Every finding on record at Cordova Wellness and Rehabilitation Center

Based on policy review, medical record review, and interview, the facility failed to complete an accurate Minimum Data Set (MDS) assessment for 3 of 33 (Resident #3, #147 and #181) residents reviewed for MDS discrepancies. The findings include: 1. Review of the facility's policy titled, RAI (Resident Assessment Instrument) -MDS 3.0 Completion, dated 1/1/2023, revealed .Residents are assessed using a comprehensive assessment process, in order to identify care needs . 2. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE], with diagnoses including Encephalopathy, Osteoarthritis, Schizoaffective Disorder, and Hypothyroidism. Review of the quarterly MDS assessment dated [DATE], revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. The MDS section O0110 was inaccurately coded to reflect Resident #3 received dialysis. Review of the Physician Orders dated 3/11/2026, revealed Resident #3 did not have an order for dialysis. During an interview on 4/15/2026 at 8:47 AM, the MDS Coordinator was asked if the quarterly MDS for Resident #3 should have been coded for dialysis. The MDS Coordinator stated, .It is not ordered and definitely should not have been on the MDS . 3. Review of the medical record revealed Resident #147 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Chronic Kidney Disease, Convulsions, Dementia, and Insomnia. Review of the Order Review History Report dated 3/15/2026-4/15/2026 revealed Resident #147 had an order dated 3/5/2026 to check wander guard function every day beginning 3/7/2026. Review of the quarterly MDS assessment dated [DATE], revealed Resident #147 scored a 6 on the BIMS assessment, which indicated she was severely cognitively impaired, and a wander/elopement alarm was not used. During an interview on 4/15/2026 at 8:47 AM, the MDS Coordinator was asked should the quarterly MDS for Resident #147 have been coded for a wander guard. The MDS Coordinator stated, .no, but it should be . During an interview on 4/15/2026 at 8:54 AM, the Director of Nursing (DON) confirmed that Resident #147 should have been coded for a wander guard. 4. Review of the medical record revealed Resident #181 was admitted to the facility on [DATE], with diagnoses including Cerebral Infraction, Gastrostomy, Aphasia, and Dysphagia. Review of the quarterly MDS assessment dated [DATE], revealed Resident #181 score a 00 on the BIMS assessment, which indicated she was severely cognitively impaired. Resident #181 was not coded for receiving nutrition by a tube feeding (a flexible plastic tube that supplies nutrition and fluids into the stomach of someone who cannot chew or swallow safely). Observation in the resident's room on 4/14/2026 at 7:41 AM, revealed Resident #181 was receiving an enteral (delivery of nutrition directly into the stomach) feeding of Jevity 1.5 (a high calorie liquid supplement for tube feeding) and a water flush running at a rate of 85 ml (milliliters) per hour through a feeding tube. During an interview on 4/15/2026 at 10:31 AM, the MDS Coordinator was asked if Resident #181 was coded for enteral feeding on the 1/29/2026 MDS. The MDS Coordinator stated, Enteral feeding is not coded. The MDS Coordinator was asked should Resident #181 have been coded for enteral feeding on the 1/29/2026 MDS. The MDS Coordinator stated, Yes.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure that an account of all controlled medications was accurately reconciled for 1 of 10 medication carts (700 Hall Medication Cart #4). The findings include: 1. Review of the undated facility policy titled, Medication Administration, revealed .If medication is a controlled substance, sign the narcotic book .Correct any discrepancies and report to nurse manager . 2. Review of the medical record revealed Resident #43 was admitted to the facility on [DATE], with diagnoses including Traumatic Brain Injury, Paralytic Syndrome, Diabetes, and Anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #43 scored a 12 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was moderately cognitively impaired. Review of the Physician's Orders dated 5/15/2025, revealed .Gabapentin [used for pain]100 MG [milligram] .Give 1 capsule by mouth three times a day . Review of the Physician's Orders dated 3/18/2026, revealed .Eszopiclone [for sleep] Tablet 1 MG .Give 1 tablet by mouth at bedtime for Insomnia . Review of the document titled, Controlled Drug Receipt/Record/Disposition Form, revealed .GABAPENTIN CAP [capsule] 100MG .GIVE 1 CAPSULE BY MOUTH THREE TIMES DAILY .Date 4/14/26 .Left 27 . Review of the document titled, Controlled Drug Receipt/Record/Disposition Form, revealed .ESZOPICLONE TAB [tablet] 1MG .Date 4/15 [4/15/2026] .Time 6 A [AM] .Left 3 . During an observation and interview at medication cart #4, in the 700 Hallway on 4/15/2026 at 7:58 AM, Licensed Practical Nurse (LPN) E was asked how many capsules of Gabapentin 100 mg were left in the med cart for Resident #43. LPN E stated, 26. LPN E confirmed there were only 26 Gabapentin 100 mg capsules left on the narcotic card in the drawer of the medication cart. The Controlled Drug Receipt/Record/Disposition Form for Resident #43's Gabapentin read that there were 27 capsules left. LPN E confirmed the count on the form did not match the number of capsules in the drawer. Registered Nurse (RN) D was standing by the medication cart and overheard the incorrect count. RN D stated that she (RN D) was working the previous shift and must have charted the administration of the medication on the wrong log because she (RN D) had administered the medication this morning. LPN E confirmed there were 4 Eszopiclone 1 mg tablets in the narcotic card in the drawer of the medication cart. The Controlled Drug Receipt/Record/Disposition Form for Resident #43's Eszopiclone 1 MG showed 3 pills left. RN D and LPN E determined that RN D had charted the administration of the Gabapentin 100 mg on Resident #43's Controlled Drug Receipt/Record/Disposition Form for Eszopiclone 1 MG, resulting in there being 1 to many Eszopiclone and 1 to few Gabapentin for Resident #43 and the count of both medications to be incorrect. RN D and LPN E were asked if they had completed a narcotics reconciliation at hand-off (shift change), to which they both stated yes. RN D also stated that when they were counting at hand-off that she (RN D) must have given LPN E the wrong number. During an Interview on 4/15/2026 at 3:37 PM, the Director of Nursing (DON) was asked if the nurses were expected to complete a narcotic count at shift change. The DON stated, Yes. The DON was then asked if she expected a narcotic count to be correct after the count at shift change. The DON stated, Yes. The DON was also asked if she expected the two nurses counting to find a discrepancy in the narcotic count if it was incorrect during the count at shift change. The DON stated, .Yes .

