Every finding on record at Citrus Heights Respiratory and Rehabilitation

Based on observation, interview, review of clinical record, and review of facility policy and procedure, the facility failed to ensure the presence of complete and readily accessible medical records for 17 out of 23 residents sampled residents (#22, #26, #43, #124, #125, #136 #137, #138, #143, #144, #146, #148, #149, #151, #154, #155, #157). The deficient practice could lead to a lack of historical data for the residents impacting their care. Findings included: On review of the residents' records in the facility's electronic health system, significant discrepancies were identified, as resident records dated prior to March 1, 2025, were not available. Requests for documentation were made on March 11, 2026, at 9:00 a.m., 9:20 a.m., and 11:10 a.m.; however, these requests for care plans, nursing progress notes, and five-day reports were unsuccessful. The facility stated that it was not in possession of documents dated prior to March 1, 2025. However, according to the State Authority (S.A.) Minimum Data Set (MDS), the residents listed below had been admitted to the facility on the following dates: Resident #148 A request for the facility's investigation report was made on March 11, 2026, at 9:20 a.m.; however, the facility indicated that it was not in possession of the requested records. Further attempts to access Resident #148's clinical records in the electronic health record (EHR) system were unsuccessful during the survey. However,according to the S.A MDS assessment, the resident had been admitted to the facility on [DATE]. Resident #149 A review of Resident #149's clinical records in the EHR revealed significant discrepancies. No care plan was available for May 2024, and no nursing progress notes corresponding to the alleged dates were found. Additional documentation, including task records, was also absent. A request was made on March 11, 2026, at 9:00 a.m. for the care plan and nursing progress notes related to the time of the alleged incident; however, the request was unsuccessful. The facility stated that it was not in possession of these documents. However, according to the S.A MDS assessment, the resident had been admitted to the facility on [DATE]. Resident #124 and Resident #97 A resident-to-resident altercation between Resident #124 and Resident #97 was reported on March 26, 2024. The earliest care plan available for Resident #97 was dated March 1, 2025, and the earliest nursing progress notes in the EHR were dated March 5, 2025. A request was made on March 11, 2026, at 9:20 a.m. for care plans and nursing progress notes corresponding to the time of the allegation; however, the request was unsuccessful. The facility stated that it was not in possession of such records. Resident #124 was not identified in the facility's EHR system. A request for a face sheet on March 11, 2026, at 9:20 a.m. was unsuccessful, and the facility reported that it was not in possession of such documentation. Additionally, a request for the facility's five-day investigation report was unsuccessful, with the facility again stating that it was not in possession of the records. No clinical records for Resident #124 were found in the EHR, and no care plan for Resident #97 corresponding to the date of the allegation was available. However, according to the S.A. MDS assessment, Resident #124 had been admitted to the facility on [DATE], and Resident #97 had been admitted on [DATE]. Resident #151 and Resident #43 A resident-to-resident altercation between Resident #151 and Resident #43 was reported on November 13, 2023. A review of records revealed no nursing progress notes corresponding to the timeframe of the incident. Nursing progress notes for Resident #151 began on February 24, 2025, and for Resident #43 began on March 1, 2025. A request for the facility's investigation report on March 11, 2026, at 9:20 a.m. was unsuccessful, and the facility stated that it was not in possession of such records. At the time of the survey, both residents remained at the facility. However, the S.A. MDS assessment stated, Resident #151 had been admitted on [DATE], and Resident #43 had been admitted on [DATE]. Resident #26 An investigation into a complaint involving the alleged misappropriation of Resident #26's financial resources were reported on July 7, 2023. A review of the medical record indicated that no care plan had been in place for 2023, and nursing progress notes were only available beginning March 1, 2025. An initial request was made on March 11, 2026, at 11:10 a.m. for progress notes, a care plan, and a five-day report covering June through August 2023. A second request was made at 3:10 p.m. on the same date; however, the facility responded that it was not in possession of these documents. According to the S.A. MDS assessment, the resident had been admitted to the facility on [DATE]. Resident #154 A fall incident involving Resident #154 was reported on May 30, 2023. Upon review of the facility's EHR system, the resident's name was not found. A request for clinical records on March 11, 2026, at 9:00 a.m. was unsuccessful. The facility stated that it was not in possession of such information, particularly for incidents occurring prior to March 1, 2025. According to the S.A. MDS assessment, the resident had been admitted to the facility on [DATE]. Resident #22 It was alleged that the resident reported to a state surveyor that he had been attacked by another resident on or about February 28, 2023. A review of records indicated that the MDS and care plan corresponding to the dates of the allegation were not available. The earliest MDS on record was dated March 6, 2023, and the earliest care plan was dated February 22, 2025. Requests were made on March 11, 2026, at 11:10 a.m. and again at 3:10 p.m. for progress notes and care plans covering December 2022 through January 2023; however, the facility stated that it was not in possession of these documents. According to the S.A. MDS assessment, the resident had been admitted to the facility on [DATE]. Resident #157 and Resident #144 A resident-to-resident altercation was reported on January 15, 2023. Upon review of the EHR, no documentation was found for Resident #144. A request made on March 11, 2026, at 9:00 a.m. indicated that Resident #144 had never resided at the facility. No MDS or care plan dated on or prior to January 15, 2023, was found. The earliest care plan in the EHR was dated February 24, 2025, and nursing progress notes were not available prior to March 1, 2025. However, the S.A. MDS assessment, Resident #157 had been admitted on [DATE], and Resident #144 had been admitted on [DATE]. Resident #155 An allegation that the resident's benefit funds had been misused was reported on May 25, 2023. A review of the facility's EHR system did not locate any records for this resident. A request for clinical records on March 11, 2026, at 9:00 a.m. was unsuccessful. The facility stated that it was not in possession of such information, particularly for incidents occurring prior to March 1, 2025. According to the S.A. MDS assessment, the resident had been admitted to the facility on [DATE]. Findings include: A record request was submitted for grievance logs on March 10, 2026 at 3:00 PM for the years of 2023, 2024 and 2025. The facility responded with a written statement from staff #11, Administrator, noting that the grievance logs for 2023 and 2024 were not in the facility's possession and that the logs for January 2025 and February 2025 were also not in their possession. A secondary record request was submitted to the facility on March 11, 2026 at 9:00 AM for medical records for residents #137, #136, #138, #146, #143, #144 and #125. Staff #11 responded with a written statement that none of the residents noted, resided at Citrus Heights. Documentation regarding the following residents (#137, #136, #138, #146, #143, #144, #125) was obtained through iQIES (Internet Quality Improvement and Evaluation System) for data submitted to CMS (Centers for Medicare and Medicaid Services) specific for resident submissions at this facility. iQIES is a web-based system that collects and analyzes patient assessment data such as the MDS (minimum data set) submitted by skilled nursing facilities and was specific for residents residing at this facility. -Regarding Resident #137 Review of the electronic health records (EHR) revealed no evidence of resident #137. Resident #137 was admitted on [DATE] with diagnosis including schizophrenia. A review of the discharge MDS (minimum data set) with a discharge date of February 20, 2024 revealed no documented BIMS (brief interview of mental status score). -Regarding Resident #136 Review of the EHR revealed no evidence of resident #136. Resident #136 was admitted on [DATE] with diagnosis including atrial fibrillation, hypertension, hyperlipidemia, thyroid disorder, arthritis, anxiety disorder and Parkinson's disease. A review of the comprehensive MDS with an assessment reference date of February 16, 2024 revealed a BIMS score of 15, indicating that the resident was cognitively intact. -Regarding Resident #138 Review of the EHR revealed no evidence of resident #138. Resident #138 was initially admitted on [DATE] with diagnosis including anemia, diabetes mellites, hyperlipidemia, non-Alzheimer's dementia, depression, psychotic disorder, schizophrenia, asthma and respiratory failure. A review of the quarterly MDS with an assessment reference date of October 5, 2023 revealed a BIMS score of 12, indicating moderate cognitive impairment. -Regarding Resident #146 Review of the EHR revealed no evidence of resident #146. Resident #146 was readmitted on [DATE] with diagnosis including peripheral vascular disease, diabetes mellitus, malnutrition, and anxiety disorder. A review of the quarterly MDS with an assessment reference date of March 21, 2023 revealed a BIMS score of 15, indicating that the resident was cognitively intact. -Regarding Resident #143 Review of the EHR revealed no evidence of resident #143. Resident #143 was initially admitted on [DATE] with diagnosis including peripheral vascular disease, diabetes mellitus, anxiety disorder and psychotic disorder. A review of the quarterly MDS with an assessment reference date of April 25, 2023 revealed a BIMS score of 13 indicating that the resident was cognitively intact. -Regarding Resident #144 Review of the EHR revealed no evidence of resident #144. Resident #144 was readmitted on [DATE] with diagnosis including coronary artery disease, heart failure, hypertension, orthostatic hypotension, renal insufficiency, neurogenic bladder, diabetes mellitus and hyperlipidemia. A review of the quarterly MDS with an assessment reference date of April 13, 2023 revealed a BIMS score of 7 indicating severe cognitive impairment. -Regarding Resident #125 Review of the EHR revealed no evidence of resident #125. Resident #125 was admitted on [DATE] with diagnosis including anemia, coronary artery disease, heart failure, hypertension, peripheral vascular disease and renal insufficiency. A review of the quarterly MDS with an assessment reference date of November 15, 2021 revealed a BIMS score of 15 indicating that the resident was cognitively intact. An interview was conducted on March 12, 2026 at 11:03 PM with staff #104, Medical Records Supervisor. Staff #104 stated that there were no medical records available for residents that were admitted and discharged prior to March 1, 2025. She further stated that some records for current residents in the facility, that were admitted prior to March 1, 2025, may also not be available. She stated that the expectation for medical record retention, to include facility generated incident reports as well as the 5-day investigative reports, is to keep the records for 10 years. She further stated that there were no paper copies available of either the incident reports or 5-day investigations for any alleged incidents. Staff #104 further stated that she no idea what the previous owners of the facility had done with the paper records and that the facility is unable to reach them as they relocated to another country. Staff #104 stated that she did not start her current role as medical records supervisor until August of 2025 and that she was not part of the transition process during the change of ownership. Staff #104 stated that going forward she would maintain records for a 10-year time frame and then archive them. She stated that the risk for not maintaining and being able to access resident records, incident reports and 5-day investigations could include legal ramifications and potential findings during a state survey. An interview was conducted on March 12, 2026 at 12:37 PM with staff #11, Administrator. The Administrator stated that an ownership transfer of the facility took place on March 1, 2025. Staff #11 stated that when he became the Administrator of this facility on March 1, 2025 and walked into the building he had 'zero' access and no physical records. Staff #11 stated in addition to medical records not being available for those residents that were admitted and discharged prior to the change of the ownership date, the incident reports as well as 5-day investigations prior to March 1, 2025 were also not available. He stated that the expectation was to maintain resident medical records for 10-years. He stated that upon transfer of ownership, the expectation would have been to have access to all resident records within the 10-year time frame. Staff #11 stated that going forward, all records would be retained according to facility policy. Staff #11 stated that the risk for not maintaining the records or having access to the records could include a lack of resident history and a lack of a clear picture of what the resident's needs are. A review of the facility's policy titled Documentation and Charting with a revision date of October 2025 revealed that it is the facilities policy to provide a complete account of the resident's care, treatment, response to care, signs, symptoms, as well as the progress of the resident's care. A review of the policy titled Record Retention Schedule with a revision date of November 2024 revaled that resident medical records need to be retained for 10 years and that all investigations need to be retained for 5 years.

Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure that three residents (Residents #4, #50, and #60) medications were administered per physician's orders of three residents sampled. The universe was 113. The deficient practice could result in unnecessary use of opioids. Findings include: Regarding Resident #4 Resident #4 was admitted to the facility on [DATE] with diagnoses that included nontraumatic subdural hemorrhage, unspecified, extradural and subdural abscess, and cognitive communication deficit. Review of the baseline care plan initiated on February 12, 2026 revealed a focus indicating Resident #4 was prescribed an opioid medication with interventions that included to administer the opioid medication as prescribed. Further review of the care plan revealed a focus indicating acute/chronic pain related to the head and abdominal areas. Interventions included to follow the pain scale and to medicate as ordered, monitor and record pain characteristics such as quality, severity, anatomical location, onset, duration, and aggravating/relieving factors.Review of the 5-day minimum data set (MDS) dated [DATE] revealed Resident #4 had a brief interview for mental status (BIMS) score of 0 indicating the resident had a severe cognitive impairment. Review of the MDS revealed Resident #4 required moderate to maximum assistance with personal hygiene and activities of daily living (ADLs). Further review of the MDS revealed the resident was on a PRN (as needed) opioid medication with a pain scale score of ten at the time of assessment. Review of a physician's order revealed an order for oxycodone hydrochloride (HCl) (opioid) five milligrams (MG) with a start date of February 20, 2026, to administer one tablet by mouth every six hours as needed for a pain scale rating of four through ten. Review of the medication administration record (MAR) for February 2026 revealed the following days in which oxycodone HCl five MG was administered with the corresponding numeric pain level. February 21, 2026 at 8:28 a.m., reported pain scale of one February 21, 2026 at 4:09 p.m., reported pain scale of oneFebruary 26, 2026 at 8:35 a.m., reported pain scale of zero February 26, 2026 at 3:23 p.m., reported pain scale of oneFebruary 27, 2026 at 9:37 a.m., reported pain scale of oneFebruary 28, 2026 at 8:03 a.m., reported pain scale of oneFebruary 28, 2026 at 3:03 p.m., reported pain scale of one Review of the medication administration record (MAR) for March 2026 revealed the following days in which oxycodone HCl five MG was administered with the corresponding numeric pain level. March 5, 2026 at 8:09 a.m., reported pain scale of zeroMarch 5, 2026 at 2:09 p.m., reported pain scale of oneMarch 6, 2026 at 7:46 a.m., reported pain scale of oneMarch 6, 2026 at 4:48 p.m., reported pain scale of oneMarch 7, 2026 at 9:01 a.m., reported pain scale of oneMarch 7, 2026 at 6:16 p.m., reported pain scale of oneRegarding Resident #50 Resident #50 was re-admitted to the facility on [DATE] with diagnoses that included lymphedema, muscle weakness (generalized), and hereditary and idiopathic neuropathy, unspecified. Review of the baseline care plan initiated on July 30, 2025 revealed a focus indicating Resident #50 was prescribed an opioid medication related to complaints of pain in the right thigh and knee. Interventions included to administer opioid medications. Review of the quarterly Minimum Data Set, dated [DATE] revealed Resident #50 had a BIMS score of 14, indicating the resident was cognitively intact. Review of the MDS revealed Resident #50 was dependent on staff for all personal cares and activities of daily living (ADLs). Further review of the MDS revealed the resident to be on scheduled and PRN pain medications, including opioids, with a pain scale rating of five out of ten at the time of the assessment. Review of a physician order revealed an order for oxycodone HCl ten MG, with a start date of August 15, 2025, to administer one tablet by mouth every four hours as needed for a pain scale rating of five through ten. Review of the MAR for February 2026 revealed the following days in which oxycodone HCl ten MG was administered with the corresponding numeric pain level. February 5 2026 at 8:56 a.m., reported pain scale of zeroFebruary 5, 2026 at 12:58 p.m., reported pain scale of oneFebruary 6, 2026 at 8:27 a.m., reported pain scale of one February 7, 2026 at 8:37 a.m., reported pain scale of one February 7, 2026 at 6:25 p.m., reported pain scale of two February 13, 2026 at 9:33 a.m., reported pain scale of twoFebruary 13, 2026 at 5:30 p.m., reported pain scale of oneFebruary 14, 2026 at 11:36 a.m., reported pain scale of one February 19, 2026 at 8:22 a.m., reported pain scale of zeroFebruary 19, 2026 at 5:15 p.m., reported pain scale of oneFebruary 20, 2026 at 4:58 pm., reported pain scale of one February 21, 2026 at 9:02 a.m., reported pain scale of one February 21, 2026 at 2:47 p.m., reported pain scale of one February 26, 2026 at 9:33 a.m., reported pain scale of zero February 26, 2026 at 5:20 p.m., reported pain scale of one February 27, 2026 at 8:58 a.m., reported pain scale of one Review of the MAR for March 2026 revealed the following days in which oxycodone HCl ten MG was administered with the corresponding numeric pain level. March 5, 2026 at 7:51 a.m., reported pain scale of twoMarch 7, 2026 at 9:13 a.m., reported pain scale of zero Regarding Resident #90Resident #90 was admitted to the facility on [DATE] with diagnoses that included a fracture of an unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing, encephalopathy unspecified, and muscle weakness (generalized). Review of the comprehensive care plan initiated on January 1, 2026 revealed a focus indicating Resident #90 to be prescribed an opioid medication for pain with interventions that included to administer opioid medications as prescribed. Further review of the care plan revealed a focus of acute/chronic pain with interventions that included following the pain scale to medicate as ordered and complete a pain assessment every shift. Review of the 5-day MDS dated [DATE] revealed Resident #90 had a BIMS score of 3, indicating a severe cognitive impairment. Review of the MDS revealed Resident #90 required maximum assistance and/or was fully dependent on staff with personal cares and ADLs. Review of the MDS revealed Resident #90 to have received as needed pain medications with a pain scale rating of eight out of ten. Further review of the MDS revealed Resident #90 to have received opioid medications. Review of a physician's order revealed an order for oxycodone HCl five MG, with a start date of January 1, 2026, to administer one tablet by mouth every six hours as needed for a pain scale rating of four through six. Review of a physician's order revealed an order for oxycodone HCl five milligrams, start date of January 1, 2026, to administer two tablets by mouth every six hours as needed for a pain scale rating of seven through ten. Review of the MAR for February 2026 revealed the following days in which one oxycodone HCl five milligram tablet for a pain scale rating of four through six, was administered with the corresponding numeric pain level. February 7, 2026 at 4:26 p.m., reported pain scale of three February 21, 2026 at 7:56 a.m., reported pain scale of one February 27, 2026 at 7:55 a.m., reported pain scale of oneFebruary 28, 2026 at 7:45 a.m., reported pain scale of one Review of the MAR for February 2026 revealed the following days in which two oxycodone HCl five MG tablets for a pain scale rating of seven through ten, were administered with the corresponding numeric pain level.February 5, 2026 at 6:54 p.m., reported pain scale of zeroFebruary 6, 2026 at 6:45 a.m., reported pain scale of zeroFebruary 7, 2026 at 7:46 a.m., reported pain scale of one February 13, 2026 at 10:25 a.m., reported pain scale of one February 14, 2026 at 8:51 a.m., reported pain scale of one February 19, 2026 at 8:39 a.m., reported pain scale of zeroFebruary 19, 2026 at 2:39 p.m., reported pain scale of one February 26, 2026 at 7:43 a.m., reported pain scale of zeroReview of the MAR for March 2026 revealed the following days in which one oxycodone HCl five MG tablet for a pain scale rating of four through six, was administered with the corresponding numeric pain level. March 5, 2026 at 9:36 a.m., reported pain scale of one Review of the MAR for March 2026 revealed the following days in which two oxycodone HCl five MG tablets for a pain scale rating of seven through ten, were administered with the corresponding numeric pain level.March 6, 2026 at 10:56 a.m., reported pain scale of one March 7, 2026 at 7:15 a.m., reported pain scale of one An interview was conducted on March 12, 2026 at 9:13 a.m. with a licensed practical nurse (LPN/Staff #109). Staff #109 stated to monitor pain, staff use facial expressions, pain scale rating, and behaviors to assess a resident's pain level. Staff #109 stated staff can only administer as needed pain medications when a resident asks for it and the pain type is within the ordered parameters. Staff #109 stated nursing staff must document the numeric pain scale rating when administering medications. Staff #109 further stated the risks associated with not administering opioid medications as ordered could lead to addiction and over-sedation. An interview was conducted on March 12, 2026 at 12:53 p.m. with a LPN (Staff #182). Staff #182 stated she would always ask the resident to rate their pain and if the resident is nonverbal assess the pain based on the resident's behaviors. Staff #182 stated she would administer as needed pain medications when the resident is showing signs and symptoms of pain or if they are asking for the pain medication and it is within the provider's set parameters. Staff #182 stated staff will try to avoid administering pain medications by utilizing non-pharmalogical interventions such as repositioning. Staff #182 further stated that the risks of not administering pain medications as ordered or not assessing pain correctly could lead to an opioid addiction and could escalate to the level of neglect. An observation of Resident #4's MAR for March 2026 with Staff #182 was made on March 12, 2026 at 1:02 p.m. Staff #182 stated that upon initial review, it appeared the nurse who administered oxycodone HCl 5 mg did not follow the ordered parameters. Staff #182 further stated that the nurse may have documented the administration incorrectly; however, she was unable to make that determination based on the information available.An interview was conducted on March 12, 2026 at 1:37 p.m. with the Director of Nursing (DON/Staff #144). Staff #144 stated the expectation for nurses when administering high-risk medications such as narcotics is to ensure there is a valid physician's order, follow all ordered parameters, and document per facility policy. Staff #144 stated nurses assess residents' pain using a standard pain scale of one through ten and administer lighter pain medications, such as tylenol, for lower pain ratings (generally 1-3), and stronger medications, including narcotics, for higher pain ratings (generally 6-10), though ranges may vary based on physician orders and patient response. Staff #144 stated that nurses are required to remove the medication from the blister pack, document the medication in the MAR and narcotic sign-out sheet, record that the resident took the medication, document the pain scale rating at the time of administration, and include any non-pharmacological interventions (NPIs) provided. Staff #144 also noted that nurses must follow parameters when determining whether to administer or hold a medication and may notify the physician if a dosage adjustment is needed. Staff #144 further stated that risks associated with improper administration include giving medication when it is not needed, however, scheduled medications do not really have any risks.An observation of Resident #4's MAR for March 2026 with Staff #144 was made on March 12, 2026 at 1:52 p.m. Staff #114 confirmed oxycodone HCl five MG was given outside of parameters, however, indicated the staff administering the medication must have documented incorrectly. Upon review, Staff #144 stated that the documentation and administration of medications for Resident #4 did not meet expectations and that medications should not be administered outside of parameters and that nurses are required to document correctly. Staff #144 indicated that additional staff training may be necessary.Review of the Oral Medication Administration policy last reviewed September 2024 revealed the facility will accurately prepare, administer, and document oral medications.

Based on observation, interview, review of clinical record, and review of facility policy and procedure, the facility failed to ensure medications were administered and stored according to policy for one resident (#36), out of 23 sampled. The universe was 113. The deficient practice could result in overdose, negative medication interactions and other residents having unrestricted access to medications.Findings include:Resident #36 was admitted on [DATE] with diagnosis including major depressive disorder, single episode, anxiety disorder, neuromuscular dysfunction of the bladder, dependence on respirator (ventilator) status, morbid obesity, obstructive sleep apnea, polyneuropathy, chronic diastolic congestive heart failure, chronic respiratory failure with hypoxia and bradycardia.A review of the quarterly MDS (minimum data set) dated December 18, 2025 revealed a BIMS (brief interview of mental status score) of 15, indicating that the resident was cognitively intact. A review of the physician order revealed no evidence of an order for the resident to self-administer medications.A review of the care plan revealed no evidence that the resident was authorized to self-administer medications.A review of the EHR (electronic health record) revealed no evidence that resident was assessed for medication self-administration.An observation was conducted on March 10, 2026 at 11:14 AM in the resident's room. A bottle of Zinc 50 mg was observed on the resident's bedside table. The bottle had both the resident's name and room number written on it. Additionally, a bag of Halls, cherry flavored menthol cough drops was also observed on the resident's bedside table. The resident stated that had both since admission.An interview was conducted on March 10, 2026 at 11:30 AM with staff #52, CNA (Certified Nursing Assistant.) Staff #52 stated that a medication is anything prescribed by a doctor to help alleviate pain or make the resident feel better. Staff #52 further stated OTC's (over the counter), including vitamins, could also be considered medications. Staff #52 stated that residents can't have medication at their bedside unless they have an order in place for medication self-administration. She stated that no one on the current unit, where resident #36 was residing, was authorized to self-administer medications. Staff #52 stated that cough drops would be a medication as well as zinc, if taken orally. Staff #52 stated that she checks for medications at bedside each time she enters a resident's room. Staff #52 stated that the risks for medications at bedside would be few, contingent on how long the medications have been there. Staff #52 entered the resident's room looked at the zinc and halls and stated that these should not have been there, but would ask the nurse on duty to confirm.An interview was conducted on March 10, 2026 at 11:38 AM with staff #15, RN (Registered Nurse). Staff #15 stated that a medication can include things used to care for a resident. She stated that a medication can be prescribed of over the count and that medications can come in pill form, but they can also be topicals, inhaled or injected. Staff #52 stated that both zinc and cough drops would be considered medications and would require an order to self-administer. Staff #52 stated that if a medication is identified at bedside, it is removed and she would then inform the unity manager. She further stated that she checks for medications at bedside, each time she enters the room. She stated the risk for unauthorized medications at bedside could include residents taking medication without staff's knowledge. Staff #15 checked the EHR for resident #36 and stated that there was no evidence of an order for zinc taken orally and that there was no evidence of an order for the cough drops either.An interview was conducted on March 11, 2026 at 11:24 AM with staff #112, RN/ Unit Manager. Staff 112 stated that residents can't have medications at bedside unless they have been assessed and an order is in place for the medication as well as the ability to self-administer the medication. Staff #112 stated that the risk for medications at bedside could include a resident taking too many.An interview was conducted on March 12, 2026 at 9:31 AM with staff #144, DON (Director of Nursing). Staff #144 stated that if a resident wanted to self-administer medication, they would let the staff know and an assessment would be conducted and if deemed to be able to self-administer medication then a lock box would be provided and it would also be care planned for the resident. Staff #144 stated that zinc was definitely a medication but stated that she wasn't sure about the cough drops and that it would depend on their ingredients. Staff #144 stated that the risk for having medications at bedside included not taking the medication as ordered and a potential with interaction with other medications.A review of the facility policy titled Self Administration of Medications with a review date of March 2025 revealed that upon admission all residents are informed of the right to self-amdinister medications and that if a resident desires to participate in self-administration, the IDT (interdisciplinary team) would assess and periodically re-evaluate the resident. The policy further revealed that if the resident is a candidate to self-administer medications, it would be documented in the 'chart'. The steps outlined in the policy included an initial review, IDT determination and then re-evaluation based on changes in the resident's status. The policy also noted that the storage and location of drug administration would comply with state and federal requirements for medication storage. Finally, the policy revealed that an appropriate notation of the determinations would be placed in the residents care plan.

