Every finding on record at Cross City Nursing and Rehabilitation Center

Based on observation, interview, and record review the facility failed to ensure food was served in a sanitary manner during the 9/10/2025 midday meal, of two meals observed. Findings include:During an observation on 9/10/2025 beginning at 11:20 AM of the food services midday Staff A, [NAME] was observed using gloved hands to retrieve scoops, metal containers and other items from various areas in the kitchen. At 11:30 AM Staff A, did not remove the gloves or perform hand hygiene and lifted two pieces of cornbread from a metal tray with her gloved hands and placed the cornbread on individual residents' plates for service to the residents.During an interview on 9/10/2025 at 11:32 AM, the Certified Dietary Manager stated, She [Staff A] should use tongs to lift the cornbread from the tray and place on plates for service to residents.During an observation on 9/10/2025 at 11:34 AM, Staff A was observed lifting plates and bowls to fill with food for service to the residents. Staff A lifted two bowls and two plates with her fingers touching the interior food surface of the bowls and her thumb touching the interior food surface of the plates. At 11:35 AM, Staff A doffed gloves and donned a new pair of gloves without performing hand hygiene and returned to the tray line to prepare meal plates to serve to the residents.During interview on 9/10/2025 at 11:36 AM, the Certified Dietary Manager confirmed Staff A should not touch the interior food surfaces of the plates and bowls used to serve food to residents. Review of the policy and procedure titled Maintaining a Sanitary Tray Line, last reviewed 12/18/2024 read, The facility prioritizes tray assembly to ensure foods are handled safely and held at proper temperatures in order to prevent the spread of bacteria that may cause food borne illness. 3. During tray assembly, staff shall: Use utensils such as tongs, serving spoons, etc. [etcetera] to handle foods as much as possible. e. Perform hand hygiene before and after wearing or changing gloves. f. Change gloves when activities are changed, or when the type of food being handled is changed, or when leaving the workstation.

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded for 1 of 3 residents, Resident #51. Findings Include:Review of the Discharge/Return Anticipated/End of PPS [prospective payment system] Part A Stay MDS for Resident #51 dated 8/12/2025, read, Section A: Discharge Status: Home/CommunityReview of the census documented Resident #51 currently resides in the facility.During an interview on 09/09/2025 at 11:32 AM, Staff C, RN/MDS Coordinator (Registered Nurse) stated, He [Resident #51] was discharged , and we thought he was coming back. He went to an appointment on that day, was admitted to the hospital and we didn't have clear information on what was going on. We thought he was discharging home from the hospital. I didn't know if he was going to come back or not. Looking back on it, I should have coded the discharge status as 04. Short-Term General HospitalDuring an interview on 09/09/2025 at 1:04 PM, Resident #51 stated, I remember going to the hospital, but I don't remember the date. Review of the policy and procedure titled, Conducting an Accurate Resident Assessment, reviewed 12/18/2024 read, Policy: The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment by staff qualified to assess relevant care areas. Definition: 'Accuracy of assessment' means that the appropriate, qualified health professionals correctly document the resident's medical, functional, and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities, and psychosocial status using the appropriate Resident Assessment Instrument (RAI) (i.e. comprehensive, quarterly, significant change in status). 2. Qualified staff who are knowledgeable about the resident will conduct an accurate assessment addressing each resident's status, needs, strengths, and areas of decline. The assessment will be documented in the medical record. 3. The appropriate, qualified health professional will correctly document the resident's medical, functional, and psychosocial problems and identifies resident strengths to maintain or improve medical status, functional, and psychosocial problems and identifies resident strengths to maintain or improve medical status, functional abilities and psychosocial status.

Based on interview and record review the facility failed to ensure physician ordered parameters were followed related to blood pressure medications resulting in the administration of unnecessary medications for 2 (Resident #16 and #35) of 5 residents reviewed for unnecessary medications.Findings include:1) Review of Resident #16's admission record documented diagnosis that include chronic obstructive pulmonary disease, unspecified, type 2 diabetes mellitus without complications, iron deficiency anemia, unspecified, vitamin b12 deficiency anemia, unspecified, chronic pain syndrome, major depressive disorder, recurrent, mild, unspecified atrial fibrillation (an irregular heartbeat), gastro-esophageal reflux disease without esophagitis, hyperlipidemia, unspecified (high cholesterol),and essential (primary) hypertension (high blood pressure).Review of Resident #16's physician order dated 4/27/2025 read, Labetalol HCl [labetalol hydrochloride] oral tablet give 150 mg (milligrams) by mouth two times a day hold if HR [heart rate] <60 bpm [less than 60 beats per minute], hold if BP [blood pressure] systolic 100 or below related to essential (primary) hypertension. Review of Resident #16's Medication Administration Record (MAR) for July 2025 documented that Labetalol HCL 150 mg (milligrams) was administered outside of physician ordered parameters for heart rate less than 60 at 0900 (9:00 AM) on 7/7/2025 heart rate of 58, on 7/8/2025 HR 55, on 7/11/2025 HR 59, on 7/16/2025 HR 54 on 7/17/2025 HR 51, on 7/18/2025 HR 53, on 7/22/2025 HR 57, on 7/24/2025 HR 54, and on 7/28/2025 HR 58.Review of Resident #16's MAR for July 2025 Labetalol HCL 150 mg (milligrams) was administered outside of physician ordered parameters for heart rate less than 60 at 2100 (9:00 PM) on 7/4/2025 HR 56, 7/5/2025 HR 54, 7/6/2025 HR 58, 7/8/2025 HR 58, 7/17/2025 HR 58, 7/20/2025 HR 52, 7/27/2025 HR 58 and on 7/30/2025 HR 57.Review of Resident #16's MAR for August 2025 documented that Labetalol HCL 150 mg (milligrams) was administered outside of physician ordered parameters for heart rate less than 60 at 2100 on 8/9/2025 HR 59, 8/10/2025 HR 56, 8/20/2025 HR 54, 8/22/2025 HR 58 and 8/27/2025 HR 552) Review of Resident #35's admission record documented diagnosis that include unspecified combined systolic congestive and diastolic congestive heart failure, chronic obstructive pulmonary disease unspecified, unspecified protein calorie malnutrition, essential primary hypertension, major depressive disorder recurrent mild, peripheral vascular disease unspecified, chronic kidney disease unspecified, gastroesophageal reflux disease without esophagitis, chronic embolism and thrombosis unspecified deep veins of right lower extremity, unspecified atrial fibrillation, hypothyroid unspecified, age-related osteoporosis without current pathological fracture, unilateral primary osteoarthritis and right knee pain.Review of Resident #35's physician order dated 1/15/2025 read, Midodrine HCl oral tablet 10 mg (Midodrine HCl) give 1 tablet by mouth three times a day for low blood pressure give if Systolic 120 or below.Review of Resident #35's July MAR documented Midodrine was administered at 08:00 (8:00 AM) on 7/15/2025 with a blood pressure (B/P) of 142/76, on 7/17/2025 with a B/P of 126/78, and on 7/26/2025 with a B/P of 136/64.Review of Resident #35's July MAR documented Midodrine was administered at 12:00 (12:00 PM) on 7/4/2025 with a B/P of 122/60, on 7/13/2025 with a B/P of 122/64, on 7/16/2025 with a B/P of 122/72, on 7/19/2025 with a B/P of 126/82, 7/20/2025 with a B/P of 126/82, on 7/21/2025 with a B/P of 122/60 and on 7/26/2025 with a B/P of 136/64.Review of Resident #35's July MAR documented Midodrine was administered at 1600 (4:00 PM) on 7/17/2025 with a B/P of 124/74, 7/21/2025 with a B/P of 126/60 and on 7/22/2025 with a B/P of 122/60.Review of Resident #35's August MAR documented Midodrine was administered at 0800 on 8/10/2025 with a B/P of 136/64.Review of Resident #35's August MAR documented Midodrine was administered at 1200 on 8/4/2025 with a B/P of 122/60, on 8/16/2025 with a B/P of 130/86, on 8/19/2025 with a B/P of 128/64, om 8/24/2025 with a B/P of 122/64, on 8/25/2025 with a B/P of 124/79, on 8/26/2025 with a B/P of 122/60 and on 8/28/2025 with a B/P of 124/86.Review of Resident #35's September MAR documented Midodrine was administered at 1200 on 9/3/2025 with a B/P of 126/88, on 9/7/2025 with a B/P of 122/60 and on 9/9/2025 with a B/P of 122/60.Review of Resident #35's September MAR documented Midodrine was administered at 1600 on 9/9/2025 with a B/P of 122/60.During an interview on 9/9/2025 at 8:27 AM Staff E, LPN stated, I guess I gave it [the midodrine]. I should have held it.During an interview on 9/10/2025 at 9:25 AM Staff F, LPN stated, I don't know if I gave it [the midodrine] or not, maybe I did. Usually, I will document that the parameters mean I hold the medicine. My initials without that means I must have administered it. I don't really know if I did or not.Review of the policy and procedure titled, Medication Administration last review date of 1/9/2025 read, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination, or infection. 8. Obtain and record vital signs when applicable or per physician orders. When applicable hold medication for those vital signs outside the physicians' prescribed parameters.

