Every finding on record at Clarewood House Extended Care Center

Based on observation, interview, and record review the facility failed to protect the confidentiality of personal health care information for 1 of 8 (Resident #1) residents reviewed for confidentiality of records.The facility failed to protect private documentation and information for Resident #1 on 07/14/2026 by having a shower sheet which contained personal, private information on the nurse counter in full view for anyone to see.This failure could affect residents by placing them at risk for loss of privacy and dignity.Findings included:Record Review of the undated Face Sheet for Resident #1 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Paralytic Ileus (a temporary cessation of intestinal movement caused by paralysis of the muscles or nerves in the gut, leading to a functional obstruction without any physical blockage), Essential (primary) hypertension (is chronically elevated blood pressure without a single identifiable cause, influenced by genetic and lifestyle factors), Lymphedema (tissue swelling caused by an accumulation of protein-rich fluid that's usually drained through the body's lymphatic system).During an observation on 07/30/2026 at 10:15 AM of the 400-nurse station there was a shower sheet (where scars, skin abnormalities or wounds are documented) for Resident #1 which was left unattended for approximately three minutes.In an interview on 07/30/2026 at 10:40 AM the ADON stated staff were trained regarding HIPAA and resident rights upon hire and during pop up in-services. She stated, the potential risk of leaving resident information in the open is someone could see what wounds they have, their privacy is important to protect.In an interview on 07/30/2026 at 11:30 AM the Administrator stated leaving the residents shower sheet open and leaving the nurse station is a HIPAA violation and a dignity violation. A resident has a right to privacy and dignity and CNA A should have covered the shower sheet or kept it with her.In an interview on 07/30/2026 at 12:30 PM the DON stated leaving patient information open on desk and leaving the desk is definitely a HIPAA violation and is a privacy concern. The staff are trained not to do this. They're trained at least once a year and during pop-up in-services.In an interview on 07/30/2026 at 12:45 PM CNA B stated she had no reason as to why she left the residents personal information uncovered. She stated she always has her paperwork in her pocket. She stated she had received training on HIPAA and in-services on keeping resident information safe, and to turn the shower sheets over or put them in her pocket. She stated, someone could come by and say it is their personal information, and someone could use the residents information.Record review of a facility HIPPA Privacy Practices Policy not dated.

Based on observation, interview and record review the facility failed to ensure that food was prepare, distributed, and served food in accordance with professional standards for food service safety. The facility failed to ensure that equipment was clean. The facility failed to ensure that plates, bowls, and cups with dried food particles, and glasses with water spots and stains were not stored with clean plates, bowls and glasses.The facility failed to ensure that menu items on the steam table were maintained at 135 degrees F and above.-The facility failed to ensure that cooked poultry in the walk-in cooler was at the correct holding temperature of 41 degrees F and below.-The facility failed to ensure that pans with food particles on them were not stored with clean pans. These failures could place residents who ate food prepared by the kitchen at risk of foodborne disease. Findings included: Observation during initial tour on 12/1/2025 from 7:25AM to 8:00AM of the facility's kitchen with Foodservice Director B revealed the following:Clean plates, bowls and cups with dried food particles and food stains on them. Clean glasses with water spots and stains on them. Holding pans with food particles in them.The stove air vent covers had dust and grease on them.The double convection oven had burnt food particles and grease in them. The walk-in-cooler had a baked turkey that was cooked on 11/30/2025 at 6:30pm was at 44 degrees Fahrenheit.The plates, bowls, cups, glasses and pans were rewashed. In an interview on 12/01/2025 at 8:00a.m., with Foodservice Director B she said usually when pots, pans, plates, bowls, cups and glasses were washed, the dishwasher personnels were expected to check for stains and food particles before they were stacked away. She said the turkeys were cooked the day before and should be cooled down in about 6 hours. She said, maybe because the turkeys were stacked on the same rack and the 4th turkey was at the bottom that could be the reason it did not cool down to the required holding temperature. She said moving forward she would ensure that hot foods were chilled to the proper temperature before they were stored away. In an interview with the Food Service Manager on 12/1/2025 at 8:05AM she said the turkey should have cool down since it was in the refrigerator from the previous day. She said the turkey was discarded because she did not want anyone to get sick. She said she was going to ensure meat was cooled down in the freezer to the correct temperature before it was placed in the cooler. Further interview at that time with the food service manager revealed they had extra cooking for Thanksgivings, and she was going to ensure the stove vent covers were clean. Observation of Breakfast meal service on 12/1/2025 at 8:10 a.m., revealed 3 menu items on the steam table were not at the correct holding temperatures. The menu items were scrambled eggs at 120 degrees and ground beef at 110 degrees and grits at 130. The menu items were reheated to 165 degrees by the food service manager.In an interview on 12/01/2025 at 8:15AM with Dietary Aide A, she said she usually serves the resident who ate in the dining room their cereal first and when they were finished eating, they would be served the main course. She said she was waiting for them to finish their cereal, before the main course was served. She said the food temperature on the steam table was okay before service began. In an interview with the Food Service Director B on 12/3/2025 at 3:10pm she said the ovens were supposed to be clean on Sundays but the staff who usually clean the oven was sick and left early on Sunday. She said she took care of all the identified issues. She said the staff were in-serviced on cleaning of equipment, food temperature and dish washing. Record review of the policy and procedures titled Food Temperatures date June 2021 read in part.Purpose1. To ensure all food served to residents is safe, palatable, and maintained at proper temperatures to prevent foodborne illness, while supporting resident comfort and dignity. 2. ScopeThis policy applies to all dietary staff, nursing staff assisting with meal service.3. Temperature Standards. Hot Foods It must be held at 135 degrees F or higher. Temperature must be checked at the start of meal service. Every 30 minutes during service.Cooling FoodCool: Cooked turkey, internal temperature to cool down to 70 degrees in two hours of preparation and from 70 to 41 degrees in an additional 4 hours. Reheating Previously Cooked and cooled food must be reheated to 165 degrees F. Record review of the policy and procedures titled Cleaning OvensPolicy: Ovens will be clean and free of buildup of grease or spill.1.Ovens will be cleaned weekly and as spill occurs. Record review of Cleaning Vent Hoods and Filters or Extractor dated Policy: Venting equipment will be clean and free of grease.Procedure: Clean vent hoods monthly to prevent accumulation of dirt and grease.Record review of the policy and procedure for Sanitation and Food handling.Sanitization can occur by means of application of heat or concentration of chemicals for enough time to reduce bacterial count on equipment and utensils. Once utensils and equipment have been cleaned and sanitized, they should be allowed to air dry. The use of towels may re-contaminate sanitized surface.

Based on interviews and record reviews, the facility failed to maintain clinical records in accordance with acceptable professional standards and practices that are complete, accurately documented, readily accessible and systematically organized for 1 of 1 resident (Resident # 1) reviewed for clinical records. The facility failed to ensure the MDS Coordinator accurately documented and uploaded Resident # 1's care conference reports for 09/10/2025. This failure could place residents at risk for missing progress towards achieving their person-centered plan of care, and delayed care.Findings included: Record review of Resident # 1's face sheet retrieved on 12/02/2025 at 2:56 pm, revealed she was a [AGE] year-old female admitted with the following diagnoses: Hemiplegia(paralysis that affects one side of the body),disorders of bladder ( condition that affects the bladder's ability to store or release urine), chronic obstructive pulmonary disease (lung diseases that causes breathing difficulties ), atherosclerotic heart disease ( fat and cholesterol build up in the arteries), anemia (low blood levels), lack of coordination(clumsy movement ), osteoporosis (causes bones to become weak), major depressive disorder ( mental condition that causes sadness, hopelessness and lose of interest in activities), generalized weakness, abnormalities of gait and mobility, dysphagia (swallow difficulty) , oropharyngeal (cancer of the tonsil),and cognitive communication deficit (difficulty in attention, memory and problem-solving). Record review of Resident # 1's MDS retrieved on 12/02/2025 at 10:20 a.m., dated 09/14/22025, reflected the following: Section A-identifiable information, subsection A0310 was coded 02, which required quarterly review assessment for Resident # 1. Subsection A1110 revealed she did not require an interpreter to communicate with a doctor or health care staff. Section C-cognitive pattern, subsection C0500 revealed she had a BIMS score of 15, which indicated she was cognitively intact. Section GG0120 revealed she uses a wheelchair. Section GG-Functional abilities revealed Resident # 1 requires assistance with ADLs. Record review of Resident # 1's care plan retrieved on 12/02/2025 at 1:07 p.m., revealed the last care conference was on 06/10/2025 and the next care conference was due for 09/10/2025. Record review of Resident # 1's care conference reports retrieved on 12/02/2025 at 12:04 p.m., revealed, the care conference documentations were not done quarterly as indicated in the MDS. The care conference documentation revealed the facility did not have care conference documentation and assessment for 09/10/2025. The documentation was for the following dates: 06/10/2025, and attendees were- ADON, SW, DM and AD. On 03/11/2025, the attendees were- ADON, AD, DM, and SW. During an interview with the MDS Coordinator on 12/02/2025 at 2:12 p.m., he said some of his job description included: attending the care conferences via telephone and taking notes during the care conference meetings. The MDS Coordinator said it was his responsibility to upload the minutes of the care conferences. He said the care conferences were held every three months for each resident. He said if Resident # 1's care conference was held on 06/10/2025, the next one would have been 09/10/2025, and the upcoming care conference would be 12/10/2025. The MDS Coordinator did not give an explanation as to why there was no documentation for Resident # 1's September 2025 care conference report in the EMR. He said from a nurse standpoint, if something is not documented, it means it did not happen. He said, we never missed the care conferences. During an interview with the SW on 12/02/2025 at 3:03 p.m., she said she attends all the care conferences which are held quarterly for all residents. She said, I complete discharged planning as well. The SW said if Resident # 1 had a care conference on 06/10/2025, the next one would have been 09/10/2025, and 12/10/2025 thereafter. She said a care conference meeting could be missed if a resident was hospitalized . The SW said some members who attended the care conferences are the SW, ADON, a member from the dietary team, the MDS Coordinator who works from home some days and attends the care conferences via telephone. If the resident was on skilled services, the rehabilitation director would be present. The SW said, after the meeting, it is the responsibility of the MDS Coordinator to upload the reports in the EMR. She said if the reports were not uploaded, anyone looking for the reports would have to ask one of the department heads that attended the meeting. During an interview with the AD on 12/02/2025 at 3:18 p.m., she said she did attend care conference meetings but did not say yes or if the facility had a care conference meeting for Resident # 1. The AD said, the care conference meetings are held every Tuesday. She said the care conferences were conducted every three months for each resident. She listed the following as attendees: SW, DON, ADON, DM and herself. She said the MDS Coordinator takes notes, and it was his responsibility to upload the care conference reports into the EMR after the meetings. The AD said if a resident had a care conference meeting in June, the subsequent ones would be in September and December of 2025. She said if an investigator/surveyor needed to know if a care conference was conducted, they would have to look at the residents EMR, because the notes should be in the EMR. The AD said if the notes were not found in the EMR, it meant the care conference was not done. She said the families, and if the residents had a POA, were invited to the meetings too. The AD said, if the residents are on Hospice, a Hospice representative would be invited. She said the residents were welcome to attend the meetings if they could and if the family wants them to attend. During an interview with the DON on 12/02/2025 at 3:36 p.m., she said care conferences were held on Tuesdays at 10 a.m., She said care conferences were conducted on admission and there after quarterly. She said she took minutes during the meeting. The DON said, it is the MDS Coordinator's responsibility to upload the reports into the EMR, and if he were out, I would upload the reports. She said Resident # 1 s September 2025 care conference record could have been missing due to human error. She said a resident would miss a care conference meeting if they were hospitalized . The DON said if Resident # 1 had a care conference in June of 2025 the next one would have been held in September 2025. The DON said if a care conference report was missing in the EMR, the reviewer should look at the previous one and request the report from one of the attendees because they were the same at every care conference. She said, as a nurse, if documentation was missing, it meant the care conference did not take place. She said she could have missed documenting the care conference report for Resident # 1 because she was newly hired and was multitasking. During an interview with the ADON on 12/03/2025 at 3:58 p.m., she said, I attend all meetings. I attended the care conferences with the families, therapy staff, SW, AD, food Director, MDS Coordinator and the DON. The ADON said most often, the time DON and MDS Coordinator would take notes. ADON said it was the responsibility of the DON and the MDS Coordinator to upload the care conference reports in the EMR, but if they are absent, it was ADON's responsibility to upload the meeting reports. ADON could not give an answer to the question why Resident # 1's care conference report for the month of September 2025 was not uploaded into the EMR. She said the facility had never missed a care conference meeting. She said the facility would reschedule if the resident's family was unavailable. She said the care conferences were held every three months. ADON said if not documented, it means it wasn't done. She said, if Resident # 1 had a care conference conducted and documented in June 2025 the next one would have been in September and documented in the EMR. She said during the care conferences, nursing department would discuss the medications, if any fall, and discuss the previous three months skin concerns, and treatment changes. She said sometimes families would voice their concerns, food service would discuss the residents' likes and dislikes. The ADON said if documentation was missing, it would break the trust between the residents, facility and family. She said missed documentation could affect the care of Resident # 1. The ADON said there was no documentation for the month of September 2025 because the DON missed documenting. During an interview with the Administrator on 12/03/2025 at 4 :48 p.m., she stated, care conference was completed quarterly for Resident # 1. She said if there was a care conference for Resident # 1 on 06/10 2025 the next one would be 9/10/2025 and the next would be 12/10/20. The Administrator said it was the responsibility of the MDS Coordinator to upload the conference reports into the EMR. Record review of facility's care planning-interdisciplinary team policy (Care Area Assessments) revised on March 2022, stated: -Residents care plans are developed according to timeframes.-Person-centered care plans are based on resident assessment and developed by an interdisciplinary team.-The IDT includes but is not limited: the physician, RN with responsibility for the resident, a nursing assistant with responsibility for the resident, a member of the food and nutrition services staff, the resident or the resident representative.-Meetings are scheduled at the best time of the day for the residents and family when possible.-If it is determined that the participation of the resident or representative is not practicable for development of the care plan, an explanation is documented in the medical records.-A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident.-Each resident's person-centered care plan is consistent with the resident's right to participate in the development and implementation of his or her plan of care.