Based on observations, staff interviews, and policy review, the facility failed to ensure food items in the kitchen and the nourishment refrigerator were labeled, dated, and stored correctly. The deficient practice could result in possible food-borne illnesses. Findings include: An initial kitchen observation was conducted on March 10, 2026 at 8:10 a.m. with the Dietary Supervisor (Staff #88). At this time an observation of the refrigerator and freezer units was conducted with Staff #88, the following was observed;Six piping bags filled with whipped cream, one of which was opened with no visible dates which was located in the refrigerator. A partially closed cardboard box which held bacon strips in a clear plastic bag, open and exposed to air which was located in the refrigerator. A partially closed cardboard box which contained a clear plastic bag of frozen burger patties, open and exposed to air, which was located in the freezer.An interview was conducted on March 11, 2026 at 8:21 a.m. with Staff #88. Staff #88 stated that the whipped cream should be dated and labeled. Staff #88 stated that they always store their bacon like that and have never had a problem with it. Staff #88 stated that the risks of incorrectly storing food could make people sick,An observation of the nourishment refrigerator on Station 1 - the behavioral unit, was conducted on March 10, 2026 at 8:25 a.m. with Staff #88. The following was observed;Trader Joe's buffalo chicken dip with no room number or datesSmall container of Fritos bean dip with no room number or datesBlack tupperware container with white rice with no room number or datesRe-used sliced peaches jar of which was filled with soup with no room number or datesHillshire farms roasted turkey breast deli meat container filled with bologna slices with no room number or datesBrown crusted and sticky substance on the floor outside of the refrigeratorWhite sticky substance on the shelving inside the refrigeratorSmall brown food crumbs inside the freezer An interview was conducted on March 11, 2026 at 8:33 a.m. with Staff #88. Staff #88 stated that what was observed in the nourishment refrigerator on the behavioral unit was not acceptable practice and there should be labels on those items. Staff #88 stated that one of the kitchen staff is expected to come in and clean out the fridges and make sure the foods are not expired. Staff #88 further stated that she did not have an answer as to why there are appropriate labels. An observation of the nourishment refrigerator on Station 4, was conducted on March 10, 2026 at 8:49 a.m. with the Dietary Director (Staff #27). The following was observed;Two lunch totes with no names, labels, or datesGlass tupperware container with a pink lid containing food that was unidentifiable Redbull energy drink with no names, labels, or datesAn interview was conducted on March 11, 2026 at 8:49 a.m. with Staff #27. Staff #27 stated that he was unsure of whose lunchboxes they were and that they may be staff lunch boxes. Staff #27 stated that staff should be storing their lunches in the break room and the nourishment refrigerator is for resident food only. Staff #27 stated residents are able to give food items to the certified nursing assistants (CNAs) and the CNAs are responsible for labeling the food correctly. Staff #27 stated the risks of storing staff food with resident food could result in cross-contamination. Staff #27 further stated that not discarding expired food items could result in food-borne illnesses. An interview was conducted on March 11, 2026 at 2:22 p.m. with the Administrator (Staff #11), a resource Registered Dietician (Staff #171), and Staff #88. Staff #88 stated staff are expected to have a received date, opened date, and a discard date on all food items. Staff #88 further stated there is a sheet taped outside of the fridge that includes specific dates for certain food items if staff need a reference and indicated that staff are shown this when orienting. Staff #11 stated the Dietary Director is expected to follow their policy regarding food safety. Review of the Policy and Procedure manual for Food Storage, last revised March 2025, revealed all foods should be covered, labeled, dated, and monitored to assure that foods will be consumed by their use by dates. Review of the Resident and Personal Food Storage Policy, last revised January 2025, revealed food brought by family members or friends will be handled according to food handling guidelines. Further review of the policy revealed food storage areas should be clean at all times.

Based on observations, interviews, and review of facility policy and procedures, the facility failed to ensure that appropriate infection prevention and control practices were followed regarding hand hygiene, and the use of proper personal protective equipment (PPE) when entering and cleaning a contact isolation room for 1(resident #84) of 2 sampled residents. The universe was 113. The deficient practice could result in the spread of infection. Findings include:- Regarding hand hygiene:An observation was conducted on March 11, 2026, at 12:56 PM, of a certified nursing assistant (CNA /Staff #95) as she passed out lunch trays to residents in the dining room of the locked unit. Staff #95 was observed moving a basket of laundry from a dining table, then redirected a resident by placing a hand on their shoulder. Immediately after, the CAN grabbed a lunch tray and delivered it to a resident. Staff #95 did not perform hand hygiene between contact with the resident and contact with the food tray. During an observation of the locked unit on March 11, 2026, at 1:02 PM, it was noticed that there were no hand sanitizer dispensers on the hallway walls, in resident rooms, or at the nurse's station. An interview was conducted on March 11, 2026, at 1:06 PM, with staff #95. Staff #95 stated she does not usually work on this unit and was not used to there not being accessible hand sanitizer. She further stated that another staff member had reminded her to perform hand hygiene. She stated that the expectation is that hand hygiene is performed so that residents do not get sick. An interview was conducted on March 11, 2026, at 1:09 PM, with a CNA (staff #47). Staff #47 confirmed there were no hand sanitizer dispensers in the unit, as this posed a risk to the resident population on the unit. He further stated that each staff member is equipped with their own personal hand sanitizer bottle for use. Staff #47 produced a bottle of hand sanitizer from his scrub pocket as evidence of this practice. Staff # 47 stated that hand hygiene should be performed between resident care, and further stated that this included passing trays to residents. An interview was conducted on March 12, 2026, at 2:24 PM with the Assistant Director of Nursing/Infection Preventionist (ADON /IP/Staff #49). Staff #49 stated that she conducts daily staff observations to verify that staff perform hand hygiene and follow other infection control practices. Staff #49 explained that staff are educated during orientation by the IP, and other department leaders are educated during daily meetings who in turn educate their employees on infection control protocols and procedures. Staff #49 said that CNAs with seniority would normally act as resources to newer staff members in terms of expectations regarding hand hygiene and other infection control practices.- Regarding the use of personal protective equipment (PPE) in a contact isolation room:Resident # 84 was admitted on [DATE], with diagnoses that included enterocolitis due to clostridium difficile (C. diff), dependence on renal dialysis, and acute respiratory failure with hypoxia. A physician order dated February 27, 2026 prescribed contact for C. diff. Per the order, all therapies, treatment, cares, and meals are in a single occupancy room every shift.A review of a physician order dated March 9, 2026 prescribed strict contact isolation precautions related to clostridium difficile. The order indicated the use of a gown and gloved. The order directed to wash with soap and water before leaving the room. An observation was conducted on March 12, 2026, at 11:48 AM of resident #84's room being cleaned. There was no signage outside of the room annotating the occupant's transmission-based precaution status. Further, there was no signage indicating which resident was the occupant of the room. A housekeeper (staff #100) was observed cleaning the floor and removing trash from the room. Staff #100 wore gloves, but no other PPE. An interview was conducted on March 12, 2026, at 11:49 AM with staff #100. Staff #100 stated that resident #84 was transferred to another room, but did not know when. The housekeeper was cleaning the room since she was informed that a new admission was being assigned to the room later in the day. Staff #100 stated there was no signage posted outside of the room before she entered. However, she indicated that she was aware that the room had been a transmission-based precaution room the day prior. The housekeeper stated that bleach is used to clean contact precaution rooms. Staff #100 noted that signage posted outside the room designated the type of transmission-based precautions to be followed. Staff #100 repeatedly stated that there was no sign posted, but that she used bleach to clean the room, and pointed to a chair she had sprayed with a bleach mixture. Staff #100 stated that she should wear a gown when cleaning a contact precaution room. When asked about the risk to a resident if infection control practices were not followed, staff #100 refused to answer. An interview was conducted on March 12, 2026, at 1:52 PM with the housekeeping supervisor (staff #16). Staff #16 stated that when cleaning isolation rooms, staff should wear the PPE indicated on the signage outside the door, which included gowns, shoe coverings, and/or masks. She was unaware how this is communicated to housekeeping staff if nursing staff remove signs without informing housekeeping staff. Staff # 16 said that a list of rooms and required precautions are communicated between her and the Infection Preventionist (IP). Staff #16 stated that the risks associated with not wearing the appropriate PPE while cleaning a contact isolation room include increased risk for contamination, and increased staff to resident transmission. An interview was conducted on March 12, 2026, at 2:24 PM with the Assistant Director of Nursing/IP (ADON/Staff #49). Staff #49 stated that she knew about the specific room in question regarding isolation rooms. Per the IP, the room had been deep cleaned the night prior by another nurse since housekeeping was not in the facility at that time. She was unsure of the time and pulled out her cellphone to confirm. Staff #49 said she believed the room was cleaned at approximately 9:00 PM based on text messages exchanged. The IP noted that she was unable to provide documentation confirming that the room was deep cleaned. Staff #49 stated that a deep clean entailed the use of the appropriate chemicals for certain organisms. The IP described a deep-cleaned room as ready for the next resident, free of trash on the floor, and cleaned by staff donning a gown. The facility policy titled IPCP (Infection Prevention and Control Program) Standard and Transmission-Based Precautions, reviewed March 2024, indicated that standard precautions were applied to the care of all residents, and included hand hygiene. Per the policy, contact precautions are used when a known infection can be spread by direct or indirect contact with a resident or their environment. Furthermore, contact precautions required a gown and gloves be worn during all physical interactions with a resident or their environment. PPE should be put on before entry to the room and should be taken off before exiting the room.Review of the facility policy titled, Infection Prevention and Control Program, reviewed August 2025, revealed that the facility must provide education and oversight to ensure hand hygiene is performed based on accepted standards. Further review revealed that staff were expected to conduct themselves and provide care to minimize the spread of infection. Review of the facility policy titled, Housekeeping Services, revised April 2025, revealed that the housekeeping supervisor is responsible for working with the infection preventionist to develop and maintain standards for cleaning. Further review revealed that housekeeping staff were expected to follow special procedures when handling infected or contaminated equipment and facility areas.

Based on staff interview, and review of the clinical record and facility policy, the facility failed to ensure that one resident (resident #90)was provided a pneumococcal vaccination. The deficient practice could result in a higher likelihood of developing pneumonia. Findings include:Resident # 90 was admitted on [DATE], with diagnoses that included fracture of the left femur, encephalopathy, and a need for assistance with personal care. Review of the resident consent for influenza, pneumococcal, and COVID-19 vaccination, dated January 2, 2026, revealed that the resident verbally consented to receiving the pneumococcal vaccination. The consent was signed by 2 nurses, one of which was identified to be the Infection Preventionist (staff # 49). Resident #90 did not sign the consent and it was noted that verbal consent was provided on the form. A review of the Medicare 5-Day Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. Further review of the MDS revealed that the pneumococcal vaccination was not offered. A review of the physician's orders revealed no evidence of an order to administer the pneumococcal vaccination. A review of the Medication Administration Record and Treatment Administration Record (MAR/TAR) from January 1, 2026 through present revealed no evidence that the pneumococcal vaccination was administered during the resident's current admission. An interview was conducted on March 12, 2026, at 2:24PM with staff #49. Staff #49 confirmed that the consent to receive vaccinations indicated that Resident #90 had consented to receive the pneumococcal vaccination. When asked to look through the physician's orders for this resident, staff # 49 stated that she knew there would not be an order for the vaccination because she was the one who ordered the vaccinations and she had not been informed that resident # 90 needed a pneumococcal vaccination. Staff # 49 further stated that this was a nursing error. On March 12, 2026 at approximately 3:35 PM, staff # 49 approached this writer to provide a new consent for vaccinations from resident # 90. The consent provided was dated March 12, 2026, and indicated that the resident no longer wished to receive vaccinations. Staff # 49 stated that she followed up with the resident and when asked if he still wished to receive the pneumococcal vaccination, he stated no. Review of the consent revealed an illegible signature from the resident, and per documentation, one nurse - Staff # 49 - witnessed the signature from resident #90. The facility policy titled Informed Consent, revised July 2022, indicated that as soon as any consent is signed, physician's orders should be implemented.

Number of residents sampled: Number of residents cited: 11F610 - TFFTE allegations of abuse were investigated for 11 residents.Based on clinical record review, facility documentation, State Agency (SA) database review, staff interviews, and facility policies and procedures, the facility failed to ensure that 11 allegations of abuse and neglect out of 67 sampled residents were thoroughly investigated in accordance with established policy. The facility's failure to conduct and maintain complete investigations had the potential to result in allegations of abuse and neglect not being fully evaluated, thereby increasing the risk that abuse and/or neglect could occur and remain unaddressed within the facility.Findings Included:Resident #148Review of SA records revealed that Resident #148 allegedly accused a nurse aide at the facility of loss of personal property on August 23, 2024. Facility staff reported that an internal investigation had been conducted immediately following the incident. A request for the facility's five-day investigation report was made on March 11, 2026, at 9:20 a.m.; however, the facility indicated it was not in possession of the requested documentation.Further attempts to access Resident #148's clinical records in the electronic health record (EHR) system were unsuccessful during the survey process. Upon request for EHR access on March 11, 2026, at 9:00 a.m., the facility stated that Resident #148 had never resided at Citrus Heights. However, according to the SA Minimum Data Set (MDS) assessment, the resident had been admitted to the facility on [DATE].Resident #149Resident #149 had been admitted on [DATE], with diagnoses including dementia with behavioral disturbances, bipolar disorder, anxiety disorder, depression, difficulty walking, generalized muscle weakness, and other comorbid conditions. The resident had been discharged on February 24, 2024.On May 24, 2024, a complaint was reported regarding the alleged misappropriation of property involving Resident #149. The report indicated that the resident's payee had exhausted the resident's financial account, resulting in an inability to pay for ongoing living expenses at the facility.A review of Resident #149's clinical records in the EHR revealed significant gaps and inconsistencies. No care plan was in place for May 2024, and no nursing progress notes corresponding to the timeframe of the alleged incident were available. Additional documentation, including task records, was also absent. A request made on March 11, 2026, at 9:00 a.m. for care plans, nursing progress notes, and supporting documentation related to the allegation was unsuccessful. The facility stated it was not in possession of the requested records. The lack of documentation limited the ability to determine whether the allegation had been appropriately investigated.Resident #124 and Resident #97A resident-to-resident altercation between Resident #124 and Resident #97 had been reported on March 26, 2024. It was alleged that on March 19, 2024, Resident #124 had been eating lunch in the dining room when Resident #97 approached and struck Resident #124's hand. Staff reported the residents were separated and that a facility investigation had been conducted.Resident #97 had been admitted on [DATE], with diagnoses including dementia, psychotic disturbances, mood and anxiety disorders, generalized muscle weakness, major depressive disorder, and other comorbid conditions, and remained in the facility at the time of the survey. The earliest nursing progress notes available in the EHR were dated March 5, 2025. A request made on March 11, 2026, at 9:20 a.m. for the facility's five-day investigation report and corresponding nursing documentation was unsuccessful, and the facility stated it was not in possession of such records.Resident #124 was not identified within the facility's EHR system. A request for a face sheet on March 11, 2026, at 9:20 a.m. was unsuccessful, and the facility reported it was not in possession of any documentation for this resident. Additionally, a request for the facility's five-day investigation report related to this incident was unsuccessful. The absence of records for both residents prevented verification that a thorough investigation had been completed.Resident #151 and Resident #43Review of SA records revealed that the facility reported a resident-to-resident altercation between Resident #151 and Resident #43 on November 13, 2023. Staff reported observing Resident #43 strike Resident #151 on the left shoulder with a hand.Resident #43 had initially been admitted in February 2020 and was readmitted on [DATE], with diagnoses including schizoaffective disorder, traumatic brain injury with depressive features, generalized anxiety disorder, major depressive disorder, bipolar disorder, and other comorbid conditions.Resident #151 had been admitted on [DATE], with diagnoses including a history of traumatic brain injury, anxiety disorder, depression, and other comorbid conditions. Both residents remained in the facility at the time of the survey.A review of clinical records revealed no nursing progress notes corresponding to the timeframe of the incident. Nursing documentation for Resident #151 began on February 24, 2025, and for Resident #43 began on March 1, 2025. A request for the facility's investigation report on March 11, 2026, at 9:20 a.m. was unsuccessful, and the facility stated it was not in possession of such records. The lack of contemporaneous documentation and investigation records prevented confirmation of an appropriate investigative process.Resident #26Review of SA records revealed that the facility reported an alleged misappropriation of financial resources involving Resident #26 on July 7, 2023. The facility indicated that an investigation had been conducted.Resident #26 had initially been admitted on [DATE], and was readmitted on [DATE], with diagnoses including hypertension without heart failure, history of transient ischemic attack and cerebral infarction without residual deficits, adjustment disorder, and other comorbid conditions. The resident remained in the facility at the time of the survey.A review of the medical record indicated that no care plan was in place for 2023, and nursing progress notes were only available beginning March 1, 2025. Requests made on March 11, 2026, at 11:10 a.m. and again at 3:10 p.m. for progress notes, care plans, and a five-day investigation report covering June through August 2023 were unsuccessful. The facility stated it was not in possession of these documents. The absence of records prevented validation of the facility's investigative actions.Resident #22Resident #22 had initially been admitted on [DATE], and was readmitted on [DATE], with diagnoses including traumatic brain injury, legal blindness, colostomy status, post-traumatic seizures, major depressive disorder, and schizoaffective disorder. The resident remained in the facility at the time of the survey.Review of SA records revealed that the resident reported to a state surveyor that he had been physically attacked by another resident on or about February 28, 2023, and that the alleged perpetrator had demonstrated aggressive behaviors toward other residents during that period.A review of records revealed that the MDS and care plans corresponding to the timeframe of the allegation were not available. The earliest MDS was dated March 6, 2023, and the earliest care plan was dated February 22, 2025. Requests made on March 11, 2026, at 11:10 a.m. and 3:10 p.m. for relevant documentation were unsuccessful. The facility stated it was not in possession of the requested records, limiting the ability to determine whether the allegation had been appropriately investigated and addressed.Resident #157 and Resident #144A complaint had been reported alleging that Resident #157 stated that his roommate, Resident #144, engaged in inappropriate sexual contact on the night of January 15, 2023.A review of the EHR revealed no documentation for Resident #144. Upon request on March 11, 2026, at 9:00 a.m., the facility stated that Resident #144 had never resided at Citrus Heights.Resident #157 had initially been admitted on [DATE], and was readmitted on [DATE], with diagnoses including hypertension, neurogenic bladder, paraplegia, depression, psychotic disorder, and other comorbid conditions. No MDS or care plan dated on or prior to January 15, 2023, was available. The resident had been discharged on November 10, 2025. The earliest care plan in the EHR was dated February 24, 2025, and nursing progress notes were not available prior to March 1, 2025. The absence of documentation prevented verification of the facility's response and investigation of the allegation.Resident #155On May 25, 2023, it was reported that Resident #155 attempted to access benefits through a nursing home insurance catalog and discovered that only fifty cents remained in the account. The resident alleged that the benefits had been misused.A review of the facility's EHR system did not identify any records for this resident. A request for clinical documentation on March 11, 2026, at 9:00 a.m. was unsuccessful. The facility stated it was not in possession of such information, particularly for residents or incidents occurring prior to March 1, 2025. The absence of records prevented verification of investigative actions taken by the facility.An interview with the facility's Administrator (Staff #11), conducted on March 12, 2026, at 12:37 p.m., revealed that the facility did not have access to medical records for residents prior to the change of ownership on March 1, 2025. Staff #11 further stated that the facility did not have access to five-day investigation reports or self-reported incidents, either electronically or in paper form, from the previous owner. Staff #11 indicated that the inability to access historical records resulted in a lack of resident history and an incomplete understanding of residents' needs.An interview with the Medical Records Supervisor (Staff #104), conducted on March 12, 2026, at 11:03 a.m., indicated that resident medical records, incident reports, and five-day investigation reports should be retained for ten years following discharge. Staff #104 stated that no paper records existed for residents prior to the change of ownership on March 1, 2025, and acknowledged that the absence of such records posed risks, including regulatory noncompliance and potential legal consequences.A review of the policy titled Abuse: Prevention of and Prohibition Against, last reviewed in September 2024, indicated that all allegations of abuse, neglect, misappropriation of resident property, and exploitation were required to be promptly reported and thoroughly investigated by the Administrator or designee. The policy outlined that investigations were to include interviews with the reporter, the resident, witnesses, and the alleged perpetrator, as well as a comprehensive review of all circumstances related to the allegation. The policy further required that all phases of the investigation be documented and maintained in accordance with confidentiality requirements.

Number of residents sampled:Number of residents cited: 11F609 - TFFTE that allegations of abuse were reported to the State Agency for 11 residents.Based on interviews, review of clinical records, and review of facility policies and procedures, the facility failed to ensure that allegations of abuse were reported to the state agency for 11 out of 67 sampled residents. The deficient practice could have led to allegations of abuse not being investigated thoroughly and in a timely manner.Findings Included:Resident #148 Resident #148 was involved in an altercation with a nurse aide at the facility regarding the loss of personal property on August 23, 2024. It was reported that the facility conducted an internal investigation immediately following the incident. A request for the facility's investigation report was made on March 11, 2026, at 9:20 a.m.; however, the facility indicated that it was not in possession of the requested records. Further attempts to access Resident #148's clinical records in the electronic health record (EHR) system were unsuccessful during the survey. The facility stated that Resident #148 had never resided at Citrus Heights, based on a request made on March 11, 2026, at 9:00 a.m. for EHR access.Resident #149 The resident had been admitted to the facility on [DATE], with diagnoses including dementia with behavioral disturbances, bipolar disorder, anxiety disorder, depression, difficulty walking, generalized muscle weakness, and other comorbid conditions. Resident #149 had been discharged on February 24, 2024. On May 24, 2024, a complaint was reported regarding the misappropriation of property involving Resident #149. The report indicated that Resident #149's payee had exhausted the resident's account, resulting in an inability to pay for living expenses at the facility.A review of Resident #149's clinical records in the EHR revealed significant discrepancies. There was no care plan in place for May 2024, and no nursing progress notes corresponding to the alleged dates were available. Additional documentation, including task records, was also absent. A request was made on March 11, 2026, at 9:00 a.m. for the care plan, nursing progress notes, or any other documents related to the time of the alleged incident; however, the request was unsuccessful. The facility stated that it was not in possession of these documents.Resident #124 and Resident #97 A resident-to-resident altercation between Resident #124 and Resident #97 was reported on March 26, 2024. It was alleged that on March 19, 2024, Resident #124 was eating lunch in the dining room when Resident #97 approached and struck Resident #124's hand. Staff separated the residents and conducted a facility investigation.Resident #97 had been admitted to the facility on [DATE], with diagnoses including dementia, psychotic disturbances, mood and anxiety disorders, generalized muscle weakness, major depressive disorder, and other comorbid conditions. At the time of the survey, Resident #97 remained at the facility. The earliest nursing progress notes found in the EHR were dated March 5, 2025. A request made on March 11, 2026, at 9:20 a.m. for the facility's 5-day report and related nursing progress notes was unsuccessful. The facility stated that it was not in possession of such records.Resident #124 was not identified in the facility's EHR system. A request for a face sheet on March 11, 2026, at 9:20 a.m. was unsuccessful, and the facility reported that it was not in possession of such documentation. Additionally, a request for the facility's five-day investigation report related to Resident #124 was unsuccessful, with the facility again stating that it was not in possession of the records.Resident #151 and Resident #43 Review of State Agency (SA) records revealed the facility reported an alleged resident to resident altercation between Residents #43 and #151 on November 13, 2023. Staff reported observing one resident strike the other on the left shoulder with a hand.Resident #43 had initially been admitted in February 2020 and was readmitted on [DATE], with diagnoses including schizoaffective disorder, traumatic brain injury with depressive features, generalized anxiety disorder, major depressive disorder, bipolar disorder, and other comorbid conditions.Resident #151 had been admitted on [DATE], with diagnoses including a history of traumatic brain injury, anxiety disorder, depression, and other comorbid conditions. At the time of the survey, both residents remained at the facility.A review of records revealed no nursing progress notes corresponding to the timeframe of the incident. Nursing progress notes for Resident #151 began on February 24, 2025, and for Resident #43 began on March 1, 2025. A request for the facility's investigation report on March 11, 2026, at 9:20 a.m. was unsuccessful, and the facility stated that it was not in possession of such records.Resident #26 Review of SA records, revealed the facility reported an alleged misappropriation of financial resources for one resident (Resident #26) on July 7, 2023. The facility conducted an investigation regarding this allegation.Resident #26 had initially been admitted on [DATE], and was readmitted on [DATE], with diagnoses including hypertension without heart failure, a history of transient ischemic attack and cerebral infarction without residual deficits, adjustment disorder, and other comorbid conditions. At the time of the survey, the resident remained at the facility.A review of the medical record indicated that no care plan was in place for 2023, and nursing progress notes were only available beginning March 1, 2025. An initial request was made on March 11, 2026, at 11:10 a.m. for progress notes, a care plan, and a five-day report covering June through August 2023. A second request was made at 3:10 p.m. on the same date. The facility responded that it was not in possession of these documents.Resident #22 Resident #22 had initially been admitted on [DATE], and was readmitted on [DATE], with diagnoses including traumatic brain injury, legal blindness, colostomy status, post-traumatic seizures, major depressive disorder, and schizoaffective disorder. At the time of the survey, the resident remained at the facility.Review of SA records, revealed that Resident #22 reported to a state surveyor that he had been attacked by another resident on or about February 28, 2023. The allegation also included that the alleged perpetrator had exhibited aggressive behavior toward other residents during that time.A review of records indicated that the minimum data set (MDS) and care plan corresponding to the dates of the allegation were not available. The earliest MDS on record was dated March 6, 2023, and the earliest care plan was dated February 22, 2025. Requests were made on March 11, 2026, at 11:10 a.m. and again at 3:10 p.m. for progress notes and care plans covering December 2022 through January 2023. The facility stated that it was not in possession of these documents.Resident #157 and Resident #144 A complaint was reported alleging that Resident #157 stated that his roommate, Resident #144, had fondled his genitals on the night of January 15, 2023. Upon review of the EHR, no documentation was found for Resident #144. A request made on March 11, 2026, at 9:00 a.m. for records indicated that Resident #144 had never resided at Citrus Heights.Resident #157 had initially been admitted on [DATE], and was readmitted on [DATE], with diagnoses including hypertension, neurogenic bladder, paraplegia, depression, psychotic disorder, and other comorbid conditions. No MDS or care plan dated on or prior to January 15, 2023, was found. Resident #157 was discharged on November 10, 2025. The earliest care plan in the EHR was dated February 24, 2025, and nursing progress notes were not available prior to March 1, 2025.Resident #155 On May 25, 2023, it was reported that Resident #155 attempted to use his benefits through his nursing home insurance catalog and discovered that only fifty cents remained in his account. The resident alleged that his benefits had been misused.A review of the facility's EHR system did not locate any records for this resident. A request for clinical records on March 11, 2026, at 9:00 a.m. was unsuccessful. The facility stated that it was not in possession of such information, particularly if the resident or incident had occurred prior to March 1, 2025.An interview with Medical Records Supervisor, Staff #104 was conducted on March 12, 2026, at 11:03 a.m. Staff #104 stated that residents' medical records should be retained at the facility for ten years after discharge. Staff #104 further stated that incident reports and 5-day investigations were retained for ten years. Additionally, Staff #104 stated that there were no paper records for residents who had been at the facility prior to the change of ownership date on March 1, 2025. Staff #104 reiterated that the risks of not having residents' medical records included legal and state findings.An interview with the facility's Administrator, Staff #11 was conducted on March 12, 2026, at 12:37 p.m. Staff #11 stated that there were no medical records or access to medical records for residents prior to the date of the change of ownership on March 1, 2025. Staff #11 also stated that the facility had no access to any 5-day investigations or self-reports, either in the electronic health record system or as paper copies, from the former owner. Staff #11 stated that the risks of not accessing medical records included lack of patient history and lack of a clear understanding of residents' needs.A review of the policy titled Record Retention Schedule, revised in March 2025, indicated that resident health records were to be retained for 10 years from the date of the most recent discharge. The same policy indicated that all facility investigations were to be retained for 5 years. Additionally, a review of the facility's policy titled Abuse: Prevention of and Prohibition Against, revised in September 2024, indicated that each resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The policy further indicated that all allegations of abuse, neglect, misappropriation of resident property, or exploitation were to be reported immediately to the Administrator and appropriate state and federal agencies in accordance with applicable timeframes and regulations.