Based on observation, interview and record review the facility failed to administer oxygen at physician ordered flow rates according to professional standards of practice for 2 (Resident #1 and #26) of 3 residents reviewed for oxygen administration. Findings include: 1) During an observation on 9/8/2025 at 10:00 AM Resident #1 was observed in bed. Oxygen was being administered via concentrator by nasal cannula at 4 liters per minute.Review of Resident #1's admission record documented diagnosis that include acute and chronic respiratory failure with hypoxia (a condition where the lungs are unable to exchange oxygen and carbon dioxide leading to low oxygen levels-hypoxia), chronic obstructive pulmonary disease (lung disease that cause breathing problems) with acute exacerbation (a sudden worsening of the symptoms), pneumonia, unspecified organism, and acute and chronic (systolic) congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should).Review of Resident #1's physician orders dated 8/1/2025 read, Oxygen at 2 liters per min [minute] via nasal cannula every shift. Verify concentrator is set to the ordered liters per minute.Review of Resident #1's comprehensive care plan read, Focus: [Resident #1's name] is at risk for altered breathing, respiratory distress secondary to COPD [chronic obstructive pulmonary disease]. Interventions: O2 [oxygen] as per MD [Medical Doctor] order.During an interview on 9/10/2025 at 9:00 AM Staff F, Licensed Practical Nurse (LPN) stated, It [the oxygen] is on 4 liters, it should be on 2 Liters. I usually check on oxygen after I do med [medication] pass. I have not checked hers [Resident #1] yet. We should follow the orders and have it on the right rate. 2) During an observation on 9/9/2025 at 7:27 AM Resident #26 was observed in bed. Oxygen was being administered via concentrator by nasal cannula at 4 liters per minute. The oxygen concentrator was outside of the resident's reach and was facing the wall.Review of Resident #26's admission record documented diagnosis that include acute and chronic respiratory failure with hypercapnia (high [NAME] dioxide levels in the blood), chronic obstructive pulmonary disease with acute exacerbation, respiratory failure unspecified with hypoxia, atherosclerotic heart disease of native coronary artery without angina pectoris (chest pain), paroxysmal atrial fibrillation (an irregular heartbeat), and obstructive sleep apnea adult (a sleep disorder when you stop breathing during sleep).Review of Resident #26's physician order dated 8/20/2025 read, Oxygen at 3 liters per min via nasal cannula every shift. Verify concentrator is set to the ordered liters per minute.Review of Resident #26's comprehensive care plan read, Focus: [Resident #26's name] is at risk for altered breathing, respiratory distress secondary to COPD. Interventions: O2 as per MD order.During an interview on 9/9/2025 at 7:27 AM Resident #26 stated, I never change my oxygen, the nurses always do that.During an interview on 9/10/2025 at 9:00 AM Staff F, LPN stated, Her [Resident #26] oxygen should be at 3 liters. I'm not sure how that happened. We should check oxygen every day and check oxygen sat's [saturations]. Review of the policy and procedure titled Oxygen Administration last revision date of 3/15/2025 read, Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Policy explanation and Compliance guidelines. 1.Oxygen is administered under orders of a physician, except in the case of emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control.

Based on interview and record review, the facility failed to ensure the administration of insulin and to notify the physician of elevated blood glucose values for 2 of 5 residents, Residents #25 and #22) reviewed for unnecessary medications.Findings include: 1) Review of Resident #25's admission record documented diagnosis to include myocardial infarction type 2 (a heart attack), cognitive communication deficit, type 2 diabetes mellitus without complications, chronic atrial fibrillation (an irregular heartbeat), unspecified, essential (primary) hypertension (high blood pressure), hyperlipidemia, unspecified (high cholesterol), and atherosclerotic heart disease of native coronary artery (heart disease) without angina pectoris (chest pain).Review of Resident #25's physician orders dated 9/4/2025 read, Insulin Glargine-yfgn [yfgn is a unique suffix identifier assigned by the U.S. Food and Drug Administration to distinguish it from other similar products]. Subcutaneous Solution Pen-injector 100 unit/ml (milliliter) (Insulin Glargine-yfgn) inject 63 units subcutaneously at bedtime related to type 2 diabetes mellitus without complications.Review of Resident #25's Medication Administration Record (MAR) for September 2025 documented a blood sugar value of 463 on 9/5/2025 at 2000 (8:00 PM), and a blood sugar value of 454 on 9/7/2025 at 2000, there were no notes within the medical record that documented the physician was notified per the Medical Doctor's orders.Review of Resident #25's MAR for August 2025 documented on 8/26/2025 at 2000 chart code 12 (vitals outside parameters) for Insulin Glargine-yfgn Subcutaneous Solution Peninjector 100 unit/ml (Insulin Glargine-yfgn) Inject 55 unit subcutaneously at bedtime related to Type 2 Diabetes Mellitus without complications. During an interview on 9/09/2025 at 6:03 AM Staff G, LPN (Licensed Practical Nurse) stated, I did not give the insulin it was outside the parameters.During an interview on 9/11/2025 at 4:08 AM Staff F, LPN stated, The blood sugar was above 450. I should have called the doctor. I don't know if I did or not. I can't tell you if I actually called the on call person about the high blood sugar. I have no notes in the chart. I should have called and documented that.2) Review of Resident #22's admission record documented diagnosis that include, Type 2 diabetes mellitus with diabetic neuropathy, unspecified, hypothyroidism, unspecified, chronic systolic (congestive) heart failure, unspecified dementia unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, and cognitive communication deficit.Review of Resident #22's physician orders dated 8/13/2025 read, Lantus SoloStar Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine) inject 14 units subcutaneously at bedtime related to type 2 diabetes mellitus with diabetic neuropathy unspecified. Review of Resident #22's MAR documented Lantus insulin was held without parameters on the physician order on 8/22/2025 and documented a chart code of 9 (other, see nurses notes). Dated 8/26/2025 documented a chart code of 9 (other see nurses notes), and dated 8/30/2025 documented chart code of 5 (hold see nurses notes).Review of Resident #22's EMAR (Electronic Medication Administration Record) dated 8/22/2025 at 2100 (9:00 PM) read, Lantus SoloStar Subcutaneous Solution Pen-injector 100 unit/ml inject 14 unit subcutaneously at bedtime related to Type 2 Diabetes Mellitus with diabetic neuropathy, unspecified (E11.40) hold due to bs [blood sugar] at 80.Review of Resident #22's REMAR dated 8/26/2025 at 21:24 (9:24 PM) read, Lantus SoloStar Subcutaneous Solution Pen-injector 100 unit/ml Inject 14 unit subcutaneously at bedtime related to Type 2 Diabetes Mellitus with diabetic neuropathy, unspecified (E11.40) BS 73.Review of Resident #22's EMAR dated 8/30/2025 at 2158 (9:58 PM) EMAR read, Lantus SoloStar Subcutaneous Solution Pen-injector 100 unit/ml Inject 14 unit subcutaneously at bedtime related to Type 2 Diabetes Mellitus with diabetic neuropathy, unspecified (E11.40) BS 71.During an interview on 9/10/2025 at 6:00 AM Staff G, LPN stated, I did hold the insulin. It was outside parameters based on the sliding scale. The physician order was reviewed with Staff G. Staff G stated, There are no parameters on that [Lantus SoloStar insulin]. I guess I shouldn't have held it.Review of the policy and procedure titled, Medication Administration last review date of 1/9/2025 read, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination, or infection.

Based on observation, interview, and record review, the facility failed to ensure the residents received medication as per physician orders for 2 (Resident #25, #211) of 4 residents reviewed for pain medication administration and for 1 (Resident #160) of 3 residents reviewed for the care and treatment related to Peripheral Inserted Central Catheter (PICC) line dressings. Findings include: 1). Review of Resident #211's physician's order dated 6/4/2024 read, Acetaminophen Tablet Give 650 mg (milligrams) by mouth every 6 hours as needed for Mild Pain Do Not Exceed 3gm (grams) in 24 hours, pain scale 1-3 Review of Resident #211's Medication Administration Record (MAR) for June 2024 documented the resident received Acetaminophen 650 mg on June 14 at 4:15 AM with a pain level of 6. Review of Resident #211's physician's order dated 6/4/2024 read, Oxycodone HCI Oral Tablet 5 MG Give 1 tablet by mouth every 4 hours as needed for Pain related to chronic pain syndrome. Pain scale 4-10 Review of Resident #211's MAR for June 2024 documented the resident received Oxycodone HCI 5 MG on June 6 at 1233 [12:33 PM] for a pain level of 2 and at 2021 [8:21 PM] for a pain level of 1, June 7 at 0152 [1:52 AM] for a pain level of 1 and at 1242 [12:42 PM] for a pain level of 2, June 14 at 2115 [10:15 PM] for a pain level of 3, and on June 15 at 0244 [2:44 AM] for a pain level of 2. 2). Review of Resident #25's physician's order dated 5/30/2024 reads, Oxycodone-Acetaminophen Tablet 5-325 MG Give 1 tablet by mouth every 6 hours as needed for Pain pain scale 4-10 Review of Resident #25's MAR for June 2024 documented the resident received Oxycodone-Acetaminophen Tablet 5-325 MG on June 2 at 1549 [3:49 PM] for a pain level of 2, June 6 at 1244 [12:44 PM] for a pain level of 2 and at 2340 [11:40 PM] for a pain level of 2, June 14 at 2007 [8:07 PM] for a pain level of 3 and June 15 at 0422 [4:22 AM] for pain level of 2. Review of Resident #25's physician's order dated 5/30/2024 reads, Acetaminophen Tablet Give 650 mg by mouth every 6 hours as for Mild Pain Do Not Exceed 3gm every 24 hours pain scale 1-3. Review of Resident #25's MAR for June 2024 documented the resident received Acetaminophen Tablet 650mg on June 6 at 0656 [6:56 AM] for pain level of 6. During an interview on 6/19/2024 at 11:36 AM the Director of Nursing stated, The nursing staff should have not given [Resident #211's name] and [Resident #25's name] the medication if the pain level were out of the parameters ordered. Review of the facility policy and procedure titled Medication Administration date reviewed 01/04/24 read, Policy: Medication are administered by license nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: 9. Obtain pain level as indicated. Administer PRN (pro re nata or as needed) analgesics according to pain scale specifications. 40559 3). During an observation on 6/17/24 at 9:43 AM Resident #160 was sitting in bed, dressed in day clothes with a (Peripheral Inserted Central Catheter) PICC line dressing dated 6/7/24. Photographic evidence obtained. Review of the admission record documented Resident #160 was admitted to the facility on [DATE] with diagnoses including osteomyelitis of vertebra, lumbar region. During an interview on 6/18/24 at 11:55 AM the DON (Director of Nursing) stated, My expectation is the nurses look at PICC line dressings when the resident is admitted and change it if it is more than 7 days and then every week unless soiled.

