Every finding on record at Desert Highlands Care Center

Based on clinical record review, staff interviews and facility policy, the facility failed to ensure procedures were activated timely when the the Resident (#11) failed to return to the facility. The deficient practice may result in unidentified residents who eloped. Findings include: Resident #11 was admitted on [DATE] with diagnoses of acute respiratory failure, paroxysmal atrial fibrillation, and alcohol abuse. An admission Minimum Data Set (MDS) dated [DATE] included that this resident was moderately cognitively impaired. A Social Services note dated July 16, 2025 included that this resident stopped by Social Services inquiring if he could get a ride to his home and get his belongings, and that he stated he wants some clean clothes and would like to check on his house. This note included that social services discussed with him that he would need to return back to the facility in a decent time so he could continue his medication regimen and therapy and that this resident stated he understand and would be back in time. A Transportation Log and Acknowledgement Form included that on July 17, this resident was transported home with a pickup time of 1 PM. The return time box was filled in with resident refused. However, review of the clinical record did not find a sign out sheet for this resident on July 17, 2025. Review of the Medication Administration Record (MAR) for July, 2025 included that on July 17, this resident received the AM medication but the 1900 observation was not performed and the resident did not receive the 2100 doses of medication. This record included that some of the MAR records for PM were noted this resident was absent from home without medications. However, review of the clinical record was unable to find attempts to contact the resident or otherwise ensure his safety from until July 18, 205 at 10:37 AM. A Social Services note dated July 18, 2025 at 10:37 AM included that Social Services called this resident to do a welfare check and that this resident did not answer, and that they left a message requesting a return call. A Social Services note dated July 18, 2025 at 11:59 AM included that Social Services called [NAME] Police Department requesting a welfare check be completed and that [NAME] Police Department was able to locate this resident at [NAME] Regional Medical Center in the Cath Lab. A Social Services note dated July 18, 2025 at 12:00 PM included that Social Services submitted an APS report regarding this resident leaving against medical advice. An interview was conducted on July 31, 2025 at 9 AM with a Certified Nursing Assistant (CNA/staff #7) who said that she thought that the facility was supposed to pick this resident back up but that she spoke to the driver who said that he was not scheduled to pick this resident up. This CNA said that the resident left his glasses in his room and that the resident left with 1 tank of oxygen, therefore she was surprised that there was not a return trip planned. This CNA said that this resident wanted to leave at 10 but that she thought he left at 1 PM because the unit coordinator said that the driver would be available at 1 PM. This CNA said that normally people coordinate their own transportation, however this resident seemed alert if you didn't know him but could be confused. An interview was conducted on July 31, 2025 at 10:07 AM with a Unit Coordinator (staff #81) who said that she schedules resident's appointments, setting up to and from trips as well as other duties. This staff said that she remembered this resident and that she scheduled a driver for dropping him off. This staff said that social services would come up and ask when the driver could take him for his trips and that for the last trip she scheduled him for, she was told not to worry about a ride back. This staff said that the social services persons came to her desk together and told her not to schedule the return trip and that she asked if they were sure that they did not want the facility driver (staff #14) to pick him up and that the social services persons said no. This staff said that she did what she was told and scheduled the trip. An interview was conducted on July 31, 2025 at 10:22 AM with the Director of Social Services (staff #39) who said that typically it's staff #81 who coordinates the travel. This staff said that this resident was not in the facility very long and needed to go home to get clothes, and had went once before and came back. This staff said that the resident had on a psychedelic mushroom shirt and hospital pants, and considered that it was undignified, and that the facility could not force the resident to stay. This staff said that they had spoken to staff #81 about transport and that this resident was going to leave at 1:00 PM and be back at 3:00 PM. This staff then said that she did not remember if it was asked to arrange there and back because she did not know it was her or her assistant. This staff said that the resident signed out with the nurses and that as far as she was aware, the resident went home. This staff said that she did not notice that the resident had not returned until the next morning because she was doing her duties. This staff said that she called Adult Protective Services and that she was told that this resident was in the cath lab at the local hospital. An interview was conducted on July 31, 2025 at 3:22 PM with the facility Driver (staff #14) who said that residents are supposed to contact the business office and then he will pick them up where-ever they are at. This staff said that rides are usually coordinated through the business office and he will drop them off and then the residents will contact the business office and he will go pick them up. This staff said that he did drive the resident to his home, that he did have an oxygen tank and a wheelchair with him, that this resident did not have his key with him, and that he had to get the manager to get his key. This staff said that he did not leave until this resident got into his trailer. This staff said that the resident needed to contact the business office to be picked up and that he gave the resident a business card to make sure this resident had the number. This staff said that he never heard anything back from this resident and that it sounded to him that this resident had every intention of calling and he had no idea why it did not happen. This staff reviewed the driving log and said that that he wrote the resident refused on it earlier on today (July 31, 2025) because the DON told him that day that the resident refused to come back and to note it on the form. This staff said that he had never had a resident refuse to come back, but if that did happen, he would let the business office know. An interview was conducted on July 31, 2025 at 12:03 AM with a Licensed Practical Nurse (staff #90) who said that for residents leave of absences, that the nurse needs to make sure the resident was alert and oriented. This nurse said that it was their policy here is that the residents sign out. This nurse said that there is now a book with the sign out sheets but before Monday the sign out sheets were placed in the residents' charts. This nurse said that only the nurse should sign out a resident. This nurse said that the sheet has the date, the time, who the responsible person is for signing out the resident, and that she thinks that it also has where the resident is going. This nurse said that she does not recall if it had a place where the resident is expected back at the facility, but that she asks when to expect them back for medication, and for their safety in general. This nurse said that she would put in a chart note about it. This nurse said that she was not this resident's nurse on July 17, 2025 but that she was in the facility and that she heard that social services set up a ride for this resident, that the facility driver took him and was not picking him up. This nurse said that she would try calling a resident that did not return to the facility and see where the resident is at and let the management know, especially social services, and that she would pass it on in report. This nurse said that she would put in a note detailing her actions into the progress notes. This nurse reviewed the resident's clinical record and said that she did not see a note. An interview was conducted on July 31, 2025 at 12:37 AM with an LPN (staff #47) who said that a resident will come to her for a leave of absence and they have to sign out, and then of course when they return, they have to sign in. This nurse said that she always asks were they are going and when they are supposed to come back because of her concern with medication and so she can keep an eye out for their return. This nurse said that If they do not return in a timely manner, then she would call the resident or representative and if that does not work that they have to get the police involved, let the administrator and management know. This nurse said that she charts all of it and makes sure to let the Director of Nursing (DON) know. This nurse reviewed this resident's chart and said that she did not see a note from the resident's leave of absence on July 17, 2025 until the social services note on July 18, 2025. An interview was conducted on July 31, 2025 at 12:49 AM with an LPN (staff #19) who said that when a resident leaves the facility, they use a sign in and sign out sheet for the resident or the resident's representative. This nurse said that this sheet has the time out and the time in and it is in a folder under the resident's name and includes whoever is taking the resident out. This nurse said that they do ask the residents the time of their return so that they know when to expect them for medication pass and meals. This nurse said that she would get a phone number so that she can reach them just in case. This nurse said that if a resident did not return to the facility that she would attempt to call the resident or representative and then she would contact her Director of Nursing (DON), and her manager and then call the police because if a resident is not answering, that's concerning. This nurse said that she would chart that she attempted to speak to the resident or family member, the entire scenario and who she contacted and go from there. This nurse reviewed the clinical record and said that she did not see that this resident's failure to return to the facility was documented until the note from social services and that she had checked where she had been taught to chart it. An interview was conducted on July 31, 2025 at 2:45 PM with the DON (staff #37) who said that if a resident is leaving for the day, they have to do therapies first, they have to sign themselves out, they have to give an approximate time of return and they have to return the same day unless there was some extenuating circumstances which the resident gets approval for. This DON said that she believed that they did not have the sign out sheet for this resident because he was signed out by the facility transport driver and not in our sign out book because he went with transport. This DON said that the facility does not have a policy about residents going with transport. This DON said that residents should be signed out by the nurses because they have access to the sign out book. This DON said that residents have to come up to the desk, then the nurse hands them the sign out book, they sign themselves out or family if necessary. This DON said that if residents are not returning when they say they are going to, staff will give a leeway of approximately an hour and then they are called to see if they are returning so we can get a better idea of what's occurring. This DON said that she did not know if the resident was called an hour later. This DON said that an Oxygen tank lasts about a shift. This DON said that the resident should have returned and that this resident should have been called and that she thought that the driver would have called since he wrote the resident returned on the sheet. This DON said that it does not meet her expectations that the resident was not called or that management, APS, and police were not notified of a resident's unexpected failure to return to the facility. This DON said that the facility does not have a policy that defines the amount of time that staff should wait before instituting safety measures. A policy titled Wandering and Elopements revised March 2019 included If a resident is missing, initiate the elopement/missing resident emergency procedure: if the resident is not located, notify the administrator and the director of nursing services, the resident's legal representative, the attending physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., emergency management, rescue squads, etc.).

