Every finding on record at Cherry Hill Manor

Based on record review and staff interview, the facility failed to ensure that a resident received timely and appropriate pain and symptom management in accordance with professional standards of practice for end-of-life care, including the prompt administration of physician-ordered medications for pain and anxiety, for 1 of 1 resident reviewed who was receiving hospice services, Resident ID #1.Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on [DATE] alleged that Resident ID #1 was experiencing terminal agitation and was not provided prescribed medications promptly to provide comfort, relief, and dignity at the end of his/her life and appeared to be in pain. The complaint further alleged that Morphine (a medication prescribed to treat severe pain) had been prescribed early in the afternoon and was not administered until approximately 7:00 PM because the nurse explained she needed a code and could not administer it. Additionally, the complaint alleged that Ativan (a medication prescribed to treat anxiety) was also delayed because it needed to be delivered from the pharmacy before it could be administered. Furthermore, the complaint alleged that after speaking with the nursing supervisor at the facility, the complainant was informed that the medications were available and should have been administered promptly. According to the American Nurses Association 2025, states in part, .Nurses are responsible for recognizing patients' symptoms, taking measures within their scope of practice to administer medications, providing other measures for symptom alleviation, and collaborating with other professionals to optimize patients' comfort and families' understanding and adaptation.According to the Hospice Foundation of America's article titled, What is Hospice dated [DATE], states in part, .Hospice provides something more for patients when a cure is not an option. It is a medical care model focused on comfort. Hospice care aims to manage the patient's symptoms while supporting their quality of life. It provides support for family caregivers, too.Hospice care is provided by an interdisciplinary team of professionals trained to address the patient's medical, physical, spiritual, and psychosocial needs. The team focuses on the person, not the illness, as they coordinate patient care, clarify the goals of care, and foster communication . Record review revealed Resident ID #1 was admitted to the facility in March of 2024 with diagnoses including, but not limited to, cognitive communication deficit, chronic obstructive pulmonary disease (COPD), and chronic congestive heart failure (CHF). Review of a Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status score of 5 out of 15, indicating severe cognitive impairment. Further review revealed the resident required moderate to maximum assistance from staff for activities of daily living (ADLs).Review of a progress note dated [DATE] revealed, hospice services were discussed with the family, and an informational consult was requested in Spanish. Further review of the progress note revealed, .this writer to contact hospice agencies to advocate for that request.Record review failed to reveal evidence that the facility contacted a hospice agency to facilitate an informational consultation in Spanish, as requested, by the family on [DATE].Review of a provider note dated [DATE] states in part, HISTORY OF PRESENT ILLNESS On [DATE] member presented again with fever, increased sob [shortness of breath]/hypoxia [insufficient oxygen in the body tissues], and lethargy. On call was notified and ordered stat labs, chest x-ray and to give IM [intramuscular injection] Ceftraixone [an antibiotic] and IM Lasix [a medication prescribed to assist the body in excreting excess fluids]. WBC [white blood cell count- a blood test that can measure an infection in the body] was normal at 9.0. Chest x-ray shows mild CHF. [S/he] is seen today for follow up. Was lethargic this am and unable to eat/drink/take medications safely. Was given a tylenol suppository and now more alert, can say a few words and was able to take PO [by mouth] lasix. Lung sounds with crackles throughout, has a weak non-productive cough. Discussed with [family] members [name redetected] and decision was made to refer to hospice as family would like member to be comfortable. Will increase Lasix to 40 mg [milligram] daily to aide in members comfort related to CHF. Discussed starting prn [as needed] morphine/ativan and atropine drops and [s/he] consents to medication. Referral sent to Gentiva hospice and they will be in to assess member this evening.ADVANCED CARE PLAN Member's Primary Goal of Care: Comfort; Family's Primary Goal of Care: Comfort.Record review revealed the following physician's orders:-[DATE] entered at 1:46 PM - Lorazepam Intensol [Ativan] 2 mg/milliliter [mL] - give 0.25 ml every 4 hours as needed for anxiety/agitation.-[DATE] entered at 1:53 PM - Morphine 20mg/mL - give 0.25 mL every 4 hours as needed for pain/SOB.Record review of a hospice visit note report, authored by Registered Nurse (RN), Staff A, dated [DATE] with the in-home start time of 4:05 PM, revealed the following assessment:-Vital Signs- Temperature: 102.5 (normal = 97-99 degrees Fahrenheit), Pulse 116 (normal= 60-100), Respirations 26 (normal= 16-20), Blood Pressure 150/86 (normal= approximately 120/80)-Clinical Evidence of Advancing Illness: symptoms present at rest, edema (swelling), functional decline to dependence in two or more for ADLs, worsening vital signs-Additional findings related to diagnosis: Actively dying-Other Findings: Moaning-Pain Severity: Severe-Describe Behavior: Occasional labored breathing (an intense uncomfortable effort to breathe), short period of hyperventilation (breathing faster or deeper than normal), repeated trouble calling out, loud moaning or groaning, crying, unable to console, distract or reassure.-Total pain score: 7 out of 10 (indicating severe pain)-Is current pain management effective: No, awaiting morphine from pharmacy-Sensory Perception: Very limited, cannot communicate discomfort except by moaning or restlessness-Neurologic: agitated, disoriented, lethargic, restless-Origin of Anxiety: Terminal Agitation (behaviors characterized by restlessness, confusion, and distress that can occur in the final days or hours of life that can be managed by medications)Further record review of the hospice visit note report, authored by Registered Nurse (RN), Staff A, dated [DATE] revealed, Narrative: .upon entering room, patient found to be having episodes of terminal agitation, unable to answer questions in [his/her] native language.order was written earlier today by [Nurse Practitioner, NP, Staff B] for Morphine Concentrate 5 mg [sublingual- administered under the tongue] [every] 4 [hours] as needed pain/dyspnea [shortness of breath], however med has not arrived from pharmacy. Unit Nurse [Licensed Practical Nurse (LPN) Staff C] calling to get over ride for medications needed.Record review of the [DATE] Medication Administration Record (MAR) revealed Morphine was not administered to the resident until 6:39 PM on [DATE], approximately 4 and a half hours after the medication had been ordered and approximately 2 hours after the hospice nurse had assessed the resident with the above-mentioned findings, which included severe pain.Further review revealed Lorazepam Intensol had not been administered to the resident until 10:40 PM on [DATE], approximately 9 hours after the medication had been ordered and approximately 6 and a half hours after the hospice nurse had assessed the resident with the above-mentioned findings, which included anxiety. Review of the available medications in the Omnicell (an automated system for medication administration) revealed, Morphine was available and could have been administered prior to 6:39 PM.Review of the available medications in the E-Kit ( an emergency medication kit supplied by the pharmacy for use when a medication is needed immediately and before it is delivered by the pharmacy) revealed, Lorazepam Intensol was available and could have been administered prior to 10:40 PM.During a surveyor interview on [DATE] at 8:57 AM with the complainant, the resident's family member, s/he revealed that on the afternoon of [DATE], less than 24 hours prior to the resident's death, there was a delay in providing the resident with his/her ordered Morphine and Ativan. Additionally, the family member indicated that the resident was in agonizing pain. S/he further indicated that the resident was experiencing anxiety and his/her feet were hanging off of the bed when s/he entered the resident's room.During a surveyor interview on [DATE] at 10:34 AM with LPN, Staff D, he revealed that all of the facility's nurses have access to the Omnicell and would expect that a medication would be taken from the Omincell to be administered to a resident if it was ordered for them and unavailable otherwise.During a surveyor interview on [DATE] at approximately 11:30 AM with Registered Nurse (RN), Staff E, she revealed that Ativan Intensol is available in the E-Kit that is provided by the pharmacy. She stated that the E-Kit requires two nurses to sign for the medication when removing medication from the E-Kit. She further revealed that the E-kit had not been opened recently. During a surveyor interview on [DATE] at 11:44 AM with hospice nurse, Staff A, she revealed that she arrived at the facility and assessed Resident ID #1 on [DATE] at approximately 4:00 PM. She indicated that the resident appeared to be exhibiting signs of terminal agitation at that time. She further revealed that the resident had periods of extreme anxiety and agitation during the visit and was told by LPN, Staff C, that she was waiting for the code from the pharmacy before administering Morphine to the resident. Additionally, she revealed that she would have expected the Morphine and Ativan to be administered to Resident ID #1 sooner than it had been on [DATE].During a surveyor interview on [DATE] at 11:57 AM with the Director of the Hospice Agency, she revealed that the hospice nurse arrived at the facility the same day that the referral was received from the facility, which was [DATE]. She further revealed that the agency had not received a referral for Resident ID #1 prior to [DATE].During a surveyor interview on [DATE] at approximately 12:00 PM with NP, Staff B, she revealed that the resident had a recent decline and was admitted to hospice on [DATE]. She further revealed that she prescribed Morphine and Ativan, as needed, prior to the hospice nurse coming to the facility to assess the resident. Additionally, she revealed that the administration of medications prescribed as needed is at the nurse's discretion and that if the resident was screaming or in pain, she would expect the medications to be administered.During a surveyor interview on [DATE] at 12:11 PM with LPN, Staff C, she revealed that she was the nurse who cared for Resident ID #1 on [DATE] during the 3:00 PM to 11:00 PM shift. She further revealed that the resident was sweaty, warm, and reaching out for people's hands because it was the end. Additionally, Staff C revealed that the resident had pain from arthritis, and she did not feel s/he needed the morphine, so she waited to get a code from the pharmacy to administer the Morphine from the Omnicell and administered it later in the evening. Furthermore, she indicated that she didn't think about the availability of the Lorazepam Intensol in the E-Kit. During a surveyor interview on [DATE] at approximately 1:40 PM with the Director of Nursing Services, she revealed, Resident ID #1 rapidly declined. She further indicated that the hospice nurse is not employed by the facility and the nurse employed by the facility is to assess the resident and administer medications as needed. Additionally, she could not provide evidence that Resident ID #1 received treatment and care in accordance with professional standards of practice, relative the administration of end-of-life medications. Further record review revealed the resident expired on [DATE] at 10:00 AM.