Number of residents sampled: Number of residents cited: 11F607 -TFFTE that the abuse policy was implemented following allegations of abuse for 11 residents.Based on clinical record review, staff interviews, review of facility documentation, policies and procedures, and the State Agency (SA) database, the facility failed to implement its policy regarding conducting thorough investigations of abuse and neglect allegations and protecting residents from further abuse for 11 out of 67 sampled residents. This deficient practice had the potential to result in continued abuse and/or neglect that was not prevented.Findings Included:Resident #148Review of the SA records revealed that Resident #148 reported that a nurse aide at the facility was involved with loss of personal property on August 23, 2024. It was reported that the facility conducted an internal investigation immediately following the incident. A request for the facility's investigation report was made on March 11, 2026, at 9:20 a.m.; however, the facility indicated it was not in possession of the requested records.Further attempts to access Resident #148's clinical records in the electronic health record (EHR) system were unsuccessful during the survey. Upon request for EHR access on March 11, 2026, at 9:00 a.m., the facility stated that Resident #148 had never resided at Citrus Heights. However, according to the S.A MDS assessment, the resident had been admitted to the facility on [DATE].Resident #149Review of SA records revealed that on May 24, 2024, a complaint was reported regarding the misappropriation of property involving Resident #149. The report indicated that the resident's payee had exhausted the resident's account, resulting in an inability to pay for living expenses at the facility.Resident #149 had been admitted on [DATE], with diagnoses including dementia with behavioral disturbances, bipolar disorder, anxiety disorder, depression, difficulty walking, generalized muscle weakness, and other comorbid conditions. The resident had been discharged on February 24, 2024.A review of Resident #149's clinical records in the EHR revealed significant discrepancies. No care plan was in place for May 2024, and no nursing progress notes corresponding to the dates of the alleged incident were available. Additional documentation, including task records, was also absent. A request made on March 11, 2026, at 9:00 a.m. for the care plan, nursing progress notes, and any supporting documentation related to the alleged incident was unsuccessful. The facility stated it was not in possession of these documents.Resident #124 and Resident #97A resident-to-resident altercation between Resident #124 and Resident #97 was documented in the SA records on March 26, 2024. It was alleged that on March 19, 2024, Resident #124 had been eating lunch in the dining room when Resident #97 approached and struck Resident #124's hand. Staff reported that the residents were separated and that a facility investigation had been conducted.Resident #97 had been admitted on [DATE], with diagnoses including dementia, psychotic disturbances, mood and anxiety disorders, generalized muscle weakness, major depressive disorder, and other comorbid conditions. The resident remained in the facility at the time of the survey. The earliest nursing progress notes available in the EHR were dated March 5, 2025. A request made on March 11, 2026, at 9:20 a.m. for the facility's five-day report and related nursing documentation was unsuccessful, and the facility stated it was not in possession of such records.Resident #124 was not identified in the facility's EHR system. A request for a face sheet on March 11, 2026, at 9:20 a.m. was unsuccessful, and the facility reported it was not in possession of such documentation. Additionally, a request for the facility's five-day investigation report related to this incident was unsuccessful, with the facility again stating it was not in possession of the records.Resident #151 and Resident #43Review of SA records revealed that the facility reported a resident-to-resident altercation between Resident #151 and Resident #43 on November 13, 2023. Staff reported that they observed Resident #43 strike Resident #151 on the left shoulder with an open hand.Resident #43 had initially been admitted in February 2020 and was readmitted on [DATE], with diagnoses including schizoaffective disorder, traumatic brain injury with depressive features, generalized anxiety disorder, major depressive disorder, bipolar disorder, and other comorbid conditions.Resident #151 had been admitted on [DATE], with diagnoses including a history of traumatic brain injury, anxiety disorder, depression, and other comorbid conditions. Both residents remained in the facility at the time of the survey.A review of records revealed no nursing progress notes corresponding to the timeframe of the incident. Nursing progress notes for Resident #151 began on February 24, 2025, and for Resident #43 began on March 1, 2025. A request for the facility's five-day investigation report on March 11, 2026, at 9:20 a.m. was unsuccessful, and the facility stated it was not in possession of such records.Resident #26Review of SA records revealed that the facility reported an alleged misappropriation of financial resources involving Resident #26 on July 7, 2023. The facility reported that an investigation had been conducted regarding this allegation.Resident #26 had initially been admitted on [DATE], and was readmitted on [DATE], with diagnoses including hypertension without heart failure, a history of transient ischemic attack and cerebral infarction without residual deficits, adjustment disorder, and other comorbid conditions. The resident remained in the facility at the time of the survey.A review of the medical record indicated that no care plan was in place for 2023, and nursing progress notes were only available beginning March 1, 2025. An initial request was made on March 11, 2026, at 11:10 a.m. for progress notes, a care plan, and a five-day investigation report covering June through August 2023. A second request was made at 3:10 p.m. on the same date. The facility stated it was not in possession of these documents.Resident #22Resident #22 had initially been admitted on [DATE], and was readmitted on [DATE], with diagnoses including traumatic brain injury, legal blindness, colostomy status, post-traumatic seizures, major depressive disorder, and schizoaffective disorder. The resident remained in the facility at the time of the survey.Further review of SA records revealed that Resident #22 reported to a state surveyor that he had been attacked by another resident on or about February 28, 2023. The allegation also included that the alleged perpetrator had exhibited aggressive behavior toward other residents during that time.A review of records indicated that the Minimum Data Set (MDS) and care plan corresponding to the timeframe of the allegation were not available. The earliest MDS on record was dated March 6, 2023, and the earliest care plan was dated February 22, 2025. Requests made on March 11, 2026, at 11:10 a.m. and again at 3:10 p.m. for progress notes and care plans covering December 2022 through January 2023 were unsuccessful. The facility stated it was not in possession of these documents.Resident #157 and Resident #144A complaint was reported alleging that Resident #157 stated that his roommate, Resident #144, had engaged in inappropriate sexual contact on the night of January 15, 2023.A review of the EHR revealed no documentation for Resident #144. Upon request on March 11, 2026, at 9:00 a.m., the facility stated that Resident #144 had never resided at Citrus Heights.Resident #157 had initially been admitted on [DATE], and was readmitted on [DATE], with diagnoses including hypertension, neurogenic bladder, paraplegia, depression, psychotic disorder, and other comorbid conditions. No MDS or care plan dated on or prior to January 15, 2023, was available. The resident had been discharged on November 10, 2025. The earliest care plan in the EHR was dated February 24, 2025, and nursing progress notes were not available prior to March 1, 2025.Resident #155On May 25, 2023, it was reported that Resident #155 attempted to access benefits through a nursing home insurance catalog and discovered that only fifty cents remained in the account. The resident alleged that the benefits had been misused.A review of the facility's EHR system did not identify any records for this resident. A request for clinical records on March 11, 2026, at 9:00 a.m. was unsuccessful. The facility stated it was not in possession of such information, particularly for residents or incidents occurring prior to March 1, 2025.An interview with the facility's Administrator (Staff #11), conducted on March 12, 2026, at 12:37 p.m., revealed that the facility did not have access to medical records for residents prior to the change of ownership on March 1, 2025. Staff #11 further stated that the facility did not have access to five-day investigation reports or self-reported incidents, either in the EHR or in paper form, from the previous owner. Staff #11 stated that the risks associated with not having access to medical records included lack of resident history and an incomplete understanding of residents' needs.An interview with the Medical Records Supervisor (Staff #104), conducted on March 12, 2026, at 11:03 a.m., indicated that resident medical records, incident reports, and five-day investigation reports should be retained for ten years following discharge. Staff #104 stated that no paper records existed for residents prior to the change of ownership on March 1, 2025, and acknowledged that the absence of such records posed risks, including legal and regulatory consequences.A review of the policy titled Abuse: Prevention of and Prohibition Against, last reviewed in September 2024, indicated that each resident had the right to be free from abuse, neglect, misappropriation of property, and exploitation. The policy stated that staff with knowledge of an actual or potential violation were required to report the information to the Administrator immediately and that the facility must identify and document abuse, neglect, exploitation, and misappropriation of resident property. The policy further indicated that indicators could include assessments, occurrences, patterns, and trends, such as resident-to-resident altercations, whether willful or accidental, with or without injury. The policy also stated that the facility was to respond immediately to protect alleged victims and preserve the integrity of the investigation, including examination of the alleged victim for signs of injury through physical and/or psychosocial assessment as indicated.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure that medical records were maintained for the regulated timeframe for one of three residents (#37). The deficient practice could result in incomplete documentation in resident medical records.Findings include: Review of an admission Minimum Data Set (MDS) that was submitted to the Centers for Medicare & Medicaid Services (CMS) and accepted on April 5, 2022, revealed that Resident #37 was admitted to the facility on [DATE]. The MDS also revealed that a Brief Interview for Mental Status (BIMS) was conducted with a score of 11, which indicated moderate cognitive impairment. The MDS further revealed that the resident exhibited verbal behaviors as well as other behavioral symptoms not directed towards others for one to three days. The MDS revealed that Resident #37 had active diagnoses of hypertension, diabetes mellitus, end-stage renal disease, hyperlipidemia, seizure disorder or epilepsy, anxiety, depression, and bipolar disorder. A request was made on February 24, 2026, at 10:25 a.m. for Resident #37's facesheet, medical diagnoses list, physician orders, Medication Administration Record/Treatment Administration Record (MAR/TAR) for her full stay, progress notes for her full stay, completed MDS, care plan, census list, and self reports or investigations, as well as a list of self-reports in 2022. The facility signed and verified on February 24, 2026, at 12:34 p.m. that Resident #37 was not a resident after March 1, 2025, and that they were unable to provide records for that resident. The facility signed and verified that they could not provide the list of self-reports in 2022 because they have no records from previous owner. An interview was conducted on February 24, 2026, at 10:46 a.m. with the Medical Records Director (Staff #45), who stated that the medical record would include the whole resident chart with insurance information, diagnoses, hospital records, or any form filled out during the resident's stay. The Medical Records Director further stated that the facility was expected to maintain resident records for 10 years, and the importance of maintaining the records was in case anything happened, for legal purposes, or if a surveyor or family member requested them. The Medical Records Director also stated that the risk of not maintaining the records was a legal risk, losing her job, and it posed a risk to the continuity of care, which could cause a delay in a resident's care if someone needed access to records but couldn't, and she gave an example of hospital records. An interview was conducted on February 24, 2026, at 11:58 a.m. with the Clinical Resource (Resource/Staff#34) and Registered Nurse Unit Manager (RN unit manager/Staff#11), who stated that they wrote on the request form that Resident #37 was not a resident at the facility, and they clarified that they could not confirm if she was a resident because they did not have access to the resident's medical records before March 1, 2025. The resource stated that they were talking with their lawyer to go after the company they acquired the facility from, and stated that they do not have access to the old records because the company with prior ownership did not pay the bill for their Electronic Medical Record (EMR). A telephonic interview was conducted on February 24, 2026, at 12:02 p.m. with the Director of Nursing, Staff #29, who stated that the medical record includes all of a resident's medical information, such as the facesheet, progress notes, care plan, information about billing, and more. The DON stated that medical records needed to be maintained for 10 years, but if she never had them, it would be hard to maintain them. The DON further stated that the importance of maintaining a residents medical record is so that you can look at the history of a patient if something comes up, and that the risk on not maintaining the medical record would be that it would be hard to find information about a resident if information was requests, and it would impact the resident because they wouldn't have access to their medical history. The DON stated that they did not have any paper or electronic records for Resident #37 because the prior owners quit paying for their EMR, and that no one could figure out how to get into their old system. The DON further stated that they would not have access to any resident records from before March 1, 2025, unless the resident was in the facility on or after that date. Review of a policy titled, Medical Record, Content of, was revised in May of 2022 and revealed that it was the policy of the facility to maintain a separate medical record for each resident admitted to the facility, and the resident's name would be placed on all medical record forms. The policy also revealed that the medical record should contain pertinent identification data to meet the facility's needs and accurately identify the resident would be recorded on admission updated periodically, and included, but were not limited to residents name, address, telephone number, date of birth , date of admission, physician's name and number, name, address, and telephone number of a resident's legal representative or interested family member. Review of a policy titled, Record Retention Schedule, was revised in November of 2024, and revealed the minimum retention requirements for skilled nursing facilities. The policy revealed that resident medical records needed to be retained for 10 years, and that all investigations needed to be retained for 5 years.

Based on clinical record review, staff interviews, facility policy review, and observation of current practice, the facility failed to ensure one resident's medications were obtained and administered as ordered by the physician. The deficient practice led to one resident not receiving prescribed antibiotics for eight days, delaying treatment of infection. Findings include: Resident #33 was admitted to the facility on [DATE], following a hospital stay, with diagnoses including persistent vegetative state, quadriplegia, and respiratory failure with hypoxia. Review of the hospital records revealed that Resident #33 had admitted to the hospital on February 6, 2025 for a malfunctioning G-tube. While at the hospital, the physician noted that the resident had been previously hospitalized for multilobar pneumonia and septic shock. The physician noted on February 11, 2025 that the resident's sepsis was originally severe, but had been improving with an antibiotic regimen of cefiderocol and newly added gentamicin. The physician also noted that the plan was to continue cefiderocol and gentamicin upon discharge, and the prescriptions had been ordered. Review of the hospital discharge orders revealed an order to administer cefiderocol 2 grams IV Piggyback, three times a day for 8 days. Further review of the discharge orders revealed an order to administer gentamicin 240 milligrams IV Piggyback every 24 hours for 10 days. These orders also gave instructions on what pharmacy to pick up the medication at. Review of the facility's physician orders revealed the following orders: Cefiderocol Sulfate Tosylate Intravenous Solution. Reconstituted 1 GM (Cefiderocol Sulfate Tosylate) Use 1 gram intravenously three times a day for Infection for 8 Days Discontinued. Start date: 02/13/2025. End date: 2/21/2025 Cefiderocol Sulfate Tosylate Intravenous Solution. Reconstituted 1 GM (Cefiderocol Sulfate Tosylate) Use 1 gram intravenously three times a day for UTI until 02/21/2025 15:59 Discontinued. Start date: 2/17/2025. End date: 02/21/2025 Gentamicin in Saline Intravenous Solution 2 MG/ML (Gentamicin in Saline). Use 240 mg intravenously one time a day for Infection for 10 Days. Gentamicin (gentamicin 100 mg/ 50 mL-NaCl 0.9% intravenous solution) Discontinued. Order date: 02/13/2025. Start date: 02/14/2025. End date: 02/24/2025 Gentamicin in Saline Intravenous Solution 2 MG/ML (Gentamicin in Saline). Use 240 mg intravenously one time a day for UTI for 10 Days gentamicin (gentamicin 100 mg/ 50 mL-NaCl 0.9% intravenous solution) Discontinued. Order date:02/17/2025. Start date: 02/18/2025. End date: 02/28/2025 Gentamicin in Saline Intravenous Solution 2 MG/ML. (Gentamicin in Saline) Use 240 mg intravenously one time a day for UTI until 02/24/2025 23:59 gentamicin (gentamicin 100 mg/ 50 mL-NaCl 0.9% intravenous solution) Active. Order date: 02/17/2025. Start Date: 02/18/2025. End date: 02/24/2025 Review of the Medication Administration Record for February 2025 revealed that no doses of Gentamicin or Cefiderocol were administered to Resident #33 between February 13, 2025 and February 18, 2025. Both orders were set originally to start on February 13, 2025. One dose of Cefiderocol was administered on February 19, 2025 at 6:00PM, and no doses of Gentamicin were administered on this date. Review of the nursing Medication Administration Notes revealed several notes stating that Gentamicin and Cefiderocol were on order and that the medications were unavailable. The nursing notes on February 14, 2025 revealed that Cefiderocol and Gentamicin IV medications were on order, and the NP was aware. The nursing note on February 15, 2025 revealed that these two medications were still not available, and that the provider and family were aware. A nursing note entered on February 18, 2025 revealed that the medications were still unavailable. The note revealed that the attending physician was notified, and a prescription order was sent to a different pharmacy. Nursing notes entered on February 19, 2025 revealed that the medications were still not obtained, and the nurse was attempting to order the medications. The nurse wrote that the provider, Director of Nursing (DON), and the resident's family were aware. Interview was conducted on February 20, 2025 at 10:34AM with Resident #33's Power of Attorney (POA) who confirmed that the resident had recently readmitted to the facility from the hospital. She stated that she was unaware of any issues obtaining the antibiotics needed to treat the resident. She also stated that the hospital had told her that they would not discharge the resident to the facility unless the facility was able to provide the needed antibiotics to the resident. The POA explained that she had some concerns about the resident's care and medications, but she was unable to reach the DON when she called, and no calls had been returned to her. Interview was conducted on February 20, 2025 at 11:08AM with a Pharmacist (Staff #291) from the pharmacy that was initially sent the order for the two antibiotics. The pharmacist stated that the timing of antibiotics is absolutely important, and that the pharmacy prioritizes filling antibiotics for this reason. The pharmacist stated that they received the orders for Resident #33's antibiotics on February 13, 2025. She then stated that their pharmacy does not fill those medications for Resident #33's insurance, and that several staff members from the facility, including the DON, were notified on February 14, 2025 via email that they would have to fill the order with the facility's other pharmacy service. Interview was conducted on February 20, 2025 at 11:31AM with a Licensed Practical Nurse (LPN/Staff #18), who explained that once an order is put in and activated, it is sent directly to the pharmacy. She stated that if the medications are not in the facility, it is expected to call and ask the pharmacy why the medication had not arrived. The LPN stated that if there is an issue getting the medication, the DON and provider are informed and the DON handles it from that point on. Interview was conducted on February 20, 2025 at 12:59PM with the [NAME] President of Quality and Operational Excellence (VP / Staff #304) from the second pharmacy to receive Resident #33's antibiotic orders. She confirmed that they had received an order from the facility for Resident #33's antibiotics on February 14, 2025. The pharmacy had then called the facility and spoke with an LPN (Staff #18), notifying them that they could not fill the orders, as the medications were outside of the formula of what their pharmacy provides. The VP then explained that the pharmacy received orders for both of the medications again on February 18, 2025, so the pharmacy had attempted to call the facility to speak with them. The pharmacy left a message with the receptionist detailing that these orders could not be filled on February 18, 2025. Interview was conducted on February 20, 2025 at 1:48PM with the Director of Nursing (DON/ Staff #27), who explained the process the nurses should take upon noticing a medication had not arrived from pharmacy is to call the pharmacy and notify the management. From there, the DON explained he would take over and contact pharmacy to see if there are issues with the fulfilment. When asked about Resident #33, the DON explained that the orders for the two antibiotics, Gentamicin and Cefiderocol, were originally sent to the first pharmacy on Thursday, February 13, 2025. On Friday, February 14, 2025, the DON stated that he talked to the pharmacy and referred the orders to the second pharmacy for fulfillment. The DON stated that both pharmacies were going back and forth with insurance authorizations. He explained that he next contacted the second pharmacy on Tuesday, February 18, 2025. He also spoke with the Nurse Practitoner (NP) on this date. He stated that he notified the NP that the facility was having difficulty obtaining antibiotics for Resident #33. The DON stated that the NP wanted the facility to wait for the antibiotics to be filled, and if they cannot be filled, the resident would be sent out. The DON could not provide a timeframe on how long the facility would wait for the medications, instead stating that the staff were monitoring the resident. The DON stated he had also inquired about using other antibiotics, but was told it was vital to use Gentamicin and Cefiderocol, due to the specific microbes needing to be treated. The DON explained that he had just received the cost of the medications from the pharmacy and had obtained approval for the facility to pay the cost of the medications through the first pharmacy this date, February 20, 2025. At this time, the facility was awaiting delivery of the medications. The DON elaborated that he educated the admission team to ensure that pre-authorizations are done prior to the resident arriving to the facility. The DON confirmed that the resident had been receiving both medications at the hospital, and identified that a delay in receiving these antibiotics could result in increased infection. Review of the facility policy titled, Administering Medications, indicated that medications shall be administered in a safe and timely manner, and as prescribed. The policy indicated that medications must be administered in accordance with the orders, including any required time frame. Review of the facility policy titled, Pharmacy Services- Role of the Provider Pharmacy, indicated that the provider pharmacy shall supply the facility with approved medications, biologicals, and supplies, as well as any compounded medications or investigational drugs that are needed. Review of the facility policy titled, Documentation of Medication Administration, revealed that if a medication is not administered, the Medical Doctor (MD) is to be notified as to why, including if the medication is not available. The policy indicated that in the event that medications that are prioritized to be critical of care are not given, including IV antibiotics, an immediate call to the MD should be made for further orders. This policy also indicated that documentation is to include the medication, dose and time scheduled, the reason for not administering, and the action plan for medication regimen.

Based on review of clinical records and policy, observations, and staff interviews the facility failed to ensure enhanced barrier precaution (EBP) policies, notably use of personal protective equipment (PPE) during wound care, were up-to-date with professional standards of practice. The deficient practice may result in development or transmission of infections within the facility. Findings include: An observation of wound care was conducted on June 13, 2024 at 08:40 AM with Certified Wound Nurse/Licensed Practical Nurse (LPN/Staff # 65) after verbal consent of approval by Resident # 89. Staff # 65 entered the room, drew curtain for privacy, and donned gloves. Staff # 65 did not wear a protective gown at this time. Staff # 65 stated the pressure ulcer right hip wound care was classified as a clean procedure; and that, was setting up supplies on medical stand. Staff # 65 utilized cleaning technique with sterile water, applied silver alginate onto the wound bed with clean dressing, and appropriately assessed pain before and after care. An interview was conducted on June 13, 2024 at 08:58 AM with Staff # 65 regarding enhanced barrier precautions (EBP). Staff # 65 stated that whenever a resident is on (EBP), staff are expected to wear gown and gloves when providing high contact care; and that, wound care was considered high contact care. Staff # 65 stated per facility policy, this only applies to wounds (stage III or greater), therefore it was unnecessary to wear a gown for wound care that was performed on Resident # 89. Staff # 65 confirmed that this is the current facility practice; and that, unless wound was staged III or greater, no gown was used during wound care of any resident in the facility at this time. An interview was conducted on June 12, 2024 at 09:50 AM with Director of Nursing (DON/Staff # 78) who stated was the designated Infection Preventionist (IP) after previous certified IP left the facility. Staff # 78 stated that EBP practice was based on the facility's policies; and that, only wounds stage III or greater require use of gowns. Staff # 78 stated that as of June 12, 2024, he did not hold any qualifying infection prevention certification or training in infection control. Staff # 78 reassured a qualified IP was presently in the hiring process; and that, a tentative start date of June 20, 2024 was planned for the prospective IP. An interview was conducted on June 14, 2024 at 01:16 PM with DON who stated after thorough review of CDC recommendations, was informed of the updated requirements for enhanced based precautions and the use of gowns during any wound care. Review of the facility's policy titled, Infection Control and Modified Enhanced Barrier Policy/Procedures (revised June 2018) revealed enhanced barrier precautions will be based on the Centers for Disease Prevention & Control (CDC) guidance. The CDC website on healthcare acquired infections revealed that the enhanced barrier precautions are an infection control intervention designed to reduce the transmission of resistant organisms that employ targeted gown and glove use during high contact resident care activities. The CDC further stated that nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDRO's (multi-drug resistant organisms). The CDC website further revealed that use of gown and glove for high-contact resident care activities is indicated when contact precautions do not otherwise apply; and that, because Enhanced Barrier Precautions do not impose the same activity and room placement restrictions as Contact Precautions, they are intended to be in place for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. Updated July 12, 2022.https://cdc.gov/hai/containment/ PPE-Nursing-Homes.html. 50595

Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to failed to report and allegation of abuse involving resident (#407) and failed to submit a 5-day written investigation to the state agency, and failed to complete a thorough investigation regarding an allegation of neglect involving resident #54. Findings include: Resident #407 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, delusional disorders, and respiratory failure. Review of the self-care deficit care plan, revealed that resident #407 required extensive assistance with ADIS related to dementia and respiratory failure dated January 3, 2023. Interventions included to use mechanical lift for transfers, wheelchair for long distance mobility, extensive assistance with bed mobility, total assistance with toileting, but it did not include a plan for bathing. The minimum data set (MDS) dated [DATE] included a brief interview for mental status (BIMS) score of 12 indicating the resident had a moderate cognitive disorder. It also included that the resident required a one-person extensive assist with bed mobility, transfers, dressing, personal hygiene, and physical help in part of the bathing activity. Review of staff #33's time card revealed that she worked on July 24, 2023 from 6:00 a.m. to 6:30 p.m. Review of the task sheets revealed that the resident received a shower on July 24, 2023. Review of a weekly skin check dated July 24, 2023 did not reveal brusing to resident #407's left arm. Review of a progress note dated July 25, 2023 revealed that during medication pass, the licensed practical nurse (LPN/staff #25), was called to the resident's room by the certified nursing assistant (CNA/staff #16). Staff #25 entered the room and staff #16 pointed to the resident's left arm and stated that the resident had a bruise on her arm. Staff #25 asked the resident what happened and the resident stated that the CNA gave me a shower and she was rough with me. The resident stated that this is how she got the bruise and she didn't want the CNA taking care of her anymore. Review of staff #33's employee file revealed a Corrective Action Memo dated July 25, 2023 for unsatisfactory customer service. Staff #33 received a verbal warning: education provided to staff on transfers by using a gait belt for 1-2 persons transfer and 2 person for mechanical lift. Staff #33 was educated on how to identify the process for a resident transfer by looking at the ICSP in the POC for each resident. An interview was conducted on August 15, 2023 at 9:47 a.m. with the Director of Nursing, who stated that the resident was bruised on the forearm when (CNA/staff #33) was pulling the resident's sweater on. She stated that she spoke to the resident and the resident is fragile, so the allegation did not meet the definition of abuse. She stated that the resident did identify staff #33 as the alleged perpetrator. She did not report the incident or submit a 5-day written investigation to the state agency. An interview conducted on August 15, 2023 at 11:01 a.m. with (LPN/staff #25), who stated that (CNA/staff #16) was with the resident and called her to look one larger bruise, the size of a quarter, and one smaller bruise next to it on the resident's arm. She stated that the resident told her that a staff grabbed her hand when she was in the shower and this was when the injury occurred. Staff #25 stated that the resident described staff #33. The resident was asked if it was staff #33 and the resident said, yes. Staff #25 stated that she reported the injury and allegation to the nurse coming on duty (LPN/staff #86) and staff #86 reported it to the DON. Staff #25 stated that she, the DON, and staff #86 went into the resident's room to interview the resident, while staff #33 remained in the hallway. During the interview, the resident stated that staff #33 was rough with her and grabbing her arm, while she was giving her a shower. She stated that after the resident was interviewed, she, staff #33, and staff #86 went to the DON's office. Staff #33 stated that when she was putting on the resident's sweater, the resident's arm got caught in the arm and reached in to pull the resident's arm through the sleeve. Staff #25 stated that staff #33 said the resident was making noises like ou, ou, ou. Staff #25 thought the sounds indicated the staff was being too rough. -Resident #54 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included morbid obesity, chronic kidney disease, and an anxiety disorder. Review of the care plan dated October 1, 2021 revealed an alteration in elimination due to a colostomy. Interventions included to empty the colostomy bag as needed, ensure that supplies are available, house bowel care protocol, monitor and document bowel movements and to respond to call-light promptly. Review of the care plan dated October 12, 2018 revealed a self-care deficit, which requires extensive assistance with activities of daily living (ADLs) related to weakness, debility, infection, pain, obesity, and refusal of care at times. Interventions included to gather and provide necessary materials and equipment for (ADLs) and to provide verbal cues, prompts, redirection and hand-over-hand assistance as needed. Review of the order summary revealed an order dated October 31, 2022 for colostomy care: wafer - change every 7 days and as needed. Date and initial wafer using correct bag size, cut wafer to around the stoma. Cleanse area around the stoma, pat dry and apply skin prep. Secure appliance every night shift every Sunday for colostomy care use size 4 in. Review of the facility investigation revealed that the (DON/staff #2) did not include information regarding the video taken by the resident during the incident, even though she was aware of the video and stated that she saw the video. On August 16, 2023 at 12:50 an interview was conducted with resident #54, who stated that she knows how to do the colostomy care. She is able to cut out the pattern and the holes in the wafer, but is not able to see if she is applying the wafer correctly and if the holes are not aligned, it will leak. She stated that staff #13 tried to make her put the wafer on by herself without washing her hands or giving her gloves. The resident stated that she told staff #13 that she couldn't see what she was doing and explained that the nurse is able to look directly down and line up the holes, but she can't see what she is doing. During the interview, the resident provided a video and a black woman with long hair could be heard saying she was here to train the resident and was not going to do the treatment, she told the resident that she could do it, they know she can. The staff said, do it. The staff was heard saying you need to do it. The resident was heard saying that she didn't have gloves and the staff didn't respond. The resident stated that staff #13 was trying to force her to remove the bag. The staff's tone was not encouraging or friendly and the resident stated that she felt staff was acting in a threatening manner. An interview was conducted on August 17, 2023 at 8:45 a.m. with the (DON/staff #2), who stated that neglect occurs when essential care is not provided for the resident. She stated that the resident has an order for ostomy care, and the resident is allowed to provide her own treatment if it is included in the physician's order. She also stated that if the resident is provided with education and training and says that he or she can't do it, or need help, it is her expectation that the staff complete the care/treatment. She stated that she reviewed the video the resident took and posted on YouTube when the incident occurred, but couldn't remember if the resident stated that she needed help, couldn't perform the task, didn't want to do it, or the resident asked for gloves. She stated that if gloves were not provided, it created a risk of infection. During the interview, she reviewed the investigation and stated that it didn't look like a second staff was present during the incident, which is required at all times. The facility's policy, Abuse and Neglect Policy, revised on October 2022 states that allegations that alleged violations involving neglect, exploitation, mistreatment, or misappropriation of resident property, and does not result in serious bodily injury must be reported within 24 hours and results of all investigations of alleged violations are to be complete within 5 working days of the incident.