Based on record review and interviews, the facility failed to provide the contact information of the practitioner responsible for the care of the resident; the resident representative information including contact information; the advance directive information; all special instructions or precautions for ongoing care, as appropriate; and comprehensive care plan goals for 1 of 3 residents (Resident #18's) reviewed for closed records reviewed for an effective discharge process. The facility failed to ensure Resident #18's, who was discharged on [DATE], discharge summary was complete. This failure could affect residents who are discharged from the facility by not ensuring that care is coordinated and the resident transitions safely from one setting to another in addition to helping reduce or eliminate confusion among the various facilities, agencies, practitioners, and caregivers involved with the resident's care. Findings included: Record review of Resident #18's Face Sheet (undated) revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: Saddle embolus of pulmonary artery (large blood clot that sits atop or saddles the main pulmonary artery where it divides and branches into the left and right lungs) with acute pulmonale (symptoms can include shortness of breath, bulging veins in your neck, swelling in your legs or belly, fatigue, chest pain, and fainting episodes.) (Primary, Admission), Chronic obstructive pulmonary disease (common lung disease causing restricted airflow and breathing problems.), unspecified. Resident #18 was discharged on [DATE]. Record review of CR#1's Discharge MDS assessment dated [DATE] revealed a BIMS score of 10 out of 15 indicating moderate mental deficit. Further review of Section X0600. Types of Assessment: F. Entry/discharge reporting coded was blank. Section A2105. Discharge Status was coded- 06- Inpatient Rehabilitation Facility. Record review of Resident #18's Care Plan initiated 06/22/2024 and updated on 07/02/2024 read in part . Problem: Modified Independence R/T BIMS Score of 10/15. Goal: Will reduce risk of complications over next 90 days. Approach: Allow extra time to collect & process thoughts. Assist to needed locations QD. Assess psycho/social needs prn. Break down activities in manageable segments. Encourage to participate in activities. Talk to resident during care explain procedures. Provide cueing & redirection prn. Provide supervision & assist /c ADLS prn. Provide consistent & routine environment QD. Problem: Decline in ADL function R/t BL Extremity weakness and unsteady gait, need extensive assistance from 1-2 person for transfer and 1 person for ADL care. Goal: Will reduce risk of complications over next 90 days. Approach: Assist /c all ADLS x aide QD prn. Staff to gather supplies, shampoo hair, bathe, oral & nail care per schedule & prn. Offer choices for what to wear. Provide assist to stand & transfer to bed/chair x 1-2 aide QD prn. Monitor for incontinence Q2hrs & prn. Assist to toilet Q2hrs & prn. Set up meal tray, open cartons, cut meat prn. Explain all procedures using terms & gestures resident can understand. Be patient & allow time to complete tasks. Provide Foley catheter care as needed, PT/OT if needed . Record review of Resident #18's Discharge Summary dated 07/15/2024 noted there was no contact information of the practitioner responsible for the care of the resident; the resident representative information including contact information; the advance directive information; all special instructions or precautions for ongoing care, as appropriate; and comprehensive care plan goals. Record review of an undated blank Post Discharge Plan of Care: Nursing Services given to me by the Social Worker to show what should have been in Resident #18's chart noted a place for the facility name, phone number, address, reason for discharge, nursing needs, personal needs, Level of assistance required with ADLs, and Level of assistance required with IADLs. There was no space for Advance Directives. Record review of Discharge Summary and Plan dated October 2022 read in part . When a resident's discharge is anticipated, a discharge summary and post-discharge plan is developed to assist the resident with discharge. 4. The post-discharge plan is developed by the care planning/interdisciplinary team with the assistance of the resident and his or her family and includes: a. where the individual plans to reside; b. arrangements that have been made for follow-up care and services; 12. A copy of the following is provided to the resident and receiving facility and a copy will be filed in the resident's medical records: a. An evaluation of the resident's discharge needs; b. The post-discharge plan; and c. The discharge summary. Interview on 09/12/2024 at 1:57 PM with the Social Worker revealed she was responsible for resident discharge planning. She said the ADON and herself were responsible for the Discharge Summary. She said she would look at the Progress notes to look for the date of discharge. She said the previous social worker may have forgotten to make a copy of the Discharge Summary. She said she was not sure what his admission status was and was not sure why he was discharged . She said she thought it may have been the resident's decision to discharge from the facility. She said the ADON might know why he was discharged . She said it was her 4th day at the facility. She said her role at the facility was as the social worker was to participate in Care Plan meetings, and discharge planning, and weekly Medicare meetings. She said she was not familiar with Resident #18. She said the policy or procedure for discharge planning was to meet with resident and or family members within 48 hours of admission and ensured everyone knew what the plan was and agreed to it, set up home health, ensured the resident had the proper equipment and she coordinated with therapy on that. She said the information that was required on discharge summary was things like home health or rehab, what equipment and where it was from, community resources, who was doing housekeeping, social support system, who their PCP and pharmacy were as well as their transportation needs, the discharge location, a contact, and the reason for discharge. She said she made 3-4 follow up calls after a discharge, but if the resident was going to another facility she would not make follow up calls. The follow up calls were only if residents were going back home. She said she had training on discharge planning when she previously worked at the facility. She said she would guess the DON or ADON were responsible for oversight to ensure staff was following protocol. She said the risk to residents if policy or procedures were not followed would be residents may not have their needs fully met once they were at their discharge location. She said the worst thing that could happen to a resident if policy or procedures were not followed was the resident may have access to things that would facilitate them to remain in their home. Interview on 09/12/2024 at 2:05 PM with the Rehab Director revealed the resident was always planned to go to another facility from the hospital and stay a while. She said Resident #18 and the family initiated the discharge. He was not set to leave when originally planned and the resident left earlier than what the facility had scheduled . She said Resident #18 was planned to discharge in a week, but the family came to get the resident 3 days later. Interview on 09/12/2024 at 2:011 PM with the LVN-ADON revealed she said when a resident left a facility, it was because they met skilled requirements. She said the social worker wrote the discharge summary. She said she was not aware of a Discharge Summary document. She was shown a copy of the Plan of Discharge document and she said the charge nurse should write the nursing part of the discharge. She said she had worked at the facility for 5 years in January. She said part of her role was to complete the Post Discharge Plan of Care. She said she was familiar with Resident #18. She said the policy or procedure for discharge summaries/discharge planning was the social worker initiated the Post Discharge Plan of Care and she the ADON completed the nursing part of it including diet. She did not know what the Discharge Summary was incomplete. She said she had not been in-serviced on that before. She said the resident left unexpectedly before she could complete it. She said the social worker was responsible for ensuring the Discharge Plan of Care was complete. She said there was no risk to residents if policy or procedure was not followed. She said staff provided patient teaching, the medication list, and the residents knew who their doctors were. She said there really was no risk. Interview on 09/12/2024 2:16 PM with Medical Records revealed the resident's family member talked about the resident going to another facility, but did not know when he would be going. When the resident left the family just took him without letting them complete the form. Interview on 09/12/2024 at 2:56 PM with the DON said the family was unsure the resident could transfer to the another facility and the facility was caught off guard when the family came to take him to the other facility. Interview on 09/12/2024 at 3:07 with the Administrator revealed he said, with discharge planning, the social worker was in charge of that. He said the Discharge Summary was supposed to have where they were going, what medications they were on, what equipment they needed, did they need home health, what supplies they would need, and whether to continue the care. He said the facility ensured where they were going was appropriate , and they called and followed up a week later to check on them. He said he had worked at the facility for [AGE] years and his role at the facility was Executive Director and Administrator. He said he was not familiar with Resident #18. He said, routinely, he ensured the facility stayed in compliance, attended standup meetings, tracked who was being discharged , talked with residents and visited with them, asked how things were going, assisted with ensuring staffing was in place, stood in on all the committees, ensured staff were there and doing their jobs, talked with staff about residents, reviewed incident/accidents, met with all directors, and communicated with families. He said the discharge plan should start as soon as possible. He said the facility needed to determine if a resident was short-term or long-term, ensured their needs were being meet, coordinated with family to get with all outside agencies, ensured the orders were sent, and got the NOMNCs signed. He said he did not know what happened with Resident #18. He said the former social worker was sick and not doing well. He said she had to resign. He said generally the social worker communicated with the team, but as Administrator he knew who was going and coming. The primary staff responsible for ensuring policy/protocol was followed, would be the social worker. He said the risk to residents if policy or protocol was not followed depended on the resident and what needs they had; their needs might not be met. He said the worst thing that can happen to the resident when proper protocols were not practiced was it could result in a lack of needed services.

Based on interview and record review, the facility failed to ensure that residents had a right to organize and participate in resident groups in the facility for 6 of 6 anonymous residents reviewed for resident council. Six residents in a confidential resident group interview were unaware that meeting minutes were created prior to their participation in the group meeting for the month of August 2023. This failure placed 6 residents that frequently would attend meetings, and that could participate in a Resident Council, at risk of not having the right to voice their concerns in a Resident Council meeting. The findings were: During a confidential group meeting on 08-16-3023 at 02:04 PM, 6 of 6 residents stated the facility assisted them with monthly resident council meetings the last Thursday of the month. One of 9 residents stated that the next group meeting was scheduled for 08-31-2023 at 10:30 AM. All 6 of the 6 residents stated that they were not aware that the 08-31-2023 meeting minutes were already created. All 6 of the 6 residents stated that the minutes could not be created before the meeting because the meeting had not taken place and the AD could not know what topics, concerns, and grievances the residents could have made. Interview on 08-17-2023 at 12:06 PM the AD stated that she had been employed with the facility a total of [AGE] years, [AGE] years as AD and the 7 prior years as a CNA. She stated in her role she created/made the activities calendar every month, researched activities that would be beneficial for the resident population at the facility and attended and typed up the Resident Council meeting minutes monthly. She stated prior to the meetings she went around and reminded residents of the meeting and asked what topics they wanted discussed at the meetings. She stated that she spoke to the resident attendees listed on the previous meeting minutes first. She stated that the residents listed on the minutes in the Attendee section are residents who attended the previous meeting and are not residents who she anticipated would attend the next group meeting. She stated once she knew the group topics that would be covered in group they are noted. She stated after the adjournment of the group those noted topics and discussions are added to the meeting minutes. She stated that the resident council had not met for the month of August 2023. She stated she created the August group minutes after this surveyor asked for the June, July, and August 2023 group minutes and she could not provide them because the August 2023 meeting had not yet taken place. She stated she prepared the 08-31-2023, minutes based off some of the items that would be discussed at that meeting. She stated it was not common practice for surveyors to ask for the meeting minutes of the same month that the facility survey had taken place. She stated that she had never before created the meeting minutes ahead of time. She stated that she told the DON that she had created the minutes ahead of time to provide to the surveyor. She stated that the DON advised her to tell the surveyor why the group meetings minutes for August 2023 were created a head of time, but she was nervous and did not say anything. Interview on 08-17-23 at 01:28 PM the DON stated that the AD had been in her role for the last 10 plus years. She stated that the AD was only the resident council facilitator. She stated that the AD's role was to write notes of what had been discussed by the residents during the meeting and type those discussion notes into minutes. She stated that the AD told her that she created the 08-31-23 group minutes prior to the meeting because the surveyor asked for the August minutes the facility had not yet had. She stated that the AD panicked when the surveyor asked for the August minutes and there was none, and therefore the AD typed up the minutes in advance to give to the surveyor as requested. She stated that the AD had not created group meeting minutes before the meeting had taken place in the past. She stated it was her expectations that the AD would not create meeting minutes prior to the minutes and put specific resident names that had attended and adjourned a meeting that had not took place. She stated that the AD should have had agenda items written down, but minutes should not have been written out until after meetings end. She stated that she attends every resident council meeting, and that the AD never created the minutes prior to the meetings she had attended. Interview on 08-17-23 at 01:50 PM the DON stated per resident's request and invitation she attended approximately 3 meetings yearly. She stated she does not know off the top of her head which 3 meetings she had attended, and she was not listed on the meeting minutes because it was an invitation to attend by the residents. Interview on 08-17-23 at 03:41 PM the ED stated that the AD had worked for the facility for a long time. He stated he does not believe the AD intended to create minutes to an event that has not taken place. He stated the AD had mistaken the agenda for the minutes. He stated that it was his expectations that the AD does not have minutes created before the resident council meetings. He stated moving forward he would assist in writing minutes and participate in the group meetings. Record Review 08-17-2023 at 11:30 AM of Resident Council Minutes dated 08-31-2023, at 10:30 AM revealed the AD and 6 residents attended the group meeting. Opening Question: Resident Rights. Do you believe you can exercise your rights without interference, discrimination, or reprisal from the facility? Residents replied- yes. Resident's Grievance and Satisfaction: Residents are satisfied with their care. Consensus: All members of the extended care center (ECC) Resident Council, as well as the other residents present, have collectively come to the consensus that they are receiving great and adequate medical and room care from our staff of RNs, LVNs and CNAs. No complaints, medically at this time. Housekeeping, Maintenance, Foodservice, Administrator's, Laundry Department, Bus Driver, Therapy Services, and ECC Activity Director work diligently seeking ways to bring stimulation presentations for resident's pleasure. Closing and Adjournment: Resident Council president adjourned the meeting until 09-28-2023. Record review of the AD's Certification of Completion dated 05-26-14 revealed she successfully completed 90 hours of course work/90 hours practicum. Record review of Resident Council Meetings revised date of February 2021. Policy Statement. The facility supports resident's right to organize and participate in the resident council. Policy Interpretation and Implementation. 1. The purpose of the resident council is to provide a forum for: a. residents, families, and resident representatives to have input in the operation of the facility's b. discussion of concerns and suggestions for improvement. c. consensus building and communication between residents and facility staff: and d. dissemination information and gathering feedback from interested residents. 2. All residents are eligible to participate in the resident council. The facility staff encourages residents who are willing to participate . 6. A Resident Council Response Form will be utilized to track issues and their resolution . Record review of Policy Charting and Documenting revised date of July 2017. Policy Interpretation and Implementation 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Record review of AD's Job Description, print, signed and dated by AD on 01-30-14. PHYSICAL AND/SENSORY REQUIREMENTS: (With or without the aid of mechanical devices). 4. Must function independently and have flexibility, personal integrity, and the ability to work effectively with residents, personnel, and support agencies . I acknowledge . and . I further understand that it is my responsibility to inform my supervisor at any time that I am unable to perform these functions . Acceptable job performance includes completion of all job responsibilities as well as compliance with the policies, procedures, rules and regulations of my department and the facility. I have read and understand this job description. Review of previous resident council meetings from June, July and August 2023 reflected an average of 7 resident council members who attended.