Based on clinical record review and staff interview, the facility failed to notify each resident, or resident representative, who receives Medicaid benefits, when the amount in the resident's account reaches $200 less than the Social Security Income (SSI) resource limit for 3 of 3 residents reviewed with over $4000 in personal needs funds handled by the facility, Resident ID #s 65, 77, and 159.Findings are as follows:Record review of Title 210-Executive Office of Health and Human Services, Chapter 50-Medicaid Long-Term Services and Supports (LTSS) under section 2.4 (G) of the Uniform Accountability Procedures for Title XIX Resident Personal Needs Funds in Community Nursing Facilities, ICF/DD Facilities, and Assisted Living Residences requires that the facility shall: .(10) The nursing facility must notify the resident in writing when his/her balance reaches $200.00 less than the resource eligibility guideline, that Medicaid eligibility is jeopardized if the account exceeds the guideline [4,000] .Review of a facility document titled, Trial Balance .Balances as of 12/31/2025 for the residents reviewed, revealed the following:- Resident ID #65 has a current balance of $4,067.67.- Resident ID #77 has a current balance of $4,171.23.- Resident ID #159 has a current balance of $7,053.36.During a surveyor interview on 1/7/2026 at 10:07 AM with the Assistant Business Office Manager, Staff A, she was unable to provide evidence that the above identified residents were notified in writing when their account balances reached $200 less than the SSI Medicaid eligibility resource limit ($4,000).

Based on clinical record review and staff interview, the facility failed to ensure that resident records are complete and accurately documented, relative to medication administration, for 1 of 2 residents reviewed for Midodrine HCL (a medication prescribed to treat low blood pressure), Resident ID #13 and for 1 of 1 resident reviewed relative to a blister of the left heel, Resident ID #80. Findings are as follows: 1) Record review revealed Resident ID #13 was admitted to the facility in June of 2025 with a diagnosis including, but not limited to, hypotension (low blood pressure (BP)). Record review revealed a physician's order dated 12/16/2025 for Midodrine HCL 2.5 milligrams (mg) 1 tablet, two times daily for hypotension. The order states to hold the medication for blood pressure greater than 130. Record review of the January 2026 Medication Administration Record (MAR) on 1/6/2026 revealed, the Midodrine was documented as given when the patient had a blood pressure above 130 on the following dates and times: - 1/4/2026 at 6:00 PM- BP 160/75 - 1/5/2026 at 6:00 PM- BP 166/73 - 1/6/2026 at 8:00 AM- BP 144/62 During a surveyor interview on 1/7/2026 at approximately 2:45 PM with the Director of Nursing Services (DNS), and the Administrator revealed, the surveyor brought the errors to their attention. Subsequent record review of the January 2026 MAR, on 1/8/2026, revealed the Midodrine documentation was modified, and the number 3 was added indicating that the vitals were outside the parameters of administration on the following days: - 1/4/2026 at 6:00 PM - 1/5/2026 at 6:00 PM - 1/6/2026 at 8:00 AM During a surveyor interview on 1/8/2026 at approximately 2:00 PM with the DNS, she revealed that she had spoken to the nurses who administered medications on the above dates and times. She further revealed that the nurses stated that they did not administer the Midodrine, so they changed the documentation in the January 2026 MAR to reflect that the medication was not administered. 2) Record review revealed Resident ID #80 was admitted to the facility in June of 2025 with diagnoses including, but not limited to, adult failure to thrive, and abnormalities of gait and mobility. Record review revealed the following physician's orders: - Apply Skin prep to left heel and cover with a clean dry dressing every 7 days for a blister. This order was dated 12/2/2025 and was discontinued on 1/7/2026. - Skin prep to left heel followed by a foam dressing every 7 days for protection. This order was dated 1/7/2026. - Skin prep to left heel followed by a foam dressing as needed if dressing is soiled or rolls off. This order was dated 1/7/2026. Record review of a progress note dated 1/7/2026 at 6:03 PM revealed that the resident has a callous to the left lateral heel, and that there is a treatment in place.Record review of the resident's weekly skin monitoring checks failed to reveal documentation regarding impaired skin integrity to the left heel on the following dates: 12/6/2025 12/20/2025 12/27/2025 1/3/2026 Record review of the resident's Weekly Skin Integrity Data Collection, dated 12/13/2025 revealed, under section A.2., Select any alteration in skin that box 2q1. other had been checked. The description box below the selection indicated, left heel/treatment in place. Surveyor observation on 1/8/2026 at 1:27 PM in the presence of the Assistant Director of Nursing (ADNS) revealed a hardened non-blanchable (visible redness of the skin that persists even with the application of pressure) area to the resident's left heel. During the observation the ADNS described the area to be a callous. During a surveyor interview on 1/8/2026 at approximately 1:40 PM with the ADNS, she acknowledged that the area was not documented on the skin checks and revealed that she would have expected the area to be assessed and described on the skin checks.

Based on clinical record review and staff interview, the facility failed to ensure residents are free from medication errors relative to 1 of 2 residents reviewed with an order for midodrine (a medication prescribed to treat low blood pressure) who received the medication outside of the ordered parameters, Resident ID #13.Findings are as follows:Record review revealed the resident was admitted to the facility in June of 2025 with diagnoses including, but not limited to, hypotension (low blood pressure) and end stage renal disease.Record review revealed a physician's order dated 12/16/2025 for Midodrine HCl oral tablet, 2.5 milligrams (mg), give 1 tablet by mouth two times a day for hypotension, hold for blood pressure (BP) greater than 130 (systolic, top number of a blood pressure reading).Record review of the December 2025 and January 2026 Medication Administration Records (MAR) revealed the midodrine was administered outside of the blood pressure parameters on the following dates and times: - 12/22/2025 at 8:00 AM, BP at 133/59 - 12/27/2025 at 8:00 AM, BP at 138/60 - 1/2/202026 at 6:00 PM, BP at 154/65During a surveyor interview with Unit Manager, Licensed Practical Nurse, Staff G, on 1/7/2026 at approximately 11:30 AM, she revealed that if the order is documented as completed in the MAR, then it was administered to the resident.During a surveyor interview with the Director of Nursing Services in the presence of the Administrator on 1/7/2026 at 2:49 PM, she was unable to provide evidence that the midodrine was held according to the blood pressure parameters on the above dates and times, as ordered.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 1 resident reviewed with a newly identified skin impairment to his/her left heel, Resident ID #80.Findings are as follows:Review of a facility policy revised on 6/11/2025, titled Skin Integrity & Ulcer/Injury Prevention, states in part, .Based on a comprehensive assessment of a resident, the facility must ensure that a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers.A skin assessment/inspection should be completed weekly by a nurse. Skin observation also occurs throughout points of care provided by CNAs [Nursing Assistants] during ADLs [activities of daily living] care. When skin breakdown occurs, it requires attention and a change in the plan of care may be indicated to treat the resident.According to the American Academy of Family Physicians 2023, .Pressure injuries are localized damage to skin or soft tissue. They commonly occur over bony prominences and often present as an intact or open wound .they significantly impact patient quality of life. Comprehensive skin assessments are crucial for evaluating pressure injuries .treatment involves pressure off-loading .deep tissue pressure injury .intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister . Stage 2 pressure injury .may also present as an intact or ruptured serum-filled blister .Record review revealed the resident was admitted to the facility in June of 2024 with diagnoses including, but not limited to, dementia and muscle weakness.Record review of a care plan dated 7/5/2025 revealed, that s/he is at risk for alteration in skin integrity due to impaired mobility with interventions including, but not limited to, assessing the location, the size, the treatment of skin injury, and to report the failure to heal to the provider. Further review of the care plan revealed the resident receives hospice services.Record review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident is at risk for developing pressure ulcers requiring pressure reducing devices while in bed and while in a chair. Further review revealed the resident did not have any pressure ulcers or skin impairments to his/her feet at the time of the assessment. Additional review revealed the resident is dependent on staff for ADLs including dressing. Record review revealed the following physician's orders:-12/2/2025- apply skin prep to bilateral heels twice daily.-12/2/2025- apply skin prep to left heel blister then cover with a dressing every 7 days.-12/3/2025- apply heel boots every shift for boggy heels (skin tissue that feels unusually soft, spongy, or mushy, indicating excess fluid and damage beneath the surface, often a warning sign for developing a pressure injury on the heel, especially in immobile patients, and requires immediate relief and assessment. It is an early sign of a deep tissue Injury appearing a discolored area) as tolerated.During surveyor observations the resident was observed without the heel boots applied on the following dates and times: -1/6/2026 at approximately 10:00 AM while in bed. -1/6/2026 at 12:30 PM while sitting the broader chair in the common area. -1/6/2026 at 1:40 PM while in the common area. -1/7/2026 at 9:38 AM the resident was in the broader chair, being wheeled out of the room by a Nursing Assistant (NA) after AM care. -1/7/2026 at 10:22 AM in the broader chair in the common area. Record review of the resident's clinical medical record failed to reveal evidence that s/he was unable to tolerate the heel boots. Further review failed to reveal evidence of measurements or descriptions of the skin impairment to the left heel which was identified in the physician's orders on 12/2/2025. During a surveyor interview on 1/7/2026 at approximately 10:30 AM with NA, Staff E, she revealed that she was not aware that the resident requires bilateral heel boots. Additionally, Staff E indicated the resident receives hospice services, so s/he does not need heel boots. During a surveyor interview on 1/7/2026 at approximately 11:00 AM with Licensed Practical Nurse (LPN), Staff F, she indicated that she failed to put the resident's heel boots on after she completed the resident's treatment to his/her left heel. Record review of the weekly skin checks failed to reveal evidence of a skin impairment to the left heel on the following dates:-12/6/2025-12/20/2025-12/27/2025-1/3/2026 During a surveyor observation of the resident's heels on 1/8/2026 at 1:27 PM, in the presence of the Assistant Director of Nursing Services (ADNS)/Wound Nurse, the resident was observed to have a non-blanchable darkened skin impairment to his/her left heel, measuring 2.4 centimeters(cm) x 2.3 cm. During a subsequent surveyor interview with the ADNS, immediately following the above observation, she acknowledged a new skin impairment that had been classified as a blister was documented in a treatment order dated 12/2/2025. She indicated that she would expect the notification of the provider to be documented in a progress note as well as the measurements of the skin impairment. Additionally, she acknowledged that she would expect skin checks to reflect skin impairments and that the impairments be described.During a surveyor interview on 1/8/2026 at approximately 2:30 PM with the resident's physician, he indicated that he would have expected the staff to document the resident's skin impairment to the left heel in his/her medical record.During a surveyor interview on 1/8/2026 at 3:07 PM with the Director of Nursing Services, in the presence of the Administrator, she was unable to provide evidence that the skin impairment identified on 12/2/2025 was documented and measured. Additionally, she was unable to provide evidence that the resident's heel boots were applied, as ordered.