Based on record review and interview, the facility failed to ensure assessments accurately reflect the resident's status for 1 (Resident #57) of 4 residents reviewed for discharge status. Findings include: Review of the admission record documented Resident #57 was admitted on [DATE] with diagnoses including surgical aftercare, type 2 diabetes mellitus, chronic kidney disease and hypertension. Review of the social services progress note dated 5/14/24 for Resident #57 read, Discharge note: Per family/resident request, resident to discharge 05/15/2024. Resident to discharge home. Son will pick up and transport home . Review of the discharge summary progress note dated 5/15/24 for Resident #57 read, Resident, who is alert and oriented, transferred by son to Appointment then will go home . Review of Resident #57's Minimum Data Set (MDS) Discharge Return Not Anticipated assessment dated [DATE] read, discharge date , 05/15/2024. Discharge Status, Critical Access Hospital. During an interview on 6/18/24 at 10:15 AM the MDS Coordinator, Registered Nurse (RN), stated, [Resident #57's Name] discharge assessment documented him as going to the hospital and he actually discharged home. During an interview on 6/18/24 at 10:33 AM, the Social Services Director stated, Yes, that is an inaccurate assessment, it documents he [Resident #57] went to the hospital, and he [Resident #57] went home. Review of the Policy titled, Conducting an Accurate Resident Assessment, date reviewed 01/04/24, read, Policy: The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas.

Based on observation and interview, the facility failed to provide a safe, functional, and sanitary environment in the food preparation, storage, and sanitation area of the kitchen. Findings include: On 2/6/2023 at 9:20 AM, during a tour of the kitchen, the surveyor observed multiple areas of the ceiling with flaking and cracking appearance in the food prep area. The wall by the dishwashing machine had an area where the wall board was pulling away, creating a break in the moisture barrier. The walk-in freezer had a large buildup of ice on the floor under the condenser unit, creating a slipping or tripping safety hazard. The kitchen had 4 of 6 light fixtures with cracked or broken light coverings. During an interview on 2/6/2023 at 9:30 AM, the Certified Dietary Manager (CDM), verified the ceiling had a flaking and cracking appearance over the food prepping area, the wall at the dishwashing machine had an area where the wall board was pulling away, creating a break in the moisture barrier, and the freezer floor had a large buildup of ice on the floor under the condenser unit. The CDM confirmed that 4 light coverings were either cracked or broken. During an interview on 2/6/2023 at 1:15 PM, the Maintenance Director stated that the ceiling and wall needed to be repaired and light fixtures needed to be replaced. The Maintenance Director verified that there should not be a buildup of ice on the floor in the walk-in freezer. Review of the facility policy and procedure titled General Kitchen Sanitation dated October 1, 2018 reads, Procedure: 1. Clean and sanitize all food preparation areas, food contact surfaces, dining facilities and equipment. Review of the facility policy and procedure titled Cleaning Schedules dated October 1, 2018 reads, Policy: The facility will maintain a cleaning schedule prepared by the Nutrition & Foodservice Manager and followed by employees as assigned in order to ensure that the kitchen is clean and free of hazards.

Based on observation, interview, and record review, the facility failed to ensure staff followed infection control practice standards during wound care to help prevent the possible development and transmission of communicable diseases and infections. Findings include: On 2/8/2023 at 9:13 AM, during an observation of Staff C, Licensed Practical Nurse (LPN), Unit Manager, and Staff D, Certified Nursing Assistant (CNA), providing wound care for Resident #11, Staff C performed hand hygiene and donned gloves. Staff C removed the soiled dressing from the resident's right heel wound. Staff C did not remove the soiled gloves and did not perform hygiene. Staff C cleansed the wound and patted it dry and completed the wound care and exited the room. After performing hand hygiene, Staff C gathered supplies to provide wound care to the resident's left heel. Staff C performed hand hygiene, entered the room, placed the wound supplies on the bedside table without applying a barrier. Staff C donned gloves and then placed a barrier on the bedside table and began to open the supplies and placed them on the barrier. Staff C removed the soiled dressing. Staff C did not remove the soiled gloves or perform hand hygiene. Staff C cleansed the wound to the left heel. Staff C removed the gloves, did not perform hand hygiene, and exited the room to collect swabs. Upon completion of the wound care, Staff C collected the soiled supplies, removed the gloves, and exited the room without performing hand hygiene. During an interview on 2/8/2023 at 9:41 AM, Staff C, LPN, Unit Manager, stated that she did not remove her gloves and perform hand hygiene after removing the old dressing and before cleansing the wound. During an interview on 2/9/2023 at 9:24 AM, the Director of Nursing (DON) stated, I expect my staff to remove gloves and perform hand hygiene after removing the old dressing and before cleansing the wound. Review of the facility policy and procedure titled Clean Dressing Change reviewed on 1/4/2023 reads, Policy Explanation and Compliance Guidelines . 9. Loosen the tape and remove the existing dressing. If needed to minimize skin stripping or pain, moisten with prescribed cleansing solution or use adhesive remover to remove tape. 10. Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle. 11. Wash hand and put on clean gloves. 12. Cleanse the wound as ordered, taking care to not contaminate other skin surfaces or other surfaces of the wound (i.e. clean outward from the center of the wound). Pat dry with gauze . 14. Wash hands and put on clean gloves.

Based on record review and interview, the facility failed to ensure assessments accurately reflected the resident's status for 2 of 15 reviewed residents, Resident #26 and Resident #15. Findings include: 1. Review of Resident #26's records revealed the resident was readmitted to the facility on [DATE] with the diagnoses including generalized anxiety disorder, Post Traumatic Stress Disorder (PTSD), and major depressive disorder. Review of Resident #26's Preadmission Screening and Resident Review (PASRR) dated 8/3/2020 did not reveal anxiety disorder, depressive disorder or PTSD under mental illness or suspected mental illness. During an interview on 2/8/2023 at 10:00 AM, the Social Services Director confirmed that Resident #26's PASRR dated 8/3/2020 did not denote Resident #26's pertinent diagnoses on page 2 of the PASSR. Review of the facility policy and procedure titled Resident Assessment- Coordination with PASARR Program reviewed on 1/4/2023 reads, Policy Explanation and Compliance Guidelines: 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. 2. Review of Resident #15's records revealed the resident was readmitted to the facility on [DATE] with the diagnoses including type II diabetes mellitus. Review of Resident #15's physician order revealed Lantus Solostar Solution Pen-Injector 100 unit/ ML- inject 30 unit subcutaneously at bedtime related to type 2 diabetes mellitus ordered on 11/27/2022 and discontinued on 1/10/2023, Lantus Solostar Solution Pen-Injector 100 unit/ ML (milliliters)- inject 27 unit subcutaneously at bedtime related to type 2 diabetes mellitus ordered on 1/10/2023 and discontinued on 1/31/2023, Insulin Aspart Solution 100 unit/ ML- inject 3 unit subcutaneously before meals for diabetes ordered on 9/27/2022 and discontinued on 1/31/2023, and Novolog Solution 100 unit/ML (Insulin Asparat)- inject as per sliding, ordered on 11/29/2022. Review of Resident #15's annual Minimum Data Set (MDS) assessment dated [DATE] did not reveal Resident #15 as receiving insulin during the 7-day lookback period or as having a change in physician orders for insulin. During an interview on 2/9/2023 at 10:17 AM, the MDS coordinator confirmed the MDS dated [DATE] for Resident #15 was inaccurately completed for the resident receiving insulin injections and insulin order changes.