Based on facility documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure one resident (#407) was not abused by staff (#33) and one resident (#54) was not neglected by staff (#13). The deficient practice could result in residents being physically and emotionally harmed and not receiving the services that are needed. Findings include: Resident #407 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, delusional disorders, and respiratory failure. Review of the self-care deficit care plan, revealed that resident #407 required extensive assistance with ADIS related to dementia and respiratory failure dated January 3, 2023. Interventions included to use mechanical lift for transfers, wheelchair for long distance mobility, extensive assistance with bed mobility, total assistance with toileting, but it did not include a plan for bathing. The minimum data set (MDS) dated [DATE] included a brief interview for mental status (BIMS) score of 12 indicating the resident had a moderate cognitive disorder. It also included that the resident required a one-person extensive assist with bed mobility, transfers, dressing, personal hygiene, and physical help in part of the bathing activity. Review of staff #33's time card revealed that she worked on July 24, 2023 from 6:00 a.m. to 6:30 p.m. Review of the task sheets revealed that the resident received a shower on July 24, 2023. Review of a weekly skin check dated July 24, 2023 did not reveal bruising to resident #407's left arm. Review of a progress note dated July 25, 2023 revealed that during medication pass, the licensed practical nurse (LPN/staff #25), was called to the resident's room by the certified nursing assistant (CNA/staff #16). Staff #25 entered the room and staff #16 pointed to the resident's left arm and stated that the resident had a bruise on her arm. Staff #25 asked the resident what happened and the resident stated that the CNA gave me a shower and she was rough with me. The resident stated that this is how she got the bruise and she didn't want the CNA taking care of her anymore. Review of staff #33's employee file revealed a Corrective Action Memo dated July 25, 2023 for unsatisfactory customer service. Staff #33 received a verbal warning: education provided to staff on transfers by using a gait belt for 1-2 persons transfer and 2 person for mechanical lift. Staff #33 was educated on how to identify the process for a resident transfer by looking at the ICSP in the POC for each resident. Review of staff #33's time card revealed that she worked on July 25, 2023 through July 28, 2023. An interview was conducted on August 15, 2023 at 9:47 a.m. with the Director of Nursing (DON/staff #2), who stated that the resident was bruised on the forearm when (CNA/staff #33) was pulling the resident's sweater on. She stated that she spoke to the resident and the resident is fragile, so the allegation did not meet the definition of abuse. She stated that the resident did identify staff #33 as the alleged perpetrator. An interview conducted on August 15, 2023 at 11:01 a.m. with (LPN/staff #25), who stated that (CNA/staff #16) was with the resident and called her to look one larger bruise, the size of a quarter, and one smaller bruise next to it on the resident's arm. She stated that the resident told her that a staff grabbed her hand when she was in the shower and this was when the injury occurred. Staff #25 stated that the resident described staff #33. The resident was asked if it was staff #33 and the resident said, yes. Staff #25 stated that she reported the injury and allegation to the nurse coming on duty (LPN/staff #86) and staff #86 reported it to the DON. Staff #25 stated that she, the DON, and staff #86 went into the resident's room to interview the resident, while staff #33 remained in the hallway. During the interview, the resident stated that staff #33 was rough with her and grabbing her arm, while she was giving her a shower. She stated that after the resident was interviewed, she, staff #33, and staff #86 went to the DON's office. Staff #33 stated that when she was putting on the resident's sweater, the resident's arm got caught in the arm and reached in to pull the resident's arm through the sleeve. Staff #25 stated that staff #33 said the resident was making noises like ou, ou, ou. Staff #25 thought the sounds indicated the staff was being too rough. An interview was conducted on August 15, 2023 at 1:48 p.m. with (CNA/staff #35), who stated that she assisted (CNA/staff #33) with the resident, who was in the shower in July, but didn't remember the exact day. She stated that staff #33 opened the bathroom door and asked her to help with the resident. She stated that she felt uneasy because usually resident #407 is easy and doesn't need someone else to help. She stated that staff #33 held the resident by standing in front of her with hands under her armpits and she stood behind the resident and pulled the resident's brief up. Staff #35 stated that knows the resident wasn't happy because she was complaining and fighting. She doesn't remember what the resident said, but the resident was in pain for sure, she knows that because the resident was saying things like ouch. She stated that the resident usually has pain, so you need to gentle with her, but she is not a hard to work with. When staff #35 was done helping, staff #33 told her to get out. Staff #35 stated that she knew staff #33 was upset because of the tone in her voice. She stated that she felt like something wasn't quite right. An interview was conducted on August 15, 2023 at 2:20 p.m. with resident #407, who stated that staff #33 yanked her up in the shower, hurt her arm and knee, and she got a bruise on her arm. She stated that she yelled in pain and the staff told her to shut-up. The resident identified staff #33. An interview was conducted on August 16, 2023 at 11:18 a.m. with (CNA/staff #33), who stated that she showered the resident and when she was dressing the resident, the resident's knitted sweater got caught on her left hand and she couldn't push it through, so she stuck her hand inside the opening of the arm of the sweater to pull the resident's arm through. Staff #33 stated that (CNA/staff #35) came into the bathroom to help her transfer the resident to her wheelchair. Staff #33 stated that staff #35 was standing on the resident's right side and she was standing on the resident's left side. She stated that both staff were facing the opposite direction of the resident and each put their arms under the armpit area to lift the resident. Staff #33 pulled the shower chair out, while staff #35 rolled the wheelchair behind the resident. She stated that they held the resident shoulder to shoulder and they were provided training after this happened on the correct way to transition a resident. She stated that they tried to do what she thought was safe, but the resident is fragile and they could have popped the resident's arm out of the socket. Staff #33 stated that the resident didn't yell when she was showering her, but she was being mouthy, and told staff #33 that she was stupid. Staff #33 stated that she is slowing down now because she does work fast and accidents can happen and sometimes she has too much strength and it could be too much for the resident. She stated that the day after the shower occurred, she came to work, and a CNA stated that the resident didn't want her in her room anymore and the resident had a bruise. The DON asked her what happened and then did the investigation right away. Staff #33 stated that it was substantiated that she had too much force when she grabbed the resident because the bruise was like a thumb print mark. -Resident #54 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included morbid obesity, chronic kidney disease, and an anxiety disorder. Review of the care plan dated October 1, 2021 revealed an alteration in elimination due to a colostomy. Interventions included to empty the colostomy bag as needed, ensure that supplies are available, house bowel care protocol, monitor and document bowel movements and to respond to call-light promptly. Review of the care plan dated October 12, 2018 revealed a self-care deficit, which requires extensive assistance with activities of daily living (ADLs) related to weakness, debility, infection, pain, obesity, and refusal of care at times. Interventions included to gather and provide necessary materials and equipment for (ADLs) and to provide verbal cues, prompts, redirection and hand-over-hand assistance as needed. Review of the order summary revealed an order dated October 31, 2022 for colostomy care: wafer - change every 7 days and as needed. Date and initial wafer using correct bag size, cut wafer to around the stoma. Cleanse area around the stoma, pat dry and apply skin prep. Secure appliance every night shift every Sunday for colostomy care use size 4 in. Review of the Treatment Administration Record (TAR) dated May 2023 revealed that colostomy care: wafer - change every 7 days and as needed. Date and initial wafer using correct bag size, cut wafer to around the stoma. Cleanse area around the stoma, pat dry and apply skin prep. Secure appliance every night shift every Sunday for colostomy care use size 4 in. treatment was provided on May 7, 2023 by staff #13. The (MDS) dated [DATE] included a brief interview for mental status score of 15 indicating the resident was cognitively intact. It also included that the resident had an ostomy and required a one-person extensive assist with toileting. Review of the task sheets dated May 2023 revealed that resident #54 had two bowel movements on May 7, 2023. It also revealed that care was to be provided to the resident in pairs. Review of the clinical record did not reveal an assessment for colostomy self-care. During an interview was conducted on August 16, 2023 at 10:00 a.m. with the MDS Coordinator (staff #17), she reviewed resident (#54's) MDS dated [DATE] and stated that in June 2023, the resident required a one-person extensive assist with toileting, which included ostomy care. Then she reviewed the colostomy care plan and stated that the resident required a one-person extensive assist with colostomy care. She explained that the amount of extensive assistance needed can change daily because the resident may want to participate some days, but not on other days. She also stated that it is the resident's right to choose not to participate in colostomy care. Staff #17 did not know to what extent the resident was able to participate in colostomy care and stated that she would have to ask a nurse and she is not aware of any formal training regarding colostomy care that is provided to the resident. On August 16, 2023 at 12:50 an interview was conducted with resident #54, who stated that she knows how to do the colostomy care. She is able to cut out the pattern and the holes in the wafer, but is not able to see if she is applying the wafer correctly and if the holes are not aligned, it will leak. She stated that staff #13 tried to make her put the wafer on by herself without washing her hands or giving her gloves. The resident stated that she told staff #13 that she couldn't see what she was doing and explained that the nurse is able to look directly down and line up the holes, but she can't see what she is doing. During the interview, the resident provided a video and a black woman with long hair could be heard saying she was here to train the resident and was not going to do the treatment, she told the resident that she could do it, they know she can. The staff said, do it. The staff was heard saying you need to do it. The resident was heard saying that she didn't have gloves and the staff didn't respond. The resident stated that staff #13 was trying to force her to remove the bag. The staff's tone was not encouraging or friendly and the resident stated that she felt staff was acting in a threatening manner. An interview was conducted on August 16, 2023 at 1:38 p.m. with the Assistant Director of Nursing (ADON/staff #13), who stated that the resident is supposed to be learning colostomy care and the resident did tell her that she couldn't see exactly where to place it. She stated that the resident is supposed to wear gloves and that she told the resident she would get her gloves. She stated that she never told the resident to do it. She stated that she told the resident she would help her to do it because the resident needed to be changed because it was messy. She stated that the resident has the right to request assistance. She also stated that there was supposed to be a second staff present during care and she was by herself. She stated that she listened to the video and there was nothing wrong with the tone of her voice. An interview was conducted on August 16, 2023 at 2:30 p.m. with the (DON/staff #2), who stated that they don't have an assessment for colostomy self-care for this resident. They don't do assessments. They teach and assist with care; this goes way back and the resident is able to do colostomy care, but just doesn't want to do it. She stated that she would look for documentation that the resident received training and is able to do colostomy care by herself. An interview was conducted on August 17, 2023 at 8:45 a.m. with the (DON/staff #2), who stated that neglect occurs when essential care is not provided for the resident. She stated that the resident has an order for ostomy care, and the resident is allowed to provide her own treatment if it is included in the physician's order. She also stated that if the resident is provided with education and training and says that he or she can't do it, or need help, it is her expectation that the staff complete the care/treatment. She stated that she reviewed the video the resident took and posted on YouTube when the incident occurred, but couldn't remember if the resident stated that she needed help, couldn't perform the task, didn't want to do it, or the resident asked for gloves. She stated that if gloves were not provided, it created a risk of infection. During the interview, she reviewed the investigation and stated that it didn't look like a second staff was present during the incident, which is required at all times. The facility's policy Abuse and Neglect Policy, revised October 2022 states that residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes, but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, neglect, deprivation of goods or services, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The facility's policy, Quality of Care, states that it is the policy of the facility to ensure it identifies and provides needed care and services that are resident centered, in accordance with the resident's preferences including colostomy care.

Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to implement their abuse policy, by failing to report an allegation of abuse, submit a 5-day written investigation involving resident (#407) to the state agency, and failed to suspend staff #33 from providing care to the resident involved or any other residents during the investigation. Findings include: Resident #407 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, delusional disorders, and respiratory failure. Review ot the self-care deficit care plan, revealed that resident #407 required extensive assistance with ADIS related to dementia and respiratory failure dated January 3, 2023. Interventions included to use mechanical lift for transfers, wheelchair for long distance mobility, extensive assistance with bed mobility, total assistance with toileting, but it did not include a plan for bathing. The minimum data set (MDS) dated [DATE] included a brief interview for mental status (BIMS) score of 12 indicating the resident had a moderate cognitive disorder. It also included that the resident required a one-person extensive assist with bed mobility, transfers, dressing, personal hygiene, and physical help in part of the bathing activity. Review of staff #33's time card revealed that she worked: -July 24, 2023 from 6:00 a.m. to 6:30 p.m. -July 25, 2023 from 6:00 a.m. to 6:30 p.m. -July 26, 2023 from 6:00 a.m. to 6:30 p.m. -July 27, 2023 from 6:00 a.m. to 6:00 p.m. -July 28, 2023 from 6:00 a.m. to 6:30 p.m. Review of the task sheets revealed that the resident received a shower on July 24, 2023. Review of a progress note dated July 25, 2023 revealed that during medication pass, the licensed practical nurse (LPN/staff #25), was called to the resident's room by the certified nursing assistant (CNA/staff #16). Staff #25 entered the room and staff #16 pointed to the resident's left arm and stated that the resident had a bruise on her arm. Staff #25 asked the resident what happened and the resident stated that the CNA gave me a shower and she was rough with me. The resident stated that this is how she got the bruise and she didn't want the CNA taking care of her anymore. Review of staff #33's employee file revealed a Corrective Action Memo dated July 25, 2023 for unsatisfactory customer service. Staff #33 received a verbal warning: education provided to staff on transfers by using a gait belt for 1-2 persons transfer and 2 person for mechanical lift. Staff #33 was educated on how to identify the process for a resident transfer by looking at the ICSP in the POC for each resident. An interview was conducted on August 15, 2023 at 9:47 a.m. with the Director of Nursing, who stated that the resident was bruised on the forearm when (CNA/staff #33) was pulling the resident's sweater on. She stated that she spoke to the resident and the resident is fragile, so the allegation did not meet the definition of abuse. She stated that the resident did identify staff #33 as the alleged perpetrator. An interview conducted on August 15, 2023 at 11:01 a.m. with (LPN/staff #25), who stated that (CNA/staff #16) was with the resident and called her to look one larger bruise, the size of a quarter, and one smaller bruise next to it on the resident's arm. She stated that the resident told her that a staff grabbed her hand when she was in the shower and this was when the injury occurred. Staff #25 stated that the resident described staff #33. The resident was asked if it was staff #33 and the resident said, yes. Staff #25 stated that she reported the injury and allegation to the nurse coming on duty (LPN/staff #86) and staff #86 reported it to the DON. Staff #25 stated that she, the DON, and staff #86 went into the resident's room to interview the resident, while staff #33 remained in the hallway. During the interview, the resident stated that staff #33 was rough with her and grabbing her arm, while she was giving her a shower. She stated that after the resident was interviewed, she, staff #33, and staff #86 went to the DON's office. Staff #33 stated that when she was putting on the resident's sweater, the resident's arm got caught in the arm and reached in to pull the resident's arm through the sleeve. Staff #25 stated that staff #33 said the resident was making noises like ou, ou, ou. Staff #25 thought the sounds indicated the staff was being too rough. The facility's policy, Abuse and Neglect Policy, revised on October 2022 states that allegations that alleged violations involving neglect, exploitation, mistreatment, or misappropriation of resident property, and does not result in serious bodily injury must be reported within 24 hours, results of all investigations of alleged violations are to be complete within 5 working days of the incident, and to suspend staff from providing care to the resident involved or any other residents during the investigation.

Based on observations, resident, resident representative, and staff interviews, and facility documentation, the facility failed to ensure that one resident's (#8) was free from sustaining injuries of unknown origin. Findings include: Resident #8 initially admitted on [DATE] with a reentry on 4/4/22 with diagnoses that included dementia, major depressive disorder, hemiplegia, and polyneuropathy. According to the Quarterly Minimum Data Set (MDS) assessment dated [DATE], the resident's mental status was unable to be assessed by an interview with her, due to both short term and long-term memory problems. Staff assessment showed severely impaired cognition. The resident had no recorded skin conditions. According to the MDS assessment, she was totally dependent on physical assistance from two persons in order to complete the Activities of Daily Living (ADL) of transferring. She had physical impairment on one side for lower extremity, and impairment on both sides for upper extremity. Resident #8 had an order to for skin checks to be completed weekly. According to the Medication Administration Record (MAR), the weekly skin check was not completed on the night shift on 6/22/23. According to her care plan initiated on 9/29/2022, Resident #8 was to have interventions due to dementia and incontinence, to help her achieve her goals. These interventions included a Body/skin audit at least weekly and reporting any red, open, or areas of concern to the wound nurse to evaluate. She was also care planned for ADL assistance due to self-care deficit related to dementia, cerebral vascular accident, and hemiplegia. Intervention for that goal was to use a mechanical lift for all transfers with the requirement of using 2 people with all transfers. A review of weekly skin checks showed no skin conditions noted on 6/9/23, 6/16/23, or 6/23/23 A review of the Certified Nursing Assistant (CNA) task log for transfers show in a 30 day look back period, on 6 occasions, the resident was transferred as a one person assist and not a two person assist (June 5, 8, 16, 22, 27, and 29) Incontinence care, which is required to be a two person change per CNA interviews and care plan, was completed with one staff 2 times on June 5th, 2x on the 8th, 2x on the 16th, 5x on the 22nd, 7x on the 27th, and 5x on the 29th. A physical therapy notes dated 6/22/2023 at 1:47pm, stated Patient seating assessment completed .Patient is non-ambulatory and requires mechanical lift for transfers. She has mobility limitations preventing the completion of mobility-related ADLs without the device. A further review of nursing progress notes shows that on 6/24/23 at 4:11pm, the nurse was called to common bathroom at the nurses' station by care nurse for this resident due to a bruise on resident's peri area and a scab on her left hand(wrist)area. Later that day at 4:13pm, the nurse noted resident has a bruise on her peri area bluish in color and a red dry scab on her left hand(wrist). At 4:35p, the physician was notified and staff was directed to monitor for any changes. On 6/26/2023 10:36am, the physician ordered an x-ray of the left him and pelvis area related to the bruising of unknown origin bruising in that area. During an interview with CNA's on 6/28/23, Staff #5 and Staff #22, they stated the provision of incontinence care should not ever cause bruising to that area. If it did, it would need to be reported to the nurse immediately, and they are trained for that. The nurse would complete the skin evaluation form in the electronic health record. Skin assessment are done by CNAs during showers and have nurses sign off on the shower sheet. Staff #22 stated she was aware the resident had bruising on her hip, but did not know where it came from. When she had come in on her first scheduled shift back, a Monday, she was shocked to see massive bruising on her hip during a brief change. She stated the bruising on her pelvic area and comes into the inner thigh. It was green/yellow and had apparently been found on Saturday. Staff #22 confirmed that Resident #8 is a two person change. During an interview on 6/28/23 at 1:15p with the Director of Nursing (DON) regarding the bruising on Resident #8, she stated when she saw it, it was yellow and healing and she did not see or know when bruising originally occurred. X-rays were ordered and did not show any concerns. They were unable to determine start point- it was wrapping around left hip, into pelvic area. During a phone interview on 7/3/23 at 10:08am with Licensed Practical Nurse (LPN), Staff #42 (who was the first nurse the bruising was reported to) stated that she recalled a bluish bruise when the CNA came and got her. The bruise was on pubic area only, and did not spread to inner leg, thigh, or hip. She stated I know that when a bruise first starts, it is not usually blue, so this is a bruise that was already healing. I do not think it was fresh. I have no idea how she got it. A skin assessment had been done the day before, but not by her. If the resident had bruising then, it would of course have been documented on the skin check. She stated she did not know if Resident #8 is a mechanical lift, but if a resident is ordered to be a mechanical lift, then it would not be okay to do a stand and pivot or manual lift. In a follow up interview with the DON on 7/3/23 at 10:38a, she stated her expectations for staff if a resident is a mechanical lift would be to only do a 2-person mechanical transfer unless therapy has deemed they can be 2-person pivot. This would be documented in the resident care plan. Regarding documentation of bruising, her expectation is for nursing staff to report if they find a concern outside of a scheduled weekly skin check. It will be reported by CNAs to the nurses and DON notified. It is nurses who document completed skin checks. The bruising on Resident #8 is something she would have expected to see documented on a skin check. In her experience and estimation, with Resident #8's age and conditions, it would have taken approximately 3 days for the bruise to have healed to the color she saw it at initially. The DON stated that she expected her staff to understand the geriatric population and provide the safest possible level of cares when completing transfers in order to preserve resident safety and prevent injury. She would not generally expect bruising from a pivot, unless the resident lost balance and needed to be propped up. A review of the facility's abuse policy revealed it is required to protect residents from abuse by anyone including but not limited to staff, residents, consultants, volunteers, outside agency staff, family members, friends, visitors, etc.; As well as require training to cover abuse prevention to staff. Policy stated they must identify and report all types of abuse including unknown injury-report in 2 hours, and complete an investigation within 5 days.

Based on clinical record review, facility documentation, staff interviews, and policy review, the facility failed to ensure four residents (#88, #66, #44, #99 and #22) were free of staff verbal abuse. The deficient practice could result in an unsafe resident environment. Findings include: -Resident #88 was admitted on [DATE] with a diagnosis of Quadriplegia. The quarterly MDS (Minimum Data Set) assessment dated [DATE] included a BIMS (Brief Interview for Mental Status) score of 15 indicating the resident had intact cognition. -Resident #66 was readmitted on [DATE] with diagnosis of hemiplegia and hemiparesis. The annual MDS assessment dated [DATE] revealed the resident had a long-term and short-term memory problem and had av moderately impaired decision-making skills. -Resident #44 was admitted on [DATE] with diagnosis of spinal stenosis. The quarter MDS assessment dated [DATE] revealed the resident had a BIMS score of 11 indicating the resident had moderately impaired cognition. -Resident 99 was admitted on with diagnoses of stenosis of the larynx and type II diabetes. The quarterly MDS assessment dated [DATE] included a BIMS score of 15 indicating the resident had intact cognition. -Resident #22 admitted on [DATE] with diagnoses of acute and chronic respiratory along with anxiety disorder. The annual MDS assessment dated [DATE] revealed the resident had a BIMS score of 15 indicating the resident had intact cognition. The facility initial report dated March 9, 2023 included that activities staff was hosting an activity in the dining room on March 8, 2023 at 2:30 p.m. when CNA #48 came into the dining room and told multiple residents that if they wanted to be put back to bed and get changed before dinner, the residents had to come now. Per the report, CNA #48 stated that the residents can either eat dinner in shit and piss or come with CNA #48 to get changed. The facility follow-up report dated March 13, 2023 included the following reports from the residents: -Resident #44 reported that CNA #48 came into the dining room and told 4 residents that they had to go to their rooms now to be laid down or would have to wait until the second shift to be laid down.; -Resident #88 reported that the CNA wanted the resident to go back to their rooms from the activity to be put to bed and if they did not go, the residents would have to stay up until 6:30 p.m. Per the documentation, resident #88 chose to go because she cannot stay up that long. Resident #88 also reported that she wanted to stay in the activity but did not feel that she had a choice.; -Resident #22 reported that the CNA came into the dining room where the residents were having activities and told three other residents that they needed to go with him now to be changed or sit in the shit and piss until 6:30 when the next shift gets here and can change them; and to pick your (referring to the residents) poison. Resident #22 reported that she wished the CNA would have talked to the residents differently and pulled the residents on the side to discuss with them individually. Further, resident #22 reported that this made her nervous and upset; -Resident #99 reported that they were playing UNO in the dining room when CNA #48 came in and made an announcement that the residents either play UNO or go to be or the residents will have to wait until the next shift. Per the documentation, resident #88 reported that CNA #48 said you are my priority; and that, the CNAs attitude was like he was in charge. The report also included that at a later time, resident #99 shared that CNA #48 said that they would be left in their piss and shit while they eat dinner if they did not go with him now. Further, resident #99 said that she did not like the way CNA #48 talked to the other residents; but, since it was not directed at her, she was okay.; -Per the documentation, resident #66 was present during the incident but was non-interviewable. Continued review of the report included an interview conducted by the facility with CNA #48 who stated he did not tell the residents that they needed to go with him now or wait to be changed until the next shift. The report included that CNA #48 admitted to telling the residents to pick your poison; but denied telling the residents that they would be left in their shit and piss until the next shift. Further, the documentation included that CNA #48 reported that he was trying to make sure everyone was changed and ready for dinner before the trays came out and the next shift arrived. The facility concluded that the allegation of abuse had been substantiated by the facility Review of the personnel file of CNA #48 revealed that the CNA received in-service training on Elder Justice Act, abuse and neglect on May 10, 2022. Per the documentation, the termination date for CNA #48 was March 10, 2023 due the verbal abuse incident on March 8, 2023. Multiple attempts to interview resident #22 was conducted on March 22, 2023 but was unsuccessful because resident #33 was out of facility at an appointment. An interview with resident #44 was conducted on March 22, 2023 at 12:05 p.m. Resident #44 stated he was told by CNA #48 to leave now or be up until night shift arrives. An interview was conducted on March 22, 2023 at 12:45 p.m. with the activity staff (#24) who stated that on Wednesday on march 8, 2023 close to 3:30 p.m., there were 6 residents playing an Uno game in the dining room when CNA #48 walked in and told the residents sorry to interrupt. Staff #24 said that CNA #48 pressured the residents to leave now or they will put to bed by night shift. He stated that on his way out of the activity room CNA #48 told the residents they would either have to leave now or eat dinner sitting in their shit and piss. In an interview with another activity staff (#60) conducted on March 22, 2023 at 1:00 p.m., staff #60 stated there were 10 residents playing Uno in the dining room on March 8, 2023 at 2:30 p.m. Staff # 60 stated that CNA #48 came in at 3:30 p.m. and told the residents that they need to come with him if they need to be changed or they can stay and play the game and have to wait until 6:30 p.m. to be changed for dinner. Staff #60 further stated that CNA #48 told the resident that they can either eat dinner in shit or come with him. During an interview with vice president of clinical services (VP/Staff #36) conducted on March 22, 2023 at 11:30 a.m., staff #36 stated that they were going over the grievances form the day before when she noticed a couple of complaints regarding CNA #48 from the residents. She stated that she then went to inquire if CNA #48 was working and was told yes. Staff #36 stated that she immediately suspended CNA #48 on March 9, 2023 until the investigation was completed. Further, staff stated that CNA #48 had been terminated and was reported to the nursing board on March 13, 2023. A review of the facility's abuse policy revealed that residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes, but not limited to freedom from corporal punishment, involuntary seclusion, verbal, sexual, psychosocial neglect, deprivation of goods or services, financial, physical abuse, and physical or chemical restraint not requires to treat residents' symptoms. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.

Based on clinical record reviews, staff interviews, and facility policies and procedures, the facility failed to ensure a baseline care plan was developed for two residents (#98 and #393). The deficient practice could result in resident's not receiving basic care and services to meet their needs. Findings include: -Resident #98 was admitted on [DATE] with diagnoses of type 1 diabetes mellitus without complications and adrenocortical insufficiency. Review of the clinical record revealed the resident was prescribed with insulin sliding scale. However, there was no evidence found in the clinical record that a baseline care plan for diabetes or blood glucose monitoring was developed with interventions. During an interview conducted with the Director of Nursing (DON/staff #149) on February 9, 2023 at 12:12 p.m., the DON stated that care plans are developed to meet resident care needs; and that, the care plans are based on hospital records, assessments, observations, provider orders, and changes in conditions. Further, the DON stated that residents with diabetic monitoring and falls would have a care plan initiated. 47341 -Resident #393 was admitted on [DATE] with diagnoses of acute respiratory failure, pulmonary disease, and anemia. Review of the clinical record revealed no evidence that a baseline care plan was developed with interventions until February 8, 2023. During an interview with social services director (staff #108) conducted on February 8, 2023 at 1:10 p.m., staff #108 stated that she complete care conferences within 5 days of resident admission. Regarding resident #393, the social services director stated that she had noticed the resident did not have a care plan. She stated that she put a section on social services is because she noticed that baseline care plan had not been done since resident admission. An interview with Director of Nursing (DON/staff #149) was conducted on February 8, 2023 at 3:32 p.m. The DON stated that care plans are completed upon admission; and that, baseline care plan will be printed, signed, and scanned back into their chart. In an interview with medical records director (staff #106) conducted on February 9, 2023 at 2:12 p.m., staff #106 stated that the ADON (assistant DON) gave her the baseline care plan on February 8, 2023 and was instructed to scan it in the electronic record. Staff #106 said that typically her process involves picking the baseline care plan from the baskets in the nursing unit, and scan them into the chart immediately daily. During an interview with the ADON (staff #28) conducted on February 9, 2023 at 2:20 p.m., the ADON stated the baseline care plan is usually completed by the interdisciplinary team (IDT) after resident admission. Regarding resident #393, the ADON stated that the resident was admitted on a weekend and because of the survey, the resident's baseline care plan was missed. The ADON stated that the standard practice if for base line care plan to be initiated and signed in the first 48 hours of resident admission. A facility care plan titled Care Plans - Baseline (revised December 2016) included that a baseline plan of care to meet the resident's immediate needs shall be developed for each resident with forty-eight (48) hours of admission. The policy is to assure that the resident's immediate care needs are met and maintained a baseline care plan will be developed with forty-eight (48) hours of resident's admission.

