Every finding on record at Crestpark Dewitt, LLC

Based on observation, interview, facility document review, and facility policy review, it was determined that the facility did not have a Registered Nurse (RN) at least eight consecutive hours a day for seven days a week. The findings include: A review of the licensed nurse schedules from 09/29/2025 – 03/23/2026, revealed there was no RN coverage for eight consecutive hours on the following dates: 10/04/2025, 10/05/2025, 10/11/2025, 10/12/2025, 02/28/2026, 03/01/2026, 03/14/2026, and 03/15/2026. During an interview on 03/23/2026 at 5:00 PM, the Administrator verified that there was a total of four days, out of the last four weekends, that there was no RN coverage for eight hours each day. The Administrator indicated that the weekend days with RN coverage were 03/07/2026, 03/08/2026, 03/21/2026, and 03/22/2026. In addition, the Administrator indicated the weekend days without RN coverage were 02/28/2026, 03/01/2026, 03/14/2026, and 03/15/2026. During an interview on 03/25/2026 at 8:15 AM, Licensed Practical Nurse #1 indicated there was a lack of RN coverage that happened every other weekend. During an interview on 03/25/2026 at 2:15 PM, the Director of Nursing (DON) confirmed they did not have an RN present on the dates listed above from October 2025 – March 2026. During an interview on 03/26/2026 at 9:35 AM, the Administrator indicated it was her responsibility to ensure the DON had an RN scheduled for at least eight hours each day and confirmed they did not have an RN present on the dates listed above from October 2025 – March 2026. A review of the Facility Assessment, last updated 02/20/2026, revealed RN Nursing Services to be an example of facility resources needed to provide competent support and care for the resident population every day and during emergencies.

Based on facility document review and interview, it was determined that the facility failed to submit the quarterly Payroll Based Journal (PBJ) information for the period of October 2025 – December 2025, to the Centers for Medicare and Medicaid Services (CMS). Specifically, the quarterly data was not submitted, per the established schedule. The findings include: A review of the facility's most recent PBJ report, dated 03/12/2026, revealed that no monthly staffing data was submitted for the timeframe of October 2025 – December 2025, to the PBJ platform. During an interview on 03/25/2026 at 2:51 PM, the Business Office Manager (BOM) stated she was responsible for submitting the PBJ data into the PBJ platform. The BOM indicated that the PBJ report was a report submitted to CMS that contained data about staffing hours that were audited from payroll records. The BOM indicated that the missing data was an error on her part, because she forgot the submission deadline of 02/15/2026. The BOM stated she had the monthly data completed, but it did not get submitted by the quarterly deadline. The BOM also indicated that by missing the submission deadline, it rendered the data as not submitted. During an interview on 03/25/2026 at 3:26 PM, the Administrator indicated it was her responsibility to ensure the BOM completed a timely PBJ submission for each respective quarter. The Administrator also indicated that the missing PBJ staffing data for October 2025-December 2025 was because the BOM did not enter the data by 02/15/2026.

Based on observations, interviews, and facility policy review, the facility failed to ensure a staff's hair was contained while preparing and serving food, and staff used proper hand hygiene while preparing and/or serving a meal. The findings include: On 10/02/24 at 9:30 AM, the Surveyor observed the Dietary [NAME] (DC) with gloved hands stop cutting raw meat, without removing the gloves and washing her hands, she grabbed a can of cooking spray and then sprayed the cooking spray on a baking pan. The Dietary [NAME] then returned to cutting raw meat without removing the gloves and washing her hands. On 10/02/24 at 9:40 AM, the Surveyor observed the Dietary Helper's hair out of the bonnet while mixing the ingredients of a pie. On 10/02/24 at 11:30 PM, the Surveyor observed the Dietary Helper's hair out of the bonnet while serving staff. On 10/02/24 at 9:50 AM, during an interview, the Dietary Manger stated the Dietary Helper was given permission to wear a hair bonnet rather than a hair net because she had a lot of hair. On 10/02/24 at 10:12 AM, during an interview, the Dietary [NAME] stated she handled raw meat, grabbed the cooking spray, and returned to handling raw meat. On 10/03/24 at 9:17 AM, during an interview, the Dietary Manger stated the Dietary [NAME] cross contaminated when she grabbed the cooking spray between handling raw meat, and when the Dietary Helper's hair was out while prepping and/or serving food she could have gotten hair in the food. A policy titled, Rules of Sanitation, noted, wear a hairnet or cap while on duty and keep your hands clean, washing them frequently.

Based on record review and interview, the facility failed to ensure the facility assessment included pertinent information to assure the necessary care and resources were allocated to meet the needs of the residents in 1 of 1 facility. This deficient practice had the potential to affect all residents of the facility. The total census was 36 residents. The findings are: A review of the Facility Assessment Tool, dated 09/12/2024, did not contain the following required information: a. Name of the governing body representative involved in the completion of the facility assessment. b. Plan to recruit and retain enough medical personnel who are adequately trained and knowledgeable in the care of residents and/or how management expectations of medical personnel. c. The facility's resources which included supplies, equipment, or other services necessary to provide for the needs of residents. d. An evaluation of any contracts, memorandums of understanding including third-party agreements for the provision of goods, services or equipment to the facility during both normal operations and emergencies. e. Heath information technology resources for managing resident records and sharing information with other organizations. f. Evaluation of the physical environment necessary to meet the needs of the residents. g. No reference to the facility-based and community-based risk assessment, utilizing an all-hazards approach/emergency preparedness plan. On 10/03/2024 at 2:42 PM, the Administrator and Administrative Assistant (AA) were interviewed with the concurrent observation concerning the facility assessment. The AA was asked who the governing body member was who was involved in completing the facility assessment. The Administrator stated, I'm the governing body. This surveyor stated to the Administrator the governing body would be someone over her. The AA stated another name of an owner of the facility as the governing body. The AA stated portions of the facility assessment were missing because they did not answer the items appropriately. The AA stated the Quality Assurance and Assessment (QAA) committee was responsible for completing the facility assessment. The Administrator stated she reviewed the facility assessment to ensure that all necessary components were in place.

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined the facility failed to maintain Legionella surveillance for 1 of 1 water management plan. Findings include: A review of the facility's water management plan with an Annual Review Date of 09/13/2024, titled Water Management Plan, indicated Legionella was a bacteria common in water systems that causes a severe pneumonia called a serious type of pneumonia called Legionnaires Disease (LD). Legionella surveillance is one component of the facility's water management plan for reduction risk of bacteria in the facility's water system. Legionella grows best in water which is stagnate or does not have enough disinfectant and at temperatures above 59 degrees Fahrenheit or below 131 degrees Fahrenheit. Temperature control measures included hot water shall be stored at above 160 degrees Fahrenheit and progressively flushing the system for a minimum of 5 minutes. A review of a facility Water Management Plan, with an annual review date of 09/13/2024, Management Team are responsible for the implementation and oversight of the Water Management Program. They must include employees with knowledge of building water systems and how those systems relate to Legionellosis. The diagram of the facility in the Water Management Plan, does not show where water is received into the building, it does not show cold water distribution, heating, hot water distribution, and waste. Second, the map did not identify areas which encourage growth and spread of Legionella and other waterborne bacteria like storage tanks, water heaters, filters, aerators, showerheads/hoses, humidifiers, hot tubs, fountains, and medical devices Third, map did not identify situations such as presence of biofilm, sediment, water temperatures fluctuations, water pressure changes, water stagnation, and inadequate disinfection. Lastly, the diagram of where control measures are applied and a system to monitor control limits and effectiveness. During an interview on 10/02/2024 at 2:20 PM, the Maintenance Supervisor (MS) was asked to test the water temperature in room [ROOM NUMBER]. The MS tested the water temperature, and it took 8 minutes for the water temperature to reach 107 degrees Fahrenheit. The MS indicated on halls 200 and 600 the water is very slow to heat up.

Based on interviews and record review, it was determined that the facility failed to provide a pneumonia vaccine for 2 (Residents #1 and #20) of 5 residents reviewed for immunizations. Findings include: A review of Resident #1's Immunizations on the resident's face sheet in the paper chart did not have information entered that the pneumonia vaccine was received. A review of Resident #20's Immunizations on the resident's face sheet in the paper chart did not have information entered that the pneumonia vaccine was received. On 10/03/2024 at 9:35 AM, the Infection Control Preventionist (IPC) was asked to provide information on the administration of the pneumococcal vaccine to Resident #1 and Resident #20. During an interview on 10/03/2024 at 12:18 PM, the IPC stated Resident #1 and Resident #20 never received the pneumococcal vaccine. The IPC provided both of the resident's shot records.