Based on observation, interview, and record review, the facility failed to ensure medical records were accurate and complete for 4 of 29 residents, Residents #2, #18, #41 and #48. Findings include: 1. Review of Resident #2's admission record revealed the resident was admitted to the facility on [DATE] with a history of heart failure, unspecified dementia, unspecified severity, anemia, other specified anxiety disorders, chronic obstructive pulmonary disease, peripheral vascular disease, chronic kidney disease stage 3, other reduced mobility, zoster without complications, muscle weakness, altered mental status, unspecified dementia, unspecified severity, without behavioral disturbances, psychotic disturbance, mood disturbance, and anxiety. Review of Resident #2's progress note dated [DATE] reads, Quarterly Assessment- Met with resident who was up in wheelchair, dressed, alert, and oriented with mild confusion and able to make needs known. Daughter present for care plan. resident and daughter has [Sic.] no complaints or concerns regarding care. Resident vision and hearing appears WNL [within normal limits]. Discussed Advance Directives: Per daughter, resident is a DNR. Social Services to follow up regarding AD. Resident is social gets out of room often, attends activities and shows no signs of depression. Review of Resident #2's care plan dated [DATE] reads, No Advance Directives executed: Full Code. Dated Initiated: [DATE]. Review of Resident #2's paper chart on [DATE] at 11:00 AM revealed no Do Not Resuscitate Order signed. During an interview on [DATE] at approximately 10:45 AM, the Social Services Director stated, Daughter travels constantly. We are waiting until she comes back to do the Do Not Resuscitate (DNR) form. During an interview on [DATE] at 11:00 AM, Resident #2's Daughter stated, Mother is a DNR. I gave the forms to the facility. 2. Review of Resident #18's admission record revealed the resident was admitted on [DATE] with a history of Alzheimer's disease, aphasia, generalized anxiety disorder, ventricular tachycardia, type 2 diabetes mellitus, syncope and collapse, other symbolic dysfunctions, cognitive communication deficit, depression, unspecified mood disorder, essential hypertension. angina pectoris, atherosclerotic heart disease of native coronary artery without angina pectoris. Review of Resident #18's care plan dated [DATE] revealed Advance Directives was executed and DNR was initiated on [DATE]. Review of Resident #18's progress note dated [DATE] reads, Quarterly Care Plan: Met with resident and daughter. Resident is alert with confusion. Able to make needs known. Resident is currently in PT. PT gave report. Nurse manager attended. Updated family on medications. Family has no concerns and happy with how her care has improved. Advance Directives review: DNR. Resident self-propels in wheel chair, is very social and attends activities. Resident has some HOH [hard of hearing], wears glasses and see podiatry. Social Services will continue to follow as needed. Review of Resident #18's paper chart revealed Full Code Agreement dated [DATE] signed by the Resident #18's Daughter. During an interview on [DATE] at 8:28 AM, Staff B, Registered Nurse (RN), stated, I would look at the code status in the electronic chart to see if the resident is a full code or Do not resuscitate. If the advance directive is not documented, I will then go to the paper chart and verify code status. Normally I assume she is a full code if the code status is empty. During an interview on [DATE] at 9:56 AM, the Regional Director of Nursing stated, Our education is to go to the chart. If Resident #18 was unresponsive, we would have done CPR [cardiopulmonary resuscitation]. During an interview on [DATE] at 9:57 AM, the Director of Nursing stated, I expect nurses to verify advance directives in resident chart. 3. Review of Resident #41's admission record revealed the resident was admitted to the facility on [DATE] with a history of chronic obstructive pulmonary disease, unspecified abnormalities of gait and mobility, essential hypertension, unspecified protein calorie malnutrition, anxiety disorder, other symbolic dysfunctions, cognitive communication deficit, chronic respiratory failure, low back pain, shortness of breath, heart failure, morbid obesity due to excess calories, major depressive disorder, recurrent, mild, unspecific mood disorder, other idiopathic peripheral autonomic neuropathy, hyperlipidemia, gastro esophageal reflux disease without esophagitis, overactive bladder, anemia, other reduced mobility, need for assistance with personal care, difficulty in walking, muscle weakness, drug induced subacute dyskinesia, COVID-19, paranoid schizophrenia, and acute respiratory failure with hypoxia. Review of the physician order dated [DATE] for Resident #41 reads, Behaviors- Monitor for the following: Yelling at staff, hallucinations, agitation, hitting, biting, kicking, spitting, cursing, delusions, psychosis, aggression, and refusal of care. Document: 'N' if monitored and none of the above observed. Document: 'Y' if monitored and the above was observed, select chart code 'Progress Note' and document findings every shift for monitoring. Review of the physician order dated [DATE] for Resident #41 reads, Code: 0= No behaviors 1= Fear/Panic 2= Anger 3= Screaming/Yelling 4= Danger to self/others 5= Delusions 6= Hallucinations 7= Other (describe in nursing note) interventions- A= Music/aromatherapy B= Reminiscence, reality orientations C= Exercise, activities D= 1:1 E= Reduce Stimulation F=PRN [as needed] give Outcome- I =improve S=Same W=worse every day shift for Behavior monitoring. Review of Resident #41's Medication Administration Record for [DATE], [DATE], and February 2023 for Behaviors- Monitor for the following: Yelling at staff, hallucinations, agitation, hitting, biting, kicking, spitting, cursing, delusions, psychosis, aggression, and refusal of care. Document: 'N' if monitored and none of the above observed. Document: 'Y' if monitored and the above was observed, select chart code 'Progress Note' and document findings every shift for monitoring. revealed staff initials and checkmarks for day, evening and night shifts. No Y or N was documented. Review of Resident #41's Medication Administration Record for [DATE], [DATE], and February 2023 Code: 0= No behaviors 1= Fear/Panic 2= Anger 3= Screaming/Yelling 4= Danger to self/others 5= Delusions 6= Hallucinations 7= Other (describe in nursing note) interventions- A= Music/aromatherapy B= Reminiscence, reality orientations C= Exercise, activities D= 1:1 E= Reduce Stimulation F=PRN [as needed] give Outcome- I =improve S=Same W=worse every day shift for Behavior monitoring. revealed the code 0 for [DATE], [DATE], [DATE], and [DATE]. Review of Resident #41's progress note dated [DATE] reads, Resident, who is alert yells out frequently instead of using call light for assist. Educated resident on the use of call light for assistance. Voiced understanding by verbalizing teach back method. Review of Resident #41's progress note dated [DATE] reads, Resident observed frequently licking lips and running tongue over bottom chin area resulting in chaffing to area. Lop balm applied to upper and lower lips. Review of Resident #41's progress note dated [DATE] reads, Late Entry from [DATE] Resident having increased anxiety. Sitting in her room calling out help me help me and when staff goes to help her she says she does not remember what she needed, when she was in the dining room for lunch she continued to say help me help me and wanting to go back to her room before eating. Collected urine to rule out uti [urinary tract infection]. Review of Resident #41's progress note dated [DATE] reads, Resident was in her wheelchair going down the hall saying help me help me the can [certified nursing assistant] asked her what she needed and she stated my room, the cna showed her room, this resident goes back in forth to her room mutli [Sic.] times a day with no issues. Approximately 10 minutes later she is yelling I can't breath [Sic.] went to her room and she is lying in her bed with hob [head of bed] elevated and her oxygen in place. O2 [oxygen] sats [saturation] 96% on room air. PRN neb [nebulizer] given with good results. Will continue to observe. Review of Resident #41's progress note dated [DATE] reads, Resident sitting in TV room yelling help me help me this nurse went to check on her and asked her what is the matter and she stated she was scared of the other resident that was gonna hurt her. Removed the other resident who was not bothering her at all and asked her to come out of the TV and go back to her room, she said ok. Approximately 5 minutes later she is yelling the same thing again about the other resident. Was able to get her back to her room. During an interview on [DATE] at 9:36 AM, Staff E, Licensed Practical Nurse (LPN), stated, [Resident #41's name] is anxious at times. No harm. She will shout out help me help me. When documenting for behaviors, I will check off if I see she is okay. If she has a behavior later in the day, I will write it in the notes. 4. Review of Resident #48's admission record revealed the resident was admitted to the facility on [DATE] with a history of unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance mood disturbance mood disturbance and anxiety, anemia, atherosclerotic heart disease of native coronary artery without angina pectoris, anxiety disorder, depression, lack of physical exercise repeated falls, essential hypertension, history falling, unspecified urinary incontinence, other reduced mobility, long term (current) use of antithrombotic/antiplatelet, hyperlipidemia, cerebral infraction, allergic rhinitis, muscle weakness, difficulty in walking, need for assistance with personal care, dysphagia, other symbolic dysfunctional, and cognitive communication deficit. Review of the physician order dated [DATE] for Resident #48 reads, Behaviors- Monitor for the following: Yelling at staff, hallucinations, agitation, hitting, biting, kicking, spitting, cursing, delusions, psychosis, aggression, and refusal of care. Document: 'N' if monitored and none of the above observed. Document: 'Y' if monitored and the above was observed, select chart code 'Progress Note' and document findings every shift for monitoring. Review of Resident #48's Medication Administration Record for [DATE], [DATE], [DATE] and [DATE], for Behaviors- Monitor for the following: Yelling at staff, hallucinations, agitation, hitting, biting, kicking, spitting, cursing, delusions, psychosis, aggression, and refusal of care. Document: 'N' if monitored and none of the above observed. Document: 'Y' if monitored and the above was observed, select chart code 'Progress Note' and document findings every shift for monitoring. revealed staff initials and checkmarks for day, evening and night shifts. No Y or N was documented. Review of Resident #48's progress note dated [DATE] reads, The CNA came to this nurse for assistance with getting the resident up to toilet him and provide care. The resident refused, this nurse educated the resident on the importance of getting up and resident continued to refuse. Attempted to redirect the resident in attempts to get him up and resident still refused. After several attempts the resident still refused. Will attempt to get up the resident after lunch and try again. Review of Resident #48's progress note dated [DATE] reads, Resident refused to get a shower, cna reported to nurse and nurse attempted to get the resident up for a shower and continued to refuse. This nurse was notified and spoke with the resident and educated him on the importance of getting a shower and personal hygiene. He verbalized understanding and continue to refuse. Notified family via phone call but no answer. Review of Resident #48's progress note dated [DATE] reads, Resident refusing to let staff preform care for him, this nurse educated resident on importance of personal care and continued to refuse. This nurse reached out to his family as requested by family and daughter in-law stated someone would be there within the hour. During an interview on [DATE] at 9:42 AM, with Staff E, LPN, stated, [Resident #48's name] is pleasant. He will wander at times and go into other residents' room, but we monitor him. During an interview on [DATE] at 10:15 AM, the DON stated, My expectation is for staff to properly document the actual behaviors on the Medication Administration Record. Review of the facility policy and procedure titled Documentation in Medical Record reviewed on [DATE] reads, Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to help prevent the possible development and transmission of communicable diseases and infections by not performing hand hygiene during medication administration and failing to follow infection prevention standards when donning personal protective equipment. Findings: 1. An observation of medication administration on 8/3/2021 at 5:32 PM showed Staff C, Registered Nurse (RN), did not clean the top of the medication cart prior to beginning his medication administration. Staff C did not place a barrier on top of the medication cart. Staff C removed the medication card for Resident #58 from the narcotic drawer. He popped the narcotic pill out of the card and the pill fell on to the unclean medication cart. He picked up the pill from the top of the medication cart, with his right hand, placed the pill into a clear medication cup and proceeded to administer the medication to the resident. He did not don gloves and perform hand hygiene prior to and during medication administration. During an interview on 8/3/2021 at 5:32 PM, Staff C, RN, stated, The Oxycodone pill that I pulled fell on to the top of the medication cart. I had not sanitized the cart prior to starting medication pass. I did not have a barrier on the top of the medication cart. I had not washed/sanitized my hands and I picked the medication up with my bare hand and placed it in the clear medication cup to administer to the patient. I forgot to sanitize my hands before I administered the medication. I should have washed/sanitized my hands prior to giving the patient her medication. I should have not given the medication after I had dropped it on the top of the unclean medication cart. I should have not picked the medication up with my bare hand. Review of the facility policy and procedure titled Handwashing/Hand Hygiene, last reviewed on 1/21/2021, reads, Policy Interpretation and Implementation: . 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively soap (antimicrobial or non-antimicrobial) and water for the following situations: . c. Before preparing or handling medications. 2. An observation on 8/4/2021 at 2:11 PM showed Staff D, Certified Nursing Assistant (CNA), walking down the Dogwood Lane with her mask being worn under her chin with her nose and mouth uncovered while passing a resident who was sitting in a wheelchair in the hallway. During an interview on 8/4/2021 at 2:12 PM, the Director of Nursing verified Staff D's mask was not being worn properly and that staff were to wear their masks fully covering their mouth and nose at all times while on the floor. Review of the facility policy titled Infection Control- COVID-19 Face Mask Use, reviewed on 1/21/2021 reads, Definitions . Mask - a device covering the mouth and nose to prevent inhalation of dangerous substances or to prevent the dispersal of exhaled infectious material Policy Interpretation and Implementation: . 1. All staff/vendors/visitors will wear a medical-grade masks [sic] when they are in the facility . 5. Staff may only remove masks in designated areas approved by the Administrator for meal breaks. Review of CDC (Centers for Disease Control and Prevention) titled Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, updated on 3/29/2021 (https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html), reads, Source Control and Distancing Measures: Implement Source Control Measures: . HCP [Health Care Personnel] should wear well-fitting source control at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers . Personal Protective Equipment: Implement Universal Use of Personal Protective Equipment: - The fit of the medical device used to cover the wearer's mouth and nose is a critical factor in the level of source control (preventing exposure of others) and level of the wearer's exposure to infectious particles . One of the following should be worn by HCP while in the facility and for protection during resident care encounters: . - A well-fitting facemask (e.g., selection of a facemask with a nose wire to help the facemask conform to the face; selection of a facemask with ties rather than ear loops; use of a mask fitter; tying the facemask's ear loops and tucking in the side pleats; fastening the facemask's ear loops behind the wear's head; use of a cloth mask over the facemask to help it conform to the wearer's face).