Based on closed clinical record review, staff and residents' interviews and policy review, the facility failed to ensure one resident (#2) was provided care and services to prevent pressure ulcers/injury from developing and/or worsening. The deficient practice could place resident at risk for developing and/or worsening of pressure ulcers/imjury. Findings include: Resident #2 was admitted to the facility with an initial admitted [DATE] with diagnoses of Pneumonia, Type 2 Diabetes Mellitus, acquired absence of left upper limb and amputation of two fingers of right hand. Review of nursing progress note titled, Skin Only, dated February 17, 2025 at 15:56 PM revealed that the resident had current skin issues. The progress note revealed resident had a healed skin post amputation of left forearm, and a scrotal excoriation which a barrier cream was ordered and initiated. Review of nursing progress note titled, Braden Scale for Predicting Pressure Ulcer Risk, dated February 17, 2025 at 19:26 PM revealed a Braden Evaluation result of 'At Risk' with a score of 18.0. Review of the wound nurse progress note dated February 17, 2025 revealed that the resident had a current skin issues which included healed wound from the amputation of left forearm, and an excoriation to scrotum which an order of barrier cream to be applied to the area was initiated, and the provider and resident/responsible party were notified. A review of order dated February 17, 2025 revealed an order for Calazinc to scrotum and buttocks with each brief change and as needed for skin integrity. However, review of resident's care plan did not reveal a care plan that resident had an excoriated scrotum area with an intervention. Review of February 2025 treatment administration record (TAR) revealed that Calazinc to scrotum and buttocks with each brief change and as needed for skin integrity every shift was transcribed in the TAR and was scheduled at 0700 AM and 1900 PM. The TAR revealed that the treatment was administered from February 17 through February 22, 2025. However, the February 2025 TAR revealed that the medication Calazinc was not accurately transcribed to show the as needed for skin integrity every shift medication administration. Review of care plan dated February 17, 2025 revealed a risk for disturbed sensory perception. The goal is resident skin will remain intact. The interventions include to educate Resident/Representative on the importance of frequent position changes, evaluate Resident's ability to feel sensations, and evaluate skin for areas of blanching or redness. Review of facility's document titled, Monthly Shower Assistance Log, for the month of February 2025 revealed that the resident received a bed bath on February 17. Review of the nurse practitioner (NP) progress notes dated February 18, 2025 revealed an admission note. The progress note revealed that the resident received the initial therapy evaluation; nursing voiced no concerns; and skin is warm, dry, multiple pressure injuries present on admission; and continue current plan of care with specific adjustments/additions. The progress notes also revealed that due to the residents age and comorbidities resident is at increased risk for rapid decompensation with little to no warning. However, the NP progress note did not reveal location of pressure injuries and plan of care. Review of dietary/nutrition progress notes dated February 18, 2025 revealed food preferences, likes and dislikes, and current diet were discussed during the visit. Review of care plan dated February 19, 2025 revealed resident's current functional performance is related to impaired mobility. The interventions include resident requires extensive assist/two-person physical assist for bed mobility, toilet use, and transfers; and resident requires limited assist/one-person assist with dressing and personal hygiene. Review of the NP progress notes dated February 20, 2025 revealed a follow up visit. The progress note revealed active medication list, allergy list, past medical history, vital signs, code status, and general physical exam. The progress note revealed to continue current plan and current medications, and due to the residents age and comorbidities resident is at increased risk for rapid decompensation with little to no warning. However, the NP progress notes did not reveal notes relating to resident's pressure injuries and plan of care. Review of admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15.0 indicate intact cognition; behavior symptoms for rejection of care was not exhibited; resident requires partial/moderate assistance with rolling left and right and sit to lying; resident requires substantial/maximal assistance with chair/bed transfer, toilet transfer and shower transfer; always incontinent of bowels; resident admitted without pressure ulcers/injuries and was assessed at risk of developing pressure ulcers/injuries; and skin treatment includes turning/repositioning program and nutrition or hydration intervention to manage skin problems. Review of nursing progress note titled, Transfer to Hospital Summary, dated February 22, 2025 revealed Resident #2 appeared lethargic and was transported to the hospital via a non-emergent transport. Resident family and the NP were notified. Review of nursing progress note titled, Admission Summary, dated February 27, 2025 at 17:59 PM revealed Resident #2 readmitted to the facility. Review of nursing progress note titled, Braden Scale for Predicting Pressure Ulcer Risk, dated February 27, 2025 at 19:32 PM revealed a readmission Braden evaluation result of at risk with a score of 18.0. Review of nursing progress note titled, Skin only, dated February 27, 2025 at 22:11 PM revealed a skin evaluation that revealed the resident has current skin issues which includes a non-pitting edema to the top of feet, and has a multi podus boot (MPB) in place to both feet. Review of the NP progress notes dated February 28, 2025 revealed a readmission note. The progress notes revealed skin is warm and dry, and decreased sensation to light touch to both feet. Resident blood albumin level result is 2.6 on February 28, 2025 and a SNP mashed potatoes ordered. The progress notes also revealed that due to the residents age and comorbidities resident is at increased risk for rapid decompensation with little to no warning. Review of progress notes revealed dietary visited resident on February 28, 2025. The progress notes revealed a discussion of resident's likes and dislikes, no change to preferences, and current diet. Resident prefers to eat in bedroom with small portions. Resident's current weight was 148.0 pounds by Hoyer lift. And, dietary will continue toencourage healthy intake. Furthermore, resident requested to have two- whole milk and a small order of mash potatoes and gravy for all meals. Review of facility's document titled, CNA Documentation, for the month of February 2025 revealed a task for repositioning for AM and PM from February 17 through February 21 and from February 27 through February 28. Review of the NP progress note dated March 3, 2025 revealed a progress note that resident is currently being seen for readmission, resident with no new complaints or concerns, and nurses report no new issues or concerns. The progress note revealed skin is warm, and without rashes. Review of nursing progress note titled, Braden Scale for Predicting Pressure Ulcer Risk, dated March 6, 2025 at 21:15 PM revealed a Braden evaluation result of At Risk with a score of 18.0. Review of the NP progress notes dated March 3, 2025 revealed no new complaints, concerns or issues from nurses. Review of NP progress notes dated March 4, 2025 revealed resident has requested physical therapy to work on standing, and it was ordered and communicated to the therapy department, including speech therapy for swallowing. The progress notes revealed that the resident denies any issues with choking though resident stated that sometimes has a difficult time with food that is not sof tand/or moist with a gravy or sauce. Review of diet order revealed an order for controlled carb diet, soft and bite size texture, regular/thin consistency. Review of nursing progress notes dated March 6, 2025 at 21:15 PM revealed a nursing progress note titled, Braden Scale for Predicting Pressure Ulcer Risk, revealed a Braden evaluation result of At Risk with a score of 18.0. Review of nursing progress note titled, Skin Only, dated March 6, 2025 at 21:52 PM revealed Resident #2 has current skin issues. Resident has both of top of feet noted non-pitting edema and MPB in place for both feet, and has a sacral pressure ulcer/injury stage 2, which is described as open, red area pressure ulcer, and covered with a gel dressing. The progress note did not reveal that the provider or resident/family were notified of the pressure ulcer. The resident's care plan for skin integrity was not updated for having stage 2 sacral pressure ulcer/injury. Review of the wound nurse progress note dated March 11, 2025 at 07:02 AM revealed resident has current skin issues: - Unstageable sacrum Pressure Ulcer/Injury with the following description: Length: 7.1 Width: 7.0 Depth: 0.1 Wound bed: Slough. Wound exudate: Serous. Peri wound condition: within normal limits (WNL). Dressing saturation: Moderate (26-75%). Wound odor: No. Tunneling: No. Undermining: No. Tissue: Warm. Skin note: sacral wound 60% slough/40% granulation tissue. - Unstageable left gluteal fold Pressure Ulcer/Injury with the following description: Length: 1.0 Width: 1.3 Depth: 0.1 Wound bed: Slough. Wound exudate: Serous. Peri wound condition: WNL. Dressing saturation: Minimal (<25%). Wound odor: No. Tunneling: No. Undermining: No. Tissue: Warm. Skin note: left gluteal fold 100% slough. The progress notes also revealed that the provider was contacted. The resident/responsible party was made aware of the diagnosis and plan of care. Review of NP progress notes dated March 11, 2025 revealed a wound care consult visit type for new pressure injuries. The progress note revealed treatment orders provided, offloading with repositioning was discussed with resident, and a mattress overlay is on order. The progress notes also revealed that the resident informed the NP that his appetite has been improving and is eating more varied diet. In addition, the progress notes revealed that physical therapy and speech therapy are still pending. Furthermore, the nurse practitioner progress notes identified and described the following wounds/pressure injuries: -Wound 1: unstageable pressure wound located in the sacrum measuring 7.1 centimeter (cm) by 7.0 cm by 0.1 cm with 60% slough, 40% granulation tissue, scant serous sanguineous exudate without odor, peri wound is intact. The treatment is to use normal saline or wound cleanser to be done daily and as needed with a primary dressing using Medihoney and a secondary dressing using an adhesive foam dressing. Additional order to offload per facility protocol, and a mattress overlay on order; -Wound 2: stage 3 pressure wound located in the left upper ischium measuring 0.4 cm by 0.4 cm by 0.2 cm without exudate or odor, peri wound intact. The treatment is to use normal saline or wound cleanser to be done daily and as needed with a primary dressing using Medihoney and a secondary dressing using an adhesive foam dressing. Additional order to offload per facility protocol, and a mattress overlay on order; and -Wound 3: unstageable pressure wound located in the left ischial tuberosity measuring 1.0 cm by 1.3 cm by 0.1 cm with 100% slough without exudate or odor and peri wound is intact. The treatment is to use normal saline or wound cleanser to be done daily and as needed with a primary dressing using Medihoney and a secondary dressing using an adhesive foam dressing. Additional order to offload per facility protocol, and a mattress overlay on order. Review of the physician progress notes dated March 11, 2025 revealed a follow-up of medical illness. The progress notes revealed that the resident is bedridden, currently is not receiving physical therapy, resident has not walked for some time. Nurses report no new issues or concerns. Resident's appetite and activity level are stable. Review of care plan initiated on March 12, 2025 revealed resident has an actual impairment to skin integrity of the sacrum related to unstageable pressure wound to sacrum. The interventions initiated on March 12, 2025 includes encourage good nutrition and hydration in order to promote healthier skin, follow facility protocols for treatment of injury, monitor/document location, size and treatment of skin injury, report abnormalities, failure to heal, signs and symptoms of infection, maceration etc. to medical doctor, and weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Review of nursing progress notes titled, Skin Only, dated March 13, 2025 at 22:15 PM revealed a skin evaluation revealing resident has current skin issues. The progress notes revealed resident's buttocks has excoriation, and a skin protectant applied. However, there was no provider notification revealed in the progress notes. Review of the wound nurse progress note dated March 20, 2025 at 09:26 AM revealed resident has current skin issues: - Unstageable sacrum Pressure Ulcer/Injury with the following description: Length: 5.1 Width: 5.0 Depth:0.1 Wound bed: Slough. Wound exudate: Serous. Peri wound condition: Maceration. Dressing saturation: Moderate (26-75%). Wound odor: No. Tunneling: No. Undermining: No. Tissue: Warm. Skin note: sacrum 80% slough/20% granulation tissue with the peri wound maceration; and - Stage II - Partial thickness skin loss left gluteal fold Pressure Ulcer/Injury with the following description: Length:0.4 Width: 0.4 Depth: 0.2 Wound bed: Granulation. Wound exudate: Serous. Peri wound condition: WNL. Dressing saturation: Minimal (<25%). Wound odor: No. Tunneling: No. Undermining: No. Tissue: Warm. Skin note: left gluteal fold 100% granulation. The progress notes also revealed that the provider was contacted. The resident/responsible party was made aware of the diagnosis and plan of care. Review of NP progress notes dated March 20, 2025 revealed a wound care follow-up visit. The progress notes revealed that the resident was evaluated by therapy last week and therapy is pending per insurance approval. The progress notes revealed that the resident's pressure injuries have improved overall but have a new moisture associated skin damage (MASD) to his right buttock. Resident has reportedly been having frequent loose stools so Metamucil was ordered to help bulk up his stool as resident does not get much fiber in the diet. In addition, the NP progress notes included resident's wounds assessment: - Wound 1: Unstageable Pressure Ulcer in the Sacrum measuring 5.1 cm x 5 cm x 0.1 cm; has 80% slough, 20% granulation tissue; has scant serosanguinous exudate without odor; the peri wound is intact. The treatment is to use Wound Cleansing: normal saline (NS) or wound cleanser daily and as needed with a primary dressing using Medihoney and a secondary dressing using Adhesive foam dressing. Offload per facility policy and the mattress overlay is on order; -Wound 2: Unstageable Pressure Ulcer in the Left upper ischium measuring 0.4 cm x 0.4 cm x 0.2 cm, base has 100% slough, no exudate, no odor, and the peri wound is intact. The treatment is to use Wound Cleansing: normal saline (NS) or wound cleanser daily and as needed with a primary dressing using Medihoney and a secondary dressing using Adhesive foam dressing. Offload per facility policy and the mattress overlay is on order; -Wound 3: Unstageable Pressure Ulcer in the Left ischial tuberosity measuring 0.8 cm x 0.9 cm x 0.1 cm, the base has 100% slough, the exudate is 20% granulation tissue, 80% slough without odor, peri wound is intact. The treatment is to use Wound Cleansing: normal saline (NS) or wound cleanser daily and as needed with a primary dressing using Medihoney and a secondary dressing using Adhesive foam dressing. Offload per facility policy and the mattress overlay is on order; and -Wound 4: MASD in the Right buttock measuring 5.0 cm x 5.0 cm x 0.1 cm, the base is pink, there is no exudate or odor, peri wound is intact. The treatment is to use Wound Cleansing: NS or wound cleanser with brief changes and a secondary dressing using barrier cream. Keep skin clean and dry. Offload per facility policy and the mattress overlay is on order. Review of March 2025 medication administration record (MAR) revealed Metamucil Smooth Texture Oral Powder give one tablespoon by mouth one time a day for bowel management, mix in eight ounces of water or juice was ordered on March 21, 2025, and the resident was administered the medication starting March 21, 2025 in the morning. Review of resident's care plan revealed no revision of care plan to include offloading per facility policy and mattress overlay. Review of care plan initiated on March 27, 2025 revealed resident refuses to turn in bed. The goal included resident will not develop new pressure wounds. The intervention dated March 27, 2025 includes resident will turn often in bed and to educate resident on importance of turning in bed for pressure relief. Review of NP progress notes dated March 27, 2025 revealed a wound care and nutrition follow-up visit. The progress notes revealed that the slough to the sacral pressure injury was softening and much of it was able to be debrided today with the resident's consent. The progress notes also revealed that the resident continues to refuse repositioning and offloading, and an alternating pressure mattress was ordered for pressure reduction and will be applied by tomorrow morning. In addition, the NP progress notes included resident's wounds assessment: -Wound 1: Unstageable Pressure Ulcer in the Sacrum measuring 5.5 cm x 5.6 cm x 0.5 cm, has an Undermining at 0300 to 0900 at 1.0 cm depth, the base has 80% slough, 20% granulation tissue, moderate Serosanguineous exudate without odor, peri wound is intact. The treatment is to use Wound Cleansing: normal saline (NS) or wound cleanser daily and as needed with a primary dressing using Medihoney and a secondary dressing using Adhesive foam dressing. Offload per facility policy and the mattress overlay is on order; -Wound 2: Unstageable Pressure Ulcer in the Left upper ischium measuring 1.0 cm x 0.8 cm x 0.1 cm, base has 100% slough, no exudate, no odor, and the peri wound is intact. The treatment is to use Wound Cleansing: normal saline (NS) or wound cleanser daily and as needed with a primary dressing using Medihoney and a secondary dressing using Adhesive foam dressing. Offload per facility policy and the mattress overlay is on order; -Wound 3: Unstageable Pressure Ulcer in the Left ischial tuberosity measuring 1.0 cm x 0.8 cm x 0.1 cm, the base has 100% slough, no exudate, no odor, and the peri wound is intact. The treatment is to use Wound Cleansing: normal saline (NS) or wound cleanser daily and as needed with a primary dressing using Medihoney and a secondary dressing using Adhesive foam dressing. Offload per facility policy and the mattress overlay is on order; and -Wound 4: MASD in the Right buttock measuring 2.0 cm x 2.0 cm x 0.1 cm, the base is pink, no exudate, no odor, and the peri wound is intact. The treatment is to use Wound Cleansing: NS or wound cleanser with brief changes and a secondary dressing using barrier cream. Review of the wound nurse progress note dated March 27, 2025 at 11:41 AM revealed resident has current skin issues: - Unstageable sacrum Pressure Ulcer/Injury with the following description: Length: 5.5 Width: 5.6 Depth: 0.9 Wound bed: Slough. Wound exudate: Serous. Peri wound condition: Fragile. Dressing saturation: Heavy (>75%). Wound odor: No. Tunneling: No. Undermining: Yes. Tissue: Warm. Skin note: sacrum 100% slough. The wound nurse progress notes revealed that the wound was debrided by the NP at bedside. The wound undermining is at the 0300-0900 with a 1.0 cm deepest aspect. Peri wound with maceration and excoriation noted. Review of care plan for actual impairment of skin integrity of the sacrum related to unstageable pressure wound to sacrum revealed a revised intervention dated March 28, 2025 that includes resident needs alternating pressure mattress (APM) to protect the skin while in bed. Review of physician orders dated March 11, 2025 revealed the following wound orders: - Sacral wound: Cleanse with wound cleanser, apply Medihoney, cover with Mepilex. Change dressing every day until resolved for skin integrity every day shift every Monday, Tuesday, Wednesday, Thursday, and Friday; and - Left gluteal fold: Cleanse with wound cleanser, apply iodosorb, cover with Mepilex. Change dressing every day for skin integrity every day shift every Monday, Tuesday, Wednesday, Thursday, and Friday. The application of iodosorb was not part of the treatment order revealed in the NP progress notes. Review of physician orders revealed an order for air mattress to bed for skin integrity check functioning every shift was ordered on March 14, 2025. Review of March 2025 TAR (Treatment Administration Record) revealed these orders were transcribed as: - Sacral wound: Cleanse with wound cleanser, apply Medihoney, cover with Mepilex. Change dressing everyday until resolved for skin integrity every day shift every Monday, Tuesday, Wednesday, Thursday, and Friday; - Sacral wound: Cleanse with wound cleanser, apply Medihoney, cover with Mepilex. Change dressing every day until resolved for skin integrity every night shift every Saturday and Sunday; - Left gluteal fold: Cleanse with wound cleanser, apply iodosorb, cover with Mepilex. Change dressing every day for skin integrity every day shift every Monday, Tuesday, Wednesday, Thursday, and Friday; - Left gluteal fold: Cleanse with wound cleanser, apply iodosorb, cover with Mepilex. Change dressing every day for skin integrity every night shifts every Saturday and Sunday; and -APM mattress to bed for skin integrity check function every shift was transcribed on March 28, 2025. Review of facility document titled, Monthly Shower Assistance Log, for the month of March 2025 revealed resident was provided bed baths on March 4, March 7, March 13, March 22, March 25, and March 30. The record revealed that the resident refused bed baths on March 17 and March 27. In addition, the document did not reveal any skin issues under comments. Review of facility's document titled, CNA Documentation, for the month of March 2025 revealed a task for repositioning for AM and PM for the whole month of March. Review of NP progress notes dated April 3, 2025 revealed a wound care follow-up visit. The progress notes revealed that the resident's MASD has resolved. However, according to the progress notes the resident's sacral pressure injury has increased in depth as the necrotic tissue continues to be debrided; slough was debrided again during today's NP's exam with the resident's consent. APM mattress is in bed, resident refuses additional repositioning to offload so the wound. The progress notes revealed that the wound healing remains difficult as the resident is always laying on his back in bed. Resident's blood sugars remained controlled. In addition, the NP progress notes included resident's wounds assessment: -Wound 1: Unstageable Pressure Ulcer in the Sacrum measuring 6.0 cm x 5.6 cm x 1.2 cm, has an Undermining at 0300 to 1200 at 3.0 cm depth, the base has 90% slough, 10% granulation tissue, small to moderate Serosanguineous exudate without odor, peri wound is intact. The treatment is to use Wound Cleansing: 1/4-strength Dakins soak for 15 minutes, then rinse with NS or wound cleanser daily and as needed with a primary dressing using AG rope and a secondary dressing using Adhesive foam dressing. Offload per facility policy and alternating pressure mattress in use; -Wound 2: Unstageable Pressure Ulcer in the Left upper ischium measuring 1.0 cm x 1.0 cm x 0.1 cm, base has 100% slough, no exudate, no odor, and the peri wound is intact. The treatment is to use Wound Cleansing: normal saline (NS) or wound cleanser daily and as needed with a primary dressing using Medihoney and a secondary dressing using Adhesive foam dressing; -Wound 3: Left ischial tuberosity status resolved, the base has 100% epithelialized, no exudate, and no odor; and -Wound 4: MASD right buttocks resolved the base has 100% epithelialized, no exudate, and no odor. Review of facility's document titled, Weekly Skin Assessment, dated April 3, 2025 revealed a pressure ulcer on the coccyx area. Review of the wound nurse progress note dated April 3, 2025 at 16:07 PM revealed resident has current skin issues. The progress note revealed an unstageable sacrum Pressure Ulcer/Injury Stage with the following description: Length: 6.0 Width: 5.6 Depth: 1.5 Wound bed: Slough. Wound exudate: Purulent. Peri wound condition: within normal limits (WNL). Dressing saturation: Heavy (>75%). Wound odor: No. Tunneling: No. Undermining: Yes. Tissue: Warm. Skin note: sacrum 100% slough, undermining is at the 0300-1200 with 3.0 cm at deepest aspect. The wound nurse progress notes also revealed the wound was debrided by the NP at bedside, the resident tolerated the procedure well, Resident continues to refuse side to side repositioning, and the alternating pressure mattress (APM) is in the bed and functioning properly. Review of NP progress notes dated April 3, 2025 revealed a wound care follow-up visit. The progress notes revealed that the resident's nutrition remains poor; resident mainly been eating Spaghetti-os, resident continues to refuse repositioning or offloading of his sacral wound, and an alternating pressure mattress has been in use. The progress notes revealed that the distal portion of the wound opened yesterday and has been draining. Also, Dakin's has not been available for wound cleansing as it is on order so Vashe has been used. The progress notes also revealed that there is now a tunnel at the distal portion of the wound that is visible and appears to be going into the resident's rectum, and stool was present on exam of this area. Resident was sent to emergency department for further evaluation and treatment. In addition, the NP progress notes included resident's wounds assessment: -Wound 1: Unstageable Pressure Ulcer in the Sacrum measuring 7.0 cm x 5.7 cm x 1.5 cm with an undermining at 0300 to 1200 at 4.0 cm depth with a base consisting of 90% slough, 10% granulation tissue, has moderate Serosanguineous exudate without odor. The treatment is to use Wound Cleansing: 1/4-strength Dakins soak for 15 minutes, then rinse with NS or wound cleanser daily and as needed with a primary dressing using AG rope and a secondary dressing using Adhesive foam dressing. Offload per facility policy and alternating pressure mattress in use. Review of facility's document titled, Monthly Shower Assistance Log, for the month of April 2025 revealed resident received bed bath on April 3 and April 6. The document revealed no documentation of skin issues under comments. Review of facility's document titled, CNA Documentation, for the month of April 2025 revealed a task for repositioning for AM and PM from April 1 through April 10. Review of nursing progress titled, Incident Note, dated April 10, 2025 revealed the nurse practitioner requested the patient to be sent out to the emergency department due to the severity of the coccyx wound. Review of record revealed on April 10, 2025 resident was sent out to hospital for wound on coccyx. An interview was conducted on April 16, 2025 at 12:50 PM with a certified nursing assistant (CNA)/Staff #115 in the conference room. Staff stated that she works day shift, does the CNA schedule, help assist with daily activities on the floor such as showers, and feeding. Regarding scheduling, she stated that for enough staff, she schedules at least eight CNAs through the day, the CNA takes care of ten to fifteen residents, and could be less depending on their census. Regarding showers, the resident gets two showers a week. They have a shower book or binder, and for instance for Monday and Thursday shower is for odd numbered rooms and Tuesday and Friday showers are for the even numbered rooms. She stated that Wednesday, Saturday, and Sundays are the make-up shower days. She stated that they use a paper charting to document the resident showers, bed baths, or if the shower or bath is refused. She stated that during showers, if she notices anything on the skin she will notify the nurse. An interview was conducted on April 16, 2025 at 1:05 PM with CNA/Staff #32 in the conference room. She stated that showers are twice a week per resident and it gets charted in the shower book. She does computer charting for activities of daily living (ADLs) such as transfers, behaviors, bowel movements, and bladder continence. She stated that she does not have bed mobility charting in the computer and maybe the nurses do it but she does not. She is not familiar with resident #2 care. She stated that regarding skin issues such as a cut, bruise, not walking right detected during a shower, she will notify the nurse. An interview was conducted on April 16, 2025 at 1:31 PM with LPN/wound nurse/Staff #106. She stated that for wound care, when resident arrives in the facility, the facility NP/Staff #400 rounds on Thursdays for weekly updates. She performs wound treatments as ordered daily from Monday through Friday, and takes care of pressure ulcers wounds and surgical wounds. Staff stated that regarding resident #2, resident's wound was brought to her attention. Resident has on admission an excoriation to scrotum, and on March 6, a skin assessment was completed by Staff #89, who is a night shift nurse. In addition, she stated that one of the aid brought to her attention about resident's sacral wound, and so she assessed the wound and started treatment such as APM (alternating pressure mattress), daily dressing changes, the NP debrided the wound on April 3, and then resident was sent out on April 10 because there might be a fistula in the wound due to increased drainage, she had an impression that it was going in the bowel. She stated that resident was non-compliant with turning, resident needs assistance with turning/repositioning but resident refused. She stated that resident has a care plan for refusal to turn. However, review of care plan revealed resident's refusal to turn in bed was initiated on March 27, 2025. An interview was conducted on April 17, 2025 at 11:23 AM with NP/Staff #400 via phone interview. Staff stated that she works for the facility. She stated that regarding resident #2, she is in the facility weekly on Thursdays. She started seeing resident on March 11, 2025 for his wound. She was notified by wound nurse. She stated that resident had an unstageable pressure wound to sacrum and the left ischial have two to three stage III wound and unstageable. She saw resident the first time on March 11, 2025 related to the wound. She was originally seeing the resident for primary care for pulmonary embolism (PE), deep vein thrombosis (DVT) and diabetes management when first admitted on [DATE]. She stated that resident did not have any wounds. She stated that resident was sent out to the hospital for altered mental status and shortness of breath and was readmitted back in the facility at the end of February. She stated that she was not aware of any skin issues after resident was readmitted to the facility on [DATE]. She stated that the resident's sacrum wound was unstageable, was covered with necrotic slough, could not tell how deep it was. The treatment was Medihoney to get rid of slough and as a microbial, encourage to reposition resident but resident constantly wants t[TRUNCATED]