Based on observations, interviews, and record reviews, the facility failed to implement a comprehensive person-centered care plan, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 13 residents (Resident #1) reviewed for care plans. -The facility failed to ensure a comprehensive care plan for pressure wounds was implemented for Resident #1. This failure placed residents at risk of not receiving care and treatment to meet the resident's physical, mental, and psychosocial needs. Findings include: Record review of Resident #1's face sheet undated revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted [DATE]. Her diagnoses included Vascular dementia (brain damage caused by multiple strokes causing memory loss ), psychotic disturbance ( A mental disorder characterized by a disconnection from reality), diabetes mellitus (a group of diseases that result in too much sugar in the blood) with diabetic neuropathy (nerve damage that can occur with diabetes), Peripheral vascular disease ( A circulatory condition in which narrowed blood vessels reduce blood flow to the extremities) atrial flutter ( the hearts upper chambers (atria) beat to quickly) and major depressive disorder (mood disorder that causes persistent feeling of sadness). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed sometimes Resident #1 made herself understood. Resident #1 sometimes understood others. Resident #1 BIMS (Brief interview for mental status) was three which indicted her cognition was severely impaired. The resident required extensive physical assistance from one staff for bed mobility and personal hygiene. Resident #1 had limited range of motion (limited movement) to her BLE ( both lower legs). The resident was always incontinent of bladder and bowel. Record review of Resident #1's care plan initiated 05/16/2023 revealed the following: Problem: Resident was at risk for pressure ulcers related to decreased mobility, incontinence, cognitive deficit, and diabetes mellitus. Goal: Resident's skin will remain intact. Approach: Start dated 05/16/2023 Use Prevalon boots (specialized boots with cushioned bottoms that keep the heels off the surface of the mattress) to relieve pressure on the heels while in bed. Record review of Resident #1's physician's orders dated 08/16/2023 revealed Apply Prevalon boots to prevent pressure sores on heels bilaterally. Special Instructions: Apply while resident in bed. Every Shift; Day, Evening, Night. Start date 09/22/2023. No end date. Observation on 08/16/2023 at 10:41 AM, assisted by LVN A revealed Resident #1 in bed. Resident #1 was not wearing the prevalon boots to her BLE. Resident was confused and unable to be interviewed. Observation on 08/16/2023 at 11:33 AM during wound care, assisted by RN C, revealed Resident #1 in bed. Resident #1 was not wearing prevalon boots to her BLE. No wounds observed to Resident #1's heels. Observation on 08/16/2023 at 2:23 PM revealed Resident #1 in bed without prevalon boots. Observation on 08/17/2023 at 9:25 AM, assisted by LVN A, revealed Resident #1 was in bed not wearing prevalon boots. Interview at the time of the observation LVN A stated Resident #1 did not have prevalon boots on now or yesterday when we looked at the resident. LVN A looked around Resident #1's room and closet. LVN A was unable to find the prevalon boots. LVN A stated Resident #1 should have the boots on to prevent sores on her heels. The LVN stated she did not know why she did not have them on. The LVN continued and stated the risk of not following the care plan could result in harm to the resident. The LVN stated the risk of not wearing the prevalon boots was the development of pressure wounds to her heels. LVN A stated the resident's care plan should have been followed for the resident's plan of care. As the interview continued LVN A stated the CNA can put the boots on. It was the treatment nurse's responsibility for monitoring every shift that the boots were on the resident. Observation and interview on 08/17/2023 at 9:37 AM, CNA B stated she did not know why Resident #1 was not wearing the boots. CNA B looked in the resident's room and closet. No boots were observed. CNA B stated maybe the boots were in the laundry. CNA stated the boots would stop Resident #1 from getting sores on her heels. Interview on 08/17/2023 at 10:15 AM, RN C stated the nurse was responsible for making sure Resident #1 had her boots on. RN C stated the boots may be in the laundry. RN C stated she did not know for sure why they were not on. RN C stated the purpose of the care plan was to make sure the resident received the individualized care needed. She stated the risk of not following the care plan was the resident may not receive the proper care. Interview on 08/17/2023 at 11:02, the MDS Coordinator stated he was responsible for development of the care plan. The coordinator stated the approach for the prevalon boots came from Resident #1's physician's order. MDS Coordinator stated the care plan approaches were important to follow; they were the steps to achieve the resident's goal. He continued and stated the care plan was monitored daily and changed daily as needed. He stated the risk of not wearing the prevalon boots was skin break down to the resident's heels due to her decreased mobility and cognitive decline Interview on 08/17/2023 at 11:43, the DON stated she expected the care plans to be followed. The DON stated the care plan identified the resident's needs with the steps to reach a goal. The prevalon boots were to prevent sores. The DON stated the resident needed the boots. She continued and stated the care plan was monitored and changed as needed for resident changes The DON, ADON, and charge nurses were responsible for monitoring that the care was provided as needed. The DON stated the staff would monitor every shift to ensure the care plans were followed. Interview on 08/17/2023 at 12:35, The ED stated he did not have clinical experience. The ED stated he expected the care plans were followed. As the ED continued, he stated the care plan was what to do for the resident's care. He continued and stated if the resident needed to have the boots, she should have had them. The ED stated he was not able to discuss the risk of not following the care plan. He stated he would discuss with the DON Record review of facility policy, Care Plans, Comprehensive Person-Centered revised March 2022 revealed, Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy, Interpretation and Implementation 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 7. The comprehensive, person-centered care plan: b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .

Based on observations, interviews, and records reviewed, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 facility reviewed for safe environment. The facility failed to ensure the lock for the emergency exit door was functioning correctly resulting in an armed intruder gaining access into the facility. An Immediate Jeopardy (IJ) was identified on 05/19/2023. While the IJ was removed on 05/22/2023, the facility remained out of compliance at a scope of widespread and severity of potential for more than minimal harm that is not immediate due to the facility's need to complete evaluate the effectiveness of the corrective systems. This failure placed residents at risk for serious physical harm, injury, emotional distress, or even death. Findings included: Observation on 05/18/2023 at 9:22 a.m. of the facility's double emergency exit door, revealed there were posted signs on the inside and outside that read STOP Emergency Exit Only Door is Alarmed. Surveyor lightly pushed on door and the alarm did not sound or stay locked. The Executive Director (ED), Director of Nursing (DON), and Maintenance Director (MD) observed and acknowledged the door did not retract and lock. Observation on 05/18/2023 at 6:49 p.m. of the facility's security footage, revealed a male intruder entered through an unlocked emergency exit door located in hallway 300 at approximately 1:29 a.m. Once inside the building he walked down the hallway toward the nurse's station. There were 3 Certified Nurse Aides (CNAs) CNA G, M, and P when he arrived at the station. CNA G left the area shortly after he arrived. CNA P left not long after CNA G, and CNA M stayed behind at the nurse's station with the intruder, until he was arrested. Before the police arrived on scene, the intruder was seen walking around the station and tried opening a couple of doors that were locked. Afterwards, he went behind the station, opened a lower cabinet door, and placed something inside (later identified as a handgun) and closed the door. He then laid down on floor, placed his finger up to lips, motioning to be quiet. He proceeded to crawl around on the floor, got up, left the gun inside the cabinet, and went back around to the other side of the nurse's station. The intruder then paced around the station. At one point, CNA M was seen opening the cabinet door where the gun was located and took a picture. Shortly after, the intruder walked down one of the hallways, police entered view, walked down the same hallway, and arrested the intruder. CNA M kept her distance throughout the event but never left the area. The entire incident lasted approximately 18 minutes. During an interview on 05/18/2023 at 8:05 a.m., the Executive Director (ED) said on 05/12/2023 at 1:30 a.m. an intruder entered the facility. He said the security footage caught the intruder jumping the facility's gate. He said the intruder appeared to be running behind the facility toward an exit gate. He said the intruder walked across the parking lot, ran toward the building, and entered an unsecured emergency exit door. He said the door was a permanently locked door. He said the door was only closed and not locked when the intruder entered the building. He said they conducted run, hide, fight video training in the past but could not recall the date. During an interview on 05/18/2023 at 9:08 a.m., CNA P said she worked the night of the incident. She said she was at the nurse's station when she heard the door alarm sound. She said Nurse G was doing rounds and waived at her because they did not see anything. She said they sat down at the nurse's station and when CNA G went to check on a resident, they saw the intruder going toward hallway 100. She said she asked him if she could help him, but he put his hand on his mouth and said, shh. She said he told her something was wrong. So CNA M and her stayed at the station. She said he went to the medication room, but it was locked. She said he then went inside the nurse's station, so they sat down and looked at him. She said she asked him again if she could help and she said he told her to shut up. She said he sat down on floor, and she got up and went to the cafeteria and hid. She said not long after, CNA P and she went and hid in a linen closet. She said CNA P told her the intruder had a gun. She said she did not know how the intruder got into the building. She said when the door was not locked all the way, someone could go in or out. She also said it could be a danger to workers and residents. She said a resident could get out and people could get inside that were not supposed to be there. During an interview on 05/18/2023 at 10:35 a.m., the Maintenance Director (MD) said he believed the emergency exit doors being unlatched was a mechanical malfunction. He said he did not know how, why, or how long the door was unlatched. He said maintenance staff checked the doors weekly and said it was fine. He said if the door was not latched anything could have happened to staff and residents and depending on the scenario, they could become unsafe. During an interview on 05/18/2023 at 12:38 p.m., CNA J said she had been working at the facility since 2018 and worked the night of the incident. She said she was scared and did not know how the intruder got in the door. She said they could have gotten hurt, or an intruder could have killed anyone. She said security was responsible for making sure the door was latched. During an interview on 05/20/2023 at 1:42 p.m., Nurse L said she worked the night before the incident, 05/11/2023, and left around 9:30 p.m. She said she used the emergency exit door that the intruder made entry through when she left the facility. She said she used the keypad to bypass the alarm. She said she did not physically check and/or pull on the door to ensure it had locked back into place. She said she was not aware that there were any issues with the door. She said she knew better and should have used the main entrance to exit the facility. She said she took the chance because it was late at night, dark, closer to her office, and there had been big loose dogs roaming around in the past. She said she did not recall active shooter/armed intruder being covered in safety in the workplace or the facility's emergency preparedness plan training. During an interview on 05/20/2023 at 3:28 p.m., CNA N said she had been working at the facility for about 4 years and worked different shifts. She said she never received training over the facility's active shooter/armed intruder protocol and never heard of it before. During an interview on 05/21/2023 at 6:41 a.m., Nurse G said she worked the night of the incident. She said she was in a resident's room when she heard the door alarm sound. She said she went to the hallway, looked at the emergency exit door, but did not see anything or anyone. She said she walked to the nurse's station and when she was almost there, she saw the intruder looking and walking around. She said she asked him what was going on, but he ignored her. She said CNA M told her the intruder had a gun. She said CNA M told the intruder to lie down on the floor and that it was ok. She said she left the area and called 911. She said she did not know how the intruder gained entry through he emergency exit door. She said to her knowledge the door worked properly. During an interview on 05/21/2023 at 10:21 a.m., Security Officer B said she worked the night of the incident. She said she checked the door after the police arrived and it was open. She said she was not responsible for monitoring the emergency exit door. She said when COVID-19 started, the ED took that door away from the officers to check. During an interview on 05/21/2023 at 12:13 p.m., the Human Resources Director (HRD) said new hire training did not include active shooter/armed intruder training. She said she turned her office upside down looking for sign in sheets but could not find documentation to show staff received the training. She said their security officers were trained by the company they worked for and not the facility. She said the risk posed to staff and residents was they needed to stay safe from anything and be trained for the worst. The ED was notified on 05/19/2023 at 1:23 p.m. that an IJ was identified due to the above failures. The IJ template was presented to the facility at this time. The facility's Plan of Removal was accepted on 05/19/2023 at 11:15 p.m. and included: Plan of Removal Name of facility: [Facility] Address: [address] Date: 5/19/2023 F921 Safe/Functional/Sanitary/Comfortable Environment Immediate action: - Emergency door was repaired by Maintenance Director with the help of professional from a local door company on 5/18/23; they adjusted the door closure mechanism and door threshold to ensure the door retracts to lock in place when opened and pushed lightly. - All facility staff are trained on Active Shooter training/intruder in the building in all three shifts by DON/ED/Maintenance Director. All scheduled staff since 5/15/23 were trained, the staff who missed the training due to being off or not scheduled will be completed by 5/22/23. staff acknowledged understanding verbally. Staff will be checked for written competency test, which will complete by 5/24/23. DON/ADON will administer the competency testing, staff must score 75% or above. The staff who do not meet passing score, will be retrained and re-tested until they pass. Facilities Plan to ensure compliance quickly: - Maintenance will inspect the door once per day to ensure the door remains safe and locked. The Maintenance staff will be responsible for maintaining the logs on a daily basis. Maintenance Director will audit the logs on a weekly basis. Any negative finding will be reported to Executive Director. QAPI will be developed for the compliance of door inspection and log maintenance. The local door company trained the Maintenance director and Maintenance director is training the maintenance staff on How to inspect the emergency doors to ensure that they are safe and locked Training will be completed by 5/22/23. - Security staff will ensure the emergency exit doors are locked every two hours. The logs will be maintained for every 2 hours checks beginning 6:00am and every 2 hours thereafter. The local door company trained the Maintenance director and Maintenance director is training the security staff How to inspect the emergency doors to ensure that they are safe and locked. Training will be completed by 5/22/23. The staff who missed the training due to being off or not scheduled will be trained by 5/24/23. - Door Lock Policy is developed as below; Maintenance Director is responsible for the policy implementation effective 5/19/23 ED will oversight the Maintenance Director to ensure he is implementing the policy. - [Facility] - Locked Door Policy Purpose In order to comply with Clarewood[facility]'s safety protocols and to prevent unauthorized access to the building, this policy provides guidance regarding all emergency exit doors remaining locked and secured at all times. Policy It is the policy of this facility to ensure the security officer on duty checks the emergency exit doors locked every two hours. Doors will be checked from inside of the facility. Emergency doors were previously checked every 8 hours, which is now changed to every 2 hours. - All facility staff are trained on below topics in all three shifts by DON/ED/Maintenance Director. All scheduled staff since 5/15/23 were trained, the staff who missed the training due to being off or not scheduled training will be completed by 5/22/23. staff acknowledged understanding verbally. Staff will be checked for written competency test, which will complete by 5/24/23. 3) Safety in Workplace - 5/19/2023 4) Door Lock Policy - 5/19/2023 - DON and ED held a meeting with staff to inform them about the incident and Plan of actions taken on 5/16/23 for the scheduled staff in all 3 shifts. For the staff who were not in attendance were sent a memo via e-mail about the Incident happened and plan of actions taken on 5/17/23. Staff are informed to contact Social worker for emotional support as needed. - Effective 5/19/23, below trainings are included in New employee orientation and Annual Mandatory in-service. The staff will be trained by HR or delegate which will be monitored by HR Director or delegate for timely completion. Competency test will be taken at the end of the training. DON/ADON will administer the competency testing, staff must score 75% or above. The staff who do not meet passing score, will be retrained and re-tested until they pass. Results will be shared with management and employees and QAPI committee. 5) Safety in workplace 6) Active shooter training/ Intruder in the building [Executive Director Name] Executive Director. Following the acceptance of the facility's Plan of Removal (POR), the facility was monitored from 05/20/2023 through 05/22/2023. Observation on 05/20/2023 at 1:15 p.m. revealed the Emergency Exit Door had been fixed and was working properly. Door was lightly pushed, and it retracted, locked, and the alarm sounded when opened. The key panel had been removed. During an interview on 05/18/2023 at 9:16 a.m., CNA B said she received active shooter/armed intruder training. She said they watched a video on how to respond in case an event was to occur. She verbalized an understanding of the training and how to respond. During an interview on 05/20/2023 at 12:09 p.m., Security Officer A said she worked the 7:00 a.m. to 3:00 p.m. shift. She said she received training, and it included what to do in the event of an active shooter/armed intruder. She said she would try to remember as many details as possible, run to a safe place, try to help others that are walking to safety, call 911 when she was in a safe place, turn off her cell phone, and if necessary, fight. She said she would barricade herself behind the doors and be quiet as much as possible. She said they also talked about making sure everything was visually safe. She said doors that should be locked must be kept locked and doors that must be unlocked needed to remain unlocked. She said they also talked about rounds and that they must be conducted every two hours and that they reviewed the lock door policy. During an interview on 05/21/2023 at 6:41 a.m., Nurse G said she received active shooter/armed intruder training. She verbalized and understanding of the training and how to respond. She said active shooter/armed intruder response included the following three steps: run, hide, and fight. During an interview on 05/21/2023 at 9:37 a.m., CNA A said she worked the 7:00 a.m. to 3:00 p.m. shift. She said she received active shooter/armed intruder training and that they reviewed the Locked Door Policy. She said the active shooter/armed intruder training included a video and the steps to take in case an event occurred. She said she needed to run, hide to protect herself, call 911 when she was safe, and if need be, fight. Record review of the facility's in-service training records related to active shooter training, dated 05/15/2023, 05/16/2023, 05/17/2023, and 05/18/2023 confirmed all staff were trained. The training included a video and competency test. Record review of the facility's door logs revealed security checks on the emergency exit doors were being completed every two hours. Record review of the door company's invoice revealed the emergency exit door was checked and fixed on 05/18/2023. An Immediate Jeopardy (IJ) was identified on 05/19/2023 at 1:23 p.m. The ED was notified on 5/22/23 at 10:52 am that the IJ was removed. While the IJ was removed on 05/22/2023, the facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy with a scope of widespread.