Based on observation, record review, and interview, the facility failed to consistently implement a system to accurately reconcile and dispose of a controlled liquid narcotic, Lorazepam, 90 days after the bottle was opened, according to the manufacturer's instructions on the bottle for 1 (Resident #5) sampled resident who was reviewed for disposition of Lorazepam. The findings are: On 10/01/2024 at 3:33 PM, this surveyor and Registered Nurse (RN) #2 entered the medication storage room. RN #2 unlocked a small refrigerator, in which the contents were observed, and a box with a bottle of Lorazepam 2 milligrams/milliliters (mg/ml) liquid was inside for Resident #5. The liquid inside the bottle was approximately at the 20 ml black line on the bottle. The manufacturer's guidelines on the bottle indicated to discard the bottle 90 days after being opened. There was no date on the box or bottle. On 10/01/2024 at 4:06 PM, a narcotic log was reviewed and indicated on page 92 that Resident #5 received a 30 ml bottle of Lorazepam liquid from the pharmacy. On 03/03/2024 at 0730 (7:30 AM), 0.25 ml of Lorazepam was signed out of the narcotic log, leaving a balance of 29.75 [ml]. A second narcotic log was reviewed and indicated page 32 was started on 05/28/2024 and indicated a balance forward of 25.25 [ml] of Lorazepam. On 09/26/2024 at 1420 (2:20 PM), 0.5 [ml] of Lorazepam was signed out of the narcotic log. Resident #5's Physician's Orders were reviewed and indicated an order dated 05/07/2024 for Lorazepam 2 mg/ml and give 0.25 ml sublingual (SL) as needed every 6 hours. Resident #5's quarterly Minimum Data Set with an Assessment Reference Date of 07/23/2024, was reviewed and indicated the resident had a Staff Assessment of Mental Status score of 3, which indicated the resident was severely cognitively impaired, and had special treatments from hospice care. On 10/03/2024 at 3:45 PM, the Director of Nursing (DON) was interviewed and asked what the facility's process was for removing and returning narcotics for destruction. She stated the narcotic medications were logged on a form and the nurse working on the medication cart where the medications were removed was the witness. She stated liquid medications were measured and placed in a [name brand] bag. She stated the logs were rubber banded around the medication, placed in a sealed box and sent by way of certified mail to be destroyed.

Based on interview and record review, the facility failed to ensure residents with a trust account had access to their personal funds after business hours and on weekends for 1 (Residents #20) sampled resident. The findings are: On 10/02/24 at 10:30 AM, the Surveyor asked Resident #20 who handled the residents' money. Resident #20 indicated that the facility handles the residents' money. Resident #20 was asked if the resident was able to access funds on the weekend. Resident #20 indicated no; you must get your money from the business office by Friday if you want money for the weekend. On 10/03/24 at 9:55 AM, the Surveyor asked the Business Office Manager (BOM) if the residents have access to their money on weekends. The BOM indicated the residents come to the BOM office by Friday and get a check to get funds, or they will tell a nurse on the weekend and the nurse will call the BOM and she will come up here and get the funds for the resident. The BOM was asked when the last time she had to come up to the facility on the weekend to get funds for a resident. The BOM indicated she could not remember; it had been a long time. The Surveyor asked the BOM if the new residents had been informed of how to acquire funds on the weekend, either by getting funds before Friday or asking a nurse to call the BOM. The BOM indicated she was not sure. On 10/03/2024 at 2:30 PM, the Administrator indicated that they did not have a personal funds policy.

Based on observation and interview, the facility failed to ensure potential hazardous chemicals were secured and stored behind a locked door. The findings are: On 09/30/2024 at 11:26 AM, this surveyor approached the beginning of hall 600. The door to the whirlpool room was observed open. This surveyor entered the whirlpool room and observed a 1-gallon jug of [brand name] surface disinfectant cleaner, 2 spray bottles of [brand name] surface disinfectant cleaner on an over bed table to the right of the whirlpool. There was a 1-gallon jug of tearless shampoo and body wash, 1 blue razor sitting directly on the whirlpool and 2 blue razors inside a purple basket with holes sitting directly on top of the whirlpool. On 09/30/2024 at 11:30 AM, Certified Nursing Assistant (CNA) #1 was observed passing by the whirlpool room on hall 600. She was asked if the door to the whirlpool was supposed to be open. She stated, As far as I know it's supposed to be shut. She stated CNA #4 was responsible for providing whirlpool baths to the residents on this day. On 10/03/2024 at 9:18 AM, CNA #4 was interviewed and asked who had access to the whirlpool room. She stated herself, housekeeping, maintenance, and all the CNAs. She confirmed the door to the whirlpool room should be closed and locked when not in use. She stated there were chemicals, soap, shampoo and conditioner in the whirlpool room. She stated the cleaner for the whirlpool room was a chemical used to clean the chair and whirlpool and they could be harmful to the residents. On 10/03/2024 at 3:40 PM, the Director of Nursing (DON) provided the Material Safety Data Sheet, not dated, for [brand name] surface disinfectant cleaner. The document was reviewed and indicated the chemical could cause moderate skin irritation, could be harmful if swallowed and to seek medical attention if ingested. On 10/03/2024 at 3:40 PM, the DON provided a typed statement which was reviewed but did not address if the facility had a policy on accidents and hazards and no policy was provided.

Based on record review and interview, the facility failed to ensure an as needed psychotropic medication, Lorazepam, was not continued past 14 days without a physician's documented rationale and duration for 1 (Resident #30) sampled resident reviewed for as needed (PRN) psychotropic medication. The findings are: Resident #30's Physician's Orders were reviewed and indicated a diagnosis of anxiety. An order dated 02/22/2024 indicated Ativan 1 milligram (mg) per tube every 8 hours as needed for anxiety. An annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/02/2024, was reviewed and indicated the resident had a Staff Assessment for Mental Status score of 2, which indicated the resident was moderately cognitively impaired and received an antianxiety medication. A Consultation Report dated 04/01/2024 was reviewed and indicated the resident had a PRN order for an anxiolytic, Ativan, without a stop date. The recommendation indicated if the medication could not be discontinued at the time, the documentation had to include 3 items: 1. an indication for use, 2. the anticipated or expected duration of therapy, which the provider left blank, and 3. the rationale for the extended time period, which the provider left blank. On 10/03/2024 at 2:03 PM, the Director of Nursing (DON) was interviewed and asked how and when the provider received the gradual dose reduction forms from the pharmacist for review. She stated she provided the forms to the doctors when they came every month. She stated the medical director looked at his on the second Wednesday of every month during his visits. She stated she followed up with the providers to ensure all areas of the GDR were completed. She was asked if she reached out to the provider if something was missing on the form. She stated no. She was asked if she knew the length of time a resident could take a PRN psychotropic. She said 14 days. On 10/03/2024, the DON provided a typed statement which was reviewed and indicated the facility did not have a written policy concerning GDRs. The statement indicated that after the pharmacist provided the facility with the recommendation, the doctor reviewed the information and was responsible for filling out the form and providing a rationale for the declination. The statement indicated psychotropic medications were administered per the physician orders.

Based on observations, interviews, record review, and facility policy review, the facility failed to maintain a medication error rate of less than 5% to prevent complications for 2 (Residents #10 and #15) sampled residents observed during medication pass resulting in medication errors. The findings include: 1. A review of the Physician's Orders, revealed Resident #10 had an order for Digoxin 125 microgram (MCG), and to hold the medication if pulse is less than 60 beats per minute (BPM) listen to pulse for one full minute. a. Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/17/2024 revealed on the Brief Interview for Mental Status (BIMS) that Resident #10 scored 11 indicating moderate cognitive impairment and had the diagnoses of heart failure and the presence of a heart assistive device. b. On 10/01/2024 at 04:21 PM, the Surveyor observed Registered Nurse (RN) #2 did not check the heart rate of Resident #10 prior to administering the medication Digoxin 125 MCG to Resident #10. c. On 10/01/2024 at 04:25 PM, during an interview RN #2 stated she had forgotten to check the resident's heart rate prior to administering the medication. 2. A review of the Physician's Orders revealed Resident #15 had an order for Renvela (a medication for chronic disease) 800 milligrams (MG) at 7:00 AM, 12:00 PM and 5:00 PM and to give with meals and Tylenol 650 mg give 2 tablets twice a day. a. Review of the quarterly MDS with an ARD of 7/23/2024 revealed on the BIMS that Resident #15 scored 15 indicating the resident was cognitively intact, and had diagnoses of renal insufficiency, renal failure, and end stage renal disease (ESRD). b. A review of the Resident Plan Of Care, for Resident #15 (problem date 5/06/2023) revealed Resident #15 was receiving hemodialysis. c. On 10/01/24 at 04:09 PM, the Surveyor observed RN #2 administer medications to Resident #15 while the resident sat in the common area not eating. d. On 10/02/24 at 2:23 PM, during an interview RN #2 stated Resident #15 was not eating at the time the Renvela was administered and she forgot to give Resident #15 the Tylenol. e. On 10/03/24 at 09:00 AM, during an interview the Director of Nursing (DON) stated that according to the Physician's Orders Renvela was to be given with food, evening meal was served starting at 5:00 PM, and an acceptable time to administer the medication would have been 30 minutes prior to mealtime. f. A policy titled, Administering Medication, noted medications must be administered in accordance with the physician's orders, including any required time frame. Medications must be administered within one hour of their prescribed time, unless otherwise specified.