Based on clinical record review, staff interviews, and facility documentation and policy review, the facility failed to ensure a baseline care plan was developed and implemented timely for two residents (#42 and #56). The deficient practice could lead to decreased communication and coordination between interdisciplinary team members, leading to a decreased quality of care for a resident. Findings include: -Resident #42 was admitted on [DATE] (with an original admitted [DATE]), with diagnoses that included major depressive disorder, anxiety disorder, end stage renal disease, essential primary hypertension, cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. A minimum data set (MDS) assessment for Resident #42 was completed March 03, 2025 with a brief interview for mental status (BIMS) score of 01 which indicated that the resident was severely cognitively intact. Resident #42 was dependent on staff with personal hygiene, however a review of the care plan for Resident #42 showed that there was no instruction regarding activities of daily living (ADL) due to a history of having a cerebral infarction affecting the right dominant side and positioning, mobility for Resident #42. -Resident #56 was admitted on [DATE], (with an original admitted [DATE]), and medical history of embolism and thrombosis of arteries of the lower extremities, alcohol abuse, essential primary hypertension, nicotine dependence, cigarettes, cannabis use, psychosis not due to substance or known physiological condition, dementia An MDS assessment for Resident #56 was completed on February 19, 2025 revealed a BIMS score of 06 which indicated that the resident was severely cognitively impaired. A review of the care plan for Resident #56 revealed that the focus for dementia care, and for the use of psychotropic medications was initiated until December 17, 2024 although the resident had an initial admission of September 28, 2022. An interview was conducted on March 14, 2025 at 08:51 a.m. with licensed practical nurse (LPN) Staff #11 who revealed that a registered nurse and the minimum data set (MDS) will initiate the development of the care plans. She was not sure about signing off on the care plans. An interview was conducted on March 14, 2025 at 08:55 a.m. with minimum data set coordinator (MDS) (Staff #22) who confirmed that she does most of the care plans. Staff #22 stated that the formulation starts on admission to the facility then the comprehensive is completed between days five to eleven. Staff #22 stated that the planned activities of daily living (ADL) would be done on admission because the certified nursing assistants (CNA) can see the toileting and ambulation on the Kardex. The care plans have been in transition from paper form to utilizing the online care plan. A review of the paper care plan binder was reviewed with Staff #22 and there were no paper care plans in the L section or the M section. The care plan was missing from the electronic medical records as well. An interview was conducted on March 14, 2025 at 09:05 a.m. with director of nursing (DON) Staff #13 who confirmed that the care plans are typically started by MDS coordinator. Staff #13 revealed that at times may initiate the 48-hour care plans, and the more comprehensive are started by MDS coordinator. Staff #13 stated that any of the nursing staff can revise a care plan; and that, care plans are reviewed with in the initial 48 hours in the morning meeting with the team. Staff #13 stated that care plans are also reviewed quarterly and after any change of condition. An interview was conducted on March 14, 2025 at 12:32 p.m. with certified nursing assistant (CNA) Staff #77 who revealed that ADL refusal would be documented in the care plan regarding nail care, especially if they refuse the care. A review of the facility policy for Care Plans - Baseline, revised March 2022, revealed that the facility will develop for each resident, a baseline plan of care to meet the resident's immediate and safety needs within forty-eight hours of admission.