Based on policy review, medical record review, observation, and interview, the facility failed to maintain and ensure the prevention and spread of infection when 4 of 8 (the Infection Preventionist Licensed Practical Nurse (LPN) A and B, and Registered Nurse (RN) C) staff failed to use Personal Protective Equipment (PPE) during wound care, failed to use proper hand hygiene, and failed to clean reusable equipment between residents. The findings include: 1. Review of the undated facility policy titled, Medication Administration, revealed .Medications are administered by licensed nurses, or other staff who are legally authorized to do so .in a manner to prevent contamination of infection .Wash hands prior to administering medication per facility protocol and product . Review of the undated facility policy titled, Hand Hygiene, revealed .All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility .Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR) .If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves .Between resident contacts .Before applying and after removing personal protective equipment (PPE), including gloves .Before performing resident care procedures . Review of the undated facility policy titled, Cleaning and Disinfecting of Resident-Care Equipment, revealed .Resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with CDC [Centers for Disease Control and Prevention] recommendations in order to break the chain of infection .Reusable multiple-resident items are items that may be used multiple times for multiple residents. Examples include stethoscopes, blood pressure cuffs .come in contact with intact skin, but not mucous membranes. These items require cleaning and low/intermittent level disinfection .use of EPA [Environmental Protection Agency]-registered disinfectants) .Staff shall follow established infection control principles for cleaning and disinfecting reusable, non-critical equipment .Each user is responsible for routine cleaning and disinfection of multi-resident items after each use, particularly before use for another resident .Multiple-resident use equipment shall be cleaned and disinfected after each use . Review of the undated facility policy titled, Enhanced Barrier Precautions, revealed .Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted Gown and gloves use during high contact resident care activities.An order for enhanced barrier precautions will be obtained for residents with any of the following.wounds, indwelling medical devices.urinary catheters [tubing in the bladder], feeding tubes [tube placed into your stomach or bowel to help you get nutrition], tracheostomy [opening that allows air into the lungs].High contact resident care activities include.dressing.transferring.changing linens.Device care or use .urinary catheters, feeding tubes, tracheostomy .wound care. 2. Review of medical record revealed Resident #11 was admitted on [DATE], with diagnoses including Respiratory Failure, Tracheostomy, Gastrostomy, and Myocardial Infarction, Contracture of Feet, Peripheral Vascular Disease, and Cerebral Infarction. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #11 scored a 00 on the Brief Interview for Mental Status (BIMS) assessment, which indicated he was severely cognitively impaired. Review of the Physician Order dated 8/27/2025, revealed Resident #11 had an order for Enhanced Barrier Precautions. Review of the Order Summary Report dated 4/8/2026, revealed Resident #11 had an order for a stage 3 pressure ulcer to the back of the neck, to clean with Normal saline, pat dry with gauze, skin prep (applied to skin before a bandage to protect from skin breakdown) to peri wound (area around a wound), calcium alginate (used to reduce the risk of infection and to absorb drainage) with silver alginate (helps remove unwanted tissue) to wound bed (open area of the wound), cover with an island border gauze (an adhesive pad used to cover wounds), to do every day and as needed and to monitor for sign and symptoms of infection. Review of the facility's Weekly Wound Progress report dated 4/13/2026 at 3:05 PM, revealed Resident #11 had a pressure ulcer at the posterior neck (back of the neck). During a random observation and interview in Resident #11's room on 4/13/2026 at 4:36 PM, the ICP and LPN A were touching the resident at the neck area with no gown or gloves on. The ICP and LPN A were asked about the care provided. The ICP stated .We are doing wound care . The ICP was asked if they should both have had on a gown and gloves. The ICP stated, Yes. During an interview on 4/15/2026 at 3:02 PM, the Director of Nursing (DON) was asked what should staff wear when providing care for a resident with a wound. The DON stated, They should wear a gown and gloves. 3. Review of the medical record revealed Resident #145 was admitted on [DATE] and then readmitted on [DATE], with diagnoses including Chronic Diastolic Heart Failure, Chronic Kidney Disease, and Diabetes Mellitus. Review of the admission MDS dated [DATE], revealed Resident #145 score a 15 on the BIMS assessment, which indicated she was cognitively intact. Observation during med administration in the 300 hallway on 4/14/2026 at 4:52 PM, revealed LPN B sanitized her hands and gathered supplies for Resident #145. She then knocked and entered Resident #145's room and placed blood glucose monitoring supplies on a barrier on the resident nightstand. LPN B washed her hands with soap and water and put on clean gloves. LPN B placed a glucometer (instrument for measuring blood sugar) strip in the glucometer, cleaned Resident #145's finger with an alcohol pad, pricked the finger with a lancet, and applied a blood sample to the strip. The glucometer gave a reading of 275. LPN B disposed of the lancet in the sharps box, removed her gloves, and washed her hands. LPN B exited the room, placed a barrier on the medication cart and placed the used glucometer on the barrier. LPN B walked back into Resident #145's room to get gloves. LPN B returned to cart, put on clean gloves without performing hand hygiene, obtained an insulin pen (medication used to help lower blood sugar) pen, and prepared then ordered amount of medication. LPN B removed her gloves and entered the resident's room with the medication and an alcohol pad. LPN B placed the insulin pen on a barrier, washed her hands, put on gloves, and administered the medication to Resident #145. LPN B failed to perform hand hygiene between handling a used glucometer and putting on gloves to prepare medication for Resident #145. 4. Review of the medical record revealed Resident #155 was admitted to the facility on [DATE], with diagnoses including Osteoporosis, Dementia, and Repeated Falls. Review of the quarterly MDS assessment dated [DATE], revealed Resident #155 scored a 4 on the BIMS assessment, which indicated she was severely cognitively impaired. 5. Review of the medical record revealed Resident #193 was admitted to the facility on [DATE], with diagnoses including Dementia, Depression, Anxiety Disorder, and Psychosis. Review of the admission MDS dated [DATE], revealed Resident #193's admission MDS was ongoing. Observation during med administration in the 600 hallway on 4/15/2026 at 9:30 AM, revealed RN C picked up the blood pressure cuff, knocked on Resident #155's door, and entered the resident's room. RN C placed the blood pressure cuff on Resident 155's left arm and obtained the blood pressure. RN C exited Resident #155's room and placed the blood pressure cuff on the med cart. RN C performed hand hygiene with hand sanitizer and prepared medications for Resident #155. RN C knocked on the door, entered the resident's room, administered Resident #155's medications, and exited the Resident's room, without performing hand hygiene. RN C signed off on Resident #155's medications. RN C gathered the previously used blood pressure cuff, entered Resident #193's room without performing hand hygiene and without cleaning the blood pressure cuff. RN C obtained a Blood Pressure reading on Resident 193 and exited the room, placing the blood pressure cuff on the side of the medication cart. RN C began preparing medications for Resident #193. RN C knocked on the door and entered the room without performing hand hygiene, administered medications to Resident #193 and exited the Resident's room. RN C failed to clean reusable equipment (blood pressure cuff) and failed to perform hand hygiene prior to administering medications and between care of residents. During an interview on 4/15/2026 at 9:43 AM, RN C was asked if she should have used some form of hand hygiene before moving on to the next resident. RN C stated, Yes. RN C was then asked, when should you practice hand hygiene. RN C stated, When entering and leaving resident rooms and after care with resident and when putting on and taking off gloves. RN C was also asked if she should have cleaned the blood pressure cuff between residents. RN C stated, Yes. During an interview on 4/15/2026 at 3:37 PM, the DON was asked if she expected staff to practice hand hygiene between glove changes and when moving between one resident's care to another. The DON stated, .Yes .either with soap and water if hands are soiled or hand sanitizer . The DON was then asked if the facility staff should clean equipment such as blood pressure cuffs, between residents. The DON stated, Yes.

Based on facility policy review, medical record review, observation, and interview, the facility failed to maintain emergency supplies at the bedside for 1 of 1 (Resident #11) sampled residents reviewed for tracheostomy (a surgically created opening in the neck to help with breathing) care. The findings include: 1. Review of the undated facility policy titled, Tracheostomy Care, Disposable Cannula [a small tube that is inserted into an open area of the body] revealed .The facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and resident goals and preferences.Maintain a suction machine, a supply of suction catheters, correctly sized cannulas, and an ambu bag [a hand held device used to deliver air or oxygen to the lungs through a self-inflating bag in order support or replace breathing during an emergency] easily accessible for immediate emergency care . 2. Review of medical record revealed Resident #11 was admitted to the facility on [DATE], with diagnoses including Respiratory Failure, Tracheostomy, and Gastrostomy. Review of the quarterly Minimum Data Set assessment dated [DATE], revealed Resident #11 scored a 00 on the Brief Interview for Mental Status assessment, which indicated he was severely cognitively impaired. Resident was dependent on staff for all activities of daily living (ADLs). Resident #11 received tracheostomy care. Review of the Physician's Orders dated 8/27/2025, revealed the following:a. Respiratory Therapist: change .trach every month . b. Perform trach [tracheostomy] and oral care every shift and as needed every shift .c. Change trach disposable inner cannula daily and as needed every day shift AND as neededd. May suction trach and mouth .every shift AND as needed Observation in Resident #11's room on 4/13/2026 at 4:02 PM, revealed there was no ambu bag in the resident's room. Licensed Practical Nurse (LPN) F was asked does the resident need an ambu bag. LPN F stated, Yes, obviously he does not have one. It should be .in the room and kept close to the bed. During an interview on 4/15/2026 at 2:58 PM, the Director of Nursing (DON) was asked where should the resident's ambu bag be kept. The DON stated, The ambu bag should be within close proximity. If an emergency, it should be available in the room for easy access.

Based on personnel file review, facility document review and interview, Administration failed to ensure that nursing services were provided by qualified personnel when the facility hired an imposter nurse (Imposter Nurse A) to function as a Licensed Practical Nurse (LPN) using another LPN's (LPN C) Tennessee license on 2 separate occasions. Imposter Nurse A worked at the facility from 02/13/2023 to 06/06/2023 and was hired a second (2nd) time at the facility from 05/03/2024 to 06/24/2024. The findings include: 1st Hire: Review of Imposter Nurse A's personnel file revealed an employee application dated 02/08/2023 with a Social Security Number (SSN) that did not match the W-4 form dated 02/13/2023. Review of the I-9 form (Employment Eligibility Verification) used to verify the identity and legal authorization of individuals hired for employment in the United States dated 02/13/2023, revealed Imposter Nurse A's legal first and last name, along with a birth certificate and a valid Driver's license from another state. The last name used on the I-9 form was the same as the Driver's license. Review of a license verification form revealed the nursing license was in the name of LPN C with a license expiration date of 06/30/2023. The license had the same first name as Imposter Nurse A but a different last name. There was no evidence provided by the facility that a Tennessee Abuse Registry check was run for Imposter Nurse A prior to the hire date of 02/13/2023. Review of the time punch data for Imposter Nurse A for February 2023, revealed she worked in this facility on February 13, 14, 15, 16, 18, 19, 20, 23, 24, 25, 26, and 27. Review of the time punch data for Imposter Nurse A for March 2023, revealed she worked in this facility on March 1, 2, 3, 4, 5, 6, 9, 10, 11, 12, 13, 14, 15, 18, 19, 20, 23, 25, 26, 29, 30, and 31. Review of the time punch data for Imposter Nurse A for April 2023, revealed she worked in this facility on April 1, 2, 4, 5, 6, 7, 8, 9, 11, 12, 13, 14, 15, 16, 17, 24, 25, 26, 27, 28, 29, and 30. Review of the time punch data for Imposter Nurse A for May 2023, revealed she worked in this facility on May 3, 5, 6, 7, and 8. Review of the Employee Termination Form dated 06/06/2023, revealed, .REASON FOR TERMINATION .Voluntarily Quit (Resigned) .Comments (reason for termination): chronic absenteeism, tardies . 2nd Hire: Review of Imposter Nurse A's personnel file revealed the SSN used on the Employment Application, the W-4 form and the Background Check were all the same SSN, but this number was different than the other two (2) numbers used on the first hire documents. Imposter Nurse A listed three (3) different SSNs for the two (2) times she was hired at this facility. Review of Imposter Nurse A's personnel file revealed no I-9 form or supporting documents for the rehire on 05/03/2024. Review of a license verification form revealed the nursing license was in the name of LPN C with a license expiration date of 06/30/2025. The license had the same first name as Imposter Nurse A but a different last name. Review of the background screening report dated 02/13/2024, revealed the SSN used was not the SSN submitted on the I-9 form. The number used was the number listed on the Employee Application. Review of the Employee Termination Form dated 06/24/2024, revealed, .REASON FOR TERMINATION .Voluntarily Quit (Resigned) .Comments (reason for termination): Failure to provide schedule did not return after orientation . Review of the time punch data for Imposter Nurse A dated May 2024, revealed she worked in this facility on May 3, 25 and 26. During an interview on 10/01/2025 at 3:00 PM, the Administrator stated the facility used the same resume for both hires and the facility does not have a policy for hiring, they just use a checklist. During an interview on 10/01/2025 at 5:00 PM, the Administrator stated she was unable to find the I-9 form and the verifying documents from the 2024 application documentation. Imposter Nurse A was hired two (2) separate times as a Licensed Practical Nurse to render nursing services. The reason for the termination was Imposter Nurse A voluntarily quit/resigned for chronic absenteeism, tardiness the first (1st) time and the reason for termination was Imposter Nurse A voluntarily quit/resigned for failure to provide a schedule and did not return after orientation the second (2nd) time. The facility employed an unqualified person. There was no information given to the surveyor as to any cross reference of inconsistencies with the different names and SSNs listed on the employment applications, I-9 form and the nursing license verification form submitted by the candidate.

Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by opened, unlabeled, undated food in the walk-in cooler and in the dry storage area, a mop lying in a bucket of dirty water near the stove during meal preparation, a dirty kitchen floor, a dirty deep fryer, a dirty convection toaster, a dirty food slicer, a scoop lying in the sugar bin, a Styrofoam cup lying in the raisin bran bin, carbon build-up on 2 sauté pans, opened, undated, unlabeled food items in the cooler, a dirty plate warmer, dirty 3-tiered cart, and a dirty tray line conveyor in the serving line area. The facility had a census of 133 with 105 of those residents receiving a tray from the kitchen. The findings include: Review of the facility's undated policy titled, .Sanitation Inspection, revealed .It is the policy of this facility .to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations .All food services areas shall be kept clean, sanitary, free from litter, rubbish .The dietary manager shall develop and provide food service personnel with standard operating procedures for sanitation and daily inspections . Review of the facility's undated policy titled, .Dietary Department Guidelines, revealed .The facility must store, prepare, and distribute food under sanitary conditions .The dietary department will be maintained in a clean and sanitary manner to prevent foodborne illness .All items stored in the refrigerator will be covered and labeled with the contents and the date .All food preparation equipment, dishes, and utensils must be maintained in a clean, sanitary, and safe manner .Any piece of equipment, dish, or utensil will be discarded when it is cracked, broken, discolored, or abraded .cleaning equipment such as mops, buckets .will be stored in a separate janitorial area, away from the kitchen/food preparation areas . Review of the facility's undated checklist titled, .SANITATION INSPECTION - KITCHEN OBSERVATION, revealed .DRY STORAGE .All opened food items are labeled, dated, and in air tight containers .WALK IN COOLER .All items are covered, labeled, dated, and in air tight containers .MAIN PRODUCTION AREA .Floor is clean .near a meal time .Work tables are clean .Following equipment is clean .Food slicer .Fryer .Tray carts are clean .Pots and pans do not have excessive carbon build up . Observation in the Kitchen on 6/20/2022 at 5:28 AM, revealed the floor had black shoe marks, a shiny, slippery substance covering the floor, debris, and dirt build-up. A mop was sitting in a bucket of dark blackish-gray water beside the stove during breakfast preparation. Observation in the walk-in cooler in the Kitchen on 6/20/2022 at 5:32 AM, revealed the following: a. an undated, unlabeled pan of gravy b. an undated, unlabeled bag of pureed eggs c. an undated, unlabeled plastic bag of whole, cooked sweet potatoes d. an undated, unlabeled plastic bag of scrambled eggs e. an undated, unlabeled pan of ground sausage with 4 sausage patties lying on top of the ground sausage f. an undated, unlabeled plastic bag of dough Observation in the dry storage area of the Kitchen on 6/20/2022 at 5:42 AM, revealed: a. an opened, undated bag of hamburger buns b. an opened, undated bag of bread c. a scoop lying in the sugar bin d. an opened, undated gallon-size maple syrup e. an opened, undated, unsealed bag of sugar f. an opened, undated, unsealed package of cookies g. an opened, undated bag of vanilla wafers Observation in the food preparation area in the Kitchen on 6/20/2022 at 5:52 AM, revealed: a. carbon build-up on 2 sauté pans b. a Styrofoam cup lying in a plastic container of raisin bran cereal c. 3 opened, undated packages of gravy mix d. 1 opened, undated, unsealed bag of confectioner sugar e. a convection toaster with a thick build-up of crumbs and dust f. dried particles of a brown and black substance on the food slicer g. balls of thick, brown grease build-up and old shiny brown build-up on both sides of the deep fryer, extending down to the floor on both sides Observation in the cooler in the Kitchen on 6/20/2022 at 6:00 AM, revealed: a. 3 opened, undated, unlabeled plastic bags of lettuce and tomatoes b. 3 opened, undated, unlabeled bowls of salad During an interview on 6/20/2022 at 6:05 AM, the Dietary Manager (DM) looked in the cooler, saw the bags of lettuce and tomatoes and the salads and stated, .those were left from last night . Observation in the Kitchen on 6/20/2022 at 9:42 AM, revealed a piece of foil lying in an uncovered pan of tomato sauce, an opened, undated, unlabeled box of quick oats was on a shelf near the stove, thick, brown balls of grease build-up and old shiny brown build-up was on both sides of the deep fryer, extending down to the floor on both sides, and the floor had black shoe marks, a shiny, slippery substance covering the floor, debris, and dirt build-up. Observation in the walk-in cooler in the Kitchen on 6/20/2022 at 9:45 AM, revealed 13 unlabeled, undated packages of sandwich meat in a pan on a shelf. Observation in the dry storage area in the Kitchen on 6/20/2022 at 9:46 AM, revealed: a. an opened, undated bag of hamburger buns b. a scoop lying in the sugar bin c. an opened, undated gallon-size maple syrup d. an opened, undated unsealed package of cookies e. an opened, undated bag of vanilla wafers Observation in the Kitchen, with the Dietary Manager, on 6/22/2022 at 9:40 AM, revealed: a. an opened, undated bag of hamburger buns b. a scoop lying in the sugar bin c. an opened, undated gallon-size maple syrup d. an opened, undated unsealed package of cookies e. an opened, undated bag of vanilla wafers f. 13 unlabeled, undated packages of sandwich meat in a pan on a shelf of the walk-in cooler During an interview on 6/22/2022 at 9:42 AM, the DM confirmed all opened items should be labeled and dated. The DM confirmed the sandwich meat in the walk-in cooler should be labeled and dated. The DM confirmed the toaster needed cleaning due to the build-up of crumbs and confirmed an opened box of oatmeal should be sealed, labeled, and dated. The DM confirmed the scoop should not be lying in the sugar bin, and the Styrofoam cup should not be lying in the container of raisin bran. The DM confirmed there was build-up on the meat slicer, and it needed cleaning. The DM confirmed a mop should not be lying in a bucket of dirty water in the Kitchen during meal preparation. Observation in the serving line area of the Kitchen on 6/22/2022 at 11:45 AM, revealed the plate warmer had a dried yellow substance smeared across the front, a 3-tiered serving cart was dirty with old food crumbs, and white and gray particles, the tray line conveyor was dirty with old food crumbs and gray and white flakes, the deep fryer had a build-up of a shiny brown substance on both sides along with thick balls of a brown shiny substance, extending down to the floor, on both sides, and the floor had black shoe marks, a shiny, slippery substance covering the floor, debris, and dirt build-up. During an interview on 6/22/2022 at 3:10 PM, the DM confirmed the plate warmer, the 3-tiered serving cart, the tray line conveyor, and the deep fryer were dirty and needed to be cleaned. She confirmed the floor was not clean and stated, .it needs some work . The DM confirmed 2 sauté pans had carbon build-up and should not be in the cooking equipment area.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure Activities of Daily Living (ADL) assistance were provided related to nail care, skin care, and facial hair for 4 of 6 sampled residents (Resident #27, #41, #58, and #115) reviewed for ADLs. The findings include: Review of the facility's policy titled, .Fingernails/Toenails, Care of, dated 10/2017, revealed .The proper care of fingernails .The purpose of this procedure is to clean the nail bed, to keep the nails trimmed, and to prevent infections. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin . Review of the facility's undated policy titled, .Activity of Daily Living ., revealed .A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good .personal .hygiene . Review of the medical record, revealed Resident #27 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #27 had moderately impaired cognition, had no behaviors, and required extensive assistance from staff for personal hygiene. Review of the Care Plan revised on 6/21/2022, revealed .Nail and oral care routinely and PRN [as needed] . Observation in the Dining Room on 6/20/2022 at 6:35 AM, 9:19 AM, and 12:34 PM, on 6/21/2022 at 3:45 PM, and on 6/22/2022 at 8:25 PM, revealed Resident #27 was sitting in a chair and her fingernails were long, dirty, and had a brown substance built up underneath them. During an interview on 6/22/2022 at 8:35 AM, Licensed Practical Nurse (LPN) #2 confirmed Resident #27's nails that needed to be cleaned and trimmed. Review of the medical record, revealed Resident #41 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan dated 2/4/2021, revealed .Check nail length and trim and clean on bath day and as necessary . Review of the quarterly MDS dated [DATE], revealed Resident #41 had moderately impaired cognition, no behaviors, and required extensive assistance from 2 staff for personal hygiene. Observation in the resident's room on 6/20/2022 at 7:38 AM, 9:39 AM, and 2:11 PM, on 6/21/2022 at 8:28 AM and 3:25 PM, and on 6/22/2022 at 3:08 PM, revealed Resident #41 was in bed, with long fingernails with a brown substance built up underneath them. During an interview on 6/22/2022 at 3:08 PM, LPN #3 confirmed Resident #41's nails needed to be trimmed and cleaned. Review of the medical record, revealed Resident #58 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #58 had severe cognitive impairment, had no behaviors, and was totally dependent on staff for personal hygiene. Review of the Care Plan revised on 5/28/2022, revealed, .Resident needs assist of 1-2 for personal hygiene . Observation in the resident's room on 6/20/2022 at 7:34 AM, 9:38 AM, and 2:10 PM, on 6/21/2022 at 8:25 AM and 3:53 PM, and on 6/22/2022 at 10:55 AM, revealed Resident #58 had long, curled, black chin whiskers. During an interview on 6/22/2022 at 10:55 AM, LPN #3 confirmed Resident #58 had long, curled, black chin whiskers and she should have been shaved. Review of the medical record, revealed Resident #115 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #115 was cognitively intact, had no behaviors, and required extensive assistance from staff for personal hygiene. Review of the Care Plan revised on 6/21/2022, revealed Resident #115 required the assistance of one staff member for personal hygiene. Observation in the resident's room on 6/21/2022 at 3:15 PM, and on 6/22/2022 at 8:40 AM, 10:30 AM, and 3:08 PM, revealed Resident #115 was in the bed with long fingernails with a brown substance built up underneath them and dry flaky skin on his ankles, shins, and the tops of his feet. During an interview on 6/21/2022 at 8:31 AM, Resident #115 confirmed staff did not honor his request to trim and clean his fingernails. During an interview on 6/22/2022 at 3:08 PM, LPN #3 confirmed Resident #115 should have received care for the flaky skin on his ankles, shins, and feet and confirmed his fingernails needed to be trimmed and cleaned.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure enteral feedings with automatic flushes were infusing at the correct rate and failed to ensure enteral feedings and automatic flush bags were correctly labeled for 3 of 3 sampled residents (Resident #17, #65, and #94) reviewed for enteral feedings. The findings include: Review of the facility's undated policy titled, Care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record, revealed Resident #17 was admitted to facility on 2/24/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the significant change Minimum Data Set (MDS) dated [DATE], revealed Resident #17 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's Order Review History Report dated 5/23/2022 - 6/23/2022, revealed Resident #17 should receive automatic water flushes at 50 milliliters (ml) an hour for 20 hours and Glucerna 1.5 at 70 ml an hour for 20 hours. Observation in the resident's room on 6/20/2022 at 7:09 AM and 9:29 AM, on 6/21/2022 at 8:04 AM and 9:53 AM, and on 6/22/2022 at 8:57 AM, revealed Resident #17 had an enteral feeding pump (a pump used to deliver an enteral feeding) with Glucerna 1.5 infusing at 50 ml per hour and an automatic water flush infusing at 60 ml per hour. During an interview on 6/22/2022 at 3:33 PM, Licensed Practical Nurse (LPN) #1 confirmed the enteral feeding was set at an incorrect rate. LPN #1 confirmed the enteral feeding of Glucerna 1.5 should be at 70 ml per hour with the automatic water flush at 50 ml per hour. During an interview on 6/22/2022 at 4:20 PM, the Director of Nursing (DON) confirmed that an enteral feeding pump and the automatic water flush should be set at the rate ordered by the physician. Review of the medical record, revealed Resident #65 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #65 had a BIMS of 99, indicating severe cognitive impairment, and received tube feedings. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation in the resident's room on 6/20/2022 at 12:07 PM, revealed Resident #65 had an enteral feeding pump with an unlabeled automatic flush bag. Observation in the resident's room on 6/22/2022 at 5:47 PM, revealed Resident #65 had an enteral feeding pump with an enteral feeding bag labeled with the resident's last name and dated 6/22/2022. An automatic water flush bag was labeled with the resident's first name, room #, a rate of 65, dated 6/22/2022, and labeled [MEDICATION(S)] 1.5. During an interview on 6/22/2022 at 4:26 PM, the DON was asked what should be on the label of a tube feeding. The DON stated, The formula, patient's name, rate, and date it was started. The DON was asked what should be on the label on the flush. The DON stated, Should have patient's name, date, and the rate. Review of the medical record, revealed Resident #94 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan dated 4/7/2020, revealed .NPO [Nothing by Mouth] status requiring 100 percent (%) needs met via [by way of] peg [Percutaneous Endoscopic Gastrostomy] tube . Review of the quarterly MDS dated [DATE], revealed Resident #94 had a BIMS score of 9, indicating moderately impaired cognition and received 51 % or more of total calories, and 501 ml or more of fluids by a tube feeding daily. Review of the Order Summary Report dated 6/22/2022, revealed .every shift Enteral: H20 Auto Flush feeding tube with 40cc/hr x [times] 18 hrs .CHANGE AND DATE TUBE FEEDING, SYRINGE AND TUBING WHEN FEEDING IS STARTED one time a day . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation in the resident's room on 6/20/2022 at 9:23 AM and 1:26 PM, revealed an enteral feeding pump with an automatic flush bag dated 6/18/2022 at 12:00 AM. During an interview on 6/22/2022 at 4:25 PM, the DON was asked how often enteral feeding flush bags and tubing should be changed. The DON stated, .every 24 hours . The DON was asked if it was acceptable for an automatic water flush bag, dated 6/18/2022 at 12:00 AM, to still be hanging and infusing water to a feeding tube on 6/20/2022. The DON stated, No, it should be changed .