Based on interviews, record review, and facility document review, it was determined the facility failed to coordinate with the state designated office to get a Preadmission Screening and Resident Review (PASARR) evaluation for a resident to ensure the resident received designated services for 1 (Resident #19) of 1 sampled resident. Findings include: A review of the electronic health records indicated the facility admitted Resident #19 on 02/28/2023 with diagnoses that included psychotic disorder with delusions due to known psychotic disorder; bipolar disorder, current episode depressed, mild; anxiety disorder, unspecified. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/06/2023, revealed Resident #19 had a Brief Interview for Mental Status (BIMS) score of 7 which indicates the resident had sever cognitive impairment, and had diagnoses of anxiety disorder, bipolar disorder, psychotic disorder (other than schizophrenia). A review of Resident #19's Resident Plan of Care, revised 06/26/2024, revealed the resident had the potential regarding Bipolar Disorder, Psychotic Disorder) Other Than Schizophrenia). Interventions included Observe for any S/S [signs/symptoms] of drug related: (if noted report to nurse), hypotension, gait disturbance, cognitive impairment, behavioral impairment, ADL [Activities of Daily Living] decline, decline in appetite. Report to physicians any negative outcomes associated with use of drug. Administer medication as prescribed by the physician. Educate resident/family on potential risk/benefits of psychotropic drug use. Monitor for effectiveness of psychotropic drug(s) and review for changes at psychotropic committee meeting. During an interview on 10/03/2024 at 2:42 PM, the Director of Nursing (DON) indicated that she was the one responsible for ensuring admission PASARRs were completed and sent to the State Designated Professional Associate. The DON indicated that they did not have a PASARR for Resident #19. The DON indicated that they completed an initial assessment on Resident #19 before admission. The DON indicated that they did not realize they had to do a PASARR after admission.

Based on observation, interview, and record review, the facility failed to ensure nail care was provided to toenails for 1 (Resident #20) sampled resident reviewed for nail care. The findings are: On 09/30/2024 at 12:25 PM, Resident #20 was observed lying in bed awake with feet exposed. The resident's great toenails on both feet were greater than a quarter inch (1/4) in length and thick. Resident #20's Physician's Orders were reviewed and indicated diagnoses of a long-term lung disease that causes difficulty breathing (chronic obstructive pulmonary disease) and lack of coordination. A physician's order dated 12/13/2016 indicated the resident may be seen by a podiatrist as needed. An annual Minimum Data Set with an Assessment Reference Date of 07/09/2024 was reviewed and indicated Resident #20 had a Brief Interview for Mental Status score of 15, which indicated cognitively intact and required partial/moderate assistance with personal hygiene. A Resident Plan of Care, dated as reviewed 07/19/2024, was reviewed and indicated Resident #20 had a self-care deficit in activities of daily living (ADLs) and required staff assistance of one person with personal hygiene. The Daily Whirlpool/Bath List sheets, provided by the Director of Nursing (DON) on 10/03/2024, were reviewed and indicated the following for Resident #20: received baths on 09/12/2024, 09/19/2024, 9/21/2024, 9/26/24, 10/1/2024; refused baths on 09/07/2024, 09/14/2024, 09/24/2024; on 09/05/2024, 3:32 Stop was documented. Resident #20's Nurse's Notes, dated 03/26/2024 through 09/28/2024, were reviewed and there was no indication nail care was refused. On 10/03/2024 at 1:33 PM, Certified Nursing Assistant (CNA) #7 was interviewed and asked when Resident #20 received a bath/shower. She stated on Tuesdays, Thursdays, and Saturdays on the evening shift, but Resident #20 had received baths on the day shift when requested. She stated the resident could bathe self, but staff washed the resident's hair and back as needed. She was asked who was responsible for nail care to the resident's hands and feet. She stated diabetic nail care was provided by the nurse, and non-diabetic nail care was provided by the CNAs. She stated CNAs did not document nail care, but they could write on the side of the bath sheet when nail care was done for residents. On 10/03/2024 at 1:24 PM, Resident #20 was observed lying in bed awake. The resident was asked if the staff provided nail care to the resident's toes. The resident stated a lady comes to the facility, but she did not do the resident's toenails. Sometimes the resident needed to go to the podiatrist because the resident has calluses on the bottom of the feet and sometimes the resident's feet hurt. On 10/03/2024 at 3:45 PM, the DON provided a typed statement which was reviewed and indicated, Nail care is provided by CNA on bath days and PRN [as needed). Diabetic nails are trimmed by license personnel only.

Based on observation, interview, and record review, the facility failed to ensure oxygen was administered at the physician's ordered rate for 1 (Resident #20) sampled resident reviewed for oxygen (O2) use and failed to provide a policy and procedure for respiratory care and services according to professional standards of practice. The findings are: Resident #20's Physician's Orders, were reviewed and indicated a diagnosis of a long-term lung disease that causes difficulty breathing (chronic obstructive pulmonary disease). A physician's order dated 09/23/2024 indicated oxygen 2 to 4 (2-4) liters (L) nasal cannula (NC) to keep O2 saturation (sat) above 93 percent (%). An annual Minimum Data Set with an Assessment Reference Date of 07/09/2024 was reviewed and indicated Resident #20 had a Brief Interview for Mental Status score of 15, which indicated cognitively intact, and the resident had shortness of breath/trouble breathing. A Resident Plan of Care, dated as reviewed 07/19/2024, was reviewed and indicated Resident #20 required oxygen by way of a NC at a rate of 2 to 4 liters to keep the O2 saturation greater than 93%. On 09/30/2024 at 12:25 PM, Resident #20 was lying in bed awake with nasal cannula prongs in the nose. The nasal cannula was attached to a humidifier bottle dated 09/29/2024. The oxygen concentrator was on and set at 4.5 liters per minute. On 10/01/2024 at 12:46 PM, Resident #20 was lying in bed with eyes closed with NC prongs in the nose. The nasal cannula was attached to a humidifier bottle dated 09/29/2024. The oxygen concentrator was on and set at 4.5 liters per minute. On 10/03/2024 at 1:26 PM, Registered Nurse (RN) #6 was interviewed with concurrent observation. She was asked to look at Resident #20's O2 and she confirmed the rate was at 4.5 liters per minute. She stated the resident's physician ordered oxygen rate was 2, but no more than 4 liters per minute. She stated the nurses set the rate on the O2 concentrator and this should be checked every shift. She stated the O2 setting should be checked to make sure the physician's orders were followed. She stated for a resident with COPD, if the O2 setting was too high, the resident could retain carbon dioxide (CO2) (a gas which stimulates breathing). On 10/03/2024, the Director of Nursing (DON) was asked to provide a policy for oxygen administration. At 3:45 PM, the DON provided a typed statement which was reviewed and indicated, The policy for oxygen is to administer oxygen per physician's orders and to change tubing and storage bag every week.

