Every finding on record at Cuba Manor Inc

Based on observation, interview and record review, facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to change gloves and wash/sanitize hands during incontinence care for three residents (Resident #3, #18, and #62), and failed to clean a mechanical lift after use for two residents (Resident #3, #62). The facility census was 47.1. Review of the facility's Handwashing policy, undated, showed the policy did not contain direction or guidance on when to perform hand hygiene. The purpose of handwashing is to reduce transmission of organisms from resident to resident, nursing staff to resident, and/or resident to nursing staff.Review of the facility's Hand Cleanser policy, undated, showed the purpose is to cleanse the hands between resident contact during care and to prevent spread of infection. Review of the facility's Cleansing and Disinfecting of Environmental Surfaces policy, undated, showed environmental surfaces will be cleansed and disinfected according to current Centers for Disease Control (CDC) recommendations for disinfection of healthcare facilities and the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogen Standard. Review of the CDC Recommendations for Disinfection and Sterilization in Healthcare Facilities, dated 12/07/23, showed:-Ensure, at a minimum, noncritical patient-care devices are disinfected when visibly soiled and on a regular basis (such as after use on each patient or once daily or once weekly);-If dedicated, disposable devices are not available, disinfect noncritical patient-care equipment after using it on a patient who is on contact precautions before using this equipment on another patient.Review of the OSHA's Bloodborne Pathogen Standard Fact Sheet, dated 2011, showed staff are to implement universal precautions (treat all bodily fluids as if known to be infectious). Review of the Federal Drug Administration's (FDA) Patient Lift Safety Guide, undated, showed to always clean a patient care lift before and after each patient. 2. Observation on 05/12/26 at 12:51 P.M., showed Certified Nurse Aide (CNA) A and CNA B used a mechanical lift and transferred Resident #3 from his/her wheelchair to bed. With gloved hands, CNA B removed the residents brief and discarded it, CNA B gathered trash and soiled linens and touched the doorknob. CNA A wheeled the lift out of the room to the hallway and did not disinfect the lift. CNA A and CNA B did not perform hand hygiene prior to leaving the room. During an interview on 05/14/26 at 2:50 P.M., CNA B said hand hygiene should be performed when entering a room and when leaving a room. He/She does not know why he/she did not do perform hand hygiene, but he/she should have. He/She said the lift should be sanitized between resident use to break the spread of infections. He/She does not know why the lift was not cleaned. Observation on 05/14/26 at 8:59 A.M., showed CNA A and CNA J used a mechanical lift and transferred the resident from his/her bed to wheelchair. With gloved hands, CNA J pulled the resident's pants and brief down, wiped bowel movement from the resident's buttocks and with the soiled gloves touched the lift sling, clean brief, bed linens, gathered trash, and touched the wheelchair while the soiled trash bag touched the lift. With the same gloves, on CNA J wheeled the lift to the hall. He/She did not perform hand hygiene before he/she left the room. During an interview on 05/14/26 at 3:02 P.M., CNA A said he/she tries to keep his/her hands clean but has a heavy resident load and gets busy. He/She said the lift should be cleaned between residents, hands should be cleansed when going into the room, between dirty and clean tasks, and before leaving the room. He/She said washing hands and cleaning the lift keep germs from spreading.During an interview on 05/14/26 at 3:27 P.M., CNA J said the lifts are cleansed weekly by housekeeping. He/She said CNAs should perform hand hygiene between residents, when leaving a room and when entering the room. He/She said he/she didn't know about hand hygiene after cleansing bowel movement from a resident. 3. Observation on 05/13/2026 at 11:25 A.M. showed CNA C performed bowel incontinence care for Resident #18. With the same soiled gloves on, CNA C changed the residents' clothes. CNA C and the Assistant Director of Nursing (ADON) did not perform hand hygiene and transferred the resident with the mechanical lift to his/her wheelchair. The CNA wheeled the resident to the dining room. 4. Observation on 5/12/26 at 2:56 P.M. showed CNA A and CNA B used the mechanical lift and transferred Resident #62 from his/her wheelchair to bed. CNA A and CNA B wiped bowel movement from the resident's bottom. With the same soiled gloves, CNA B applied powder to the resident's bottom, touched the resident's clean clothes and lift sling. With the same soiled gloves, the CNAs transferred the resident back to his/her wheelchair, arranged the bedding and placed a blanket on the resident. CNA B did not perform hand hygiene at the completion of the tasks or before he/she propelled the resident to the television room. Staff wheeled the mechanical lift to the hall and did not clean the lift. 5. During an interview on 05/13/26 at 09:00 A.M., the Infection Preventionist (IP) said hand hygiene should be performed when entering and exiting a resident room, and when moving from a dirty task to a clean task. The IP said mechanical lifts and reusable supplies should be cleaned after each resident use. He/She said staff received training throughout the year which included hand hygiene and use of gloves.During an interview on 5/13/26 at 10:00 A.M., the Director of Nursing (DON) said hand hygiene is expected to be done when a room is entered and exited. He/She said hands should be washed and gloves changed anytime contaminated with feces. The DON said staff have received training on the use of personal protective equipment and hand hygiene at hire and throughout the year.

Based on observation, interview, and record review, facility staff failed to ensure medications not in use and expired were properly discarded. The facility census was 62.1.Review of the facility's Storage of Medication's Policy, undated, showed no discontinued, outdated or deteriorated drugs or biologicals may be retained for use. All such drugs must be returned to the issuing pharmacy or destroyed in accordance with established guidelines. Review of the facility's Destruction of Medications Policy, undated, showed two licensed nurses or one licensed nurse and facility pharmacist will destroy all medications, except controlled substances which will require Director of Nursing (DON) supervision. The medications will be placed in a sealable container such as a plastic bag. An unpalatable substance such as kitty litter or used coffee grounds will be added to the plastic bag of medications. Before sealing the plastic bag approximately one cup of fluid will be added to the plastic bag of medications. 2. Observation on 05/12/26 at 10:15 A.M., showed the East Hall medication room contained:-One opened bottle of Genteal eye drops dated 03/31/26 (eye lubricant);-A box of Lantus insulin (to treat diabetes) with an expiration date of 09/30/24;-A box of Lantus insulin with an expiration date of 09/30/25;-Five cards of discontinued Lithium 150 milligrams (mg) tablets (used for mania); -Two cards of discontinued Naproxen 500 mg tablets; -One card of discontinued Lamotrigine 100 mg tablets (used for seizures and mood); -One opened bottle of artificial tears dated 03/12/26;-One opened bottle of artificial tears dated 03/26/26;-One opened and undated vial of tuberculin solution;-Two unopened, influenza vaccine bottles with an expiration date of 06/30/25.During an interview on 05/12/26 at 10:45 A.M., Licensed Practical Nurse (LPN) M said the nurses and the medication technicians are responsible for ensuring expired, outdated and discontinued medications are returned or destroyed. He/She was not aware discontinued and expired medications were in the medication room.During an interview on 05/12/16 at 10:50 A.M., Certified Medication Technician (CMT) L said he/she pulls expired or discontinued medications and puts them into the medication room for return or destruction. He/She said the nurses are responsible for the medication room. 3. Observation on 05/14/26 at 08:28 A.M., showed a medication cart contained an unlabeled cup of pills in a drawer. At this time, CMT D said he/she prepared the medications for Resident #67, but the resident was not available to take them. CMT D said they were saved to give to the resident when available, although he/she knows it is not the correct procedure. During an interview on 05/14/26 at 10:13 A.M., LPN E said any medications not administered immediately after being pulled from the package should not be set aside for later administration. 4. During an interview on 05/15/26 at 9:54 A.M., the Director of Nursing (DON) said the charge nurse is responsible for the contents of the medication room. He/She said medications that need to be returned to the pharmacy should be returned weekly, and medications that require destruction should be destroyed immediately with two nurses present. He/She was not aware of the expired/discontinued medications stored in the east medication room. The DON said medications should be administered immediately after removal from original packaging and if the medications are not administered, they should not be stored to administer later. Disposal of medications should be completed by the charge nurse and another nurse and should not be completed by CMT's. During an interview on 05/15/26 at 10:57 A.M., the Administrator said the DON and Assistant DON are responsible for oversight of the medication room. He/She said expired, outdated or discontinued medications could be given inadvertently or would not be effective if given. The Administrator said CMT's are not allowed to dispose of medications, it should be the nurses.

Based on observation, interview, and record review, facility staff failed to transfer two residents (Residents #3 and #62) out of three sampled residents by mechanical lift in a manner to prevent accidents. The facility census was 62.1.Review of the facility's Mechanical Lift policy, undated, showed to follow the manufacturer's instructions when using any type of lift. The policy showed the purpose is to enable one individual to lift and move a resident safely. The policy did not contain directions or guidance regarding the number of staff required during a mechanical lift transfer. Review of the Mechanical Lift Manual, dated 2022, showed although the company recommends two assistants be used for all lifting preparation and transferring-from and transferring-to procedures, our equipment will permit proper operation by one assistant. The use of one assistant is based on the evaluation of the healthcare professional for each individual case. The manual did not contain direction or guidance for guiding or hands on the resident while suspended or transferring to a bed from the wheelchair. Review of the facility's orientation Transferring the Patient guide, dated June 2012, showed the guide did not contain direction or guidance for lift transfers to bed from the wheelchair or guidance for guiding the resident while suspended in the air. 2. Review of Resident #3's Significant Change in Status Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/17/26, showed staff assessed the resident as cognitively impaired and dependent on staff for transfers. Review of the resident's care plan, dated 04/07/26, showed the resident is to be transferred by two staff and a mechanical lift.Observation on 05/12/26 at 12:51 P.M., showed Certified Nurse Aide (CNA) A and CNA B attached a mechanical lift sling to a mechanical lift. CNA A raised the resident from a reclining wheelchair. With the resident suspended over the tile floor, CNA A moved the lift over to the bed and lowered the resident onto the bed. CNA B did not guide or hold the resident as the resident was suspended over the floor. Observation on 05/14/26 at 8:59 A.M., showed CNA A and CNA J attached a mechanical lift sling to a mechanical lift. CNA A raised the resident from the reclining wheelchair. With the resident suspended over the tile floor, CNA A moved the lift over to the bed and lowered the resident onto the bed. CNA J did not guide or hold the resident as the resident was suspended over the floor. 3. Review of Resident #62's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively impaired and dependent on staff for transfers. Observation on 05/12/2026 at 02:56 P.M., showed CNA A and CNA B attached a mechanical lift sling to a mechanical lift. CNA A raised the resident from the wheelchair. The resident was not centered in the sling, CNA A assisted the resident to reposition. With the resident suspended over the tile floor, CNA A moved the lift over to the bed and lowered the resident onto the bed. CNA B did not guide or hold onto the resident as the he/she was suspended over the floor. After resident care, CNA A and CNA B attached the sling to the mechanical lift for transfer back to the wheelchair. CNA A raised the resident from the wheelchair into the air. CNA B did not guide or hold the resident as the he/she was suspended over the floor. During an interview on 05/14/16 at 2:50 P.M., CNA B said he/she has been certified for over a year. Mechanical lift transfers require two staff for safety. One staff works the lift, and the other staff should maintain the sling. He/She is not sure why the resident was not held onto but should have been for safety and so it does not tip while the resident is in it. During an interview on 05/14/26 at 3:02 P.M., CNA A said two staff should be in the room during lift transfers. One should operate the lift, and the other staff should make sure the legs go where they are supposed to go. He/She said staff should guide the residents when up in the sling to maintain safety. He/She said there wasn't enough room to maneuver the lift and do the best he/she can.During an interview on 05/14/26 at 3:27 P.M., CNA J said staff should have two people present during lift transfers to prevent accidents. One person to work the lift and the other person to keep an eye out for trouble and step in when needed. He/She said it didn't matter if staff held onto the resident while suspended in the air because the lift does the work. 4. During an interview on 05/15/26 at 9:54 A.M., the Director of Nursing (DON) said one staff member should operate the lift and the other should be the spotter for safety. The residents should never be suspended in the air over the floor without staff holding on to them for safety. The lift could tip over or the straps could fail.During an interview on 05/15/26 at 10:57 A.M., the Administrator said staff are trained on hoyer transfers upon hire and annually during a skills training day with return demonstrations. Staff are expected to hold the resident once they leave the surface until they get lowered to the next surface in case the lift tips over.

Based on observation, interview and record review, facility staff failed to ensure five residents (Resident #3, # 5, #9, #37, and #50) out of eight residents who are unable to carry out activities of daily living received the necessary services to maintain good personal hygiene and grooming. The facility census was 62.1. Review of the facility's policy titled Care of Nails (fingers and toes) policy, undated, showed nursing assistants may perform nail care on the residents who are not at risk for complications of infection. The licensed nurse or podiatrist must perform nail care on residents suffering from diabetes or vascular disease (poor circulation). The policy did not provide guidance on when to perform nail care.Review of the facility's policy titled Perineal Care, undated, showed the purpose is to clean the perineum and prevent infection and odor. The policy did not provide guidance on when to perform perineal care. Review of the facility's Shower policy, undated, showed the policy did not contain direction or guidance for nail care. Review of the facility's Toileting Plan for Urinary Incontinence, undated showed:-Review the resident's care plan for any special needs;-This technique involves the resident resisting or inhibiting the sensation to urinate according to a timetable;-The goal is for the resident to urinate every two to three hours;-Record the resident's current urinating pattern, including times and amounts;-Plans that require resident cooperation and motivation for learning and practice to occur include bladder retraining/rehabilitation and pelvic floor muscle rehabilitation;-Plans that are relatively more dependent on staff involvement and assistance as opposed to resident function include: prompted urinating, habit training/scheduled toileting, and incontinence management;-Assess the resident for appropriate program to enhance urinary continence. -The program did not contain direction or guidance on how often to offer toileting or incontinence care. 2. Review of Resident #3's Significant Change of Status Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/17/26, showed staff assessed the resident as: -Cognitively impaired;-Did not have behaviors or reject care;-Range of motion impaired on one upper and one lower extremity;-Always incontinent of urine and bowel;-Dependent on staff for toileting, showers, dressing and personal hygiene;-Diagnoses of dementia and diabetes.Review of the resident's care plan, dated 04/07/26, showed the resident wears a brief for dignity and to provide perineal care after each incontinent episode. The care plan did not provide direction or guidance for fingernail care. Observation on 05/12/26 at 12:51 P.M., showed the resident fingernails long and jagged with dark debris under the nail. Observation on 05/13/26 at 8:35 A.M., showed the resident fingernails long and jagged. Observation on 05/13/26 at 9:41 A.M., the resident fingernails long and jagged. Observation on 05/13/26 at 1:53 P.M., showed the resident fingernails long and jagged with dark debris under the nail. Observation on 05/14/26 at 8:59 A.M., showed CNA A and CNA J transferred the resident to bed. CNA J cleansed the resident's inner and outer buttocks. CNA A and CNA B did not clean the resident's abdominal folds, inner thighs, or perineal area. During an interview on 05/14/26 at 3:27 P.M., CNA J said he/she should have provided full perineal care to include the front perineal area, abdomen and inner thighs of the resident. He/She said he/she had other things on his/her mind. CNA J said fingernails are clipped by the nurse monthly. 3. Review of Resident #5's admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired;-Did not reject care;-Functionally impaired range of motion in both lower extremities;-Dependent on staff for personal hygiene;-Diagnoses of dementia and diabetes. Review of the resident's care plan, dated 04/12/26, showed the care plan did not contain direction or guidance for nail care. Observation on 05/15/26 at 8:47 A.M., showed resident's toenails long and jagged. During an interview on 05/15/26 at 8:47 A.M., Licensed Practical Nurse (LPN) G said diabetic nails are trimmed by the podiatrist. He/She did not know if the resident was on the podiatry list. 4. Review of Resident #9's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired;-Did not have behaviors or reject care;-Dependent on staff for personal hygiene;-Diagnosis of dementia.Review of the resident's care plan, dated 03/27/26, showed the care plan did not contain direction or guidance for nail care. Observation on 05/12/26 at 3:04 P.M., showed the resident fingernails long and jagged.Observation on 05/13/26 at 8:27 A.M., showed the resident fingernails long and jagged with debris.Observation on 05/13/26 at 1:53 P.M., showed the resident in a group activity with fingernails long and jagged with debris.Observation on 05/14/26 at 8:18 A.M., showed the resident in the television room with long and jagged fingernails. 5. Review of Resident #37's, Annual MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired;-Did not have behaviors of reject care;-Functionally impaired range of motion in all extremities;-Dependent on staff for personal hygiene;-Diagnosis of Parkinson Disease. Review of the resident's care plan, dated 04/28/26, showed the care plan did not provide direction or guidance for nail care.Observation on 05/12/26 at 1:32 P.M., showed the resident hands contracted with long fingernails with visible debris under the nail. Observation on 05/13/26 at 9:45 A.M., showed the resident with long fingernails. Observation on 05/13/26 at 1:53 P.M., showed the resident in the day room with long fingernails and visible debris under the nail. Observation on 05/14/26 at 8:21 A.M., showed the resident hands contracted and with long fingernails. During an interview on 05/13/26 at 9:45 A.M., CNA K said he/she gave the resident a bed bath but did not trim his/her fingernails. He/She said the nurse trims the nails. During an interview on 05/12/26 at 1:32 P.M., a family member said he/she noticed the long fingernails but knew the staff were busy and didn't say anything. 6. Review of Resident #50's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired;-Did not reject care;-Dependent on staff for toilet hygiene and dressing;-Required partial to moderate assistance of staff for toilet transfers;-Frequently incontinent of urine and occasionally incontinent of bowel;-Toileting program to manage incontinence. -Diagnosis of Dementia. Review of the resident's care plan, dated 05/10/26, showed: -Occasionally incontinent of bowel and bladder;-Provide incontinence care as needed;-One-Two staff assist with toileting upon rising in the morning;-Position the resident upright on the toilet or bedside commode;-The care plan did not contain direction or guidance to offer toileting or incontinence care prior to naps or upon rising from naps. Observation on 05/12/26 at 12:51 P.M., showed CNA A and CNA B entered the resident's room, applied a gait belt to the resident and transferred the resident to bed. CNA A and CNA B did not offer to toilet resident or provide incontinence care.During an interview on 05/14/26 at 2:50 P.M., CNA B said he/she is newer to the facility and still learning the resident routines and amount of assistance needed. He/She said the resident should have been offered toileting and assisted to be cleansed when laid down for a nap to prevent skin issues. During an interview on 05/14/26 at 3:02 P.M., CNA A said toileting and perineal should have been offered before laying the resident down for a nap. He/She said not providing toileting or care could result in skin irritation. During an interview on 05/15/26 at 9:54 A.M., the Director of Nursing (DON) said staff should offer toileting each time care is provided. He/She can also tell staff when he/she needs to go. 7. During an interview on 05/15/26 at 9:32 A.M., Licensed Practical Nurse (LPN) K said CNA's clip residents' fingernails unless they are diabetic, then the nurse does it. Nails should be clipped when needed and checked during showers. He/She said the aides have not informed him/her of any nails needing clipped. Residents who are incontinent should be offered to toilet or provided incontinent care at least every two hours to prevent skin issues. Incontinent care includes wiping all skin that was in contact with the body fluid. During an interview on 05/15/26 at 9:54 A.M., the DON said the nursing staff should provide incontinent care on all incontinent residents every two hours or more often upon request. Incontinent care includes cleansing all skin that encounters body fluids. Fingernails should be clipped by the aides at least twice a week on shower days or as needed. The nurses are responsible for ensuring diabetic nails are clipped. The podiatrist comes monthly, and residents are added to the list when nail care is needed. He/She is not sure who is on the list. During an interview on 05/15/26 at 10:57 A.M., the administrator said fingernails should be trimmed with showers and when needed by the aides if not diabetic and the nurse if diabetic. If the aides do not have time, they are to let management know so someone can be assigned to do it. He/She said to get on the podiatrist list, the resident or the nurse will let management know and then will be added to the list. He/She is not sure who is on the list. The administrator said perineal care should include the wiping of all skin surfaces in contact with body fluids to include the front and abdominal folds to prevent infections, decrease odors, and maintain resident skin. Residents should be offered toileting or perineal care at least every two hours.