Based on policy review, medical record review, observation, and interview, the facility failed to provide the necessary respiratory care and services when a [CONDITION(S)] tubing condensation collection bag was lying on the floor, humidification bottles were on the floor, a dusty fan was blowing on a resident's [CONDITION(S)], and there were no physician orders for oxygen for 4 of 4 sampled residents (Resident #23, #41, #44 and #45) reviewed for oxygen therapy. The findings include: Review of the facility's policy titled, .[CONDITION(S)] [[CONDITION(S)]] Care, dated 10/2017, revealed .Our policy is to provide care for the resident with a [CONDITION(S)] present to prevent nosocomial infections . Review of the facility's policy titled, .Oxygen, dated 12/2017, revealed .Oxygen therapy is administered to the resident only upon the written order of a licensed physician . Review of the medical record, revealed Resident #23 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician's Orders dated 6/22/2022, revealed .May suction [CONDITION(S)] [[CONDITION(S)]] . There was not an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Observation in the resident's room on 6/20/2022 at 7:32 AM, 9:37 AM, and 1:58 PM, revealed Resident #23's [CONDITION(S)] tubing condensation collection bag was lying in the floor. Review of the medical record, revealed Resident #41 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Care Plan revised 6/21/2022, revealed, .OXYGEN as ordered . Observation in the resident's room on 6/20/2022 at 7:38 AM, 9:39 AM, and 2:11 PM, revealed Resident #41's oxygen humidification bottle was lying on the floor. Review of the medical record, revealed Resident #44 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Physician's Order dated 6/22/2022, revealed, .O2 [Oxygen] .3 .LPM [Liters Per Minute] via ballard [CONDITION(S)] . Observation in the resident's room on 6/20/2022 at 7:29 AM, 9:41 AM, 1:58 PM, on 6/21/2022 at 8:37 AM and 3:37 PM, and on 6/22/2022 at 9:24 AM, revealed a fan, covered in dust, was blowing directly toward Resident #44's [CONDITION(S)]. During an interview on 6/22/2022 at 9:30 AM, Respiratory Therapist (RT) #1 confirmed a dusty fan should not be blowing on the resident's [CONDITION(S)] and confirmed the fan should be clean and free of dust. Review of the medical record, revealed Resident #45 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician's Orders dated 6/12/2022, revealed there was no order for oxygen administration. Observation in the resident's room on 6/20/2022 at 6:44 AM, 9:32 AM, and on 6/21/2022 at 8:39 AM, 1:26 PM, and 3:18 PM, revealed Resident #45 was receiving oxygen through a binasal cannula in her nose and the oxygen humidification bottle was lying in the floor. During an interview on 6/22/2022 at 4:04 PM, the Director of Nursing (DON) confirmed there should be a physician's order for oxygen for a resident receiving oxygen therapy. During an interview on 6/22/2022 at 4:29 PM, the DON was asked if humidifier bottles should be lying on the floor of a resident's room. The DON stated, No.

Based on policy review, medical record review, and interview, the facility failed to provide information regarding a resident's right to formulate an Advanced Directive for 1 of 32 sampled residents (Resident #113) reviewed for Advanced Directives. The findings include: Review of the facility's policy titled, Admission Process: Advance Directives, dated 10/2017, revealed .protect the resident's rights and resident choice to advance life support initiatives upon admission/readmission .advance directives .will be signed prior to admission . Review of the medical record, revealed Resident #113 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #113 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated severe cognitive impairment. Review of Resident #113's medical record, revealed there was no documentation the resident or their legal representative was informed of or provided written information regarding their right to formulate an Advanced Directive upon admission. During an interview on 6/22/2022 at 5:29 PM, the Director of Nursing confirmed all residents should be provided the information regarding Advanced Directives on admission.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure the environment was free from accident hazards for 1 of 4 sampled residents (Resident #19) reviewed for accidents. The findings include: Review of the facility's undated policy titled, Accidents and Supervision, revealed .The resident environment remains as free of accident hazards as is possible .The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents . Review of the medical record, revealed Resident #19 was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)], Diabetes, Heart Disease, Dementia, and Obesity. Review of the quarterly Minimum Data Set, dated dated dated [DATE], revealed Resident #19 had moderately impaired cognition. Review of the Care Plan revised on 4/20/2022, revealed, .The resident's safety will be maintained . Observation in the Dining Room on 6/20/2022 at 9:18 AM and 12:32 PM, and on 6/21/2022 at 8:20 AM and 3:47 PM, revealed Resident #19 was sitting at a table that had torn jagged veneer on all sides. During an interview with 6/22/2022 at 8:38 AM, Licensed Practical Nurse #2 confirmed the table in the Dining Room had rough and jagged veneer and could be a safety hazard for residents.

Based on policy review, medical record review, and interview, the facility failed to follow the pharmacy recommendations in a timely manner 1 of 5 sampled residents (Resident #12) reviewed for unnecessary medications. The findings include: Review of the facility's policy titled POLICIES AND PROCEDURE Pharmacy Services, dated 6/1/2021, revealed The consultant pharmacist documents activities performed and services provided on behalf of the residents and the facility. A written or electronic report of findings and recommendations resulting from the activities as described above is given to the, attending physician, director of nursing, medical director and others as may be appropriate (e.g. [example] administrator, regional manager .) monthly. The facility has a process to ensure that the findings are acted upon . Review of medical record, revealed Resident #12 was admitted on [DATE], and readmitted on [DATE], with diagnoses of Femur Fracture, Diabetes, Acute Failure Kidney, Dementia and [CONDITION(S)]. Review of the significant change Minimum Data Set (MDS) dated [DATE], indicated moderate cognitive impairment and Resident #12 was receiving insulin. Review of the Consultant Pharmacist Communication to the Physician sheet dated 4/2022, revealed .[MEDICATION(S)] is currently being given 3 times daily. Due to the fast-acting nature of this insulin and the risk of [CONDITION(S)], please consider adding a hold parameter to [MEDICATION(S)] order so that dose will not be administered if blood sugar is too low or resident is not eating . The facility was unable to provide documentation that the 4/2022 Pharmacy recommendation was reviewed by a Physician or Nurse Practitioner until 6/2/2022. During an interview on 6/22/2022 at 4:05 PM, the Director of Nursing (DON) was asked what the process was for Pharmacy recommendations. The DON confirmed that Pharmacy recommendations should be addressed before the next month. During an interview on 6/23/2022 at 10:13 AM, Nurse Practitioner #1 was asked if a Pharmacy recommendation from 4/2022 should be addressed prior to 6/2022. Nurse Practitioner #1 confirmed the recommendations should be addressed timely.