Based on observation, record review, and interview, the facility failed to accurately account for a controlled liquid narcotic, Lorazepam, after narcotic being administered to 1 (Resident #5) sampled resident who was reviewed for pharmaceutical services. The findings are: On 10/02/2024 at 3:33 PM, this surveyor and Registered Nurse (RN) #2 entered the medication storage rooms. RN #2 unlocked a small refrigerator, in which the contents were observed, and a box that contained a bottle of Lorazepam 2 milligrams/milliliters (mg/ml) liquid was inside. The liquid inside the bottle was approximately at the 20 ml black line on the bottle. The manufacturer's guidelines on the bottle indicated to discard an opened bottle 90 days after being opened. There was no date on the box or bottle. On 10/01/2024 at 4:06 PM, a narcotic log was reviewed and indicated on page 92, a 30 ml bottle of Lorazepam liquid was received from the pharmacy. On 03/18/2024 at 1215 (12:15 PM), a 0.5 (ml) dose of Lorazepam was signed out of the log but was added to the balance, instead of subtracted and the balance indicated 29.75 (ml) remaining, instead of 29.25 ml. On 05/23/2024 at 1600 (4:00 PM), the balance indicated 25.25 [ml] of Lorazepam remaining in the bottle. A second narcotic log was reviewed and indicated page 32 was started on 05/28/2024, with a balance-forward of 25.25 (ml) of Lorazepam. On 09/26/2024 at 1420 (2:20 PM), the balance indicated 22.25 (ml) of Lorazepam should be in the bottle (a 2.25 ml discrepancy). On 10/01/2024 at 4:55 PM, this surveyor informed the Director of Nursing (DON) of a discrepancy in the liquid Lorazepam remaining count. She was informed the bottle indicated about 20 ml remained, and the narcotic log indicated 22.25 ml remained which was a 2.25 ml difference. She stated she would review the concern. Resident #5's Physician's Orders were reviewed and indicated a diagnosis of anxiety. An order dated 05/07/2024 indicated Lorazepam 2 mg/ml and give 0.25 ml sublingual (SL) as needed every 6 hours. Resident #5's quarterly Minimum Data Set with an Assessment Reference Date of 07/23/2024, was reviewed and indicated the resident had a Staff Assessment of Mental Status score of 3, which indicated the resident was severely cognitively impaired. On 10/02/2024 at 10:10 AM, an in-service training report on medication administration, dated 06/10/2024 and conducted by the DON, was reviewed and indicated if any discrepancies were found, the DON was to be notified. On 10/02/2024 at 11:38 AM, the DON provided a typed statement, which was reviewed and indicated during calculation of a dose in the narcotic log on 03/18/2024, a dose was added, instead of subtracted from the count and the correct remaining balance was 21.25 ml [a 1.25 ml discrepancy]. On 10/02/2024 at 1:39 PM, the DON stated the pharmacy consultant did not conduct narcotic audits but audited if the narcotic log matched the medications the nurses signed on the MAR as administered. She stated the pharmacist comes monthly but only does random narcotic counts. She stated the facility did not have a process on how the nurses performed narcotic counts, but the nurses counted the narcotics every shift. On 10/02/2024, the DON provided a copy of the Controlled Drug Count narcotic log from 03/18/2024 to 10/02/2024. The count was performed 430 times by licensed nurses during this period. There were 29 occurrences where one signature was observed instead of two signatures of licensed nurses for a shift count. On 10/02/2024 at 5:55 PM, this surveyor observed RN #2 and Licensed Practical Nurse (LPN) #3 perform a change of shift narcotic count of the medication cart used to administer medications to the 300 Hall in the medication storage room, with the DON present. During the count, LPN #3 observed the bottle of Lorazepam from the refrigerator and stated there were approximately 19 ml in the bottle. RN #2 stated the bottle was over 20 ml. LPN #3 requested to measure the contents of the bottle manually. The DON stated the contents had been measured earlier with 3 people observing the process. LPN #3 accepted the DON and RN #2's account of the amount in the Lorazepam bottle and the count continued. After the narcotic count was complete, both nurses signed the narcotic log and LPN #3 accepted the keys to the medication cart. On 10/03/2024, the DON provided a list of all the nurses who counted the bottle of Lorazepam after the discrepancy occurred on 03/18/2024 and 14 licensed nurses were listed. The Lorazepam insert, provided by the DON on 10/03/2024, was reviewed and indicated in the dosage and administration section to use only the calibrated dropper provided with the product.

Based on observations, interviews, record reviews, and facility policy reviews, the facility failed to ensure the nurse checked the heart rate for 1 (Resident #10) sampled resident prior to the administration of a medication used to treat a heart condition by slowing down the heart rate and making sure the heart beats stronger resulting in a significant medication error. The findings include: A review of the Physician's Orders, revealed Resident #10 had an order for Digoxin 125 microgram (MCG), and to hold the medication if pulse is less than 60 beats per minute (BPM) listen to pulse for one full minute. Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/17/2024 revealed on the Brief Interview for Mental Status (BIMS) that Resident #10 scored 11 indicating moderate cognitive impairment and had the diagnoses of heart failure and the presence of a heart assistive device. On 10/01/2024 at 04:21 PM, the Surveyor observed Registered Nurse (RN) #2 did not check the heart rate of Resident #10 prior to administering the medication Digoxin 125 MCG to Resident #10. On 10/01/2024 at 04:25 PM, during an interview RN #2 stated she had forgotten to check the resident's heart rate prior to administering the medication. On 10/03/24 at 09:00 AM, during an interview the Director of Nursing (DON) stated that according to the Physician's Orders the nurse should have checked the heart rate prior to administering the medication and the medication should have been held if the heart rate was less than 60 BPM. The DON stated administering the medication without knowing the heart rate could potentially have a negative outcome on the resident by causing a low heart rate, which is serious. A policy titled, Administering Medication, noted that medications must be administered in accordance with the physician's orders and vital signs must be checked if necessary prior to administering the medication.

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN), was on duty for 8 consecutive hours a day seven days a week. The findings are: Review of staffing for August, September, and October 2023 for 8 consecutive hour work shifts showed the following: a. On 9/02/23 and 9/03/23, no RN was on duty. b. On 10/14/23, no RN was on duty. c. On 10/15/23, a RN was on duty from 5:59 PM until midnight for a total of 5 hours and 59 minutes. During interview on 10/17/23 at 2:51 PM, the Director of Nurses verified the findings above.

Based on observation, interview and policy review, the facility failed to store, prepare, and serve food for residents in a safe and sanitary manner in 1 of 1 kitchen in the facility. The findings are: 1. On 10/17/2023 at 3:05 PM Surveyors observed red and white ice chests were being used to provide ice to residents in their rooms. The chests had a dark yellow stain on the inside where the ice made contact. The scoop used to move ice from the ice chests to drinking vessels for the residents had a dark yellow stain. 2. On 10/18/2023 at 11:04 AM, Surveyors entered the kitchen dry storage area and observed eight 111-ounce (oz) cans of cut squash with dents in the rims of the cans. 3. On 10/18/2023 at 11:05 AM, Surveyors observed four 111- oz cans of pinto beans with dents in the rims of the cans. 4. On 10/18/2023 at 11:07 AM, Surveyors observed four 48 oz cans of ham [NAME] unlabeled and undated. 5. On 10/18/2023 at 11:09 AM, Surveyors observed one 26 oz can of corned beef hash with dents in the rims of the cans. 6. On 10/18/2023 at 11:13 AM, Surveyors observed one plastic resealable bag containing three heads of Romaine lettuce in the kitchen refrigerator. The bag was on the middle shelf and was not closed. 7. On 10/18/2023 at 11:19 AM, Surveyors observed an air conditioning vent above the table used to prepare meals for residents and the rack used to hang large pots and pans. Black debris was hanging from the ceiling tiles and light fixtures surrounding the vent directly above the work surface. 8. On 10/18/2023 at 11:19 AM, Surveyors observed the steam table used to serve resident meals with water basins stained a brown color, and the water they contained was brown with floating debris. Dietary Employee (DE) #1 used a scoop to remove a portion of the water in the water basin. As DE #1 moved to discard the brown water, the scoop dripped water into a serving dish of fried potatoes that was to be served to residents. 9. On 10/18/2023 at 11:34 AM, Surveyors observed DE #2 scratching arms with bare hands, and then resume handling resident food without performing handwashing. 10. On 10/18/2023 at 11:40 AM, Surveyors observed DE #2 scratching their face with their bare hands, and then resume handling resident food without performing handwashing. 11. On 10/18/2023 at 1:55 PM the Surveyor asked the Dietary Manager to cycle the dishwasher used to wash dishes for preparing and serving resident meals three times. a. Cycle one reached a wash temperature of 88 degrees Fahrenheit and a rinse temperature of 105 degrees Fahrenheit. b. Cycle two reached a wash temperature of 91 degrees Fahrenheit and a rinse temperature of 111 degrees Fahrenheit. c. Cycle three reached a wash temperature of 99 degrees Fahrenheit and a rinse temperature of 120 degrees Fahrenheit. 12. On 10/18/2023 at 2:05 PM, Surveyors observed red and white ice chests being used to provide ice to residents in their rooms. The chests had a dark yellow stain on the inside where the ice made contact. The scoop used to move ice from the ice chests to drinking vessels for the residents had a dark yellow stain. 13. On 10/17/2023 at 3:07 PM, the Dietary Manager was interviewed. a. The Dietary Manager said the dented cans had just been delivered the previous day and confirmed that food from cans with dents on the rims or seams should not be served to residents. b. The Dietary Manager said cans stored in the kitchen should be labeled with the date the items were received in the facility, and that cans missing dates were accidentally overlooked. c. The Dietary Manager said bags containing produce should be sealed when stored in the kitchen's refrigerator. d. The Dietary Manager said Maintenance was responsible for cleaning the ceiling and both the ceiling and vent hood were very dirty and needed cleaning. e. The Dietary Manager said DE #2 was new to the facility and was not performing proper hand hygiene due to lack of experience. f. The Dietary Manager said the kitchen's dishwasher had frequent malfunctions and had required repairs and adjustments on numerous occasions but was supposed to reach 120 degrees Fahrenheit on the wash cycle. g. The Dietary Manager said the ice chests were either ran through the kitchen's dishwasher, or hand washed if they would not fit, as needed. 14. Review on 10/19/2023 at 1:30 PM of the user guide and manufacturer's recommendations for the kitchen's dishwasher, titled Auto-Chlor System A4 WaterSaver showed water supply temp should be at 120 degrees Fahrenheit minimum.