Based on interviews, and record review, facility staff failed to ensure dental care services were provided as recommended by a dentist for one resident (Resident #4) out of one sampled resident. The facility census was 47.1. Review of Resident #4's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/13/26, showed staff assessed the resident as:-Cognitively intact;-Diagnosed with dental caries, unspecified;-Abnormal mouth tissue, obvious or likely cavities or broken natural teeth, and mouth or facial pain, discomfort or difficulty with chewing.Review of the resident's care plan, revised 05/08/26, showed staff are to assist with dental/oral hygiene needs, and he/she has own teeth in poor condition. Review of the resident's physician's order set (POS), dated May 2026, showed the resident may be seen by dental provider as needed. Review of the resident's dental visit summary, dated 01/22/26, showed the resident has a compromised medical disposition and oral surgery should be completed under the medical license of an oral surgeon. The resident has multiple teeth that need to be removed in four to six areas of the oral cavity. Review of the resident's medical record, dated 01/26/26, showed an oral surgery referral sent to the contracted dental service provider. Review showed the record did not contain documentation staff followed up to ensure dental care services were provided. During an interview on 05/13/2026 at 9:41 A.M., the resident said he/she has loss of teeth. He/She said a dental appointment had not been requested, but an aid said he/she needs new teeth. The resident said he/she would like to have dentures because some food is hard to chew. During an interview on0 5/15/26 at 08:50 A.M., the Social Services Director (SSD) said after receiving the dentist's summary, a referral was sent to the contracted dental service provider, and the charge nurse was asked to request a dental order from the provider. He/She said the regular dentist could not accommodate the resident because of his/her mobility issues. The SSD could not locate any notes related to conversations about the residents' dental services. During an interview on 05/15/26 at 9:00 A.M., Licensed Practical Nurse (LPN) E said the progress notes showed a dental referral was received on 3/24/26. He/She said staff would call the oral surgeon's office to schedule the appointment. LPN E said the resident's medical record did not contain documentation staff called to get an appointment with the oral surgeon. During an interview on 5/15/26 at 10:00 A.M., the Director of Nursing (DON) said he/she was familiar with the resident's dental issues and was told he/she refused to go to the appointments because of mobility limitations. He/She was not familiar with the current status of the resident's dental services.

Based on observation, interview, and record review, facility staff failed to promote and facilitate the right of self-determination when staff failed to honor two residents (Resident #33 and #58) preferences to sleep later in the morning for two out of eight sampled residents. The facility census was 62.1. Review of the facility's Resident Rights policy, undated, showed the resident has the right to participate in his/her own care and to be fully respected and adhered to.2. Review of Resident #33's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/08/26, showed staff assessed the resident as cognitively intact.Review of the resident's face sheet, dated 05/15/26, showed the resident is responsible for himself/herself.Review of the resident's care plan, dated 05/12/26, showed the care plan did not contain direction or guidance to residents' preference for sleeping in and/or staying in bed later in the day. Review of the resident's Patients [NAME] of Rights, signed 04/29/26, showed residents are entitled to take part in planning their care and in being informed in all aspects of their care. Residents may refuse any treatment they do not want. During an interview on 05/12/26 at 1:16 P.M., the resident said he/she feels forced to get up early in the morning. He/She tells staff every day he/she does not want to get out of bed early, but they don't listen. He/She said he/she does not feel respected as a human being. During an interview on 05/15/26 at 9:54 A.M., the Director of Nursing (DON) said the resident prefers to stay in bed all the time, and staff encourage him/her to get up. He/She has sores which make being in bed worse for him/her. The DON said if the resident did not want to get out of bed, he/she would let staff know. 3. Review of Resident #58's admission MDS, dated [DATE], showed staff assessed the resident as cognitively impaired and received hospice services.Review of the care plan, dated 04/28/26, showed the care plan did not contain direction or guidance to resident preference for sleeping in or rising later in the morning. Review of the resident's Patients [NAME] of Rights, signed 04/22/26, showed the resident is entitled to take part in planning their care in being informed in all aspects of their care. The resident may refuse any treatment they do not want. During an interview on 05/13/26 at 8:27 A.M., the resident said he/she doesn't feel well most days and is tired all the time. Everyday staff come in really early and wake him/her up and make him/her sit in a wheelchair for what feels like hours before breakfast. He/She said he/she tells staff every single day he/she does not want to get out of bed just to eat a couple of bites, but staff does not listen and gets him/her up anyway. During an interview on 05/15/26 at 9:54 A.M., the DON said if given the option, the resident would stay in bed all the time and eat jellybeans. He/She does need assistance with eating and really should not eat in bed, but staff should not force him/her to get out of bed. 4. During an interview on 05/15/26 at 9:54 A.M., the Director of Nursing (DON) said residents should have the option of sleeping in if they choose to. Facility staff do try to encourage the residents to get up though for more socialization and decreased depression. He/She said staff should never force a resident to get up when they do not want to. He/She was not aware resident #33 and #58 wanted to sleep later in the morning. He/She said residents #33 and #58 would stay in bed all day if they were allowed to.During an interview on 05/15/26 at 10:57 A.M., the administrator said staff should encourage residents to get out of bed daily to decrease depression. He/She said the residents are getting to where none of them want to get out of bed, but staff should never force them to get up. It's the resident's right to stay in bed.

Based on observation, interview, and record review, facility staff failed to provide an ongoing activity program designed to meet the resident's interest, mental, and psychosocial well-being for five dependent residents (Resident #11, #13, #20, #29, and #52) out 24 sampled residents. The facility census was 59. 1. Review of the facility's policy titled Resident Activities, dated 03/2012, showed staff were directed to: -The Activity Director (AD) plans and organizes a program of approved activities for residents on a group level and for individuals to meet the needs of the residents; -All staff is responsible for assisting residents to activities of their choice; -An activity program is planned for each resident as a part of their total resident care by the AD; -An individualized program will be implemented for residents unable to participate or attend activities; -The AD or designated person will make announcement of all activities; -The activity staff is responsible for encouraging resident participation. 2. Review of the facility's activity calendar, dated December 2024, showed: -Sunday, 12/08/24: 9:00 A.M. Watch Church on television (TV), 10:00 Church, 1:00 P.M. Go Outside, 6:00 P.M. Watch a Movie; -Monday, 12/09/24: 9:30 A.M. Exercise and Games, 10:00 A.M. Cooking Club, 2:30 P.M. Bingo, 4:00 P.M. Mail Pass, 6:00 P.M. Chit Chat; -Tuesday, 12/10/24: 9:30 A.M. Music, 10:30 A.M. Church, 1:30 P.M. Nails, 4:00 P.M. Mail Pass, 6:00 P.M. Visit A Friend; -Wednesday, 12/11/24: 9:30 A.M. Exercise and Games, 10:00 A.M. Shopping, 10:00 A.M. One on Ones (1:1's), 1:00 P.M. Church, 2:00 P.M. Bingo, 4:00 P.M. Mail Pass, 6:00 P.M. TV Time. 3. Review of Resident #11's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/20/24, showed staff assessed the resident as severely cognitively impaired, and unable to be interviewed for activity preferences. Review of the resident's care plan, dated 11/11/24, showed staff were directed to: -Inform of what activities are happening and when; -Provide activities that don't require much decision making; -Enjoys watching TV, listening to music, visiting with friends and family. Observation on 12/08/24 at 1:52 P.M., showed the resident in bed with eyes closed. Observation on 12/09/24 at 2:44 P.M., showed the resident sat in the common area with eyes closed and the TV on. Observation on 12/10/24 at 3:05 P.M., showed the resident in bed with his/her eyes closed. Observation on 12/11/24 at 9:27 A.M., showed the resident in his/her wheelchair in his/her room with eyes closed. 4. Review of Resident #13's Annual MDS, dated [DATE], showed staff assessed the resident as moderately cognitively impaired, and not very important to have books, newspapers, and magazines to read, do favorite activities or go outside. Review of the resident's care plan, dated 10/13/24, showed staff were directed to: -Impaired hearing; -Allow activity options; -Encourage and invite to become involved in activities; -Provide verbal reminders of activities; -Provide 1:1 visits; -Radio or TV is preferred. Observation on 12/09/24 at 9:45 A.M., showed the resident in the common area with the TV on and his/her eyes closed. Observation on 12/10/24 at 8:40 A.M., showed the resident in the common area with the TV on and his/her eyes closed. Observation on 12/10/24 at 3:00 P.M., showed the resident in the common area with the TV on and his/her eyes closed. Observation on 12/11/24 at 9:26 A.M., showed the resident in the common area with the TV on and his/her eyes closed. 5. Review of Resident #20's Significant Change MDS, dated [DATE], showed staff assessed the resident as severely impaired cognition and unable to be interviewed for activity preferences. Review of the resident's care plan, dated 12/05/24, showed staff were directed to: -Impaired hearing; -Provide 1:1 visits; -Clergy visits; -Encourage participation and allow to decide what activity to attend. Observation on 12/09/24 at 8:43 A.M., showed the resident in the dining room with his/her eyes closed. Observation on 12/10/24 at 10:26 A.M., showed the resident in the common area with eyes closed and the TV on, while a church activity took place in another area of the facility. Observation on 12/11/24 at 9:26 A.M., showed the resident in the common area with his/her eyes closed and the TV on. 6. Review of Resident #29's Significant Change MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Very important to participate in religious activities; -Somewhat important to listen to music, do favorite activities; -Not very important to have books, newspapers, and magazines to read. Review of the resident's care plan, dated 11/05/24, showed staff were directed to: -Provide 1:1 visits; -Clergy visits; -Encourage participation and allow to decide what activity to attend. Observation on 12/08/24 at 1:23 P.M., showed the resident in the common area with eyes closed and the TV on. Observation on 12/09/24 at 2:47 P.M., showed the resident in bed with eyes closed. Observation on 12/10/24 at 10:00 A.M., showed the resident in the common area asleep where a church activity started. Observation showed staff did not attempt to wake or engage him/her. Observation on 12/11/24 at 9:26 A.M., showed the resident in the common area with his/her eyes closed and the TV on. 7. Review of Resident #52's Quarterly MDS, dated [DATE], showed staff assessed the resident as moderately cognitively impaired. Review of the resident's care plan, revised 11/19/24, showed staff are instructed to: -Encourage to become involved with activities he/she may have an interest in; -Involve with those who have shared interests; -Provide verbal reminders and written calendar of upcoming activities; -Encourage the resident to participate in small group activities. Observation on 12/10/24 11:14 A.M., showed the resident in the front living area. Observation on 12/11/24 at 1:09 P.M., showed the resident in the front living area. 8. During an interview on 12/11/24 at 11:30 A.M., Licensed Practical Nurse (LPN) A said staff used to provide more activities for the cognitively impaired residents. LPN A said the nursing staff are responsible to remind and assist residents to activities if one is scheduled. LPN A said the facility has books and games available but he/she does not see them used. LPN A said staff should make sure the resident is awake and encourage them to engage in participation of activities. During an interview on 12/11/24 at 1:10 P.M., the AD said when it is time for an activity, he/she will make an announcement over the facility's intercom system. The AD said he/she tries to go to the rooms and invite the residents but he/she is not able to go to all the rooms himself/herself usually. The AD said it is his/her responsibility to ensure all residents receive activities appropriate for each individual, and social interaction. The AD said other staff are responsible to assist residents to and from activities and should ensure the resident is awake to be engaged in the activity and not asleep in their chair. The AD said if residents fall asleep staff should encourage them to wake up and engage. The AD said the residents should not be left sitting in a common area asleep in front of the TV for long periods of time, he/she said this is not an activity. The AD said he/she tries to do 1:1's with the residents who are unable to participate in most activities, but he/she said there are too many residents for him/her to do them often enough. The AD said each day every resident in the facility should have an activity to participate and engage in, including those who are cognitively or physically not able to participate in most activities. During an interview on 12/11/24 at 2:05 P.M., the Director of Nursing (DON) said he/she expects all staff to assist in taking residents to and from activities. The DON said residents should not be left in a common room asleep with the TV on for long periods of time and this is not considered an activity. The DON said all staff should ensure and encourage residents to be awake and engage in activities. During an interview on 12/11/24 at 2:05 P.M., the administrator said the AD is responsible to plan activities and adjust activities as needed. The administrator said he/she is responsible to oversee the activities department and ensure activities are being completed. The administrator said he/she expects staff to go room to room and invite each resident to the activities, he/she said all staff should help do this. The administrator said all staff should ensure and encourage residents to be awake and engage in activities and not bring them asleep in their chairs from one room to another. The administrator said residents should not be left in a common room asleep with the TV on for long periods of time, and this should not be considered an activity. The Administrator said residents who are cognitively impaired or physically not able to do certain activities should be asked if they want to attend activities. 42484 48982

Based on observation, interview, and record review, facility staff failed to store and label creams and ointments in a safe and effective manner when staff did not document the open date on the creams and ointments in the treatment carts and failed to discard the expired creams and ointments. The facility census was 59. 1. Review of the facility's Medication Storage policy, undated, showed no discontinued, outdated, or deteriorated drugs or biologicals may be retained for use. All such drugs must be returned to the issuing pharmacy or destroyed in accordance with established guidelines. Each resident must have a space assigned to them that prevents the possibility of a drug for one resident being administered to another. Review of the facility's Medication Destruction policy, undated, showed all medications not returned to the issuing pharmacy will be destroyed. Medications to be destroyed including pills, capsules, liquids, creams, etc., will be placed in a sealable container such as a plastic bag. The plastic bag will them be sealed and placed in the trash. 2. Observation on [DATE] at 10;29 A.M., of the East hall treatment cart showed: -One bottle of Nyamyc Nystatin powder (used to treat fungal or yeast infections) opened and undated, with an expiration date of [DATE]; -One tube of Lidocaine 4% topical cream (used for pain relief), opened and undated; -One tube of Nystatin cream, opened and undated; -One tube of Clotrimazole and Betamethasone cream (used to treat fungal infections), opened and undated; -One tube of Collagenase Santyl ointment, (used to remove damaged tissue from chronic skin ulcers), opened and undated; -One tube of Clobetasol Propironate topical solution (used to treat eczema and psoriasis, with no resident label. Resident could not be identified. 3. Observation on [DATE] at 12:46 A.M., of the [NAME] hall treatment cart showed: -One tube of Hydrogel (used to heal wounds), opened and undated, with an expiration date of ,d+[DATE]; -One tube of Hydrogel, opened and undated with an expiration date of ,d+[DATE]; -One box of chlorhexidine gluconate cloths (used to reduce bacteria on skin), unopened with an expiration date of [DATE]. 4. During an interview on [DATE] at 12:50 P.M., Licensed Practical Nurse (LPN) D said he/she is responsible for overseeing the treatment carts. The LPN said the facility does not have a process for checking the treatment carts for outdated ointments or creams. The LPN said he/she will sometimes go through the carts when a resident is discharged . The LPN said if an item is expired he/she would ask the Director of Nursing (DON) how to dispose of it. The LPN said he/she did know there were expired items in the carts. During an interview on [DATE] at 12:56 P.M., the DON said all the nurses are responsible for periodically checking the treatment carts for outdated or unlabeled ointments, and creams. The DON said he/she expects the nursing staff to remove outdated products and dispose of the products per the destruction policy. The DON said he/she did not know why there were expired unlabeled creams in the cart. During an interview on [DATE] at 1:10 P.M., the Administrator he/she and the DON are responsible for ensuring the treatment carts are checked for outdated or unlabelled products. The Administrator said he/she relies on the nurses and Certified Medication Technicians (CMT) to check dates and discard outdated products according to the medication destruction policy.