Based on surveyor observation, clinical record review, and staff and resident interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative to 1 of 1 resident reviewed with an observed skin tear, Resident ID #7.Findings are as follows:Review of a facility policy last reviewed 8/29/2025 titled, Changes in Resident's Condition or Status states in part, .The facility will notify the resident, his/her primary care provider, and resident/resident representative of changes in the resident's condition or status.Record review revealed Resident ID #7 was admitted to the facility in February of 2025 with diagnoses including, but not limited to, hemiplegia and hemiparesis following a cerebral infarction (stroke) affecting the left side. Review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15, indicating intact cognition. Further review revealed the resident required maximum assistance from staff for activities of daily living including personal hygiene and upper body dressing.Surveyor observations revealed the resident had an undated, white bordered gauze dressing to his/her elbow with visible dark drainage on the following dates and times:- 1/5/2026 at 12:58 PM- 1/5/2026 at 3:08 PM- 1/6/2026 at approximately 3:30 PMDuring a surveyor interview with the resident on 1/5/2026 at 12:58 PM, s/he indicated that s/he had hit his/her elbow on the arm rest of the wheelchair recently and a nurse had applied the dressing. The resident was unsure of when the dressing was first applied but stated that it was probably time for the dressing to be changed.Record review of the physician's orders, failed to reveal evidence of an order for a dressing to the left arm.Record review failed to reveal any documentation of the wound including a description, measurements, or that the provider was notified of a new skin impairment requiring a dressing.During a surveyor observation and interview on 1/7/2026 at 9:52 AM with the resident, a pink bordered foam dressing was observed to be on the resident's left elbow labeled 1/7/26 7-3. The resident indicated that the dressing had been changed that morning but had not been changed for a few days.During a surveyor interview on 1/7/2025 at approximately 10:00 AM, with Licensed Practical Nurse, Staff B, she indicated that she had worked on the unit the day before but had just been made aware of a new skin impairment to the resident's arm that morning, when there was blood everywhere. She further indicated that she applied a dressing to the resident's left arm and would be texting the Nurse Practitioner (NP) to notify her of the wound. Additionally, she acknowledged that an order was not in place for a dressing to the resident's left elbow or that were was any documentation that the wound had been identified prior to 1/7/2026. Furthermore, she indicated that she would expect the provider, family, and risk management, to be notified of a new wound and a progress note to be completed. During a surveyor interview on 1/07/2026 at 10:07 AM with the Unit Manager, Staff C, she revealed that she had just been made aware of the resident's skin impairment. She then stated, you're calling the NP right, [Staff B]? During a surveyor interview and observation on 1/7/2026 at approximately 10:30 AM, with the Assistant Director of Nursing and wound nurse, Staff D, she indicated that she had just been made aware of the wound to the resident's left arm and then measured and assessed the wound. The wound consisted of three skin tear areas collectively measuring 3 centimeters (cm) by 3 cm.During a surveyor interview on 1/7/2026 at 3:11 PM with the Director of Nursing Services, she indicated that she would expect the provider to be notified when a wound is identified. Additionally, she could not provide evidence that the provider had been notified or that an order had been given pertaining to the treatment of the wound to the resident's left arm, when it was initially identified.

Based on surveyor observation and clinical record review, the facility failed to protect identifying information for four (4) current residents listed in a resident-identifying document located in the facility's survey results binder for 1 of 2 surveys reviewed.Findings are as follows:A surveyor observation on 1/7/2026 at approximately 12:45 PM of the first-floor lobby area revealed a black survey results binder was stored on a wall in the facility lobby, accessible to the public.Record review of the survey binder revealed a resident roster (a list provided to a facility that corresponds to a number identifier utilized in a survey to protect privacy) included with the statement of deficiencies for the following surveys:-Survey results for exit date 12/7/2023, identifying Resident ID #s 8, 46, 62 and 146.Further record review of the above survey with the attached rosters contained information including, but not limited to, physician's orders and medical diagnoses.During a surveyor interview on 12/7/2025 immediately following the above observation with the Administrator, she acknowledged that the residents' names along with their corresponding number identifiers were included in the binder and should not have been.