Based on observations, interviews, and records reviewed, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 3 incidents reviewed for reporting: -The facility failed to report, to the State Agency within 24-hours, an armed intruder incident on 05/12/2023. This failure could affect residents by placing them at risk of neglect if the reportable allegations are not reported timely after they are discovered. Findings included: Record review of the facility's Provider Investigation Report, incident date 05/12/2023 at 1:40 a.m., reported date to Health and Human Services Commission (HHSC) 05/17/2023, reported time not listed, read in part: a stranger intruded the facility through the emergency exit door. He crawled into the nurses' station, hid a gun in a cabinet and crawled away. All staff walked away from the station except one CNA. The CNA stayed around the nurses' station and later called 911. Police arrived shortly and arrested the stranger. The report indicated there were no injuries to staff or residents. Observation on 05/18/2023 at 6:49 p.m. of the facility's security footage, revealed a male intruder entered through an unsecured emergency exit door at approximately 1:29 a.m. on 05/12/2023. At one point, the intruder went behind the nurse's station, opened a lower cabinet door, and placed a handgun inside. During an interview on 05/22/2023 at 10:56 a.m., the Executive Director (ED) said he was responsible for reporting the incident and it was reported late because they were racing to figure out what happened and working on obtaining all the other information related to the incident. He said reporting the incident escaped his mind. He said incidents were to be reported immediately or within 24-hours. He said the risk associated for not reporting incidents timely varied. He said he did not want to speculate what type of risks were associated. Record review of the facility's revised April 2021 Abuse, Neglect, Exploitation and Misappropriation Prevention Program, read in part: Policy Statement Residents have the right to be free from .neglect. Policy interpretation and implementation The resident .neglect prevention program consists of a facility-wide commitment .to support the following objectives: 1. Protect residents from .neglect .by anyone including, but not necessarily limited to: j. any other individual. Record review of the facility's revised September 2017 Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy and procedure, read in part: Policy Statement All reports of resident .neglect .are reported to local, state, and federal agencies (as required by current regulations) and . Policy Interpretation and Implementation Reporting Allegations to the Administrator and Authorities 1. If resident .neglect .is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; 3. Immediately is defined as: b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Record review of the facility's revised December 2017 Unusual Occurrence Reporting policy, read in part: Policy Statement As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees, or visitors Policy Interpretation and Implementation 1. Our facility will report the following events to appropriate agencies: g. Allegations of abuse, neglect, and misappropriation of resident property; and h. Other occurrences that interfere with facility operations and affect the welfare, safety, or health of residents, employees, or visitors. 2. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations.

Based on interview and record review the facility failed to ensure the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week were used for 8 out of 54 days reviewed for RN coverage. Days not covered 05/7/2022, 05/8/2022, 05/21/2022, 05/22/2022, 06/4/2022, 06/5/2022, 06/18/2022, 06/19/2022. The facility failed to maintain RN coverage for 8 hours a day/7days a week. Days not covered 05/7/2022, 05/8/2022, 05/21/2022, 05/22/2022, 06/4/2022, 06/5/2022, 06/18/2022, 06/19/2022. This failure could place residents at risk of adverse events and not having staff to attend to events. The findings were: During record review of the staffing schedule from 05/01/2022 to 06/19/2022 revealed 8 of 54 days there was no RN coverage on the weekends (Saturday/Sunday) for the following dates: -05/7/2022 -05/8/2022 -05/21/2022 -05/22/2022 - 06/4/2022 -06/5/2022 -06/18/2022 -06/19/2022 An interview with Director of Nursing on 6/23/22 at 12:44 p.m. revealed there were 24-hour licensed nurses in the building 7 days a week, 8-hr registered nurses Monday through Friday and alternate weekends. The DON was at the facility 5 days weekly and was on-call on the weekends. The DON stated a RN was needed on weekends- for continuity of care for the residents. An interview with the DON and Administrator on 6/23/22 at 4:30 p.m. revealed there was not a RN on all weekends because one of the weekend nurses no longer worked for the facility and they were actively trying to hire another RN for the weekends.

Based on observation, interview and record review the facility failed to ensure drugs and biological's used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable when applicable for 1 of 1 medication room reviewed for medication storage. The facility failed to ensure the medication (med) room did not have expired medication of [MEDICATION(S)] (used for blood thinner), [MEDICATION(S)] (used as antidepressant or appetite stimulant), [MEDICATION(S)] (used to lower blood pressure), [MEDICATION(S)] (for blood pressure) and [MEDICATION(S)] (used for blood pressure). This failure could place residents at risk of not receiving the therapeutic benefit of medications or adverse reactions to medications. Findings include: Observation on 06/23/22 at 10:01 AM with the ADON, of the medication room revealed the following: The medication listed below were dated expired in the original packet from the pharmacy and 1 bottle: - [MEDICATION(S)] 2.5 mg, [MEDICATION(S)] 15 mg, [MEDICATION(S)] 10 mg, [MEDICATION(S)] 5 mg, expired 6/15/22. - [MEDICATION(S)] 10 mg -expired 6/16/22, - [MEDICATION(S)] 10 mg - expired 6/15/22, - [MEDICATION(S)] 15 mg- expired 5/6/22 - [MEDICATION(S)] 10 mg - expired 6/14/22, - [MEDICATION(S)] tab 2.5 mg & [MEDICATION(S)] 10 mg - expired 6/15/22 - [MEDICATION(S)] tab 2.5 mg - expired 4/26/22. -[MEDICATION(S)] 40 mg I BID (twice daily) bottle: Date filled 6/13/21 discard after 6/13/22 (1 bottle) Interview with the ADON on 03/09/22 at 10:01 AM, the ADON said the medications came from the assisted living to skilled unit and it should not be in the medication room, it should have been given to the assisted living staff or given to the residents family. The ADON said she and the charge nurses were supposed to check the medication room for expired medications every month, there was no log for when the med room was last checked for expired medications. The ADON said her expectation was to not have any expired medications in the med room and she knew expired medications would not produce desire result. In an interview with the DON on 6/23/22 at 11:03 AM revealed her expectation was for the nurses to return the medications listed above to the assisted living staff or the family after reconciling current with current medications resident was on. She would have the ADON audit the medication room more frequently instead of monthly. The DON stated she knew giving residents expired medications could change chemical composition of the drugs over time which and could be rendered unsafe or ineffective. Record review of the facility policy on storage of medications, dated 2001 MED-PASS, Incorporated. (Revised November 2020) read . store all drugs and biologicals in a safe, secure and orderly manner .#4 .Discontinued, outdated or deteriorated drugs or biological's are returned to the dispensing pharmacy or

Based on interview and record review the facility failed to develop and implement a baseline care plan for each resident which included instructions needed to provide effective and person-centered care of the resident that met professional standards of quality of care for 1 of 2 residents (CR # 41) closed record reviewed for baseline care plan. The facility failed to initiate a base line-care plan with goals, interventions, treatments, and psychosocial needs to address CR # 41's medical needs, coordinate care with interdisciplinary teams to assure the resident received care at professional standards. This deficient practice could place residents at risk of not having their immediate individual, medical, functional, and psychosocial needs identified and met and could cause a physical or psychosocial decline in health. Findings include: Record review of CR #41 face sheet, dated June 2022, indicated Closed Record ( CR) #41 was an [AGE] year-old female admitted to the facility on [DATE]. CR #41 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The date of discharge was 04/02/2022. Record review of CR #41's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #41's medical record revealed there was no documentation of a baseline care plan. There were no plans to address care for pain, medications, ADL's, ( activity of daily living) psychosocial well-being, Diet, skin, advanced directives, bowel and bladder incontinence or any of CR #41's diagnoses. Record review of CR #41's Admission Minimum Data Set Assessment (MDS), dated [DATE], revealed she was severely impaired cognitively and ADL activity assistance occurred with two-person physical assist. CR #41 was documented to be occasionally incontinent of urine and bowel. Record review of CR #41's Discharge MDS assessment, dated 4/2/22, revealed the discharge was death in the facility on 4/2/22. During an interview on 6/22/22 at 11:28 AM with the MDS coordinator (LVN) revealed she care planned for CR #41's admission on hospice on 3/30/22 and the admitting nurse was supposed to initiate the 48 hours care plan. The admitting nurse was not available for interview. During an interview on 6/23/22 at 11:02 AM, the DON said the admission nurse was responsible for completing the base line care plan The DON said the admitting was not available for interview . The DON said if the nurse missed it, it would be her responsibility to catch it. In an interview on 6/23/22 at 3:51 PM, the DON said baseline care plans were to ensure the proper care of residents and know interventions needed. She stated every resident must have a baseline care plan on admission to provide the best quality of care and she would be auditing baseline care plans and this would be ongoing. Record review of the facility's Care Plan on - Baseline, Policy Statement (revised December 2022) indicated A baseline care plan to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. .