Based on interview and record review, facility staff failed to ensure as needed psychotropic medication (a drug that affects behavior, mood, thoughts, or perception) orders were limited to 14 days unless specific duration and clinical rationale were provided for two of five sampled residents (Resident #14 and #45). The facility census was 59. 1. Review of the policies provided by the facility showed they did not contain a psychotropic medication policy. 2. Review of Resident #14's Significant Change MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Had inattention and disorganized thinking, but no altered level of consciousness, delusions or behavioral symptoms; -Used antianxiety mediations; -Diagnosis of aphasia (the loss of ability to understand or express speech), Parkinson's Disease, anxiety, depression, bipolar disease, and schizophrenia; -Received hospice care. Review of the resident's POS, dated 12/2024, showed an order for Lorazepam (medication used to decrease anxiety), 0.5 milligrams (mg), one tablet every six hours as needed for anxiety disorder. The order had a start date of 08/27/24 and a stop date of 02/05/25. The order did not contain a 14 day stop date or a clinical rationale for the specified time frame. Review of the medical record showed it did not contain a clinical rationale for the specified time frame. Review of the resident's Medication Administration Record (MAR), dated 11/01/24 to 12/11/24, showed staff did not document the resident received the as needed Lorazepam. 3. Review of Resident #45's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/25/24, showed staff assessed the resident as: -Severely cognitively impaired; -Demonstrated inattention, disorganized thinking, delusions, physical and verbal behavioral symptoms, and rejection of care; -Used antianxiety medications; -Diagnoses of Alzheimer's disease, dementia, anxiety, depression, a psychotic disorder other than schizophrenia, and post-traumatic stress disorder (PTSD). Review of the resident's Physician Order Sheet (POS), dated 12/2024, showed and order for Xanax (medication used to decrease anxiety) 0.25 mg every eight hours as needed for anxiety disorder. The order had a start date of 08/01/24 and a stop date of 01/16/24. The order did not contain a 14 day stop date or a clinical rationale for the specified time frame. Review of the medical record showed it did not contain a clinical rationale for the specified time frame. Review of the resident's MAR, dated 11/01/24 to 12/11/24, showed staff documented the resident received Xanax on 11/12/24. During an interview on 12/11/24 at 1:11 P.M., Licensed Practical Nurse (LPN) A said when an order is received, the charge nurse is responsible to ensure as needed psychotropic medications are limited to 14 days and let the doctor know if it is not. LPN A said any PRN psychotropic medications must be limited to 14 days. If it is not used in 14 days, the order should be discontinued; if it is used regularly, it should be added as a scheduled medication; if it is used off and on, it would have to be stopped and reactivated after 14 days. LPN A said he/she did not know why psychotropic medication orders would be allowed for more than 14 days. LPN A said when the resident was admitted and the nurse was entering the orders into the facility's electronic orders, the PRN order greater than 14 days must have been overlooked. During an interview on 12/11/24 at 2:06 P.M., the Director of Nursing (DON) said the charge nurse who enters the orders is responsible to review for any questions or changes needed and verify with the physician. The DON said psychotropic drugs should not ordered as PRN for great than 14 days, unless the resident receives hospice services, then the medications can be ordered for 30 days.

Based on interview, and record review, facility staff failed to communicate pharmacy recommendations to the physicians of three residents (Resident #30, #34, and #56) to prevent or minimize adverse consequences related to medication therapy to the extent possible. The facility census is 67. 1. Review of the facility's policy, titled Drug Review, undated, showed staff were directed to do the following: -All medications given to each resident will be reviewed on a monthly basis in order to: - Review drug interactions; - Ensure adherence to stop orders; - Ensure accuracy in administration; - Evaluate medications are appropriate to diagnosis; -The pharmacist reviews all federal indicators, and a monthly report form is filled out to show any problem areas; -Problems identified shall be addressed according to need in consultation with the physician. 2. Review of Resident #30's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 06/15/23, showed staff assessed the resident as: -Cognitively intact; -Diagnosis of cancer, peripheral vascular disease (PVD) (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), malnutrition (when the body does not get enough nutrients), anxiety (intense, excessive, and persistent worry or fear about everyday situations), and manic depression (a mental illness that causes ununusual shifts in a person's mood, energy, activity levels and concentration). Review of the Pharmacist's monthly Medication Regimen Review (MRR) note, dated 08/07/23, showed MRR- see report for gradual dose reduction (GDR) recommendation. Review of the resident's medical record showed no documentation of the pharmacist's report or the physician's response. 3. Review of Resident #34's Admission MDS, dated [DATE], showed staff assessed the resident as: -Diagnoses of coronary artery disease (CAD) (damage or disease in the heart's major blood vessels), high blood pressure, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), anxiety, malnutrition, chronic kidney disease, dementia with behavioral disturbances, and major depressive disorder (MDD) (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life); -Received antipsychotic and antidepressant medications seven out of seven days in the look back period (period of time used to complete the assessment). Review of the Pharmacist's monthly MRR notes showed: -05/12/23 MRR - see report for recommendation; -08/07/23 MRR - see report for GDR recommendation. Review of the resident's medical record showed no documentation of the pharmacist's report or the physician's response. 4. Review of Resident #56's Annual MDS, dated [DATE], showed staff assessed the resident as: -Diagnoses of heart disease, high blood pressure, diabetes, anxiety, depression, and Chronic Obstructive Pulmonary Disease (COPD) (a group of lung diseases that block airflow and make it difficult to breathe); -Received antidepressants, insulin, anticoagulants (makes the blood thinner), and opioids seven out of seven days in the look back period. Review of pharmacist's monthly MMR, note dated 03/24/23, showed MRR- see report for GDR recommendation. Review of the resident's medical record showed no documenation of the pharmacist's report or physician's response. During an interview on 09/21/23 at 10:15 A.M., the Assistant to the Director of Nursing (ADON) said he/she and another staff member were responsible for ensuring the physician received a copy of the recommendations from the pharmacist. The ADON said the recommendations are placed in a folder for the physician to review when at the facility. The ADON said the physician should agree or disagree with the recommendation and the information is then update in the electronic health record (EHR). The ADON said he/she did not know why the residents did not have physician responses to the MRRs. During an interview on 09/21/23 at 12:01 P.M., the Administrator said the Director of Nursing (DON) was responsible for ensuring pharmacy recommendations are completed. The pharmacist gave the recommendations to the DON and then the DON sent the recommendations to the physician and waited for a response. The physician was in the building on Thursdays and staff should follow up with them. The Administrator said there was no system in place to ensure the recommendations were completed. 42815 45489

Based on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans, to address the care needs for three residents (Residents #22, #29 and #58). The census was 67. 1. Review of the facility's policy, titled Care Planning - Interdisciplinary Team, undated, showed a comprehensive care plan for each resident is developed within seven days of completion of the resident assessment. 2. Review of Resident #22's Admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 09/02/23, showed staff assessed the resident as follows: -Cognitively intact; -No dental or oral status concerns. Review of the resident's baseline care plan, dated 08/30/23, showed it did not contain documentation the resident wore dentures. Observation on 09/18/23 at 2:49 P.M., showed the resident had no natural teeth and without dentures. Observation on 09/20/23 at 11:25 A.M., showed the resident's dentures were on the bathroom sink. During an interview on 09/18/23 at 2:49 P.M., the resident said he/she wore dentures. The resident said he/she was visually impaired, so staff had to help him/her put his/her dentures in. The resident said staff did not always help him/her with his/her dentures, and it was difficult for him/her to eat without them in. During an interview on 09/20/23 at 11:24 A.M., the resident said staff had not put in his/her dentures or asked him/her if he/she wanted to wear dentures. 3. Review of Resident #29's Admission MDS, dated [DATE], showed staff assessed the resident as follows: -admitted [DATE]; -A Brief Interview for Mental Status (BIMS) (a screen for cognitive impairment) score of 12 out of 15, showed the resident as cognitively intact; -Diagnoses of coronary artery disease (heart disease), hypertension (high blood pressure), hyperlipidemia (high cholesterol), cerebrovascular accident (CVA, stroke), renal insufficiency (kidney failure), hyponatremia (low sodium), and malnutrition. Review of the resident's medical records showed no care plan for the resident. 4. Review of Resident #58's Admission MDS, dated [DATE], showed staff assessed the resident as follows: -admitted [DATE]; -A BIMS score of 14 out of 15, showed the resident as cognitively intact; -Diagnoses of high blood pressure, depression, asthma, chronic obstructive pulmonary disease (COPD) (a group of lung disease that block airflow and make it difficult to breathe), arthritis, gastroesophageal reflux disease (GERD) and anxiety disorder. Review of the resident's medical record showed no care plan for the resident. During an interview on 09/21/23 at 10:15 A.M., Licensed Practical Nurse (LPN) A and the Assistant to the Director of Nursing (ADON) said care plans should be updated if the resident has a significant change and/or on a quarterly and yearly basis. The ADON said he/she is responsible for updating the care plans, and the care plan should include resident specific information. During an interview on 09/21/23 at 12:02 P.M., the Administrator said the care plans should be complete and updated with resident specific information. 42815

Based on observation, interview, and record review, facility staff failed to to clean and store respiratory equipment and devices in a manner to prevent the spread of infection for four residents (Residents #22, #26, #30 and #40). The facility census was 67. 1. Review of the facility's policy titled, Continuous Pressure Airway Pressure (CPAP) (a machine that uses mild air pressure to keep breathing airways open while you sleep) Administration, dated March 2015, showed no direction for staff in regard to storing the mask in a sanitary manner when not in use. Review of the facility's policy titled, Oxygen Administration, undated, showed staff no direction for staff in regard to oxygen tubing storage when not in use. 2. Review of Resident #22's Admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 09/02/23, showed staff assessed the resident as follows: -Cognitively intact; -Used a BiPAP (Bilevel positive airway pressure) (a type of ventilator-a device that helps with breathing) or CPAP machine. Review of the resident's baseline care plan, dated 08/30/23, showed no direction for staff in regard to the resident's BiPAP machine. Review of the resident's Physician Order Summary (POS), dated 08/21/23 through 09/21/23, showed no order for BiPAP use. Observation on 09/18/23 02:43 PM., showed a BiPAP mask and tubing on the resident's nightstand. Further observation showed no bag in the room to store the BiPAP mask in a sanitary manner Observation on 09/20/23 at 9:09 A.M., showed the resident lay in his/her bed with the BiPAP mask and tubing above his/her head. Further observation showed no bag in the room to store the BiPAP mask in a sanitary manner. During an interview on 09/18/23 at 3:20 P.M., the resident said he/she used the BiPAP machine every night. The resident said he/she was visually impaired and staff set the machine up for him/her prior to use. 3. Review of Resident #26's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Used oxygen. Review of the resident's POS, dated 08/21/23 through 09/21/23, showed an order for oxygen to be administered at 2 liters per minutes (LPM) continuously per nasal cannula. Review of the resident's care plan, dated 08/23/23, showed staff documented the resident used oxygen. Observation on 09/19/23 at 9:24 A.M., showed the resident wore oxygen. Further observation showed no bag in the room to store the oxygen mask or tubing in a sanitary manner. Observation on 09/20/23 at 12:32 P.M., showed the resident's oxygen tubing on the resident's bedside table. Further observation showed no bag in the room to store the oxygen mask or tubing in a sanitary manner. 4. Review of Resident #30's Annual MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Did not use oxygen. Review of the resident's POS, dated 08/21/23 through 09/21/23, showed an order for the use of a nebulizer administered as needed and continuous oxygen administered at 2 LPM. Review of the resident's care plan, dated 08/10/23, showed staff documented the resident received oxygen. Observation on 09/19/23 at 10:16 A.M., showed the nebulizer mask lay on the resident's nightstand. Further observation showed no bag in the room to store the oxygen mask or tubing or nebulizer mask in a sanitary manner. Observation on 09/20/23 at 12:30 P.M., showed the resident's oxygen tubing and nasal cannula lay on the floor and the nebulizer mask lay on top of the nebulizer machine. Further observation showed no bag in the room to store the oxygen mask or tubing or nebulizer mask in a sanitary manner. 5. Review of Resident #40's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Did not use a BiPAP or CPAP. Review of the resident's POS, dated 08/21/23 through 09/21/23, showed an order for the use of CPAP administered during the evening or at bedtime (HS). Review of the resident's care plan, dated 08/09/23, showed it directed staff to change CPAP tubing weekly and as needed. Further review showed it did not direct staff in regard to tubing and mask storage when not in use. Observation on 09/18/23 at 11:30 A.M., showed the resident's CPAP mask and tubing on his/her table. Further observation showed no bag in the room to store the CPAP mask in a sanitary manner. Observation on 09/21/23 at 10:54 A.M., showed the resident's CPAP mask and tubing on his/her table. Further observation showed no bag in the room to store the CPAP mask in a sanitary manner. During an interview on 09/20/23 at 4:31 P.M., the Director of Nursing (DON) said CPAP masks, oxygen tubing, and nebulizer masks and tubing should be stored in a bag when not in use. The bag should be changed every week when the tubing or mask is changed. The DON said if a resident's nasal cannula touches the floor, bed or any contaminated area it should be thrown away and replaced with new tubing. The DON said he/she did not know why staff were not putting the masks and tubing in bags when not in use. He/She said staff had in-services in regard to this. The DON said he/she did not know why staff were not replacing tubing that touched contaminated surfaces. During an interview on 09/21/23 at 10:15 A.M., Licensed Practical Nurse (LPN) A and the Assistant to the Director of Nursing (ADON) said new plastic bags were placed on the oxygen concentrators on Fridays for storage of oxygen tubing and masks. They said they did not know why the residents who used respiratory equipment did not have bags to sanitarily store the equipment. The LPN and ADON said there was an infection control concern if the tubing and mask were not placed in the storage bag. The LPN and ADON said staff were directed to dispose of the tubing and/or mask if it touched the floor or the bed. During an interview on 09/21/23 at 11:24 A.M., Certified Nurse Aide (CNA) B said the residents' oxygen tubing and equipment should be placed in a plastic bag when not in use. The CNA said he/she thought there were a couple of rooms without plastic bags because it was just so busy. The CNA said the nebulizer and BiPAP masks were also supposed to be in plastic bags when not in use. The CNA said he/she should have stopped and gotten bags for the masks and oxygen tubing. The CNA said if the mask or nasal cannula touched contaminated surfaces, like a bed or floor, staff were supposed to throw it away and go to the nurse to get replacements. During an interview on 09/21/23 at 11:50 A.M., the Administrator said all tubing was supposed to be placed in plastic bags, when not in use. The administrator said if the tubing touched a contaminated surface the staff should discard it and replace it. Staff have been instructed to place masks and tubing in plastic bags. 42815