Based on observation, interview, and policy and procedure review, the facility failed to ensure the drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles in 2 of 2 medication carts and 1 of 1 medication storage rooms, and the facility failed to ensure medications were secured to allow only authorized personnel to have access. Findings: 1. An observation of the Dogwood Lane medication cart on [DATE] at 9:02 AM showed one bottle of [MEDICATION(S)] ,d+[DATE] Insulin for Resident #29 with no opened date documented, and one vial of [MEDICATION(S)]/[MEDICATION(S)] 1% multi dose for Resident #23 with no opened date documented. During an interview on [DATE] at 9:10 AM, Staff E, Licensed Practical Nurse (LPN), stated, This is my first day at work here. I do not know why the insulin does not show a date the insulin was opened, and I don't know anything about the [MEDICATION(S)]/[MEDICATION(S)]. During an interview on [DATE] at 9:15 AM, Staff A, LPN, stated, The insulin should show the date the insulin was opened. The multi dose vial of [MEDICATION(S)]/[MEDICATION(S)] should show the date the [MEDICATION(S)] was opened. I do not see the date the insulin or the [MEDICATION(S)] was opened. An observation of the Magnolia Lane medication cart on [DATE] at 9:20 AM showed one 5 ml (milliliter) bottle of refresh tears eye drops with no resident identifier, and one [MEDICATION(S)] (Xalatan) 2.5 ml ophthalmic eye drops for Resident #44 with a label showing as opened on [DATE] and a label on the bottle reading discard after 42 days. An observation of the treatment cart on the Magnolia Lane on [DATE] at 9:30 AM showed three Vaseline pure ultra-white petroleum jelly cases that were expired on [DATE], one [MEDICATION(S)] multi use powder for Resident #59 with no opened date, one 4.5 ml fluid ounce bottle of pure and gentle enema expired on ,d+[DATE], one Iodosorb Cedexomer Iodine 0.5 ounce gel with no resident identifier or date opened, and one jar of [MEDICATION(S)] cream 1% with no resident identifier or date opened. During an interview on [DATE] at 9:40 AM, Staff B, LPN, stated, I don't know why the refresh eye drops do not have documentation to show who the eye drops belong to or when they were opened. I confirm the date on the Xaltan eye drops for [Resident #44's name] shows the eye drops were opened on [DATE]. I am not sure how long eye drops are good for after they are opened. I am not sure why the iodine and the [MEDICATION(S)] cream does not have the date they were opened. The enema is expired and should not be in the treatment cart. The [MEDICATION(S)] powder should have a date opened on the bottle. An observation of the [NAME] Lane medication storage room refrigerator on [DATE] at 9:53 AM showed Purified Protein Derivative (PPD) 0.1 ml (Apisol) expired on [DATE] for Resident #54, four PPD for house account, one expired on [DATE] and three on [DATE]. During an interview on [DATE] at 10:00 AM, Staff A, LPN, stated, I confirm the PPDs in the [NAME] Court refrigerator are expired. The PPDs are ordered for new staff administration. The PPDs should be removed from the refrigerator and returned to the pharmacy when they are outdated. 2. A tour of the Dogwood Lane Court on [DATE] at 9:00 AM showed one 3-ounce antifungal powder on Resident #13's bedside table; one 4-ounce antifungal cream, and one 3-ounce antifungal powder on Resident #17's bedside table; one 14-ounce bottle of [MEDICATION(S)] on Resident #16's bedside; three 4-ounce tubes of skin cream, one 4-ounce antifungal cream, and one 30 ml clear medication cup containing 5 ml of an unidentified white cream on Resident #55's bedside table; one 4-ounce tube of antifungal cream, and one 2.5-ounce of [MEDICATION(S)] cream on Resident #32's bedside; and one 10-count box of 6 X 4 preparation H wipes with [MEDICATION(S)] containing 6 remaining pads for Resident #2 with no opened date. During an interview on [DATE] at 10:00 AM, Staff A, LPN, stated, These residents are not supposed to have medications on their bedside table. Medications are supposed to be stored in the medication cart. Only one of the residents had a prescription for the medications on the bedside table. I confirm the medications were on the resident's bedside tables. Review of the facility policy and procedure titled Storage Medications, last reviewed on [DATE], reads, Policy Interpretation and Implementation: 1. Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed upon discovery.

Based on observation and interview, the facility failed to ensure precautions were initiated to prevent the potential for foodborne illness for the 49 of 49 resident population specific to a precautionary boil water order enacted by the county and the lack of response by the Nutritional Services Department in the handling of water based production. Findings: An observation of residents' rooms and bathroom sinks on 12/09/2019 during the initial tour beginning at 9:35 AM, revealed small signs at each of the sinks indicating, Do not drink water. Staff at the nurse's station were overheard discussing the water concern. An interview was conducted with the Maintenance staff on 12/09/2019 at approximately 10:15 AM. When asked if there was a boil water order currently in place. He confirmed the facility was in contact with the County and they were waiting on the results of testing regarding the quality of the water. The ice machine along with juice and coffee machines were observed during the kitchen tour that same morning and showed they were in service with the ice machine full and the coffee and juice machines operating. Information obtained during a telephone call to the local Water Department on 12/10/2019 at approximately 12:10 PM confirmed the county was under a Precautionary Boil Water order, and had been in place since 12/09/2019. The Water Department representative clarified it was not a mandatory order but precautionary initiated the morning of 12/09/2019 due to a gasket crack and repair. An interview was conducted with the facility Administrator, Director of Nursing and Corporate Nurse Consultant at 12:25 PM. It was confirmed the Nutritional Services Department had not taken steps to ensure the water production to include the coffee and juice machines as well as ice production had been ceased due to the precautionary alert, due to the susceptible population in the facility. The interview with the Administrator confirmed the facility should have ceased producing those products which were produced from water sources from the community to include ice production, juices and coffee. Further interview confirmed a lack of communication between staff regarding the status of the precautionary boil water order and the steps the Nutritional Services Department should have taken as of 12/09/2019. It was confirmed bottled water was utilized on the nurse's station for fluids during medication pass. A review of the facility precautions protocol for any boil water order (both for precautionary and mandatory) included, Dietary Safety for Water Supply During Advisory to Boil Notice, 1) The ice machines will be disconnected prior to the planned water disruptions. Discontinue service of food and beverage equipment with water line connections (post-mix beverage machines, auto-fill coffee/tea makers, instant hot water heaters, ice machines. Discard ice made prior to the boil water advisory issuance and discontinue making ice.

Based on observation, policy review, and interview the facility failed to ensure the Federal Nurse Staffing Forms were updated in 2 of 2 posted areas, the front lobby and the Magnolia hallway. (Photographic Evidence) Findings: During the Initial Tour of the Front Lobby on 12/9/19 beginning at 9:35 AM revealed the Federal Daily Nurse Staffing Form was dated 12/7/19, which was two days earlier. During an interview on 12/9/19 with Staff A, Licensed Practical Nurse the form for the front lobby was reviewed. Staff A confirmed the form had not been updated. During the Initial Tour of the Magnolia Hall on 12/9/19 beginning at 9:35 AM revealed the Federal Daily Nurse Staffing Form was dated 12/7/19, which was two days earlier. A review of the staffing policies revealed the following policy for Posting Direct Care Daily Staffing Numbers: At the beginning of each day, the number of Licensed Nurses and the number of unlicensed nursing personnel directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. During an interview on 12/11/19 at 10:50 AM Staff B, Registered Nurse (RN) confirmed the form was not updated on the Magnolia hallway. The RN stated, the third shift nurse is assigned the duty of completing a new form and inserting it into the clear view holder. No further information was provided.

