documentation regarding the coccyx pressure ulcer, however, there was no documentation of any wounds to the right and left heels or to the left 5th metatarsal. Under plan, it was documented to continue off loading the heels and to explain the importance of off loading the heels to a family member. A Wound Consult note dated November 15, 2016 indicated the resident had no new issues. There was no documentation regarding any wounds to the right and left heels or to the left 5th metatarsal. Under plan, the documentation included to continue off loading. Review of the physician's orders and the Treatment Administration Records (TAR) for October and November 2016, revealed there were no orders for skin prep to the heels as care planned, and no orders to float the resident's heels, as recommended in the wound consult notes. There was also no documentation that skin prep had been applied to the resident's heels or that the heels had been floated from admission through November 16. Review of the Wound Care Evaluation dated November 17, 2016 revealed the resident now had pressure ulcers to the right and left heels. The right heel wound measured 0.8 cm x 0.8 cm and the depth was UTD (unable to be determined), and the left heel wound measured 1.0 cm x 1.0 cm and the depth was UTD. Both wounds were described as dark purple, with an intact blister and that the wounds were SDTI (suspected deep tissue injury) related to the use of a mechanical device. The note also included that the resident uses prafo boots while in bed to assist with proper foot alignment. The note did not address if the mechanical device causing the pressure ulcers was discontinued. A physician's order dated November 17, 2016 included to paint the purple blisters on the resident's bilateral heels with [MEDICATION NAME] each shift, allow to dry and place [MEDICATION NAME] to bilateral lower extremities and to float heels on pillows. Review of the TAR for November 2016 revealed the above orders, however, there was no documentation that the above treatment orders were completed on the night shift on November 18 and 19, and on the day shift on November 23 and 28. Continued review of the clinical record revealed there was no documentation of thorough assessments completed of the resident's heels from November 18 through December 27, which included a description of the wound bed and surrounding skin, measurements of the wounds or if any drainage was present. A Wound Care Evaluation dated December 28, 2016 at 1:10 p.m., revealed the following: wound #3 - unstageable pressure ulcer to the right achilles which measured 0.8 cm x 0.5 cm, with greater than 90% slough; wound #4 - unstageable pressure ulcer to the left achilles which measured 1.2 cm x 1.2 cm, with greater than 90% slough. Per the note, both wounds were a medical devise associated pressure injury. The documentation did not address if the medical devise was the prafo boots or some other device. Further review of this assessment revealed the resident had a new wound to the left 5th metatarsal, which measured 1.6 cm x 1.2 cm and was a SDTI. There was no description of the wound bed. The assessment included it was a devise associated pressure injury, however, the specific device was not mentioned. Preventative measures included a pressure reduction mattress, multi-purpose off loading boot, repositioning throughout shifts, off load heels, skin prep to heels, and for preventative skin care. Review of the pressure ulcer care plan updated on December 28, 2016 revealed the resident had a SDTI to the right and left heels and to the 5th metatarsal. The goal included that the resident will have no avoidable pressure ulcers. However, there were no new interventions implemented. Physician orders dated December 28, 2016 included to cleanse and dry the achilles wounds, apply [MEDICATION NAME] and cover with a foam dressing daily, and to apply [MEDICATION NAME] to the 5th metatarsal daily and leave open to air. A physician's order dated December 29, 2016 now included to keep the pressure causing boots off the resident. A wound care observation was conducted on December 29, 2016 at 12:30 p.m., with the wound nurse (staff #112). At this time, staff #112 stated the resident had been wearing boots to prevent foot drop and the boots caused the pressure ulcers to the achilles area and the metatarsal area. During the observation, the resident was observed to have the following pressure ulcers: right achilles which measured 1.5 cm x 1.6 cm, with eschar present and left achilles which measured 1.8 cm x 2.0, with eschar present; left 5th metatarsal which measured 2.5 cm x 1.8 cm and the wound bed was a grayish, brown eschar. Regarding the coccyx pressure ulcers: Review of the initial Wound Care Evaluation dated October 26, 2016 revealed the resident had two pressure ulcers to the coccyx area, one which measured 1.0 cm x 1.1 cm and the depth was UTD, and another coccyx wound which measured 3.5 cm x 3.3 cm and the depth was UTD. Both wounds were described as having slough, with a large amount of purulent drainage, and the surrounding skin was pink and friable. Pressure reduction devices included for an air mattress, wheelchair cushion and repositioning throughout the shift. A care plan dated October 26, 2016 identified that the resident was at risk for skin breakdown, related to decreased mobility and pressure ulcers on admission. The care plan identified that the resident had a sacrum pressure ulcer. Goals