Based on record review and staff interview, it has been determined that the facility failed to ensure that nursing staff have the appropriate competencies and skill sets to provide nursing and related services to assure resident safety to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as determined by resident assessments, and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment as required for 2 of 5 staff reviewed, Licensed Practical Nurses (LPNs) Staff A and B. Findings are as follows: Record review of the facility assessment states that the resident population may have a diagnosis that includes surgical wounds. Further review revealed nurse competencies should be completed during orientation, annually, and as dictated by the care needs of the residents. Record review of the policy titled Treatment of Surgical Wounds with an issue date of 7/9/2024, revealed in part, Closed-wound drains are typically inserted during surgery in anticipation of substantial postoperative drainage .A closed-wound drain .prevents exudate (liquid produced by the body in response to tissue damage and wound healing) from accumulating at the wound site .Hemovac closed drainage systems are most commonly used. These drains are considered vacuum drains that use low negative pressure. The collection chamber expands as it collects the draining fluid by exchanging negative pressure for fluid .The drain should be emptied and its contents measured every 4 to 8 hours or more often according to the patient's condition, the amount of drainage, and the practitioner's orders. Removing excess drainage maintains maximum suction and avoids straining the drain's suture line . Record review revealed the resident was admitted to the facility in March of 2025 with diagnosis including, but not limited to, fusion of the spine of the thoracic vertebrae 11-12. Record review of a facility document titled, .Admission/Readmission Collection Tool - V 6 dated 3/28/2025 at 4:57 PM, authored by LPN, Staff A, states in part, .Surgical dressing intact to posterior back, drain connected to HV (Hemovac) to back, serosanguineous drainage (a type of fluid discharge that is a combination of serous (clear) fluid and blood, typically appearing as a light pink, thin, and watery fluid( noted . During a surveyor interview on 4/24/2025 at 11:14 AM with Staff A, she revealed that she did not recall receiving a training specific to the care of a Hemovac drain from the facility prior to caring for Resident ID #1. During a surveyor interview on 4/24/2025 at 11:18 AM with LPN, Staff B, she revealed that she cared for Resident ID #1 and she did not receive any training specific to the care of a Hemovac drain from the facility prior to caring for the resident. During a surveyor interview on 4/24/2025 at 7:58 AM with the Director of Nursing Services, after the surveyor requested the competencies for Staff A and B, she revealed that the facility does not provide education or competencies specifically related to Hemovac drain care for any of their nursing staff. Cross reference- F 658

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality relative to a Hemovac drain (a device that is used to remove fluids that build up in an area of your body after surgery. The Hemovac drain removes fluid by creating suction in the tube. The circular device is squeezed flat and expands as it fills with fluid) for 1 of 1 resident reviewed, Resident ID #1. Findings are as follows Review of a community reported complaint submitted to the Rhode Island Department of Health on 4/22/2025, revealed, Resident ID #1 recently underwent surgery and was discharged from the hospital to the skilled nursing facility (SNF). On his/her post operative visit s/he came from the facility and on exam s/he presented as not alert, babbling, lethargic, and altered. Labs that were taken at the SNF demonstrated elevated white blood cells (indicating an infection) and s/he was sent to the emergency room . Resident ID #1 was found to have multiple medical concerns and was subsequently admitted to the hospital for care. Record review of the policy titled Treatment of Surgical Wounds with an issue date of 7/9/2024, revealed in part, Closed-wound drains are typically inserted during surgery in anticipation of substantial postoperative drainage .A closed-wound drain .prevents exudate (liquid produced by the body in response to tissue damage and wound healing) from accumulating at the wound site .Hemovac closed drainage systems are most commonly used. These drains are considered vacuum drains that use low negative pressure. The collection chamber expands as it collects the draining fluid by exchanging negative pressure for fluid .The drain should be emptied and its contents measured every 4 to 8 hours or more often according to the patient's condition, the amount of drainage, and the practitioner's orders. Removing excess drainage maintains maximum suction and avoids straining the drain's suture line . Record review revealed the resident was admitted to the facility in March of 2025 with diagnosis including, but not limited to, fusion of the spine of the thoracic vertebrae 11-12. Record review of a facility document titled, .Admission/Readmission Collection Tool - V 6 dated 3/28/2025 at 4:57 PM, authored by Licensed Practical Nurse (LPN), Staff A, states in part, .Surgical dressing intact to posterior back, drain connected to HV (Hemovac) to back, serosanguineous drainage (a type of fluid discharge that is a combination of serous (clear) fluid and blood, typically appearing as a light pink, thin, and watery fluid) noted . Further record review failed to reveal evidence of the Hemovac drain's output measurement per the facility policy. During a surveyor interview on 4/23/2025 at 1:50 PM with Staff A, she acknowledged that the resident had a Hemovac drain on his/her back. Additionally, she revealed that she could not remember if there was an order to measure the amount of drainage. She was unable to provide evidence that the drain was emptied and its contents measured every 4 to 8 hours per the facility policy. Record review of the physician's orders failed to reveal an order to empty the Hemovac drain's contents, the frequency, amount and description of the drainage per the facility policy. Additionally, the record failed to have an order for monitoring the Hemovac drain's function from 3/28/2025 through 3/30/2025. During a surveyor interview on 4/23/2025 at approximately 3:00 PM with the Assistant Director of Nursing Services, she was unable to provide documentation of Hemovac drain's output monitoring during the resident's stay from 3/28/2025 through 3/31/2025. Additionally, she was unable to provide evidence of a physician's order to monitor the Hemovac drain's function from 3/28/2025 through 3/30/2025. During a surveyor interview on 4/23/2025 at 3:50 PM with the resident's facility physician, he revealed that for residents who have a Hemovac, the general rule is to have a physician's order to monitor how much drainage is coming out of the drain, ensure of proper functioning, monitor for signs and symptoms of infection, and to have a follow up appointment scheduled with the surgeon. During a surveyor interview on 4/24/2025 at 10:23 AM with the surgeon's physician assistant, he revealed that during the resident's follow-up appointment, the facility failed to provide documentation of the resident's Hemovac drain's output. He added that he would expect the facility to monitor and document the Hemovac drain's output at least two times daily, decompressing it to empty the drainage and compressing it again to reset the drain to ensure that negative pressure is in place. During a surveyor interview on 4/24/2025 at 9:40 AM with the Director of Nursing Services, she was unable to provide evidence of an order to empty the Hemovac drain's contents, its frequency, amount and description of the drainage per the facility policy. Additionally, she was unable to provide evidence of a physician's order to monitor that the Hemovac drain was properly functioning from 3/28/2025 through 3/30/2025, per the facility policy. Cross Reference F 726

Based on record review and staff interview, it has been determined that the facility failed to develop and implement a baseline care plan for each resident within 48 hours of a resident's admission, that includes the instructions needed to provide effective and person-centered care for the resident, that meets professional standards of quality relative to a surgical wound and the use of a Hemovac drain (a device that is used to remove fluids that build up in an area of your body after surgery. The Hemovac drain removes fluid by creating suction in the tube. The circular device is squeezed flat and expands as it fills with fluid) for 1 of 1 resident reviewed for baseline care plans, Resident ID #1. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 4/22/2025, revealed, Resident ID #1 recently underwent surgery and was discharged from the hospital to the skilled nursing facility (SNF). On his/her post operative visit s/he came from the facility and on exam s/he presented as not alert, babbling, lethargic, and altered. Labs that were taken at the SNF demonstrated elevated white blood cells (indicating an infection) and s/he was sent to the emergency room . Resident ID #1 was found to have multiple medical concerns and subsequently admitted to the hospital for care. Record review revealed that Resident ID #1 was admitted to the facility in March of 2025 with diagnoses including, but not limited to, fusion of the spine and orthopedic aftercare. Record review of a facility document titled, .Admission/Readmission Collection Tool - V 6 dated 3/28/2025 at 4:57 PM states in part, .Surgical dressing intact to posterior back, drain connected to HV (Hemovac) to back, serosanguineous drainage (a type of fluid discharge that is a combination of serous (clear) fluid and blood, typically appearing as a light pink, thin, and watery fluid) noted . Record review of the baseline care plan initiated on 3/28/2025 failed to reveal evidence of a care plan related to the surgical wound or the Hemovac drain which includes treatment or interventions required. During a surveyor interview on 4/24/2025 at 9:40 AM with the Director of Nursing Services and the Assistant Director of Nursing Services, they acknowledged that the resident had a surgical wound and a Hemovac drain on admission. Additionally, they were unable to provide evidence that the baseline care plan included instructions needed to provide effective and person-centered care relative to the use of a Hemovac drain for Resident ID #1.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections, relative to Enhanced Barrier Precautions (EBP; involves using gown and gloves during high-contact resident care activities) for 1 of 1 resident observed for high-contact resident care activities, Resident ID #1. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 12/3/2024, alleged concerns with proper hygiene care and proper sanitization before seeing a resident. Review of a facility policy titled Enhanced Barrier Precautions states in part, The facility should use Enhanced Barrier Precautions (EBP) as an additional MDRO [multidrug resistant organism] mitigation strategy for residents that meet the following criteria, during high-contact resident care activities .EBP are indicated for residents with .Wounds .Wounds generally include chronic wounds, not shorter lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage (e.g., Band-Aid) or similar dressing .Examples of resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: Dressing .Transferring .Wound Care: any skin opening requiring a dressing . Record review revealed Resident ID #1 was admitted to the facility in July of 2024 with a diagnosis that includes, but is not limited to, assistance with personal care. Record review of the October 2024 Treatment Administration Record (TAR) revealed the resident required the following wound treatments: - Cleanse wound with normal saline followed by Prisma (collagen) and a foam dressing to the coccyx, every 3 days, with a start date of 10/29/2024 and an end date of 11/12/2024. Record review of the November 2024 TAR revealed the resident required the following wound treatments: - Cleanse wound with normal saline followed by Prisma and a foam dressing to the coccyx every 3 days with a start date of 10/29/2024 and an end date of 11/12/2024. - Cleanse wound with normal saline followed by honey (a treatment with antibacterial properties that provides autolytic debridement and a moist wound healing environment) and maxorb (a dressing that needs to be cut to size that is made of calcium alginate with superior absorption of fluid, ideal for moderate to heavy draining wounds and aids in autolytic debridement) and a foam dressing to the coccyx, every day with a start date of 11/12/2024 and an end date of 12/02/2024. Record review of the December 2024 TAR revealed the resident required the following wound treatments: - Cleanse wound with Daskins (broad-spectrum antimicrobial cleanser that is effective against some multidrug resistant organisms and bacteria, viruses, molds, fungi, and yeast. Also used for odor control), 1/4 strength wash, followed by Santyl (prescription medicine that removes dead tissue from wounds so they can start to heal) and maxorb and a foam dressing to the coccyx ,every day with a start date of 12/3/2024 and an end date of 12/10/2024. - Cleanse wound with Daskins 1/2 strength wash followed by Santyl and maxorb and a foam dressing to the coccyx every day with a start date of 12/10/2024. A surveyor observation on 12/10/2024 at 11:05 AM, of Resident ID # 1's room revealed signage posted at the resident's door which indicated that staff are to wear a gown during high contact care activities, such as dressing and transferring a resident. Additional observation revealed Nursing Assistants (NA), Staff A and B were in the resident's room, pulling up his/her pants over his/her brief and wound dressing, which is located on his/her coccyx, in preparation to transfer the resident via Hoyer Lift. Further observation revealed Staff A and B were not wearing a gown, as required for a resident who has a wound that requires a dressing. Further observation on 12/10/2024 at 11:09 AM, revealed Licensed Practical Nurse (LPN), Staff C entered the resident's room and assisted Staff A with transferring the resident from his/her bed, without wearing a gown or gloves. During a surveyor interview on 12/10/2024 at 11:16 AM, with Staff A, she acknowledged the signage posted at the resident's door and revealed that the signage was new. She further acknowledged that she should have been wearing a gown when providing care to and transferring the resident. During a surveyor interview on 12/10/2024 at 11:19 AM, with LPNs, Staff C and D, they revealed that they would expect staff to wear both gloves and gowns for high contact care activities such as helping someone get dressed. When questioned if they should wear gowns and gloves during a transfer, they revealed that didn't believe so but would have to check with the Director of Nursing [DNS]. During a subsequent interview on 12/10/2024 at 11:21 AM with Staff C, she revealed that yes, gowns and gloves should have been worn during the transfer with Resident ID #1, per the signage posted at the door. Additional record review failed to reveal evidence that the resident was placed on EBP prior to 12/10/2024, although they developed a skin opening that required a dressing on 10/29/2024. During a surveyor interview on 12/10/2024 at 12:08 PM, with the Infection Preventionist, she revealed that she would expect staff to follow the EBP signage, and wear a gown and gloves during high contact care activities for a resident on EBP. During a surveyor interview with the DNS, the Assistant Director of Nursing, and the Infection Preventionist on 12/10/2024 at 12:40 PM, they were unable to provide evidence that the facility followed EBP per the facility policy and the posted signage found outside of Resident ID #1's room.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that each resident has the appropriate assistive device to prevent accident hazards for 3 of 3 units reviewed for relative to Hoyer's (Mechanical lift/assistive device) transfers, Resident ID #s 1, 22, 42, 59, 61, 73, 82, 94, 121, 127, and 130. Findings are as follows: According to the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities last revised on 2/3/2023, states in part, .Assistive devices also can help to prevent accidents. Assistive devices and equipment can help residents move with increased independence, transfer with greater comfort, and feel physically more secure. However, there are risks associated with the use of such devices and equipment, particularly if or when they are not properly maintained, and these risks need to be balanced with the benefits gained from their use. Training of staff .on the proper use of assistive devices/equipment is crucial to prevent accidents. It is also important to communicate clearly the approaches identified in the care plan to all staff, including temporary staff. It is important to train staff regarding resident assessment, safe transfer techniques, and the proper use of mechanical lifts including device weight limitations .Personal Fit and Device Condition. Devices can pose a hazard if not fitted and/or maintained properly .Personal fit, or how well the assistive device meets the individual needs of the resident, may influence the likelihood of an avoidable accident; and .Additionally, staff needs to ensure assistive devises properly fit the resident and the resident has received proper training in the use of the assistive device . Review of the facility policy titled Limited Lift Program (Safe Patient Handling) last revised 8/9/2023, states in part, .the facility will assess the resident to determine transfer status .This information will be captured in the medical record and communicated through the care plan .2. If a lifting device is required, the manufacture guidelines will be used to determine the type and size of sling that should be utilized . Review of an education document provided by the facility dated 11/13/2023 titled Safe Hoyer Use states in part, .1) Ensure you are using the right size Hoyer pad. There is a list of everyone's sizes in the CNA [Certified Nursing Assistant] folder if you are questioning some ones [sic] size. Size is determined based on weight . Record review of a facility document titled Hoyer Pad Sizes indicates the following for determining Hoyer pad sizes: - orange = small - grey = medium slim - yellow = medium - blue = large - black = extra large - white = extra extra large - grey mesh = shower 1. Record review revealed that Resident ID #94 sustained a fall during a Hoyer lift transfer on 11/12/2023, Hoyer machine and Hoyer pad were inspected for safety with no issues found and education was provided to the nursing staff on proper Hoyer and Hoyer pad use. During a surveyor observation on 12/7/2023 at 9:00 AM with Staff A, Resident ID #94's whiteboard failed to reveal what size Hoyer pad to utilize. Staff A revealed she uses a medium or large pad when transferring the resident as s/he is tall. She further acknowledged that the white board does not list what size Hoyer pad to use. During a surveyor observation on 12/7/2023 at 10:30 AM with Nursing Assistant (NA), Staff C and NA Staff A during a transfer of the resident, revealed the use of a yellow striped pad, indicating a medium pad was utilized. Review of the fourth floor master list of Hoyer pads, revealed that Resident ID #94 uses a Grey pad for transfers. During a surveyor interview on 12/7/2023 at 10:34 AM with the 4th floor Unit Manager, she revealed that the resident is listed as using a grey hoyer pad as it is the unit managers preference. 2. Record review of Resident ID #1's Kardex (type of index card system used to relate relative resident care needs to staff) states in part, Transferring .Transfer via Hoyer lift (small pad) with two assists- matrix cushion between [the resident] and Hoyer pad with the transfer. Record review of the special instructions on care plan states in part .Hoyer lift 2 assist (small Hoyer pad) with matrix cushion inside Hoyer lift during the transfer . Review of the facility provided 3rd floor master list titled Hoyer & Resident Hoyer Pad Sizes revealed the resident is listed as using a medium pad. During a surveyor interview on 12/7/2023 at 10:58 AM with the third floor Unit Manager, she acknowledged the discrepancies in the documentation. 3. Record review of Resident ID #22's Kardex states in part, Transferring .TRANSFER: Hoyer lift with 2 assists . Record review of the residents care plan revealed the following intervention, .2-Assist Hoyer for transfers . Record review of the special instructions on the care plan states in part, .2-Assist Hoyer for transfers .ENSURE WHEN UTILIZING HOYER NOT TO CROSS STRAPS IN BETWEEN LEGS. During a surveyor observation on 12/7/2023 at 10:31 AM revealed a white board located in his/her room which states in part, 2 assist Hoyer. Further review of the white board failed to reveal evidence of a Hoyer pad size. Record review failed to reveal evidence of documentation in the resident's medical record or plan of care relative to which size Hoyer pad the resident should use. During a surveyor interview on 12/7/2023 at 10:58 AM with the third floor Unit Manager, she acknowledged the white board and care plan did not identify which size hoyer pad to utilize for this resident. 4. Record review of Resident ID #42's special instruction on the care plan revealed s/he utilizes a Hoyer for transfer with two assists. Review of the resident white board in his/her room revealed the resident utilizes a Hoyer but failed to reveal evidence of which size Hoyer pad to utilize with the resident. During a surveyor interview on 12/7/2023 at 8:50 AM with Nursing Assistant (NA), Staff A, she revealed that you can identify what size pad each resident needs based on what Hoyer pad is either in their room or bagged outside their room. She further revealed that her assignment does not list the resident Hoyer pad size. When asked how she could identify what size Hoyer pad was needed for a resident, Staff A revealed she would review the resident care plan and white board. Additionally, she acknowledged the white board and care plan failed to identify the size of Hoyer pad required. She further revealed that she would only find the Hoyer pad size specific to each resident on the care plan and the white board. 