Based on observation, record review and interview, the facility did not follow facility policies as well as devise, implement and update care and services for behavioral issues using measurable objectives for 1 of 27 residents reviewed during Stage Two. (# 26) Findings: During an interview with Resident # 26 on 12/26/18 ay approximately 11:00 AM, he stated (past employee) Certified Nursing Assistant / Staff A said to him you should use a bed pan, you stink and are nasty. He stated he complained to the floor nurse at the time and she stated to him she partially heard the comment. He stated he repeated the complaint to the Director of Nursing (DON). He stated no one told him about the outcome of his complaint but he has not seen Staff A again. He stated he is presently upset with one of his two main Certified Nursing Assistants / Staff B. He said when the other aide goes on break, no one answers the call bell when Staff B is on duty. He stated he told the past DON about this matter several times. He stated he was told Staff B would be placed in another hall but she is still assigned to his hall. He stated he is willing to speak with psychological professionals. He stated the Psychiatrist visited him several weeks ago but they did not discuss his problems just his medications. He stated he has had no other counseling visits in the past 3 months. He stated the Activities Department did not have tasks he likes. He stated he discussed the incident with a state agency protective services worker. He stated he understood the worker verified the case. Review of Resident #26's record revealed an Incident Report which stated on 10/10/18 the resident complained about Staff A saying you should use a bed pan, you stink and are nasty, while she was rendering care to him. The report notes the floor Nurse/ Licensed Practical Nurse / Staff C witnessed aspects of the incident and reported to the DON. Review of the Behavior Monitoring Sheets revealed there were 3 episodes of Depression out of 19 days in December, (YEAR). There was no further information provided about the specific details of the episode. There were 4 episodes of Uncooperativeness out of 19 days in December, (YEAR) with no specific details of the episodes. On (MONTH) 4, (YEAR) the Nurse wrote in the Progress notes Resident continues with agitation and behaviors with staff, You know why I am mad at you and I will make sure they know why, Resident continued with verbal accusations as he went to the shower room, notified Social Services to speak with Resident. Notified MD of Resident's behaviors. There was no information about the response to the Resident's behavior. In the Progress Notes, dated 12/8/18, the nurse stated the Psychiatrist visited the Resident. She noted he has become more agitated and aggravated towards staff. There was no documentation provided regarding the Psychiatric visit except for the order for the increase in the [MEDICATION NAME] medication. Review of the 12/18 Medication Administration Record [REDACTED]. There was no summary of non pharmacological interventions provided. Further review of the Behavior Monitoring Sheets dated November, (YEAR) revealed 35 episodes of Uncooperativeness with 0 episodes of Depression. There were no specific details for any of the episodes. For October, (YEAR) the Behavioral Sheets documented 0 episodes of Depression and 32 for Uncooperativeness. The forms noted the interventions as redirection and 1 on 1. There was no information regarding any changes in interventions or meetings to discuss the continuing issues. Review of Resident #26's record revealed the Social Services assessment dated [DATE] which states refer to Psych as needed, Behaviors at times. The last referral and Psychological assessment was 7/19/18. It states he suffered from Confusion and Depression. It stated his Primary Concerns were 2 aides he was aggravated with. It stated he feels he treats the staff the way they treat him. It states he declined further intervention. There was no documentation of offering him another visit, at a later date, since he cooperated with the Psychologist on that visit. Review of the Progress Notes beginning 9/24/18 revealed the Nurse wrote: 16:25 -Resident arrived to the facility via transport from follow up to ortho, CNA stated the resident fell while transferring with the doctor causing both resident and doctor to fall to the floor. 16:43-CNA stated resident fell while attempting to back up in wheelchair from the ramp on the van. Resident was instructed to Stop and be still. Resident did not follow command and flipped wheelchair backwards causing resident to hit his head. 10/28/18- Resident started talking loudly to another resident already agitated. Other resident threatened to throw her coffee on him. Resident told her to go ahead and do it and he would show her something. She threw her coffee on the left side of his face and body. 11/22/18-Resident complained about Certified Nursing Assistant /Staff B not doing anything when the other aide goes on break. Review of the Resident # 26's Care Plan revealed there was an update on 9/24/18 to educate resident on safe van use. There was no further information or intervention discussed for the issue. There was no update after the other entries of behavioral issues written in the Progress notes or Behavioral Flow sheets. It stated under Memory problems, BIMs of 14: Reassess orientation and adjust care Converse with resident during care Encourage participation in Activities Encourage resident to make choices Give simple clear directions Orient to time and place daily Under Behavioral Symptoms: Avoid over emphasizing behavior pattern Encourage resident in conversation Monitor for medication side effects Obtain (Psych name) consultation PRN. None of the objectives were written in measurable form. There was no monitoring specific to the behavioral interventions provided. No further information was provided. Review of the Psychiatrist's schedule for November, (MONTH) and September, (YEAR) revealed Resident # 26 was not on the list. Review of the personnel record for Staff A revealed she was separated from the facility on 10/10/18. Review of the Training Agendas and Sign in sheets dated 10/22/18 revealed 34 of 66 possible direct care staff employed by the facility were trained on Resident Rights. Another training on 12/21/18 covered Managing Older Patients with Cognitive Impairments The sign in sheets revealed 45 staff of 66 participated. There was no documentation provided for specific training or review of directives for working with Resident #26. Review of the facility's Abuse policy it states their Abuse Prevention program includes ongoing review and analysis of abuse incidents and implementation of changes to prevent future occurrences of abuse. Further, it discusses Assisting or rotating staff working with difficult or abusive residents and Assessing , care planning and monitoring residents with needs and behaviors that may lead to conflict or neglect. During an interview with Resident # 26's family member at 1:00 PM on 12/27/18 , he stated he spoke with the resident right after the incident happened on 10/10/18. He confirmed the resident was very upset with Staff A's comments to him. During an interview with Licensed Practical Nurse /Staff C on 12/27/18 at 4:45 PM, she confirmed Staff A spoke to Resident # 26 in an abusive manner on 10/10/18. She stated she came to the room and spoke with the resident immediately and confirmed he was very upset about being referred to as nasty. She stated she reported the incident to the DON at the time. She stated Staff A separated from the facility the same day. During interviews with 6 of 6 Certified Nursing Assistants /Staff B, D, E, F, G, H beginning at 8:30 AM on 12/27/18, they stated they have not received any trainings or directives for dealing with Resident # 26's behaviors. All of the aides stated they are aware of his aggressive behaviors but could not give a clear statement of what they do when he refuses to cooperate. They had no information about any behavioral program, interventions or monitoring. During interviews with 2 of 2 Licensed Practical Nurses/ Staff I & J on 12/27/18 beginning at 9:00 AM, they had no specialized training for working with Resident # 26. They stated they redirect as much as they can. They had no information regarding any updated behavioral interventions. During an interview with the facility's Risk Manager on 12/26/18 at approximately 3:45 PM she stated the DON employed during the (MONTH) 10, (YEAR) incident is no longer employed by the facility. The DON left a couple of weeks earlier and the new DON has been on duty for a week. No further information was provided. She stated Staff A separated from the facility after the incident with Resident #26. There was no clear documentation of direct and timely responses regarding Resident # 26's issues and concerns which included the outcome of reviews or changes in the care plan. During an interview with the new DON on 12/27/18 at 12:00 PM she confirmed there was no updated interventions or care plan directives correlated to the behaviors Resident #26 is currently experiencing. She confirmed there was no Physician's Order available for psychological services. During an interview with the Administrator on 12/28/18 at 9:00 AM, she confirmed the facility had not provided documented interventions which were updated based on monitoring of Resident # 26. She confirmed the training was not complete.

Based on observation, policy review and interview, the facility failed to maintain proper dishwasher chemical levels and clean food preparation equipment. Findings: Observation of the Kitchen on 1/2/18, with the Kitchen Manager, revealed kitchen food preparation equipment was not clean . Observation of the freestanding deep fryer revealed the oil was dark brown with food debris throughout the oil and encrusted along the sides. The convection oven had dried, baked on food spatters and spillages which cause the window, bottom and sides, of the inside, of the oven, to be a dark brown. There was debris inside on the bottom of the oven. Observation revealed the Dishwasher staff was in the process of washing breakfast dishes. A test strip of the dishwasher water revealed the test strip was colorless as the chemical was not reaching the dishwasher water. Further interview with the Kitchen Manager on 1/2/18 at 1:00 PM revealed the Manager discovered the primer had not been reset after the last chemical bottle change. The Manager called the company with which they contract, for the dishwasher services and he is coming today. She provided no information as to how long the chemical had not been applied to the water. Review of the Dishwasher Daily Log dated 1/2/18 was not provided until after the priming of the machine was completed by the Kitchen Manager. Review of the Facility policy for the Dishwasher noted under #2: Record and document prior to ware washing for each meal. Rinse should be tested at 50 parts per million.