included that the resident would not have any avoidable pressure ulcers and that pressure ulcers will show signs of healing. Physician's orders dated October 26, 2016 included to cleanse the coccyx wounds with cleanser, pat dry and apply honey foam dressing daily. Review of the TARs for October and November 2016 revealed the wound care was not completed on October 31 or November 1. Review of the admission MDS assessment dated [DATE] revealed the resident had two unstageable pressure ulcers at the time of admission. A Wound Consult note dated November 1, 2016 indicated the resident had an irregular shaped ulcer to the sacrum/coccyx area with slough. Only one wound was documented and it was described as unstageable. A physician's order dated November 2, 2016 included to cleanse the coccyx wound with normal saline (NS), apply Santyl ointment topically every day shift, and cover with adaptik and [MEDICATION NAME] dressing. Review of the Wound Care Evaluation dated November 7, 2016 revealed an unstageable coccyx wound which measured 1.7 cm x 1.5 cm and depth was UTD and another unstageable coccyx wound which measured 3.2 cm x 4.2 cm and depth was UTD. Both pressure ulcers were described as having slough and a moderate amount of purulent drainage, and the surrounding skin was pink and friable. Review of the November 2016 TAR revealed wound care was not provided on November 8. Review of the Wound Consult note dated November 10, 2016, revealed the coccyx pressure ulcer had necrotic yellow slough present to 80% of the wound bed. The wound was debrided and a Santyl dressing was applied. Only one coccyx wound was documented. A Wound Consult note dated November 15, 2016 indicated the resident had no new issues. Per the note, the sacral wound was larger, but had less yellow slough with mild granulation and mild serous drainage. Documentation included the wound extended into the subcutaneous tissue and was described as a stage 3. Review of the Wound Care Evaluation dated November 17, 2016 revealed one coccyx wound measured 1.0 cm x 1.0 cm and was unstageable, with 75% yellow adherent slough and 25% red granulation tissue and the other coccyx wound measured 3.5 cm x 5.0 cm and was unstageable Further review of the clinical record revealed there was no documentation of thorough assessments which were completed of the coccyx wounds from November 18 through December 27, which included a description of the wound bed and surrounding tissue, measurements of the wounds or if any drainage was present. A Wound Care Evaluation dated December 28, 2016 documented the resident declined to have the coccyx wounds assessed, because the ulcers had been cleaned earlier by the floor nurse. An interview with the wound nurse (staff #112) was conducted on December 28, 2016 at 2:37 p.m. Staff #112 stated that she had started at the facility recently and completed her first wound rounds on November 29. She stated her responsibilities include seeing residents with wounds and making sure wounds are measured, staged, and that physicians are contacted. She said she is to ensure that interventions are in place to prevent wounds from developing or worsening. She further stated that she will see a resident with a pressure ulcer every 2-3 days to review the wound, obtain measurements and will provide a detailed description of the wound on the wound care evaluations. Staff #112 stated she saw resident #76 on November 29, but had difficulty entering the wound documentation in the computer system for the coccyx and heel wounds. She stated the Information Technology department fixed the problem within the hour, but she did not go back and re-enter the wound notes for that day. She stated there are no additional wound notes on this resident. She stated that she has seen the resident more, but only wrote measurements on pieces of paper and never entered them in the chart. In an interview with the Director of Nursing (DON/staff #62) on December 28, 2016 at 2:55 p.m., the DON stated that pressure ulcers should be assessed at least once a week and should include measurements, a detailed description of the wound, and that the physician should be notified of any changes. The DON further stated that this information should be entered into the chart by the wound nurse. She stated they had a problem with wound documentation and that is why a new wound nurse was hired. A wound care observation was conducted with the wound nurse (staff #112) on December 29, 2016 at 12:30 p.m. During the observation, the following pressure ulcer was identified: coccyx area which measured 3.0 cm x 2.0 cm x 1.6 cm, with approximately 90% slough with a small amount of pink granulation tissue present, no drainage or odor was noted. At this time, staff #112 stated that the two coccyx wounds had merged. -Resident #378 was admitted on [DATE], with [DIAGNOSES REDACTED]. A physician's order dated December 7, 2016 included for wound treatment for [REDACTED]. A Nursing Comprehensive Admission Data Collection dated December 8, 2016 documented the resident had two pressure ulcers; a left trochanter ulcer which was open and measured 1 cm (centimeter) x 1 cm; and a sacrum ulcer in the coccyx area which was open and was approximately dime sized. The wound documentation did not include any further description of the pressure ulcers, such as a description of the wound beds, the condition of the surrounding tissue, if any drainage was present or the stage of the pressure ulcers. Despite