Based on review of clinical record review, staff interviews, facility policy and procedures, the facility failed to ensure nail care was provided for one resident (#42). The deficient practice could result in resident grooming and hygiene needs not being met. Findings include: -Resident #42 was admitted on [DATE] (with an original admitted [DATE]), with diagnoses that included major depressive disorder, anxiety disorder, end stage renal disease, essential primary hypertension, cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. A minimum data set (MDS) assessment for Resident #42 was completed March 03, 2025 with a brief interview for mental status (BIMS) score of 01 which indicated that the resident was severely cognitively intact. Resident #42 was dependent on staff with personal hygiene, however a review of the care plan for Resident #42 showed that there was no instruction regarding activities of daily living (ADL) due to a history of having a cerebral infarction affecting the right dominant side and positioning, mobility for Resident #42. Resident #42 was observed on March 11, 2025 at 2:31 p.m. with long fingernails and brown debris underneath them. On March 12, 2025 at 3:34 p.m., a second observation was conducted with Resident #42 in his room. Resident #42 was observed with long fingernails with brown debris underneath. An interview was conducted on March 13, 2025 at 12:32 p.m. with Certified Nursing Assistant (CNA)/Staff #77 who stated that residents have showers twice a week and their whole body is washed including their hands. They can have their hands washed as often as they want. When asked if dirty fingernails are seen, what do they do. The staff will put gloves on and get a rag and do the best that they can. A CNA can not cut diabetic nails, the nurse has to cut the diabetic nails. The CNA has to inform the nurse to cut the diabetic resident nails. An interview was conducted on March 13, 2025 at 12:36 p.m. with Licensed Practical Nurse (LPN)/Staff #14 who revealed that residents receive showers twice a week including that the nail care is done on those days. Staff #14 stated that resident's hands are washed normally before breakfast, if they are soiled, some if able, after they go to the bathroom if continent. If dirty hands or nails are seen, the CNA will be asked to take care of them; and that, activities will have a manicure day and do nails. An interview was conducted on March13, 2025 at 12:47 with Director of Nursing (DON)/Staff #13 who revealed that residents have at least two showers a week. Their body and hair are washed. Hands are washed multiple times a day if they are visibly soiled and if they use the restroom. If dirty fingernails are seen, their hands would be washed including under their nails. If they refuse to have their nails cut, it would be documented and care planned. A third observation took place on March 13, 2025 at 1:56 p.m. in Resident #42's room. Resident had returned back from dialysis and was observed eating donuts. Fingernails were long and brown debris noted underneath the nails. Resident #42 was asked if he wanted his nails cut and Resident #42 nodded his head yes. On March 13, 2025 at 1:58 p.m., Staff #14 was notified that Resident #42 wanted his fingernails cut. An observation took place on March 14, 2025 at 8:53 a.m. with Resident #42 sitting at the tables in the area near his room. Resident #42's nails were clean and short. Review of the facilities policy titled, Activities of Daily Living (ADL), Supporting' revision date March 2018, revealed, residents will be provided with care treatment and services as appropriated to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