Based on observations, interviews and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 4 of 4 Residents (Resident #30, #36, #35 and #26 ) observed for infection control. The facility failed to ensure OT removed gloves and used hand hygiene after providing Occupational Therapy (OT) for Resident #30. The facility failed to ensure MA A performed appropriate hand hygiene when dispensing Resident #36's medications. The facility failed to ensure CNA #A performed appropriate hand hygiene during incontinent care for Resident #35. The facility failed to ensure RN A performed appropriate hand hygiene during wound care for Resident #26. These failures could affect facility residents and place them at risk of facility acquired infections and diseases. Findings include: Resident # 30 Record review of Resident #30's face sheet revealed an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident # 30's admission MDS dated [DATE] revealed a BIMS score of 8 out of 15 indicating moderately impaired cognition. Further review of the MDS dated [DATE] revealed he required one person assist with toileting, grooming, transfers, bed mobility, dressing, bathing and personal hygiene. Observation on 3/18/21 at 10:20am revealed OT exiting Resident # 30's room . OT had a used glove in each of his hands whiling walking down the hallway. While exiting Resident #30's room, OT did not perform any hand hygiene. In an interview on 3/18/21 at 10:26 am the OT said he had been working with Resident # 30 inside the room with his gloves on and he did not throw his used gloves away after exiting the room because he had turned the gloves inside out while walking down the hallway and that was okay to do because the insides of his used gloves were not dirty. The OT said, he was trained to remove the gloves after use, and wash or sanitizing his hands before and after he had contact with residents because he could spread germs or cause infections. The OT said he was going back to the rehabilitation room to throw his gloves away and then wash his hands. During an interview on 3/18/21 at 10:35a.m. the Director of Rehabilitation (DOR) said all rehab staff was in-serviced and trained last month February 2021 on when to remove dirty gloves and to perform hand hygiene before and after providing resident care. The DOR said it was never acceptable for OT staff to walk out of a resident's room and down the hallway with dirty gloves because he would be spreading germs around that could spread infections to others. During an interview on 3/18/21 at 2:00p.m. the Director of Nursing (DON) said all staff was in-serviced and trained January 2021 on handwashing/hygiene procedures and must remove gloves and perform hand hygiene before and after resident care because of the risk of infections. Resident #36 Record review of Resident #36 admission face sheet revealed a [AGE] years old female admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the quarter Minimum Data Set (MDS) dated [DATE] revealed Resident #36 had a BIMS (Brief Interview for Mental Status) of 10 out of 15 indicating moderately cognitive impairment. Observation on 03/17/21 at 8:10 a.m., revealed MA A started medication administration without any hand hygiene. She picked up Resident #36's blister packets from the medication cart, punched out medications into her hand and then placed them into the medicine cup and the administered the medications to Resident # 36. MA A did not wash hands or use hand sanitizer throughout Resident #36's medications administration observation. MA A removed and administered the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] - Acetaminophen 325 mg 2 tablets by mouth - [MEDICATION(S)] plus D maximum 1 tablet by mouth - Acidophilus 2 capsule by mouth - [MEDICATION(S)] 20 mg 1 tablet by mouth - [MEDICATION(S)] 100 mg capsule by mouth - [MEDICATION(S)] 10 mg 1 tablet by mouth - [MEDICATION(S)] 50 mg 1 tablet by mouth - Vitamin B-12 1000 mcq 1 tablet by mouth - Stool Softener ( [MEDICATION(S)]) 100 mg 1 tablet Further observation revealed MA A took one tablet of Stool Softener ( [MEDICATION(S)]) 100 mg from the bottle (facility stock) and placed it into a medicine cup. MA A then realized she took the wrong medication, she returned the same [MEDICATION(S)] tablet into the original facility stock bottle. Interview on 03/17/21 at 8:45 a.m., MA A regarding punching medications into her hand, then placed it in medicine cup before administering it to the resident. MA A said she was very sorry, and she was nervous. MA A said she had been working with facility over 4 years and she had training annually on medication administration. Resident #35 Record review of Resident #35's face sheet revealed a [AGE] year old admitted to facility on 02/26/21 with the following diagnoses; acute [CONDITION(S)] w/ [CONDITION(S)] ( low oxygen in the lungs), [CONDITION(S)] , Pain in unspecified hip, Muscle weakness ( generalized ) , Urinary tract infection site not specified, other abnormalities of gait & mobility, other lack of coordination, urinary retention, indwelling Foley catheter (F/C) ( used for urine collection from the bladder) and history of urinary tract infection on admission. Record review of Resident #35's admission MDS dated [DATE] revealed a BIMS score of 15 out of 15 indicating no cognitive impairment for decision skills. Further record review revealed that Resident required extensive assistance with ADLs and was frequently incontinent of bowel. Further review of the MDS documented that the Resident had a catheter and was incontinent of bowel. Record of Resident #35's care plan dated 2/26/21 Goal: Reduce risk of complications. Approach : F/C care Q shift .Monitor urine for color , amount, sediment, foul odor & notify MD PRN complications, encourage fluids w/ & between meals, change F/C per orders, Lab work PRN s/s infection . Monitor skin for redness /irritation. Observation on 3/17/21 at 3:16 PM of CNA #A, performing indwelling catheter and incontinent care on Resident #35. CNA #A washed her hand and wore gloves then transferred Resident #35 from wheel chair to bed with urine catheter connected to a leg bag strapped to her left thigh with 50 mls of urine in the collection bag. CNA #A removed the resident's pull up, and began cleaning the peri- areas , she changed her gloves after cleaning the peri-area, then cleaned the thighs. CNA #A did not clean resident's catheter tube starting from the point of insertion and outwards, she did not separate the labia to clean the resident. CNA#A changed gloves six times during the procedure without performing any hand hygiene. She also placed a clean brief, and clean pants on the resident without hand hygiene. Interview on 03/17/21 at 3:36 PM CNA #A said she had been working at the facility for approximately over 3 years. When surveyor asked CNA #A how she did with the incontinent/Foley catheter care. CNA #A said she I did a great job. She received training or in-service on incontinent care/Foley catheter care at this facility sometime in December 2020. When asked why she did not perform any hand hygiene with gloves changes throughout the car, she said she forgot, and the resident was not soiled. Resident #26 Record review of Resident #26's face sheet revealed a 8 year old admitted to facility on 02/6/2018 with the following diagnoses; cerebral infarction due to [CONDITION(S)] of unspecified precerebral artery, Unspecified symptoms and signs involving the nervous system, Other speech and language deficits following cerebral infarction, Dysphagia following cerebral infarction, Unspecified [CONDITION(S)], unspecified site, Other lack of coordination, Dysphagia, oral phase, [CONDITION(S)], unspecified, not intractable, without status epileptics , secondary to [CONDITION(S)], Muscle weakness (generalized, and fusion of spine, lumbar region Record review of Resident #26's quarterly MDS dated [DATE] revealed a BIMS score of 12 out of 15 indicating moderate cognitive impairment for decision skills. Further record review revealed that Resident required extensive assistance with ADLs and was frequently incontinent of bowel. Record review of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 3/17/21 at 2:54 PM of RN A performing wound care treatment to Resident #26's left lower buttock with lanced abscess. RN A washed hands prior to initiating the procedure. RN A wore gloves ,removed the soiled dressing and discarded his gloves. RN A at this time wore new gloves without any hand hygiene , he then cleaned wound using normal saline and 4x4 gauze . After cleaning the wound, he changed his gloves but did not perform hand hygiene with the glove change . RN A then irrigated the wound using a syringe with normal saline and used 4x4 in his left hand to collect excess saline irrigating the wound. RN A then removed his gloves and did not perform hand hygiene. RN A picked up plain packing strips, saturated it with triple antibiotic ointment and then packed the wound and covered it. RN A did not change his gloves but picked up wet wipes and cleaned in-between Resident #26's buttocks which at this time had moderate amount of bowel movement. RN A picked up clean brief and put it on Resident #26, then changed his gloves and washed hands. Interview with RN A on 3/17/21 at 4:00 PM regarding wound care and hand washing and using hand sanitizer, she said the wound was a cleaned wound and she did wash her hands after the procedure. Interview on 03/17/21 at 4:45 PM the DON said she had ADON that now works PRN ( as needed) that does the dressing, incontinent /indwelling catheter training and sometimes and monitored the CNA's and nurses. The DON said she would now have to do more monitoring of incontinent/F/C care and wound care. The DON said hand hygiene should be performed with every glove change. In an interview with the DON on 3/17/21 at 5:20 PM, she said she would have to look to see when the last time was an in-service on incontinent care was done. She however did not provide any in-service documentation on incontinent care or infection control prior to survey exit. Record review of the facility Handwashing/Hand Hygiene policy revised on August 2019 read in part: This facility considers hand hygiene the primary means to prevent the spread of infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents; m. after removing gloves. 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. 9. The use of gloves does not replace hand washing/hand hygiene. Record review of Perry and Potter Clinical Nursing Skills and Techniques 6th edition, Chapter 8 page 192 reflected, .If hands are not visibly soiled, an alcohol-based hand rub should be used for routinely decontaminating hands in the following situation: 1. Before having direct contact with clients .3. After contact with intact skin .4. After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressing .5. When moving from a contaminated body site to a clean body site during care . Based on observations, interviews and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 4 of 4 Residents (Resident #30, #36, #35 and #26 ) observed for infection control, in that: - The facility failed to ensure staff removed gloves and used hand hygiene after providing Occupational Therapy (OT) for Resident #30. - MA A did not handwash or sanitize prior to dispensing Resident #36's medications. - Staff did not follow acceptable hand sanitizing practices during incontinent care for Resident #35. - RN A did not follow acceptable hand sanitizing practices during dressing treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] These failures could affect residents living in the facility at risk of infection from the transmission of communicable diseases. Findings include: Resident # 30 Record review of Resident #30's face sheet revealed an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident # 30's admission MDS dated [DATE] revealed a BIMS score of 8 indicating moderate impaired cognition. Further review of the MDS dated [DATE] revealed he required one person assist with toileting, grooming, transfers, bed mobility, dressing, bathing and personal hygiene. During observation on 3/18/21 at 10:20am the OT was observed exiting Resident # 30's room without sanitizing his hands carrying used gloves and walking down the hallway with them. In an interview on 3/18/21 at 10:26 am the OT said he had been working with Resident # 30 inside the room with his gloves on and he did not throw his used gloves away after exiting the room because he had turned the gloves inside out while walking down the hallway and that was okay to do because the insides of his used gloves were not dirty. The OT said, he was trained to remove the gloves after use, and wash or sanitizing his hands before and after he had contact with residents because he could spread germs or cause infections. The OT said he was going back to the rehabilitation room to throw his gloves away and then wash his hands. During an interview on 3/18/21 at 10:35a.m. the Director of Rehabilitation (DOR) said all rehab staff was in-serviced and trained last month, February 2021, on when to remove dirty gloves and to perform hand hygiene before and after providing resident care. The DOR said it was never acceptable for OT staff to walk out of a resident's room and down the hallway with dirty gloves because he would be spreading germs around that could spread infections to others. During an interview on 3/18/21 at 2:00p.m. the Director of Nursing (DON) said all staff was in-serviced and trained January 2021 on handwashing/hygiene procedures and must remove gloves and perform hand hygiene before and after resident care because of the risk of infections. Resident #36 Record review of Resident #36 admission face sheet revealed a [AGE] years old female admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the quarter Minimum Data Set (MDS) dated [DATE] revealed Resident #36 had a BIMS (Brief Interview for Mental Status) of 10 out of 15 indicating moderately cognitive impairment. Observation on 03/17/21 at 8:10 a.m. of MA A administering medication to Resident #36. She did not wash hands or use hand sanitizer before administering medication to Resident #36. MA A picked up Resident#36's blister packets from the medication cart, punched the following medications in her hand and then placed them in the medicine cup before administering to Resident # 36: - Acetaminophen 325 mg 2 tablets by mouth - [MEDICATION(S)] plus D maximum 1 tablet by mouth - Acidophilus 2 capsule by mouth - [MEDICATION(S)] 20 mg 1 tablet by mouth - [MEDICATION(S)] 100 mg capsule by mouth - [MEDICATION(S)] 10 mg 1 tablet by mouth - [MEDICATION(S)] 50 mg 1 tablet by mouth - Vitamin B-12 1000 mcq 1 tablet by mouth - Stool Softner ( [MEDICATION(S)]) 100 mg 1 tablet taken from on counter stock bottle (OTC) in a medicine cup then picked [MEDICATION(S)] up when MA A noticed it was an error and put in the same OTC bottle. Interview on 3/17/21 at 8:45 a.m. MA A regarding punching medications into her hand, then placing it in medicine cup before administering it to Resident #36. MA A said she was very sorry and she was nervous. MA A said she had been working with facility over 4 years and she had training annually on medication administration. Resident #35: Record review of Resident #35's face sheet revealed a [AGE] year old admitted to facility on 02/26/21 with the following diagnoses; acute [CONDITION(S)] w/ [CONDITION(S)] ( low oxygen in the lungs), [CONDITION(S)] , Pain in unspecified hip, Muscle weakness ( generalized ) , Urinary tract infection site not specified, other abnormalities of gait & mobility, other lack of coordination, urinary retention, indwelling Foley catheter (F/C) ( used for urine collection from the bladder) and history of urinary tract infection on admission. Record review of Resident #35's admission MDS dated [DATE] revealed a BIMS score of 15 indicating no cognitive impairment for decision skills. Further record review revealed that Resident required extensive assistance with ADL's and was frequently incontinent of bowel. Further review of the MDS documented that the Resident had a catheter and was incontinent of bowel. Record of Resident #35's care plan dated 2/26/21 Goal: Reduce risk of complications. Approach: F/C care Q shift. Monitor urine for color, amount, sediment, foul odor & notify MD PRN complications, encourage fluids w/ & between meals, change F/C per orders, Lab work PRN s/s infection. Monitor skin for redness /irritation. Observation on 3/17/21 at 3:16 PM of CNA A, performing indwelling catheter and incontinent care on Resident #35. C.NA A transferred from wheel chair to bed with urine catheter connected to a leg bag strapped to her left thigh with 50 mls of urine in the collection bag. C.NA A did not clean resident catheter tube starting from the urethra, making sure to open and separate the labia, and cleaning away from the urethra. CNA-A changed gloves six times during the procedure without washing or using sanitizing hands. Interview on 03/17/21 at 3:36 PM CNA-A said she had been working at the facility for approximately over 3 years. CNA-A said she received training or in-service on incontinent care/Foley catheter care at this facility sometime in December 2020. Resident #26 Record review of Resident #26's face sheet revealed a 8 year old admitted to facility on 02/6/2018 with the following diagnoses; cerebral infarction due to [CONDITION(S)] of unspecified precerebral artery, Unspecified symptoms and signs involving the nervous system, Other speech and language deficits following cerebral infarction, Dysphagia following cerebral infarction, Unspecified [CONDITION(S)], unspecified site, Other lack of coordination, Dysphagia, oral phase, [CONDITION(S)], unspecified, not intractable, without status epileptics , secondary to [CONDITION(S)], Muscle weakness (generalized, and fusion of spine, lumbar region Record review of Resident #26's quarterly MDS dated [DATE] revealed a BIMS score of 12 indicating moderately cognitive impairment for decision skills. Further record review revealed that Resident required extensive assistance with ADL's, and was frequently incontinent of bowel. Record review of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 3/17/21 at 2:54 PM of RN A , performing wound care treatment to Resident #26, to left lower buttock with lanced abscess ( method used to drain pus/abscess) , RN A cleaned wound with 4x4 gauze wet with normal saline and charged gloves 4 times not using hand sanitizer or washing hands. RN A irrigated the wound using a syringe with normal saline, did not change gloves, picked up plain packing strips, saturated it with triple antibiotic ointment and then packed the wound and covered. RN A did not change her gloves, picked up wet wipes and cleaned in-between Resident #26's buttocks with moderate bowel movement, RN A then got a clean brief and placed it on Resident #26. RN A then changed gloves and washed her hands. Interview with RN A on 3/17/21 at 4:00 PM regarding wound care and hand washing and using hand sanitizer, she said the wound was a cleaned wound and she did wash her hands after the procedure. Interview on 03/17/21 at 4:45 PM the DON said she had a ADON that now works PRN (as needed) that does the dressing, incontinent /indwelling catheter training and sometimes monitored the CNA's and nurses. The DON said she would now have to do more monitoring of hand washing, incontinent/F/C care and wound care. DON said were supposed to wash hands or used hand sanitizer after changing their gloves. In an interview with the DON on 3/17/21 at 5:20 PM, she said she would have to look to see when was the last time an in-service on incontinent care was done. No in-service documentation on incontinent care was provided before surveyors exited the building on 3/18/21. Record review of the facility Handwashing/Hand Hygiene policy revised on August 2019 read in part: This facility considers hand hygiene the primary means to prevent the spread of infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents; m. after removing gloves. 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. 9. The use of gloves does not replace hand washing/hand hygiene. Record review of Perry and Potter Clinical Nursing Skills and Techniques 6th edition, Chapter 8 page 192 reflected, .If hands are not visibly soiled, an alcohol-based hand rub should be used for routinely decontaminating hands in the following situation: 1. Before having direct contact with clients .3. After contact with intact skin .4. After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressing .5. When moving from a contaminated body site to a clean body site during care .

Based on observation, interview, and record review the facility failed to ensure Residents who are incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 2 of 2 residents ( Resident#35 and 33) reviewed for incontinent care, in that; CNA #A did not separate Resident #35's labia to clean during incontinent and catheter care and did not perform appropriate hand hygiene with glove changes throughout the care. Resident #33's catheter was not secured to prevent it from pulling at the insertion site. CNA #B raised Resident #33's indwelling urinary catheter bag up above the level of the bladder to prevent return of urine to the bladder during catheter care .CNA #B did not clean Resident #33's scrotum during incontinent care . These deficient practices could affect residents with bladder incontinence and indwelling urinary catheters and place them at risk of urinary tract infections. Findings include: Resident #35 Record review of Resident #35's face sheet revealed an [AGE] year old female admitted to facility on 02/26/21 with the following diagnoses; acute [CONDITION(S)] w/ [CONDITION(S)] ( low oxygen in the lungs), [CONDITION(S)] , Pain in unspecified hip, Muscle weakness ( generalized ) , Urinary tract infection site not specified, other abnormalities of gait & mobility, other lack of coordination, urinary retention, indwelling Foley catheter (F/C) ( used for urine collection from the bladder) and history of urinary tract infection on admission. Record review of Resident #35's admission MDS dated [DATE] revealed a BIMS score of 15 out of 15 indicating no cognitive impairment for decision skills. Further record review revealed that Resident required extensive assistance with ADLs and was frequently incontinent of bowel. Further review of the MDS documented that the Resident had a catheter and was incontinent of bowel. Record of Resident #35's care plan dated 2/26/21 Goal: Reduce risk of complications. Approach : F/C care Q shift .Monitor urine for color , amount, sediment, foul odor & notify MD prn complications, encourage fluids w/ & between meals, change F/C per orders, Lab work prn s/s infection . Monitor skin for redness /irritation. Observation on 3/17/21 at 3:16 PM of CNA #A, performing indwelling catheter and incontinent care on Resident #35. CNA #A washed her hand and wore gloves then transferred Resident #35 from wheel chair to bed with urine catheter connected to a leg bag strapped to her left thigh with 50 mls of urine in the collection bag. CNA #A removed the resident's pull up, and began cleaning the peri- areas , she changed her gloves after cleaning the peri-area, then cleaned the thighs. CNA #A did not clean resident's catheter tube starting from the point of insertion and outwards, she did not separate the labia to clean the resident. CNA#A changed gloves six times during the procedure without performing any hand hygiene. She also placed a clean brief, and clean pants on the resident without hand hygiene. Interview on 03/17/21 at 3:36 PM CNA #A said she had been working at the facility for approximately over 3 years. When surveyor asked CNA #A how she did with the incontinent/Foley catheter care. CNA #A said she I did a great job. She received training or in-service on incontinent care/Foley catheter care at this facility sometime in December 2020. When asked about not separating the Resident#35's labia to clean the resident, she said she did not because the resident was not soiled . When asked why she did not perform any hand hygiene with gloves changes throughout the car, she said she forgot, and the resident was not soiled. Interview on 03/17/21 at 4:45 PM, the DON said she expected staff to use hand sanitizers or wash their hands with glove change during care. DON said she expected staff to separate the residents labia and clean them appropriately, clean the Foley from point of insertion outwards and wash hands . In an interview with the DON on 3/17/21 at 5:20 PM, DON was asked for in-services provided to facility staff on incontinent and catheter care, she said she would have to look to see the last time an in-service on incontinent care was provided. No in-service documentation on incontinent care was provided prior to exit. Resident #33 Record review of Resident #33's face sheet revealed he was admitted on [DATE] and readmitted on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident # 33's MDS dated [DATE] revealed a BIMS score of 0 out of 15 indicating his cognition was severely impaired. Further review of the MDS dated [DATE] revealed he required one person assist with toileting, grooming, bed mobility, dressing, bathing, personal hygiene and transfers. During an observation on 3/18/21 at 10:50a.m. CNA B was observed assisting Resident # 33 into bed for incontinent care. Resident #33 was lying flat on his back with a urinary catheter leg bag strapped to his left leg. One strap was on his upper thigh and the other strap was on his lower calf area with the tubing stretched out. CNA B removed Resident #33's brief placed him on his right side and cleaned his bottom. Resident # 33 was turned on his back and said he was in pain when he straightened his leg out. CNA B wiped Resident # 33's penis area without cleaning in between his scrotum area. While Resident #33 was lying on his back in bed, CNA B raised Resident #33's left leg above his bladder and emptied 300cc's of amber urine from his catheter bag still attached to his left leg . In an interview on 3/18/21 at 11:20a.m. CNA B confirmed she lifted the catheter bag above the level of the bladder when she emptied it and did not clean his scrotum while performing perineal care. CNA B said she should have made sure the leg bag was not being pulled because the resident could be in more pain and it could have caused bleeding when the resident was repositioned in bed. The CNA B said she had received in-service training on perineal and catheter care last month February 2021, but she did not follow the procedures during care of the resident and not doing so put him at risk for infection. In an interview on 3/18/21 at 1:40p.m. the RN #A said all staff received an in-service on catheter care, perineal care and infection control last month February 2021. The RN #A said the care staff should always make sure the catheter straps are secured properly to prevent pain from the tube being pulled and they had to make sure the catheter tubing is kept below the bladder because the back flow of urine could cause a bladder infection. Record review of the facility Perineal Care policy revised on February 2018 read in part: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. For a male resident: b. Wash perineal area starting with urethra and working outward. C. If the resident has an indwelling catheter, gently wash the juncture of the tubing from the ureter down the catheter about 3 inches. F. continue to wash the perineal area including the penis, scrotum and inner thighs. H. If the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter. Further review above policy read in part: .b Wash perineal area, wiping from front to back: 1. Separate labia and wash area downward from front to back ( Note: If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches . Avoid tension on indwelling catheter if present and clean around it .3. Clean the catheter from where it enters the body and then down, away from the body. Hold the catheter at the point it enters your body so not to put tension . Record review of the facility Catheter Care, Urinary policy revised on September 2014 read in part: The purposes of this procedure is to prevent catheter-associated urinary tract infections. Maintaining Unobstructed Urine Flow. 3. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site.