Based on observation, interview, and record review, facility staff failed to review and revise the plan of care with changes in the resident's needs for six residents (Resident #4, #20, #30, #40, #52, and #53). The facility census was 67. 1. Review of the facility's policy, titled Care Planning - Interdisciplinary Team, undated, showed a comprehensive care plan for each resident is to be developed within seven days of completion of the resident assessment. Review of the policy showed no time frame for revisions of care plans. 2. Review of Resident #4's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 07/15/23, showed staff assessed the resident as follows: -Cognitively intact; -Required limited assistance from one staff member for personal hygiene and dressing. Review of the resident's care plan, dated 08/09/23, showed staff were directed to assist the resident with ADLs per his/her needs. Further review showed no direction for staff in regard to the level of assistance the resident required for ADLs. Review of the resident's shower sheets showed staff documented the resident had a shower on 08/31/23, and staff did not trim the resident's nails. Further review showed no additional shower sheets had been completed. Observation on 09/18/23 at 11:37 A.M., showed the resident's nails were long and jagged. Observation on 09/19/23 at 9:20 A.M., showed the resident's nails were long and jagged. During an interview on 09/19/23 at 9:20 A.M., the resident said he/she had only received one shower in the past two weeks and he/she has asked for a shower but had not gotten one. The resident said he/she liked his/her nails cut short and staff did not always trim his/her nails when asked. The resident said he/she is unable to trim his/her nails without help. 3. Review of Resident #20's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Required extensive assistance from two staff members for bed mobility and transfers; -Required extensive assistance from one staff member for dressing, toilet use and personal hygiene; -Required total assistance from two staff members for bathing. Review of the resident's care plan, last reviewed 04/18/23, showed no direction for staff in regard to the resident's ADL needs. 4. Review of Resident #47's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Required total assistance from two staff member for bed mobility, transfers, dressing, toilet use, hygiene and bathing; -Independent with eating. Review of the resident's care plan, last reviewed 03/23/22, showed no direction for staff in regard to the resident's ADL needs. 5. Review of Resident #30's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Did not use Continuous Positive Airway Pressure (CPAP) (a machine that uses mild air pressure to keep breathing airways open while you sleep); -Diagnosis of cancer; -Did not receive an infusion treatment. Review of the resident's medical record showed the resident had a diagnosis of lung cancer. Review of the resident's Physician Order Summary (POS), dated 08/21/23 through 09/21/23, showed an order for the use of CPAP administered during the evening or at bedtime (HS). Further showed the resident had a code status (type of resuscitation provided if found with no heartbeat or not breathing) of Do Not Resuscitate (DNR) (Do not provide treatment is found without a heartbeat or not not breathing). The POS did contain an order for infusion treatments. Review of the resident's care plan, dated 08/10/23, showed it directed staff to change CPAP tubing weekly and as needed (PRN). The care plan did not direct staff in regard to interventions, goals and monitoring of the use of the CPAP. Additional review showed the care plan showed a code status of Full Code, but updated with the correct advance directive status of DNR after the surveyor addressed the physician order did not match the information in the care plan. Additional review showed it did not contain direction for staff in regard to the resident's lung cancer diagnosis and infusion treatments. Observation on 09/18/23 at 11:30 A.M., showed the resident had a CPAP machine in his/her room. During an interview on 09/21/23 on 10:15 A.M., Licensed Practical Nurse (LPN) A and the Assistant to the Director of Nursing (ADON) said the resident receives a monthly infusion of Keytruda (cancer treatment) as a treatment for lung cancer. The LPN and ADON said CPAP use, infusion treatments, and code status information should all be included in the resident's care plan. 6. Review of Resident #40's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Required extensive assistance from one staff member for personal hygiene; -Required limited assistance from one staff member for dressing. Review of the resident's care plan, dated 08/09/23, showed staff documented the resident will remain clean, dry, odor free and maintain hygiene/dignity with staff assistance. Further review showed no direction for staff in regard to the level of assistance required for ADLs. Review of the shower sheets showed staff documented the resident had a shower on 09/11/23. Further review showed it did not contain documentation the resident was shaved. Observation on 09/18/23 at 11:47 A.M., showed the resident with hair on his/her chin. During an interview on 09/18/23 at 11:47 A.M., the resident said he/she had not received a shower in two weeks. The resident said staff were told to shave his/her face on shower days, but they do not and it make his/her face itch. Observation on 09/19/23 at 9:50 A.M., showed the resident wore the same hospital gown as the day before with a large orange stain on the front and had hair on his/her chin. 7. Review of Resident #52's Annual MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Diagnoses of Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), anxiety, Bipolar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and Post Traumatic Stress Disorder (PTSD), a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event. Review of the resident's face sheet showed staff documented the resident's code status as DNR. Review of the resident's POS showed an order for a DNR code status, dated 08/21/23. Review of the resident's care plan, last reviewed 06/24/23, showed no direction for staff in regard to the resident's code status. 8. Review of Resident #53's Annual MDS, dated [DATE], showed staff assessed the resident as: -admitted to the facility on [DATE]; -Cognitively intact; -Diagnoses of high blood pressure, other fracture, depression, peripheral vascular disease (PVD) (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and diabetes; Review of the resident's face sheet showed staff documented the resident's code status as DNR. Review of the POS showed an order for a Full Code status, dated 08/14/23. Review of the resident's care plan, last reviewed 08/14/23, showed staff documented the resident's code status as Full Code. Review of the resident's progress notes, dated 08/17/2023 at 07:35 A.M., showed staff documented the facility received the signed DNR paper work from the physician on 08/16/23. Observation on 09/18/23 at 2:25 P.M., showed the resident's name printed on red paper on the door to their room. During an interview on 09/18/23 at 11:11 A.M., Housekeeper G said if the resident's name was printed on red paper it indicated the resident was a DNR, and if the paper was green it indicated the resident was a full code. During an interview on 09/21/23 at 10:15 A.M., LPN A and the ADON said care plans should be updated whenever a resident had a significant change in status and on a quarterly and yearly basis. The ADON said he/she was responsible for updating the care plans. The LPN and ADON said respiratory treatments, code status, cancer diagnoses and treatments, and the level of assistance required for ADLs should be included in the residents' care plans. During an interview on 09/21/23 at 12:02 P.M., the Administrator said he/she expected respiratory treatments, code status, cancer diagnoses and treatment, and the level of assistance required for by residents included in the care plan. The Administrator said the resident's code status should be accurately reflected in the care plan, and staff should update the care plans with the resident's accurate code status after it was brought to the staff's attention.

Based on observation, interview, and record review, facility staff failed to destroy discontinued and As Needed (PRN) medications in a timely manner for two residents (Resident #8 and #14). The facility census was 67. 1. Review of the facility's policy titled, Storage of Medications, dated 02/07/2013, showed staff were directed to do the following: -Discontinued medications will be place in a locked cabinet for destruction; -Medications will be destroyed at least weekly; -No discontinued medications may be retained for use. 2. Observation on 09/18/23 at 2:22 P.M., showed the following medications for resident #8 in the medication destruction cabinet of the [NAME] Side Medication Room: -14 capsules (caps.) of 100 milligram (mg) Gabapentin (anticonvulsant) with a discontinued date of 03/22/23; -10 caps. of 100 mg Gabapentin with a discontinued date of 03/22/23; -28 caps. of 100 mg Gabapentin with a discontinued date of 03/22/23; -28 caps. of 100 mg Gabapentin with a discontinued date of 03/22/23; -19 caps. of 100 mg Gabapentin with a discontinued date of 03/22/23; -8 tablets (tabs) of Potassium Chloride 20 milliequivalents (MEQ) with a discontinued date of 03/21/23. -29 tabs of Haloperidol (antipsychotic) 0.5 MG with a discontinued date of 03/08/23. 3. Observation on 09/18/23 at 2:22 P.M., showed the following medications for resident #14 in the medication destruction cabinet of the [NAME] Side Medication Room: -90 tablets of 10 mg Baclofen (muscle relaxant) with an order date of 09/16/22; -90 tablets of 10 mg Baclofen with an order date of 12/06/22; -79 tablets of 10 mg Baclofen with an order date of 01/02/23; -90 tablets of 10 mg Baclofen with an order date of 01/30/23; Review of the resident's Medication Administration Record (MAR), dated 09/16/22 through 09/18/23, showed the resident never requested and staff had never administered Baclofen 10 mg to the resident. During an interview on 09/18/23 at 2:50 P.M., Licensed Practical Nurse (LPN) M said staff should have destroyed the medications already. The LPN said Resident #14's PRN Baclofen was in the destruction cabinet because the resident doesn't ever ask for the medication. The LPN said the facility preferred Registered Nurses (RN)s destroy the medications, even if the medications were not controlled. The LPN said he/she did not know what was going on with the medications in the destruction cabinet. The LPN said he/she did not know if there was a set time for destroying medications after they have been discontinued. The LPN said there should not be medications in the cabinet that were discontinued six months ago. The LPN said if the resident had a PRN medication, but did not use it, staff should get rid of the medication. The LPN said he/she can not find where the resident ever requested the PRN Baclofen. During an interview on 09/20/23 at 4:31 P.M., the Director of Nursing (DON) said PRN medications should be discontinued after 30 days if the resident did not use it. The DON said staff should destroy medications as soon as there were two nurses available. The DON said he/she did not know why the medications weren't destroyed, but they should have been. During an interview on 09/21/23 at 10:56 A.M., LPN A said when a medication was discontinued staff was supposed to destroy the medication with two nurses and document the medications were destroyed. The LPN said he/she did not know what the facility's policy said about timeframe for destruction of medications. During an interview on 09/21/23 at 11:50 A.M., the Administrator said when medications were discontinued staff had five days to ensure the medications were destroyed. The Administrator said staff absolutely should have destroyed the medications and he/she did not know why it was not done.

Based on observation, interview and record review, facility staff did not maintain a safe, clean, comfortable and homelike environment, when staff failed to properly maintain residents' rooms, bathroom vanities and furniture. Additionally, facility staff failed to clean and maintain oxygen concentrator filters for two residents (Resident #4 and #26). The facility census was 67. 1. Review of the policies provided by the facility showed no policy for reporting and/or reporting concerns with resident rooms, bathrooms or furniture. 2. Observation on 09/18/23 at 11:37 A.M., showed room [ROOM NUMBER] floor had black marks, stains and a buildup of debris between the tiles. The bathroom vanity had missing paint and a yellow substance on the front and the walls had gouges and black marks. 3. Observation on 09/18/23 at 2:59 P.M., showed room [ROOM NUMBER] floor had a buildup of debris between the tiles, scratches, black marks and stains. The walls had black marks, nail holes and exposed nails. 4. Observation on 09/19/23 at 10:16 A.M., showed room [ROOM NUMBER] floor had cracked, scratched and stained tiles. The bathroom vanity had black marks and the walls had gouges, black marks and nail holes. 5. Observation on 9/21/23 at 9:49 A.M., showed room [ROOM NUMBER] had paint chipping off of a green dresser, black marks on floor, and a crack in the wall next to the air conditioner. 6. Observation on 9/21/23 at 9:50 A.M., showed room [ROOM NUMBER] had paint chipping off of the dresser, carpet frayed by the door and a missing threshold strip. 7. Observation on 9/21/23 at 9:53 A.M., showed room [ROOM NUMBER] had paint chipping off of the dresser, and a missing rubber strip on the threshold by the door. 8. Observation on 9/21/23 at 9:54 A.M., showed room [ROOM NUMBER] had paint chipping off of the dresser. 9. Observation on 9/21/23 at 9:54 A.M., showed room [ROOM NUMBER] had paint chipping off of the dresser. 10. Observation on 9/21/23 at 9:54 A.M., showed room [ROOM NUMBER] had paint chipping off of the dresser. 11. Observation on 9/21/23 at 9:54 A.M., showed room [ROOM NUMBER] had paint chipping off of the dresser. 12. Observation on 9/21/23 at 9:56 A.M., showed room [ROOM NUMBER] had black marks on the floor in front of the dressers, black marks on the floor beside the bed and both dressers with chipped paint. 13. Observation on 9/21/23 at 9:58 A.M., showed room [ROOM NUMBER] had a dark black substance on the floor tiles next to the residents bed, food crumbs on the floor next to the bed, snack crumbs all over the top of the dresser and on the floor in front of the dresser and holes in the walls above the television and mini refrigerator. 14. Observation on 09/18/23 at 11:37 A.M., showed Resident #4's oxygen concentrator had a white substance covering the filter. 15. Observation on 09/18/23 at 11:37 A.M., showed Resident #26's oxygen concentrator had a white substance covering the filter. During an interview on 09/21/23 at 10:15 A.M., Licensed Practical Nurse (LPN) A and the Assistant to the Director of Nursing (ADON) said staff should document environmental concerns in the maintenance log. They said the logs are checked daily. They had not noticed environmental concerns. They said the nurses should clean the oxygen concentrator filters every Friday when the oxygen tubing is changed. During an interview on 09/21/23 at 10:44 A.M., Floor Technician K said staff should report environmental concerns to the maintenance staff and/or charge nurse. They should fill out a work order sheet to give to the maintenance department. Floor Technician K said the resident rooms are inspected monthly, and he/she had not noticed any issues with the floors on the 200 hall. He/She said the floors are buffed every couple of weeks, and he/she had completed repairs in some of the rooms. He/She said staff had not reported any environmental concerns to the maintenance department recently. During an interview on 09/21/23 at 11:31 A.M., Certified Nurse Aide (CNA) B said staff are directed to document maintenance issues in the maintenance log located at the nurses' station, which is checked daily. The CNA said he/she had not noticed any environmental concerns or reported any concerns. During an interview on 09/21/23 at 12:02 P.M., the Administrator said staff are directed to report environmental concerns including floors, walls, dressers and vanities to the supervisor or to him/her. He/She said there is a maintenance form on each hall and it is checked daily. The Administrator said the resident rooms are inspected daily and there had not been any reports of environmental concerns. Oxygen filters are cleaned every 14 days by the nurse. 42815

Based on observation, interview and record review, facility staff failed to ensure three residents (Residents #4, #22 and #40), who were unable to complete their own activities of daily living (ADLs) (showering/bathing, dressing, and personal hygiene), received the necessary care and services to maintain good personal hygiene. The facility census was 67. 1. Review of the facility's policy titled, Activities of Daily Living, undated, showed it did not contain direction for staff in regards to how often to change resident's clothing, brush hair, or provide showers. Review of the facility's policy titled, Nails, Care of (Fingers and Toes), undated, showed staff were directed to do the following: -The purpose is to provide cleanliness, comfort, and prevent the spread of infection; -The nursing staff assistants may perform nail care on the residents who are not at risk for complications of infection. Review of the facility's policy titled, Shaving the Resident, undated, showed staff were directed to remove facial hair and improve the resident's appearance and morale. 2. Review of Resident #4's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 07/15/23, showed staff assessed the resident as follows: -Cognitively intact; -Required limited assistance from one staff member for personal hygiene and dressing. Review of the resident's care plan, dated 08/09/23, showed staff were directed to assist the resident with ADLs per his/her needs. Further review showed no direction for staff in regard to the level of assistance the resident required for ADLs. Review of the resident's shower sheets showed staff documented the resident had a shower on 08/31/23, and staff did not trim the resident's nails. Further review showed no additional shower sheets had been completed. Observation on 09/18/23 at 11:37 A.M., showed the resident's nails were long and jagged. Observation on 09/19/23 at 9:20 A.M., showed the resident's nails were long and jagged. Observation on 09/20/23 at 3:31 P.M., showed the resident's nails were long and jagged. During an interview on 09/19/23 at 9:20 A.M., the resident said he/she had only received one shower in the past two weeks and he/she has asked for a shower but had not gotten one. The resident said he/she liked his/her nails cut short and staff did not always trim his/her nails when asked. The resident said he/she is unable to trim his/her nails without help. 3. Review of Resident #22's Admission MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Did not document having no natural permanent teeth in the mouth or complete tooth loss. Review of the resident's baseline care plan, dated 08/30/23, showed no direction for staff in regard to the resident's dentures. Observation on 09/18/23 at 2:49 P.M., showed the resident without his/her dentures. During an interview on 09/18/23 at 2:49 P.M., the resident said he/she wore dentures. The resident said he/she is visually impaired so staff are supposed to help him/her with his/her dentures. The resident said staff did not always help him/her put his/dentures in, and he/she had difficulty eating without them. During an interview on 09/20/23 at 11:24 A.M., the resident said staff had not put in his/her dentures or asked him/her if he/she wanted to wear dentures. Observation on 09/20/23 at 11:25 A.M., showed the resident's dentures on the bathroom sink. During an interview on 09/20/23 at 12:23 P.M., Certified Nurse Aide (CNA) B said he/she took the resident his/her meal tray this morning and did not ask the resident if he/she would like his/her dentures. The CNA did not know the resident had dentures. Additionally, the CNA said when he/she went back to ask the resident why he/she did not ask for the dentures, the resident said because it was embarrassing. 4. Review of Resident #40's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Required extensive assistance from one staff member for personal hygiene; -Required limited assistance from one staff member for dressing. Review of the resident's care plan, dated 08/09/23, showed staff documented the resident would remain clean, dry, odor free and maintain hygiene/dignity with staff assistance. Further review showed no direction for staff in regard to the level of assistance required for ADLs. Review of the shower sheets showed staff documented the resident had a shower on 9/11/23. Further review showed it did not contain documentation the resident was shaved. Observation on 09/18/23 at 11:47 A.M., showed the resident with hair on his/her chin. Observation on 09/19/23 at 9:50 A.M., showed the resident wore the same hospital gown with a large orange stain on the front and had hair on his/her chin. Observation on 09/20/23 at 12:36 P.M., showed the resident had hair on his/her chin. Observation on 09/21/23 at 10:54 A.M., showed the resident had hair on his/her chin. During an interview on 09/18/23 at 11:47 A.M., the resident said he/she had not received a shower in two weeks. The resident said staff were told to shave his/her face on shower days, but they do not and it made his/her face itch. During an interview on 09/21/23 at 10:15 A.M., Licensed Practical Nurse (LPN) A and the Assistant to the Director of Nursing (ADON) said staff were directed to shower residents twice a week, but the facility was short staffed, so residents may not always receive showers. They said staff provided nail care and shaved residents on shower days and when needed. The LPN and ADON said they have noticed residents with unkempt facial hair and long nails and it was addressed with the CNAs and aides during an in-service. They said clothing should be changed daily or as needed and the resident's hair should be brushed daily and as needed. They said dentures should be given to the resident per their preference. During an interview on 09/21/23 at 12:02 P.M., the Administrator said the aides and other staff were responsible to provide showers. He/She said residents should be showered twice a week. He/She said nail care and shaving were done on shower days and as needed. He/She said clothing should be changed daily or as needed, as well as, brushing the resident's hair. He/She said the facility was understaffed, so resident's received one shower a week and some cares were not always completed.