Based on observations and staff interviews, the facility failed to ensure that the nurse staff data was visibly posted daily. The deficient practice could result in the accurate daily staffing information not being available. Findings include: An observation was conducted on March 11, 2025 at 11:10 a.m. The daily staff posting was located on the wall above the facility copier in the business office hall. The staff posting was from the previous date March 10, 2025. On March 12, 2025, at 2:24 p.m., an observation in the main foyer was conducted, the daily staff posting was updated but was in the same place which was still unavailable for review and out of sight to residents and visitors. An observation was conducted on March 13, 2025 at 7:05 a.m. The daily staff posting had not been updated to the current day and was in the same location. An observation was conducted on March 13, 2025 at 10:01 a.m. The daily staff posting was updated to the current day, but still in a non-visible area. An interview was conducted on March 14, 2025 at 10:47 a.m., with the Director of Nursing (DON/staff #13) who stated that the daily staff postings were completed by the unit coordinator. The DON stated that she knows the daily staff posting forms are not the most detailed and should be accounting for actual staffing hours. The DON stated that the postings were located in the main foyer or entry way about a month or two ago, but were moved to the current location above the copier due to the preference of the administrator, and were not visible to visitors and residents. The DON stated that the expectation would be that the postings were in a visible location and accessible to the residents and visitors in addition to being accurately filled out. The DON further stated that the risks included residents and visitors would not know the actual staffing ratios and hours, and potential staffing concerns could fall through the cracks due to lack of staffing information. The facility policy received on March 14, 2025 and Revised August of 2022; stated that staff postings should be posted within two (2) hours of the beginning of each shift the number of licensed nurses (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs and NAs) directly responsible for resident care is posted in a prominent location (accessible to residents and visitors) and in a clear and readable format.

Based on an observation, staff interviews, and the facility policy and procedures, the facility failed to ensure one medication cart was secured when left unattended. The deficient practice could result in residents, visitors and/or staff members having unrestricted access to medications. Findings include: During an observation of the medication pass conducted on March 13, 2025 at 07:49 a.m. with registered nurse (RN) Staff #19, revealed that the medication cart was left unattended and unlocked outside of room [ROOM NUMBER]-A. The cart was against the wall and facing the hallway. The cart was not left in the doorway, facing the resident's room or near staff. An interview was conducted on March 13, 2025 at 07:51 with Staff #19 who confirmed that the cart was unlocked outside of room [ROOM NUMBER]-A. The RN Staff #19 stated that if the cart is left unlocked and unattended, people could steal medications. An interview was conducted on March 13, 09:00 a.m. with licensed practical nurse (LPN) Staff #17 who revealed that the carts should be kept locked including the cart for medications that are kept in the locked storage room. An interview was conducted on March 13, 2025 at 12:47 p.m. with director of nursing (DON) Staff #13 who stated that if a medication cart is left unlocked and unattended, someone could steal the medications and take them. The facility policy titled, Administering Medications, revealed that during the administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide.

Based on observations, staff interviews and policy review, the facility failed to ensure that food were distributed to residents at a safe and appetizing temperature. The deficient practice could result in the potential of bacterial growth in susceptible conditions. Findings include: -Resident #70 was admitted [DATE] with diagnoses that included encounter for other orthopedic aftercare and fracture of left femur. Review of the resident ' s admission minimum data set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) summary score of 15 indicating the resident was cognitively intact. Review of the resident ' s orders revealed the resident had an active order, as of February 20, 2025 at 19:52 p.m., for a regular diet, regular texture, regular/thin consistency. An interview was conducted with resident #70 on March 11, 2025 at 12:44 p.m., who stated that all the food is cold and that he would prefer if his food was hot when it is brought to him. 50595 -Resident #45 was admitted [DATE] with diagnoses that included encounter for other orthopedic aftercare and type two diabetes mellitus without complications. Review of the resident ' s admission minimum data set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) summary score of 15 indicating the resident was cognitively intact. Review of the resident ' s orders revealed that the resident had an active order, as of December 13, 2025 at 16:30p.m., for a NAS (No added salt) diet, regular texture, regular/thin consistency. An interview was conducted with Resident #45 on March 13, 2025 at 12:44 p.m., who stated that breakfast is the most important meal and her favorite meal of the day. Resident #45 stated that when the kitchen delivers her meal in her room in the morning, the food is already cold so she can't enjoy it. The resident added that she sometimes skips lunch, but not breakfast and dinner and the kitchen deliver the dinner sometimes cold. 51239 An observation was conducted on March 13, 2025 at 05:49 P.M. during tray line food preparation. A test tray for the food temperature was conducted with the Dietary Manager staff #68. Temperature of the test tray revealed the following temperature for hamburger patty 110 degrees Fahrenheit, Fries 103 degrees Fahrenheit, and banana pudding 57.3 degrees Fahrenheit. An interview was conducted on March 12, 2025 at 05:49 P.M. with the Dietary Manager (staff #68), who stated that pudding is warm, she would eat cold putting rather than hot pudding. She also stated that the hamburger patty should be hotter and the fries. She further stated that the temperatures do not meet her expectations. An interview was conducted on March 14, 2025 at 10:23 P.M. with the Administrator (staff #2), who stated that she expected the food tray temperatures for residents to be at regulation that is required. She stated that if the food not at the right temperature, the resident could have potential for food borne illness and or it won ' t appropriate to the resident liking. Review of the policy titled Food Preparation and Service revealed that Danger zone means temperatures above 41 degrees (F) and below 135 degrees F allow for the rapid growth of pathogenic microorganisms that can cause foodborne illness. Review of the policy titled Dietary Department revealed that meals should be attractive, palatable, served at appropriate temperatures and delivered to residents in a timely fashion.

Based on observation, staff interviews, and facility policy, the facility failed to ensure that refrigerated food was not expired. The deficient practice could result in potential foodborne illness to residents in the facility. Findings include: During the initial tour of the kitchen on [DATE] at 12:15 P.M., conducted with the Dietary Manager (staff #68), an observation of the refrigerator revealed one box of Tomato Juice which was labeled with a best by date of [DATE]. Further observation revealed that it was half full with tomato juice. The Dietary Manager immediately threw the Tomato Juice into a trash can. An interview was conducted on [DATE] at 12:17 P.M. with the Dietary Manager (Staff #68), who confirmed that the juice was expired. He stated that the facility process for expired food is to be thrown away. The dietary manager stated that the risk for serving expired tomato juice to residents could include the resident getting sick. An interview was conducted on [DATE] at 10:23 A.M. with the Administrator (Staff #2), who stated that the facility process regarding expired food is that they are to be disposed of. She also stated that if there is expired food she expects the dietary manager to notify her and then dispose of it. The administrator stated that if expired food were consumed by the residents they could be impaired and there would be a potential for harm. Review of the facility policy titled, Food Receiving and Storage, revealed that rRefrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen or discarded. Review of the facility policy titled, refrigerators and freezers, revealed that supervisors are responsible for ensuring food items in pantries, refrigerators, and freezers are not past use by or expiration dates. Requested expired food policy on [DATE] at 7:16AM, but the Director of Nursing did not have an expired policy.