Based on observation, interview and record review the facility failed to change oxygen (O2) tubing and continuous positive airway pressure (CPAP) tubing for 1 (Resident's #27) of 3 (Resident's #4, #5, and #27) residents. The findings are: Review of Resident #27's physician's orders dated 10/1/23-11/15/23 showed change oxygen tubing every week and clean filters on the oxygen concentrators weekly. Review of Resident #27's Treatment Administration Record dated 10/1/23-10/31/23 showed, change oxygen tubing every week and clean filters on the oxygen concentrators weekly with no documentation noted of being performed. On 10/16/23 at 10:38 AM, the Surveyor observed Resident #27's oxygen tubing was undated. The Continuous Positive Airway Pressure [CPAP] tubing was dated 9/24/23. On 10/17/23 at 9:12 AM, the Surveyor observed oxygen tubing undated, and the CPAP tubing was dated 9/24/23. On 10/17/23 at 2:37 PM, the Surveyor observed oxygen tubing undated, and the CPAP tubing was dated 9/24/23. On 10/18/23 at 9:19 AM, the Surveyor asked, can you tell me what the date is on Resident #27's oxygen and CPAP tubing? LPN #1 stated, There is no date on the oxygen tubing and the CPAP tubing is dated 9/24/23. On 10/18/23 at 9:37 AM, the Surveyor asked the Director of Nursing (DON) should items that are changed out be dated? The DON replied, Everything should be dated.

Based on observation and interview, the facility failed to ensure medications were stored in a secure location under the manufacturer's specified conditions, to ensure accuracy and quality of medication administration and ensure medications were secure for one of one medication rooms. The findings are: 1. On 10/18/23 at 7:49 AM, the Medication Storage Room was checked with Licensed Practical Nurse (LPN) #1. The medication storage room narcotic refrigerator contained narcotics stored in the locked refrigerator but were not in a separately locked permanently affixed box in the refrigerator. 2. On 10/18/2023 at 7:49 AM, LPN #1 was asked, should there be a locked box inside this refrigerator where you store the narcotics? LPN #1 stated, Not that I know of, we have always just stored them in this refrigerator like it is now. 3. On 10/18/2023 at 10:37 AM, the Surveyor asked the Director of Nurses (DON) can you tell me the proper way narcotics are stored in the refrigerator? The DON stated, We place them in a small mini refrigerator that is locked, and we have a thermometer in it to make sure they are kept cool. Surveyor asked, should there be a box that is locked in the refrigerator that they are put in? The DON stated, Yes, I have worked at another facility that had the box locked down in the narcotic refrigerator. Review of facility policy Controlled Substances showed controlled substances must be stored in the medication room in a locked container and separate from the container for any non-controlled medications. The container must always remain locked except when it is accessed.