Based on observation, interview, and record review, the facility failed to ensure a communication process, including how the communication will be documented between the LTC facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day for 1 of 12 residents (Resident #11) reviewed for hospice services. The facility did not notify Resident #11's hospice agency that she had no more medications for administration and to re-order her medication ( [MEDICATION NAME]) . Resident #11 did not receive her physician ordered medication [MEDICATION NAME] for 5 weeks. As a result, Resident #11's pain was not effectively controlled. This failure affected one resident and placed her at risk of increased pain and a decline in health and quality of life. Findings included: Resident #11 Record review of Resident #11's Face Sheet revealed a [AGE] year-old female initially admitted to the facility on [DATE] with a readmission of 1/15/19. Her [DIAGNOSES REDACTED]. Further review revealed she was admitted to hospice services on 4/29/19 with heart failure as her admitting [DIAGNOSES REDACTED]. Record review of Resident #11's Quarterly MDS dated [DATE] revealed a BIMS was not conducted. A SAMS indicated her memory was okay. She required extensive assistance of one staff for ADLs. She was coded as being on a scheduled pain medication regimen and had not received any PRN pain medications. The pain assessment interview indicated she had no pain. She was not indicated to have a prognosis that resulted in a life expectancy of less than 6 months. Record review of Resident #11's Care Plan dated 4/30/19 did not address she received hospice services. Record review of Resident #11's MAR indicated [REDACTED]. The last dosage was given on (MONTH) 20th. Observation on 06/26/19 at 09:05 AM revealed Resident #11 was lying in bed asleep. A quick tour around the room was done and within minutes her eyes were open. She asked if she could have her tray and was instructed to push her call button to request help from staff. She said, Oh honey they're not gonna answer that thing at this time of day. She was again instructed to call for help and reached for the light with a very slow visible shaky hand. 7 minutes later the call light was answered by CNA #27. She asked Resident #11 if she was ready to eat and explained she needed to position her upright. Resident #11 repeatedly said she could not understand CNA #27 because she was laying on her good ear. After a couple of minutes CNA #27 grabbed her by the shoulders and positioned her upright in the bed without any assistance from Resident #11. Resident #11 was grunting in pain and said, Oh that hurts! She then said she was 93 and things did not work like they used to. CNA #27 placed the tray in front of Resident #11 who continued grunting. CNA #27 was asked what she would do, she said the resident always complained of pain and the nurse already knew of it. Interview and record review on 06/27/19 at 10:15 AM , RN #2 said the hospice agency took care of reordering medications unless the medication was not covered by hospice. She said the facility staff had to call and inform the hospice agency when the resident was running low on medications for them to reorder it. The staff member passing medications were responsible for informing the nurse once there were about 12 pills left. She said she believed [MEDICATION NAME] was a medication covered by hospice. When asked what happened when a resident ran out of medications she said All the time we follow up on our meds. We call it in multiple times so the resident doesn't have to be without it. When asked what could be expected from a resident who did not receive their scheduled [MEDICATION NAME] she said increased nerve pain, moaning/groaning, and being uncomfortable. She said Resident #11 had no recent complaints of pain and CNA #27 didn't inform RN #2 of pain. She said CNA #27 did inform her Resident #11 did not want to get out of bed for breakfast on 6/26 and told her to bring her a tray. When asked if Resident #11 received [MEDICATION NAME], she looked at the current orders and said she received prescribed [MEDICATION NAME] medication . When she checked the MAR indicated [REDACTED]. She said it was not brought to her attention, but she would call the hospice company and family. Interview on 06/27/19 at 10:31am, CNA #27 said she was a floater and did not work with Resident #11 often. She said she noticed Resident #11 Getting tired and tired every day. She said it was common for Resident #11 to moan. She said she worked with Resident #11 over the weekend and she moaned when she got her up. She said she told nurse yesterday she was in pain and refused to get up and the nurse said to order Resident #11 a room tray. She said Resident #11 moved very slowly and often complained You know I can't do this. I used to be able to do this, but I can't anymore. Interview on 06/27/19 at 10:41AM , the DON said the medication aide must notify the hospice nurse once the medication is running low on medications with 5-10 pills left. She said the hospice nurses usually kept an eye on medication and were good about reordering the medications. She said if the medication is a night medication, the medication aide was still responsible for notifying hospice. The DON was not aware Resident #11 did not have her ordered [MEDICATION NAME] in stock and had not received the medication for 5 weeks. Interview on 06/27/19 at 11:01 AM, the Hospice Nurse said when medications need to be reordered the facility nurse called him and he called it into the pharmacy. He said staff should have his direct phone number, but after-hours there were staff on-call to answer the office phone. He said he reordered medications last week for Resident #11 but could not recall if [MEDICATION NAME] was one of the medications. He said the pharmacy usually delivered the medications the same day that they were ordered, but they did not provide any type of confirmation. He said no one informed him she was missing the medication for 5 weeks. Observation on 06/27/19 at 12:11 PM revealed Resident #11 sitting in her wheelchair by her room door. CNA #27 grabbed a cardigan out of the closet and guided her arms through the sleeves. Resident #11 said Ow ow ow while CNA #27 put on the cardigan. Interview on 06/27/19 at 12:17 PM RN #2 said shortly before this interview, she gave Resident #11 [MEDICATION NAME] from the emergency kit as ordered by the physician. Phone interview on 7/2/19 at 8:31am, physician A returned a phone call made during the survey and said once a resident was admitted to hospice, the agency took over reordering medications. He said if the resident was in pain he would write an order for [REDACTED]. Interview on 06/27/19 at 02:45 PM , Resident #11 rated her pain as an 8.5/10 but the pain was higher that morning. When asked how often staff asked her pain level she said no one ever checked on her to ask her pain levels. A policy on Hospice Coordination was requested on 6/27/19 at 4:30 pm was requested from the DON, but not received prior to exit. Record review of the facility's Pain Assessment and Management Policy dated (MONTH) (YEAR) revealed Possible behavioral signs of pain: verbal expressions such as groaning. behavior such as resisting care, irritability, depression, decreased participation in usual activities. difficulty eating or loss of appetite, evidence of depression.

Based on observation, record review and interview, the facility failed to ensure the attending physician documented in the resident's medical record that identified irregularities by the Pharmacist had been reviewed and what, if any, action had been taken to address it and if there was to be no change in the medication, document his or her rationale in the resident's medical record for two of 12 Residents (Resident #35 and #11) reviewed for drug regimen review, in that; The facility's Pharmacist Consultant recommended Resident #35's [MEDICATION NAME] dose be evaluated and considered for gradual dose reduction and there was no documented rationale in the medical record why the recommendation was not approved by the Physician. The facility's Pharmacist Consultant recommended Resident #11's [MEDICATION NAME] dose be evaluated and considered for gradual dose reduction and there was no documented rationale in the medical record why the recommendation was not approved by the Physician. These failures affected two residents and placed them at risk for adverse drug consequences and unnecessary use of [MEDICAL CONDITION] medications. Findings include: Resident #35 Record review of Resident #35's face sheet revealed a [AGE] year-old female admitted on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #35's significant change MDS dated [DATE] revealed a BIMS score of 10 indicating moderately impaired cognition. Further review of MDS revealed no behaviors but had use of antipsychotics and antidepressants. The resident reported on MDS Mood Interview she sometimes felt down, depressed, or hopeless, and she frequently felt tired and had little energy. [DIAGNOSES REDACTED]. Record review of Resident #35's quarterly MDS dated [DATE] revealed a BIMS score of 10 indicating moderately impaired cognition. Further review of MDS revealed no behaviors but had use of antipsychotics and antidepressants. The resident reported on MDS Mood Interview she sometimes felt down, depressed, or hopeless, and felt tired and had little energy. [DIAGNOSES REDACTED]. Record review of Resident #35's quarterly MDS dated [DATE] revealed the resident could not complete the BIMS assessment. Staff Assessment for Mental Status revealed resident had short term memory problems, but long-term memory was okay. Further review of MDS revealed no behaviors but had use of antipsychotics and antidepressants. The resident reported on MDS Mood Interview she frequently felt tired and had little energy. [DIAGNOSES REDACTED]. Record review of Resident #35's care plan dated 6/14/19 revealed she was on [MEDICAL CONDITION] medication [MEDICATION NAME]. Her interventions included: Obtain family consent to administer antipsychotic med before giving. Administer [MEDICATION NAME] per orders. Monitor for signs and symptoms of adverse reactions: hallucinations, dizziness, fatigue, constipation, [MEDICAL CONDITIONS], and blurred vision. Notify the MD prn complications. Monitor and record behavior problems every day. Provide queuing and redirection QD PRN. Notify doctor if there's an increase in behavior issues. Pharmacist consultant to review medication monthly. Further review of the care plan revealed her mood was impaired related to little interest in doing things, feeling down, tired moving slowly, and speaking slowly. Her interventions included: Administer medications and PRN medications per MD orders and observe effectiveness. Allow resident to express feelings/thoughts in a non-judgmental manner. Assess psycho social well being PRN. Provide calm environment at night helping individual sleep. Encourage activity participation. Encourage resident centered activities. Assess for pain. Discuss why the resident feels a certain way. Monitor to ascertain mood. Record review of Resident #35's physician's orders [REDACTED]. Hallucinations, 2. Delusional thoughts, 3. Refusing ADL or out of room activity, 4. Inconsolable crying or agitation over her paranoia or delusional thoughts; Interventions: 1. One on one, 2. Allow resident ample time to express herself and listen attentively, 3. Provide opportunity for divisional activity. 4. Provide her with books she likes to read, 5. Attempt to changed subject, away from her delusion or hallucination if causing her anxiousness, 6. Offer food or fluids, 7. Offer room temp change, 8. Offer warm blanket for comfort, 9. Charge nurse assess pain, offer pain management per MD orders, 10. [MEDICATION NAME] per MD orders; Outcome: 1.+ improved, 2. 0 unchanged, 3. - worsened; Side effects: 1. HTN, 2. Aspiration, 3. Low white blood count (WBC), 4. Constipation, 5. Twitching, 6. Rigidity, 7. Increased heart rate, 8. Headache, 9. Dizziness, 10. Fatigue, 11. Tremor, 12. Twitching, 13. Rash, 14 nausea, 15. Vomiting to be checked Every Shift (Night, Day, Evening). Record review of Resident #35's physician's orders [REDACTED]. Record review of the Pharmacy review binder revealed a gradual dose reduction for Resident #35's [MEDICATION NAME] was requested by the pharmacist on 8/1/18. The form in the binder was blank and had no response from Physician on it. Record review of Resident #35's Medication regimen review dated 8/1/18 that was provided on 6/27/19 at 4:00PM revealed, This resident has been on [MEDICATION NAME] 50 MG every 12 hours since 8/2017. Please evaluate the current dose and consider a gradual taper to ensure this resident is using the lowest possible effective/optimal dose. Please check the appropriate response and add additional information as requested. Further review of the medication regimen review revealed the physician's response was other and required rationale for not accepting recommendation. The comment/rationale entered by physician was, continue current treatment and was signed on 9/13/18. Record review of Resident #35's (MONTH) 2019 MAR, (MONTH) 2019 MAR, and (MONTH) 2019 MAR behavior monitoring revealed Resident had no behaviors. Record review of Resident #35's (MONTH) 2019 MAR and (MONTH) 2019 MAR revealed she received [MEDICATION NAME] (quetiapine) tablet; 50MG; amount: 1 tab; oral for [MEDICAL CONDITION] at 9:00AM and 9:00PM everyday (5/1/19 - 6/26/19). Record review of Resident #35's clinical record for 2019 revealed no behavioral concerns. Observation on 6/26/19 at 12:21PM, Resident #35 was in dining room pulled up to a table in her wheel chair. Resident was moving slowly feeding herself and was observed dripping soup on herself while trying to feed herself soup. Surveyor asked her how her food was, she slowly looked up at surveyor and did not respond. Observation and interview on 6/27/19 at 11:52AM, Resident #35 was sitting in wheel chair outside of dining room. Resident said she was not doing good and when asked what was wrong by the surveyor the resident began pulling off her slipper from left foot. She was asked if she was hurting and she shook her head up and down to answer yes. Interview on 6/27/19 at 1:27PM, CNA #27 said Resident #35 was very quiet and didn't observe any behaviors from her. She said the resident spoke in a very low and slow tone. Observation and interview on 6/27/19 at 3:00PM, Resident #35 was sitting in wheel chair in room. Resident was observed leaning to her right side. Resident was asked how she was doing, and she did not respond right away. After a few seconds passed the resident attempted to slowly mumble some words that were not understood by surveyor. A Medication Aide entered the room and gave Resident #35 some PRN [MEDICATION NAME] and reported she was complaining of pain. After medication aide left the room the resident was asked if she was having pain in her side area or foot. Resident was able to say she has had pain under her breast. She said it didn't hurt all the time but said it had hurt on and off. Interview and record review on 6/27/19 at 3:20PM, DON said she was not sure why Resident #35 had not had a dose reduction of her [MEDICATION NAME] since (YEAR). The DON reviewed the blank form found in the Pharmacy review binder and said there should be a filled-out copy by the physician in the resident's electronic records. The electronic record was pulled up and revealed no attachments of Dose reduction recommendation. The DON said she would go and see if she could locate the filled-out form. The DON returned at 4:00PM with the form in question filled out by the physician. Interview on 4/27/19 at 4:00PM, the DON was asked for the rationale for the physician not reducing Resident #35's [MEDICATION NAME] when she hadn't presented any behaviors or current need for the medication, as the rationale written on the medication review form only said, continue current treatment. The DON said she would look for documented rationale for continuing the medication. Interview on 6/27/19 at 4:15PM, the DON said the facility did not have anything documented on the rationale for continuing the medication, but she called the physician to see if she had any documentation she could send over. She said the physician did not send anything but said Resident #35 had been stable with her current dose of [MEDICATION NAME] and did not see need to change. The DON explained the Physician worked under Resident #35's old physician (Physician #2) and took over his practice in March. She said the physician reported she reviewed the resident in (MONTH) and saw no need to taper her medication and the reason she was on the medication was for her [DIAGNOSES REDACTED]. Interview on 4/27/19 at 4:25PM, physician said she reviewed Resident #35 in (MONTH) of 2019 and saw she was doing fine/stable. The physician stated I saw no need to reduce her medications or discontinue them. She said she will not reduce the resident's medication just because the state department required she do so. The physician said Resident #35 had a [DIAGNOSES REDACTED]. The Physician said she would review the resident again in (MONTH) and would reevaluate her then but for now she will not reduce her [MEDICATION NAME] even though she has not presented any behaviors. Resident #11 Record review of Resident #11's Face Sheet revealed a [AGE] year-old female initially admitted to the facility on [DATE] with a readmission of 1/15/19. Her [DIAGNOSES REDACTED]. Further review revealed she was admitted to hospice services on 4/29/19 with the primary [DIAGNOSES REDACTED]. Record review of Resident #11's Quarterly MDS dated [DATE] revealed a BIMS was not conducted. A SAMS indicated her memory was okay. The mood interview was conducted by a staff member. She scored an 8 with symptoms being feeling tired, poor appetite, moving/speaking slowly, and being short tempered. She received an anti-depressant 7/7 days in the look-back period. Depression was marked as a current diagnosis. Record review of Resident #11's Care Plan dated 1/23/19 revealed Resident #11 is on [MEDICAL CONDITION] medication [MEDICATION NAME] and has potential for adverse reactions. The goal was to reduce the risk of adverse reactions over the next 90 days. The interventions included having a consent form, administering medications per orders, and monitoring for signs and symptoms of adverse reactions. She also was to be reviewed quarterly by the pharmacist. Record review of Resident #7's physician's orders [REDACTED]. Record review of Resident #11's Medication Regimen Review dated 4/19/19 revealed This resident has been on an the antidepressant duloxetine 30 mg daily since (MONTH) (YEAR). Please evaluate the current dose and consider a gradual taper to ensure this resident is using the lowest possible effective/optimal dose. Please check the appropriate response and add additional information as requested. There was a check mark placed next to the statement Patient has a good response to treatment and requires this dose for condition stability. Dose reduction is contraindicated because benefits outweigh risks for this patient and a reduction is likely to impair the resident's function and/or cause psychiatric instability. (Please elaborate with patient specific information): At the bottom of the form there were three checkboxes: agree, disagree, other. None of the boxes were checked. The section where the physician was to provide a rationale was blank. It was signed and dated on 4/24/19. Record review of Resident #7's MAR dated (MONTH) 2019 revealed [MEDICATION NAME] was administered as ordered with no observed side effects. Side effects targeted included sedation, drowsiness, dry mouth, blurred vision, [MEDICAL CONDITIONS] muscle tremor, agitation, headache, skin rash, photosensitivity, and excess weight gain. Record review of Resident #11's Nursing Note dated 06/16/2019 revealed Resident lying in bed AAOx3. Resident c/o of not feeling well and states that she wants to stay in bed.Will continue to monitor. Observation on 06/26/19 at 09:05 AM revealed Resident #11 was lying in bed asleep. Interview on 06/27/19 at 02:51 PM, the DON said if the physician did not agree with the rationale for dose reduction he/she was required to document a reason. Record review of facility's Behavioral Assessment, Intervention, and Monitoring Policy dated (MONTH) (YEAR) revealed If the resident is being treated for [REDACTED]. If antipsychotic medications are used to treat behavioral symptoms, the IDT will monitor their indication and implement a gradual dose reduction, or document why this cannot or should not be done. Record review of Antipsychotic Medication Use policy (Revised (MONTH) (YEAR)) revealed in part, .Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental cause of behavioral symptoms have been identified an addressed . Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review . 7. Antipsychotic medications shall generally be used only for the following condition/[DIAGNOSES REDACTED]. [MEDICAL CONDITION] in the absence of dementia 8. [DIAGNOSES REDACTED]. In addition to the above criteria, antipsychotic medications will generally only be considered if the following conditions are also met: a. The behavioral symptoms present a danger to the resident or others; AND: (1) The symptoms are identified as being due [MEDICAL CONDITIONS] (such as auditory, visual, or other hallucinations; delusions, paranoia or grandiosity); or (2) Behavioral interventions have been attempted and include in the plan of care, except in an emergency . Further review of the policy revealed in part, .The physician shall respond appropriately by changing or stopping problematic doses or medication, or clearly documenting (based on assessing the situation) why the benefits of the medication outweigh the risks or suspected or confirmed adverse consequences .