Based on observations, record reviews, staff interviews, and review of facility policy and procedures, the facility failed to ensure that proper hand hygiene was conducted during pressure ulcer care for one resident #27. The deficient practice could result in contamination. Findings Include: Resident #27 was admitted on [DATE], with diagnoses that included a pressure ulcer of the sacral region, stage 3, ankylosing spondylitis, Crohn's disease, pressure ulcer of the left buttock, stage 2, and major depressive disorder. Review of the care plan-initiated December 12, 2024 revealed that resident #27 had stage 3 pressure coccygeal pressure ulcer, history of pressure ulcers and the potential for pressure ulcer development. The goal for resident #27 revealed that the pressure ulcer will show signs of healing and remain free from infection by/through review date. Further review of the care plan-initiated December 12, 2024, revealed that resident #27 refuses wound care.The noted goal revealed that resident #27 will allow nursing to administer treatments as ordered through the next review Date.The interventions included providing daily education on the daily on the importance of wound care and the risks of continued skin breakdown, encourage residents to participate in wound care, offer wound treatments daily, and that the resident will be able to demonstrate dressing changes once educated. A review of the annual Minimum Data Set assessment dated [DATE], revealed that resident #27 had BIMS Score of 15 indcating he is cognitively intact and had stage 2 and 3 pleasure ulcers. An observation was conducted on March 13, 2025 at 8:50 A.M. of wound care with resident #27 which revealed treatment nurse (staff #27) at bedside with all wounds open to air at the start of the observation. Wound 1 was cleaned and the nurse then changed her gloves and no cleansing of hands was observed prior to donning clean gloves. Wound 1 was treated and dressed. Wound 2 was cleansed and gloves were changed. No cleansing of hands was noted between glove change. Wound 2 was treated and dressed. Wound 3 was cleansed and gloves were changed. No cleansing of hands was noted between glove change. Wound 3 was treated and dressed. Wound 4 was cleansed and gloves were changed. No cleansing of hands was noted between glove change. Wound 4 was treated and dressed. An interview was conducted on March 13, 2025 at 09:40 A.M. with the Licensed Practical Nurse (LPN/Staff #27), who stated that the facility process for hand washing when it comes to pressure ulcers is to either wash or sanitize the hands before entering the room. She stated that she changes her gloves in between touching one wound to the next. The LPN stated that she does not use the same gloves on different wounds and sanitizes her hands in between wounds so she does not cross contaminate. She stated that if her hands are visibly soiled she will wash her hands. She stated the risk of improper hygiene during wound care would could cause infection in the resident. An interview was conducted on March 14, 2025 at 09:43 A.M. with the certified nursing assistant (CNA/Staff #39), who stated that her expectation regarding hand hygiene included washing hands in the bathroom and using hand sanitizer. The CNA stated that the facility process for hand hygiene, when providing care to residents, is to wear gloves when entering the room and when done take off gloves and use hand sanitizer. She also stated that if proper hand hygiene is not done there can be a risk of cross contamination. An interview was conducted on March 14, 2025 at 09:53 A.M. with the Registered Nurse (RN/Staff #17), who stated that her expectation for hand hygiene is that if there is any bodily fluid on the hands they must be washed because the gloves alone won ' t do the job. When exiting the room, the staff should hand sanitize after providing care. She also stated that staff members who provide wound care must wash their hands. RN stated the facility process is to use hand sanitizer before and after exiting the resident room and if they make contact with bodily fluids hand washing is required. The risk of not doing proper hand hygiene could cause infections. An interview was conducted on March 14, 2025 at 09:53 A.M. with the Director of Nursing (DON/staff #13), who stated that she expects that whenever a staff member is providing treatment for a wound, the staff should wash or sanitize hands, put on gloves, set up the treatment, switch out gloves in between treatments, the hands should always be gloved, if hands are soiled in between-then hands should be washed. Staff #13 stated if there are multiple wounds, staff should change gloves and wash hands each time, hand sanitize then put on gloves and work on other wounds. Staff #13 stated proper gloving and hand hygiene needs to transpire to avoid cross-contamination. Staff #13 stated upon completion of wound care, take off the gloves, wash and sanitize hands before leaving. She stated that if hand hygiene is not performed when providing pressure ulcer care there can be multiple risks. such as cross contamination, infection, illness, and staff illness Review of the policy titled Handwashing/Hand Hygiene, revealed that all personnel are trained and regularly in-service on the importance of hand hygiene in preventing the transmission of healthcare-associated infection. It has also revealed that all personal are expected to adhere to hand hygiene polices and practices to help prevent the spread of infection to other personnel, residents, and visitors.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that resident (#7) was not exposed to inappropriate sexual behaviors by resident (#10). The deficient practice could result in residents being sexually abused. Findings include: Resident #7 was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, dementia, and generalized muscle weakness. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 9 indicating the resident had a mild cognitive impairment. An incident note dated November 17, 2024 revealed that a certified nursing assistant (CNA) reported at 2:15 p.m. that resident #10 was in resident #7's room and exposed himself to resident #7. Review of a progress note dated November 17, 2024 revealed that the central nurse reported on November 17, 2024 at 2:15 p.m. that the nurse's aid observed resident #10 in resident #7's room displaying inappropriate behavior. Resident #10 redirected immediately to stay on the East Hall until further notice . The incident was reported to the Administrator. A social services progress note dated November 20, 2024 revealed that the facility made a police report. -Resident #10 was admitted to the facility on [DATE] with diagnoses that included type II diabetes, acute kidney failure, and alcohol abuse. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 14 indicating the resident was cognitively intact. A progress note dated November 19, 2024 revealed that resident #10 was discharged home with a family member. Review of the 5-day investigation dated November 20, 2024 revealed that on November 17, 2024, between 2:30 p.m. and 3:30 p.m. a licensed nursing aid (LNA/staff #12) informed the Director of Nursing (DON/staff #60) that resident #10 had exposed his private parts to resident #7 in the hallway. A licensed nurse practitioner (LPN/staff #8) stated that they didn't witness the incident and reiterated to with resident #10 that he was not permitted into the hallway. Staff #12 immediately redirected resident #10 back to his room and reported the incident to the Administrator (staff #1). On Monday, November 18, 2024, the Administrator (staff #1) initiated a formal investigation. The Administrator interviewed resident #7, who stated that she did not recall the incident. During the interview with resident #10, he denied intentionally exposing himself, but acknowledged scratching his genital area. On Tuesday, November 19, 2024 resident #10 was discharged from the facility. Given that resident #10 had a similar history of behavior in other facilities, he was discharged promptly. An interview was conducted with (LNA/staff #12) on November 20, 2024 at 12:22 p.m., who stated that she has received training on abuse, which includes sexual abuse and emotional abuse. She stated that resident #10 visits resident #7 in her room. Staff #12 stated that the door was open and resident #10 was in his wheelchair facing away from the door towards the resident, who was in bed, when she entered the room looking for wipes. She stated that resident #7 looked a little red as if she was blushing and the two residents were talking, but she couldn't hear what they were saying. Staff #12 glanced over and saw resident's #10's penis was out and in his hand. Staff #12 reached up on the dresser to get the wipes and when she turned around, resident #10 had put his penis back in his pants. Staff #12 told resident #10 to leave the room. She asked resident #7 if she knew what resident #10 was doing and the resident was babbling and then said, well, I told him to put it away. Staff #12 stated that she believes that (LPN/staff #8) told resident #10 not to leave his hallway, not to go past the nurse's station and imagined that he was in his room. She stated that resident #10 has visited another female resident (#4), but doesn't think that she would remember anything because she has severe dementia. An interview was conducted on November 20, 2024 at 2:37 p.m. with a registered nurse (RN/staff #2), who stated that (LPN/staff #8) told her that (LNA/staff #12) told her that resident #10 exposed himself and resident #7 told the CNA that she was uncomfortable with what had happened. An interview was conducted on November 20, 2024 at 2:57 p.m. with a licensed practical nurse (LPN/staff #8), who stated that (LNA/staff #12) told her that resident #7 stated that she was uncomfortable or didn't like it when resident #10 was in her room. Staff #8 stated that resident #10 visits resident #7's room frequently. She stated that (RN/staff #2) told resident #10 that he had to stay in his room and staff #2 said that he kind of looked guilty. She stated that she only had about an hour left on her shift and charting at the nurse's station when resident #10 tried to go down another hall and she told him no. An interview was conducted with resident #7 on November 22, 2024 at 11:05 a.m. She stated that resident #10 started by coming by her door and then made his way to her room. At first, she told resident #10 that he can't come into her room, but he kept coming by and smiling. She stated that she knew that he was doing something with his private parts and every time, he would have his pants undone and his hand was there. She stated that she is not stupid, she knew what resident #10 was doing and something was wrong. She stated that resident #10 asked her if it bothered her and she told him that it did and he would stop and say that he wouldn't do it again. She stated that when he came to her room, he would do it again. She stated that she couldn't see his penis, but she could see his hand/fingers moving over his crotch. She stated that resident #10's pants were often open and unzipped, but she couldn't see everything because her bed is higher than his wheelchair. An interview was conducted with the Director of Nursing (DON/staff #60) on November 21, 2024 at 11:52 a.m. She stated that she has received training on abuse and sexual abuse includes masturbating in front of another person and the other person doesn't want it. She stated that staff were told that resident #10 could not be in other residents' rooms, but could be in common areas with supervision. She stated that if staff were sitting at the nurse's station while supervising the resident, it would not be sufficient because staff cannot see down the East Hall where the resident room was located. She stated that there were three to four women in rooms on the East Hall at the time of the incident and if the hall wasn't watched, it is possible that resident #10 could have entered one of the females rooms on the East Hall. An interview was conducted on November 21, 2024 at 12:14 p.m. with the Administrator (staff #1). She stated that sexual abuse includes masturbation, someone touching themselves in front of someone else. She stated that the allegation was inconclusive because resident #10 stated that he was scratching himself. The facility policy, Abuse Prevention Program states that the facility will not tolerate verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, neglect, or misappropriation of resident property, by employees, family members, visitors, or other residents.

Based on documentation, staff interviews, and policy and procedures, the facility failed to report an allegation of sexual abuse to the state agency within the regulated timeframe. Findings include: Review of the online report to the state agency revealed that the facility reported an allegation of sexual abuse that occurred on November 17, 2024 at 3:10 p.m., on November 18, 2024. Review of the 5-day investigation dated November 20, 2024 revealed that on November 17, 2024, between 2:30 p.m. and 3:30 p.m. a licensed nursing aid (LNA/staff #12) informed the Director of Nursing (DON/staff #60) that resident #10 had exposed his private parts to resident #7 in the hallway. A licensed nurse practitioner (LPN/staff #8) stated that they didn't witness the incident and reiterated to with resident #10 that he was not permitted into the hallway. Staff #12 immediately redirected resident #10 back to his room and reported the incident to the Administrator (staff #1). On Monday, November 18, 2024, the Administrator (staff #1) initiated a formal investigation. An interview was conducted on November 21, 2024 at 11:52 a.m. with the Director of Nursing (DON/staff #60), who stated that an allegation for sexual abuse should be reported within two hours of the facility becoming aware of the allegation. An interview was conducted on November 21, 2024 at 12:14 p.m. with the Administrator (staff #1), who stated that sexual abuse included a person masturbating in front of another person and has to be reported to the state agency if it is confirmed as sexual abuse. She stated that she received a call from the facility on November 17, 2024 and reported to the state agency on November 18, 2024. The facility policy, Abuse Prevention Program states that If the events that cause the allegation involve abuse or result in serious bodily injury to a resident, a report must be made immediately and not later than 2 hours after receiving the allegation, If the events that cause the allegation do not involve abuse and do not result in serious bodily injury, the report must be made within 24 hours of receiving the allegation. The facility must report the allegation and not wait until confirmed with an investigative process.