Based on observations, clinical record review, interviews, policy and manufacturer guidelines, the facility failed to ensure physician was notified as ordered of the status of one resident (#98); and failed to ensure medication was administered as ordered by the physician for one resident (#33). The deficient practice could result in resident not receiving the medication to meet and treat their needs. Findings include: -Resident #98 was admitted on [DATE] with diagnoses of type 1 diabetes mellitus without complications and DiGeorge's syndrome. Review of the physician order recap revealed the orders to call the physician if BS (blood sugar) is 0-70 mg (milligrams)/dl (deciliter) and if BS is 351 mg/dl or higher. Review of the clinical record from November through December 2021revealed BS readings >351 mg/dl on the following dates: -November 5 = 393 mg/dL; -November 7 = 398 mg/dL; -November 17 = 363 mg/dL; -November 18 = 405 mg/dL and 389 mg/dL; -November 19 = 369 mg/dL; -November 20 = 392 mg/dL; -November 23 = 358 mg/dL; -November 24 = 516 mg/dL; -November 25 = 387 mg/dL and 500 mg/dL; -November 26 = 390 mg/dL and 451 mg/dL; -November 30 = 550 mg/dL; -December 4 = 373.0 mg/dL; and, -Decmber 5 = 351.0 mg/dL. Despite documentation of BS >351 mg/dl, there was no evidence found in the clinical record that the physician was notified of these BS readings as ordered. An interview was conducted on February 9, 2023 at 11:07 a.m. with a licensed practical nurse (LPN/staff #202) who stated that if the blood sugar level was high, she would notify the provider as ordered. Staff #202 stated that notifications to the provider are documented in the clinical record. Staff #202 also stated that when the blood sugar is high enough to call the provider, the provider usually gives another dose of insulin and the staff would recheck the blood sugar in 30 minutes. During an interview conducted with the Director of Nursing (DON/staff #149)bon February 9, 2023 at 12:12 p.m., the DON stated the expectation was that staff would to follow physician orders. The DON stated that blood sugars are checked as ordered and if the result was elevated the staff should recheck the blood sugar and report it to the provider. The DON stated that the notification to the provider should be documented in the clinical record; and that, if it was not documented, it was not done. 47179 -Resident #33 was readmitted on [DATE] with diagnoses that included cellulitis of chest wall, hypotension, and chronic kidney disease. A physician order dated October 26, 2022 revealed an order for midodrine hydrochloride (vasoconstrictor) 10 milligrams (mg) one tablet by mouth three times a day for hypotension; and, to hold for systolic blood pressure (SBP) greater than 105. The MDS (minimum data set) dated December 20, 2022 revealed resident had a BIMS (brief interview for mental status) score of 15. indicating intact cognition. Active diagnosis included orthostatic hypotension. The care plan dated December 28, 2022 revealed resident had a diagnosis of hypotension. Intervention included to give medications as ordered. Another care plan dated December 28, 2022 revealed resident was alert, makes own decisions and was non-compliant with medication management. Intervention included encourage compliance and educate resident regarding non-compliance. The physician order for midodrine was transcribed on the medication administration record (MAR) October 2022 through February 2023. Review of the MAR from October 2022- February 2023 revealed that midodrine was documented as administered as ordered on multiple dates when the resident's systolic blood pressure reading of greater than 105. There was no evidence found in the clinical record why the medication was administered outside the ordered parameter and that the physician was notified. An interview was conducted on February 6, 2023 at 1:07 p.m. Resident #33 stated that staff attempted to give her midodrine when her blood pressure was high and that staff do not check her blood pressure before administering the medication. The resident identified the director of nursing (DON, staff #149) as one of the nurses that attempted or had given the medication when her blood pressure was high. An interview was conducted with a licensed practical nurse (LPN/staff #133) on February 9, 2023 at 10:59 a.m. The LPN (staff #133) stated that when a medication has ordered parameters, it must be given within, less or above the parameter, depending on the parameter. The LPN said that if the vital sign was outside the ordered parameter, he would contact the physician and would wait for orders whether or not the medication can be given. According to the LPN, midodrine is used for hypotension and it is a medication ordered with parameters. He stated that when the parameter was to hold for SBP greater than 105, then medication is held for a blood pressure of 117/80 because it is outside of the parameter; and, he would notify the physician. Further, LPN #133 stated that giving a medication outside of the parameter violates one of the laws of the medication rights and it can lead to issues with the resident; for example, resident can crash, become hypertensive and cause distress. An interview was conducted on February 10, 2023 at 2:00 p.m. with the DON (staff #149) with the administrator (staff #27), and a corporate executive (staff #60) present. The DON stated that midodrine is given to someone with low blood pressures and it is a medication that usually has ordered parameter that is by the physician. Regarding resident #33, the DON stated that the resident had a physician order to give midodrine 10 mg and to hold for SBP greater than 105. Review of the clinical record was conducted during the interview and the DON stated that midodrine was administered to the resident outside of parameter and this did not meet her expectations. Review of the facility's policy titled, Administering Medications revised on April 2019 revealed medications are administered in a safe and timely manner, and as prescribed. The following information is checked/verified for each resident prior to administering medications: vital signs, if necessary.

Based on clinical record review, staff interviews, and review of facility documentation and policies, the facility failed to ensure on resident (#143) received necessary care and services in a timely manner after a fall. The deficient practice could result in negative resident outcomes. Findings include: -Resident #143 admitted to the facility on [DATE] with diagnoses that included osteomyelitis, type 2 Diabetes Mellitus (DM), and muscle weakness. The physician order dated [DATE] included for heparin sodium (anticoagulant) solution 5000 units/milliliter (ml) inject 1 ml subcutaneously every 8 hours for deep vein thrombosis (DVT) prophylaxis. A fall risk screen dated [DATE] included the resident had a history of falls. Review of the baseline care plan dated [DATE] included the resident's needs for activities of daily living (ADL), devices used, and a history of falls. The admission Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident's cognition was intact. The assessment included resident was frequently incontinent of bowel and bladder, received extensive assist for bed mobility, transfers, and toileting; had an impairment on one side of the lower extremities/functional limitation in range of motion (ROM) that interfered with daily functions or placed the resident at risk of injury. It also included that the resident did not ambulate, used a walker and a wheelchair. The assessment also coded a fall during the month prior to entry and no falls since admission to the facility. The associated Care Area Assessment (CAA) for falls included the resident was at risk for falls due to balance, medications, history of falls, incontinence, behaviors, occasional confusion and predisposing diagnoses. The care plan dated [DATE] revealed resident had the potential for fall secondary to debility, history of falls, incontinence, medication, and poor balance; and, was on anticoagulant therapy. The goals were that the facility would reduce the likelihood of the resident experiencing a fall and resident would have no ill effects from use of anticoagulant medication. Interventions included to assist with ADLs; call light and personal items within reach; monitor for adverse effects of medications, notify physician if present; and if resident sustains fall to assess the for injuries, obtain vital signs, notify physician and responsible party of incident and any injuries; monitor frequently for signs and symptoms of neurological impairment; and, to take precautions to avoid falls and signs and symptoms of bleeding. The [DATE] Medication Administration Record (MAR) revealed the resident was receiving the ordered heparin (anticoagulant). A nursing progress note dated [DATE] at 5:00 a.m. included the resident had a fall on [DATE] at 4:00 a.m.; and that, the resident was found lying on the floor in supine position. Per the documentation, the resident was alert and oriented at time of fall and sustained a raised area to the back of the head and to the left side of scalp. The note also included neurological checks were initiated, the provider was notified and was pending further instructions. Review of a nursing progress note dated [DATE] at 6:05 a.m. included that the neurological checks were within normal limits (WNL). The neurological flow sheet revealed that on [DATE] revealed the following documented change in resident at a given time: -Between 5:00 a.m. and 5:30 a.m. - pupil reactions changed from brisk to sluggish; -Between 5:30 a.m. and 6:00 a.m. - level of consciousness changed from fully conscious to lethargic; -Between 6:00 a.m. and 7:00 a.m. - change on Level of Consciousness (LOC) to obtund- very drowsy, responded to touch stimuli, movement of the left arm, hand grasps with left weakness, and pupil reaction, fixed. A nursing progress note dated [DATE] revealed that at 8:01 a.m., the resident was sent to the emergency room (ER) via 911. Another nursing progress note dated [DATE] at 11:00 a.m. revealed that at approximately 4:00 a.m. the resident was placed on fall protocol and neuro checks were initiated per facility protocol. The note documented that hands grips were weak but equal, pupils reactive, bilateral lower extremity (BLE) Range of Motion (ROM) within normal limits (WNL); and that, the physician was notified and was waiting for further instructions. In another nursing note dated [DATE] at 11:40 a.m. included that at approximately 7:30 a.m., the resident was verbally unresponsive and unresponsive to sternal stimuli, pupils were not reacting to light, and that the rapid responsive code was activated and 911 was called. Per the documentation, the staff continued to assess and monitor the resident until 911 arrived at approximately 7:15 a.m. and took over care. The note also included that the resident was taken to the ER (emergency room ) for evaluation and the physician was notified. Review of another nursing note dated [DATE] at 4:47 p.m., revealed documentation of correction of time even happened from 7:30 a.m. to approximately 7:15 a.m. Despite documentation that physician was notified, there was no evidence found in the clinical record that the facility took additional action when the physician has not called back to give orders to assess the resident's change in condition. A care plan initiated on [DATE] revealed the resident had a fall with injury hematoma and skin tear. The goal was that the resident's injury would be resolved. Interventions included to assess the resident for injury such as pain, decreased ROM, skin injury, etc.; initiate neurological checks per fall protocol, report any abnormal findings to the physician; monitor for any new increased pain, discomfort or signs or symptoms of injury over 72 hours after fall; and, document any new problems and report to physician. Review of the Emergency Medical Services (EMS) records for [DATE] revealed the resident had altered level of consciousness (LOC), a ground level fall (GLF) with hematoma to the head and was on aspirin and heparin. Glasgow Coma Score (GCS-used to describe the level of consciousness in an individual) was 8 which indicated severe alteration in LOC. Per the report, the resident was dispatched for altered LOC; and that, the resident was only responsive to painful stimuli. The assessment included that resident made an audible groan in response to a sternal rub, but was not able to speak; had eyes shut and pupils unreactive to light. A physician order dated [DATE] revealed to send the resident to the hospital for evaluation and treatment related to a fall. The hospital records from [DATE] through [DATE] revealed resident presented to the emergency department (ED) at a trauma red on [DATE] status post ground level fall with head strike, was intubated on arrival due to low GCS and ED workup was notable for a large left sided Subdural Hematoma (SDH). The computed tomography revealed a large, acute left-sided subdural hematoma measuring up to 3.2 centimeters (cm); and, there was significant local mass effect with 1.8 cm of subfalcine herniation, left uncal herniation, and at least partial entrapment of the left lateral ventricle. Per the documentation, resident was given one unit of platelets and was taken to the OR with neurosurgery for craniotomy. The documentation also included that the resident was placed on comfort care on [DATE] and pronounced deceased at 4:51 p.m. Discharge Summary included diagnoses of acute encephalopathy, brain herniation, fall, and SDH. Review of the facility investigation dated [DATE] revealed the resident fell from the bed to the floor with hematoma to the back of the head. Per the documentation, neurological check within normal limits, the physician was notified and staff was waiting for a call back from the physician for orders at 4:00 a.m. During neurological checks, noted neurological difference resulting in resident being sent to the hospital. This incident was reported as an injury of unknown source of fall with major injury. The investigation also included that per hospital representative verbal report of Computed Tomography (CT) of head revealed resident had a brain bleed and was taken to the operating room (OR) to evacuate bleed. Further, the documentation included the resident expired on [DATE] in the hospital. It also included that an in-service was initiated with nursing staff to identify the process related around falls and neurological conditions and steps to be taken if call back from provider has not occurred. A corrective action memo for staff #46 dated [DATE] revealed that staff #46 had a violation of the facility policy or procedure. Per the documentation, resident had a change in condition with neurological checks and was not sent out of the facility to the hospital for the change. A phone interview was conducted on February 7, 2023 at 12:42 p.m. with the resident's provider (staff #200) who stated falls were common in the nursing home related to the population and resident's with dementia. He stated he recommended a resident be sent to the ER to rule out a brain bleed if the resident sustained a head trauma (i.e. any obvious signs and symptoms of bumps, lacerations, the resident fell and bumped their head); and, if the resident was on anticoagulation. He stated the resident would be sent to the ER if there were changes in their neurological checks. He stated if nursing staff was concerned they should send the resident out even if they were unable to speak to the provider or had not received a call back from the provider. He stated if the resident experienced a change, had a lump on the head, and was receiving anticoagulation; he would not expect the nurse to wait for a call back from the doctor before sending the resident to the ER; and that, the nurse had a license and could make that decision. He stated due to review of treatment times in the ER he did not know if it would have changed the outcome for the resident, even if the facility had called EMS at 5:45 or 6:00 a.m. when the resident was exhibiting changes in her neurological status. A phone interview was conducted with a Licensed Practical Nurse (LPN/staff #133) on February 7, 2023 at 1:12 p.m. The LPN stated he remembered he was told about the fall incident for resident #143 and he took her vital signs and did her neurological check. He stated he noticed a loss of consciousness and sent the resident out through 911. The LPN said that if a resident fell and the staff started neurological checks and the nurse saw changes in the checks it should be reported to the doctor and the resident should be sent out through 911. Further, he stated that as a nurse, if the doctor did not respond it was his responsibility to act in the best interest of the resident. He stated if he was on shift when the changes occurred he would send the patient out to the hospital. A phone interview was conducted on February 8, 2023 at 6:53 a.m., with the LPN (staff #46) who stated that if a resident had a change in neurological status/neurological checks it would be an altered LOC; and, the resident would need to be sent out to the hospital as they had potentially experienced trauma was on shift at the of the resident's fall. Regarding the fall incident of resident #143, she stated she remembered the resident; and that, during the shift the certified nursing assistant (CNA) was yelling that the resident was on the floor. She stated that she went to the room and found the resident on the floor with the bed controls in her hand. She stated she took the vitals, did a neurological check that had results that were normal at that time. She stated staff got the resident back into bed and she found the resident had skin tears and a bump on the back of her head/left side. Staff #46 said she left a message for the doctor by phone and texted him and was waiting for orders; and, continued with the fall protocol including neurological checks. She stated she never spoke to the doctor during her shift. She further stated she did not recall that the resident was exhibiting neurological changes. She stated the resident was sleeping and had to be woken up for neurological checks. However, staff #46 said that she did not know if it was a change in LOC or if the resident was less alert related to being woken up. She stated she could not recall if she had made any further call to the doctor or to administrative staff. She stated she should have sent the resident out if the resident was showing neurological changes as per protocol and would not need to wait to hear back from the provider. Staff #46 stated she received education/in-service and was written up for this incident. She stated she was told if a resident fell and had a suspected head injury, especially if they were on a blood thinner, she was supposed to send the resident to the hospital regardless of provider response. An interview was conducted on February 8, 2023 at 10:15 a.m. with the DON (staff #149) who stated if the fall was unwitnessed, staff would start neurological checks, even if the resident could tell staff what happened. She stated if the neurological checks begin to change, the nurse should notify the doctor to let them know what had changed; and, if staff cannot get hold of the doctor, the nurse should send the resident out for higher level of care and notify the DON. She stated the protocol was changed, as a result of this resident's incident. She stated that a resident on anticoagulation who had a fall, with or without evidence of head trauma, need to be sent out for a CT scan. She stated the nurse (staff #46) taking care of the resident left a message for the doctor and was waiting for orders. She stated when staff #46 noted a pupil reaction change for resident #143, she (DON) would have expected staff #46 to update the doctor, notify the DON, and send the resident out regardless of provider response. She stated it was important because a neurological change showed an obvious neurological deficit. The DON stated she always would have expected this resident to go out at the time of the fall, and because of the situation, she made the protocol more specific. Review of the 2021 Saunders Nursing Drug handbook revealed that the adverse effects for Heparin included bleeding complications, ranging from local ecchymosis to major hemorrhage (cutaneous, gastrointestinal, genitourinary, intracranial, nasal, oral, pharyngeal, urethral, and vaginal). The facility policy on Falls and Fall Risk included that based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Resident conditions that may contribute to risk of falls include medication side effects. In conjunction with the attending physician, staff will identify and implement relevant interventions to try to minimize serious consequences of falling. The facility's fall protocol dated [DATE] included that when a fall occurs, a call was to be placed to the ADON or DON after a fall; and, neuro checks were to be initiated on all residents unless it is witnessed with no head injury. Any change in Neuro examination, call to be place.

Based on record reviews, staff interviews, facility documentation and policies and procedures, the facility failed to ensure that one resident (#1) received care and treatment in accordance with professional standards of practice, the person centered care plan and the resident's choices to meet their highest practicable well-being. The deficient practice resulted in a lack of care being provided to a resident with a change of condition, resulting in actual harm. Findings include: Resident #1 was admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A care plan initiated on [DATE] (and was the current care plan through [DATE]) identified that the resident was a Full Code. Per the care plan, the resident was unable to make his own decisions and the resident's POA (Power of Attorney) would communicate specific advance directives. The care plan included the following interventions: Resident is a Full Code-if the resident becomes unresponsive, call for help immediately and begin Basic Life Support sequence; Maintain the resident's advance directive documents accessible in the medical record file; Provide copies of advance directives to appropriate entities upon any transfer from the facility; Review the advance directives with the resident and/or agent at least quarterly and with any change in condition and execute any wishes and implement any changes as desired. Review of a form titled Right to Formulate Advance Directive dated [DATE], revealed a statement the resident certified that the facility had provided him with information concerning his rights to accept or refuse medical or surgical treatment, and his right to formulate advance directives. The form listed multiple advance directive options and included an option that read I wish to be full code, which was circled on the form. The form was signed by a family member and witnessed by a staff member. A form titled Allegiant Healthcare of Mesa Healthcare Directives dated [DATE], included a statement that read In the event that my health condition turns to a terminal or irreversible state, I hereby direct my caregiver to act in the following manner. The form listed multiple advance directive options and were marked with check-marks for sections that read I would like to be transferred to a hospital if my medical status changes or worsens to a terminal or irreversible condition and I would like to be resuscitated. A quarterly MDS (Minimum Data Set) assessment dated [DATE] included the resident had memory problems, had severe cognitive impairment, rarely/never was able to make himself understood, rarely/never was able to understand others and was totally dependent on staff for care. The MDS included the resident did not have a condition or chronic disease that may have resulted in a life expectancy of less than 6 months. According to a physician's history and physical report dated [DATE], resident #1 had been diagnosed with [REDACTED]. The report included that the resident was a full code and was being admitted to the hospital ICU (Intensive Care Unit). A hospital visit summary report dated [DATE] included the resident was being transferred back to the skilled nursing facility, was totally dependent for care and had a code status of Full Resuscitation. An admission clinical evaluation dated [DATE] completed by a LPN (Licensed Practical Nurse) included the resident had been readmitted from the hospital and was alert, had wheezing and had impaired cognition and speech. A physician's orders [REDACTED]. A nursing progress note completed by a LPN (night shift nurse/staff #82) dated [DATE] at 5:38 a.m. included that (earlier in the nurses shift) at 6:15 p.m., the resident had been transferred from the hospital and had unclear lung sounds and had coarse crackles upon auscultation in all lung fields. The note included the resident was congested with built up mucus and was on droplet precautions for COVID-19. Review of a temperature record with an entry dated [DATE] at 10:09 a.m., revealed the resident's temperature was 99.7 degrees and a warning listed on the record included High of 99.0 exceeded. Review of the weights and vitals summary dated [DATE] revealed an entry at 1:43 a.m. which included the resident's temperature was 101.4 degrees. A warning notation listed on the record included High of 99.0 exceeded. A clinical note dated [DATE] at 5:39 a.m. completed by the LPN (night shift nurse/staff #82) included that resident #1 had pyrexia (a fever), was continuously foaming in his mouth and nose and had frothy saliva coming out of his mouth and nose. The note also included the resident had been pouring out saliva foam from his mouth and nose since he came back from the hospital. The note included that the physician had been called, but had not responded back to the nurse. The note further stated that the resident was unstable at this time and that respirations were labored, due to a built up mucus in the lungs. A clinical note dated [DATE] at 6:23 a.m. included that Tylenol 325 mg (milligrams) 2 tablets had been given with less effect. Further review of the clinical record revealed there was no documentation that the physician/nurse practitioner (NP) had been called again or if respiratory therapy, the RN unit manager on duty or the Director of Nursing were called, regarding the resident's condition of foam coming continuously out of his nose and mouth. There was also no documentation of any new orders or additional care and treatment that was provided to the resident on the night shift, despite the resident's condition. Review of the weights and vitals summary dated [DATE] revealed the following: -An entry at 12:05 p.m. included the resident's pulse rate was 116 BPM (beats per minute). A warning listed on the record included High of 100.0 exceeded. -An entry at 12:05 p.m. included the resident's respiratory rate was 26 breaths per minute. A warning listed on the record included High of 25.0 exceeded. Continued review of the clinical record revealed that from [DATE] at 6:24 a.m. - 4:20 p.m., there were no additional nursing assessments by the day shift nurse (LPN/staff #200) that were documented, nor was there any documentation of any contact with the physician/NP, respiratory therapy or the RN unit manager regarding the resident's condition. There were also no new orders, and no documentation of any care and treatment or of any emergency care that was provided to the resident during this time frame, based on the resident's condition. A nursing progress note dated [DATE] was written at 4:21 p.m. by the day shift LPN (staff #200). Per the note, the resident was reportedly not doing well since he was readmitted from the hospital and had been foaming from his mouth according to the outgoing nurse. The note included that staff #200 notified the physician (no time was documented) that the resident had crackles/bubbling when exhaling, and by the time the physician got back (no time documented) with orders to send the resident to the hospital because of his condition, this nurse went to the room to check on the patient as he was talking to the MD and the patient was none responsive and I let the doctor know that the patient looks that he has expired and he instructed to call the family and let them know. This author called the RN in the building to confirm the expiration time 1340. (1:40 p.m.) The clinical record did not include any documentation that a rapid response was called overhead or of any emergency procedures which were initiated when the resident was found unresponsive. A physician's progress note dated [DATE] at 8:59 p.m. included that on [DATE] at 3:59 a.m., the physician (staff #202) received a text message from a nurse that resident #1 had returned from the hospital, looked ill and had a temperature of 101.4. The note included that the physician did not read the text until 8:06 a.m. and then asked to speak with the nurse caring for the resident. The note included that at 12:13 p.m., the nurse responded to the physician and stated that the resident had crackling/bubbling sounds (with breathing), a heart rate of 116 and respirations were 26. The note included the physician messaged the nurse immediately to send the resident to the hospital and at 1:19 p.m., the nurse responded with a message of OK. The note further stated that sometime later the nurse called and notified the physician that the resident had expired. Review of the facility's investigative report revealed that an investigation was initiated on [DATE], during a routine audit of resident #1's clinical record. The report included the following summary details regarding the events that occurred on [DATE]: -At 1:30 p.m. while staff #200 was on the phone with the physician, staff #200 found resident #1 unresponsive and notified the physician that the resident looked like he had expired. The physician instructed the nurse (staff #200) to call the family. -At 1:35 p.m., staff #200 notified a RN (Registered Nurse/staff #153) who was on duty. Staff #153 assessed the resident and determined the resident was deceased . Staff #153 did not have prior contact from staff #200 that day. The facility's investigative report also included the resident was a full code and was receiving palliative hospice care. Per the report, when a patient does not have an advance directive for DNR (Do Not Resuscitate), Rapid Response will be initiated. The report stated that staff #200 did not initiate a Rapid Response because he felt the patient was deceased . The facility's investigative report also included the following witness statements: -A statement dated [DATE] at 10:30 a.m. from a LPN (staff #130) included that on [DATE], staff #200 told staff #130 that the physician said to send the resident to the hospital, and he instructed staff #130 to prepare the paperwork for the resident's transfer. Staff #130 reported that staff #200 requested that she go to the resident's room, and stated that resident #1 appeared pale and his chest was not rising. The statement included that staff #200 was talking to the physician and told her that CPR would not be initiated, as the resident appeared to be deceased and to call the resident's family. -A statement dated [DATE] at 1:40 p.m. from the physician (staff #202) included the night nurse notified him at 4:00 a.m. (on [DATE]) that resident #1 had crackly and bubbly sounds in his lungs, that he was afebrile, vital signs normal, but appeared to be in bad shape. The statement included the doctor received the message at 8:00 a.m., and asked the day nurse to call him. The statement included the physician received a message from staff #200 at 12:00 p.m. and he returned the call with no answer. An hour later, the physician received a message from staff #200 that just stated OK. The statement further included the physician returned the call to staff #200 and was told by staff #200 that the resident appeared to have passed away. -A statement dated [DATE] at 3:00 p.m. from staff #200 included that on [DATE], the physician (staff #202) stated to send the patient to the hospital. The statement included that when staff #200 arrived at the resident's room, the resident was not breathing. The statement included that staff #200 called the physician and told the physician that the resident looked like he was dead, and the physician told him to call the resident's family. The statement further included that staff #200 asked the physician if staff can do chest compressions and the doctor said to call the resident's family. The investigative report also included in-service training records and staff sign in sheets for the following staff training's due to this incident: -An in-service training record dated [DATE] with a subject titled Consents/Code Status with a duration of 30 minutes and sign in sheets with 52 staff signatures from various departments and disciplines. -An in-service training record dated [DATE] to [DATE] regarding Rapid Response Policy, Transfer/Discharge Documentation, Emergency Physician's care, Change in Condition, Emergency Procedure-CPR, with a duration of 45 minutes. The sign in sheets included 79 staff signatures from various departments and disciplines. On [DATE] at 12:08 p.m., two phone calls were placed to staff #200, however, staff #200 was unable to be reached by phone. During an interview conducted on [DATE] at 12:30 p.m. with a Unit Manager (staff #94), she stated that when the nurse (night nurse) called the physician and the call was not returned, the nurse should have attempted to call the physician again. Staff #94 said the facility has managers on call on the weekend and on off hours. She said that night there was a manager working and the nurse (staff #82) could have called when the resident was having symptoms. Staff #94 stated that when the night nurse noticed the resident had frothy saliva coming out of his nose and mouth, she should have called 911 to send the resident to the hospital. Staff #94 also said the day nurse should have immediately called the physician on [DATE] after he assessed the resident, and that the nurse is supposed to double check a resident's chart for their code status. Staff #94 said the nurse should have immediately called Rapid Response overhead on [DATE], when the resident was found unresponsive and should have started CPR and asked another staff to call 911. During an interview conducted on [DATE] at 1:00 p.m., with the night shift LPN (staff #82), she stated that her notes described the condition that the resident was in when she provided care to the resident (on [DATE] and [DATE]). Staff #82 stated that (on [DATE]) she phoned the physician but had not spoken to him, and when the oncoming day shift nurse reported to duty, she reported the resident's condition to the day nurse (staff #200) prior to leaving. Staff #82 stated that while she was giving report to the day nurse, he stopped report, went to the resident's room and returned to receive the remainder of the shift report. When staff #82 was asked if there were any managers or other staff that she could have notified of the resident's symptoms and change in condition on [DATE], staff #82 became angry and shouted that it wasn't her fault the resident died . An interview was conducted on [DATE] at 1:50 p.m., with the DON (Director of Nursing (staff #55). The DON said that when a resident has a change in condition, the nurse calls Rapid Response overhead and that Respiratory Therapy, a Nurse Supervisor and the CNA (Certified Nursing Assistant), all respond to assist with the resident, and staff immediately calls the physician. The DON stated there is always a Respiratory Therapist and a RN Nurse Supervisor in the facility around the clock, and that a NP is also on call due to the facility having patients on ventilators. The DON said the night nurse should have called the nurse supervisor on [DATE], when the resident started having a change in condition. The DON also said the day nurse should have called the doctor immediately for the resident's change in condition. The DON said the day nurse should have called Rapid Response and should have called the NP on call and if unable to reach the physician or NP, he should have called the DON. The DON stated that staff #200 did not follow any of the emergency protocols that were in place. An interview was conducted on [DATE] at 9:30 a.m. with a RN (staff #153), who stated that on [DATE], staff #200 had asked her to come to the resident's room to assess him and declare death. Staff #153 stated that staff #200 had not called Rapid Response, and had not asked her for assistance, prior to being asked to declare death. Staff #153 said when she assessed the resident, he was very mottled, gray and had no vital signs. Staff #153 said that staff #200 told her that the resident was a full code, but the physician had told him not to do CPR on the patient, just to call the family. Staff #153 stated she did not know if the physician had spoken to the resident's family or if the resident's family had changed the resident's advance directive to DNR (Do Not Resuscitate). Staff #153 said that earlier in the day, staff #200 had called a code blue overhead for a different patient, so she knew that staff #200 was aware of the procedure for CPR and how to call a code blue (Rapid Response) overhead. Review of a policy titled, Advance Directives revealed that advance directives will be respected in accordance with State Law and facility policy. The policy included that changes or revocations of an advance directive must be submitted in writing to the Administrator. A policy and procedure titled, Emergency Physician Care included that emergency physician care is available to all residents when their Attending Physicians are unavailable, on a 24 hour basis. The policy stated that should the resident's attending physician be unavailable, the nurse supervisor/charge nurse must first attempt to contact the physician's designated referral physician or practitioner. The policy titled, Rapid Response-Medical Emergency included multiple steps listed for dealing with a medical emergency including the following: -Announce Rapid Response with the resident's room number or other location. -Perform an assessment to determine the resident's status and acuity. -Initiate CPR. -Call 911 -Notify the attending physician and responsible party. -Obtain assistance from other staff if available. -Notify the Administrator and Director of Nursing. According to a policy regarding Change in a Resident's Condition or Status, the facility shall promptly notify the resident, his or her attending physician or physician on call of changes in the resident's medical condition and status, when there is a need to transfer a resident to a hospital/treatment center, or a need to alter the resident's medical treatment significantly. A policy and procedure titled, Emergency Procedure-Cardiopulmonary Resuscitation included if a resident is found unresponsive and not breathing, normally a licensed staff member who is certified in CPR shall initiate CPR unless it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR or external defibrillator exists for the resident. The policy also included that CPR shall be initiated, unless there are obvious signs of irreversible death, such as rigor mortis.