Based on observation, record reviews and interviews, the facility failed to ensure a pressure relieving device was in place, failed to ensure the physician was notified of the deterioration of a pressure ulcers, failed to ensure a dressing was applied consistently to prevent the reoccurrence of a pressure ulcer and to off load feet and failed to prevent shearing for 1 (Resident #2) of 2 (Residents # 1 and #2) case mix resident's with pressure ulcers. The facility also failed to ensure dressings were removed prior to whirlpool bath and to ensure if dressings were wet the treatment nurse was notified immediately for 1 (Resident #1) of 2 (Residents # 1 and #2) case mix resident's with pressure ulcers. These failed practices caused a pattern of harm for Resident #2, who had a reoccurring Pressure ulcer to the right and left buttocks, and had the potential to cause more than minimal harm for 3 residents currently residing in the facility with pressure ulcers as per a list provided by the Administrator on 11/29/12 at 3:37 p.m. The findings are: 1. On 11/29/12 at 10:00 a.m., the Director of Nursing (DON) provided the facility ' s POLICY AND PROCEDURE FOR PRESSURE ULCER TREATMENT that documented: General Guidelines: The pressure ulcer treatment program should focus on the following strategies: 1) Managing Tissue loads and 2) Pressure ulcer care. Reduce cause of Shearing/Friction by using transfer techniques and devices as needed. If a wound does not improve in 2-3 weeks, notify physician. The Prevention of Pressure ulcers documented, " Pressure ulcers are often made worse by continual pressure, heat, moisture irritating substances on the resident's skin. A resident in the chair should have a position change every hour and the use of foam, gel or air cushion as indicated to relieve pressure. Protect bony prominences as needed. When in bed every attempt should be made to "float heels" (keep heels off of bed) by placing a pillow from knee to ankle or with other devices as recommended. 2. Resident # 2 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an assessment reference date of 9/12/12 documented the staff assessed the resident to be severely impaired for daily decision-making skills; dependent for bed mobility, dressing, eating, and personal hygiene, at risk for pressure ulcer development; and had interventions of a pressure relieving device in the bed and the chair. a. The Plan of Care updated 8/6/12 identified a problem of " At risk for skin breakdown related to impaired mobility" with interventions that included: "1) Provide skin care, monitor skin and report any change of condition promptly, and 2) Turn and reposition q (every)2 hrs., using supportive devices for good body alignment and comfort. Avoid shearing forces." The plan of care did not document any interventions related to pressure relieving devices. b. On 11/26/12 at 2:35 p.m., during initial tour, the resident was observed in bed. LPN #1 stated the resident had skin breakdown on her coccyx, "Might have healed." She was asked "What stage?" She replied, "Superficial, only top layer a (stage) 1?" She further stated, "It comes & goes." The resident's Geri chair did not have any pressure relieving device in it. The Weekly Nursing Summary dated 5/31/12 documented, "Pink superficial abrasion 1 cm (centimeter)" located on the coccyx per the skin diagram. The Weekly Nursing Summary dated 6/07/12 documented, "Abrasions 1 cm. each" located on the coccyx per the skin diagram. The Weekly Pressure/Non-Pressure Skin Record documented, " ...Pressure Ulcer ...Date Onset 7/18/12 ...Acquired (checked) Site/Location: Coccyx ...Date 7/18(2012) ... Stage II (checked) ...Length x Width 1.5 cm. x 1.5 cm Depth .2 cm ..." The Weekly Pressure/Non-Pressure Skin Record dated 8/23/12 documented the pressure sore to the coccyx was healed. c. On 11/27/12 at 8:54 a.m. and 9:44 a.m., the resident was observed up in the Geri chair and there was no pressure relieving device in the chair. d. On 11/27/12 at 9:52 a.m., Registered Nurse (RN) #1 performed wound care. The RN stated, "It (stage II pressure ulcers) will go away and then it returns, an off and on thing." She was asked, "Why do you think it returns?" She replied, "Too much pressure." She applied a non-adhering dressing with paper tape. Certified Nursing Assistant (CNA) # 5 performed incontinent care. There was a smear of feces on the brief, the tape was not attached at the base of the dressing and the feces could have been smeared up into the wound. CNA #5 turned the resident to the left side and pulled the resident ' s body up in the bed by the draw sheet, which allowed the resident ' s body to remain in contact with the surface of the bed and exposed her skin to shearing factors. Her right great toe and left outer foot surfaces were against the surface of the bed and her feet were not off-loaded to relieve pressure prior to CNA #5 left the room. 1) At the time of the treatment the 2 areas to the right lower buttocks were Stage II (one area measured 1.5 cm in diameter, 0.1 cm in depth, with 0.5 cm white maceration surrounding the area; the second area measured 0.5 cm in diameter). The Weekly Pressure/Non-Pressure Skin Record documented, " ...Pressure Ulcer ...Date Onset 10/21/12 ...Acquired (checked) Site/Location: R (right) buttock ...Date 10/24/2012 ... Stage II (checked) ...Length x Width .7 cm. x .2 cm Depth (less than).2 cm ..." A Physician order [REDACTED]." The Weekly Pressure/Non-Pressure Skin Record dated 11/21/12 documented the pressure sore to the right buttock remained a stage II length x width 2.1 x 1.4 cm with depth less than .2 cm. The Weekly Nursing Summary dated 11/8/12, documented, " ...Dressed coccyx area Stage II open areas x 3 approx (approximately 0.5 cm) each ..." The diagram indicated the open areas were across left buttock, coccyx, and right buttock. The Physician order [REDACTED]. Apply collagen to wound bed. Cover with bordered foam dressing daily." 2) At the time of the treatment the 2 areas to the left lower buttocks were stage II (one area measured 2.0 - 2.5 cm in diameter, 0.1 in depth, with 2+ cm white maceration surrounding the area; the second area measured 1 cm in diameter and was very superficial). The Weekly Pressure/Non-Pressure Skin Record documented, " ...Pressure Ulcer ...Date Onset 11/14/12 ...Acquired (checked) Site/Location: L (left) buttock ...Date 11/1/2012 ... Stage II (checked) ...Length x Width .7 cm. x .5 cm Depth (less than).2 cm ..." A physician order [REDACTED]." The Weekly Pressure/Non-Pressure Skin Record dated 11/21/12 documented the pressure sore to the left buttock remained a stage II (with increase in size noted) length x width 2.1 x 1.4 cm with depth less than .2 cm. There was no documentation in the Nurses Notes the physician was consulted regarding the deterioration in size of the pressure sore to the left buttocks until 11/26/12 at which time the Nurses Notes documented order changed per physician. A physician order [REDACTED]. The Nurses Notes and Physician order [REDACTED]. e. On 11/27/12 at 11:51 a.m., the resident was observed up in the Geri chair in the dining room. There was no pressure relieving device in the chair. At 1:29 p.m., the resident was pushed to the TV area in her Geri chair and there was no pressure relieving device in the chair. At 1:31 p.m., CNAs #2 and #8 pushed the resident to her room and transferred her to bed. The CNA's provided incontinent care for urine incontinence. The dressing over the inner buttocks had an area of red drainage that measured approximately 1 cm round and the lower edge of the dressing was not adhered to the resident's skin, which allowed for transmission of infectious organisms. f. On 11/28/12 at 9:40 a.m., the Treatment Nurse entered the resident's room to perform wound care. She stated, "Dressings were staying on well, (before she took vacation six days ago)." When she uncovered the resident, there was no dressing to the buttocks. She stated she had been in the facility since 6:00 a.m.. She was then asked, "Are the Certified Nurse Assistants supposed to tell you if there is no dressing?" She replied, "Yes, they usually do." She was then asked, "Have they notified you of the dressing being off?" She replied, "No, Ma ' am." The resident's left foot was not offloaded.. The outer left foot and the inner right foot were against a surface of a large 4 inch cushion. 1) The right lower buttocks had 3 open areas instead of the 2 observed 11/27/12: Area #1 measured 1.0 cm x 0.8 cm with less than 0.2 cm depth, Area #2 measured 0.5 cm x 0.4 cm with less than 0.2 cm depth and 1.5 cm area of maceration, and Area #3 measured 1.0 cm x 0.9 cm, with less than 0.2 cm depth. 2) The left lower buttocks had the 2 areas observed 11/27/12 but they had deteriorated in size: Area #1 measured 3.2 cm x 2.4 cm with 0.2 cm in depth and 3-4 cm area of white maceration; Area #2 measured 1.3 cm x 0.8 cm with 0.2 cm depth. 3) The Treatment Nurse was asked what caused the white macerated areas of the resident ' s pressure ulcers and she stated, "staying too moist." The Treatment Nurse was shown the resident's geri-chair that had a blue chair-padding device and asked if that could provide pressure-relief and she stated, "I wouldn't think so." The resident's feet were observed as follows: The right center heel was depressed and released by CNA #9 who described the heel as "soft." The right inner ankle was reddened over the bony prominence in an area that measured approximately 2.5 cm and was slow (greater than 4 seconds) to blanch. CNA #9 stated the resident's medial left heel was "soft," and the left foot and heel had dry skin with cracks in it. The left outer ankle and outer heel both were slow to blanch, greater than 5 seconds. 4) The Treatment Nurse used a bordered foam outer dressing to complete the resident's wound care and was asked why, since RN #1 did not use the same outer dressing on 11/27/12. The Treatment Nurse stated, "I like this kind, the (physician's) order says 'cover with dressing' so it's up to nurse. " 5) The Nurses Notes and Physician order [REDACTED]. g. On 11/28/12 at 11:52 a.m., the DON provided a Wound Care Consultant ' s Evaluation dated 11/9/12 that documented, " Daily FOAM indicated because the moisture provided by the wound fluid is maximally retained by using this moisture-retentive dressing . . . cover with BORDERED FOAM dressing. " h. On 11/29/12 at 10:55 a.m., the resident's physician was asked if he had ever viewed the resident's pressure ulcers. The Physician stated, "No one ever told me about that." On 11/29/12 at 4:12 p.m., Physician #1 (the resident ' s staff physician) was informed the facility was not always following the wound care consultant's recommendations and he stated, "I didn't know anything about that. " On 11/29/12 at 4:49 p.m., the Physician (Physician #1) was informed by the surveyor of the presence on 11/27/12 of 4 and 11/28/12 of 5 pressure ulcers (to the left and right buttocks) and he stated, "I didn't know anything about that." 3. Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 11/14/12 documented the resident scored a 5 (0-7 indicates severe impairment), required total assistance of one person for bed mobility, eating, toilet use and personal hygiene, had no functional limitations in range or motion for upper or lower extremities, used a wheelchair, was at risk for pressure ulcer development, had 1 stage II pressure ulcer with "granulation tissue-pink or red tissue with shiny, moist granular appearance," used pressure relief devices in the bed and chair and had pressure ulcer care. a. The Admission Nursing assessment dated [DATE] documented the resident's pressure ulcer measured 14 cm x 9 cm. A physician's orders [REDACTED]." b. The Resident Plan of Care dated 11/16/12 documented a problem for "admitted with a stage II decub to coccyx" with approaches, "wound care as ordered by physician" and "notify nurse immediately of any new areas of skin breakdown . . . noted during bathing or daily care." c. On 11/27/12 at 11:57a.m., CNA's #7 and #10 returned the resident to her room after she had received a whirlpool. The resident was assisted back to bed via mechanical lift. A wet dressing covered the resident's coccyx, the location of a stage II pressure ulcer. The dressing's adhesive had pulled loose on three sides, which exposed the pressure ulcer. CNA #10 [MEDICATION NAME] the wet dressing down and held it in place while a clean brief was fastened, which allowed moisture to remain directly against the stage II pressure ulcer. The resident was dressed, placed in a wheelchair and taken to the dining room for the lunch meal at 12:05a.m. At 12:44p.m., the resident was served lunch. At 1:17 p.m., the resident was moved from the dining room table and placed in front of a window. At 1:20p.m., the resident was moved from dining room to the living room. At 1:30p.m., CNA #10 took the resident back to her room and assisted the resident back to bed. The brief was left in place. d. On 11/27/12 at 1:40p.m., LPN #1 removed the dressing from the resident's coccyx. The resident had been kept in line-of-sight between 11:57 a.m. and 1:40 p.m., a time period of 1 hour and 43 minutes. LPN #1 was asked, " Has anyone told you anything about the dressing? " She stated, "Not this afternoon, she has a dressing change daily and prn (as needed)." LPN #1 was asked, "Was the dressing wet?" She stated, "Being cool to the touch, yes." LPN #1 was asked, "Did anyone tell you the dressing needed to be changed? " She stated, "No, not until just now." The stage II pressure ulcer was white in color at the top and along the left edge, the skin had a wrinkled appearance above and below the area of the dressing and the skin was reddened in an area that measured approximately 4 inches around the wound. e. On 11/27/12 at 1:45p.m., LPN #2 was asked, "Did you change the dressing this morning? " She stated, "The wound nurse (LPN #3) changed it, there's a lot of drainage." LPN #2 was asked, "Shouldn't it wick away? " She stated, "Yes, it usually does." LPN #2 was asked, "Would you say that dressing needed to be changed? " She stated, "Yes." LPN #2 was asked if the dressing was wet and she stated, "The dressing was cool to the touch so I would say yes. The dressing was obvious, it was too moist and the edges were white, like you had been in a bath too long." f. On 11/27/12 at 1:47p.m., LPN #3 was asked, "When did you change the (resident ' s coccyx) dressing? " She stated, "This morning about 6:15 (a.m. to) 6:20 (a.m.) because she does not go to breakfast." LPN #3 was asked, "Do you usually need to change it this quick? " She stated, "No." LPN #3 was asked, "Is it normally that wet? She stated, "No." LPN #3 was asked if anyone had told her the dressing needed to be changed and she stated, "No, not until just now." g. On 11/28/12 at 9:55a.m., the Treatment Nurse measured the pressure ulcer and the measurements were; .5 x 1.1cm open area, 4.5cm macerated area, with the open area 2.2 cm at it's widest point. On 11/28/12 at 1:30p.m., the Treatment Nurse was asked, "The last assessment on the weekly skin record was done on the 21st, you saw it today, would you say it looks worse today than the last assessment?" She stated, "Yes ma ' am, I would say the total area has gotten bigger." The Treatment Nurse was asked, "Does it usually look that macerated? " She stated, "No." h. On 11/30/12 at 10:25a.m., CNA #10 was asked, "Did you notify anyone (Resident #1's) dressing was wet after the whirlpool? " She stated, "No, ma ' am, I didn't." CNA #10 was asked, "Have you had any instruction regarding what to do if a resident's dressing gets wet or soiled? and she stated, "Yes." CNA #10 was asked, "What did they tell you? " She stated, "To go and let the nurse know."