Based on observation, interview, and record review, facility staff failed to accurately code oxygen use for two residents (Resident #4 and #30), chemotherapy (drug treatment that uses powerful chemicals to kill fast-growing cells in the body) for one resident (Resident #20) and Continous Positive Airway Pressure (CPAP), a machine that uses mild air pressure to keep airways open while sleeping, use for one resident (Resident #40). The facility census was 67. 1. Review of the policies provided by the facility showed no Minimum Dat Set (MDS), a federally mandated assessment tool completed by facility staff, policy. 2. Review of Resident #4's Annual MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Did not use oxygen. Review of the resident's Physician Order Summary (POS), dated 08/21/23 through 09/21/23, showed an order to administer three liters of oxygen continously via nasal cannula during waking hours. Review of the resident's care plan, dated 08/09/23, showed staff documented the resident received oxygen therapy related to potential for shortness of breath and breathing difficulty. Observation on 09/19/23 at 9:24 A.M., showed the resident wore oxygen. 3. Review of Resident #30's Annual MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Did not use oxygen. Review of the resident's POS, dated 08/21/23 through 09/21/23, showed an order to administer two liters of oxygen continously. Review of the resident's care plan, dated 08/10/23, showed staff documented the resident received oxygen therapy. Observation on 09/20/23 at 12:30 P.M., showed the resident's oxygen tubing and nasal cannula lay on the floor. Observation on 09/20/23 at 3:38 P.M., showed the resident's oxygen tubing and nasal cannula lay on the floor 4. Review of Resident #20's Quarterly MDS, dated [DATE], showed staff documented the resident did not receive chemotherapy. Review of the resident's care plan, revised 04/18/23, showed staff documented the resident received chemotherapy due to a diagnosis of Malignant Neoplasm of Sigmoid Colon (colon cancer) and secondary Malignant Neoplasm of Liver and Bile Duct (liver cancer). During an interview on 09/19/23 at 10:39 A.M., LPN M said the resident was out of the facility today for his/her Chemotherapy. The LPN said the resident normally returned to the facility in the afternoon. During an interview on 09/21/23 at 10:56 A.M., Licensed Practical Nurse (LPN) A said the resident received Chemotherapy and it should be identified on the MDS, under treatments. 5. Review of Resident #40's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Did not use a CPAP. Review of the resident's POS, dated 08/21/23 through 09/21/23, showed an order for CPAP use in the evening or at bedtime (HS). Review of the resident's care plan, dated 08/09/23, showed staff were directed to change CPAP tubing weekly and as needed. Further review showed it did not direct staff in regard to use. Observation on 09/18/23 at 11:30 A.M., showed the resident's CPAP mask and tubing lay on his/her table. During an interview on 09/21/23 on 10:15 A.M., Licensed Practical Nurse (LPN) A and the Assistant to the Director of Nursing (ADON) said oxygen and CPAP use should be coded on the MDS Assessment, as well as infusion treatments. The ADON said he/she is responsible for completing the MDS assessments. During an interview on 09/21/23 at 12:02 P.M., the Administrator said chemotherapy, and oxygen and/or other respiratory equipment should be indicated on the MDS if the resident used or received the treatments. 42815

Based on record review and interview, facility staff failed to complete a baseline care plan within 48 hours of admission for two residents (Resident #29 and #58). The facility census was 67. 1. Review of the facility's policy, titled Care Plan, Temporary, undated, showed staff were directed to do the following: -A temporary care plan will be implemented to meet the new resident's immediate needs; -To assure that the resident's immediate care needs are met and maintained, a temporary care plan will be implemented within 24 hours of admission; -The temporary care plan will be used until the comprehensive assessment has been completed and an interdisciplinary care plan has been developed according to the Resident Assessment Instrument (RAI) (assessment used to determine resident care needs) process. 2. Review of Resident #29's medical record showed staff documented the resident was admitted to the facility on [DATE]. The record did not contain a baseline care plan. 3. Review of Resident #58's medical record showed staff documented the resident was admitted to the facility on [DATE]. The record did not contain a baseline care plan. During an interview on 9/28/23 at 2:02 P.M., Licensed Practical Nurse (LPN) A said whoever is working when the resident is admitted is responsible for completing the baseline care plan. LPN A said if the baseline care plan was not completed on the admitting shift the next shift should complete it. LPN A said they give the aides an update on the resident so they will know how to care for them. During an interview on 9/28/23 at 2:10 P.M., the Administrator said the baseline care plans were completed upon admission. The administrator said the baseline care plan should be completed, if not staff will go by the report from the hospital. The administrator said he/she was responsible for making sure they were completed.

Based on interview and record review, facility staff failed to designate one or more individuals with specialized training in Infection Prevention and Control (IPC) as the Infection Preventionist (IP) for the facility's infection prevention and control program. The facility census was 67. 1. Review of the policies provided by facility staff showed no policy for Infection Preventionist training. During an interview on 09/20/23 at 4:31 P.M., the Director of Nursing (DON) said he/she was supposed to be the facility's IP. The previous IP stopped working for the facility on 07/15/22. The DON said he/she went online and signed up for the IP training, but he/she had not started the training because he/she kept getting pulled to the floor to work as a charge nurse. During an interview on 09/21/23 at 11:50 A.M., the Administrator said the facility currently did not have an IP. The DON has been tracking infections and antibiotic use and was going to take over the IP position, but had not completed the training. The administrator said he/she did not know why the DON had not completed the IP training and thought it had already been done.

Based on observation, interview, and record review, facility staff failed to provide reasonable accommodations to meet the needs of dependent residents by failing to keep the call lights within reach for three residents (Resident #12, #24, and #29). The facility census was 56. 1. Review of facility Call light policy, undated, showed the staff were instructed as follows: - All facility personnel must be aware of call lights at all times; - When providing care to residents, be sure to position the call light conveniently for the resident's use; - Tell the resident where the call light is and show him/her how to use the light; - Be sure all call lights are placed on the bed at all times, never on the floor or bedside stand. 2. Review of Resident #12's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/16/22, showed staff assessed resident as: - Severely cognitively impaired; - Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - Required extensive two person physical assistance for bed mobility, transfers, and toileting; - Required limited two person physical assistance for dressing and personal hygiene; - Wheelchair used as a mobility device with one person physical assist for locomotion on/off the unit. Review of the resident's care plan, last reviewed 02/22/22, showed an Activities of Daily Living (ADL's) deficit related to Down's Syndrome. Further review showed the resident at risk for falls related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 05/15/21, at 04:57 P.M., showed the resident in his/her bed. Observation showed the call light out of his/her reach on the wall. Observation on 05/16/22, at 10:20 A.M., showed the resident's call light hung on the wall attached to itself and out of his/her reach. Observation on 05/17/22, at 01:36 P.M., showed the resident in his/her bed. Observation showed the call light out of his/her reach on the wall. Observation on 05/18/22, at 05:40 A.M., showed the resident in his/her Broda chair (chair reducing skin breakdown). His/Her call light hung on the wall attached to itself and out of his/her reach. During an interview on 5/18/22 at 11:32 A.M., CNA A said he/she was not aware of Resident's call light hooked to the wall. During an interview on 05/18/22 at 12:48 P.M., the Director of Nursing (DON) said resident may not have the cognition to use their call lights but should still have them in reach at all times. During an interview on 5/18/22 at 1:04 P.M., the Administrator said he/she is not aware of the call light not being placed within reach for the resident. During an interview on 05/18/22, at 1:20 P.M., CMT B said he/she wasn't sure if the resident could use his/her call light, but it should still be within reach. During an interview on 05/18/22, at 02:15 P.M., LPN H said resident did not know how to use his/her call light. 3. Review of Resident #24's Annual MDS, dated [DATE], showed staff assessed resident as: - Cognitively intact; - Active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] - Required extensive one person physical assistance for personal hygiene; - Required limited one person assistance for dressing, toileting, bed mobility, transfers, and locomotion on the unit; - Required two person physical assist for locomotion off the unit; - Wheelchair used as a mobility device with one person physical assist for locomotion on/off the unit. Review of the resident's care plan, undated, showed an ADL self-care performance deficit related to bilateral arm amputation just below the elbow, dementia, muscle weakness, and incontinence of bowl and bladder. Interventions directed staff to make sure the call light is within the resident's reach. Observation on 05/15/22, at 2:48 P.M., showed the resident in his/her bed. Observation showed the call light out of his/her reach on the the nightstand Observation on 05/16/22, at 8:11 A.M., showed the resident in his/her bed. Observation showed the call light out of his/her reach on the the nightstand Observation on 05/16/22, at 1:57 P.M., showed the resident in his/her bed. Observation showed the call light out of his/her reach on the the nightstand, Observation showed nursing aide (NA) E and NA G entered the room to provide care and did not place the resident's call light within reach before they exited the room. Observation on 05/17/22, 09:01 A.M., showed the resident in his/her bed. Observation showed the call light out of his/her reach on the the nightstand Observation on 05/17/22, at 01:12 P.M., showed the resident in his/her bed. Observation showed the call light out of his/her reach on the the nightstand. NA G and Licensed Practical Nurse (LPN) H did not place the resident's call light within reach before they exited the room. Observation on 05/18/22, at 07:32 A.M., showed the resident in his/her bed. Observation showed the call light out of his/her reach on the the nightstand During an interview on 05/16/22, at 01:57 P.M., the resident said his/her spouse helps with his/her needs when his/her call light is not within reach. During an interview on 05/16/22, at 01:59 P.M., the resident's spouse said he/she helps him/her and staff generally do not put the call light within his/her reach. During an interview on 5/18/22 at 11:32 A.M., CNA A said he/she placed the resident's call light on his/her chest. He/She said there were a lot of new staff, so he/she knows there were staff who have left his/her call light on the bedside table. He/She said the resident's spouse feeds him/her and will place the call light on the bedside table. He/She said the staff move the call light back within reach when they check on him/her. During an interview on 05/18/22 at 12:48 P.M., the DON said the resident not have the cognition to use his/her call light, but should still have it in reach at all times. During an interview on 5/18/22 at 1:04 P.M., the Administrator said he/she is not aware of the call light not being placed within reach for the resident. During an interview on 05/18/22, at 1:20 P.M., CMT B said the resident knew how to use his/her call light. During an interview on 05/18/22, at 02:15 P.M., LPN H said the resident could use his/her and his/her spouse could help utilize it. 4. Review of Resident #29's Annual MDS, dated [DATE], showed staff assessed resident as: - Severely cognitively impaired; - Active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Required limited two person physical assistance for toileting and personal hygiene; - Required extensive two person physical assistance for bed mobility and transfers; - Wheelchair used as a mobility device with one person physical assist for locomotion on/off the unit. Review of the residents care plan, undated, showed he/she had an ADL self-care performance deficit related to bowel and bladder incontinence, was at risk for falls due to a history of falls and repeated falls. Interventions directed staff to keep his/her call light within reach at all times and to keep call light within reach at all times (she may forget use call light due to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Observation on 05/15/22, at 2:40 P.M., showed the resident in bed with his/her call light on the floor, at the foot of the bed and out of his/her reach. Observation on 05/16/22, at 8:17 A.M., showed the resident in bed with his/her call light on the floor, at the foot of the bed and out of his/her reach. Observation on 05/16/22, at 1:54 P.M., showed the resident in bed with his/her call light on the floor, at the foot of the bed and out of his/her reach. Observation on 05/16/22, at 3:00 P.M., showed the resident in bed with his/her call light on the floor, at the foot of the bed and out of his/her reach. Observation on 05/17/22, at 9:00 A.M., showed the resident's call light on the floor, at the foot of the bed and out of the residents reach. Observation on 05/17/22, at 1:06 P.M., showed the resident in bed with his/her call light on the floor, at the foot of the bed and out of his/her reach. Observation on 05/18/22, at 05:48 A.M., showed the resident's call light on the floor, at the foot of the bed and out of his/her reach. During an interview on 5/18/22 at 11:32 A.M., CNA A said he/she clipped the resident's call light on the bed. He/She had not seen staff clip the call light to a string at the bottom of the bed and not sure how the resident would reach it if it was located there. During an interview on 05/18/22 at 12:48 P.M., the DON said the resident may not have the cognition to use his/her call light but should still have them in reach at all times. During an interview on 5/18/22 at 1:04 P.M., the Administrator said he/she is not aware of the call lights not being placed within reach for the resident. During an interview on 05/18/22, at 1:20 P.M., CMT B said the resident knew how to use his/her call light. 5. During an interview on 5/18/22 at 11:32 A.M., CNA A said the call light should be located within the resident's reach at all times. He/She had not seen staff clip call lights to a string at the bottom of the beds and not sure how the resident would reach it if it was located there. During an interview on 05/18/22 at 12:48 P.M., the Director of Nursing said all staff are responsible to ensure the call lights are in reach of residents at all times. During an interview on 5/18/22 at 1:04 P.M., the Administrator said call lights should be placed within reach of the resident and not wrapped around any items, such as a halo bar. During an interview on 05/18/22, at 1:20 P.M., CMT B said call lights are always supposed to be within reach of each resident when they are in their room. He/She was not aware of any call lights being out of reach and said all staff who enter and exit the room are responsible for making sure the call lights are within reach. During an interview on 05/18/22, at 02:15 P.M., LPN H said call lights should be within reach of the resident no matter where they are in their room and everyone is responsible for monitoring residents call lights. During an interview on 05/18/22 at 02:29 P.M., LPN C said the call light should be within reach of the resident and not hooked on things.