Based on record reviews, staff interviews, facility documention and policies and procedures, the facility failed to ensure that one resident (#1) was provided emergency basic life support including CPR (Cardiopulmonary Resuscitation), in accordance with physician's orders [REDACTED]. The deficient practice resulted in basic life support measures including CPR not being provided to a resident. Findings include: Resident #1 was admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A care plan initiated on [DATE] (and was a current care plan through [DATE]) identified the resident was a Full Code. Per the care plan, the resident was unable to make his own decisions and the resident's POA (Power of Attorney) would communicate specific advance directives. The care plan included the following interventions: Resident is a Full Code-if the resident becomes unresponsive, call for help immediately and begin Basic Life Support sequence; Maintain the resident's advance directive documents accessible in the medical record file; Provide copies of advance directives to appropriate entities upon any transfer from the facility; Review the advance directives with the resident and/or agent at least quarterly and with any change in condition and execute any wishes and implement any changes as desired. Review of a form titled Right to Formulate Advance Directive dated [DATE], revealed a statement that the resident certified that the facility had provided him with information concerning his rights to accept or refuse medical or surgical treatment, and his right to formulate advance directives. The form listed multiple advance directive options and included an option that read I wish to be full code, which was circled on the form. The form was signed by a family member and witnessed by a staff member. A form titled Allegiant Healthcare of Mesa Healthcare Directives dated [DATE], included a statement that read In the event that my health condition turns to a terminal or irreversible state, I hereby direct my caregiver to act in the following manner. The form listed multiple advance directive options and were marked with check-marks for sections that read I would like to be resuscitated. A quarterly MDS (Minimum Data Set) assessment dated [DATE] included that resident #1 had memory problems and severely impaired cognition. The assessment included that the resident rarely/never was able to make himself understood, rarely/never was able to understand others and was totally dependent on staff for care. The MDS included that resident #1 did not have a condition or chronic disease that may have resulted in a life expectancy of less than 6 months. A hospital visit summary report dated [DATE] included that resident #1 was admitted to the hospital on [DATE] and was being transferred to the skilled nursing facility. The summary report included that resident #1 was totally dependent for care and had a code status of Full Resuscitation. A physician's orders [REDACTED]. A nursing progress note dated [DATE] at 5:39 a.m. completed by the night shift LPN (staff #82) included that resident #1 had pyrexia (a fever), was continuously foaming in his mouth and nose and had frothy saliva coming out of his mouth and nose. The note also included that the resident had been pouring out saliva foam from his mouth and nose since he came back from the hospital. The note included that the physician had been called, and had not responded back to the nurse, and that the resident was unstable at this time and that respirations were labored, due to built up mucus in the lungs. A nursing progress note dated [DATE] was written at 4:21 p.m. by the day shift LPN (staff #200). Per the note, the resident was reportedly not doing well since he was readmitted from the hospital and had been foaming from his mouth according to the outgoing nurse. The note included that staff #200 notified the physician (no time was documented) that the resident had crackles/bubbling when exhaling, and by the time the physician got back (no time documented) with orders to send the resident to the hospital because of his condition, this nurse went to the room to check on the patient as he was talking to the MD and the patient was none responsive and I let the doctor know that the patient looks that he has expired and he instructed to call the family and let them know. This author called the RN in the building to confirm the expiration time 1340. (1:40 p.m.) Review of the clinical record revealed there was no documentation that a Rapid Response was called overhead or of any emergency procedures including CPR that were initiated, when the resident was found unresponsive, despite the resident being a full code status. Review of the facility's investigative report revealed that an investigation was initiated on [DATE], during a routine audit of resident #1's clinical record. The report included that on [DATE] at 1:30 p.m. while staff #200 was on the phone with the physician, staff #200 found resident #1 unresponsive and notified the physician that the resident looked like he had expired. Per the report, the physician instructed the nurse (staff #200) to call the family. The report included that resident #1 was a full code and was receiving palliative hospice care. The report included that when a patient does not have an advance directive for DNR (Do Not Resuscitate) a Rapid Response will be initiated. The report further stated that staff #200 did not initiate a Rapid Response because he felt the patient was deceased . Continued review of the facility's investigative report included the following witness statements: -A statement dated [DATE] at 10:30 a.m. from a LPN (staff #130) included that on [DATE], staff #200 told staff #130 that the physician said to send resident #1 to the hospital, and when staff #130 was asked to go to the resident's room, the resident appeared pale and his chest was not rising. The statement included that staff #200 was talking to the physician and stated to staff #130 that CPR would not be initiated as the resident appeared to be deceased . -A statement dated [DATE] at 3:00 p.m. from the day shift LPN (staff #200) included that on [DATE], the physician (staff #202) stated to send the patient to the hospital. The statement included that when staff #200 arrived at the resident's room, the resident was not breathing. The statement included that staff #200 called the physician and told the physician that resident #1 looked like he was dead, and the physician told him to call the resident's family. The statement further included that staff #200 asked the physician if staff can do chest compressions and the doctor said to call the resident's family. The investigative report also included in-service training records and staff sign in sheets for the following staff training's due to this incident: -An in-service training record dated [DATE] with a subject titled Consents/Code Status with a duration of 30 minutes and sign in sheets with 52 staff signatures from various departments and disciplines. -An in-service training record dated [DATE] to [DATE] regarding Rapid Response Policy, Transfer/Discharge Documentation, Emergency Physician's care, Change in Condition, Emergency Procedure-CPR, with a duration of 45 minutes. The sign in sheets included 79 staff signatures from various departments and disciplines. Further review of the clinical record revealed there was no evidence that the resident's advance directives had been changed from a full code status to a DNR status, prior to this incident. On [DATE] at 12:08 p.m., two phone calls were placed to the day shift nurse (staff #200) however, staff #200 was unable to be reached by phone. During an interview conducted on [DATE] at 12:30 p.m. with a Unit Manager (staff #94), she stated that the (day shift) nurse should have immediately called Rapid Response overhead on [DATE] when he found the resident unresponsive, and that he should have started CPR and had another staff call 911. An interview was conducted on [DATE] at 1:50 p.m. with the DON (Director of Nursing (staff #55), who stated that when a resident has a change in condition, the nurse calls Rapid Response overhead and that Respiratory Therapy, a Nurse Supervisor, and the CNA (Certified Nursing Assistant) all respond to assist with the resident, and that staff immediately calls the physician. The DON stated that staff #200 did not follow any of the emergency protocols that were in place. During an interview conducted on [DATE] at 9:30 a.m. with a RN (staff #153) who stated that on [DATE], staff #200 asked her to come to the resident's room to assess him and declare death. Staff #153 said that staff #200 had not called a Rapid Response and had not asked her for assistance prior to being asked to declare death. She said that staff #200 told her that the resident was a full code, but the physician had said not to do CPR on the patient, and to just call the patient's family. Staff #153 stated she did not know if the physician had spoken to the resident's family or if the resident's family had changed the resident's advance directive to DNR. Staff #153 stated that earlier in the day, staff #200 had called a code blue overhead for a different patient, so she knew that staff #200 was aware of the procedure for CPR and how to call a code blue (Rapid Response) overhead. Review of a policy titled, Advance Directives revealed that advance directives will be respected in accordance with State Law and facility policy. The policy included that changes or revocations of an advance directive must be submitted in writing to the Administrator. A policy titled, Rapid Response-Medical Emergency included multiple steps listed for dealing with a medical emergency including the following: Announce Rapid Response with the resident's room number or other location; Perform an assessment to determine the resident's status and acuity and Initiate CPR. A policy titled, Emergency Procedure-Cardiopulmonary Resuscitation included if a resident, is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR shall initiate CPR unless it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR or external defibrillator exists for the resident. The policy also stated that CPR shall be initiated unless there are obvious signs of irreversible death, such as rigor mortis.

Based on observation, interview, and record review, the facility failed to operationalize all components of the infection prevention and control program and the Centers for Disease Control and Prevention (CDC) recommendations to provide a safe, sanitary environment to help prevent and/or contain COVID-19 (an infectious disease by a new virus causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, dizziness, nausea, vomiting, diarrhea, loss of taste and/or smell, and in severe cases difficulty breathing that could result in severe impairment or death) when: 1) staff failed to follow droplet precautions for personal protective equipment (PPE) eye wear (goggles, face shields, etc.) during the care of presumptive COVID-19 residents and COVID-19 positive residents and then proceed to leave the area and/or proceed to care for other residents were COVID-19 negative, and 2) staff failed to properly clean and disinfect a blood pressure cuff after use on several COVID-19 positive residents. These failures increased the likelihood for serious injury, serious harm or death and required immediate action to prevent the spread of COVID-19 from residents who were positive and/or presumptive for COVID-19 to negative COVID-19 residents and staff. On 7/9/2020 at 1:05 PM, the administrative staff (Administrator, Director of Nursing (DON), and Infection Preventionist (IP)) were informed of the immediate jeopardy situations. Findings include: The facility policy entitled, New Admissions During COVID-19 State of Emergency (undated) indicated that: Residents with confirmed or suspected cases of COVID-19 will be cared for in accordance with guidelines as stipulated by the CDC. All efforts will be made to prevent transmission, treat symptoms .Facility will continue to follow the recommendations of the Center for Disease Control, including handwashing procedures and wearing of personal protective equipment (PPE) when indicated by the resident's presenting condition .PROCEDURES: ADMISSION: 1. Patients admitted to the facility will be placed onto transmission-based precautions. 2. The patient will be placed on transmission-based precautions for 14 days .4. c. Appropriate transmission-based PPE will be placed inside of rooms-gowns, masks, face shield/goggles and gloves. d. When possible, dedicated equipment will be stored in patient rooms, if not then equipment will be sanitized between each use per manufacturer's recommendations . The facility's undated policy for Isolation-Categories of Transmission-Based Precautions indicated the following: .2. Transmission-based precautions are additional measures that protect staff, visitors, and other residents from becoming infected. These measures are determined by the specific pathogen and how it is spread from person to person. The three types of transmission-based precautions are contact, droplet, and airborne .6. When transmission-based precautions are in effect, non-critical resident-care equipment items such as a stethoscope, sphygmomanometer (an instrument for measuring blood pressure, typically consisting of an inflatable rubber cuff which is applied to the arm and connected to a scale, which by increasing and gradually releasing the pressure in the cuff provides a blood pressure reading), or digital thermometer will be dedicated to a single resident (or cohort of residents) when possible. a. If re-use of items is necessary, then the item will be cleaned and disinfected according to current guidelines before use with another resident .1. Droplet Precautions may be implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets .3. Masks will be worn when entering the room. 4. Gloves, gown, and goggles should be worn if there is risk of spraying respiratory secretions. Allegiant Healthcare of Mesa is in Maricopa County. It should be noted that Maricopa County in Arizona was and continued to be a hotspot for COVID-19. As of 7/15/2020, the State of Arizona reported a total number of COVID-19 cases to be 131,354 with 86,483 cases in Maricopa County, which would be considered a substantial community transmission rate. https://www.azdhs.gov/preparedness/epidemiology-disease-control/infectious-disease-epidemiology/covid-19/dashboards/index.php Protective Eye Wear: The CDC's recommendations included the following, Use of eye protection is recommended in areas with moderate to substantial community transmission. The CDC recommendations also included the following, Prioritize eye protection for selected activities such as: During care activities where splashes and sprays are anticipated, which typically includes aerosol generating procedures. During activities where prolonged face-to-face or close contact with a potentially infectious patient is unavoidable. https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/eye-protection.html. Per CDC information, Infectious diseases can be transmitted through various mechanisms, among which are infections that can be introduced through the mucous membranes of the eye (conjunctiva) .Infectious agents are introduced to the eye either directly (e.g., blood splashes, respiratory droplets generated during coughing or suctioning) or from touching the eyes with contaminated fingers or other objects. As for the type of eye protection, the CDC indicated that Many safety goggles .fit comfortably over street eyewear and can provide satisfactory protection without impairing the fit of the prescription eyewear. Prescription safety glasses with side protection are available, but do not protect against splashes or droplets as well as goggles https://www.cdc.gov/niosh/topics/eye/eye-infectious.html The residents in room [ROOM NUMBER]: *Resident (R1) was admitted to the facility on [DATE] and had a physician's orders [REDACTED]. Review of R1's medical record revealed that R1 had a positive COVID-19 test on 6/17/2020. R1's [DIAGNOSES REDACTED]. *Resident (R2) was admitted to the facility on [DATE] and had a physician's orders [REDACTED]. R2's [DIAGNOSES REDACTED]. The residents in room [ROOM NUMBER]: *Resident (R5) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. *Resident (R6) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R6 had a physician's orders [REDACTED]. Observation on the Isolation Unit: On 7/9/2020 at approximately 6:55 AM, Certified Nursing Assistant (CNA11) was observed donning PPE before entering resident room [ROOM NUMBER]. The sign on the door indicated the residents in room [ROOM NUMBER] were on droplet precautions and that Doctors/Staff must: Wear eye protection with respiratory symptoms and standard precautions if contact with secretions likely. CNA11 did not don eye protection before entering the room. At 7:05 AM, while CNA11 was still in the room, Licensed Nurse (LN4) donned full PPE including goggles to enter the resident's room. CNA11 came out of room [ROOM NUMBER] at 7:13 AM and was wearing a pair of prescription glasses. At 7:20 AM, CNA11 went to room [ROOM NUMBER] (an isolation room for R5 and R6) donned PPE except for eye protection and went into the resident room. On 7/9/2020 at 9:20 AM, CNA11 was observed in resident room [ROOM NUMBER]. CNA11 had full PPE on including goggles. CNA11 came to the door and looked in the hallway. CNA11 asked if I, the surveyor could get the LN. There was a LN in the Nurse's Station 2B. The LN went to speak with CNA11. CNA11 was observed to have her goggles pushed up on the top of her head when the LN approached the room. The resident in room [ROOM NUMBER]: *Resident (R3)-R3's [DIAGNOSES REDACTED]. (a surgical procedure that placed a tube into the stomach, which is done due to a patient's inability to swallow). R3 had a physician's orders [REDACTED]. The Resident in room [ROOM NUMBER] *Resident (R4)-R4's [DIAGNOSES REDACTED]. R4 had a physician's orders [REDACTED]. Observation on the Respiratory Unit: On 7/9/2020 at 7:55 AM, CNA13 was observed donning PPE before entering R3's room (room [ROOM NUMBER]); however, CNA13 did not put on eye protection. The signs on the door indicated that the resident was on droplet precautions. On 7/9/2020 at 8:10 AM, LN6 was observed preparing medications near R4's room (room [ROOM NUMBER]), which included insulin and crushed medications in a cup. After preparing the medications, LN6 donned PPE. LN6 wore prescription glasses and did not don protective eye wear over his glasses. LN6 took the medication into R4's room and gave the medication via R4's PEG tube and gave the insulin injection. LN6 was interviewed on 7/9/2020 at 8:35 AM, LN6 was asked about donning PPE. LN6 stated that for those residents in isolation, he needed to don PPE, which included gloves, a gown, and a mask. LN6 further explained that he did not need to wear goggles because he wore glasses (prescription). LN6's prescription glasses did not have any side protection. LN6 was asked if that was what he was taught in facility in-services. LN6 stated that he had not attended any in-services. LN6 explained he had worked at the facility before but had left and was now returning; in fact, today (7/9/2020) was his first day working. LN6 prepared medications for R3 (room [ROOM NUMBER]). At approximately 8:45 AM, the Unit Manager (UM) approached LN6 to speak with him. LN6 asked the UM for a face shield. The UM told LN6 that he did not need a face shield because he wore glasses; however, she would get him a face shield. LN6 explained to the UM, he wanted the face shield because R3 had respiratory issues. On 7/9/2020 at 10:20 AM, LN5 was interviewed regarding PPE. LN5 explained PPE use and how he donned and doffed PPE. LN5 was asked about eye protection. LN5 stated that he did not have to use eye protection because he wore glasses (prescription). LN5 further explained that his glasses were for reading only so he tried to wear goggles over them but the goggles did not work very well so he was trying to just wear the goggles. On 7/9/2020 at 11:15 AM, the UM of the respiratory unit was interviewed. The UM stated that the respiratory unit [MEDICAL CONDITION] ventilator dependent residents. The UM was asked about PPE use on the respiratory unit. The UM indicated that if the residents had COVID-19 symptoms the staff would wear full PPE (mask, gloves, gown, and eye protection); however, if the resident was just on a 14-day quarantine no goggles were required. The failure of staff to wear protective eye covering when providing care had the potential of spreading COVID-19 from positive and/or presumptive COVID-19 residents to negative COVID-19 residents and staff. Cleaning and Disinfecting Equipment: The CDC recommended the following for cleaning and disinfecting, Disinfect-Recommend use of EPA registered household disinfectant. https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-[DIAGNOSES REDACTED]-cov-2-covid-19 Follow the instructions on the label to ensure safe and effective use of the product. Many products recommend: Keeping surface wet for a period of time (see product label) . https://www.cdc.gov/coronavirus/2019-ncov/community/disinfecting-building-facility.html On 7/9/2020 at approximately 7:00 AM, a vital sign monitor was observed on the isolation unit. In the attached basket was a spray bottle that indicated it was Virex II 256, one-step disinfectant cleaner and deodorant. There were no directions on the spray bottle directing how the spray should be used. Virex II 256 is a product distributed by Diversey, a one-step disinfectant cleaner concentrate that provides broad spectrum disinfection used in healthcare and other facilities where cleaning and prevention of cross-contamination are critical. The directions indicate the following, apply solution to hard, non-porous environmental surfaces. To disinfect, all surfaces must remain wet for 10 minutes. Air dry, wipe surfaces to dry and remove any residue, or rinse with potable water as necessary. https://diversey.com/en/product-catalogue/virex-ii-256-one-step-disinfectant-cleaner-and-deodorant- The residents in room [ROOM NUMBER]: *Resident (R1) was admitted to the facility on [DATE] and had a physician's orders [REDACTED]. Review of R1's medical record revealed that R1 had a positive COVID-19 test on 6/17/2020. R1's [DIAGNOSES REDACTED]. *Resident (R2) was admitted to the facility on [DATE] and had a physician's orders [REDACTED]. R2's [DIAGNOSES REDACTED]. The residents in room [ROOM NUMBER]: *Resident (R5) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. *Resident (R6) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R6 had a physician's orders [REDACTED]. On 7/9/2020 at approximately 7:13 AM, CNA11 came out of resident room [ROOM NUMBER] (isolation room-R1 and R2) pushing a vital sign monitor. In the monitor's attached basket was a white cloth and a spray bottle. CNA11 sprayed the cloth with the fluid from the spray bottle and wiped the blood pressure cuff and the temperature probe. The cleaning process took less than 3 minutes. At approximately 7:25 AM, CNA11 pushed the vital sign monitor out of resident room [ROOM NUMBER]. CNA11 sprayed the Virex II onto the cloth (that was in the attached basket) and wiped the blood pressure cuff. CNA11 was asked if the blood pressure cuff was kept wet. CNA11 stated No, it's not wet. CNA11 wiped the blood pressure cuff for less than 3 minutes. During the observation, at no time did the blood pressure cuff appear to be wet with the Virex II. On 7/9/2020 at 9:40 AM an interview was conducted with CNA10. CNA10 was asked about the cleaning of the vital sign monitor. CNA10 indicated that because it was the isolation unit the monitor needed to be cleaned between each resident. CNA10 indicated that the solution in the spray bottle was sprayed onto the equipment and then wiped off. CNA10 was unable to say if the equipment needed to stay wet for a certain period of time. At 11:00 AM, the Acting Housekeeping Supervisor stated that the Virex II spray solution needed to stay wet for 10 minutes to be affective. The failure to clean and disinfect resident shared equipment had the potential of spreading COVID-19 from positive and/or presumptive COVID-19 residents to negative COVID-19 residents and staff. On 7/9/2020 at 2:24 PM, the administrative staff provided two acceptable removal plans: 1. The removal plan for the wearing of protective eye wear: *Effective immediately, staff were in-serviced on use of proper protection (shield or goggles) in a droplet isolation room *An audit was completed to ensure that staff had access to proper eye protection *The DON and/or designee will audit the use of protective eye wear daily for seven days, then weekly for three months *Results of the audit will be reported to and monitored by the Quality Assurance committee 2. The removal plan for the cleaning and disinfecting of shared resident equipment: *Effective immediately, each isolation room will be issued its' own designated blood pressure cuff *All blood pressure cuffs currently in use were sanitized using Sani cloth bleach wipes *Staff would be in-serviced on the proper sanitation of blood pressure cuffs and vital sign monitors using Sani cloth bleach wipes. The in-service will include proper surface drying times *The DON and/or designee will audit daily for the next seven days and then weekly for the next three months *Results of the audits will be reported to and monitored by the Quality Assurance committee. On 7/10/2020 at 6:30 AM, the facility's two removal plans were verified as being implemented and the immediate jeopardizes were removed.