Based on documentation, staff interviews, and policy and procedures, the facility failed to protect residents from further abuse by one resident (#10). The deficient practice could result in residents being abused. Findings include: Review of the 5-day investigation dated November 20, 2024 revealed that on November 17, 2024, between 2:30 p.m. and 3:30 p.m. a licensed nursing aid (LNA/staff #12) informed the Director of Nursing (DON/staff #60) that resident #10 had exposed his private parts to resident #7 in the hallway. A licensed nurse practitioner (LPN/staff #8) stated that they didn't witness the incident and reiterated to with resident #10 that he was not permitted into the hallway. Staff #12 immediately redirected resident #10 back to his room and reported the incident to the Administrator (staff #1). On Monday, November 18, 2024, the Administrator (staff #1) initiated a formal investigation. The Administrator interviewed resident #7, who stated that she did not recall the incident. During the interview with resident #10, he denied intentionally exposing himself, but acknowledged scratching his genital area. On Tuesday, November 19, 2024 resident #10 was discharged from the facility. Given that resident #10 had a similar history of behavior in other facilities, he was discharged promptly. Review of facility documention and the floor map, revealed that resident #10's room [ROOM NUMBER] was located on the East Hall along with three female residents (#37, #45, and #58) in rooms #28 and #30. The nurse's station was located in the middle of the building and the resident would need to cross by the nurse's station to access the Central Hall where resident's #7 and #4 reside. An observation conducted on November 22, 2024 at 10:58 a.m. revealed that the staff had a limited view of the East Hall from the nurse's station. It was observed that residents' #10, #37, #45, and #58 were not visible from the nurse's station. An interview was conducted with (LNA/staff #12) on November 20, 2024 at 12:22 p.m., who stated that she has received training on abuse, which includes sexual abuse and emotional abuse. She stated that resident #10 visits resident #7 in her room. Staff #12 stated that the door was open and resident #10 was in his wheelchair facing away from the door towards the resident, who was in bed, when she entered the room looking for wipes. She stated that resident #7 looked a little red as if she was blushing and the two residents were talking, but she couldn't hear what they were saying. Staff #12 glanced over and saw resident's #10's penis was out and in his hand. Staff #12 reached up on the dresser to get the wipes and when she turned around, resident #10 had put his penis back in his pants. Staff #12 told resident #10 to leave the room. She asked resident #7 if she knew what resident #10 was doing and the resident was babbling and then said, well, I told him to put it away. Staff #12 stated that she believes that (LPN/staff #8) told resident #10 not to leave his hallway, not to go past the nurse's station and imagined that he was in his room. She stated that resident #10 has visited another female resident (#4), but doesn't think that she would remember anything because she has severe dementia. She stated that resident #10 wanders up and down the East Hall to the Central Hall. An interview was conducted on November 20, 2024 at 2:37 p.m. with a registered nurse (RN/staff #2), who stated that (LPN/staff #8) told her that (CNA/staff #12) told her that resident #10 exposed himself. Staff #2 told resident #10 that he had to stay on the East Hall and was not to pass the nurse's station. Staff #2 stated that she informed resident #10 that there was an allegation about him and he didn't ask any questions and seemed nervous. She stated that there were three female residents on the East Hall at the time of the incident where resident #10's room was located. She stated that she has received training about abuse and the staff are supposed to keep the residents safe. The staff were told to keep an eye on resident #10, but no one sat at the nurse's station the entire time and it is possible that resident #10 went somewhere if staff were not present at all times. An interview was conducted on November 20, 2024 at 2:57 p.m. with a licensed practical nurse (LPN/staff #8), who stated that (LNA/staff #12) told her that resident #7 stated that she was uncomfortable or didn't like it when resident #10 was in her room. Staff #8 stated that resident #10 visits resident #7's room frequently. She stated that (RN/staff #2) told resident #10 that he had to stay in his room and staff #2 said that he kind of looked guilty. She stated that she only had about an hour left on her shift and charting at the nurse's station when resident #10 tried to go down another hall and she told him no. An interview was conducted with the Director of Nursing (DON/staff #60) on November 21, 2024 at 11:52 a.m. She stated that she has recieved training on abuse and sexual abuse includes masterbating in front of another person and the other person doesn't want it. She stated that staff were told that resident #10 could not be in other residents' rooms, but could be in common areas with supervision. She stated that if staff were sitting at the nurse's station while supervising the resident, it would not be sufficient because staff cannot see down the East Hall where the resident room was located. She stated that there were three to four women in rooms on the East Hall at the time of the incident and if the hall wasn't watched, it is possible that resident #10 could have entered one of the females rooms on the East Hall. An interview was conducted on November 21, 2024 at 12:14 p.m. with the Administrator (staff #1), who stated that sexual abuse included a person masterbating in front of another person. She stated that she strongly recommended that staff not allow resident #10 back into the hallway, he was to remain in his room. She wanted to protect resident #7 from resident #10 and stated that when the allegation was reported to her, she didn't know about protecting the female residents on the East Hall. She also stated that if the staff were monitoring resident #10 from the nurse's station, staff would not have been able to see down the East Hall. The facility policy, Abuse Prevention Program states that the facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress.

Based on documentation, staff and resident interviews, the facility policy and procedures, the facility failed to report an allegation of sexual abuse for one resident (#15). The deficient practice could result in residents being abused. Findings include: Resident #15 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, hypertension, and anemia. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 13 indicating the resident was cognitively intact Review of the activity daily living (ADL) care plan dated September 1, 2023 revealed that the resident needs help with ADLs due to decreased ADL participation and is receiving therapy. Interventions included to assist with ADLs as needed and to reinforce therapy by following occupational and physical therapy instructions. Watch the resident for fatigue. The order summary included an order dated September 1, 2023 for excoriation to the buttocks, cleanse, with normal saline (NS). Apply Calazinc twice daily until resolved for skin integrity. Review of the facility work schedules revealed that Certified Nursing Assistant (CNA/staff #22) and (CNA/staff #10) worked on February 12, 2024. An interview was conducted on February 21, 2024 at 2:36 PM with a (CNA/staff #22), who stated that he provided continence care with (CNA/staff #10) for resident #15, the day before the resident was discharged , and the resident was discharged on [DATE]. He stated that the resident had a rash and he applied ointment, while staff #10 helped stabilize the resident on his side. He stated that during this time, the resident said, I don't do that. You put your finger in my butt hole. Staff #22 said that he immediately apologized for whatever the resident thought had happened. An interview was conducted on February 21, 2023 at 3:00 PM with (CNA/staff #56), who stated that she has received abuse training. She stated that if a resident reports that staff has done anything to him/her, she is to report it within 2 hours to the supervisor. An interview was conducted on February 21, 2024 at 3:14 PM with (CNA/staff #10), who stated that she has received abuse training and has 2 hours to report it to the supervisor. She stated that she and staff #22 were providing continence care. Staff #22 was applying cream and the resident said, Ow and tugged away and staff #22 explained what he was doing. She stated that the resident said, That's my butt hole. She stated that the nurse was also in the room assisting the roommate on the other side of the curtain and the resident seemed to calm down. An interview was conducted on February 21, 2024 at 3:31 PM with a Licensed Practical Nurse (LPN/staff #38), who stated that she went into the room when CNA/staff #22) and (CNA/staff #10) were providing continence care for resident #15 because she needed to hang an IV for the roommate. She stated that she didn't hear the resident make any statements that would indicate that something was wrong, but she left the room while the two CNAs were still providing continence care. She stated that she has received abuse training and if the resident stated, That's my butt hole, I don't do that, the CNAs should have reported it to her. She stated that she would have removed the staff and interviewed the resident to understand his perception of what happened. An interview was conducted on February 22, 2024 at 9:50 AM with the Administrator, who stated that she was going to provide staff with additional training on abuse. The facility policy, Abuse Prevention Program revised September 2021 states that any person(s) observing, or having reason to suspect, resident abuse, neglect, mistreatment or misappropriation of resident property, is to report the findings either their supervisor or the charge nurse. If the events that cause the allegation involve abuse result in serious bodily injury to a resident, a report must be made immediately and no later than 2 hours after receiving the allegation.

Based on closed clinical record review, staff interviews, and facility policy review, the facility failed to ensure medications were administered as ordered by the physician for two residents (#20 and #51). The deficient practice could result in adverse effects to the residents. Findings include: Resident #20 was admitted on [DATE] with a diagnosis of COPD (Chronic Obstructive Pulmonary Disease), dementia, essential hypertension and status post fall with left hip fracture. A review of the current active physician orders revealed the following orders for: -4-ounce health shake with all meals (order date of July 19, 2023); and, -Colace (laxative) 100 milligrams -daily (order date of September 29, 2022). These orders were transcribed onto the MAR (Medication Administration Record) and the TAR (Treatment Administration Record) for August 2023. Review of the MAR and TAR for August 2023 revealed that Colace and the health shake was not documented as administered from August 16 through 20, 2023. There was no documentation found in the clinical record that the resident refused these medications on dates marked as not administered in the MAR and TAR. Further review of the clinical record revealed no documentation of reason why these medications were not administered as ordered; and that, the physician was notified. An interview with the assistant director of nursing (ADON/staff #72) was conducted on August 30, 2023 at 2:22 p.m. The ADON stated that when an order for medication/treatment is written by the provider, the nurse who received the order will administer the medication as ordered. The ADON stated that at the time of the survey, the facility was utilizing a paper MAR; and that, the expectation was that the nurse will transcribe the order onto the paper MAR/TAR as necessary. The ADON stated that orders for supplements should be followed as ordered for the resident; and that, a negative outcome of not following orders could depend on the medication. The ADON said that not administering Colace as ordered could lead to constipation of the resident. 40581 -Resident #51 was admitted on [DATE] with diagnoses of anemia, diabetes, atrial fibrillation, and depression. The standard care plan dated June 2, 2023 included the resident had a potential for skin breakdown related to incontinence and/or immobility. Interventions included treatment per protocol and physician order and to chart effectiveness. The minimum data set (MDS) assessment dated [DATE] included a brief interview for mental status (BIMS) score of 15 indicating the resident was cognitively intact. A dermatology visit note dated August 16, 2023 included that an impression of allergic contact dermatitis with unknown/unspecified cause. Per the documentation, the resident had blisters located on the trunk; and the status was documented as inadequately controlled. Plan included a prescription for triamcinolone acetonide (topical steroid) 0.1% topical cream twice daily for 4 weeks. Regarding prednisone: A physician order dated August 15, 2023 included for prednisone (steroid) 10 milligrams (mg) tablet give one tablet by mouth daily for seven days. The order for prednisone was transcribed onto the medication administration record (MAR) for August 2023; and, it had a stop date of August 22, 2023. However, review of the MAR for August 2023 revealed that prednisone was not marked as administered from August 16 through 20, 2023. Regarding triamcinolone: A physician order dated August 18, 2023 included for triamcinolone cream 0.1%, apply topically to affected area twice daily for 4 weeks for skin integrity. The orders for triamcinolone was transcribed onto the medication administration record (MAR) for August 2023 and had a stop date of September 15, 2023. However, review of the MAR for August 2023 revealed that triamcinolone was not marked administered until August 21, 2023 (approximately 3 days after it was ordered). The order for triamcinolone continued to be transcribed onto the MAR for September 2023. It included for triamcinolone acetonide 0.1% apply topically to affected area twice daily for 4 weeks. However, continued review of the MAR revealed that this medication was not marked as administered from September 1 through 7, 2023 Further review of the clinical record revealed no documentation why prednisone and triamcinolone were not administered as ordered; and that, the physician was notified. An interview and a review of the clinical record was conducted with a licensed practical nurse (LPN/staff #53) on September 7, 2023 at 8:53 a.m. The LPN said that MAR for August 2023 revealed no evidence that prednisone was administered to the resident's rash was given as prescribed. The LPN also stated that the MAR for September 2023 also showed no documentation that triamcinolone was administered to the resident as ordered. Further, the LPN said that if there was no documentation that it was given, then technically it was not done. An interview with the Director of Nursing (DON/staff #32) was conducted on September 7, 2023 at 9:54 a.m. During the interview a review of the clinical record was conducted with the DON who stated that the MAR for August 2023 and September 2023 revealed that prednisone and triamcinolone were not administered to the resident as ordered. She stated that there was a risk of the condition worsening when the medications and treatments were not administered. A review of the facilities Medication Administration policy, revised April 2019 revealed that the facility did not follow the policy to ensure medications are administered in accordance with prescriber orders, including any required time frame and that if a drug is withheld, refused or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug or dose.