Based on policy review, medical record review, and interview, the facility failed to administer the prescribed medication for 3 of 3 sampled residents (Resident #1, #2 and #3) reviewed for physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The findings include: Review of the facility's undated policy titled, .Medication Administration, revealed .This facility will provide medications under the direction of the prescribing medical practitioner .DOCUMENTATION .Record the name, dose, route, and time of medication on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] 0.25 milligram (mg) give 1 tablet by peg (Percutaneous Endoscopic Gastrostomy)-tube three times a day. 2. [MEDICATION(S)] 5 mg give 1 tablet via peg-tube one time a day 3. [MEDICATION(S)] Sodium 100 mg give 1 tablet a day by peg-tube one time a day. 4. [MEDICATION(S)] Capsule 20 mg give 1 tablet by peg-tube one time a day. 5. [MEDICATION(S)] 4 mg give 1 tablet by peg-tube three times a day. 6. Multiple Vitamin give 1 tablet by peg-tube one time a day. 7. [MEDICATION(S)] Sulfate give 300 mg by peg-tube one time a day. 8. [MEDICATION(S)] 15 mg give 1 tablet by peg-tube one time a day. 9. [MEDICATION(S)] 5 mg give 1 tablet by peg-tube one time a day. 10. [MEDICATION(S)] 12.5 mg give by peg-tube two times a day. 11. [MEDICATION(S)] Solution 20 mg give by peg-tube one time a day. 12. [MEDICATION(S)] Tablet 1000-unit 1 tablet by peg-tube one time a day. 13. Calcium 500 mg give 1 tablet give by peg-tube one time a day. 14. Aspirin 81 mg chewable tablet give by peg-tube one time a day. Review of the July 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record, revealed Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] tablet 100 mg give 1 tablet by peg-tube three times a day. 2. [MEDICATION(S)] tablet 10 mg give 1 tablet by peg-tube one time a day. 3. [MEDICATION(S)] tablet give 1 tablet by peg-tube one time a day. 4. [MEDICATION(S)] Solution 250 mg/5 ml (milliliter) give 10 ml by peg-tube three times a day. 5. Aspirin Tablet Chewable 81 mg give 1 tablet by peg-tube one time a day. 6. [MEDICATION(S)] [MEDICATION(S)] tablet 25 mg give 12.5 mg by peg-tube two times a day. 7. [MEDICATION(S)] tablet 1 mg by peg-tube two times a day. 8. [MEDICATION(S)] tablet 20 mg give 1 tablet by peg-tube one time a day. Review of the July 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record, revealed Resident #3 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)]-[MEDICATION(S)] Solution 0.5-2.5 (3) mg 3 ml inhale orally every 6 hours. 2. [MEDICATION(S)] Solution 2 ml by peg-tube every 6 hours. 3. [MEDICATION(S)] tablet 20 mg give 1 tablet by peg-tube two times a day. 4. [MEDICATION(S)] tablet give 20 mg by peg-tube two times a day. 5. Tamsulosin 0.4 mg give 1 capsule by peg-tube one time a day. 6. Aspirin tablet chewable 81 mg give 1 tablet by peg-tube one time a day. 7. [MEDICATION(S)] Tablet 12.5 mg give 1 tablet by peg-tube two times a day. 8. [MEDICATION(S)] tablet 5 mg give 1 tablet by peg-tube two times a day. 9. [MEDICATION(S)] 100 unit/ml inject 10 unit subcutaneously two times a day. 10. [MEDICATION(S)] Solution give 10 mEq by peg-tube one time a day. 11. [MEDICATION(S)] 12.5 mg tablet give 1 tablet by peg-tube one time a day. 12. [MEDICATION(S)] tablet 25 mg give 1 tablet by peg-tube one time a day. Review of the July 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During a telephone interview on 8/11/2021 at 11:55 AM, the Director of Nursing (DON) confirmed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .they should sign the medications when they are given . The DON was asked if this had been an area of concern. The DON stated, .Just nurses not doing what they are supposed to do .signing them out . During a telephone interview on 8/11/2021 at 3:34 PM, Registered Nurse #1 confirmed she did not sign out the 6:00 AM medications on July 29th, 30th and 31st for Resident #1, #2 and #3 and stated, .I got distracted .just didn't mark it off the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on policy review, record review, and interview, the facility failed to ensure Resident #1's Physician, Responsible Party and facility Administration were promptly notified of bruising for 1 of 3 sampled residents (Resident #1) reviewed for notification. The findings include: Review of the facility's undated policy titled, .COMMUNICATION, revealed .To insure the proper and timely communication occurs between all disciplines to provide continuity of care to residents of this facility .Our facility shall promptly notify .his or her attending physician, and representative .of changes in the resident's medical/mental condition and/or status .Nursing services will notify the resident's attending physician when .The resident is involved in any accident or incident .the nurse will notify the resident's next of kin or responsible party by phone or written communication or face to face when .The resident is involved in any accident or incident .Except in medical emergencies, notifications will be made within twenty-four (24 hours of a change occurring in the resident's condition or status . Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Incident/Accident Action Plan for Resident #1 dated 7/16/2021, revealed .Incident Description .Staff informed me that resident was noted with discoloration to right inner arm and right upper chest .resident unable to tell me what happened .Resident was assessed and lift pad was observed underneath her armpit creased next to her skin. Assessment revealed discoloration with reddish purple tinge to .Attempted to call RP [Responsible Party] with no answer. Call placed to FNP [Family Nurse Practitioner] with no answer .Agencies/People Notified .No Notifications found . Review of the Family Nurse Practitioner (FNP) Progress Note dated 7/21/2021, revealed .Chief Complaint .bruising to right lateral anterior chest wall and right upper arm .81 yo [ year old] .with dementia .Unit manager asked if I would evaluate patient secondary to bruise to the right chest and right upper arm discovered on Friday has increased in size. Unit manager denies trauma however concerned that the weight strap could possibly caused friction to the armpit area resulting in bruising .RP notified of bruise and requesting transfer to hospital for further evaluation .Right lateral anterior chest wall with 10.3 cm [centimeters] x [time] 5cm bruising with yellowish discoloration noted skin intact, right upper arm 17cm x 6 cm bruising with skin intact/yellowish discoloration .Ecchymosis to the right lateral anterior chest wall extending to the right upper extremity: Xrays ordered .family requesting further evaluation in the ED [Emergency Department]. Transfer to ED for x-rays .and evaluation . During an interview on 8/2/2021 at 11:12 AM, Licensed Practical Nurse (LPN) #1 was asked about the bruising on Resident #1's arm. LPN #1 stated, .one of the staff members came to me and said that saw [Named Resident #1] with discoloration to the right side of her arm and right side of her breast .when I went in the room .I observed the lift pad under her arm and the shirt was over it .the pad was creased up .wasn't over her like it should have been .so I straighten it out .did attempt to call her daughter she didn't answer .I called the Nurse Practitioner didn't get her .I did an incident report .I forget to follow-up calling them again .this was on July 16th .so when her daughter came up here and asked me about the discoloration [on July 21st] .told her it happened on the 16th .I apologized for not following up on her .the daughter said she would feel better if her mom would go to the hospital .we sent her out on the 21st [July] . During an interview on 8/4/2021 at 1:50 PM, the Director of Nursing (DON) confirmed she was not aware of Resident #1's bruising until the day she got sent out to the hospital. The DON was asked if she should have been aware before then. The DON stated, Yes, ma'am . During an interview on 8/6/2021 at 1:25 PM, the FNP was asked when she was made aware of Resident #1's bruising on her right arm. The FNP stated, .7/21 was brought to my attention . The FNP was asked if she should have been notified when it happened. The FNP stated, Yes, ma'am . During interview on 8/10/2021 at 2:01 PM, the DON was asked when would she expect the physician and family to be notified of Resident #1's bruising. The DON stated, I would expect the physician and the family to be notified when it was observed.

Based on policy review, medical record review, and interview, the facility failed to monitor weights for 2 of 3 (Resident #3 and Resident #8) sampled residents reviewed for nutrition. The findings include: The facility's undated policy titled, Weight Procedure, revealed .Residents are weighed at admission, readmission .Weekly weights are completed for an additional 3 weeks (or longer if not stable) on the following .Admit, Readmit .New and readmissions will have 3 additional weekly weights after admit weight (total of 4 weeks) . Review of the medical record, revealed Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 12, which indicted mild cognitive impairment. Resident #3 required supervision and staff assistance for meals with a weight of 135 pounds [lbs]. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's Admit and Readmit assessment dated [DATE], revealed Resident #3 was readmitted back into the facility on [DATE]. Review of the Weight and Vital Summary sheet, showed the following weights for Resident #3: 8/13/2020-150 lbs 8/18/202-144 lbs 8/25/2020-144 lbs The facility failed to obtain weights on the week of 8/31/2021 according to company policy to ensure weekly weights were obtained 3 times after the initial readmission weight for a total of 4 weeks. Review of the medical record, revealed Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS assessment dated [DATE], revealed Resident #8 had a BIMS of 6, which indicated severe cognitive impairment. Resident #8 required extensive to total assistance from staff members for Activities of Daily Living (ADLs) and weighed 120 lbs. Review of the Weight and Vital Summary sheet, revealed the following weights for Resident #8: 1/28/2021- 140 lbs 2/10/2021 - 136 lbs 2/24/2021 - 130 lbs The facility failed to obtain weights on the week of 2/1/2021 and the week of 2/15/2021 according to company policy to ensure weekly weights were obtained 3 times after the initial admission weight for a total of 4 weeks. Review of the medical record, revealed Resident #8 went to the hospital on 3/22/2021 and was readmitted back to the facility on [DATE]. Review of the Weight and Vital Summary sheet, showed the following weights for Resident #8: 4/6/2021-120 lbs 4/21/2021-115 lbs 4/28/2021-115 lbs The facility failed to obtain weights on the week of 4/12/2021 according to company policy to ensure weekly weights were obtained 3 times after the initial readmission weight for a total of 4 weeks. During a telephone interview conducted on 5/3/2021 at 3:10 PM, the Registered Dietician (RD) confirmed weekly weights should be obtained according to policy and Resident #3 should have had a weight completed the week of 8/31/2020 and Resident #8 should have had a weight completed the week of 2/1/2021, 2/15/2021, and the week of 4/12/2021 according to the facility's policy. During a telephone interview conducted on 5/4/2021 at 1:39 PM, the Administrator confirmed weekly weights should be completed 3 weeks post admission and readmission for a total of 4 weeks according to the facility's policy.