documentation that the resident had two pressure ulcers on admission, there were no physician orders for wound treatment to the left trochanter pressure ulcer, and there was no care plan which had been developed upon admission related to pressure ulcers. A physician's order dated December 10, 2016 included for weekly skin and foot evaluations to be done. Review of the admission MDS assessment dated [DATE], revealed the resident had short and long term memory problems and had poor decision making skills. The assessment also included the resident was at risk for pressure ulcer development and had two DTI's, which were present upon admission. The care area regarding pressure ulcers triggered for care planning. A care plan for pressure ulcers was developed on December 14, 2016. The care plan included that prolonged pressure related to impaired mobility, caused the skin breakdown. The goal included the resident will have no complications related to pressure ulcers. Interventions were as follows: apply pressure reduction cushion to chair or wheelchair as needed, apply pressure reduction mattress to bed as needed, frequent repositioning in bed and chair as needed, treatments as ordered and for the wound nurse to eval and treat. However, review of the clinical record revealed no documentation that thorough wound assessments of the left trochanter or sacrum/coccyx pressure ulcers had been completed which included measurements, description of the wound bed and surrounding skin, and if any drainage was present, from the time of admission through December 18, 2016. The pressure ulcers were assessed on December 19, 2016. Per the Wound Care Evaluation, the resident now had four pressure ulcers as follows: -left heel: DTI (deep tissue injury), the documentation did not include a description of the wound bed or periwound area, nor were there any measurements. -sacral: the wound was described as a stage III and measured 0.5 cm x 0.5 cm x 0.1 cm. The assessment did not include a description of the wound or periwound area, or if any drainage was present. -sacrum: the wound was described as a stage III and measured 1.0 cm x 0.5 cm x 0.1 cm. This assessment did not include a description of the wound bed or periwound area, or if any drainage was present. -left ischium: the wound was noted as a stage III and measured 1.0 cm x 0.6 cm x 0.8 cm. This assessment did not include a description of the wound bed or periwound area, or if any drainage was present. On December 22, 2016, which was three days after the Wound Care Evaluation, orders to treat the following pressure ulcers were obtained: -left heel DTI: cleanse with wound cleaner and pat dry, paint with [MEDICATION NAME], cover with gauze and wrap with Kerlix, change daily on day shift. -left ischium: cleanse and pat dry, apply Triad to wounds, cover with dry adhesive dressing, change daily on day shift. -sacral pressure ulcer: cleanse and pat dry, place Triad and cover with foam dressing, change daily on day shift. During the survey, a wound care observation was conducted on December 30, 2016 at 10:00 a.m., with the wound nurse (Licensed Practical Nurse/staff #112). The following wounds were observed: -left heel pressure ulcer-DTI: measured approximately 7 cm x 5 cm, which was an increase in size and the area was a brownish discoloration. -sacral pressure ulcer: measured 3.0 cm x 2.0 cm with no depth, which was an increase in size and the wound bed was beefy red with no exudate. -sacrum pressure ulcer: measured 1.8 cm x 2.0 cm x with no depth, which was an increase in size and the wound bed was beefy red with no exudate. -left ischium pressure ulcer: healed In addition, during the wound care observation, it was observed that the dressing on the resident's left heel was dated December 28. However, the December 2016 TAR indicated that the dressing had been changed on December 29. An interview was conducted with the wound nurse (staff #112) on December 30, 2016 at 10:20 a.m. She stated that she has only worked at the facility for two weeks. She said that it has been a constant problem of dressings not being changed by the floor nurses. An interview was conducted with the DON (staff #62) on December 30, 2016 at 11:51 a.m. She stated that it was her expectation that full assessments are completed upon admission and documented. She also stated that it is her expectation that the doctor's orders are followed for daily wound dressing changes. Review of the facility policy regarding Pressure Ulcer Prevention revealed to ensure that all patients admitted receive a complete head-to-toe assessment, at which time a thorough examination of the skin shall be done. The policy further included that staff shall remain alert to potential changes in patient's skin condition and shall evaluate and document identified changes on a daily basis (i.e. at the time of the patient's bath). The policy also included With each dressing change, or at least weekly, the pressure ulcer wound shall be assessed and documented as follows: - Date - Location of ulcer and staging - Size - Depth of the pressure ulcer wound - Presence, location, and extent of any undermining or tunneling/sinus tract - Presence of exudates which includes: type, color, odor, amount, wound bed color (color and type of tissue/characteristics) including evidence of necrosis - Description of wound edges and surrounding tissue such as: rolled edges, redness, hardness/induration, and a description of the healing of the pressure ulcer