Based on observation, record review and interview, the facility failed to ensure residents who use [MEDICAL CONDITION] drugs receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue these drugs for two of 12 residents (Resident #35 and #11), reviewed for [MEDICAL CONDITION] drugs, as evidenced by: Resident #35 was on [MEDICATION NAME] tablet 50 mg twice a day for [MEDICAL CONDITION] for a year and 10 months without any attempt to reduce dose. Resident #35 had no current documented behaviors associated with [DIAGNOSES REDACTED]. Resident #11 was on [MEDICATION NAME] daily for 3 years and 3 months without an attempted gradual dose reduction . There was no documented rationale from the physician on why a gradual dose reduction was not attempted. These failures affected two residents and placed them at risk for adverse drug consequences and continued use of possible unnecessary medications. Findings include: Resident #35 Record review of Resident #35's face sheet revealed a [AGE] year-old female admitted on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #35's significant change MDS dated [DATE] revealed a BIMS score of 10 indicating moderately impaired cognition. Further review of MDS revealed no behaviors but had use of antipsychotics and antidepressants. The resident reported on MDS Mood Interview she sometimes felt down, depressed, or hopeless, and she frequently felt tired and had little energy. [DIAGNOSES REDACTED]. Record review of Resident #35's quarterly MDS dated [DATE] revealed a BIMS score of 10 indicating moderately impaired cognition. Further review of MDS revealed no behaviors but had use of antipsychotics and antidepressants. The resident reported on MDS Mood Interview she sometimes felt down, depressed, or hopeless, and felt tired and had little energy. [DIAGNOSES REDACTED]. Record review of Resident #35's quarterly MDS dated [DATE] revealed the resident could not complete the BIMS assessment. Staff Assessment for Mental Status revealed resident had short term memory problems, but long-term memory was okay. Further review of MDS revealed no behaviors but had use of antipsychotics and antidepressants. The resident reported on MDS Mood Interview she frequently felt tired and had little energy. [DIAGNOSES REDACTED]. Record review of Resident #35's care plan dated 6/14/19 revealed she was on [MEDICAL CONDITION] medication [MEDICATION NAME]. Her interventions included: Obtain family consent to administer antipsychotic med before giving. Administer [MEDICATION NAME] per orders. Monitor for signs and symptoms of adverse reactions: hallucinations, dizziness, fatigue, constipation, [MEDICAL CONDITIONS], and blurred vision. Notify the MD prn complications. Monitor and record behavior problems every day. Provide queuing and redirection QD PRN. Notify doctor if there's an increase in behavior issues. Pharmacist consultant to review medication monthly. Further review of the care plan revealed her mood was impaired related to little interest in doing things, feeling down, tired moving slowly, and speaking slowly. Her interventions included: Administer medications and PRN medications per MD orders and observe effectiveness. Allow resident to express feelings/thoughts in a non-judgmental manner. Assess psycho social well being PRN. Provide calm environment at night helping individual sleep. Encourage activity participation. Encourage resident centered activities. Assess for pain. Discuss why the resident feels a certain way. Monitor to ascertain mood. Record review of Resident #35's physician's orders [REDACTED]. Hallucinations, 2. Delusional thoughts, 3. Refusing ADL or out of room activity, 4. Inconsolable crying or agitation over her paranoia or delusional thoughts; Interventions: 1. One on one, 2. Allow resident ample time to express herself and listen attentively, 3. Provide opportunity for divisional activity. 4. Provide her with books she likes to read, 5. Attempt to changed subject, away from her delusion or hallucination if causing her anxiousness, 6. Offer food or fluids, 7. Offer room temp change, 8. Offer warm blanket for comfort, 9. Charge nurse assess pain, offer pain management per MD orders, 10. [MEDICATION NAME] per MD orders; Outcome: 1.+ improved, 2. 0 unchanged, 3. - worsened; Side effects: 1. HTN, 2. Aspiration, 3. Low white blood count (WBC), 4. Constipation, 5. Twitching, 6. Rigidity, 7. Increased heart rate, 8. Headache, 9. Dizziness, 10. Fatigue, 11. Tremor, 12. Twitching, 13. Rash, 14 nausea, 15. Vomiting to be checked Every Shift (Night, Day, Evening). Record review of Resident #35's physician's orders [REDACTED]. Record review of the Pharmacy review binder revealed a gradual dose reduction for Resident #35's [MEDICATION NAME] was requested by the pharmacist on 8/1/18. The form in the binder was blank and had no response from Physician on it. Record review of Resident #35's Medication regimen review dated 8/1/18 that was provided on 6/27/19 at 4:00PM revealed, This resident has been on [MEDICATION NAME] 50 MG every 12 hours since 8/2017. Please evaluate the current dose and consider a gradual taper to ensure this resident is using the lowest possible effective/optimal dose. Please check the appropriate response and add additional information as requested. Further review of the medication regimen review revealed the physician's response was other and required rationale for not accepting recommendation. The comment/rationale entered by physician was, continue current treatment and was signed on 9/13/18. Record review of Resident #35's (MONTH) 2019 MAR, (MONTH) 2019 MAR, and (MONTH) 2019 MAR behavior monitoring revealed Resident had no behaviors. Record review of Resident #35's (MONTH) 2019 MAR and (MONTH) 2019 MAR revealed she received [MEDICATION NAME] (quetiapine) tablet; 50MG; amount: 1 tab; oral for [MEDICAL CONDITION] at 9:00AM and 9:00PM everyday (5/1/19 - 6/26/19). Record review of Resident #35's clinical record for 2019 revealed no behavioral concerns. Observation on 6/26/19 at 12:21PM, Resident #35 was in dining room pulled up to a table in her wheel chair. Resident was moving slowly feeding herself and was observed dripping soup on herself while trying to feed herself soup. Surveyor asked her how her food was, she slowly looked up at surveyor and did not respond. Observation and interview on 6/27/19 at 11:52AM, Resident #35 was sitting in wheel chair outside of dining room. Resident said she was not doing good and when asked what was wrong by the surveyor the resident began pulling off her slipper from left foot. She was asked if she was hurting and she shook her head up and down to answer yes. Interview on 6/27/19 at 1:27PM, CNA #27 said Resident #35 was very quiet and didn't observe any behaviors from her. She said the resident spoke in a very low and slow tone. Observation and interview on 6/27/19 at 3:00PM, Resident #35 was sitting in wheel chair in room. Resident was observed leaning to her right side. Resident was asked how she was doing, and she did not respond right away. After a few seconds passed the resident attempted to slowly mumble some words that were not understood by surveyor. A Medication Aide entered the room and gave Resident #35 some PRN [MEDICATION NAME] and reported she was complaining of pain. After medication aide left the room the resident was asked if she was having pain in her side area or foot. Resident was able to say she has had pain under her breast. She said it didn't hurt all the time but said it had hurt on and off. Interview and record review on 6/27/19 at 3:20PM, DON said she was not sure why Resident #35 had not had a dose reduction of her [MEDICATION NAME] since (YEAR). The DON reviewed the blank form found in the Pharmacy review binder and said there should be a filled-out copy by the physician in the resident's electronic records. The electronic record was pulled up and revealed no attachments of Dose reduction recommendation. The DON said she would go and see if she could locate the filled-out form. The DON returned at 4:00PM with the form in question filled out by the physician. Interview on 4/27/19 at 4:00PM, the DON was asked for the rationale for the physician not reducing Resident #35's [MEDICATION NAME] when she hadn't presented any behaviors or current need for the medication, as the rationale written on the medication review form only said, continue current treatment. The DON said she would look for documented rationale for continuing the medication. Interview on 6/27/19 at 4:15PM, the DON said the facility did not have anything documented on the rationale for continuing the medication, but she called the physician to see if she had any documentation she could send over. She said the physician did not send anything but said Resident #35 had been stable with her current dose of [MEDICATION NAME] and did not see need to change. The DON explained the Physician worked under Resident #35's old physician (Physician #2) and took over his practice in March. She said the physician reported she reviewed the resident in (MONTH) and saw no need to taper her medication and the reason she was on the medication was for her [DIAGNOSES REDACTED]. Interview on 4/27/19 at 4:25PM, physician said she reviewed Resident #35 in (MONTH) of 2019 and saw she was doing fine/stable . The physician stated I saw no need to reduce her medications or discontinue them. She said she will not reduce the resident's medication just because the state department required she do so. The physician said Resident #35 had a [DIAGNOSES REDACTED]. The Physician said she would review the resident again in (MONTH) and would reevaluate her then but for now she will not reduce her [MEDICATION NAME] even though she has not presented any behaviors. Resident #11 Record review of Resident #11's Face Sheet revealed a [AGE] year-old female initially admitted to the facility on [DATE] with a readmission of 1/15/19. Her [DIAGNOSES REDACTED]. Further review revealed she was admitted to hospice services on 4/29/19 with the primary [DIAGNOSES REDACTED]. Record review of Resident #11's Quarterly MDS dated [DATE] revealed a BIMS was not conducted. A SAMS indicated her memory was okay. The mood interview was conducted by a staff member. She scored an 8 with symptoms being feeling tired, poor appetite, moving/speaking slowly, and being short tempered. She received an anti-depressant 7/7 days in the look-back period. Depression was marked as a current diagnosis. Record review of Resident #11's Care Plan dated 1/23/19 revealed Resident #11 is on [MEDICAL CONDITION] medication [MEDICATION NAME] and has potential for adverse reactions. The goal was to reduce the risk of adverse reactions over the next 90 days. The interventions included having a consent form, administering medications per orders, and monitoring for signs and symptoms of adverse reactions. She also was to be reviewed quarterly by the pharmacist. Record review of Resident #7's physician's orders [REDACTED]. Record review of Resident #11's Medication Regimen Review dated 4/19/19 revealed This resident has been on an the antidepressant duloxetine 30 mg daily since (MONTH) (YEAR). Please evaluate the current dose and consider a gradual taper to ensure this resident is using the lowest possible effective/optimal dose. Please check the appropriate response and add additional information as requested. There was a check mark placed next to the statement Patient has a good response to treatment and requires this dose for condition stability. Dose reduction is contraindicated because benefits outweigh risks for this patient and a reduction is likely to impair the resident's function and/or cause psychiatric instability. (Please elaborate with patient specific information): At the bottom of the form there were three checkboxes: agree, disagree, other. None of the boxes were checked. The section where the physician was to provide a rationale was blank. It was signed and dated on 4/24/19. Record review of Resident #7's MAR dated (MONTH) 2019 revealed [MEDICATION NAME] was administered as ordered with no observed side effects. Side effects targeted included sedation, drowsiness, dry mouth, blurred vision, [MEDICAL CONDITIONS] muscle tremor, agitation, headache, skin rash, photosensitivity, and excess weight gain. Record review of Resident #11's Nursing Note dated 06/16/2019 revealed Resident lying in bed AAOx3. Resident c/o of not feeling well and states that she wants to stay in bed.Will continue to monitor. Observation on 06/26/19 at 09:05 AM revealed Resident #11 was lying in bed asleep. Interview on 06/27/19 at 02:51 PM, the DON said if the physician did not agree with the rationale for dose reduction he/she was required to document a reason. Record review of facility's Behavioral Assessment, Intervention, and Monitoring Policy dated (MONTH) (YEAR) revealed If the resident is being treated for [REDACTED]. If antipsychotic medications are used to treat behavioral symptoms, the IDT will monitor their indication and implement a gradual dose reduction, or document why this cannot or should not be done. Record review of Antipsychotic Medication Use policy (Revised (MONTH) (YEAR)) revealed in part, .Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental cause of behavioral symptoms have been identified an addressed . Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review . 7. Antipsychotic medications shall generally be used only for the following condition/[DIAGNOSES REDACTED]. [MEDICAL CONDITION] in the absence of dementia 8. [DIAGNOSES REDACTED]. In addition to the above criteria, antipsychotic medications will generally only be considered if the following conditions are also met: a. The behavioral symptoms present a danger to the resident or others; AND: (1) The symptoms are identified as being due [MEDICAL CONDITIONS] (such as auditory, visual, or other hallucinations; delusions, paranoia or grandiosity); or (2) Behavioral interventions have been attempted and include in the plan of care, except in an emergency . Further review of the policy revealed in part, .The physician shall respond appropriately by changing or stopping problematic doses or medication, or clearly documenting (based on assessing the situation) why the benefits of the medication outweigh the risks or suspected or confirmed adverse consequences .