Based on policy review, medical record review, and interview, the facility failed to report allegations of sexual abuse and neglect within 2 hours for 2 of 6 (Resident #1 and #6) sampled residents reviewed. The findings include: Review of the facility's Abuse Prevention Policy and Procedure documented, .Immediately means as soon as possible, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse .Report to State Health Department and other regulatory agencies immediately .Administrator Guidance for Investigations .The initial report to the State Agency may be made by phone, fax, or electronic submission to meet the 2 hour reporting requirement . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #1 scored 6 on the Brief Interview of Mental Status, which indicated severely impaired cognition for decision making tasks. Review of the Resident Incident Report dated 4/22/19 at 8:35 PM documented, .IT WAS REPORTED TO CHARGE NURSE THAT RESIDENT WAS SEEN BY CNA (Certified Nursing Assistant) IN ROOM INAPPROPRIATELY TOUCHING ANOTHER RESIDENT GENITALS THAT WERE EXPOSED TO HIM . Review of the Nurse's Note dated 4/23/19 documented, .Late entry for 4/22/19 8:35pm. Cna reported resident 516b in bed propped up on right side holding resident 508a (Resident #1) penis in hand .Supervisor and DON (Director of Nursing) were immediately notified. DON immediately notified Administrator . Review of the Facility Reported Incident (FRI) reported to the State Agency revealed the incident was reported to the State Agency on 4/22/19 at 11:38 PM. Interview with Licensed Practical Nurse (LPN) #1 on 5/2/19 at 2:08 PM, revealed LPN #1 checked her cell phone to determine the time the DON was notified. LPN #1 stated, .I called and talked to (Named DON) at 8:35 (PM). Interview with the Administrator on 5/2/19 at 3:12 PM, in the Conference Room, the Administrator stated, I know its 2 hours, but that's a lot to do. I knew at 9:01 (PM). When the Administrator was asked if the allegation was reported within 2 hours, she stated, No. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Concern/Comment Report dated 4/30/19 documented .RR (Resident Representative) states that resident was found in floor when he visited .RR feels that staff was neglectful .DATE/TIME OF INITIAL CONTACT WITH CONCERNED PARTY 4/23/19 1:35PM . Interview with the Social Worker (SW) on 5/2/19 at 11:30 AM, in the Conference Room, the SW confirmed she had talked with Resident #6's son and filled out the Concern/Comment report dated 4/23/19 at 1:35 PM. When asked what time the allegation of neglect was reported, the SW looked at the fax confirmation sheet and stated, .1644 (4:44 PM) (3 hours and 9 minutes after the staff became knowledgeable of the neglect allegation) .I had to wait on the Administrator to approve what I had written and get back to me. She had to proofread it first. It was a little longer than 2 hours. Interview with the DON on 5/2/19 at 1:55 PM, in the Conference Room, the DON confirmed she was knowledgeable of the allegation of neglect by Resident #6's son at the time of the call at 1:35 PM or right after. The DON confirmed attempts were made to contact the Administrator, but were unable to reach by phone until approximately 3:43 PM.

Based on policy review, observation, and interview, the facility failed to serve chicken at an acceptable holding temperature, ensure the microwave was clean for 2 of 2 days (11/5/18, and 11/6/18) of observation, and failed to ensure tea glasses was appropriately covered. This had the potential to affect 154 of the 190 residents receiving meal trays from the kitchen. The findings include: 1. The facility's Food Temperatures (undated) policy documented, .Foods should be served at proper temperature to insure (ensure) food safety and palatability .Acceptable serving temperatures* are: Meat, entrees .(sign for greater than or equal to)140 (degrees) . Observations on 11/6/18 at 12:25 PM, at the dining room steam table revealed the temperature of the chicken breast with cream of chicken soup was 120 degrees. The chicken was then reheated and brought back to the steam table and the temperature of the chicken was 135 degrees. The last reheat of the chicken before it was served was 145 degrees. 2. The facility's Microwave Oven (undated) policy documented, .Sanitation Of Equipment Frequency: Daily Wipe down inside . Observations on 11/5/18 at 9:15 AM and 11/6/18 at 12:05 PM, in the kitchen revealed food particles stuck to the inside top of the microwave. Observations on 11/6/18 at 12:10 PM, in the kitchen revealed a Dietary Aide #1, prepared tea glasses on a stainless table in the kitchen and took the tray of tea glasses to a room where trays were being served and stacked the tray on top of another tray of tea glasses twice. Interview with the Kitchen Manager on 11/6/18 at 12:06 PM, the Kitchen Manager confirmed the microwave was dirty and unacceptable. The Certified Dietary Manager (CDM) on 11/6/18 at 12:50 PM, confirmed the chicken had been reheated too many times and should not have been served to 2 residents and that stacking trays of tea glasses that were not covered was inappropriate and an infection control issue.

Based on policy review, observation, medical record review, and interview, the facility failed to ensure each resident was repositioned to promote comfort and provide pressure relief for 1 (Resident #22) of 4 residents reviewed for positioning. The findings include: 1. The facility's Repositioning policy documented, .A turning /repositioning program includes a continuous consistent program for changing the resident's position and realigning the body .Place the resident in a comfortable position in accordance with the resident's individualized care plan .The following information should be recorded in the resident's medical record .The position in which the resident was placed .The name and title of individual who gave the care .signature and title of the person recording the data . 2. Medical record review revealed Resident #22 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Annual Minimal Data Set ((MDS) dated [DATE] and a quarterly MDS dated [DATE] documented a Brief Interview of Mental Status (BIMS) 2 indicating severe cognitive impairment, extensive assistance with bed mobility. Observations of Resident #22 on 11/5/18 at 9:35 AM, in the resident's room revealed, the resident was lying in bed on her right side. Observations of Resident #22 on 11/6/18 at 7:43 AM, 11:40 AM, 12:04 PM, 1:09 PM, and 4:09 PM, in the resident's room revealed, the resident was lying in bed asleep on her right side with her head and neck in a bent position to the right. Observations of Resident #22 on 11/8/18 at 7:44 AM, in the resident's room revealed, the resident was lying in bed on the right side with head bent to the right. Interview with Licensed Practical Nurse (LPN) #1 on 11/6/18 at 4:25 PM, in the 800 Hall, LPN #1 was asked if Resident #22 was totally dependent on staff for turning and positioning. LPN #1 stated, Yes, she is . Interview with LPN #2, on 11/08/18 at 9:37 AM, in Resident #22's room, the LPN #2 was asked do you expect the resident to have support under her head. LPN #2 stated, .Yes I would . Interview with LPN #2 on 11/8/18 at 1:05 PM, at the 800 hall desk, LPN #2 confirmed that the documentation was incomplete for positioning.

Based on policy review, observation, and interview the facility failed to ensure practices to prevent the development and transmission of infection when 1 of 32 staff members (Certified Nurse Assistant (CNA) #1) handled food with their bare hands during 2 of 2 (11/5/18 and 11/6/18) meal observations. The findings include: The facility's Assistance with Meals (undated) policy documented, .3. All employees .will be trained and shall demonstrate competency in the prevention of foodborne illness, including personal hygiene practices and safe food handling. Observations in the 600 hall dining room on 11/5/18 beginning at 12:14 PM, CNA #1 removed the bread from a plastic sandwich bag and placed it on a resident plate, picked up a piece of chicken off of a resident's plate, and pulled a piece of chicken apart with her bare hands. Observations in the 600 hall dining room on 11/6/18 beginning at 7:47 AM, CNA #1 dropped a paper package into a resident's cup of coffee and used her bare hands to remove the package from the cup. Interview with the assistant Director of Nursing (ADON) on11/8/18 at 9:40 AM, in the 800 hall, the ADON confirmed that staff should not touch food with their bare hands.

Based on policy review, medical record review, observation and interview, the facility failed to preserve the dignity of 1 of 1 (Resident #80) sampled residents observed for [MEDICAL CONDITION] care by failing to provide privacy during care and for 1 of 12 (Resident #145) residents observed during assisted dining by failing to assist the resident timely. The findings included: 1. The facility's Resident's Rights policy documented, .It is our belief that you as a resident have the right to expect certain standards of care and considerations while at our facility . Medical record review revealed Resident #80 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation in Resident #80's room on 12/6/17 at 9:32 AM revealed Resident #80 was receiving [MEDICAL CONDITION] care from the Respiratory Supervisor without the privacy curtain pulled or the door to the hallway closed. Interview with the Respiratory Supervisor on 12/6/17 at 9:40 AM in the sub acute hallway, the Respiratory Supervisor was asked if the Resident's privacy curtain should have been pulled and the door to the hallway closed while performing [MEDICAL CONDITION] care. The Respiratory Supervisor stated, Yes . Interview with the Director of Nursing (DON) on 12/7/17 at 5:20 PM in the conference room, the DON was asked if the privacy curtain should be pulled and the door to the hallway closed when performing [MEDICAL CONDITION] care. The DON answered Yes. 2. The facility's Assistance with Meals policy documented, Residents shall receive assistance with meals in a manner that meets the individual needs of each resident .Nursing staff and/or Feeding Assistants will feed those residents needing full assistance within (blank) minutes of this delivery of food trays . Medical record review revealed Resident #145 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] documented, Resident #145 had severe cognitive impairment. Observations in the restorative dining room on 12/3/17 at 11:40 AM, revealed Resident #145 was served her lunch tray but was not assisted with her lunch until 12:28 PM, 52 minutes after the tray was placed in front of her. Interview with the DON on 12/7/17 at 5:23 PM in the conference room, the DON confirmed it was not acceptable for a resident to wait 52 minutes before being assisted with their meal.