Based on observations, clinical record reviews, resident and staff interviews and policies and procedures, the facility failed to ensure that four sampled residents (#'s 73, 131, 113 and 18) received the necessary care and services to promote healing and/or prevent new pressure ulcers from developing. As a result, the condition of Substandard Quality of Care was identified. The deficient practice resulted in preventive measures not consistently being implemented, a lack of thorough and/or accurate pressure ulcer assessments and delays in obtaining and/or providing wound treatments. The number of residents in the facility with pressure ulcers which were greater than stage 1 was 23 residents. Findings include: -Resident #73 was admitted to the facilty on (MONTH) 28, (YEAR), with [DIAGNOSES REDACTED]. A physician's order dated (MONTH) 4, 2019 included for weekly skin checks every Tuesday on the day shift. A skin assessment dated (MONTH) 18, 2019 revealed the resident's skin was intact. Review of the clinical record revealed there was no documentation that the resident had a pressure ulcer to the neck area from (MONTH) through (MONTH) 22, 2019. A skin event assessment dated (MONTH) 23, 2019 revealed a skin issue was identified on the back of the resident's neck, near the right side. Per the assessment, the wound nurse assessed the neck area and implemented a treatment. The assessment did not include a thorough description of the skin issue to the resident's neck. A physician's order dated (MONTH) 23, 2019 was entered into the resident's electronic medical record at 8:37 a.m. by a Licensed Practical Nurse (LPN/wound nurse/staff#18), which included to wipe the left neck with normal saline, apply [MEDICATION NAME] to wound base every other day for skin alteration. However, the documentation in the electronic medical record further showed that the order was immediately discontinued at 8:40 a.m. Continued review of the physician orders revealed that another order for wound treatment to the neck wound was not obtained on (MONTH) 23, 2019. A quarterly Minimum Data Set (MDS) assessment dated (MONTH) 26, 2019 included the resident had long and short term memory problems and was severely impaired with cognitive skills for daily decision making. The MDS assessed the resident to be totally dependent for all activities of daily living (ADLs) and had limited range of motion bilaterally to upper and lower extremities. Per the MDS, the resident was at risk for pressure ulcers, but did not have any pressure ulcers. A care plan for skin integrity updated on (MONTH) 27, 2019 revealed the resident was at risk for breakdown related to [MEDICAL CONDITION], impaired mobility, decreased sensation and muscle contraction. Interventions included for body and skin audits weekly and report any red or open areas of concern to the wound nurse to evaluate. However, the care plan did not reflect the resident had a neck wound. Further review of the clinical record revealed there was no additional documentation regarding the neck wound from (MONTH) 24-30. There were also no physician orders for any wound treatment to the neck from (MONTH) 24-30, nor any documentation that treatments were provided. A skin event record dated (MONTH) 3, 2019 included no skin issues and [MEDICAL CONDITION] care was provided. However, a Wound Assessment Detail Report dated (MONTH) 9, 2019 now included documentation the resident had a facility acquired stage 3 pressure ulcer to the right lateral neck. The neck wound measured 1.5 x 8.0 x 0.1 cm (centimeters) in depth, the wound bed was described as 100% bright beefy red, exudate was light and bloody and wound edge was distinct and attached, with [DIAGNOSES REDACTED] and maceration to periwound. A physician's order was obtained on (MONTH) 10, 2019 and included to cleanse with normal saline and apply silver foam every 2 days, [MEDICAL CONDITION]. A physician's note dated (MONTH) 17, 2019 included the presence of a stage 3 pressure injury to the right posterior neck, due [MEDICAL CONDITION] pressure. The note did not include a description of the pressure ulcer to the neck. The Wound Assessment Detail Report dated (MONTH) 18, 2019 included the neck wound measured 1.1 x 6.2 x 0.1 cm. The wound bed was described as 100% bright beefy red, exudate was light and bloody and wound edge was distinct and attached, with [DIAGNOSES REDACTED] and maceration to periwound. The Wound Assessment Detail Report dated (MONTH) 26, 2019 revealed the neck wound measured 1.1 x 5.0 x 0.1 cm. The wound bed was described as 100% bright beefy red, exudate was light and bloody and wound edge was distinct and attached, with [DIAGNOSES REDACTED] and maceration to periwound. Per the (MONTH) 2019 TAR, wound treatments were provided from (MONTH) 10-31. Review of the Wound Assessment Details Report for (MONTH) 2 and 12, 2019 revealed the neck wound measured 1.5 x 8.0 x 0.1 cm in depth, the wound bed was described as 100% bright beefy red, exudate was scant and bloody and wound edge was distinct and attached, with [DIAGNOSES REDACTED] and maceration to periwound. A wound assessment dated (MONTH) 20, 2019 included the pressure ulcer to the neck measured .5 x 1.8 x .1 cm, had 100% bright beefy red tissue with a scant amount of bloody exudate and the wound edge was distinct and attached with periwound [DIAGNOSES REDACTED] and maceration. A wound care observation was conducted on (MONTH) 22, 2019 at 9:10 a.m., with a wound nurse (LPN/staff #68) and the Director of Respiratory Therapy (staff #77). The respiratory therapist removed [MEDICAL CONDITION] and positioned the resident for wound care. The LPN removed the prior dressing and serosanguineous drainage was noted on the pillow. With some difficulty, due to the resident contracting, the LPN changed the wound dressing according to the physician orders. Staff #68 described the wound as red, with pink/red serosanguineous drainage and the wound measured .4. x 2.0 cm. A telephone interview was conducted on (MONTH) 22, 2019 at 11:36 a.m., with the wound nurse (staff #18-the LPN who initially put in the wound care orders for the neck on (MONTH) 23, and then immediately discontinued the order). She stated that if a new wound is brought to her attention she will assess the situation, contact the provider, chart in the notes, start care and notify the rest of the wound team. Staff #18 stated that if she wrote an order and then discontinued it, it was because she made an error. Staff #18 stated she was unable to recall the situation with resident #73. An interview was conducted with staff #68 on (MONTH) 22, 2019 at 12:14 p.m. He stated that resident #73's wound was identified on (MONTH) 9, 2019. He said he was not aware of any skin concerns prior to this date. He stated that respiratory notified him of blood on [MEDICAL CONDITION] and he immediately went to assess the resident. He stated it was a stage 3, due to the fact that subcutaneous tissue was showing. Staff #68 said that he contacted the provider and put a treatment in place. He said the physician came in later and confirmed it was a stage 3 pressure ulcer. An interview was conducted with the Director of Nursing (DON/staff #125) on (MONTH) 22, 2019 at 1:17 p.m. She stated her expectation is that residents are assessed on admission and weekly for skin issues. She said any identified wounds should be forwarded to the wound team, and the wound team would conduct a follow up assessment of the wound the next day. She stated once a wound is identified, the team should initiate treatments, measurements and staging, in conjunction with the wound doctor. An interview was conducted with staff #77 on (MONTH) 23, 2019 at 8:47 a.m. She stated [MEDICAL CONDITION] for resident #73 are changed 3 times per week. She stated it is the responsibility of both respiratory therapy and nursing to check the skin integrity beneath [MEDICAL CONDITION]. Another interview was conducted with the DON on (MONTH) 23, 2019 at 10:55 a.m. The DON stated she did not know what happened in this case. She stated she could not explain why there were no orders put into place when redness was noted to resident #73's neck (back on (MONTH) 23) to prevent it from progressing to a pressure ulcer. -Resident #131 was admitted to the facility on (MONTH) 26, 2019, with [DIAGNOSES REDACTED]. Review of the admission Braden Scale for Predicting Pressure Ulcer Risk dated (MONTH) 26, 2019, revealed a score of 15, which indicated the resident was at mild risk for developing a pressure ulcer. Review of a skin assessment dated (MONTH) 27, 2019, revealed the resident had a surgical incision to the midline abdomen which was present on admission. The assessment did not list any other skin issues. A care plan dated (MONTH) 27, 2019 included the resident was at risk for impaired skin integrity with a goal that the resident would not have skin breakdown. Interventions were to keep the bed linens dry and wrinkle free, and to keep the resident clean and dry. The care plan did not include an intervention to turn and reposition the resident. Review of the admission MDS assessment dated (MONTH) 2, 2019, revealed a BIMS score of 11, which indicated the resident had moderate cognitive impairment. The MDS included the resident required extensive assistance of two or more staff members for bed mobility and transfers. The MDS also included the resident did not have any unhealed pressure ulcers. Regarding the sacrum/coccyx wound: A skin assessment dated (MONTH) 5, 2019 revealed no documentation of any pressure ulcers. Review of the nurse aide documentation from (MONTH) 5-8, 2019 revealed the resident was to be turned and repositioned every 2 hours and as needed. The documentation on (MONTH) 6 and 7 regarding turning and repositioning of the resident every 2 hours and as needed on the second shift was marked as not applicable. A progress note dated (MONTH) 8, 2019 included the resident had a coccyx injury. Per the note, the resident had poor mobility and required one to two person assistance with turning and repositioning. The note included that the wound assessment would be documented during wound rounds. The note did not include a description of the coccyx wound. A care plan for skin breakdown dated (MONTH) 8, 2019 identified the resident had a sacrum pressure ulcer. The goal included the resident would not have further skin breakdown. Interventions included routine measurements of the wounds, treatments as ordered, a pressure reducing mattress and to turn and reposition the resident. The care plan did not include an intervention for any type of cushion for the resident's chair. An initial wound assessment for the coccyx was completed on (MONTH) 9, 2019. The documentation included the resident had an unstageable pressure ulcer which was facility acquired. The wound measurements were 1.5 centimeters (cm) by 1.5 cm, with an unknown depth. The tissue type was described as 100% deep maroon, and the wound edges were distinct and intact, with [DIAGNOSES REDACTED] noted in the periwound. Review of the clinical record revealed a wound photograph from (MONTH) 9, which showed that the wound was not opened. Despite documentation of an unstageable pressure ulcer, there were no physician orders that addressed the sacrum/coccyx pressure ulcer from (MONTH) 9-11, 2019 and there was no documentation of any wound treatments that were provided. A physician's order dated (MONTH) 12, 2019 now included to cleanse the sacrum with normal saline, apply [MEDICATION NAME] and cover with a foam dressing daily. Review of the coccyx wound assessment dated (MONTH) 16, 2019, revealed an unstageable pressure ulcer which measured 1.5 cm by 1.5 cm and 0.1 cm depth. The tissue type was described as 100% deep maroon and the wound edges were distinct and intact, with [DIAGNOSES REDACTED] noted in the periwound. Review of the wound photograph from (MONTH) 16, 2019 in the clinical record revealed the wound was now opened. Review of the TAR for (MONTH) 2019 revealed the treatments were administered as ordered from (MONTH) 12 through 20. The coccyx wound assessment dated (MONTH) 21, 2019 revealed the resident had an unstageable pressure ulcer which measured 1.7 cm by 1.2 cm, with an unknown depth. The wound bed was described as having 100% slough, and the wound edges were distinct and intact, with [DIAGNOSES REDACTED] in the periwound. Regarding the left buttock wound: Review of the shower sheet dated (MONTH) 5, 2019 revealed the resident had redness to the left buttock. A physician's order dated (MONTH) 5, 2019 included for a low air loss mattress. A care plan for the potential for skin integrity due to decreased bed mobility, pain and weakness was revised on (MONTH) 5, 2019. The goal included the resident would not have further skin breakdown. Interventions included a pressure reducing mattress, weekly skin checks and to assist and/or teach the resident to reposition every 2 hours and to report any red, open or areas of concern to the wound nurse to evaluate. The care plan was not updated to reflect the redness on the resident's left buttock. According to the CNA documentation, barrier cream was applied with incontinent episodes and as needed on 3 shifts on (MONTH) 5, on 1 out of 3 shifts on [DATE] and 2 out of 3 shifts on (MONTH) 7. Regarding turning and repositioning the resident every 2 hours and as needed, the documentation showed that on the second shift on (MONTH) 6 and 7 not applicable was marked. Review of the clinical record revealed no further documentation regarding the redness to the left buttocks on (MONTH) 6 or 7, 2019. A progress note dated (MONTH) 8, 2019 now included the resident had a left buttock pressure injury. Per the note, the resident had poor mobility and required one to two person assistance with turning and repositioning. The note further included that the wound assessment would be documented during wound rounds. Review of the initial wound assessment for the left buttocks dated (MONTH) 8, 2019 revealed the resident now had an unstageable pressure ulcer, which was facility acquired. The wound measurements were 8 cm by 4.1 cm with an unknown depth, the wound bed had 60% bright pink or red tissue and 40% slough and wound edges were distinct and intact, with [DIAGNOSES REDACTED] in the periwound. A care plan dated (MONTH) 8, 2019 identified the resident had a left buttock pressure ulcer. Interventions included routine measurements of the wounds, treatments as ordered, a pressure reducing mattress and to turn and reposition the resident. The care plan did not include an intervention for any type of cushion for the resident's chair. A wound assessment dated (MONTH) 9, 2019, revealed the resident had a stage 3 facility acquired pressure ulcer to the left buttocks. The wound measurements were 8 cm by 4 cm by unknown depth. The wound bed was described as having 60% bright pink or red tissue and 40% slough and wound edges were distinct and intact, with [DIAGNOSES REDACTED] to the periwound. Despite documentation of an unstageable pressure ulcer/stage 3 pressure ulcer to the left buttocks, there were no physician's orders for wound treatment which were obtained from (MONTH) 9-11, 2019. The TAR for (MONTH) 2019 also contained no documentation of wound treatments being done from (MONTH) 9-11. A physician's order dated (MONTH) 12, 2019 now included to cleanse the left buttock with normal saline, apply [MEDICATION NAME] and cover with a foam dressing daily. A wound assessment dated (MONTH) 16, 2019 included the resident had a stage 3 pressure ulcer to the left buttocks, which measured 3 by 4 cm, with a depth of 0.1 cm. The wound bed was described as having 60% bright pink or red tissue and 40% slough, and the wound edges were distinct and intact, with [DIAGNOSES REDACTED] in the periwound. Review of the nurse aide documentation from (MONTH) 9-19, 2019, revealed that turning and repositioning the resident every 2 hours and as needed was documented as not applicable at least one shift each day on (MONTH) 9, 10, 11, 13, 14, 15, 16 and 19. Review of the wound assessment dated (MONTH) 20, 2019, revealed a stage 3 pressure ulcer to the left buttocks which measured 1 cm by 1 cm, with an unknown depth. The wound bed was described as having 60% bright pink or red tissue and 40% slough, and the wound edges were distinct and intact, with [DIAGNOSES REDACTED] in the periwound. Review of the (MONTH) 2019 TAR revealed the treatments were administered as ordered from (MONTH) 12 through 20. An observation of wound care for resident #131 was conducted on (MONTH) 21, 2019 at 1:03 p.m., with two wound nurses (LPN/staff #68 and Registered Nurse/staff #94). At this time, there was one wound observed on the resident's left buttock and there was one wound on the lower left buttock. Staff #94 labeled the left buttock wound as the coccyx wound, and the lower left buttock wound was labeled as the left buttock wound. The left buttock wound (which staff #94 labeled the coccyx wound) measured 3 cm by 2.5 cm and contained approximately 75% bright pink tissue and approximately 25% slough. Staff #94 did not measure the lower left buttock wound. Following the cleansing of the two wounds, the resident was repositioned in order to visualize the coccyx area. Observed on the coccyx was a third wound which contained 100% yellowish slough like tissue. At this time, staff #94 did not cleanse the coccyx wound. Staff #94 measured this wound as 1.8 cm by 1.5 cm. Staff #94 then labeled this wound as the coccyx wound. Staff #94 stated that the left buttock wound and the lower left buttock wound were both part of the same wound and relabeled them as the left buttock wound. However, the wounds were observed to be separated by approximately 4 cm of intact tissue. Staff #94 then measured the entire area covering both the left buttock wound and the lower left buttock wound and stated the wound measured 7.9 cm by 3 cm. The lower left buttock wound was not measured separately during this observation. During this same observation, wound treatments were observed. Staff #94 was observed using an applicator to apply [MEDICATION NAME] to the coccyx wound, then used the same applicator and applied the rest of the [MEDICATION NAME] that was left on the applicator to the left buttock wound. She then used a new applicator and applied more [MEDICATION NAME] to the left buttock wound, and then used the same applicator and applied the remainder of the [MEDICATION NAME] to the lower left buttock wound. A wound assessment dated (MONTH) 21, 2019, revealed a stage 3 pressure ulcer to the left buttocks which measured 8 cm by 2.5 cm, with an unknown depth. (Although, these measurements were different than the measurements during the wound observation). The tissue type was described as having 60% bright pink or red tissue and 40% slough, and the wound edges were distinct and intact, with [DIAGNOSES REDACTED] in the periwound. Review of the clinical record revealed no evidence that the wound on the lower left buttock had been identified as a new wound and thoroughly assessed. An interview was conducted on (MONTH) 22, 2019 at 12:00 p.m., with staff #94. She stated that wounds are assessed, measured and photographed weekly. She said the wound team was responsible for assessing and measuring wounds and performing treatments. She said the wound doctor is responsible for staging the wounds and reviewing and/or changing treatment orders. She stated that common interventions for pressure ulcers would include a low air loss mattress, a wheelchair cushion, heel boots and positioning devices. She said that a regular wheelchair cushion would be a common intervention for a stage 2 pressure ulcer, and a Roho cushion would be a common intervention for a stage 3 or 4 pressure ulcer, however, each resident's needs would be considered on a case by case basis. She stated the wound team would notify therapy to evaluate the resident if a cushion or positioning device was indicated. Staff #94 did not know if the resident currently had a cushion. She stated she had not treated the resident's wounds prior to the wound observation, so she had reviewed the previous wound photos and documentation before administering the wound treatments. She said the description of the location of the coccyx wound was confusing. She said she would have called it the inner left buttock wound. She said the reason she called the two wounds on the left buttock the same wound is because she thought they had originally been part of one large open area that had partially healed in the middle. She said if a new wound was identified, the doctor should be notified and treatments should be initiated. She said the wound team would not wait for the doctor to assess a wound before beginning treatment. She said treatments should be initiated and then modified by the doctor when onsite or the team could send the doctor a photo of the wound for clarification. An observation of the resident was conducted on (MONTH) 22, 2019 at 12:54 p.m., with a LPN (staff #44) present. The resident was observed sitting in a geri-chair. Staff #44 stated the resident was not seated on any type of cushion, just the geri-chair. An interview was conducted with a Certified Nursing Assistant (CNA/staff #162) on (MONTH) 22, 2019 at 12:59 p.m. She stated that she helped transfer the resident out of bed and into his chair that morning. She said the resident did not have a cushion, but was sitting on a pillow. An interview was conducted with the DON (staff #125) on (MONTH) 22, 2019 at 1:17 p.m. She stated her expectation is that residents are assessed on admission and weekly for skin issues. She said any identified wounds would be forwarded to the wound team, and the wound team would conduct a follow up assessment the next day. She stated once a wound was identified, the team should initiate treatments, measurements and staging, in conjunction with the wound doctor. She said if there was intact skin between two wounds, they should be considered as two separate wounds, and if there were multiple wounds in an area, then each wound would be measured, treated and documented separately. She said if a new wound was identified, an assessment and measurements should be conducted right away, and treatments should be initiated. She said common preventative measures for wounds would include a low air loss mattress, skin checks and turning and repositioning. She said turning and repositioning is documented by the CNA's. She said a response of not applicable under turning and repositioning was not acceptable. An interview was conducted with the Director of Rehabilitation (staff #221) on (MONTH) 22, 2019 at 1:41 p.m. He stated the wound team and the therapy department coordinate together to provide preventative treatments for residents. He said common evaluations for residents at risk for pressure ulcers include mobility and positioning evaluations, and evaluations for pressure relieving equipment. He said this resident had received regular treatment and instruction from therapy regarding repositioning in his chair to relieve pressure. Staff #221 said the resident also received verbal instruction on transfers. He said for pressure relieving cushions, a Roho cushion would be good for pressure relief, but not a pillow. He said a pillow was not a pressure relieving device. -Resident #113 was admitted on (MONTH) 31, 2019 with [DIAGNOSES REDACTED]. An admission clinical evaluation dated (MONTH) 31, 2019 included the resident had pressure ulcers. The assessment did not include any additional information regarding the pressure ulcers. Review of a pressure ulcer unavoidable assessment dated (MONTH) 31, 2019 revealed the resident had a history of [REDACTED]. The assessment included the resident had a Braden score of 12, which indicates high risk for developing pressure ulcers. The assessment further included the resident had only one wound to the sacrum which was open, and that the wound team was caring for the wound. The assessment did not include any descriptors of the sacrum wound such as; measurements, a description of the wound bed and surrounding skin, the stage of the wound or if any drainage or odor was present. A wound care note dated (MONTH) 1, 2019 included the resident has pressure ulcers to the coccyx. The note included that co-morbidities placed the resident at risk for skin breakdown and delayed healing. The note did not include any description of the pressure ulcers to the coccyx. A care plan initiated on (MONTH) 1, 2019 included the resident has skin breakdown related to decreases in sensation due to [MEDICAL CONDITION], diabetes, impaired mobility and incontinence. The care plan included the resident had a sacrum pressure ulcer. A goal included that the resident will not have further skin breakdown. Interventions included to discuss compliance with the resident, pressure relieving mattress, routine measurement of wounds and treatment as ordered. Review of the physician orders revealed there were no wound treatment orders obtained for (MONTH) 31 and (MONTH) 1, 2019. Review of a physician wound round note dated (MONTH) 2, 2019 revealed no documentation regarding any pressure ulcers on the coccyx. A wound assessment report dated (MONTH) 2, 2019 included the first thorough assessment of the pressure ulcer since admission (on (MONTH) 31). Per the assessment, the resident had an unstageable pressure ulcer on the sacrum, which was present on admission and measured 6 cm x 6 cm, with unknown depth, wound bed had 60% bright pink or red tissue and had 40% slough, with serosanguineous exudate. The wound assessment report dated (MONTH) 2, 2019 also included a photograph of the sacrum/coccyx. Review of this photograph revealed the edge of a measuring tape which was marked in centimeters. Closer inspection of the photograph revealed a second wound was clearly visible. This wound was separated from the sacrum wound by a region of pink and healthy appearing skin. As seen in the photograph, the second wound measured more than one cm in circumference and appeared to have a dark reddened wound bed with depth. The wound bed also contained two smaller round regions of dark or blackened tissue. The second wound was not identified in this wound assessment report. A wound care note dated (MONTH) 2, 2019 included the resident had been seen by the wound physician for a wound care consultation and there were no new physician's orders, and that [MEDICATION NAME] was being applied to the sacral pressure ulcer. Despite documentation that the resident had an unstageable pressure ulcer to the sacrum/coccyx, there were no physician orders for any wound treatment or for medi-honey to be applied from (MONTH) 2-5, 2019. According to the (MONTH) 2019 TAR, there was no documentation of any treatments that were done to the sacrum/coccyx from (MONTH) 1, through 5. An admission MDS assessment dated (MONTH) 6, 2019 included a BIMS score of 14, which indicated the resident was cognitively intact. The MDS included the resident required extensive physical assistance from two or more staff for bed mobility and personal hygiene, and did not transfer from the bed. Per the MDS, the resident was always incontinent of urine, frequently incontinent of stool and was at risk for developing pressure ulcers. The MDS included the resident had one unstageable pressure ulcer upon admission, had a pressure relieving device on the mattress and received pressure ulcer care. A physician's order dated (MONTH) 6, 2019 now included to cleanse the sacrum/buttock with normal saline, apply medi-honey, silver alginate and cover with a dry dressing one time a day for wound care. The (MONTH) 2019 TAR included the above wound treatment orders. The documentation showed that the wound treatment was initiated on (MONTH) 6. A care plan initiated on (MONTH) 7, 2019 included a potential for skin integrity due to decreased bed mobility, incontinence, pain and weakness. A goal was the resident would have minimized risk of pressure ulcer related breakdown and have good skin integrity. Interventions were to assist the resident to reposition himself every 2 hours, complete body/skin audits at least weekly, pressure reducing mattress to the bed, report any red or open areas of concern to the wound nurse to evaluate and treatments as ordered. The care plan did not reflect any pressure ulcers to the sacrum/coccyx area. A wound assessment report dated (MONTH) 9, 2019 included the resident had an unstageable pressure ulcer on the sacrum which measured 6 cm x 6 cm with unknown depth, the wound bed had 60% bright pink or red tissue and 40% slough, with serosanguineous exudate. The assessment also included a photograph of the wound. Closer inspection of the photograph revealed the undocumented second wound (identified by a wound photograph on (MONTH) 2) was now separated from the sacral wound by a slightly larger region of healthy appearing skin. The second wound in the photograph had approximately a one or more centimeter circumference, with a dark, reddened wound bed with depth, and there were no smaller round regions of dark or blackened tissue located within this wound. Further review of the (MONTH) 2019 TAR revealed that wound care was not provided on the following days: (MONTH) 7, 8, 10, 11 and 17. The spaces for staff to initial that the treatments were performed had a 9, indicating other/see nurse notes. Review of the corresponding nurses notes revealed only one nurses note dated (MONTH) 7, 2019, which included the resident had refused wound care. There was no additional documentation regarding why the wound treatments were not provided on the above dates. Review of a wound care note by the wound nurse dated (MONTH) 16, 2019 revealed the resident was seen by the wound physician and there were no new orders at this time. The note included [MEDICATION NAME] to sacral pressure ulcer and to see wound round note for further description of the wound. A physician's wound rounds note dated (MONTH) 16, 2019 included the resident had a stage 3 pressure injury to the right buttock and was receiving medi-honey and foam every 3 days. However, the note did not include any description of the right buttock pressure ulcer, nor any measurements. A wound note dated (MONTH) 19, 2019 included Wound is stable and the resident was followed by the physician frequently for wound care follow up, had a low air loss mattress in place and that an assessment had been documented. A wound assessment report dated (MONTH) 19, 2019 now included a thorough assessment of the sacrum pressure ulcer. The assessment included the resident had an unstageable pressure ulcer on the sacrum which measured 5.3 cm. x 5.3 cm. with unknown depth, with 20% bright pink or red tissue and 80% slough, and had serosanguineous exudate. The wound assessment included a photograph of the wound. Closer inspection of the photograph revealed a deterioration of the sacral wound, with more depth in one region of the wound, and wound margins appeared to have eroded with black tissue along the edges in some areas. The photograph also showed the second undocumented wound was separated from the sacral wound by a region of healthy appearing skin. The undocumented second wound as seen in the photograph had blackened and/or dark tissue in the wound bed. A wound care observation was conducted with a certified wound nurse/LPN (Licensed Practical Nurse/staff #68) on (MONTH) 21, 2019 at 9:40 p.m. Staff #68 measured the proximal right sacral wound which was 2.3 cm. x 3.0 cm. Approximately 2/3 of the wound was covered with yellowish slough like tissue and approximately 1/3 of the wound had dark grey slough like tissue. The margins were macerated and redden, and had two areas that had dark, blackish tissue. During this same observation, an additional wound was identified by the surveyor, which was approximately 1.5 cm below the right sacral wound. The wound nurse