Based on observation, record review, and interview, facility staff failed to provide appropriate care and services to prevent and treat facility acquired pressure ulcers for three out of 15 sampled residents (Resident #1, #2, and #3) and two off sample residents (Resident #16 and #17). The facility staff failed to properly assess and stage wounds for Resident #1, #2, #3, #16, and #17. The facility staff failed to provide interventions to prevent the development of multiple stage II pressure ulcers (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister) for Resident #17. Additionally facility staff failed to provide a low air loss mattress and wheelchair cushion to aide in the prevention of skin breakdown for one resident (Resident #3). The facility census was 67 residents. 1. Review of the facility's Wound Care and Treatment policy and procedure, dated 03/2015, showed the facility staff defined stage I as redness only, no break in skin, stage II as partial thickness, skin loss involving epidermis or dermis. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. Stage III presents full thickness skin loss involving damage or neurosis of subcutaneous tissue, which may extend down to, but not through, underlying fascia. The ulcer clinically as a deep crater with or without undermining of adjacent tissue. Stage IV as a full thickness skin loss with extensive destruction, tissue neurosis or damage to muscle, bone or supporting structures such as tendon or joint capsule. An eschar covered wound is an unstageable wound covered with dry devitalized tissue. Facility staff are directed to: -Provided positioning and pressure reduction of pressure-reduction mattress or overlay for residents at moderate risk for skin breakdown, wheelchair positioning should include pressure-reduction cushion. 2. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment instrument, dated 01/20/16, showed staff assessed the resident as: -Required total assistance of two plus persons physically assist with bed mobility, transfers, and personal hygiene; -Occasionally incontinent of bowel; -Three stage II pressure ulcers. Review of the resident's plan of care, dated 01/22/16 showed staff documented the resident with a history of skin breakdown, and with one stage II to his/her buttock. Review showed staff are directed to assist the resident to turn and reposition every two hours and as needed, avoid shearing during positioning, transferring, and turning. Review of the resident's wound assessments, dated 04/04/16, showed staff assessed the resident's wounds as: -Left Buttock, date of onset 01/08/16, stage II pressure ulcer 0.8 centimeters (cm) by 0.6 cm by zero depth; -Right Buttock, date of onset 04/03/16, stage II pressure ulcer 1.2 cm by 0.9 cm by zero depth; -Right Buttock, date of onset 04/03/16, stage II pressure ulcer 2.1 cm by 1.4 cm by zero depth. Observation on 04/07/16 at 12:30 P.M. showed the resident with three open areas on his/her bilateral upper thighs/buttocks. Licensed Practical Nurse (LPN) P assessed the smaller left buttock wound as 1.1 centimeters (cm) by 0.4 cm by zero depth, and described the wound as a stage II, with granulation tissue and bloody drainage Observation showed this wound appeared to have measurable depth. LPN P assessed the larger left buttock wound as 1.3 cm by 3.2 cm by zero depth, and described the wound as stage II with granulation tissue. LPN P assessed the right buttock wound as 3.0 cm by 1.2 cm by zero depth, and described the wound as a stage II with granulation tissue. Observation showed this wound appeared to have measurable depth. LPN P did not accurately assess the wound measurements for the right buttock wound, and the smaller left buttock wound. 3. Review of Resident #2's MDS, dated [DATE], showed staff assessed the resident as: -Severely impaired cognitive skills for daily decision making; -Required limited assistance of one staff with transfers, dressing, toileting, and personal hygiene; -One stage II pressure ulcers and three unstageable pressure ulcers. Review of the resident's plan of care, dated 12/07/15, showed staff directed to: -Use moisture barrier to perineal area; -Have wound care consult, evaluate, and treat; -Conduct a systematic skin inspection every shift and as needed; -Keep clean and dry as possible; -Turn and reposition assist as needed; -Report any signs of skin breakdown. Review of the resident's Physician order [REDACTED]. -(1/21/16) Treatment to left heel: cleanse with normal saline, dry dressing, skin prep (a liquid film forming dressing that is applied to intact skin for protection), and cover with [MEDICATION NAME] (non-adherent dressing) , abdominal (abd) pad (absorbent dressing), and kling (gauze wrap) daily and as needed. -(02/03/16) Santyl ointment to right and left heel wound daily; -(02/15/16) Left heel cleanse then apply Santyl ([MEDICATION NAME] ointment used to remove dead tissue from a wound) and a dry dressing daily and as needed, Right heel cleanse then apply skin prep and dry dressing daily and as needed, pressure relief at all times; -(2/26/16) Mobile Wound Solutions to consult, evaluate, and treat; -(3/21/16) Discontinue treatment to right heel due to healed; -Pressure relief to bilateral lower extremities at all times; -(3/1/16) Cleanse the right lower leg and left heel with wound cleanser, rinse with normal saline, apply Santyl, Vaseline gauze, guard wrap ( gauze wrap) daily and as needed. Review of the resident's weekly skin assessments conducted by licensed staff, dated 01/18/16, showed staff documented the resident with bruises to his/her bilateral upper extremities. Review showed staff did not document any further skin issues. Review of the resident's weekly skin assessments conducted by licensed staff, dated 02/1/16, 2/8/16, 2/15/16, 2/23/16, and 2/29/16, showed staff documented the resident with open areas to both heels with treatment. Review of the resident's weekly skin assessment conducted by licensed staff, dated 03/07.16, showed staff documented the resident with an open ulcer on right heel with treatment. Review of the resident's weekly skin assessment conducted by licensed staff, dated 03/14/16, showed staff documented the resident with an open ulcer on both lower extremities. Review of the resident's weekly skin assessment conducted by licensed staff, dated 03/21/16, showed staff documented the resident's right open ulcer as healed. Review showed staff document the resident with an open ulcer on his/her left lower extremity and left shin with treatment. Review of the resident's weekly wound report, dated 01/18/16, showed staff documented the resident with a deep tissue injury pressure ulcer to his/her left heel with measurements of 3.8 cm length by 6.5 cm width by zero depth. Staff documented the wound's onset date as 01/15/16, acquired in house, and staff are directed to provided pressure relief at all times and monitor. Review showed staff did not document the peripheral (outer) tissue of the wound, the type of tissue in the wound bed, and if there was exudate (drainage) from the wound. Review of the resident's weekly wound report, dated 01/25/16, showed staff documented the resident with a deep tissue injury pressure ulcer to his/her left heel with measurements of 3.5 cm length by 6.9 cm width by zero cm depth. Review showed staff are directed to cleanse the wound with normal saline, dry, apply skin prep to the heel and cover with [MEDICATION NAME], abd pad, and kling wrap daily and as needed. Review showed the resident is to have pressure relief at all times. Review showed staff did not document the peripheral (outer) tissue of the wound and the type of tissue in the wound bed. Review of the resident's weekly wound report, dated 01/30/16, showed staff documented the resident with a deep tissue injury pressure ulcer to his/her left heel with measurements of 2.7 cm length by 6.5 cm width by zero cm depth. Review showed staff are directed to cleanse the wound with normal saline, dry, apply skin prep to the heel and cover with [MEDICATION NAME], abd pad, and kling wrap daily and as needed and provide pressure relief at all times. Additional review showed staff documented the resident with a new deep tissue injury pressure on his/her right heel, with measurement of 4.3 cm length by 4.3 cm width by zero cm depth, and an onset date of 01/29/16. Staff were directed to provide the same treatment as done on the left heel. Review showed staff did not document the peripheral tissue of the wound and the type of tissue in the wound bed. Review of the resident's weekly wound report, dated 02/7/16, showed staff documented the resident with a deep tissue injury pressure ulcers to both heels. The left heel measured 3.0 cm length by 7.0 cm width by zero cm depth and the right heel measured 4.1 cm length by 4.1 cm width. Staff did not document a depth. Staff were directed to apply skin prep and dry dressing daily and as needed to both heels. Review showed staff did not document the peripheral tissue of the wound and the type of tissue in the wound bed. Review of the resident's weekly wound report, dated 02/12/16, showed staff documented the resident with a deep tissue injury pressure ulcers to both heels. The left heel measured 4.0 cm length by 7.0 cm width by 0.1 cm depth and the right heel measured 4.0 cm length by 4.0 cm width. Staff did not document a depth. Staff were directed to apply skin prep and dry dressing daily and as needed to both heels. Review showed staff did not document the peripheral tissue of the wound and the type of tissue in the wound bed. Review of the resident's weekly wound report, dated 02/21/16, showed staff documented the resident with a deep tissue injury pressure ulcers to both heels. The left heel measured 1.8 cm length by 3.0 cm width by 0.2 cm depth with exudate and the right heel measured 3.9 cm length by 4.4 cm width. Staff did not document a depth. Staff were directed to cleanse with wound cleanser, rinse with normal saline, apply skin prep, and dry dressing daily and as needed to the right heel and clean with wound cleanser, rinse with normal saline, apply Santyl, and a dry dressing daily and as needed to the left heel. Review showed staff documented the resident with a stage II pressure ulcer on his/her left heel measuring 0.5 cm by 0.4 cm by zero depth, with an onset date of 2/20/16. Review showed staff were directed to clean with wound cleanser, rinse with normal saline, apply Santyl, and a dry dressing daily and as needed. Review showed staff did not document the peripheral tissue of the wound and the type of tissue in the wound bed. Review of the resident's weekly wound report, dated 02/29/16, showed staff documented the resident with an unstageable pressure ulcer on his/her left heel measuring 3.0 cm length by 3.5 cm width by 0.3 cm depth with moderate exudate, the second left heel wound combined with the first left heel wound, an unstageable pressure ulcer to the right heel measuring 3.8 cm length by 4.0 cm width by 0.1 cm depth. Review showed staff were directed to cleanse with wound cleanser, rinse with normal saline, apply Santyl, and a dry dressing to the left heel wounds, pressure relief at all time and wound clinic to consult. Staff were directed to cleanse with wound cleanser, rinse with normal saline, apply skin pre, and a dry dressing daily and as needed to the right heel wound. Staff did not document an assessment of the peripheral skin or the type of tissue in the wound bed. Review of the resident's weekly wound report, dated 03/07/16, showed staff documented the resident with an unstageable pressure ulcer on his/her left heel measuring 1.6 cm length by 3 cm width by 0.2 cm depth with moderate exudate, the second left heel wound combined with the first left heel wound, an unstageable pressure ulcer to the right heel as healed. Review showed staff were directed to cleanse with wound cleanser, rinse with normal saline, apply Santyl, Vaseline gauze, and gauze wrap to the left heel wounds, pressure relief at all time and a wound clinic visit. Staff were directed to cleanse with wound cleanser, rinse with normal saline, apply skin pre, and a dry dressing daily and as needed to the right heel wound. Staff did not document an assessment of the peripheral skin or the type of tissue in the wound bed. Review of the resident's weekly wound report, dated 03/15/16, showed staff documented the resident with an unstageable pressure ulcer on his/her left heel measuring 1.5 cm length by 3 cm width by 0.2 cm depth with moderate exudate, the second left heel wound combined with the first left heel wound, an unstageable pressure ulcer to the right heel as healed. Review showed staff were directed to cleanse with wound cleanser, rinse with normal saline, apply Santyl, Vaseline gauze, and gauze wrap to the left heel wounds, pressure relief at all time and wound clinic visit. Staff were directed to cleanse with wound cleanser, rinse with normal saline, apply skin pre, and a dry dressing daily and as needed to the right heel wound. Staff did not document an assessment of the peripheral skin or the type of tissue in the wound bed. Review of the resident's weekly wound report, dated 03/21/16, showed staff documented the resident with an unstageable pressure ulcer on his/her left heel measuring 1.5 cm length by 2.5 cm width by 0.2 cm depth with moderate exudate, the second left heel wound combined with the first left heel wound. Review showed staff were directed to cleanse with wound cleanser, rinse with normal saline, apply Santyl, Vaseline gauze, and gauze wrap to the left heel wounds, pressure relief at all time and wound clinic visit. Staff did not document an assessment of the peripheral skin or the type of tissue in the wound bed. Review of the resident's weekly wound report, dated 03/28/16, showed staff documented the resident with an unstageable pressure ulcer on his/her left heel measuring 1.3 cm length by 2.2 cm width by 0.2 cm depth with moderate exudate. Review showed staff were directed to cleanse with wound cleanser, rinse with normal saline, apply Santyl, Vaseline gauze, and gauze wrap to the left heel wounds, pressure relief at all time and wound clinic visit. Staff did not document an assessment of the peripheral skin or the type of tissue in the wound bed. Review of the resident's weekly wound report, dated 04/04/16, showed staff documented the resident with a diabetic ulcer Wagner grade 2 (deep ulcer to tendon, bone or joint) on his/her left heel measuring 1.5 cm length by 1.1 cm width by 0.1 cm depth with moderate exudate. Review showed staff were directed to cleanse with wound cleanser, rinse with normal saline, apply Santyl, Vaseline gauze, and gauze wrap to the left heel wounds, pressure relief at all time and wound clinic visit. Staff did not document an assessment of the peripheral skin or the type of tissue in the wound bed. Review of the resident's wound clinic report, dated 02/29/16, showed the the physician documented the resident's right heel pressure ulcer as unstageable and measured 3.8 cm length by 4 cm width by 0.1 cm depth with extensive amount of necrotic tissue, no exudate, or [DIAGNOSES REDACTED] (redness). Staff were directed to clean the wound cleanser, apply skin prep, cover with 4x4, 3 ply gauze, and secure with gauze wrap, change daily and as needed for soiling. The physician documented the resident's left heel unstageable pressure ulcer measured 3 cm length by 3.5 cm width and 0.3 cm depth had an extensive amount of slough (fibrous necrotic tissue), with pink granulation tissue, mild odor, and a moderate amount of serosanguineous (blood tinged) drainage. Staff were directed cleanse the left heel wound with wound cleanser apply Santyl for enzymatic abridgement, Vaseline gauze, and cover with gauze 3 ply of 4x4 and secure with gauze wrap. Change dressing daily and as needed for soiling. Review of the resident's wound clinic report, dated 03/07/16, showed the physician documented the resident with bilateral deep venous thrombus ([MEDICAL CONDITION]) on lower extremities. Review showed the resident's unstageable pressure ulcer to his/her right heel as improved with no measurements documented. The resident's left heel unstageable pressure ulcer measured 1.6 cm length by 3 cm width by 0.2 cm depth, with extensive amount of slough, pink granulation tissue, mild odor, moderate amount of serosanguineous drainage. Staff were directed to cleanse the wound with wound cleanser, apply Santyl, Vaseline gauze, 4x4 gauze, and secure with gauze. Change daily and as needed for soiling. Review of the resident's wound clinic report, dated 03/14/16, 03/21/16, 03/28/16, and 04/04/16, showed the physician changed the resident's unstageable pressure ulcer to a diabetic wound staged at a Wagner 2 with a moderate amount of slough, pink granulation tissue, mild odor, moderate amount of serosanguineous drainage, measured as: -(3/14/16) 1.5 cm length by 3 cm width by 0.2 cm depth; -(3/21/16) 1.5 cm length by 2.5 cm width by 0.2 cm depth; -(3/28/16) 1.3 cm length by 2.2 cm width by 0.2 cm depth; -(4/4/16) 1.5 cm length by 1.1 cm width by 0.1 cm depth. Review showed staff were directed to cleanse the wound with wound cleanser, apply Santyl, Vaseline gauze, 4x4 gauze, and secure with gauze, change daily and as needed for soiling. Observation on 04/07/16 at 11:14 A.M., showed Registered Nurse (RN) A entered the resident's room. The resident's lay in bed with his/her feet resting on the outside of his/her heel. The RN A removed the resident's left heel protector and sock and observation showed an open area to the outer left heel . The RN assessed the wound on the outer left heel as 0.6 centimeters (cm) length by 2.1 cm width by 0.1 cm depth, and described the wound as a stage II with yellow slough in the center of the wound and granulation tissue surrounding the slough with bloody drainage. Observation showed the RN did not accurately stage the wound on the resident's left heel according to the facility policy. 4. Review of Resident #3's annual MDS, dated [DATE], showed staff assessed the resident as: - Moderate cognitive impairment; -Always incontinent of bowel; -Indwelling catheter; -Required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene; - No current skin issues. Review of the resident's comprehensive care plan, dated 03/18/16, showed the resident is non-ambulatory, has a supra pubic catheter, has pressure relieving devices to both heels in bed, is incontinent of bowel, needs extensive assistance with bed mobility, transfers, locomotion, dressing, eating, personal hygiene of one to two assist. Additionally staff are to monitor for signs and symptoms of skin breakdown related to incontinence, turn and reposition every two hours, encourage to stay off back side as much as possible, turn with pillows, wedges to keep pressure off area and as the resident returns to his/her back side, has a cushion in his/her wheelchair, keep clean and dry as possible, and minimize pressure to buttocks/coccyx. Review of the resident's POS, dated 02/18/16 through 04/17/16, showed the resident's physician ordered a wound clinic consult, evaluation, and treatment on 02/26/16. Review showed staff were directed to apply bilateral heel protectors on every shift and cleanse the resident's left and right thigh with wound cleanser, rinse with normal saline, apply skin prep, xeroform gauze, 4x4 gauze, silicone border dressing daily and as needed. Review of the resident's weekly wound report, dated 02/07/16 showed staff documented the resident with a stage II pressure ulcer on his/her left buttock measuring 16 cm length by 8 cm width by zero depth, with exudate, and deteriorating, with an onset date of 12/5/15 acquired in house. Review showed the resident with a stage II pressure ulcer on his/her right buttock measuring 10 cm length by 5 cm width by zero depth, exudate, and healing, with an onset date of 01/24/16 acquired in house. Staff did not document the current treatment on the report. Staff were directed to turn and reposition the resident every two hours, lay down between meals, and provide pericare after each incontinent episode. Review of the resident's weekly would report, dated 02/15/16, showed staff documented the resident's stage II pressure ulcers on his/her right and left buttock as healed. Review of the resident's weekly wound report, dated 02/21/16, showed staff documented the resident with two new stage II pressure ulcers to his/her right posterior upper thigh measuring 1.7 cm length by 0.3 cm width by zero depth and 0.9 cm length by 0.6 cm width by zero depth. Staff were directed to cleanse the wounds with wound cleanser, rinse with normal saline, apply z-guard (barrier cream) every shift, and as needed. Review of the resident's weekly wound report, dated 02/29/16, showed staff documented the resident developed two new wounds to his/her left buttock and left posterior proximal thigh, documented as partial thickness moisture associated skin damage (MASD). Review showed the two stage II pressure ulcers on the resident's right upper posterior thigh documented as partial thickness MASD that combined with each other. Review of the resident's weekly wound report, dated 03/21/16, showed staff documented the resident's left buttock and left posterior proximal thigh partial thickness MASD wounds as healed. Review of the resident's weekly wound report, dated 04/04/16, showed staff documented the resident's right posterior proximal thigh MASD wound as healing with scant drainage, 1 cm length by 0.6 cm width by 0.1 cm depth. Staff were directed to cleanse with wound cleanser, rinse with normal saline, apply xeroform gauze, 4x4 gauze, silicone border dressing daily and as needed. Staff were directed to provide pericare after incontinent episodes, turn and reposition every two hours and as needed, and a wound clinic staff to follow. Review of the resident's wound clinic report, dated 08/03/15 and 08/10/15, showed the physician assessed the resident with a MASD partial thickness wound to his/her left buttock and right buttock. Staff were directed to keep weight off left buttock at all times, provide a low air loss mattress, seat cushion, and minimize time up in wheelchair, and apply a wedge to remove pressure on the buttock. Review of the resident's wound clinic report, dated 02/29/16, showed the physician assessed the resident with partial thickness MASD to his/her left buttock, left thigh, and right thigh. Staff were directed to apply a thin amount of dimehticone then calzime, cover with 4x4 gauze, secure with silicone border dressing, change daily as as needed. Staff were directed to keep the weight off of the resident's left buttock, provide a low air loss mattress, and turn and position every two hours. Review of the resident's wound clinic report, dated 03/7/16, showed the physician assessed the resident with partial thickness MASD to his/her left buttock, left thigh, and right thigh and the wounds were deteriorating. Staff were directed to cleanse wound with wound cleanser, apply skin prep, xeroform gauze, cover with 4x4 gauze, secure with silicone border dressing, change daily as as needed. Staff were directed to keep the weight off of the resident's left buttock, provide a low air loss mattress, and turn and position every two hours. Review of the resident's wound clinic report, dated 03/14/16, showed the physician assessed the resident with partial thickness MASD to his/her left thigh, and right thigh. Review showed the resident's left buttock wound as healed. Staff were directed to cleanse wound with wound cleanser, apply skin prep, xeroform gauze, cover with 4x4 gauze, secure with silicone border dressing, change daily as as needed. Staff were directed to keep the weight off of the resident's left buttock, provide a low air loss mattress, and turn and position every two hours. Review of the resident's wound clinic report, dated 04/4/16, showed the physician assessed the resident with partial thickness MASD to his/her right thigh. Review showed the resident's left buttock and left thigh wound as healed. Staff were directed to cleanse wound with wound cleanser, apply skin prep, xeroform gauze, cover with 4x4 gauze, secure with silicone border dressing, change daily as as needed. Staff were directed to keep the weight off of the resident's left buttock, provide a low air loss mattress, and turn and position every two hours. Review of the resident's nurses notes, dated 12/4/15 through 02/17/16, showed staff did not document the resident with wounds and/or treatment for [REDACTED]. Review of the resident's monthly summary, dated 2/9/16, showed staff documented the resident requires total care, is incontinent of bowel, and treatment provided to pressure ulcer on coccyx. Review of the resident's monthly summary, dated 3/9/16, showed staff documented the resident is confused at times, able to make his/her wants/needs known, incontinent of bowel, suprapubic catheter intact, skin warm and dry, continue with treatment on buttocks. Observation on 04/06/16 at 12:10 P.M., showed the resident in the television room in his/her wheelchair. Observation showed the resident's wheelchair did not have a wheelchair cushion as ordered. Observation on 04/07/16 at 02:30 P.M., showed the resident lay on his/her back. An unidentified Certified Nursing Assistant (CNA) positioned the resident on his/her right side. RN I removed a dressing from the resident's right and left upper thigh and left lower gluteal. Observation showed the resident with multiple open areas to his/her buttock/upper thighs. RN I assess the wounds as: -Right upper thigh (#1) 2.5 cm length by 0.25 cm width by zero depth, pink wound bed with some slough, stage II pressure ulcer; -Left upper thigh (#2) 0.5 cm length by 0.5 cm width by zero depth, red wound bed with some slough, stage II pressure ulcer; -Middle left gluteal crease (#3) 1.5 cm length by 0.25 cm width by zero depth, pink wound bed, stage II pressure ulcer; -Lower left gluteal crease (#4) 0.75 cm length by 5.5 cm width by zero depth, pink wound bed -Right upper gluteal crease (#5) as closed. Observation showed the peripheral skin as scaly and wounds #1, #2, #3, and #4 with measurable depth. RN I cleansed the wounds with wound cleanser and applied skin prep , Vaseline gauze, 4x4 gauze, and silicone border to the wounds. Further observation showed the RN did not apply a dressing to the resident's right gluteal crease as ordered by the physician and did not accurately stage wounds #1 and #2, the resident's bed did not have a low air loss mattress, and the resident did not have a wheelchair cushion in his/her chair as ordered. Observation on 04/08/16 at 12:30 A.M., showed CNA O and Licensed Practical Nurse (LPN) B position the resident from his/her back side to his/her right side. Observation showed the peripheral skin around the wound as macerated (white softening or breaking down of the skin caused by prolonged exposure to moisture). LPN B cleansed the wounds and applied the dressing as ordered to the right gluteal crease and the bilateral upper thighs. Further observation showed the LPN did not apply a dressing to the left gluteal crease open areas. The resident's bed did not have a low air loss mattress and the resident's wheelchair did not have a cushion in the wheelchair. During an interview at the same time, LPN B said the resident sweats a lot and is frequently incontinent of bowel. During an interview on 04/07/16 at 3:00 P.M., RN I said the night shift nurse typically completes the wound assessments on residents. Staff are directed to turn and reposition residents every two hours and as needed in bed and in their wheelchairs. RN A said Resident #3 has a special cushion for his/her wheelchair. The resident acquired the wounds in the facility. His/Her wounds frequently open and close and reopen. His/Her peripheral skin has not been scaly for very long, staff are not putting anything on it that he/she is aware of. 5. Review of Resident #16's quarterly MDS, dated [DATE], showed staff assessed the resident with mild cognitive impairment, required extensive assist with bed mobility, transferring, toileting, and personal hygiene, always incontinent of bowel and frequently incontinent of urine and is not at risk for pressure ulcers. Review of the resident's comprehensive care plan, dated 12/31/15, showed staff assessed the resident as frequently incontinent of bowel and bladder, requires extensive assist of one to two staff with mobility, transfers, dressing, toileting personal hygiene, and bathing. Staff are directed to assist the resident with turning and positioning, conduct systematic skin inspections every shift and as needed, provide a wheelchair cushion, keep clean and dry as possible, minimize skin exposure to moisture, and provide ointment, creams, or treatments as ordered. Review of the resident's POS, dated 03/18/16 through 04/17/16, showed the resident's physician ordered barrier paste to the right gluteal fold every shift and as needed. Review of the resident's weekly skin assessment conducted by licensed staff, dated 03/26/16, showed staff documented the resident with an open ulcer to his/her right gluteal fold and reddened areas that remain after 30 minutes of pressure reduction to his/her bilateral buttocks. Review of the resident's weekly skin assessment conducted by licensed staff, dated 04/2/16, showed staff documented the resident with reddened areas that remain after 30 minutes of pressure reduction to buttocks and gluteal folds. Review of the resident's weekly wound report, dated 03/19/16, 03/26/16, and 04/3/16, showed staff assessed the resident with a partial thickness MASD to his/her right gluteal fold, with an onset date of 03/19/16 acquired in house. Staff assessed the wound as 0.6 cm length by 1.3 cm width by zero depth on 03/19/16, 0.3 cm length by 1.3 cm width by zero depth on 03/26/16, and healed on 04/3/16. Review showed staff documented on the back side of the wound report on 03/19/16 pressure as the cause of the wound, pink granulation tissue with a red peripheral skin., 03/26/16 pressure as the cause of the wound with eschar and a red peripheral skin. Staff were directed to cleanse with wound cleanser, rinse with normal saline, and apply barrier paste every shift and as needed. Review of the resident's nurses notes, dated 03/18/16 through 04/11/16, showed staff did not document assessments of the resident's open area on his/her right buttock, the notification of the physician or family, of the wound. Observation on 04/07/16 at 09:45 P.M., showed the resident in bed on his/her back. CNA N assisted the resident to his/her left side. Observation showed the resident with a quarter size non-blanchable red area on his/her left gluteal crease and an open area on his/her right gluteal crease and a pink peripheral skin. LPN B assessed the skin as a stage I pressure ulcer to his/her left buttock and a stage II pressure ulcer to his/her right gluteal crease. LPN B applied barrier past to the right gluteal crease wound. Further observation showed the LPN did not apply barrier paste or dressing to the resident's left gluteal crease. During an interview at the same time, LPN B said the resident has had an open area to his/her right buttock for about two weeks. 6. Review of Resident #17's POS, dated 03/29/16 through 04/17/16, showed the resident's physician directed staff to apply Excuderm dressing to the open areas and gluteal crease, change every 72 hours until healed on 04/07/16. Review of the resident's nurses notes, dated 04/5/16 through 04/09/16, showed staff did not document an assessment of the open areas on the resident's bilateral buttock and gluteal crease. Review of the resident's weekly skin assessment