Based on National Pressure Ulcer Advisory Panel (NPUAP) reference guide, policy review, medical record review, review of shower records and interview, the facility failed to put preventative measures in place prior to the development of pressures sores, failed to timely identify, accurately assess and/or treat pressure ulcer for 2 of 4 (Residents #96 and 134) sampled residents with pressure ulcers. The facility failed to put preventative measures in place prior to the development of elbow pressures sores, failed to timely identify, accurately assess and/or treat pressure ulcers resulted in actual harm to Resident #96. The findings included: 1. Review of the NPUAP quick reference guide defined a Stage IV (4) pressure ulcer as, .Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleous do not have (adispose) subcutaneous tissue and these ulcers can be shallow . Stage IV ulcers can extend into muscle and/or supporting structures . making osteo[DIAGNOSES REDACTED] (bone infection) or osteitis (bone inflammation) likely to occur. Exposed bone/muscle is visible or directly palpable . Review of the NPUAP quick reference guide defines an Unstageable wound as, .full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Stage III (3) or IV (4) . 2. The facility's .Wound Care Management policy documented, .Each resident receives the care and services necessary to retain or regain optimal skin integrity to the extent possible. Each resident is evaluated by the interdisciplinary team to determine his or her risk for skin compromise or the presence of wounds and/or pressure ulcers. A plan of care is developed and implemented based on this evaluation with ongoing review. If skin compromise occurs, evaluation is conducted by the interdisciplinary team to ensure appropriate measures are in place to minimize further compromise and aid in healing to extent possible . Risk Factors for Pressure Ulcers . Impaired/decreased mobility and decreased functional ability . Co-morbid . 3. Medical record review revealed Resident #96 was admitted to the facility on [DATE], with a readmission date of [DATE], with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set ((MDS) dated [DATE], and an annual MDS dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 3, indicating Resident #96 was severely impaired cognitively and did not have any documented wounds at this time. The care plan dated 7/4/13 and revised 8/14/15 documented, .has actual (potential) for skin breakdown related to immobility and incontinence . Left elbow stage 3, stage 4 on Right elbow . Approaches . Teach family / significant others risk factors for development of pressure ulcers . Report any changes in skin condition . Pressure relief mattress . Administer medication as ordered to manage contact [MEDICAL CONDITION] . Turn and reposition routinely and PRN (as needed) . Ear protectors . Podus boots . Incont (Incontinent) care as needed . Treatment as ordered 8-14-15 . Vitamins and supplements as ordered . Lab (laboratory tests) as ordered . Braden Risk Assessment Reports (indication for risk at developing pressure ulcers) dated 5/13/15 and 8/17/15 documented a Braden score of 11 indicating the resident was a high risk level for developing pressure ulcers. Resident #96's bath roster did not document bathing or skin assessments from 8/7/15 until 8/14/15. Resident #96's shower / skin assessment form dated 8/3/15 completed by Certified Nursing Assistant (CNA) #2 documented, .wound . on the right elbow and on 8/5/15 documented, .soar (sore) . on the right elbow. A typed interview dated 8/18/15 documented CNA #2 notified Registered Nurse (RN) #3 on 8/3/15 and Licensed Practical Nurse (LPN) #7 on 8/5/15 when she gave them Resident #96's shower sheet that documented elbow wounds on 8/3/15 and 8/5/15. The interview documented, .Right elbow was very red but skin was not broken . CNA #2 stated that LPN #7 stated, I'm glad you told me. The Director of Nursing (DON) spoke to LPN #7 on 8/14/15, LPN #7 acknowledged that she had been made aware of the area on the elbow, but stated, I just forgot, I missed it. The DON spoke with RN #3, who also acknowledged that she was made aware of the area on the elbow and stated, I (RN #3) signed the sheet and really did not look at it (the elbow), because I was so busy. No new interventions or treatments were implemented on 8/3/15 or 8/5/15 when the pressure ulcers were discovered. A Nurses' Note dated 8/14/15 at 2:41 AM documented, .When resident was turned to clean & (and) change a 3 cm (centimeter) x (by) 2 cm wound was noted to area above right elbow, wound is tan color with slough tissue noted . On 8/14/15 at 7:36 AM the nurse's note documented, .When full skin assessment completed, wounds found to both elbows, an open area to sacrum, and a sealed scratch to right buttock . On 8/14/15 at 12:09 PM the nurse's note documented, .Opened area to right elbow, yellow slough present with purulent drainage. left elbow has abrasions and scabbing, shearing noted to left buttock . A wound assessment dated [DATE] documented unstageable pressure ulcers to the left and right elbows. The wound measurements were documented as follows: a. Right Elbow - L (length) 3.70 x W (width) 3.00 x D (depth) 0.20 Unstageable . b. Left Elbow - L 1.10 x W 1.70 x D _ Unstageable A wound assessment dated [DATE] documented stage 4 pressure ulcers to the left and right elbows. Wound care specialist evaluations documented the following: a. 9/8/15 - .Stage 4 Pressure Wound of the Left Elbow . Stage 4 Pressure Wound of The Right Elbow b. 9/15/15 - .Stage 4 Pressure Wound of the Left Elbow . Stage 4 . Pressure Wound of the Right Elbow . Observations in Resident #96's room on 9/23/15 beginning at 8:40 AM, revealed Resident #96 had a healing stage 4 wound on her left elbow dry and no odor with granulation tissue present. The right elbow had a wound 3 centimeters in diameter and appeared to have some undermining at the edge toward the upper arm with some yellow slough noted on the wound bed and no odor. Telephone interview with CNA #3 on 9/22/15 at 3:55 PM, CNA #3 stated, .August 14th (2015) I was helping clean up (Resident #96). We noticed an ulcer on her right elbow. I notified the nurse. She (Resident #96) had another ulcer forming on her left elbow. On August 3rd I did notify the nurse there was a wound on her (Resident #96) right elbow. CNA #3 was asked if Resident #96 had any protectors on her elbows on the 8/14/15. CNA #3 stated, No, nothing on her elbows. She had nothing else in place. Interview with LPN #3 on 9/23/15 at 9:05 AM, beside unit 2 nurses' station, LPN #3 was asked if Resident #96's elbow wounds were acquired in the facility or somewhere else. LPN #3 stated, Here . Both elbows were unstageable . LPN #3 was asked what was in place prior to the elbow wounds developing. LPN #3 stated, She had a mattress that we upgraded to a bigger one, we were turning and repositioning and about a month ago we added skin assessments to have more eyes. Before the wounds developed the CNA was doing skin assessments when they were getting their showers and the floor nurse was assigned to weekly skin assessments head to toe, now this was implemented about a month ago: CNA does assessments with their shower, the Nurse on the floor is assigned skin assessments and the treatment nurse does skin assessments weekly on residents with wounds . LPN #3 was then asked why was this implemented a month ago? To have more eyes on resident assessments . Interview with the DON on 9/23/15 at 1:20 PM, in the conference room, the DON stated, .(named CNA #2) identified the wound on her (Resident #96's) right elbow as a red area on 8/3/15 . (named CNA #2) told (named Registered Nurse (RN #3) and she got busy and forgot it. She (RN #3) never looked at it (the red area). The same CNA (#2)documented a sore on the right elbow on her (Resident #96's) bath sheet skin assessment and told (named LPN #7) and she (LPN #7) did not look at it. Interview with the DON and the Nurse Consultant on 9/23/15 at 2:15 PM, in the conference room, the DON was asked if there were no shower sheets provided did that mean there were no skin assessments performed. The Nurse Consultant stated, If not documented, not done. I see what your saying. Telephone interview with RN #3 on 9/24/15 at 8:50 AM, in the DON's office, RN #3 was asked about Resident #96's wound that the CNA had notified her of. RN #3 stated, I didn't ever look at it. I just signed it (the skin care assessment), because somebody asked me to. I came in late and did not talk to anybody. Interview with Resident #96's wound care physician on 9/24/15 at 3:10 PM, in the conference room, the physician was asked if the lack of treatment and assessment for a wound identified by a CNA as a red spot or wound could it deteriorate into an unstageable wound. The physician stated, Could have, sometimes you can put preventative things in place to help. The facility failed to put preventative measures in place prior to the development of pressures sores, nurses failed to timely identify, accurately assess and/or treat pressure ulcers resulted in actual harm when Resident #96 developed unstageable pressure ulcers to the right and left elbows. 4. Medical record review revealed Resident #134 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident was receiving hospice services. A significant change MDS dated [DATE] documented Resident #134 required extensive to total staff assistance for all Activities of Daily Living. The MDS documented Resident #134 had a stage 4 and an unstageable pressure ulcer that was present on admission and receiving hospice care. Wound assessment reports for Resident #134 documented the following: a. 2/9/15 - .Pressure Ulcer . Right Buttock; right and left buttocks . Date wound identified . 2/8/15 . Present upon admission . No . New Wound . Stage . 2 . Border Definition . Normal Healthy Skin . b. 2/16/15 - .Pressure Ulcer . Right Buttock; right and left buttocks . Wound Status . Deteriorated . Date wound identified . 2/8/15 . Present upon admission . No . Stage . 2 . Border Definition . Rolled . c. 2/23/15 - .Pressure Ulcer . Right Buttock; right and left buttocks . Deteriorated . Date Wound Identified . 2/8/15 . Present upon admission . No . Stage . 2 . Border Definition -Well Defined . Description - Rolled . Resident has stage two to the sacrum and buttocks . d. 3/2/15 - .Pressure Ulcer . Right Buttock; right and left buttocks . Wound Status . Deteriorated . Date Wound Identified . 2/8/15 . Present upon admission . No . Stage . 2 . Border Definition - Well Defined . Description - Rolled . resident has wound to the sacrum . open area to buttocks . cleanse sacral area with wound cleanser, dry and apply Santyl . Nurses notes documented the following: a. 2/26/14 at 1:30 PM - .Stage 2 pressure wound to sacral area is deteriorating . b. 3/4/15 - .This nurse discussed sacral / buttock wound with RP (responsible party) and let her know the wound is getting worse . A dietary note dated 3/6/15 at 1:50 PM, documented, .Stg (stage) 2 to sacrum . A hospital admission history and physical consult dated 3/7/15 documented, .developed a sacral decubitus ulcer that progressively worsened . stage 4 sacral decubitus ulcer was noted . A hospital progress note dated 3/8/15 documented, .Sacral decubitus ulcer, stage 4, present on admission . Observations in Resident #134's room on 9/23/15 at 9:50 AM, revealed a stage 2 large fist sized open sacral wound with pink tissue. Interview with Resident #134's physician in the conference room on 9/24/15 at 3:10 PM, the physician was asked if she recalled Resident #134. The physician stated, Yes. I remember she had a large stage 4 ulcer. The physician was asked if she felt it would be possible for a stage 2 pressure ulcer to progress to a stage 4 on the way to the hospital. The physician stated, No. That question I can answer. The physician was asked if she felt the stage 2 description for Resident #134's sacral wound up until hospitalization on [DATE] was accurate. The physician stated, I'm thinking not. The physician also confirmed that specific wound descriptions were not documented. The facility inaccurately assessed the sacral wound as a stage 2 when the wound was actually a stage 4.