Based on observations, record review and interview, the facility Quality Assessment and Assurance (QA&A) Committee failed to identify quality deficiencies in order to implement corrective actions in areas of Pressure ulcer prevention and infection control as evidenced by: The facility failed to ensure the physician was notified of the deterioration of a pressure ulcers, failed to ensure a dressing was applied consistently to prevent the reoccurrence of a pressure ulcer and to off load feet and failed to prevent shearing for 1 (Resident #2) of 2 (Residents # 1 and #2) case mix resident's with pressure ulcers. The facility also failed to ensure dressings were removed prior to whirlpool bath and to ensure if dressings were wet the treatment nurse was notified immediately for 1 (Resident #1) of 2 (Residents # 1 and #2) case mix resident's with pressure ulcers. These failed practices caused a pattern of harm for Resident #2, who had a reoccurring Pressure ulcer to the right and left buttocks, and had the potential to cause more than minimal harm for 3 residents currently residing in the facility with pressure ulcers as per a list provided by the Administrator on 11/29/12 at 3:37 p.m. The facility's failure to ensure the infection control log accurately documented the onset of symptoms and resolution of infections for 6 of 6 months reviewed. The failed practice had the potential to affect all 56 residents who resided in the facility and could potentially experience infections requiring documentation on the Infection Control Log, as documented on the Resident Census and Conditions of Residents form dated 11/26/12 at 11:24 a.m. The findings are. 1. Resident # 2 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an assessment reference date of 9/12/12 documented the staff assessed the resident to be severely impaired for daily decision-making skills; dependent for bed mobility, dressing, eating, and personal hygiene, at risk for pressure ulcer development; and had interventions of a pressure relieving device in the bed and the chair. a. The Plan of Care updated 8/6/12 identified a problem of " At risk for skin breakdown related to impaired mobility" with interventions that included: "1) Provide skin care, monitor skin and report any change of condition promptly, and 2) Turn and reposition q (every)2 hrs., using supportive devices for good body alignment and comfort. Avoid shearing forces." The plan of care did not document any interventions related to pressure relieving devices. b. On 11/26/12 at 2:35 p.m., during initial tour, the resident was observed in bed. LPN #1 stated the resident had skin breakdown on her coccyx, "Might have healed." She was asked "What stage?" She replied, "Superficial, only top layer a (stage) 1?" She further stated, "It comes & goes." The resident's Geri chair did not have any pressure relieving device in it. The Weekly Nursing Summary dated 5/31/12 documented, "Pink superficial abrasion 1 cm (centimeter)" located on the coccyx per the skin diagram. The Weekly Nursing Summary dated 6/07/12 documented, "Abrasions 1 cm. each" located on the coccyx per the skin diagram. The Weekly Pressure/Non-Pressure Skin Record documented, " ...Pressure Ulcer ...Date Onset 7/18/12 ...Acquired (checked) Site/Location: Coccyx ...Date 7/18(2012) ... Stage II (checked) ...Length x Width 1.5 cm. x 1.5 cm Depth .2 cm ..." The Weekly Pressure/Non-Pressure Skin Record dated 8/23/12 documented the pressure sore to the coccyx was healed. c. On 11/27/12 at 8:54 a.m. and 9:44 a.m., the resident was observed up in the Geri chair and there was no pressure relieving device in the chair. d. On 11/27/12 at 9:52 a.m., Registered Nurse (RN) #1 performed wound care. The RN stated, "It (stage II pressure ulcers) will go away and then it returns, an off and on thing." She was asked, "Why do you think it returns?" She replied, "Too much pressure." She applied a non-adhering dressing with paper tape. Certified Nursing Assistant (CNA) # 5 performed incontinent care. There was a smear of feces on the brief, the tape was not attached at the base of the dressing and the feces could have been smeared up into the wound. CNA #5 turned the resident to the left side and pulled the resident ' s body up in the bed by the draw sheet, which allowed the resident ' s body to remain in contact with the surface of the bed and exposed her skin to shearing factors. Her right great toe and left outer foot surfaces were against the surface of the bed and her feet were not off-loaded to relieve pressure prior to CNA #5 left the room. 1) At the time of the treatment the 2 areas to the right lower buttocks were Stage II (one area measured 1.5 cm in diameter, 0.1 cm in depth, with 0.5 cm white maceration surrounding the area; the second area measured 0.5 cm in diameter). The Weekly Pressure/Non-Pressure Skin Record documented, " ...Pressure Ulcer ...Date Onset 10/21/12 ...Acquired (checked) Site/Location: R (right) buttock ...Date 10/24/2012 ... Stage II (checked) ...Length x Width .7 cm. x .2 cm Depth (less than).2 cm ..." A Physician order [REDACTED]." The Weekly Pressure/Non-Pressure Skin Record dated 11/21/12 documented the pressure sore to the right buttock remained a stage II length x width 2.1 x 1.4 cm with depth less than .2 cm. The Weekly Nursing Summary dated 11/8/12, documented, " ...Dressed coccyx area Stage II open areas x 3 approx (approximately 0.5 cm) each ..." The diagram indicated the open areas were across left buttock, coccyx, and right buttock. The Physician order [REDACTED]. Apply collagen to wound bed. Cover with bordered foam dressing daily." 2) At the time of the treatment the 2 areas to the left lower buttocks were stage II (one area measured 2.0 - 2.5 cm in diameter, 0.1 in depth, with 2+ cm white maceration surrounding the area; the second area measured 1 cm in diameter and was very superficial). The Weekly Pressure/Non-Pressure Skin Record documented, " ...Pressure Ulcer ...Date Onset 11/14/12 ...Acquired (checked) Site/Location: L (left) buttock ...Date 11/1/2012 ... Stage II (checked) ...Length x Width .7 cm. x .5 cm Depth (less than).2 cm ..." A physician order [REDACTED]." The Weekly Pressure/Non-Pressure Skin Record dated 11/21/12 documented the pressure sore to the left buttock remained a stage II (with increase in size noted) length x width 2.1 x 1.4 cm with depth less than .2 cm. There was no documentation in the Nurses Notes the physician was consulted regarding the deterioration in size of the pressure sore to the left buttocks until 11/26/12 at which time the Nurses Notes documented order changed per physician. A physician order [REDACTED]. The Nurses Notes and Physician order [REDACTED]. e. On 11/27/12 at 11:51 a.m., the resident was observed up in the Geri chair in the dining room. There was no pressure relieving device in the chair. At 1:29 p.m., the resident was pushed to the TV area in her Geri chair and there was no pressure relieving device in the chair. At 1:31 p.m., CNAs #2 and #8 pushed the resident to her room and transferred her to bed. The CNA's provided incontinent care for urine incontinence. The dressing over the inner buttocks had an area of red drainage that measured approximately 1 cm round and the lower edge of the dressing was not adhered to the resident's skin, which allowed for transmission of infectious organisms. f. On 11/28/12 at 9:40 a.m., the Treatment Nurse entered the resident's room to perform wound care. She stated, "Dressings were staying on well, (before she took vacation six days ago)." When she uncovered the resident, there was no dressing to the buttocks. She stated she had been in the facility since 6:00 a.m.. She was then asked, "Are the Certified Nurse Assistants supposed to tell you if there is no dressing?" She replied, "Yes, they usually do." She was then asked, "Have they notified you of the dressing being off?" She replied, "No, Ma ' am." The resident's left foot was not offloaded.. The outer left foot and the inner right foot were against a surface of a large 4 inch cushion. 1) The right lower buttocks had 3 open areas instead of the 2 observed 11/27/12: Area #1 measured 1.0 cm x 0.8 cm with less than 0.2 cm depth, Area #2 measured 0.5 cm x 0.4 cm with less than 0.2 cm depth and 1.5 cm area of maceration, and Area #3 measured 1.0 cm x 0.9 cm, with less than 0.2 cm depth. 2) The left lower buttocks had the 2 areas observed 11/27/12 but they had deteriorated in size: Area #1 measured 3.2 cm x 2.4 cm with 0.2 cm in depth and 3-4 cm area of white maceration; Area #2 measured 1.3 cm x 0.8 cm with 0.2 cm depth. 