Based on observation, interview and record review, the facility failed to provide activities of daily living to maintain good grooming and personal hygiene to 1 of 2 residents reviewed for activities of daily living (Resident # 8). Findings: Observation on 1/3/2018 at 2:15 PM revealed the resident is in bed, awake, alert and watching television. All fingernails on both hands have a black discolored substance underneath each fingernail. During an interview with the resident on 1/3/2017 at 2:20 PM he stated he has lived here for two years and goes to [MEDICAL TREATMENT] on Monday -Wednesdays and Fridays. Observation on 1/4/2018 at 9:26 AM revealed the resident is in bed. Observed all fingernails with dark discolored substance. Resident stated that they trim his fingernails but they do not clean them. Hopefully it get cleaned today on my shower schedule. Observation on 1/4/2018 at 12:15 PM revealed the resident is in the main dining room having lunch. Fingernails remained discolored with black colored substance under each nail. Unable to observe the resident on 1/5/2018 as he is out to [MEDICAL TREATMENT]. Review of the resident's activities of daily living (ADL) care plan initiated on 2/29/2016 reads: Resident is unable to perform his own ADL's without assistance from staff. At risk of further decline, skin breakdown, and weight changes related to End Stage [MEDICAL CONDITIONS]. Interventions includes: Allow time to complete task. Encourage independence / participation and give praise for tasks completed. Provide assist with dress, groom, oral hygiene, bath and feeding as warranted. During an interview with the primary certified nursing assistant (CNA) on 1/3/2018 at 2:24 PM, she stated she has worked the evening shift for 2 years. CNA stated that Resident #8 gets showered on Thursdays and Saturdays and more often if he requests it. We clean, trim his fingernails during shower days.

Based on observation, record review and interview, the facility failed to provide proper and consistent communication exchange for Hospice care and services for 1 of 2 residents reviewed for Hospice (Resident #1). Findings: Observation of Resident #1 on 1/2/18 beginning at 9:30 AM revealed she had difficulty answering any questions and breathing. She was not clear which holiday occurred the day before our conversation. She likes activities and her Hospice staff but could not remember anything specific. An interview with the Unit Manager of Dogwood Hall on 1/2/18 at approximately 1:30 PM revealed the Hospice staff had just been in the building and provided care/services to Resident #1. She confirmed she did not receive any documentation directly from the Hospice staff before she left the building. She stated the Aides provide shower/baths 1-2 times per week and the nurse comes weekly. She stated other Hospice staff come frequently. Review of Resident #1's record revealed she was admitted to Hospice services on 10/2/17. She has a BIMS cognitive score of 6 which is low. There was no documentation regarding Hospice visits since 11/24/17. Review of the notes entitled HCA Clinical Note dated 11/24/17 revealed the Certified Nursing Assistant answered yes to the following questions: Was there any sign of abuse? Also, any new safety issues, new change in breathing, new or increased pain, new changes in mental status, new changes to the skin and new Falls or injuries was answered yes. There was no documentation of any response to these issues by the facility. During an interview with the Unit Manager for Dogwood on 1/2 17 at approximately 1:30 PM she denied knowledge of the documentation noting an allegation of abuse or a resulting abuse investigation by the facility. Further review of Resident #1's chart revealed notes on 11/1/17-Hospice HHA states patient becomes dyspneic when they bathe her even with her oxygen on; 11/24/17-SOB-patient dyspnea with any activity and with speaking in full sentences despite 02 at 3 liters. No documentation was provided regarding any response or communication about this resident. Review of Resident #1's Hospice documentation obtained after the facility requested it on 1/2/17, revealed a note on 12/20/17 under the Narrative written by the Hospice Registered Nurse noting he made a a visit to evaluate respiratory distress. Hospice HHA called earlier to report patient's cough sounded much worse and sounded congested. He wrote Lungs sounded clear but diminished in lower lobes. He wrote he discussed with staff who report no increase in or severity of cough. Education provided to staff to observe for signs of infection. There was no documentation provided for these visits or any communication in the facility charts. Review of Resident #1's chart revealed a Care Plan for Hospice dated 10/11/17. It notes: administer pain mediation as ordered, consult with Hospice nurse as needed, encourage resident to notify staff at onset of discomfort, encourage resident to participate in plan of care, provide comfort measures, massage, as needed, provide emotional support, refer to activities for stimulation, use pillows/blankets to position and provide comfort, use touch gently, visit resident frequently as needed. There is no specific objective for coordination of services or communication/ monitoring directives between Hospice and the facility staff. It should be noted Resident #1's Care Plan for Shortness of Breath was devised 10/13/17 with no revisions. It states : elevate HOB, encourage resident to call staff upon onset of SOB or any respiratory distress, encourage rest period, ensure call light within reach, monitor breath sounds, monitor 02 saturation, monitor vital signs, provide emotional support, respiratory treatment as needed. There were no specific directives coordinated with the Hospice notes/ information. Review of the Hospice contract with the facility to provide services was dated originally on 3/1/12. It states on page 4 letter F-All such services shall be promptly document according to mutually agreed upon procedures, and entered into the medical record of the Hospice patient at the Facility. Hospice staff and Facility staff will document in the same medical record. On page 5 it statesThe facility shall prepare and maintain complete and detailed medical record for each Hospice patient receiving services pursuant to this Agreement. The medical records shall consist of but not be limited to progress notes and clinical notes describing all inpatient services and events. During a telephone interview with the Hospice Manager of the area providing care to Resident #1, on 1/4/18 at 10:30 AM, she stated the resident is receiving ongoing care with no change at this time. During an interview with the Director of Nursing on 1/4/18 at approximately 9:00 AM, she confirmed there was no documentation between Hospice and the facility between 11/24/17 and 1/2/18. She confirmed no response to the yes answer left in Resident #1's chart dated 11/24/17 regarding new abuse. Review of a faxed note written by the Hospice Certified Nursing Assistant on 1/2/18 states she made a computer error on the abuse and injury questions on Resident #1's chart on 11/24/17. She stated she should have answered no.

Based on closed record review and interview, the facility failed to provide the care and services necessary to prevent accidents and ensure safety for 1 of 2 residents reviewed for falls (Resident #54). Findings: Review of the closed record for Resident #54 revealed he was admitted on [DATE]. A Progress Note dated 11/19/17 revealed he had a fall in the front lobby after he had attempted to get out the security coded door. The Nurse wrote resident slid to the floor from his wheelchair, while trying to enter the code, to get out of the front door of the lobby area. Another resident's wife witnessed it and said he did not hit his head. She stated he was pushing the buttons and pushing on the door handle. He lost his balance and sat on the floor. His Daily Nursing Summary dated 11/19/17 noted Wandering in his Behavior section. Under Additional notes, the nurse wrote he has moments of confusion and forgetfulness. He has been oob wandering this shift. Further, she wrote Resident observed climbing out of his window, resident brought back inside through door. Further review of the record revealed a Fall Risk assessment dated [DATE]. It states he had fallen 1-2 times in the past 6 months, confined to a chair and disoriented, exhibits loss of balance while standing, requires hands on assistance to move from place to place. His [DIAGNOSES REDACTED]. His Falls risk score was 14 at Moderate risk. Review of the Assessments revealed no further assessments on 11/19/17 between or after the incidents. There was no change of interventions to the Care Plan. The Care Plan is dated 11/13/17. The Falls section states: keep room free from clutter, assist with toileting, bed in low position, safety equipment such as alarms as needed, educate family, monitor drug regime, observe for dizziness, difficulty with balance, orient to new environment, check frequently for comfort and safety, items within reach, PT/OT to screen as necessary. There were no specific directives with measurable objectives for observing and monitoring the resident. There was no revision between or after the incidences. There was no assessment/plan for Elopement. He was discharged from the facility on 11/22/17. During an interview with the Director of Nursing and the Unit Managers for Magnolia and Dogwood Halls on 1/4/18 at approximately 8:40 AM, they confirmed there was no revision in the documentation For Resident #54 between or after the incidences on 11/19/17, and no measurable objectives for interventions to prevent accidents and ensure safety/prevent elopements.

Based on interview, observation, and record review, the administration failed administer the facility in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 3 of 3 sampled (resident #5, #12, and #57) and 30 other resident identified. Administration identified that the physician/medical director was not visiting residents as necessary to ensure the provision of adequate and appropriate medical care. However, the facility failed to take timely action to ensure that resident's received the physician care and evaluation necessary. The administration's failure to provide physician care resulted in resident #12 sustaining a increase in size and stage ( stage II to stage III) of a pressure ulcer. FINDINGS: 1. Record review of Skin Wound Log dated December, 2011 for resident #12 revealed Stage II pressure ulcer to coccyx measured at 2 cm x 2 cm x 0.1 cm. Noted as facility acquired. Stage II pressure ulcer to coccyx measured at 3 cm x 1 cm x 0.1 cm with scant drainage on 3/18/2012. Pressure ulcer to coccyx was noted as Stage III on 4/23/2012. Record review for resident #12 revealed that physician was notified of increase in pressure wound size on 4/15/2012. Interview and observation on 5/9/2012 at 10:00 AM with wound care nurse providing dressing change for resident #12 was conducted. The wound was noted at glutei fold and measured at 5 cm x 2.5 cm with white slough throughout wound bed. Interview and record review on 5/9/2012 at 11:15 AM with the Director of Nursing (DON) revealed that physician's visit dated 7/12/2011 was the last time resident #12 was examined by her physician. She confirmed that the physician has not examined resident's pressure wound when first acquired in August, 2011 nor since then. The DON stated she does not round with resident #12's physician because she never knows when he comes in. She confirmed that all physician order [REDACTED]. 2.) Record Review on 5/9/2012 revealed that physician's visit dated 7/14/2011 was the last time resident #5 was examined by her physician. 3.) Record Review on 5/9/2012 at 11:15 AM revealed that physician's visit dated 3/15/2011 was the last time resident #57 was examined by her physician. 4.) Interview on 5/10/2012 at 9:45 AM with Administrator and Director of Nursing revealed that the physician for residents #5 and #57 is also the facility Medical Director. 5.) Continued interview on 5/10/2012 at 9:45 AM with Administrator and Director of Nursing revealed that they had identified that thirty-three resident to include residents #12, #5 and #57 had not been seen by the physician/ Medical Director as required and necessary. The DON confirmed her last attempt to notify Medical Director of the need for facility visits to exam residents was on 3/14/2012. They were unable to provide information as to why the facility did not take any additional action to provide these residents with the necessary and required physician's visits.