Based on review of the facility's investigation summary, medical record review and interview, it was determined the facility failed to ensure interventions were implemented to prevent accidents for 1 of 4 (Resident #1) sampled residents identified with falls. The failure to implement the interventions to protect Resident #1 resulted in actual harm when Resident #1 sustained a fracture during a transfer. The findings included: Review of the facility's event summary dated 8/8/11 documented, "(Resident #1's name and room number) Event Date: 8/2/11 at 7:45 PM An investigation was completed regarding above stated incident... (staff) didn't use a mechanical lift to transfer the patient... The two CNAs (Certified Nurse Assistants) attempted to transfer the patient using a "2 man lift" technique that resulted in injury to the patient. The patient was transferred to the hospital and admitted for orthopedic treatment. The patient's daughter has reported that there is a "broken femur"..." A Follow-up Report dated 8/8/11 for Resident #1 documented, "...8/3/11 F/U (follow-up) phone call + (positive) femur fx (fracture)..." Medical record review for Resident #1 documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician telephone order dated 8/2/11 documented, "Send to (hospital name) for evaluation of Rt (right) knee." The lift/transfer assessment form dated 6/8/11 documented, "...TOTAL LIFT REQUIRED yes..." The care plan dated 5/4/11 documented, "...At risk for falls r/t (related to) requires total assist with transfers... Ensure adequate staff and proper equipment for safe transfers... Use hoyer lift for transfers..."A nurses note dated 8/2/11 at 10:42 PM documented, "...resident (#1) sitting on floor upright position but rt (right) leg bent in odd position it was laying sideways... shower chair was next to bed this nurse was told by CNA that resident was being transferred to shower chair from bed resident's leg caught in shower chair. CNA attempted to reposition leg heard a pop CNAs attempted to assist resident back on to bed resident unable to stand CNAs assisted the resident to the floor..." During an interview in the administrator's office on 8/24/11 at 4:30 PM, the Director of Nursing stated, "...(CNA) got a shower chair, supposedly looked for a lift, said none (no lift available), got co-worker assist to transfer (Resident #1) to shower chair. The resident's leg wrapped around the chair... (CNA) tried to lay her down and heard a pop... " The failure to implement the interventions documented on the lift/transfer assessment and care plan to protect Resident #1 resulted in actual harm when Resident #1 sustained a fracture during a transfer on 8/2/11.

Based on review of the national pressure ulcer prevention quick reference guide, policy review, medical record review, observation and interview, it was determined the facility failed to prevent and identify the development of pressure sores and failed to accurately assess and treat pressure sores for 2 of 10 (Residents #13 and 29) sampled residents with pressure sores. The failure to identify and prevent skin breakdown prior to the development of a stage 4 pressure sore resulted in actual harm to Resident #13. The findings included: 1. Review of the national pressure ulcer prevention quick reference guide documented, "...3. Inspect skin regularly for signs of redness... Ongoing assessment of the skin is necessary to detect early signs of pressure damage. 4. Skin inspection should include assessment for localized heat, [MEDICAL CONDITION], or induration (hardness), especially in individuals with darkly pigmented skin..." 2. Review of the facility's "Prevention of Pressure Sores & (and) Other Ulcers" policy documented, "...Pressure sore risk should be reassessed periodically... Skin integrity assessments are performed weekly by nurses on all residents paying particular attention to all pressure points. The Weekly Skin Integrity Assessment form is used. Treatment is initiated immediately... Do an assessment for risk of skin breakdown on admission and quarterly... Do skin integrity assessment/checks weekly... The pressure sore should be reassessed at least weekly..." 3. Medical record review for Resident #13 documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the comprehensive care plan dated 4/16/10 documented, "...Skin checks weekly per facility protocol..." Review of the "Skin Concerns Roster 9/1/10 thru (through) 9/30/10" documented, "...9/23/10... skin check Yes skin concern-nurse notified..." Review of the annual Minimum Data Set ((MDS) dated [DATE] documented, "...Section M. Skin Condition 1. Ulcers (due to any cause)... b. State 2... Number at Stage... 1... d. Stage 4... Number at Stage... 2... 2. Type of ulcer ...a. Pressure ulcer - any lesion caused by pressure resulting in damage of underlying tissue... Number at stage 4..." Review of the "Departmental Notes" for Resident #13 documented the following: a. "...8/11/2010... skin assessment (assessment) done - no bruises or skin break noted @ (at) this time..." b. "9/23/11... Resident observed with 3 dark fluid filled intact blisters to rt (right) great toe, one @ the top of rt great toe, one @ the outer side of rt great toe and one below the rt great toe. the lt (left) and rt feet, in between toes noted with dark discoloration and dry scally (scaly) skin. o (no) skin break noted @ this time. staff will continue to monitor..." c. "10/5/10... nurse instructed to call resident's RP (responsible party) to request house shoes for comfort r/t (related to) possible friction wirh (with) sneakers and socks..." d. "10/9/10... CNA (Certified Nursing Assistant) reported a fluid filled blister to the lateral Rt (right) foot sole. Report given to the oncoming nurse who explained that it is an ongoing - issue with the Resident, and wound care nurse is handling it..." e. "10/11/10... 10-7-10 Client (Resident #13's) Rt great toe noted to have a fluid filled blister to the anterior surface... Size 1.7x (by) 1.5. Purple in color. No drainage or odor noted. Two hard purple areas noted to lateral side and posterior surface. FNP (Family Nurse Practitioner) ...notified with the following orders: Skin prep RT (right) great toe blister, and two hard purple areas x (times) 14 days... tx (treatment nurse) informed 'that i ( treatment nurse) will be doing skin prep treatments to right great toe'..." f. "10/12/10... resident appears to be comfortable with wearing her houseshoes to ease pressure of formed blisters of right great toe..." g. "11/3/10...Treatment nurse is monitor right great toe..." Review of Resident #13's "SKIN CONDITION RECORD" dated 10/6/10 documented, "...Rt big toe (top)... 10/6/10 SIZE IN CM (centimeter) (LENGTH x WIDTH) 1.7 x 1.5... WOUND BED purple filled blister SURROUNDING SKIN COLOR brown... 10/4 SIZE IN CM (LENGTH X WIDTH) 1.2 x 1.1... WOUND BED purple scab SURROUNDING SKIN COLOR brown... 10/19 SIZE IN CM (LENGTH X WIDTH) o (zero)... WOUND BED scabing (scabbing) off pink SURROUNDING SKIN COLOR brown..." Review of Resident #13's "SKIN CONDITION RECORD" dated 10/6/10 documented, "...Posterior R (right) big toe...10/6 SIZE IN CM (LENGTH x WIDTH) 0.8 x 2.2... WOUND BED hard purple scabed area SURROUNDING SKIN COLOR brown... 10/14 SIZE IN CM (LENGTH X WIDTH) 0.8 x 2.2... WOUND BED hard purple scabed area SURROUNDING SKIN COLOR brown..." Review of the "SKIN CONDITION RECORD" dated 10/6/10 documented, "...Posterior R big toe... 10/6/10 SIZE IN CM (LENGTH x WIDTH) 1.0 x 0.6... WOUND BED hard dark purple SURROUNDING SKIN COLOR brown... 10/14 SIZE IN CM (LENGTH x WIDTH) 1.0 x 0.6... WOUND BED hard dark purple scabing SURROUNDING SKIN COLOR brown..." Review of Resident #13's physician telephone orders dated 10/7/10 documented, "...Skin prep the Rt great toe fluid filled blister to anterior surface and two hard darken areas to posterior surface of toe everyday x 14 days..." Observations in Resident #13's room on 7/7/11 at 2:55 PM, revealed Nurse #3 removed Resident #13's sock. Resident #13's right great toe skin was intact with no areas of skin breakdown or darkened areas. During an interview at the Station 3 nurses' station on 7/7/11 at 9:20 AM, Nurse #7 was asked about the initial staging of the darkened areas in between Resident #13's toes. Nurse #7 stated, "...it's either stage 4 or unstageable... it was staged as stage 4." During an interview on the 100 hall on 7/7/11 at 10:20 AM, the Assistant Director of Nursing (ADON) confirmed that the nursing skin assessments should have been completed weekly and stated, "...there is a definite gap in the skin assessments." The ADON confirmed there was no treatment of [REDACTED]. The failure to identify and prevent skin breakdown prior to the development of a Stage 4 pressure ulcer resulted in actual harm to Resident #13. 2. Medical record review for Resident #29 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the "Departmental Notes" dated 11/24/10 at 8:59 PM documented, "...open area to sacrum noted..." Review of the "Departmental Notes" dated 11/25/10 at 11:29 AM documented, "...received new order for floor nurse to apply [MEDICATION NAME] cream to sacral creases q (every) shift and prn (as needed) until excoritation (excoriation) healed..." Review of the MDS dated [DATE] documented, "...Section M - Skin Conditions... Resident has Stage 1 or higher pressure ulcer... No". Review of the "WOUND / SKIN HEALING RECORD" dated 12/3/10 documented, "...DATE OF ONSET: 12-3-10... ORIGINAL STAGE: III... SITE/LOCATION: coccyx..." During an interview in the conference room on 7/7/11 at 7:35 PM, Resident 29's physician was asked about the open area on Resident #29's sacral area and the Stage 3 area on the coccyx. Resident 29's physician stated, "...I think the MDS made a mistake... if it's (pressure ulcer) open it has to be at least a Stage 2 on admit... we should have been more specific... the treatment was ok if it was small... didn't document on admission the way they (staff) should have..."