Based on observation, interview, and record review, the facility staff failed to provide appropriate care and services to prevent the development of new facility acquired stage II pressure ulcers (partial thickness skin loss of the top layers of the skin) for two residents (Resident #1 and #3) of 15 sampled residents. The facility census was 74. Review of the facility's Care and Prevention of Pressure Ulcer policy dated March, 2012 showed staff are directed to do the following: -Observe skin for any reddened area that remains after pressure is relieved; -Apply skin lotion gently to dry skin; -Change bed linen promptly whenever wet or soiled; -Keep sheets dry, free of wrinkles and debris; -Use pressure-reducing devices to relieve pressure; -Turn the resident every two hours and position with pads or pillows to protect bony prominences; -Perform active and passive range of motion if ordered by physician to improve circulation; -If possible, teach the resident to change his/her own position at regular intervals; -Use elbow and heel protectors if needed; -Use bed cradle to relieve pressure of bed clothing; -Assist at mealtime to assure adequate nutrition; -Offer fluids frequently for adequate hydration. 1. Review of Resident #1 annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 5/31/13, showed the facility staff assessed the resident as the following: -Severe cognitive impairment; -No depression; -Extensive assistance of two staff for bed mobility, transfers, dressing, toileting, personal hygrine, and bathing; -Frequently incontinent of bowel and bladder; -At risk for pressure ulcers; -One stage two pressure ulcer; -Has a pressure reducing device for chair and bed; -Turning and repositioning program. Review of the residents Braden assessment (assessment tool used to determine the residents risk of developing a pressure ulcer) dated 5/31/2013 showed that staff assessed the resident as having a score of 13 which indicates a moderate risk for developing pressure ulcers. Review of the residents Plan of Care updated 6/3/2013 showed staff are to do the following: -Frequently incontinent of bladder and bowel and needs assist with toileting; -Check him/her for incontinent episodes upon arising, before and after meals, at bedtime, and as needed; -Provide incontinence care to him/her after each incontinent episode; -Mechanical lift for transfers; -Assist with all Activities of Daily Living (ADLs); -Keep resident clean and dry as possible and minimize skin exposure to moisture; -Assist him/her with turning and position every two hours and as needed; -Conduct a systemic skin inspection weekly and as needed and report any signs of further skin breakdown; -Keep cushion in his/her wheelchair; -Keep bony prominence from direct contact with one another; -Keep linens clean, dry, and wrinkle free; -Minimize pressure to coccyx and buttock. Review of the resident's Wound Reports showed the following: -5/24/2013: Facility Acquired Stage II pressure ulcer on coccyx, previously healed but reopened on 5/23/2013 measuring 1.0 centimeters (cm) x 1.7 cm; -5/31/2013: Facility Acquired Stage II pressure ulcer on coccyx measuring 0.6 cm x 0.2 cm; -6/7/2013: Facility Acquired Stage II pressure ulcer on coccyx measuring 0.4 cm x 0.4 cm which is deteriorating. Review of the resident's shower sheets showed the following; -6/4/2013 - no open areas; -6/7/2013 - no open areas or redness; -6/12/2013 - open area to residents coccyx and right buttock. Review of the resident's Physicians Order Sheet dated 5/18/2013 through 6/17/2013 showed the physician ordered on [DATE], [MEDICATION NAME] to open areas on buttocks three times daily. Review of the resident's skin assessments on the back of the Treatment Administration Record dated 5/18/2013 through 6/17/2013 showed the staff assessed the resident as having the following: -5/20/2013 - no open areas; -5/25/2013 - wound bed pink to small open area; -5/29/2013 - small open area wound bed pink; -5/30/2013 - open area to coccyx with pink wound bed; -6/9/2013 - small open area to coccyx with pink wound bed; -6/10/2013 - coccyx wound bed pink; -6/12/2013 - wound bed pink; -6/13/2013 -two small open areas, coccyx and right buttocks, wound beds pink. Review of the resident's nursing notes for May 2013 or June 2013 did not show documentation of the open areas to the coccyx or right buttock. Observation on 6/11/2013 at 12:37 P.M., showed the resident sat in his/her Broda wheelchair in the dining room. Observation on 6/11/2013 at 2:20 P.M., showed the resident sat in his/her Broda wheelchair in his/her room in front of the television. Observation on 6/11/2013 at 5:39 P.M., showed an unidentified staff member took the resident to the dining room. Staff failed to check the resident for incontinence before the resident was wheeled out of his/her room. Observation on 6/11/2013 showed the resident sat in the same position in his/her Broda wheelchair from 12:37 P.M. until 5:39 P.M., for a total of five hours before the resident was checked, toileted, or provided incontinent care. Observation on 6/12/2013 at 8:47 A.M., showed unknown staff wheeled the resident back to his/her bedroom after breakfast. The staff member failed to check the resident for incontinence, toilet, or provide perineal care to the resident. Observation on 6/12/2013 at 10:14 A.M., showed the resident sat in his/her room in his/her Broda chair in the same position. The odor of urine permeated the room. Observation on 6/12/2013 at 11:51 A.M., showed the resident sat alone in his/her room in the same position in the Broda wheelchair. Further observation showed the room continued to have a urine odor. Observation on 6/12/2013 at 12:10 P.M., showed the resident sat in his/her room in the same position in the Broda wheelchair with his/her eyes closed. A urine odor was noticed in the room. CNA L walked into his/her room called the resident's name a couple of times, the resident did not open his/her eyes. CNA L left the room and failed to check the resident for incontinence. Observation on 6/12/2013 at 1:26 P.M., showed the resident continued to sat in the same position alone in his/her room. The urine odor continued to be present in the room. Further observation showed an empty lunch tray sat outside the resident's room. Observation on 6/12/2013 at 1:58 P.M., showed the resident continued to sat in his/her room, in the same position in the Broda wheelchair, with his/her eyes closed. A urine odor continued to be noticed in the room. Observation on 6/12/2013 at 2:34 P.M., showed the resident continued to sat in the same position in the wheelchair with his/her eyes closed. Further observation showed the room continued to have a urine odor. Observation on 6/12/2013 at 3:34 P.M., showed the resident continued to sat in the same position with his/her eyes closed. Food and saliva stains were noted on the front of the resident's clothes. Further observation showed the room continued to smell of urine. Observation on 6/12/2013 at 3:59 P.M., showed the resident continued to sat in his/her room in the same position in the wheelchair with his/her eyes closed. Further observation showed a strong urine odor from the resident's room. CNA R wiped the resident's mouth. CNA R and CNA S washed their hands, put on gloves and transferred the resident to his/her bed with the Hoyer Lift (mechanical lift). CNA R removed the resident's wet brief and rolled the resident on his/her left side while CNA S provided peri-care. Observation showed One open area to the resident's coccyx approximately 1.0 centimeter (cm) x 1.0 cm and two open areas noted to the resident's right buttock approximately 2.5 cm x 1.0 cm and 1.5 cm x 1.0 cm. CNA S applied [MEDICATION NAME] cream to the resident's buttocks. CNAs S and R applied a clean incontinent brief, pulled the residents pants up, and transferred him/her back to the wheelchair. CNA R changed the resident shirt and noted a red rash on his/her back. CNA S left to get the nurse. LPN X walked into the room and evaluated the rash. CNAs R and CNA S did not tell the nurse about the new open areas on the resident's buttocks. CNA R wheeled the resident in front of the television in his/her room. During an interview at this time CNA R and CNA S stated that the open area on the resident's coccyx has been there and the two other open areas on the resident's right buttock were new. CNA R also stated that they were from pressure and moisture. Observation on 6/12/2013 showed the resident sat in his/her wheelchair from 8:47 A.M. untill 3:59 P.M. for a total of eight hours before the resident was checked, toileted, or provided incontinent care. 2. During an interview on 6/12/2013 at 4:15 P.M., CNA R stated that the resident has had the open area on his/her coccyx for a week or two and the open areas on the resident's right buttock were not there yesterday. CNA R said the resident has a history of open areas but as long as staff put the [MEDICATION NAME] cream on them they heal up fast. 3. During an interview on 6/12/2013 at 4:34 P.M., LPN X stated he/she was not aware of any open areas on the resident and there was no report of open areas that was passed on during report. LPN X further stated the resident is prone to developing pressure ulcers on his/her bottom and has an order for [REDACTED]. Observation on 6/13/2013 at 5:39 A.M., showed the resident lay in bed on his/her back with his/her eyes closed. Further observation showed a very strong urine odor in the room. Observation on 6/13/2013 at 6:15 A.M., showed the resident continued to lay in bed on his/her back with his/her eyes closed. Further observation showed a very strong urine odor in the room. Observation on 6/13/2013 at 6:51 A.M., showed the resident continued to lay in bed on his/her back with his/her eyes closed. Further observation showed a very strong urine odor in the room. Observation on 6/13/2013 at 6:57 A.M., showed CNA L and LPN T entered the resident's room. The resident lay in bed on his/her back with his/her eyes closed. A strong urine odor was noted in the room. CNA L provided frontal perineal care, then rolled the resident on his/her right side. LPN T wiped the resident's bottom. Observation showed three open areas on the resident's bottom. First open area noted on the resident's coccyx measured approximately 1.0 cm x 1.0 cm. Second open area noted on the resident's right buttock measured approximately 2.5 cm x 1.0 cm and the third open area measured approximately 1.5 cm by 1.0 cm. LPN T applied [MEDICATION NAME] to the open areas. CNA L applied a new brief and dressed the resident in his/her clothes. CNA L placed the Hoyer lift (mechanical lift) pad under the resident and CNA L and CNA Q hooked the Hoyer pad to the Hoyer lift and transferred the resident to his/her Broda wheelchair and wheeled him/her to the east side television room. 4. During an interview on 6/13/2013 at 6:57 A.M., during observation of care LPN T stated that the open area on the coccyx had been there for a little while but the two open areas on the resident's right buttock were found by the night shift nurse last night who measured and put [MEDICATION NAME] cream on the open areas and notified the physician but no new order was given. Observation on 6/13/2013 at 8:05 A.M., showed the resident sat in his/her Broda wheelchair at the dining room table. Observation on 6/13/2013 at 8:22 A.M., showed unknown staff member wheeled the resident back to the east side television room from the dining room. The staff member failed to check the resident for incontinence, toilet or provide perineal care before he/she left the resident. Observation on 6/13/2013 at 10:18 A.M., showed the resident sat in his/her Broda wheelchair in his/her room in front of the television. Observation on 6/13/2013 at 11:27 A.M., showed the resident continued to sat in his/her room in the Broda wheelchair. Further observation showed a urine smell in the room. 5. During an interview on 6/13/2013 at 11:44 A.M., LPN T said the following: -The night nurse passed on that she found two new open areas on the resident's right buttock and he/she measured them; -The two new open areas are caused by pressure; -The resident has a history of pressure ulcers and sheering on the bottom, occurring in the same areas most of the time; -CNAs are to try to reposition the resident every two hours and is to keep him/her clean and dry; -CNAs are expected to report new open areas to the charge nurse immediately; -The nurse is expected to measure the new open area and then notify the physician; -The new area and the notification of the doctor should be documented in the nurses notes and a wound report created. Observation on 6/13/2013 at 11:52 A.M., showed the resident continued to sat with his/her eyes closed in his/her room in the same position. Further observations showed the room continued to have a urine smell. Observation on 6/13/2013 at 12:20 P.M., showed CNA P wheeled the resident to the dining room. The CNA did not check the resident for incontinence, toilet, or provide perineal care to the resident. 6. During an interview on 6/13/2013 at 12:25 P.M., LPN T stated CNAs are expected to toilet residents every two hours and before and after meals. LPN T said if CNAs found an open area on the resident the day before they should have told their nurse right away. The nurse who found the open areas did notify the physician, but there is no documentation that he/she notified the physician. No new order was given for the open areas. 7. During an interview on 6/13/2013 at 12:50 P.M., CNA M stated the following: -CNAs are expected to toilet residents every two hours, when residents are laid down, and anytime a resident is incontinent of bowel or bladder; -Check for incontinence before and after meals; -The resident is to have heel protectors on in and out of bed and is to be repositioned in bed every two hours and to be laid down after lunch to prevent pressure ulcers; -CNAs are expected to tell the nurse immediately after noticing an open area. 8. During an interview on 6/13/2013 at 12:59 P.M., CNA L stated the following: -CNAs are to toilet residents when residents are gotten up in the morning, after toileting, before and after meals, and as needed; -Staff are to change the resident's brief often along with repositioning every two hours, and encourage the resident to lay down to prevent pressure ulcers; -He/she stated that immediately after finding a new open area on the resident CNAs are expected to report it to the nurse. Observation 6/13/2013 at 1:05 P.M., showed CNA L wheeled the resident into his/her room. CNA L and CNA Q washed their hands, put on gloves, then hooked the Hoyer pad under the resident to the Hoyer lift and transferred the resident to the bed. CNA L removed the resident's pants and wet brief. CNA Q provided pericare then rolled the resident on his/her right side. The CNAs cleansed the resident's bottom. The open area remained on the resident coccyx and two area noted on the right buttock. A new open area was noted on the resident's left buttock which measured approximately 0.5 cm by 0.5 cm. CNA Q applied [MEDICATION NAME] cream to the open areas. CNA Q placed a new brief on the resident and CNA L and CNA Q pulled the resident's pants up. CNA L placed the Hoyer pad under the resident and CNA L and CNA Q hooked the Hoyer pad to the Hoyer lift and transferred the resident to his/her Broda wheelchair. The CNAs left the resident in his/her room in front of the television. 9. During an interview on 6/13/2013 at 1:05 P.M., during observation CNA Q said the opened area on the resident's left buttock is new and is probably from pressure and moisture. Observation on 6/13/2013 showed the resident sat in his/her Broda wheelchair in the same position from 8:05 A.M. until 1:05 P.M. for a total of five hours before the resident was checked, toileted, or provided incontinent care by the staff. 10. During an interview on 6/13/2013 at 1:35 P.M., the Director of Nursing stated the following: -Knows the resident has one open area on his/her coccyx; -CNAs are expected to notify the charge nurse if he/she notices a new open area; -Would have expected the CNAs who found the open area on the resident's right buttock on the evening 6/12/2013 to have told the charge nurse immediately; -The resident has a history of open areas and the staff are expected to turn and reposition every two hours, the resident is to have a cushion in his/her wheelchair; -The resident does have an order for [REDACTED]. -If a new open area is found the nurse is then expected to notify the physician to get a treatment order and document and to document that in the treatment book, telephone odors, POS, nurses notes, and the wound report. 11. Review of Resident #3's annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 3/8/13, showed the facility staff assessed the resident as the following: -Severe cognitive impairment; -Extensive assistance of two staff for bed mobility, transfers, personal hygiene, and bathing; -Limited assistance of two staff for dressing and eating; -Frequently incontinent of bowel and bladder; -Uses a chair to prevent rising daily; -At risk for pressure ulcers. Review of the residents plan of care updated 3/11/2013 showed staff are to do the following: -Frequently incontinent of bladder and bowel; -Check him/her for incontinent episodes upon arising, before and after meals, at bedtime, and as needed; -Provide perineal care after each incontinent episode; -Keep resident clean and dry as possible and minimize skin exposure to moisture; -Monitor for signs and symptoms of skin breakdown, notify charge nurse of signs; -Assist with turning and positioning to decrease pressure; - Release lap tray at least every 2 hours and during meals and supervised activities. Review of the resident's Braden assessment (assessment tool used to determine the residents risk of developing a pressure ulcer) dated 3/8/2013 showed that staff assessed the resident as having a score of 11 which indicates a high risk for developing pressure ulcers. Review of the resident's Physician order [REDACTED]. Observation on 6/12/2013 at 8:45 A.M., showed staff wheeled the resident to the main TV room after breakfast. Staff did not toilet or check the resident for incontinence. The resident sat in the TV room with a lap tray connected to the wheelchair from 8:45 A.M. until 12:05 P.M. when staff wheeled the resident to the dining room table for lunch. Further observation showed staff failed to toilet the resident for more than 3 1/2 hours. Observation on 6/12/13 at 2:06 P.M., showed CNA R and CNA S wheeled the resident from the TV room to the resident's room. CNA R and CNA S transferred the resident from his/her wheelchair to his/her bed. CNA R and CNA S removed the resident's urine soaked brief. The resident had also had a small bowel movement. Observation showed the resident had two open areas on his/her right buttock. One open area was beefy red, no slough present and approximately dime-sized. The second open area was beefy red with no slough present and approximately pencil eraser-sized. CNA R and CNA S said the areas were new skin issues. Observation on 6/13/13 at 6:20 A.M., showed CNA L provided early morning care to the resident. The resident had been incontinent of bowel and bladder. CNA L used a wash cloth to cleanse the crease of the buttock and the left side of the buttock only. CNA L failed to thoroughly cleanse the back and frontal perineal areas before he/she dressed the resident in a clean brief and clothing. Further observation showed the resident had two open areas on his/her right buttock. One open area was beefy red with no slough present and approximately dime-sized. The second open area was beefy red with no slough present and approximately pencil eraser-sized. The third area, which was a new open area from the previous observation, was located on the left buttock. Observation showed it was pencil eraser-sized and beefy red in color with no slough present. CNA L did not apply a barrier cream or notify a charge nurse at that time. CNA L said all three areas were new skin issues. Review of the facility's shower sheets on 6/12/13 showed staff documented on 6/4/13, 6/7/13 and 6/11/13 the resident had no skin areas open, no [MEDICAL CONDITION]/cuts/ lacerations/skin tears or abrasions. Record review of the resident's current nurse's notes on 6/12/13 and 6/13/13 show no documentation of any skin issues reported or any new orders for pressure ulcer treatment. 12. During an interview on 6/13/13 at 12:30 P.M., LPN T said she was not aware of any skin issues the resident was having on his/her bottom. LPN T also said the aides apply a barrier cream as prevention and have been laying her down in bed more often to off load pressure. 13. During an interview on 6/13/13 at 1:30 P.M., the DON said she/he was just made aware of the new skin issues on the resident's bottom today. The DON agrees the staff should have informed the charge nurse immediately after noticing a new skin issue or open area. The resident currently has an order for [REDACTED].