5. Review of Resident ID #59's special instructions on the care plan states in part, .Transfers with 2 assists with Hoyer lift . Review of Resident ID #59 white board revealed the resident transfers with a medium Hoyer pad. Review of the resident weights revealed s/he should utilize a large hoyer pad for transfers. During a surveyor interview on 12/7/2023 at 10:58 AM with the 3rd floor Unit Manager, she acknowledged that Resident ID #59 has a medium sized hoyer pad listed on the white board. She further acknowledged that according the manufactures weight chart the resident should be in a large hoyer pad. 6. Record review of Resident ID #61's special instructions on the care plan indicates to utilize a large Hoyer pad. Record review of the resident care plan revealed the resident is documented as requiring a medium pad for Hoyer transfers. Review of the fourth floor master list for hoyer pad sizes identified Resident ID #61 as utilizing a large hoyer pad. During a surveyor observation on 12/7/2023 at 1:04 PM of the resident's white board failed to reveal what size Hoyer pad to utilize during a transfer. During a surveyor interview on 12/7/2023 at 1:06 PM with NA, Staff B, she acknowledged that the white board doesn't specify what size Hoyer pad to utilize. During a subsequent observation and interview on 12/7/2023 with Staff B about Resident ID #61, she revealed that the resident is currently sitting on a green strap Hoyer pad and further revealed that indicated it was an extra large Hoyer pad related to his/her height. Review of a document titled Hoyer Pad Sizes failed to list a green strap Hoyer pad with a corresponding size. 7. During a surveyor observation on 12/7/2023 at 10:09 AM of Resident ID #73 revealed, s/he was sitting in the dining room in a wheelchair on a Hoyer pad. Record review of Resident ID #73 revealed s/he utilizes a Hoyer pad for transfers. Record review of the care plan and special instructions failed to reveal what size Hoyer pad to utilize for the resident. Review of the resident's white board in his/her room failed to reveal evidence of what size Hoyer pad to utilize during his/her transfer. During a surveyor interview and observation on 12/7/2023 at 10:12 AM with the 4th floor unit manager, she acknowledged that the white board, care plan and special instructions failed to reveal what size Hoyer pad should be utilized for transfers. She further revealed that there is a master list at the nurse's station. Immediately following the above interview and observation with the 4th floor unit manager, the fourth floor master Hoyer list was reviewed with the unit manager and failed to identify Resident ID #73 documented as a Hoyer lift transfer with the corresponding Hoyer pad size. The 4th floor unit manager acknowledged that the resident was not listed on the Hoyer lift list with the corresponding size. 8. Record review for Resident ID #82 revealed that s/he utilizes a large Hoyer pad for transfers. During surveyor observations on 12/7/2023 at 9:00 AM and 1:14 PM revealed the white board in Resident ID #82's room documented as requiring a medium Hoyer lift pad. Review of the 4th floor master list of residents revealed the resident utilizes a large, blue Hoyer pad. During a surveyor interview and observation on 12/7/2023 at 1:15 PM with Staff B, she revealed the resident uses a large (blue stripe) Hoyer lift for the resident. She further acknowledged the white board indicates that the resident utilizes a medium hoyer pad. Additionally, she revealed she uses own judgment to determine pad size for each resident. 9. Record review for Resident ID #121's special instructions revealed that s/he requires a Hoyer for transfers. Record review of the resident's care plan revealed s/he utilizes a Hoyer lift for transfers. Further record review failed to identify what size Hoyer pad to utilize during his/her Hoyer transfer. During a surveyor observation on 12/7/2023 at 11:03 AM of the resident's white board failed to reveal what size Hoyer lift pad to utilize for transfers. During a surveyor interview on 12/7/2023 at approximately 11:30 AM with NA, Staff D, she revealed that the NA's look at the resident and decide on the appropriate size. She further revealed that the NA's are expected to use their professional judgement and common sense to determine their Hoyer pad size. During a surveyor interview on 12/7/2023 at approximately 1:00 PM with the second floor Unit Manger she revealed that she does not have a master list of Hoyer pad sizes on the second floor. Additionally, she was unable to provide evidence of where to find the appropriate size hoyer pad for this residents. 10. Record review of Resident ID #127's Kardex states in part, .Transferring .TRANSFER: Hoyer lift with 2 assists . Record review of the resident care plan revealed the following intervention, .TRANSFER: Hoyer lift with 2 assists into Broda chair . Record review of the special instructions on care plan states in part, .1 assist with adls [activities of daily living], 2 for Hoyer transfer . During a surveyor observation on 12/7/2023 at 10:31 AM revealed a white board located in his/her room which states in part, 2 assist Hoyer Further review of the white board failed to reveal a Hoyer pad size. During a surveyor interview on 12/7/2023 at 10:58 AM with the third floor Unit Manager, she acknowledged that this resident uses a hoyer for transfer. Additionally she acknowledged that the white board does not identify the appropriate size hoyer pad for transfers. 11. Record review of Resident ID #130's special instructions revealed that the resident requires a Hoyer lift for transfers. Review of the resident's white board revealed the resident utilizes a Hoyer lift for transfers. Record review failed to reveal evidence of what size Hoyer lift pad to utilize for transfers. During a surveyor interview on 12/7/2023 at 8:50 AM with Staff A, she revealed that her assignment does not list the resident Hoyer pad size. When asked how she could identify what size Hoyer pad was needed for a resident, Staff A revealed she would review the resident care plan and white board. Additionally, she acknowledged the white board and care plan failed to identify the size of Hoyer pad required. She further revealed that she would only find the Hoyer pad size specific to each resident on the care plan and the white board. During a surveyor interview on 12/7/2023 at 9:57 AM, with Licensed Practical Nurse, Staff E, she acknowledged the Hoyer pad size is not listed on the care plan or the white board in the residents room. During a surveyor interview on 12/7/2023 at 12:38 PM with the Director of Nursing Services, the Assistant Director of Nursing Services, the Administrator and the Unit Managers from the 2nd, 3rd and 4th floor revealed, that initially, therapy assess if the Hoyer is needed then the nurse determines the size based on the weight. They further revealed that they had a master list and the master list on each unit has the correct sizes. They were unable to provide evidence of an updated list for unit 4 and a complete list for unit 2. They further, were unable to provide evidence of an effective system in place that communicates with the direct care staff on which size Hoyer pad to utilize with each resident to prevent accident hazards. 46241 46539 46715 47279

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections relative to staff wearing appropriate personal protective equipment (PPE) for 1 of 1 units observed experiencing a COVID-19 (SARS-CoV-2) outbreak, 4th floor. Findings are as follows: Review a document titled, COVID-19 Information for Nursing Homes last updated 6/15/2023 states in part, .Facilities should implement broad use* of respirators and eye protection by HCP [Healthcare Personnel] during patient care encounters when COVID-19 .is increasing .and outbreaks in long-term care settings .*Facilities may implement universal use of NIOSH [National Institute for Occupational Safety & Health]-approved particulate respirators with N95 filters of higher for HCP during all patient care encounters or in specific units or areas of the facility at higher risk for COVID-19 transmission . During the entrance conference on 12/4/2023 at 9:18 AM, with the Administrator and the Assistant Director of Nursing Services (ADNS) / Infection Preventionist (IP), they revealed the facility had one COVID-19 positive resident on the 4th floor unit and indicated an N-95 mask must be worn by staff at all times on that unit. They further revealed a surgical mask was required to be worn by staff on all additional units. During surveyor observations, on all days of the survey, revealed signage posted on the 4th floor which states, ATTENTION N95 ARE REQUIRED FOR ALL EMPLOYEES AT ALL TIMES ON THIS UNIT! THANK YOU. During a surveyor interview on 12/6/2023 at 10:34 AM with the IP, during the infection control task, she revealed another resident on the 4th floor tested positive for COVID-19, totaling two residents, and indicated multiple staff, who only worked on the 4th floor, were also positive for COVID-19. A. During surveyor observations on 12/7/2023 from 8:33 AM to 8:43 AM of the Administrator on the 4th floor unit, revealed the following: - 8:33 AM, observed to be wearing only a surgical mask - 8:35 AM, observed entering room [ROOM NUMBER], left and entered room [ROOM NUMBER], collecting a meal tray - 8:36 AM, observed entering room [ROOM NUMBER], collected a meal tray and left the room - 8:37 AM, observed in the dining room speaking with residents - 8:39 AM, observed entering room [ROOM NUMBER] - 8:40 AM, observed sticking her head into room [ROOM NUMBER], which was a COVID-19 positive room, left and entered room [ROOM NUMBER], and removed a meal tray. - 8:41 AM, observed pulling down her surgical mask, wiped her nose with a tissue, and pulled the mask back up. She then proceeded to open the door to room [ROOM NUMBER] - 8:42 AM, observed opening the door to room [ROOM NUMBER] During a surveyor interview, immediately following the above observations, with the Administrator, she acknowledged an N-95 mask was required to be worn when on the 4th floor and was unable to explain why she was wearing only a surgical mask. B. During a surveyor observation on 12/7/2023 at 8:43 AM, revealed Registered Nurse, Staff F, wearing only a surgical mask, while working on the 4th floor. During a surveyor interview on 12/7/2023 at 8:45 AM with Staff F, she acknowledged that she was only wearing a surgical mask on the 4th floor and indicated that she only wears a N-95 mask in COVID-19 positive rooms because she cannot tolerate wearing an N-95 mask due to having asthma. Further, she revealed she was a per diem nurse at the facility. During a surveyor interview on 12/7/2023 at 9:21 AM, with the ADNS/IP, she acknowledged the Administrator was only wearing a surgical mask on the 4th floor and indicated she should have been wearing an N-95 mask. She further revealed Staff F was only wearing a surgical mask and indicated it was a risk she can take. Further, she was unable to explain why Staff F was assigned to work on a floor requiring the use of an N-95 mask at all times, when there were additional floors that only required the use of a surgical mask.