Based on observation, interview, and record review, the facility failed to ensure resident who is fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for one of 12 residents (Resident #33) , in that: LVN #3 did not check the placement and residual for Resident #33's G- tube prior to medication administration. This failure affected one resident and placed her at risk of [DEVICE] clogging/obstruction, tube replacement, or a decline in health. Findings include: Record review of Resident #33 's clinical record revealed a [AGE] years old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of care plan dated 04/17/19 revealed Resident #33 had a [DEVICE] for bolus feeding and was at risk for aspiration. Intervention included: reduce risk of nutrition complications through nursing and dietary. Provide fluids and meds per [DEVICE]. Record review of Resident #33 's physician orders [REDACTED]. Flush with 30 ml water before and after medication (med) pass. Observation and interview on 6/26/19 at 10:10AM revealed LVN #3 prepared the [MEDICATION NAME] 40 mg suspension 1 packet and added 10 water to the medication cup to dilute it prior to administration. LVN #3 did not check for [DEVICE] placement and did not check for residual. She administered the medication then flushed with 30ml of water prior and after med administration. Interview immediately after medication administration above, LVN #3 stated she only checked the residual and [DEVICE] placement before bolus feeding and not prior to medication administration. Interview on 6/2719 at 10:00 am, the DON stated LVN #3 had already informed her that she did not check placement and residual during [DEVICE] administration. The DON added she was told by LVN #3 that she got nervous during med pass observation. Interview on 6/27/19 at 10:30 am, LVN #3 stated she got nervous and forgot and was rendered staff in-service on G- tube medication administration protocol. Interview on 6/2719 at 10:40 am, DON added she reinforced in-service to the staff and personally to LVN #3 that [DEVICE] placement and residual checks should be done before medication administration and bolus feeding. Record review of the facility's policy entitled Confirming Placement of Feeding Tubes not dated revealed the purpose was to ensure proper placement of the feeding tube to prevent aspiration.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet residents' mental and psychosocial needs for 1 of 12 Residents (Resident #11) reviewed for comprehensive care plans, in that: Resident #11's care plan for a regular diet with mechanical soft ground meat was not followed. This failure affected one resident and placed her at risk of weight loss, choking and decline in health. Findings include: Resident #11 Record review of Resident #11's face sheet revealed a [AGE] year-old female initially admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Further review revealed she was admitted to hospice services on 4/29/19. Record review of Resident #11's Quarterly MDS dated [DATE] revealed a BIMS was not conducted. A SAMS indicated her memory was okay, she received hospice services, no indicated weight-loss and weighed 233 pounds. She received both mechanically altered and therapeutic diet and had difficulty with chewing . Record review of Resident #11's Release of Responsibility of Aspiration dated 1/6/16 revealed This is to certify that I, Resident #11, have been advised by the Speech Pathologist and/or other members of the health care team at (facility) of the risks of aspiration because of foods and/or fluids taken orally. I/we have been made aware of complications that could include aspiration pneumonia and/or death. I assume all responsibility for any complications related to this decision. I hereby release the facility employees, its administration, and the attending physician from any and all liability. It was signed by Resident #11. Record review of Resident #11's Physician's Telephone Order dated 12/12/18 revealed an order for [REDACTED]. Record review of Resident #11's dietary note dated 04/26/2019 at 2:11pm revealed Update on Resident #11's dietary needs. She is on MS (ground) w/ NAS and diet is as tolerated. Cannot have corn, lettuce, fresh cooked beans and pineapple. Resident can feed self and fluid intake is good. Record review of Resident #11's Care Plan dated 4/30/19 revealed Resident #11 has increased coughing noted with meal intake & higher potential for aspiration related to swallowing problem and refuses pureed and mechanical altered diets. Has agreed to try ground meat. The goal was the risk of aspiration/respiratory distress would be reduced. Interventions included assisting with meals as needed. Resident #11 has signed a Responsibility of Aspiration form and has requested to be on a regular diet with regular fluids as her choice, under person centered care. Serve meat ground unless resident refuses. Observation and record review on 06/26/19 at 09:05 AM revealed Resident #11 was lying in bed asleep. A quick tour around the room was done and within minutes her eyes were open. She asked if she could have her tray and was instructed to push her call button to request help from staff. She said, Oh honey they're not gonna answer that thing at this time of day. She was again instructed to call for help and reached for the light with a very slow visible shaky hand. 7 minutes later the call light was answered by CNA #27. She asked Resident #11 if she was ready to eat and explained she needed to position her upright. Her meal ticket revealed she was to receive a regular ground diet. One whole piece of bacon was observed on the tray. Observation on 06/26/19 at 12:28 PM revealed Resident #11 was sitting at a table in the dining room. She was had a plate with regular shrimp fettucine. The shrimp was whole. Observation on 6/27/19 at 12:25pm, Resident #11 was observed in the dining room eating lunch. She was noted eating beef soup and then started coughing and choking on it. Nurse was called to her attention . Interview on 06/27/19 at 02:15 PM Dietary Manager said if a resident had an order for [REDACTED]. She said some residents have orders for bacon either written by the nurse, therapy, or doctor. She said the beef stew served at lunch constituted mechanical soft. She said Resident #11 coughed a lot during meals. She said Resident #11 refused her diet often and requested regular meal trays but would first be given the ordered diet. Interview on 7/2/19 at 8:31am, Physician A said Resident #11 needed to be on a mechanical soft diet due to her swallowing issues and had refused pureed in the past. When asked the specific diet order he said he did not have her chart in front of him. When asked if he ordered whole bacon at breakfast for Resident #11, he said, I don't usually go into those details. Record review of the facility's Care Plan Policy dated (MONTH) (YEAR) did not address the above concern.

Based on observation, interview and record review, the facility failed to complete a significant change MDS assessment within 14 days after a significant change in the resident's physical condition for 1 of 12 residents (Resident #11) reviewed for comprehensive assessment after significant change. The facility failed to complete a significant change MDS for Resident #11 following her decline and admission to hospice services. This failure affected one resident and placed her at risk of her needs not communicated and met. Findings include: Resident #11 Record review of Resident #11's face sheet revealed a [AGE] year-old female initially admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Further review revealed she was admitted to hospice services on 4/29/19. Record review of Resident #11's Quarterly MDS dated [DATE] revealed a BIMS was not conducted. A SAMS indicated her memory was okay, she received hospice services, no indicated weight-loss and weighed 233 pounds. She received both mechanically altered and therapeutic diet and had difficulty with chewing . Record review of Resident #11's records revealed no significant change MDS completed following her admission to hospice services. Record review of Resident #11's care plan dated 4/30/19 revealed weight loss was expected due to hospice care and end of life condition. The goal was she would be kept comfortable and nutrition/hydration provided. Interventions included documenting meal intake, following hospice care orders and monitoring skin. Further review revealed no further weights to be obtained or required. Care plan did not address hospice. Observation on 06/26/19 at 09:05 AM revealed Resident #11 was lying in bed asleep. Record review of Resident #11's weights revealed the following: February 2019 - 240.6 lbs March 2019 - 238.2 lbs April 2019 - 233 lbs May 2019 - 228.4 lbs Interview on 06/27/19 03:49 PM, MDS Nurse said hospice should be care planned as its own focus area. When asked what constituted a significant change MDS, she said a change in ADLs, weight loss, hospice, and/or weight loss. She said a significant change MDS was done for Resident #11 because she had weight loss and was admitted to hospice. The MDS was requested but was not provided prior to exit. Interview on 06/27/19 03:54 PM, MDS Nurse said she thought she completed the MDS, but had not. She said she was not sure what happened, but Resident #11 needed one. She said the MDS dated [DATE] was the most current assessment. A policy on MDS was requested on 6/27/19 at 4:30 pm from the DON, but not received prior to exit.

Based on observation, interview and record review the facility failed to provide the necessary treatment and services to prevent the development, promote healing and prevent infection for one of two residents (Resident #24) reviewed for pressure ulcers. The facility failed to perform a skin pressure ulcer risk assessment on Resident #24 upon admission and failed to ensure pressure ulcer preventative measures were in place to prevent his development of pressure ulcers. Resident #24 who admitted to the facility without a pressure ulcer developed stage III pressure ulcer to his sacral area, which became a stage IV following a wound infection, necessitating surgical debridement. These failures affected one resident and placed six other residents with pressure sores at risk of infections, neglect, and a decline in health status. Findings include: Resident #24 Record review of Resident #24's face sheet revealed a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #24's nursing admission assessment notes dated 2/28/17 revealed the resident had no pressure ulcers or skin concerns. No pressure risk assessments was completed. Record review of Resident #24's admission assessment MDS dated [DATE] revealed a BIMS score 15, indicating intact cognition. Further review revealed he required extensive assistance with transfers, dressing and bathing, supervision with hygiene, but was independent with eating. Resident #24 was always incontinent of bowel and bladder. This MDS further revealed the resident had no unhealed pressure ulcers but was at risk of developing pressure ulcers. Record review of Resident #24's observation report dated 3/24/17 revealed the resident had a deep tissue injury (DTI) acquired in the facility. Original stage of wound - DTI. Current stage of wound - DTI. Wound measured: 1.6cm by 1.2cm. Record review of Resident #24's nurse's notes written by the wound care nurse dated 3/24/17 revealed 1.6cm by 1.2cm deep tissue injury noted to sacrum, called MD and resident's family member. Treated per facility protocol. Record review of Resident #24's nurse's notes written by the wound care nurse dated 3/28/17 revealed writer noticed DTI to sacrum opened, measure 2.7cm by 2cm. Treated per facility protocol. Notified MD and resident's family member. Record review of Resident #24's TAR dated March 2017 revealed an order for [REDACTED]. Record review of Resident #24's observation report dated 3/31/17 revealed the resident had a stage III pressure ulcer acquired in the facility. Original stage of wound - stage III. Current stage of wound - stage III. Wound measured: 3.0cm by 2.0cm by 0.1cm. Granulation tissue present pink, tissue character - moist, wound margins - open. Necrosis - 100 %, necrosis type - slough with heavy exudate. Exudate color was tan. Record review of Resident #24's TAR dated April 2017 revealed an order to cleanse stage III to sacrum with normal saline, pat dry, apply zinc oxide to peri-area, then cover with silver calcium alginate and cover with super absorbent dressing and secure and change twice daily. Order was dated 4/4/17. Record review of Resident #24's observation report dated 4/07/17 revealed the resident had an unstageable pressure ulcer acquired in the facility. Original stage of wound - unstageable. Current stage of wound - unstageable. Wound measured: 3.0cm by 2.0cm by 0.04cm. Granulation tissue present - none, tissue character - moist, wound margins - open. Wound bed color - yellow. Necrosis - 100%, necrosis type - slough. Debridement type - Enzymatic. Exudate - heavy and exudate color was tan. Odor - mild, and pain was intermittent. Record review of Resident #24's observation report dated 4/14/17 revealed the resident had a stage III pressure ulcer acquired in the facility. Original stage of wound - stage III. Current stage of wound - stage III. Wound measured: 3.0cm by 2.0cm by 0.04cm. Granulation tissue present - pink, tissue character - moist, wound margins - open. Wound bed color - yellow. Necrosis - 25%, necrosis type - slough. Debridement type - Enzymatic. Exudate - heavy and exudate color was bloody. Odor - none, and pain was intermittent. Record review of Resident #24's clinical record revealed he was transferred to hospital 4/21/17 and readmitted on [DATE] with the following wound care order cleanse stage III to sacrum with normal saline, pat dry, cover with silver calcium alginate rope and cover with super absorbent dressing and secure and change twice daily. Record review of Resident #24's observation report post debridement created by the ADON and dated 4/28/17 revealed the resident had a stage IV pressure ulcer acquired in the facility. Original stage of wound - stage IV. Current stage of wound - stage IV. Wound measured: 6.0cm, by 2.5cm by 3.2cm. Granulation tissue present - pink, tissue character - moist, wound margins - open. Wound bed color - yellow. Necrosis - 25%, necrosis type - slough. Debridement type - Autolytic. Exudate - heavy and exudate color was tan. Odor - none, and pain was intermittent. Record review of Resident #24's care plan dated 5/2/17 revealed he received antibiotics for a wound infection and was at risk of adverse reactions, had a stage IV pressure ulcer to his sacrum and had a wound vac. The goals and approaches were outlined. Record review of the facility's pressure ulcer report dated 5/26/17 revealed Resident #24 had a stage IV pressure ulcer with an onset date of 3/24/17, located to his sacrum which measured 5.0cm by 1.5cm by 2.5cm. Record review of the facility's pressure ulcer report dated 6/02/17 revealed Resident #24 had an improving stage IV pressure ulcer with an onset date of 3/24/17, located to his sacrum which measured 5.0cm by 1.5cm by 2.2cm. Observation on 6/7/17 at 10:27am, revealed Resident #24 had a stage IV sacral pressure ulcer. The wound bed was slightly pink in color and the area surrounding the wound was moist. The wound was deep and his sacral bones were exposed. Interview on 6/7/17 at 2:40pm, LVN #16 was asked when a comprehensive skin assessment was completed following Resident #24's admission to the facility on [DATE]. LVN #16 said she was not in the facility at the time and was unsure when and skin assessment was done. She said she was notified of the DTI on 3/34/17. She said she followed the facility's protocol but the wound deteriorated very quickly and became infected and Resident #24 ended up going to the hospital for surgical debridement. She said Resident #24 returned to the facility with a stage IV wound and antibiotic therapy. When asked about the wound assessment and documentation which indicated Resident #24's wound was a DTI, then a stage III, then unstageable, LVN #16 said she was not the nurse who completed the assessments. Interview on 6/8/17 at 9:34am, the ADON said Resident #24 did not have any wounds. Staff found a DTI on his sacral area which worsened. When asked when Resident #24 was assessed for pressure ulcer risk, the ADON was unsure and did not know. When asked what preventative measures were in place to prevent the development of pressure ulcers, the ADON said it was usually based on the result of the risk assessment. The ADON said Resident #24 was ordered an air mattress but could not recall when. The ADON said she was responsible for Resident #24's wound observation reports. She further said she realized there were inconsistencies with the staging of the wound and progress reports. The ADON agreed an unstageable wound should not have a depth. Record review of the facility's policy on pressure ulcer staging, which was not dated, revealed .stage II - extends into the subcutaneous fat and muscle. May be associated with exudate, necrosis, and foul smelling discharge. Wound infection - [DIAGNOSES REDACTED], exudate, and foul odor. Record review of the facility policy on pressure ulcer prevention, which was not dated, revealed .initial head to toe assessment on admissions, mattress overlays, wheelchair cushion, weekly skin report to DON and weekly skin assessment. Facility CMS form 672 dated 6/6/17 revealed 6 residents with pressure ulcers.