Based on interview, observation, and record review, the medical director failed to carry out his duties as the medical director by failing to ensure the coordination of medical care to 3 of 3 resident sample for provision of physician services (#12, #5, #57) and 30 other residents identified who have not received the required/necessary physician examinations. All residents identified as not receiving necessary physician examinations were found to have the Medical Director as their physician. Moreover, the Medical Director failed to physically examine and determine appropriate treatment for [REDACTED]. FINDINGS: 1.) Observation on 5/9/2012 at 10:00 AM with the wound care nurse providing dressing change for resident #12 revealed a wound at the gluteal fold which measured at 5 cm x 2.5 cm with white slough throughout wound bed. Record review for resident #12 revealed that she was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Skin Wound Log dated December, 2011 for resident #12 revealed Stage II pressure ulcer to coccyx measured at 2 cm x 2 cm x 0.1 cm. Pressure ulcer was noted as facility acquired. Stage II pressure ulcer to coccyx measured at 3 cm x 1 cm x 0.1 cm with scant drainage on 3/18/2012 Record review for resident #12 revealed that physician was notified of increase in pressure wound size on 4/15/2012 and order received to cleanse with normal saline, pat dry, apply [MEDICATION NAME] every 3 days and as needed. Pressure ulcer to coccyx was noted as Stage III on 4/23/2012. Review of Weekly Pressure Ulcer Record dated 5/8/2012 for resident #12 revealed that pressure wound to coccyx noted as Stage III and measured at 5 cm x 2 cm x 0.3 cm with small amount of serosanguinous exudate, foul odor, and white slough at wound bed. Surrounding tissue noted as pink, blanchable with edges sloughing. Resident status is noted with weight stable and at ideal body weight, food intake at 75%, fair skin turgor, and an adequate urine output. Interventions noted to turn resident #12 every 2 hours, use side-lying pillow, and keep resident clean and dry. Interview and record review on 5/9/2012 at 11:15 AM with Director of Nursing (DON) revealed that physician's visit dated 7/12/2011 was the last time resident #12 was examined. She confirmed that the physician has not examined resident #12's pressure wound since first acquired in August, 2011. The DON stated she does not round with physician because she never knows when he comes in. She stated all physician order [REDACTED]. 2.) Record review for Resident #5 revealed that physician's visit dated 7/14/2011 was the last time resident #5 was examined by her physician. Interview on 5/10/2012 at 9:45 AM with Administrator and Director of Nursing revealed that physician for resident #5 is also the facility Medical Director. 3.) Record Review on 5/9/2012 at 11:15 AM revealed that physician's visit dated 3/15/2011 was the last time resident #57 was examined by her physician. Interview on 5/10/2012 at 9:45 AM with Administrator and Director of Nursing revealed that physician for resident #57 is also the facility Medical Director 4.) Continued interview on 5/10/2012 at 9:45 AM with the Administrator and Director of Nursing revealed that the DON's last attempt to notify the physician (Medical Director) of need for facility visits to exam residents was on 3/14/2012. Thirty three resident names were given to the physician at this time that have not been seen by him. 5.) Interview was conducted on 5/10/2012 at 1:30 PM with Medical Director. He stated that he does examine residents in the facility, but does not keep good records of the residents' health condition or progress notes. No additional information was provided.

Based on observation, interview, and record review, the facility failed to provide necessary care and services to promote healing and prevent regression for 1 of 3 residents observed with pressure ulcers (#12). The facility failed to ensure that a physician physically observed the pressure ulcer and ordered treatment based on his assessment or seek outside consultation for wound care to promote healing. This failure resulted in resident #12's pressure ulcer to increase in size and to increase in stage from a stage II, first observed August 2011, to a stage III by April 23, 2012. Findings: 1. Observation on 5/9/2012 at 10:00 AM was conducted with the wound care nurse providing the dressing change for resident #12. The wound was observed at the gluteal fold, and measured at 5 cm x 2.5 cm with white slough throughout wound bed. 2. Record review for resident #12 revealed that she was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Skin Wound Log dated December, 2011 for resident #12 revealed Stage II pressure ulcer to coccyx measured at 2 cm x 2 cm x 0.1 cm. Pressure ulcer was noted as facility acquired. Stage II pressure ulcer to coccyx measured at 3 cm x 1 cm x 0.1 cm with scant drainage on 3/18/2012 Record review for resident #12 revealed that physician was notified of increase in pressure wound size on 4/15/2012 and order received to cleanse with normal saline, pat dry, apply [MEDICATION NAME] every 3 days and as needed. Pressure ulcer to coccyx was noted as Stage III on 4/23/2012. Review of Weekly Pressure Ulcer Record dated 5/8/2012 for resident #12 revealed that pressure wound to coccyx noted as Stage III and measured at 5 cm x 2 cm x 0.3 cm with small amount of serosanguinous exudate, foul odor, and white slough at wound bed. Surrounding tissue noted as pink, blanchable with edges sloughing. Resident status is noted with weight stable and at ideal body weight, food intake at 75%, fair skin turgor, and an adequate urine output. Interventions noted to turn resident #12 every 2 hours, use side-lying pillow, and keep resident clean and dry. Review of the care plan reviewed for resident #12 addressing pressure ulcer to coccyx was updated 4/23/2012 noting wound at Stage III with interventions for healing of current pressure ulcer and to decrease risk for further pressure ulcer development. The care plan documents that resident #12 had a Stage II pressure ulcer on her coccyx which first appeared in August, 2011 and was marked as healed in October, 2011. It then reappeared 11/25/2011 and treatment was changed periodically. 3. Interview and record review on 5/9/2012 at 11:15 AM with Director of Nursing (DON) revealed that physician's visit dated 7/12/2011 was the last time resident #12 was examined. She confirmed that the physician has not examined resident #12's pressure wound since first acquired in August, 2011. The DON stated she does not round with physician because she never knows when he comes in. She stated all physician order [REDACTED]. 4. Interview on 5/10/2012 at 9:45 AM with the Administrator and Director of Nursing revealed that physician for resident #12 is also the facility Medical Director. The DON confirmed her last attempt to notify physician of need for facility visits to exam the resident was on 3/14/2012. 5. Interview was conducted on 5/10/2012 at 1:30 PM with the physician for resident #12, who is also the Medical Director. He stated that he does examine residents in the facility, but does not keep good records of the residents ' health conditions or progress in the resident's medical record in the facility. No additional information was provided at this time.

Based on interview, observation, and record review, the physician/medical director failed to visit, at least once every 60 days, 3 of 3 residents sampled for timeliness of visits for which the physician/medical director is responsible, Resident's #5, #12 and #57. In addition, 30 other residents were identified by the facility as requiring physician visits. This failure to visit and examine resident #12 resulted in the resident sustaining an increase in size and stage ( from a stage II to a stage III) of a pressure ulcer. FINDINGS: 1.) Observation on 5/9/2012 at 10:00 AM with the wound care nurse providing dressing change for resident #12 revealed a wound at the gluteal fold which measured at 5 cm x 2.5 cm with white slough throughout wound bed. Record review for resident #12 revealed that she was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Skin Wound Log dated December, 2011 for resident #12 revealed Stage II pressure ulcer to coccyx measured at 2 cm x 2 cm x 0.1 cm. Pressure ulcer was noted as facility acquired. Stage II pressure ulcer to coccyx measured at 3 cm x 1 cm x 0.1 cm with scant drainage on 3/18/2012 Record review for resident #12 revealed that physician was notified of increase in pressure wound size on 4/15/2012 and order received to cleanse with normal saline, pat dry, apply [MEDICATION NAME] every 3 days and as needed. Pressure ulcer to coccyx was noted as Stage III on 4/23/2012. Review of Weekly Pressure Ulcer Record dated 5/8/2012 for resident #12 revealed that pressure wound to coccyx noted as Stage III and measured at 5 cm x 2 cm x 0.3 cm with small amount of serosanguinous exudate, foul odor, and white slough at wound bed. Surrounding tissue noted as pink, blanchable with edges sloughing. Resident status is noted with weight stable and at ideal body weight, food intake at 75%, fair skin turgor, and an adequate urine output. Interventions noted to turn resident #12 every 2 hours, use side-lying pillow, and keep resident clean and dry. Interview and record review on 5/9/2012 at 11:15 AM with Director of Nursing (DON) revealed that physician's visit dated 7/12/2011 was the last time resident #12 was examined. She confirmed that the physician has not examined resident #12's pressure wound since first acquired in August, 2011. The DON stated she does not round with physician because she never knows when he comes in. She stated all physician order [REDACTED]. 2.) Record review for Resident #5 revealed that physician's visit dated 7/14/2011 was the last time resident #5 was examined by her physician. Interview on 5/10/2012 at 9:45 AM with Administrator and Director of Nursing revealed that physician for resident #5 is also the facility Medical Director. 3.) Record Review on 5/9/2012 at 11:15 AM revealed that physician's visit dated 3/15/2011 was the last time resident #57 was examined by her physician. Interview on 5/10/2012 at 9:45 AM with Administrator and Director of Nursing revealed that physician for resident #57 is also the facility Medical Director 4.) Continued interview on 5/10/2012 at 9:45 AM with the Administrator and Director of Nursing revealed that the DON's last attempt to notify the physician (Medical Director) of need for facility visits to exam residents was on 3/14/2012. Thirty three resident names were given to the physician at this time that have not been seen by him. 5.) Interview was conducted on 5/10/2012 at 1:30 PM with Medical Director. He stated that he does examine residents in the facility, but does not keep good records of the residents' health condition or progress notes. No additional information was provided. 3.) Record Review on 5/9/2012 at 11:15 AM revealed that physician's visit dated 3/15/2011 was the last time resident #57 was examined by her physician. Interview on 5/10/2012 at 9:45 AM with Administrator and Director of Nursing revealed that physician for resident #57 is also the facility Medical Director. DON has confirmed her last attempt to notify physician of need for facility visits to exam residents was on 3/14/2012. Thirty three resident names were given to physician that have not been seen by physician.