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that residents who require [CONDITION(S)] receive services consistent with professional standards of practice, for 2 of 2 residents reviewed for [CONDITION(S)], Resident ID #s 36 and 69. Findings are as follows: According to the Illustrated Manual of Nursing Practice, 2nd, 1994, .after completion of hemo-[CONDITION(S)], monitor the access device for bleeding .Assess circulation at the access site at least four times daily by auscultating for bruit [audible vascular sound associated with turbulent blood flow] and palpating for thrill [vibration felt of blood flow]. Lack of bruit may indicate a blood clot, requiring immediate surgical attention . According to the facility policy titled [CONDITION(S)] with a revised date of 8/18/2022 states in part, .Ongoing assessment of the resident's condition and monitoring for complications before and after [CONDITION(S)] treatments received at a certified [CONDITION(S)] facility .The vascular access site shall be checked daily with physician notification for any known or suspected problem .Assess vascular access site for signs of clotting or bleeding every shift . 1. Record review revealed Resident ID #36 was admitted to the facility in June of 2022 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . S/he is dependent on renal [CONDITION(S)]. Review of the resident's record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the September and October 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further record review failed to reveal evidence that the resident's bruit and thrill was assessed according to the facility policy or the standard of practice. During an interview with the Director of Nursing Services on 10/5/2022 at 4:16 PM, she could not explain why the resident's bruit and thrill were not assessed per the facility policy or standard of practice. According to the manufacturer's instructions for [MEDICATION(S)] which states in part, .1 INDICATIONS AND USAGE [MEDICATION(S)] ([MEDICATION(S)]) is indicated for the control of serum phosphorus in adults .with chronic kidney disease (CKD) on [CONDITION(S)]. 2 DOSAGE AND ADMINISTRATION .taken orally with meals . 2. Record review revealed Resident ID #69 was admitted to the facility in June of 2022 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . S/he is dependent on renal [CONDITION(S)]. Record review of a facility document titled Pre/Post [CONDITION(S)] Communication dated 9/19/2022 revealed recommendations from the [CONDITION(S)] center to give [MEDICATION(S)] with meals. Review of the resident's record revealed the following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] Tablet 800 MG ([MEDICATION(S)]) Give 2 tablet by mouth three times a day every Mon, Wed, Fri for Renal -Order Date-04/06/2022 . Review of the September and October 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the progress note dated 9/19/2022 authored by the Registered Dietitian (RD) states in part, .Lab Review with RD at [CONDITION(S)]. Reports elevated Potassium and Phosphorous . During a surveyor interview on 10/5/2022 at 3:53 PM with the RD, she revealed the resident has elevated phosphorus levels. Additionally, she was unaware the resident's [MEDICATION(S)] was scheduled to be administered at 9:00 PM on Monday, Wednesday and Friday and she further acknowledged [MEDICATION(S)] is to be given with meals and 9:00 PM was not a good time for the medication to be administered. During a surveyor interview with the resident on 10/5/2022 at 4:02 PM s/he is aware of the medication's indication for use and that it needs to be given with food. The resident acknowledged refusing [MEDICATION(S)] at times, when it is not administered with food.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 units observed, Unit 2, including Resident ID #s 36, 42, 114 and 500. Findings are as follows: Review of the facility policy titled, [CONDITION(S)], revised 8/18/2022, states in part: .Arrangement for safe transportation to and from the [CONDITION(S)] facility .Additionally, communication should be maintained with the local ambulance and other contracted providers that transport residents between the [CONDITION(S)] facility and the nursing facility to ensure appropriate infection precautions are followed. Review of the facility's contract titled, Ambulance Service Agreement, dated 7/15/2016, signed by a representative of the facility and of [name redacted] ambulance company revealed in part, .The Service will provide medical transportation services for employees, patients, and visitors .The Service will comply with all applicable federal and state laws and regulations in connection with its provision of Services hereunder . According to the Centers for Disease Control and Prevention (CDC), healthcare personnel (HCP) are defined as .all paid and unpaid persons serving in healthcare settings who have the potential for direct or indirect exposure to patients .HCP include, but are not limited to .contractual staff not employed by the healthcare facility . During the survey teams' initial entry to the facility on [DATE] at approximately 7:45 AM, the team was instructed to wear N-95 respirators (a particulate-filtering mask that provides enhanced protection versus a surgical mask) due to COVID-19 positive residents residing in the building. During an interview on 10/3/2022 at approximately 8:00 AM with Director of Nursing Services (DNS) she revealed they were in a COVID outbreak and several residents had tested positive. During an interview on 10/5/2022 at 8:24 AM with the Infection Preventionist Nurse (IP) revealed there are 22 residents and 9 staff that tested positive for COVID-19. 1. Record review revealed Resident ID #36 was readmitted to the facility in June of 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a surveyor observation on 10/4/2022 at 2:45 PM revealed two contracted ambulance employees both wearing surgical masks while transporting the resident in the facility. Both ambulance employees acknowledged they were only wearing regular masks [surgical mask] to transport the resident. During a surveyor interview with the Director of Nursing Services (DNS) on 10/4/2022 at 2:53 PM, she indicated that the contracted ambulance employees are considered visitors and are not required to wear N-95 masks. During an additional surveyor interview on 10/4/2022 at 4:00 PM with Nurse Staff H, he would expect that transport ambulance personnel to wear an N-95 respirator. During a surveyor telephone interview with the ambulance company manager on 10/5/2022 at 12:10 PM, he revealed that the ambulance employees' conduct is situationally appropriate, and the company complies to the facility's recommendations. 2. Record review revealed Resident ID #42 was readmitted to the facility in May of 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed a physician's order dated 7/22/2022 for Isolation: Contact and Droplet Precautions Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] During a surveyor observation on 10/3/2022 at 9:46 AM, revealed a sign displayed outside the resident's room indicating the resident was on contact precautions and instructing those entering his/her room to wear a gown and gloves. Further surveyor observation at this time revealed the Unit Secretary, Staff I, entering the resident's room wearing only an N-95 respirator. She was observed talking to the resident at the foot of his/her bed with her clothing touching the bed and then opening the bureau drawers. Staff I was then observed exiting the resident's room without performing hand hygiene. She then entered a supply room to obtain items and re-entered the resident's room without a gown or gloves and without performing hand hygiene. During a surveyor interview on 10/5/2022 at 11:00 AM with Staff I, she revealed she went to give items to the resident and she revealed she was unaware that the resident was on contact precautions. Additionally, she did not know the required PPE (personal protective equipment) to wear when entering the resident's room. During an additional surveyor interview on 10/5/2022 at 12:19 PM with the IP regarding the above observations, she stated, that is a violation of our policy and indicated that she would expect the staff to wear the appropriate PPE as indicated on the signage at the resident's doorway. 3. Record review revealed Resident ID #114 was admitted to the facility in September of 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed a physician's order dated 9/23/2022 for Isolation: Enhanced Barrier Precautions Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . During a surveyor observation on 10/3/2022 at 11:47 AM, revealed a sign displayed outside the resident's room which states in part, ENHANCED BARRIER PRECAUTIONS EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following High-Contact Resident Care Activities .Changing Linens Providing Hygiene .Device care or use: central line, urinary catheter, feeding tube . Additional surveyor observation on 10/3/2022 at 11:47 AM revealed Registered Nurse. Staff J, adjusting the resident's linen without wearing a gown or gloves. She was then observed to have a pair of gloves in her hand and approached the bed without a gown and proceeded behind the privacy curtain. During a surveyor interview on 10/3/2022 at 11:57 AM with Staff J, she revealed she went into the resident's room to flush the g-tube. During a surveyor interview on 10/5/2022 at 12:19 PM with the IP, she revealed she would expect Staff J to have worn a gown when flushing the resident's g-tube. 4. Surveyor observation on 10/5/2022 at 12:08 PM revealed two contracted ambulance employees, both wearing surgical masks while transporting Resident ID #500 to his/her room. During a surveyor interview on 10/5/2022 at 12:18 PM, both ambulance employees revealed they wear surgical masks to transport residents and that they wear N-95 masks only for residents who test positive for COVID-19. During a surveyor interview on 10/5/2022 at approximately 12:30 PM, with the unit manager, Staff A, she revealed the ambulance employees are just dropping off a new admission. She acknowledged the ambulance employees were only wearing surgical masks.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free from any significant medication errors for 1 of 6 residents reviewed, Resident ID #59. Findings are as follows: Record review revealed the resident was admitted to the facility in February of 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed THE ORDER Record review of the document titled Continuity of Care Consultation and Referral Form from the resident's urologist dated 8/29/2022 revealed the following consultation note: .should continue Trospium [medication used to treat an overactive bladder] 20mg [milligrams] BID [two times daily] . Record review of a nursing progress note authored by Nurse Staff X dated 8/29/2022 at 2:48 PM revealed the following: Resident returned from urology with new recommds [recommendations]: to continue with trospium 20mg bid .DR. [doctor] [name redacted] notified and in agreement with recommendation. Record review of the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a surveyor interview with Nurse Staff F on 10/4/2022 at approximately 11:55 AM, she was unable to explain why the trospium order was discontinued on 8/29/2022. During a surveyor interview with the 3rd floor Unit Manager, Staff G, on 10/4/2022 at 3:18 PM, she revealed she would expect the urologists' recommendations would be followed once the recommendations were approved by the resident's physician.