3) The Treatment Nurse was asked what caused the white macerated areas of the resident's pressure ulcers and she stated, "staying too moist." The Treatment Nurse was shown the resident's geri-chair that had a blue chair-padding device and asked if that could provide pressure-relief and she stated, "I wouldn't think so." The resident's feet were observed as follows: The right center heel was depressed and released by CNA #9 who described the heel as "soft." The right inner ankle was reddened over the bony prominence in an area that measured approximately 2.5 cm and was slow (greater than 4 seconds) to blanch. CNA #9 stated the resident's medial left heel was "soft," and the left foot and heel had dry skin with cracks in it. The left outer ankle and outer heel both were slow to blanch, greater than 5 seconds. 4) The Treatment Nurse used a bordered foam outer dressing to complete the resident's wound care and was asked why, since RN #1 did not use the same outer dressing on 11/27/12. The Treatment Nurse stated, "I like this kind, the (physician's) order says 'cover with dressing' so it's up to nurse. " 5) The Nurses Notes and Physician order [REDACTED]. g. On 11/28/12 at 11:52 a.m., the DON provided a Wound Care Consultant ' s Evaluation dated 11/9/12 that documented, " Daily FOAM indicated because the moisture provided by the wound fluid is maximally retained by using this moisture-retentive dressing . . . cover with BORDERED FOAM dressing. " h. On 11/29/12 at 10:55 a.m., the resident's physician was asked if he had ever viewed the resident's pressure ulcers. The Physician stated, "No one ever told me about that." On 11/29/12 at 4:12 p.m., Physician #1 (the resident's staff physician) was informed the facility was not always following the wound care consultant's recommendations and he stated, "I didn't know anything about that. " On 11/29/12 at 4:49 p.m., the Physician (Physician #1) was informed by the surveyor of the presence on 11/27/12 of 4 and 11/28/12 of 5 pressure ulcers (to the left and right buttocks) and he stated, "I didn't know anything about that." 2. Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 11/14/12 documented the resident scored a 5 (0-7 indicates severe impairment), required total assistance of one person for bed mobility, eating, toilet use and personal hygiene, had no functional limitations in range or motion for upper or lower extremities, used a wheelchair, was at risk for pressure ulcer development, had 1 stage II pressure ulcer with "granulation tissue-pink or red tissue with shiny, moist granular appearance," used pressure relief devices in the bed and chair and had pressure ulcer care. a. The Admission Nursing assessment dated [DATE] documented the resident's pressure ulcer measured 14 cm x 9 cm. A physician's orders [REDACTED]." b. The Resident Plan of Care dated 11/16/12 documented a problem for "admitted with a stage II decub (Decubitus) to coccyx" with approaches, "wound care as ordered by physician" and "notify nurse immediately of any new areas of skin breakdown . . . noted during bathing or daily care." c. On 11/27/12 at 11:57 a.m., CNA #7 and CNA #10 returned the resident to her room after she had received a whirlpool. The resident was assisted back to bed via mechanical lift. A wet dressing covered the resident's coccyx, the location of a stage II pressure ulcer. The dressing's adhesive had pulled loose on three sides, which exposed the pressure ulcer. CNA #10 [MEDICATION NAME] the wet dressing down and held it in place while a clean brief was fastened, which allowed moisture to remain directly against the stage II pressure ulcer. The resident was dressed, placed in a wheelchair and taken to the dining room for the lunch meal at 12:05a.m. At 12:44p.m., the resident was served lunch. At 1:17 p.m., the resident was moved from the dining room table and placed in front of a window. At 1:20p.m., the resident was moved from dining room to the living room. At 1:30p.m., CNA #10 took the resident back to her room and assisted the resident back to bed. The brief was left in place. d. On 11/27/12 at 1:40p.m., LPN #1 removed the dressing from the resident's coccyx. The resident had been kept in line-of-sight between 11:57 a.m. and 1:40 p.m., a time period of 1 hour and 43 minutes. LPN #1 was asked, "Has anyone told you anything about the dressing?" She stated, "Not this afternoon, she has a dressing change daily and prn (as needed)." LPN #1 was asked, "Was the dressing wet?" She stated, "Being cool to the touch, yes." LPN #1 was asked, "Did anyone tell you the dressing needed to be changed?" She stated, "No, not until just now." The stage II pressure ulcer was white in color at the top and along the left edge, the skin had a wrinkled appearance above and below the area of the dressing and the skin was reddened in an area that measured approximately 4 inches around the wound. e. On 11/27/12 at 1:45 p.m., LPN #2 was asked, "Did you change the dressing this morning?" She stated, "The wound nurse (LPN #3) changed it, there's a lot of drainage." LPN #2 was asked, "Shouldn't it wick away?" She stated, "Yes, it usually does." LPN #2 was asked, "Would you say that dressing needed to be changed?" She stated, "Yes." LPN #2 was asked if the dressing was wet and she stated, "The dressing was cool to the touch so I would say yes. The dressing was obvious, it was too moist and the edges were white, like you had been in a bath too long." f. On 11/27/12 at 1:47 p.m., LPN #3 was asked, "When did you change the (resident's coccyx) dressing?" She stated, "This morning about 6:15 (a.m. to) 6:20 (a.m.) because she does not go to breakfast." LPN #3 was asked, "Do you usually need to change it this quick? " She stated, "No." LPN #3 was asked, "Is it normally that wet? She stated, "No." LPN #3 was asked if anyone had told her the dressing needed to be changed and she stated, "No, not until just now." g. On 11/28/12 at 9:55 a.m., the Treatment Nurse measured the pressure ulcer and the measurements were; .5 x 1.1cm open area, 4.5cm macerated area, with the open area 2.2 cm at it's widest point. On 11/28/12 at 1:30p.m., the Treatment Nurse was asked, "The last assessment on the weekly skin record was done on the 21st, you saw it today, would you say it looks worse today than the last assessment?" She stated, "Yes ma ' am, I would say the total area has gotten bigger." The Treatment Nurse was asked, "Does it usually look that macerated?" She stated, "No." h. On 11/30/12 at 10:25 a.m., CNA #10 was asked, "Did you notify anyone (Resident #1's) dressing was wet after the whirlpool? " She stated, "No, ma ' am, I didn't." CNA #10 was asked, "Have you had any instruction regarding what to do if a resident's dressing gets wet or soiled? and she stated, "Yes." CNA #10 was asked, "What did they tell you? " She stated, "To go and let the nurse know." 3. On 11/30/12 at 12:23 p.m., the Administrator was interviewed. The Administrator stated that they had wound meetings. The Administrator was asked, "How are the interventions monitored?" The Administrator stated that they do QA rounds, but do not document anything unless it is wrong. The Administrator was then asked, "Who is responsible for getting new interventions in place?" The Administrator stated, "Whoever it is assigned to." The Administrator was asked who monitored placement of a pressure relief device in Resident #2's geri-chair after that intervention had been planned during the Wound Meeting held 11/21/12 and she stated QA rounds were done on a daily basis, but there was no documentation of the new interventions planned, "unless wrong." The Administrator was asked who was assigned to monitor the placement of the pressure relieving device for Resident #2. The Administrator stated, "Don't remember." 4. On 11/30/12 at 10:15 a.m., the Infection Control Log for 5/1/12 through 10/28/12 was reviewed. There was no documentation of dates of resolution for the documented infections. The Assistant Director of Nursing (ADON) was asked how resolution of infections was documented in the Infection Control Log. The ADON stated, "I honestly, I don't. We always do a follow-up UA (urinalysis) for UTI's (urinary tract infections)." She also stated the onset dates that were documented in the log were actually the date of the initial telephone order for treatment, not the actual date symptoms were first noted. On 11/30/12 at 12:30 p.m., the Administrator and Director of Nursing both agreed they had not identified that there was no resolution dates, dates of onset were inaccurate and the continued presence of infections was not carried over on the infection log at the end of the month.