Based on interview and record review, facility licensed and certified staff failed to assess one resident for injuries (Resident #1) of four sampled residents after an accident during a transfer, failed to report the accident and the resident's complaints of pain to the resident's physician in a timely manner, and failed to report the incident to on-coming staff during change of shift report. The resident suffered a fractured femur (thigh bone) as a result of the accident around 3:20 P.M. on 12/27/10 and staff did not send the resident to the hospital for evaluation and treatment until 12/28/10 around 10:35 P.M.. The facility census was 61. 1. Review of Resident #1's fall risk assessment, dated 11/15/10, showed staff assessed the resident with a rating of 10 (a rating of 10 or above represented a high risk for falls). Record review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument, dated 12/28/10, showed staff assessed the resident with the following: -Moderately impaired cognitive skills for daily decision-making; -Dependent on staff for transfers from bed, chair, and wheelchair; -Experienced pain three to four times a week. Record review of the resident's plan of care, dated 5/18/10 and updated on 12/28/10, showed direction for staff to do the following interventions: -Utilize one or two staff to assist with transfers; -Use mechanical lift when needed; -Use gait belt for all transfer assistance; -Monitor for periods of unsteadiness; -Find out reasons for falls; -Notify doctor of falls. Review of the resident's physician's orders for 12/18/10 through 1/17/11 showed the resident's [DIAGNOSES REDACTED]. Review of the resident's nursing notes showed the following: -A nurse's note, dated 12/28/10 at 8:00 A.M., showed Licensed Practical Nurse (LPN) D wrote the resident complained of severe pain and cried due to right hip pain. Staff did not record they notified the resident's physician of the resident's pain. -A nurse's note, dated 12/28/10 at 11:30 A.M., showed the resident remained in bed during lunch due to continued pain. Staff did not record they notified the resident's physician of the resident's pain leading to an inability to eat in the dining room. -A nurse's note, dated 12/28/10 at 3:00 P.M., showed staff did not contact the resident's physician until this time regarding the resident's pain. The resident's physician ordered an x-ray. -A nurse's note, dated 12/28/10 at 10:20 P.M., showed staff noted two abrasions to the resident's right knee. Staff wrote, "CNA (certified nursing assistant) stated that according to one evening aide, resident was lowered to floor by another aide Monday evening (previous day). CNA also stated that charge nurse assisted resident and resident transferred back to bed. Right leg larger in size compared to left lower extremity ...resident continues to complain of pain." -A nurse's note, dated 12/28/10 at 10:35 P.M., showed staff did not notify the physician about staff lowering the resident to the floor on 12/27/10 as well as the resident's continued pain until this time. The physician ordered staff to send the resident to the emergency room . Review of the resident's hospital x-ray report, dated 12/29/10, showed the resident sustained [REDACTED]. During an interview on 1/7/10 at 12:29 P.M., the Director of Nursing (DON) said CNA A lowered the resident to the floor on 12/27/10. During a telephone interview on 1/7/10 at 1:41 P.M., CNA A said he/she attempted to transfer the resident from the resident's bed to a wheelchair by himself/herself on 12/27/10 between 3:20 P.M. to 3:45 P.M. CNA A said he/she "almost" lost his/her grip on the resident which resulted in the resident "getting lower." CNA A said he/she could not lift the resident up to get him/her in the wheelchair, so he/she lowered the resident to the floor. CNA A said he/she called out for help. Certified Medication Technician (CMT) B and Registered Nurse (RN) C came to the room and assisted him/her in getting the resident up in the wheelchair. CNA A said RN C did not perform an assessment of the resident while in the room. CNA A said RN C left the room and stated, the resident "seems fine, give (him/her) some pain medicine." During an interview on 1/7/10 at 2:21 P.M., CMT B said CNA A called out that he/she had a resident on the floor, so he/she went in the room and called out for RN C to come to the resident's room. CMT B said when he/she entered the room, he/she saw the resident "squatted down" on the floor on his/her knees with his/her feet tucked under his/her buttocks. CMT B said after RN C left the room, he/she asked the resident if he/she had pain and the resident pointed to his/her right thigh. CMT B said he/she informed RN C of this, so he/she instructed CMT B to give the resident [MEDICATION NAME] (pain medication). CMT B said RN C did not perform an assessment on the resident while in the room. CMT B said he/she did not see RN C check the resident's skin or check the resident's extremities for range-of-motion function. During an interview on 1/7/11 at 2:32 P.M., RN C said on 12/27/10 between 6:00 P.M. to 7:00 P.M., CNA A attempted transferring the resident; but the resident's feet slipped, so CNA A lowered the resident to the floor. RN C said he/she came in the resident's room and saw CNA A and CMT B with the resident who sat on the floor on his/her knees with his/her feet underneath his/her buttocks. RN C said then he/she assisted the resident to his/her wheelchair and into the bed. RN C said he/she did not document the incident or assessment in the nursing notes at the time of the incident because the facility policy did not require documenting incidents involving lowering residents to the floor. During an interview on 1/7/11 at 2:57 P.M., the administrator said the facility accident policy did not instruct staff to "disregard" incidents involving residents lowered to the floor. She said a lot of staff "had the impression" that if staff lowered residents to the floor, they did not have to treat the incident like a fall. Review of the facility policy (not dated) on fall prevention showed direction for staff to check the resident's vital signs and "assess the condition of the resident." The policy further directed staff to notify the the attending physician and the responsible party of the occurrence, make an entry in the nursing notes including a summary of the event, physical assessment of the resident, any intervention provided for the resident, notification of the physician, and notification of the resident's responsible party. In addition, the policy directed staff to check resident "as his/her condition warrants" and report follow-up care needed to the charge nurse on the next tour of duty. The policy directed licensed nurses to document follow-up assessments on each shift for 72 hours following the event. During a telephone interview on 1/13/11 at 12:58 P.M., LPN E said he/she worked the night shift that began 12/27/10 and ended 12/28/10. LPN E said RN C did not tell him/her about the incident during change of shift report. During an interview on 1/7/11 at 2:10 P.M., LPN D said no one told him/her during report the morning of 12/28/10 that staff had lowered the resident to the floor the previous evening. LPN D said if he/she had known that, he/she would have called the doctor that morning. LPN D said he/she did not call the doctor about the resident's pain on 12/28/10, because the resident typically experienced severe pain three to four times a week which staff addressed by administering pain medications as needed. Review of the resident's nursing notes from 7/20/10 through 12/28/10 showed staff only documented the resident experienced pain on 12/28/10. During an interview on 1/13/11 at 2:48 P.M., the administrator said she expected nurses to assess and document any incidents involving staff lowering residents to the floor. She also said she expected nurses to report any incidents involving staff lowering residents to the floor to the next shift's nurses for follow-up. MO 557