Based on clinical record reviews, staff interviews, facility and hospital documentation and policies and procedures, the facility failed to ensure one resident (#281) was transferred in a safe manner resulting in a fall and failed to ensure that leg rests were in place on one resident's (#281) wheelchair, prior to transporting the resident out of the facility. The facility also failed to implement additional safety measures to prevent further falls for one resident (#65). Findings include: -Resident #281 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Regarding the fall: A respiratory care plan included the resident had an altered airway related to having a [MEDICAL CONDITION] (trach). The goal was for a healthy, [MEDICAL CONDITION] stoma site and that the airway will remain patent. Review of a self care deficit care plan included the resident required assistance with Activities of Daily Living (ADLs) related to [MEDICAL CONDITION] and [MEDICAL CONDITION]. The goal included that the resident will maintain his current level of independence by the next review. An intervention included to gather and provide necessary materials and equipment for ADL tasks. A fall risk care plan revealed the resident was at moderate risk for falls due to [MEDICAL CONDITION] and [MEDICAL CONDITION] to the right side. The care plan addressed that the resident did not have a fall history, but was unable to come to a standing position on his own. The goal was to reduce the likelihood of the resident experiencing a fall. One of the interventions included to conduct physical and occupational PT/OT) therapy evaluations and treat per the physician's orders [REDACTED].>Review of the PT daily treatment note dated 9/18/17 revealed the resident was dependent with functional transfers and required a Hoyer lift for transfers. A PT daily treatment note dated 10/4/17 also indicated that the resident was transferred from the bed to his wheelchair with a Hoyer lift. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident scored a 15 on the Brief Interview for Mental Status (BIMS), indicating he was cognitively intact. Per the MDS, the resident was assessed to require extensive assistance of two persons with bed mobility, transfers and toileting. The MDS further included the resident had impairment to both upper and lower extremities. The resident was also coded as not having any falls. Review of the Certified Nursing Assistants (CNA) ADL documentation under transfers revealed that from (MONTH) 1 through 13, (YEAR), there were multiple times that the CNAs had documented that the resident only needed the assistance of one for transfers. Review of a Respiratory Therapist (RT) note dated 10/13/17 revealed a RT responded to a Certified Nursing Assistant (CNA/staff #306) who was yelling for help. The resident was in his room on his knees and the CNA was holding the resident. The note indicated that the resident'[MEDICAL CONDITION] out and he was unresponsive. The RT called a rapid response (facility emergency response). Per the note, the RT placed [MEDICAL CONDITION] and bagged the resident until his oxygen saturations were 95%. The note included that the resident's airway was patent and secured and the Nurse Practitioner was notified. A nursing note dated 10/13/18 included that the resident was observed sitting on the right side of the bed with the CNA, and the resident was being bagged by the RT, with oxygen saturations above 90%. The resident was awake, alert and responsive and was assisted back to bed. No injury was noted. Per the note, the CNA stated that the resident's knees had buckled and she lowered him gently to the floor onto his knees. The note included that while the CNA was lowering the resident to the floor, [MEDICAL CONDITION]. The CNA called for help and the RT immediately responded and called a rapid response. The RT stabilized [MEDICAL CONDITION] bagged the resident ensuring that his airway was patent. The physician was notified with no new orders. A nurse practitioner note dated 10/13/17 indicated that the patient had become a rapid response and his airway became occluded. The note indicated that [MEDICAL CONDITION] out and was replaced and required to be bagged until his oxygen saturation came up. The note indicated that he was doing okay after the incident. The facility was unable to provide any documentation that this incident was investigated. Further review of the clinical record revealed that on (MONTH) 16, (YEAR), the resident was transferred to the hospital for chest pain. Review of the PT progress and discharge summary dated 10/16/17 revealed the resident was totally dependent with all transfers and required the assistance of two staff, and required a mechanical lift for transfers for safety. According to the Hospital documentation, the resident was admitted with [DIAGNOSES REDACTED]. The resident was readmitted to the facility on (MONTH) 26, (YEAR). Review of the employee file for the CNA (staff #306) revealed concern reports dated 10/16/17, which included that staff #306 transferred a resident who was a Hoyer lift alone, without a gait belt. The documentation included the resident could not bear weight and his knees buckled. The resident'[MEDICAL CONDITION] pulled out and he became non responsive requiring the facility to call a rapid response. The CNA stated that the resident had watery stool and she had to shower him and that he was weak, due to the watery stools. An interview was conducted with a Registered Nurse (RN/staff #73) at 3:40 p.m. on 7/2/18. She said that she remembered this resident and remembered the fall that he had on 10/13/17, as she was the nurse on duty and the one who wrote the nursing note regarding the fall. She stated that she responded to a rapid response in the resident's room. She said and the CNA was transferring the resident when his knees buckled and she lowered him to the floor. She said that by the time she got to the resident he had been stabilized, so she did not see what happened to his trach, but knew that it had dislodged and that RT replaced it and bagged him, since he was unresponsive. She further stated that when a mechanical lift such as a Hoyer is required therapy staff will tell nursing this information and that it should be care planned. She said that the facility did not do an investigation, because the administration at the time did not consider this a fall, as the resident was assisted to the ground. Another interview with staff #73 was conducted at 8:30 a.m. on 7/3/18. Staff #73 stated at the time of the fall, the resident was suppose to be transferred with a mechanical lift, and that the staff #306 did not do this. She stated that she reported this to management at the time. She said staff #306 does not work in the building any longer. An interview was conducted with the therapy manager (staff #266) at 1:55 p.m. on 7/2/18. He stated that he was not in the building during this incident. He said that normally, therapy will do an evaluation of new admissions and they may make recommendations on how to transfer a resident, especially if they need a mechanical lift such as a Hoyer. He reviewed the resident's therapy notes and stated that it appeared that the resident would have required a Hoyer lift, because the resident was requiring maximum assistance of two staff members. He said the notes do indicate that a Hoyer lift was being used. He said if for some reason a Hoyer lift was not used, there should have been at least two staff members present, because the resident was not able to assist with the transfer and the staff would be doing all the work, which could be unsafe. Staff #266 stated that the transfer information for this resident would have been passed on to nursing via the daily stand up meetings, and that the therapist's talk with the CNAs and educate them on this type of information. During an interview with a CNA (staff #156) at 8:45 a.m. on 7/3/18, he said that when he transfers a resident for the first time he checks the clinical record, including the care plan for diagnoses, weaknesses and specifics on how to transfer the resident. He said that he would also talk to the resident to determine what they might need. Staff #156 stated that he would also talk to therapy to see what their recommendation was. He said that most of the residents on his hall require total assistance and a lot of them require Hoyer lifts. He said that he remembered this resident and had worked with him. He said the resident did require a Hoyer lift and would never have transferred the resident by himself. An interview was conducted with a CNA (staff #207) at 8:50 a.m. on 7/3/18. He said that he usually asks the nurse or the previous CNA how to transfer a resident, as he is not really able to get into the care plan to see how they are transferred. He said he was not aware of any other way to get this information. He said there is a cardex for the CNAs, but it does not include this type of information. In an interview with the interim Director of Nursing (DON/staff #75) at 9:15 a.m. on 7/3/18, she stated that she was not working in the building at the time of this incident. She said that she and the Assistant Director of Nursing, the administrator and many other staff are new. She said that she looked for an incident report on this fall, but could not locate one. She said the expectation is that a resident is evaluated by therapy on admission and they would make recommendations as to how the resident should be transferred. She said that this should be communicated in the morning meetings to staff so they are aware of this. She stated that this information should be care planned, but she could not find anything in this resident's care plan regarding his transferring needs. She said she reviewed the record and from what she found the resident required extensive assistance of two people with transfers. An interview was conducted with the Regional Director of Human Resources (staff #305) at 9:30 a.m. on 7/3/18. She said that the CNA was termed on 10/17/17. An interview was conducted with a CNA (staff #90) at 11:00 a.m. on 7/3/18. She said that she remembered the resident and that he required a Hoyer lift for all transfers. She said there should have been two people for each and every transfer. A telephone interview was attempted with staff #306, but was unable to reach the former staff member. A policy for lifting machines included the purpose was to help lift residents using a manual lifting device. The policy noted that preparation included to review the resident's care plan to assess for any special needs of the resident. The policy also included that two CNAs are required to perform the procedure. Regarding the incident with the wheelchair leg rests: Review of the clinical record revealed no evidence that the resident had any skin breakdown to his toes in (MONTH) (YEAR). According to a psych consult dated 10/2/17, the resident stated that he did not feel depressed and was trying to keep a positive attitude. He reported that he was hoping to be able to go home. Per the consult, the resident had been hospitalized about [AGE] years ago for depression. He denied any suicidal thoughts or attempts. He was noted to be tearful at times. The plan was to continue with his antidepressant medication at the current dose for tearfulness. Review of a skin check dated 10/2/17 indicated that the resident did not have any skin issues on his toes. Review of the physician orders [REDACTED]. The order indicated that the resident was to be transported by his insurance company's transportation service. A nursing note dated 10/3/17 revealed the resident left the facility for an appointment via medical transport. The resident reported that the foot rests were not placed on the wheelchair by the CNA orientee (staff #304). The note included that the Assistant Director of Nursing spoke with the resident's advocate and the advocate and the resident requested psych follow-up, x-rays and for the wound doctor to see his toes. The note also included that an investigation was completed. A nursing note dated 10/3/17 included the resident stated the foot rests were not placed on his wheelchair, prior to leaving for his appointment. The note included that the tops of the residents toes were assessed upon arrival back to facility and were cleaned, treated, and dressings were applied. The note further included that the wound physician assessed the wounds and there were no new orders. A physician's orders [REDACTED]. Review of the x-ray report dated 10/4/17 revealed there were no fractures of the foot/toes. A physician's orders [REDACTED]. A physician's note dated 10/5/17 documented that the resident appeared disheartened and was upset that he was always sick, and that things kept happening one after another. He was upset about the abrasions on his feet and was concerned that they would develop into another infection. The physician indicated to continue the wound care to the resident's feet. The note also included that the resident was noted to appear depressed. On 10/5/17, a psych follow-up was conducted. The documentation included the staff at the facility had reported that the resident had become more depressed over the past 2 days. The note included that there was an incident that occurred while he was being transported and the foot rests were not put on his wheelchair, causing his feet to drag, resulting in multiple abrasions to his feet. After the incident, staff reports that the resident has become more depressed and wants to give up and has been refusing wound care and medications. The resident reported that he wanted to give up especially after the incident that occurred with his feet. The resident stated he realized that he was never leaving the facility. The note indicated that the resident appears depressed with signs of tearfulness. The plan was to double his antidepressant medication for the tearfulness and was a danger to himself if he continues to refuse care. There was no clinical record documentation of any description of the wounds on the resident's toes from (MONTH) 3 - 16, (YEAR), other than the physician reference to abrasions on his feet. Further review of the clinical record indicated that the resident was sent to the hospital on [DATE] for a medical issue not related to his toes and returned on 10/26/17. An interview was conducted with a RN (staff #73) at 9:57 a.m. on 7/2/18. She said that she remembers this resident and that he needed to be pushed when he was in his wheelchair, as he had very limited ability to self propel. She said if the resident was in his wheelchair, staff would need to put foot pedals on it. In an interview with a charge nurse (staff #53) at 3:45 p.m. on 7/2/18, she said that she remembered the resident and that he had limited ability to proper himself in a wheelchair and mostly needed to be pushed. Staff #53 stated that they did use foot pedals on the wheelchair. She said the resident had an appointment and staff got him ready, but the foot pedals were not put on his wheelchair, when transportation came to pick him up. She said that normally he has shoes on when going out to appointments, but when this happened he did not and did not know why. She said that she believed the injury to his toes occurred while the resident was being transported by the transport company. During an interview with the therapy manager (staff #266) at 1:55 p.m. on 7/2/18, he said that this resident would be a good candidate for having foot rests on the wheelchair when going out for an appointment, since he had one side of his body which was paralyzed. A telephonic interview was attempted with a CNA (staff #304) at 8:30 a.m. on 7/3/18, as she was the CNA orientee during the incident, but she was unable to be reached. An interview was conducted with a CNA (staff #156) at 8:45 a.m. on 7/3/18. He said that part of getting a resident ready for an appointment is to put the foot rests on the wheelchair. He said that he would also make sure the resident had shoes on, unless the resident cannot wear shoes. He said that he remembered resident #281 and that he did use foot rests and also wore shoes. In an interview with a CNA (staff #207) at 8:50 a.m. on 7/3/18, he said that he would put foot rests on a wheelchair when getting a resident ready for an appointment, as the transport company needs the foot rests on the wheelchair, so they can push the resident. He said that some residents do self propel, but even those residents should have foot rests on their wheelchairs when going out for an appointment. An interview was conducted with the Director of Nursing (DON/staff #75) at 9:15 a.m. on 7/3/18. She said that she was not working in the building when this incident occurred. She said that she could not find an incident report for this occurrence. She said when it comes to foot rests, it depends on the resident. She said that if they use their feet for mobility, then they may not need foot rests on the wheelchair, but if they cannot use their feet for mobility or have a limited ability to do so, she would expect that the foot rests are applied. After reviewing the resident's chart, staff #75 stated it appeared that he did use medical transport when this occurred and the CNA orientee did not put the foot rests on when she should have. She also acknowledged that he was seen by psych and that they had increased his antidepressant medication after the event. During an interview with a CNA (staff #90) at 11:00 a.m. on 7/3/18, she stated that she was the CNA who was orienting staff #304 the day that the resident injured his toes. She said it was the CNA's last day as an orientee, so she was on her own more. She said that she put the foot rests on the resident's bed for the orientee to put on the wheelchair and then left the room. Staff #90 said that the orientee did not put them on the resident's wheelchair. She said the resident usually had foot rests on his wheelchair and had shoes on for appointments. She said that he certainly needed foot rests for his wheelchair, as he was not capable of moving his feet and he did not have any feeling in them. Review of the facility transportation policy revealed a statement that the facility will assist residents in arranging transportation to and from appointments when necessary. The policy included that the appointment scheduler or designees will be responsible for arranging the transportation and will confirm special needs with the charge nurse. -Resident #65 was admitted on (MONTH) 26, (YEAR) and readmitted on (MONTH) 11, (YEAR), with [DIAGNOSES REDACTED]. The resident was discharged on (MONTH) 18, (YEAR). A history and physical report dated (MONTH) 11, (YEAR) included the resident had a history of [REDACTED]. The resident had confusion, [MEDICAL CONDITION] and was unable to follow commands consistently. The resident also had a contracture of the right arm, both legs and was able to move her left arm. A physician's orders [REDACTED]. A self care deficit care plan included the resident required assistance with ADL's (Activities of Daily Living), due to [MEDICAL CONDITION], right [MEDICAL CONDITIONS] and contracture's. A goal was the resident will maintain current level of independence with ADL's. An intervention included for half side rails x 2 for increased bed mobility. A care plan for a potential for falls addressed that the resident was at risk for injury from falls, due to right [MEDICAL CONDITION], subarachnoid hemorrhage, [MEDICAL CONDITION] and [MEDICAL CONDITION]. A goal included to reduce the likelihood of the resident experiencing a fall. Interventions included a high/low bed with a mat on the floor, educate the resident, family and caregivers about safety, and to encourage the resident to transfer and change positions slowly. Review of a significant change MDS (Minimum Data Set) assessment dated (MONTH) 14, (YEAR) revealed the resident was rarely or never understood, had severely impaired cognition, and had problems with short and long term memory. The MDS assessed the resident to be totally dependent on staff for bed mobility and transfers and required the physical assistance of two or more staff. The resident was assessed to have functional limitation with range of motion to upper and lower extremities. The MDS also included that the resident did not have a history of falls and had no falls since admission. A nurse's note dated (MONTH) 19, (YEAR) at 1:16 a.m. included that an aide was changing the resident's brief while the resident was on the bed and the resident suddenly started scratching herself, and then started sliding off the bed. The aide attempted to hold onto the resident, but the resident slid onto the floor. The resident was assisted back onto the bed by multiple staff and was assessed to have a bump on the left side of her head. The resident was sent to the hospital. There was no clinical record or facility documentation which addressed the lack of utilizing half side rails just prior to the fall for bed mobility, turning and positioning as ordered and as care planned. There were also no interventions implemented following the fall which addressed this concern. A nurse's note dated (MONTH) 19, (YEAR) at 5:47 a.m. included that the resident had returned from the hospital and did not have any serious injuries. Further review of the clinical record including the resident's care plans revealed that following this fall, the was no evidence of any additional interventions which were implemented to prevent further falls, despite the resident falling out of bed during care. A nurse's note dated (MONTH) 23, (YEAR) included the nurse had called the facility rapid response team to the resident's room to assist with assessing the resident and helping her back into bed. Per the note, the resident had a small abrasion on the left side of her eye that was bleeding. The resident was sent to the emergency room for further evaluation. Review of an incident report dated (MONTH) 23, (YEAR) revealed that a CNA (staff #151) reported that she was attempting to change the resident's brief and the resident slipped out of the bed. The facility rapid response team was called and assisted the resident back into bed. The resident had a small abrasion on the left side of the eye, which was bleeding. The resident was sent to the emergency room for further evaluation. The report did not address the lack of side rail use as ordered and as care planned. A nurses note dated (MONTH) 24, (YEAR) included that the resident returned from the hospital and and had not sustained any fractures. Continued review of the clinical record including the resident's care plans revealed that from (MONTH) 24 through (MONTH) 27, (YEAR), there was no documentation of any additional safety measures which were implemented to prevent further falls. In addition, there was no clinical record or facility documentation which addressed the lack of utilizing half side rails just prior to the fall for bed mobility, turning and positioning as ordered and as care planned. There were also no interventions implemented following the fall which addressed this concern. According to the Fall care plan, it was revised on (MONTH) 28, (YEAR) to reflect the need for two staff to assist with bed mobility and transfers. This was more than four weeks after the fall. An interview was conducted on (MONTH) 28, (YEAR) at 9:20 a.m. with a LPN (Licensed Practical Nurse/staff #159). Staff #159 stated that resident #65 was able to assist staff when they were cleaning her, by using her left hand to hold onto the side rail when on her right side. She stated that on (MONTH) 23, (YEAR), she was called to the resident's room by a CNA (staff #151), because the resident had rolled off of the bed. She said stated that staff #151 was providing ADL care to the resident alone. She said the side rail on the bed was pulled up on the side of the bed where the CNA was standing, but was down on the side of the bed that the resident was facing. Staff #159 stated that the CNA rolled the resident away from her onto her side, facing away from the CNA, and because the side rail was down, the resident did not have anything to hold onto and the resident rolled away from the CNA onto the floor. Staff #159 stated that a rapid response code was called and multiple staff assisted the resident back to the bed. She stated that staff #159 was new to the unit and had never taken care of this resident before and did not know how many staff were needed to provide care. An interview was conducted on (MONTH) 28, (YEAR) at 12:00 p.m. with a LPN (staff #14). Staff #14 stated that resident #65 was able to hold onto the grab bar on her bed with her left hand, when care was provided. Staff #14 stated that both of the resident's legs were contracted and for this reason the resident required two staff to provide ADL care for the safety of the resident. An interview was conducted on (MONTH) 28, (YEAR) at 12:15 p.m. with a CNA (staff #49). The CNA stated that resident #65 was totally dependent on staff for all of her care and required two staff during care. Staff #49 stated that the off-going CNA's provide a verbal report to the on-coming CNA's at shift change regarding the level of assistance that resident's need. An interview was conducted on (MONTH) 28, (YEAR) at 12:50 p.m. with a Nurse Manager (staff #50). During the interview, staff #50 stated that if a CNA assigned to work on the unit does not know the resident, she should ask the charge nurse or the nurse on duty regarding how many staff are required to safely assist the resident. An interview was conducted on (MONTH) 28, (YEAR) at 1:36 p.m., with the Director of Nursing (staff #75). Staff #75 stated that if a CNA is not familiar with the resident, she is supposed to ask staff who are familiar with the resident regarding how much assistance is needed to provide care to the resident. Staff #75 stated that the resident should have had two CNA's providing care. Staff #75 was unable to provide any documentation that additional interventions were immediately implemented after both falls. During the survey, telephonic interviews were attempted with staff #151, but was unable to reach staff #151. Review of the Fall Prevention policy revealed the purpose was to implement/maintain an individualized fall prevention care plan for at risk residents. The policy included that fall risk is to be assessed on admission, quarterly and with any significant change of condition. At the time of a fall, the assigned nurse is to complete a full detailed incident report. Per the policy, the unit coordinator shall ensure that care plans are updated to reflect any changes or additions to the fall prevention plan, based on circumstances of the fall.

Based on clinical record review, staff interviews, and review of facility policies and procedures, the facility failed to immediately transfer one resident (#5) to the hospital after the resident sustained [REDACTED]. Findings include: Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the resident's clinical record revealed the resident was a full code status. The resident's clinical record revealed Nurse's Notes dated [DATE] at 4:40 a.m. which documented "CNA (certified nursing assistant) reported to this writer to check resident not responding well. Difficulty in awakening resident. White foam noted at her mouth. Vital signs ,[DATE] pulse 66 respirations 16 blood sugar 115 skin warm to touch. HOB (head of bed) up. Supervisor notified." The resident's clinical record revealed Nurse's Notes dated [DATE] at 5:00 a.m. which documented "Oxygen saturation 95 pulse 74. Supervisor present." The resident's clinical record revealed Nurse's Notes dated [DATE] at 5:05 a.m. which documented "(Provider ' s name) notified,,,order to send to (name of hospital) for evaluation as soon as possible...(name of ambulance company) on their way." A review of the resident's clinical record revealed Physician's Telephone Orders dated [DATE], which documented "T.O. (telephone order) NP (nurse practitioner)...send to (hospital name) for evaluation ASAP." There was no documentation in the resident's clinical record that 911 was called to transport the resident immediately to the hospital. The resident's clinical record revealed Nurse's Notes dated [DATE] at 5:10 a.m. which documented "blood pressure ,[DATE] pulse 78 respirations 16 oxygen saturations at 98 oxygen on at 2 liters via nasal cannula." The resident's clinical record revealed Nurse's Notes dated [DATE] at 6:30 a.m. which documented "(Name of ambulance company) in to take resident to (name of hospital)." A review of the resident's clinical record revealed that the resident was not transferred to the hospital until one hour and 50 minutes after the resident first experienced symptoms of being difficult to arouse as a non-emergent transfer was arranged instead of staff member #3, a licensed practical nurse, calling 911. A review of hospital documentation dated [DATE] documented "At 5 this morning, when the night nurse went to check on the patient, the patient was found unresponsive and foaming at the mouth. The exact onset of symptoms is unknown. The exact duration of loss of consciousness and foaming of the mouth is unknown. She was then transferred to the emergency room ...The patient was found unconscious and also foaming at the mouth at the nursing home. She was brought to the hospital. She was intubated for [MEDICAL CONDITION]." An interview was conducted with an RN (registered nurse) on Mach 13, 2012. The RN stated that if a resident was non-responsive, 911 should be called first and then the physician. An interview was conducted with the DON (director of nursing) on [DATE]. The DON stated that if a resident was non-responsive, 911 should be called immediately. A review of the facility's policy Emergency Discharge documented "Once a resident's CODE status is established the Licensed Personnel will initiate CPR and have available personnel call 911, if indicated."

Based on clinical record review, hospital record review, staff interview, review of facility policy and procedure, and review of facility documentation, the facility failed to ensure that one resident (#1) had his anti-coagulant medications, [MEDICATION NAME] and Aspirin, held for seven days prior to his dental surgery and per physicians order, resulting in hospitalization for uncontrolled bleeding. Findings include: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. A later order dated January 12, 2012, revealed that the resident was to have his ASA (aspirin) and [MEDICATION NAME] held starting January 13, 2012. A review of the physician's progress notes of January 20, 2012, revealed that the dentist had removed five of the resident's teeth that day, and the resident had tolerated the procedure well. A later progress note from an internal medicine physician revealed that the resident was experiencing a large amount of bleeding, and was going to be sent to the emergency room for treatment. Nurses' notes from January 20, 2012 at 10:57 PM, revealed that the resident had returned from the emergency room , but was still having continued bleeding from his mouth. The nursing supervisor called the physician, and at 12:45 am on January 21, 2012, the resident was again transported to the emergency room . Hospital records revealed the resident was a patient from January 21, 2012, through January 25, 2012. During that time he was intubated (had a tube placed into his trachea to assist him to breathe), and put on a mechanical ventilator. His bleeding was controlled. By January 25, 2012, he was able to breathe on his own, and was stable enough to return to the facility. Review of facility documentation related to resident #1's tooth extractions, revealed that the facility had failed to transcribe the physician's orders [REDACTED]. In an interview with the Director of Nurses on March 13, 2012, he revealed that he had instituted a new daily practice for all of his unit coordinators to ensure that all orders had been transcribed from the previous day. He has also conducted mandatory in-service education classes about medication administration for all of the nurses. He also said that medication administration has been added to the quality assurance plan in order to continue the monitoring. Additionally, he said that his assistant directors of nursing are doing daily medication administration audits. In an interview also conducted March 14, 2012, a second licensed staff (Staff #2) member stated she had not transcribed the order to hold the two anti-coagulants onto the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A review of facility policy entitled "Telephone Order/Order Transcription" revealed that telephone orders are to be signed by the nurse transcribing the order, placed on the MAR indicated [REDACTED].

Based on observation, clinical record review, resident and staff interviews, and facility policy, the facility failed to provide the necessary treatment and services to prevent one resident (#2) from developing a pressure ulcer. Resident #2 sustained actual harm. The sample size was three. Findings include: Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the clinical record and the comprehensive resident assessment dated [DATE], documented that the skin was intact upon admission. A Braden Scale dated April 25. 2011, had a score of 18, which placed the resident at risk for a pressure sore. The continuing care transfer form dated April 25, 2011, had an order for [REDACTED]. The clinical record revealed admission orders [REDACTED]. The care plan for the brace was dated April 26, 2011. The brace was to be worn 24 hours seven days a week. The following approaches included to document when to apply the brace, make sure the brace was used per MD orders, that it fit properly, and to conduct weekly skin checks. Another care plan dated April 26, 2011, was for a surgical procedure, recovery, and right hip wound. The approaches included to provide wound care per MD orders, to observe/check site for infection, document wound care, Braden Scale weekly times four weeks, then quarterly, and weekly skin assessments. However, there was no documented evidence of the Braden Scale in the resident's clinical record, which was to be completed weekly times four weeks as part of the resident's care plan. A physician's order dated April 27, 2011, had an order for [REDACTED]. According to the clinical record review, there was no documented interventions for the care of the resident's skin under the brace, nor clarification of the order for the brace application. A physician progress notes [REDACTED]. The admission Minimum Data Set (MDS) dated [DATE], assessed that the resident had no short or long term memory problems nor difficulty with decision making for daily living. Also, the resident was able to be understood and understand. Transfer and bed mobility was coded as extensive assist with one/two person physical assist. Limited ambulation occurred with a one person assist. The resident's skin was intact. However, the resident had a surgical wound. Section V. of the care area assessment (CAA) summary revealed that pressure ulcers were triggered and directed staff to care plan. Also, the CAA summary report documented that the resident was at risk for skin breakdown due to decreased bed mobility. A review of the weekly nursing skin assessments for May 2, and 9, 2011, documented the placement of a brace on the back and hip. The skin was intact at this time. A care plan dated May 15, 2011, was developed for the potential for skin breakdown due to decreased mobility. Goals included in the care plan were to reduce the risk of pressure related breakdown and have good skin integrity through next review. Care plan approaches included to assess risk for pressure ulcers formation with the Braden Scale, body/skin audit weekly, pressure reducing mattress, ensure that braces were applied properly, and to report any red, open areas of concern to wound nurse, treatment as ordered. A review of the weekly nursing skin assessment (a form) dated May 16, 2011, was not completed, although this was documented as one of the identified approaches on the care plans. The May 18, 2011, physician progress notes [REDACTED]. However, the resident had not been able to stand alone and was not walking. The resident was mostly bed and chair bound. A further review of the physician progress notes [REDACTED]. Review of the clinical record and the weekly nursing skin assessment dated [DATE], documented that the resident had a pressure area and the wound nurse was notified. The physician order dated May 25, 2011, had an order for [REDACTED]. Although the resident was bed and chair bound, the resident was placed on a clinitron bed after the resident had acquired an unstageable pressure ulcer on his back, which was under the back brace. A review of the physical therapy (PT) treatment encounter note dated May 25, 2011, documented an observation of a wound on the mid back that was from the brace. The PT staff notified nursing concerning the resident's complaints of pain. The progress notes documented that the resident had a "decubitus ulcer of the back secondary to brace." Also, that the resident complained of pain, when lying on his back. The May 25, 2011, physician progress notes [REDACTED]. However, the resident could not stand alone and was not walking. The resident was mostly bed and chair bound. The documentation continued that the "...decubitus ulcer on the mid back was caused by the brace and a [DIAGNOSES REDACTED]. In addition, the resident was to lie on his side to help with healing and use a clinitron bed. A further review of the physician's orders dated May 25, 2011, had a treatment order for the mid spine pressure ulcer. The orders were to apply [MEDICATION NAME]/Santyl 1:1 after cleaning with normal saline and to cover with petroleum gauze pad and 4 x 4, non adherent dressing. In addition, the same physician order had the resident as full weight bearing and to remove the brace at bedtime and for personal hygiene. The revised care plan for an appliance dated May 25, 2011, had a goal for the resident to wear the brace when up in chair or when ambulating with therapy. The approaches included documentation of when to apply the appliance per MD orders, and to conduct weekly skin checks. A review of the weekly pressure ulcer assessment form dated May 25, 2011, measured 6.2 x 3.2 cm (centimeter) with depth unable to determine (UTD). The pressure ulcer was unstageable, with a wound bed that was 10 percent red and 10 percent yellow. The May 27, 2011, physician progress notes [REDACTED]. Physician's orders dated May 27, 2011, revealed an order to turn the patient from side to side only, except for meals, and when out of bed for therapy. The weekly pressure ulcer assessment form dated May 29, 2011, revealed an open area on the left heel that measured 1.5 x 2 cm. The area was staged as a deep tissue injury (DTI) and the skin was purple in color. Review of the weekly pressure ulcer assessment form dated May 29, 2011, revealed an open area on the right heel that measured 3.5 x 2.5 cm, which was staged as a deep tissue injury (DTI) and the skin was purple in color. The physician's orders dated May 29, 2011, ordered Prafo boots on both heels at all times (DTI), and apply to both heels with skin prep pad and wrap with Kerlix daily by wound team. Also, to float heels until Prafo boots were available. The June 1, 2011, physician progress notes [REDACTED]. A further review of the progress note revealed that the decubitus ulcer of upper back still had 80 percent slough, right and left heel continued with [MEDICATION NAME] and left heel had a small dry black eschar. Although the left heel area had resolved, a review of the weekly pressure ulcer assessment form dated June 4, 2011, documented a stage ll, area on the right heel that measured 3.8 x 2.8 x 0.1 cm. The wound bed was 50 percent pink and 50 percent red, with drainage. A review of the June 8, 2011, physician progress notes [REDACTED]. Per the note, the wound had 50 percent slough and 50 percent granulation. Review of the weekly pressure ulcer assessment form dated June 10, 2011, revealed an unstaged area on the mid back/spine, which measured 4.8 x 2.4 cm. The wound bed was now 100 percent yellow with drainage. The Braden Scale for July 11, 2011, had a score of 21, which was moderate risk for the development of a pressure ulcer. Another physician progress notes [REDACTED]. The wound was also sharply debrided at the mid back. The note further documented that the wound nurse would notify MD if no improvement. The July 25, 2011, physician progress notes [REDACTED]. Furthermore, the wound had tunneling at 12 o'clock, which was 3 cm. If no improvement, then resident may need an MRI (magnetic resource images) to rule out osteomyethis. On August 1, 2011, the resident was seen with the wound nurse. The resident received antibiotics for [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) wound infection from the pressure ulcer located on the resident's back. The review of the August 8, 2011, physician progress notes [REDACTED]. The wound also had slough and was not improving. The note further documented that a WBC (white blood count) would be used to rule out osteo[DIAGNOSES REDACTED], because the MRI was unable to be obtained. An August 23, 2011, physician progress notes [REDACTED]. A review of the physician's orders dated August 29, 2011, revealed an order for [REDACTED]. August 29, 2011, physician progress notes [REDACTED]. The note documented a recommendation for a plastic surgeon for further evaluation and treatment. A September 9, 2011, physician progress notes [REDACTED]. The resident was stable medically if surgical intervention was necessary to heal the wound. The review of the September 26, 2011, physician progress notes [REDACTED]. During the observation September 28, 2011, the resident stated a concern in regards to the mid back wound, because of the slow non-healing wound. On September 28, 2011, at 12:30 p.m., the resident's wound care was observed without incident. The wound measured 4.6 x 3.2 x 1.1 cm and undermining .7 cm at 9/12. The tunneling was 2 cm. The wound had a small amount of yellow slough. An interview was conducted with the wound nurse on September 28, 2011, after the wound observation. The wound nurse stated there was a concern with the fit of the back brace, because it seem to not fit in places. However, there was no documentation of the orthopedic physician being notified of the concern. During an interview with a certified nursing assistant (CNA), conducted on October 3, 2011, at 8:45 a.m. The CNA stated that the skin assessment was completed daily and as part of the bath/shower. The CNA stated that the skin assessment was limited to the skin that was exposed. An interview was conducted with the licensed Practical Nurse (LPN) on October 3, 2011, at 9 a.m. The LPN stated the September 16, 2011, weekly skin assessment was missed, and another assessment was not completed prior to discovering the pressure ulcer on the back. Review of the facility policy titled "Skin Integrity and Wound Care Management" documented "...All residents should be assessed for pressure ulcer risk using the Braden scale upon admission and weekly for first four weeks of admission, then reassess quarterly thereafter...A thorough skin assessment should be conducted by the licensed nurse: on admission, any changes, and weekly as assigned...Skin checks are documented on the weekly skin assessment form...The physician would be notified promptly of wounds or need for treatment...Interventions: provide a pressure reducing device for seating surface, provide a pressure reducing/relieving mattress or overlaying bed...dynamic support surface if resident was less mobile or if the wound was resistant to healing...offloading heels in bed...management of [MEDICAL CONDITION]"