Based on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from unnecessary drugs for 1 of 6 residents reviewed for unnecessary medications, Resident ID #59. Findings are as follows: Record review revealed the resident was admitted to the facility in February of 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the document titled Continuity of Care Consultation and Referral Form from the resident's urologist dated 8/29/2022 revealed the following consultation note: .May D/C [discontinue] .[MEDICATION(S)] [medication used to treat an enlarged prostate] . Record review of a nursing progress note authored by Nurse Staff X dated 8/29/2022 at 2:48 PM revealed the following: Resident returned from urology with new recommds [recommendations]:may d/c .[MEDICATION(S)] .DR. [doctor] [name redacted] notified and in agreement with recommendation. Record review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's August, September and October 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During a surveyor interview with Staff F on 10/4/2022 at approximately 11:55 AM, she was unable to explain why the [MEDICATION(S)] order was not discontinued. During a surveyor interview with the 3rd floor Unit Manager, Staff G, on 10/4/2022 at 3:18 PM, she revealed she would expect that the urologists' recommendations would be followed once the recommendations were approved by the resident's physician.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure accurate assessments reflecting the residents' status for 3 of 5 residents reviewed relative to weekly skin assessments, Resident ID #s 46, 113, and 200 and 1 of 5 residents reviewed relative to pain, Resident ID #202. Findings are as follows: Record review of a facility policy titled, Skin Integrity & Pressure Ulcer/Injury Prevention and Management last reviewed on 4/19/2022 states in part, .1. A comprehensive skin inspection/assessment on admission and re-admission to the center may identify pre-existing signs of possible deep tissue damage already present .3. A skin assessment/inspection should be performed weekly . 1. Record review revealed Resident ID #46 was admitted to the facility in September of 2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a surveyor observation on 10/5/2022 at 12:54 PM of the resident in the presence of the Assistant Director of Nursing (ADON), revealed the resident has a red rash to both feet and ankles. Record review of the physician orders revealed an order dated 9/26/2022 for Triamcinolone [MEDICATION(S)] Cream 0.1% Apply to ankles and feet topically every day and evening shift for rash. Record review of the Weekly Skin Integrity Data Collection revealed the following: 9/27/2022- 1. Skin Intact a.Yes .2. New finding (s): No .3 .Description scattered bruising r/t[related to] insulin administration on abdomen and thighs/back arms 10/4/2022- 1. Skin Intact a.Yes 2. New findings b. No . Further review of the document failed to reveal a site or description of the skin impairment. During a surveyor interview on 10/5/2022 at approximately 12:54 PM with the ADON, she acknowledged that the resident's skin assessments on 9/27/2022 and 10/4/2022 were inaccurate. During a surveyor interview on 10/5/2022 at 2:53 PM with the Director of Nursing Services, she revealed that she would expect the resident's rash on his/her feet to be documented on both skin assessments mentioned above. 2. Record review revealed Resident ID #113 was admitted to the facility in August of 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Weekly Skin Integrity Data Collection revealed the following: -10/4/2022: Chest open area, Left knee (front) LAKA [left above knee amputation] surgical incision, open area, Right lower leg (front) open area from scratching. During surveyor observations on 10/3/2022 at approximately 10:00 AM and 10/4/2022 at 4:26 PM revealed an undated dressing to the resident's right forearm with a small amount of drainage observed on the exterior dressing. During a surveyor observation on 10/4/2022 at 4:38 PM revealed an open area with dark red drainage to the left forearm (approximately 1.25 centimeter (cm) in length and 1.25 cm in width). During a surveyor observation on 10/5/2022 at 9:16 AM in the presence of the Unit Manager, Staff A, revealed the following open areas: - right forearm with dark red drainage (approximately 1.25 cm x 1.25 cm). - left forearm (approximately 0.5 cm x 0.5 cm) - 2 scabs on the left elbow (approximately 1.25 cm x 1.25 cm and 0.75 cm x 0.75 cm) During a surveyor interview on 10/5/2022 at 9:22 AM with Staff A, she acknowledged the resident's skin assessment on 10/4/2022 was inaccurate. 3. Record review revealed Resident ID #200 was admitted to the facility in August of 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Weekly Skin Integrity Data Collection revealed the following: - 9/22/2022: Open area/wound - 9/30/2022: Open area/wound Review of the above documents failed to reveal a site, description or measurements for the above open areas noted. Additional review of the physician orders revealed an order dated 8/19/2022 which states in part, [MEDICATION(S)] to right toes and cover with CDD [clean dry dressing] . Record review of the Wound Observation Tool dated 9/27/2022 revealed a wound to the resident's right foot (great toe, second toe and 5th toe), and right plantar. During a surveyor interview on 10/5/2022 at 2:38 PM with the Wound Nurse, she acknowledged the resident's skin assessments on 9/22/2022 and 9/30/2022 were incomplete. Review of the facility policy with a revised date of 9/8/2022 states in part, .All residents will be assessed for pain indicators upon admission/readmission . 4. Record review revealed Resident ID #202 was admitted to the facility in September of 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of an admission Minimum Data Set assessment dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) score was a 15 out of 15, indicating s/he is cognitively intact. Record review of the Admission/Readmission Collection Tool dated 9/22/2022 revealed the resident's pain level indicated 4 out of 10. Further review of this document failed to reveal details including Location .What makes the pain worse .What makes the pain better .Pharmacological methods for alleviating pain . During a surveyor interview on 10/5/2022 at 9:00 AM with the Unit Manager, Staff A, she acknowledged that the resident's admission pain assessment was incomplete. During a surveyor interview on 10/5/2022 at 9:11 AM with Licensed Practical Nurse, Staff B, she revealed she completed the admission assessment and revealed during the assessment the resident stated she did not have pain, but s/he had reported pain earlier that day.

Based on record review, resident's family, and staff interview, it has been determined that the facility failed to provide the necessary services to residents who are unable to carry out activities of daily living (ADL) relative to showers for 1 of 6 residents reviewed, Resident ID #135. Findings are as follows: Record review of a facility policy titled, Activities of Daily Living (ADLs) last reviewed on 8/22/2022, states in part, Policy The resident will receive assistance as needed to complete activities of daily Living (ADLs) .Procedure .Bathing Frequency- Tub baths or showers will be scheduled at least two (2) times per week based on resident preference. Staff will encourage residents to complete a minimum of one (1) tub bath, shower, or bed bath per week . Record review revealed the resident was admitted to the facility in September of 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of an admission Minimum Data Set assessment dated [DATE], revealed the resident is totally dependent with bathing and showering and requires the assistance of one staff member to complete this task. Review of a care plan for ADL assistance dated 9/16/2022 revealed an intervention for, .One assist with ADLs . During a surveyor interview during the initial tour on 10/3/2022 at approximately 9:00 AM, the resident's family revealed the resident does not get showers as scheduled. S/he further revealed that since the resident was admitted to the facility s/he had only 2 showers. The resident was supposed to get a shower on the first shift last Wednesday, but s/he did not get it. The family member revealed that last Wednesday, the resident's hair was greasy, and s/he had to ask the second shift staff to give him/her a shower. Record review of the Unit Shower Schedule indicates the resident is to receive a shower on Wednesday and Sunday on the 7:00 AM-3:00 PM shift. Record review of the nursing assistant (NA) task titled POC [point of care] Response History from 9/11/2022 through 10/4/2022 failed to reveal evidence that the resident received showers twice weekly as per the shower schedule and/or that s/he had refused a shower. During a surveyor interview on 10/4/2022 at 12:09 PM with the Unit Manager Staff A, she revealed the NAs document in the record (under the task section) if they provide either a shower, a tub bath, or bed bath to their residents. NAs are to report to the nurse if their residents refuse a shower, tub bath or bed bath and the unit nurse will document in a nursing progress note. Additionally, Staff A was unable to provide evidence that the resident received showers twice weekly or that s/he was offered and refused a shower as per the shower schedule. During a surveyor telephone interview on 10/4/2022 at 2:27 PM with NA Staff C, he revealed he had taken care of the resident on multiple occasions on both the 7-3 and 3-11 shifts. Staff C revealed he worked during the 3:00 PM-11:00 PM on last Wednesday and gave a shower to the resident because the resident's family requested it. When questioned, Staff C revealed he documents in the record (task section) if he provided showers to a resident, or the resident refused. Additionally, Staff C revealed he would inform the unit nurse of resident's a refusal.

Based on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 5 residents observed relative to skin conditions, Resident ID #113. Findings are as follows: Record review of the facility policy titled, Skin Integrity & Pressure Ulcer/Injury Prevention and Management, last reviewed on 4/19/2022, states in part, .A skin assessment/inspection occurs on admission/readmission. Skin observations also occur throughout points of care provided by CNAs [certified nursing assistants] during ADL [Activities of Daily Living] care (bathing, .incontinent care, etc). Any change or open areas are reported to the nurse. CNAs will also report to nurse if topical dressing is identified as soiled, saturated, or dislodged. Nurse will complete further inspection/assessment and provide treatment if needed .skin cleansing with appropriate cleanser at the time of soiling and at routine intervals . Record review revealed the resident was admitted to the facility in August of 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set assessment dated revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating no cognitive impairment. During surveyor observations of the resident revealed a non-adhesive dressing without a date and a small amount of dark brown drainage noted through the dressing on the following dates and times: -10/3/2022 at approximately 10:00 AM -10/4/2022 at 4:26 PM Record review of the physician's orders failed to reveal evidence that a treatment was in place for his/her right forearm wound. Additionally, record review failed to reveal evidence that there was documentation of the wound's location, size, origin, and/or treatment. Further observation on 10/4/2022 at 4:38 PM revealed a wound on the resident's right forearm (approximately 1.25 centimeter (cm) in length and 1.25 cm in width). During a simultaneous interview with the resident at the time of the observation, s/he revealed that s/he has had the open area for a while and that staff applied the dressing to it. The resident further revealed s/he took the dressing off because it was dirty. Duting surveyor observation and interview on 10/5/2022 at 9:16 AM, with the Unit Manager, Staff A, revealed an open area on the resident's right forearm with dark red drainage. Staff A revealed she was unaware that the resident had an open area to his/her right forearm. Additionally, Staff A acknowledged there was no documentation or treatment in place for the resident's right forearm wound.