Based on clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure care and services was to promote healing of pressure ulcers was provided for one resident (#22). The deficient practice could result in the development and worsening of pressure ulcers. Findings include: Resident #22 was admitted on [DATE] with diagnoses of pyonephrosis, sepsis, protein calorie malnutrition, and lack of coordination. Review of a care plan dated March 21, 2022 included the resident had the potential for skin breakdown. The weekly skin assessments dated June 5 and 20, 2022 included the resident had a pressure ulcer. The coccyx area was circled in the body image of the note. The wound assessment report dated June 22, 2023 included stage 2 pressure ulcer to the sacrum that measured 1.8 cm (centimeters) x 1.3 cm x 0.2 cm, with 100% granulation tissue, well-defined border and normal surrounding skin. Treatment included to cleanse with normal saline, apply alginate over wound bed, cover with 4x4 and change dressing every day until resolved. The physician order dated June 22, 2023 included to cleanse coccyx wound with normal saline, apply alginate over wound bed, cover with 4x4 and change dressing every day until resolved. This order was transcribed onto the Treatment Administration Record (TAR) for June 2023. Review of the TAR for June 2023 included that alginate was not marked as administered as ordered on June 25 and 27, 2023. The care plan dated July 7, 2023 included that a skin breakdown was present. The wound assessment report dated July 13, 2023 included stage 2 pressure ulcer to the sacrum that measured 2.3 cm x 1.5 cm x 0.2 cm, with 90% granulation tissue, 10% slough, well-defined border, slight edema and pink surrounding skin. Treatment included to cleanse with normal saline, place promagram prisma to wound bed, cover with foam dressing and change dressing every day until resolved. The quarterly Minimum Data Set assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. The assessment also revealed the presence of one stage 2 pressure ulcer. Review of physician's orders revealed an order dated July 25, 2023 for coccyx wound, cleanse with normal saline, Prisma to wound bed, foam dressing, change every other day until resolved. The wound assessment report dated July 27, 2023 included stage 2 pressure ulcer to the sacrum that measured 1.6 cm x 1 cm x 0.1 cm, with 100% granulation tissue, well-defined border and normal surrounding skin. Treatment included to cleanse with normal saline, place promagram prisma to wound bed, cover with foam dressing and change dressing every other day until resolved. The order for daily promagram prisma and foam dressing was transcribed onto the TAR for July 2023. However, the TAR revealed that this treatment was not documented as administered on July 18 and 19. The wound assessment report dated August 10, 2023 included stage 2 pressure ulcer to the sacrum that measured 1.6 cm x 1 cm x 0.1 cm, with 100% granulation tissue, well-defined border and normal surrounding skin. Treatment included to cleanse with normal saline, place promagram prisma to wound bed, cover with foam dressing and change dressing every other day until resolved. The order for every other day promagram prisma and foam dressing continued to be transcribed onto the TAR for August 2023. However, review of the TAR revealed that the treatment was not marked as administered on August 21, 23, 25, 27 and 29. Review of the clinical record revealed no evidence that resident refused these treatments on dates not marked as administered in the TAR for June, July and August 2023. Further review of the clinical record revealed no documentation why the treatment was not administered as ordered; and that, the physician was notified. An interview and a review of the clinical record was conducted on August 30, 2023 at 12:23p.m. with a Licensed Practical Nurse (LPN/staff #53) who stated that there was no evidence found that the wound treatment to the coccyx was provided as ordered in dates not marked in the TAR for June, July and August 2023. The LPN also stated that there was also no evidence that the resident refused the treatment; and that, the provider was notified. Further, the LPN said that the facility policy was for staff to complete wound treatments as ordered; and that, if the treatment was not completed as ordered or the resident refused, the provider should be notified and there should be documentation in the progress note. The LPN also stated that the risk of not completing wound treatments as ordered could result in infection or deterioration of the wound. In an interview with a Registered Nurse (RN/staff #72) conducted on August 30, 2023 at 12:53 p.m., the RN said that the clinical record did not have any evidence that the coccyx wound care treatment had been provided as ordered in multiple dates in June, July and August 2023. The RN said that there was no evidence the resident had refused the wound treatments; and that, the provider was notified that the treatments had not been provided as ordered. The RN said that her expectation was that wound treatments are completed as ordered; and, if not, the provider was notified and document in the progress note the reason. Further, the RN stated that the facility policy was to complete wound treatments as written; and, the risk of not completing the wound treatments as written could result in the wound no progressing or worsening. Review of the facility policy on Administering Topical Medications included to follow the medication administration guidelines in the policy entitled Administering Medications. Notify the supervisor if the resident refuses the procedure. The facility policy on Administering Medications revealed that medications are administered in accordance with prescriber orders, including required time frame. Topical medications used in treatments are recorded on the resident's treatment record (TAR). Review of the facility policy titled, Documentation of Medication Administration, revealed the facility shall maintain a medication administration record to document all medications administered. Administration of medication must be documented immediately after it is given. The facility policy on Protocols for At Risk Residents included to complete ongoing documentation by charge/treatment nurses in the medical record to describe the effectiveness of interventions and resident's response to therapy.

Based on clinical record review, staff interviews, and facility policy and procedures, the facility failed to ensure pain management was provided to two residents (#229 and #223). The deficient practice could result in pain not being addressed. Findings include: -Resident #229 was admitted on [DATE] with diagnoses the included encephalopathy, sepsis, and acute kidney injury. The minimum data set (MDS) assessment included a brief interview for mental status (BIMS) score of 15 indicating the resident was cognitively intact. Review of the pain care plan dated August 24, 2023 revealed the resident was able to verbalize pain. Interventions included pain medication as ordered, monitor/document medication effectiveness; medication side effect, notify the provider if medication is not effective, assess complaints of pain immediately and document pain level. A physician order dated August 25, 2023 included for oxycodone hydrochloride (narcotic analgesic) tab 5 mg (milligram) one tablet by mouth every 6 hours as needed for pain with a stop date of October 24, 2023. However, the order did not include pain parameter for the medication. The order for oxycodone and for pain level every shift was transcribed onto the medication administration record (MAR) for August 2023. Review of the MAR for August 2023 revealed that oxycodone was administered to the resident on August 29, 30 and 31 for pain level of 0. Continued review of the clinical record revealed no documentation that medication effectiveness and the side effects associated with the medication were monitored. -Resident #223 was admitted on [DATE] with diagnoses of obesity, sepsis, pneumonia, and tachycardia. The admission orders dated August 22, 2023 included for the following: -Tylenol (analgesic) 650 mg by mouth every 6 hours as needed for a pain scale of 1-3; and, -Oxycodone 10 mg by mouth every four hours as needed for a pain scale of 4-10. The consent for opioid therapy dated August 24, 2023 included the resident was prescribed with a narcotic analgesic, oxycodone 10 mg every 4 hours as needed. The 48-hour care plan dated August 24, 2023 included the resident had pain medication, oxycodone. The standard care plan dated August 25, 2023 revealed the resident was able to verbalize pain. Interventions included pain medication as ordered, monitor/document medication effectiveness; medication side effect, notify the provider if medication is not effective, assess complaints of pain immediately and document pain level. The order for oxycodone and Tylenol were transcribed onto the MAR for August 2023. Review of the August 2023 MAR revealed that oxycodone was administered without a documented pain scale on August 24, 25, 27, 28, and 30, 2023. It also revealed that Tylenol was administered without a documented pain scale on August 25, 2023. An interview was conducted on September 7, 2023 at 8:53 a.m. with a licensed practical nurse (LPN/staff #53) who stated that if she was administering a pain medication as needed, a pain scale was required. The LPN said that generally, Tylenol was for a lower pain level and oxycodone was for a higher pain level. She stated that the pain level should be assessed and documented in the MAR whether it is effective or ineffective. During the interview, a review of the clinical record for resident #223 and #229. The LPN stated that the order for oxycodone for resident #229 did not include a pain scale; and that, for both residents (#223 and #229), there was no documentation that pain level and the effectiveness of the medication were documented. The LPN also said that clinical records of resident #223 showed that the medications (oxycodone and Tylenol) were not administered as ordered. She stated that the monitoring for side effects associated with medications was documented in the MAR/TAR; and, if there was no documentation, then it was not monitored. During an interview with the Director of Nursing (DON/staff #32) conducted on September 7, 2023 at 9:54 a.m., the DON stated that pain level and the effectiveness of the pain medication should be documented in the MAR when a pain medication is administered as needed; and, the side effects of pain medications are also supposed to be monitored and documented. The facility policy, Administering Pain Medications, revised in October 2022 included that when opioids are used for pain management, the resident is monitored for medication effectiveness, adverse effect and potential overdose. Any resident who uses opioids for long-term management of chronic pain is at risk for opioid overdose. The policy also included to document the following in the resident's medical record: -Results of the pain assessment; -Medication; -Dose; -Route-of-administration; and, -Results of the medication (adverse or desired). The facility policy on Administering Medication included that medications are administered in a safe and timely manner, and as prescribed.

Based on observations, staff interviews, and facility policy review, the facility failed to ensure infection prevention and control standards were maintained during medication administration. The deficient practice could result in transmission of infection. Findings include: During medication administration observation with a Registered Nurse (RN/staff #8), conducted on August 31 2023 at 8:05 a.m., the RN dropped a medication on the floor. The RN picked up the medication from the floor and discarded the medication in the sharps' container. The RN then replaced the medication, placed it into the medication cup, then entered the resident's room to administer the prepared medications. The RN did sanitize her hands after removing the medication from the floor and prior to administration of the medications to the resident (#39). The RN entered the room of another resident (#26) with a wrist type blood pressure monitor, took the resident's blood pressure. She removed the blood pressure cuff from the resident's arm, administered the medication, exited the room and placed the cuff on top of the medication cart. However, the RN did not sanitize the wrist blood pressure cuff after using it and also did not sanitize her hands after exiting the resident's room. The RN then proceeded to preparing the medications for administration for another resident (#25). However, the RN did not sanitize her hands after exiting the previous room or prior to medication preparation for resident #25. She then entered room of the resident (#25) and administered the medications to the resident. The RN did not sanitize her hands prior to entering the resident's room, or after exiting the resident's room. Continued observation of medication administration with the RN revealed that the RN carried a medication bubble pack into a resident's (#23) room and laid it on the resident's bed. The RN proceeded to take the resident's pulse, removed the tablet from the bubble pack, placed the medication in the medication cup and administered the medication. She then carried the bubble pack back to the medication cart and placed the bubble pack into the medication cart drawer. The RN then removed an inhaler from the medication cart. For the duration of this observation, the RN did not sanitize her hands after taking the resident's pulse or upon exiting the resident's room or prior to removing the inhaler from the medication cart. An interview with the RN (staff #8) was conducted at 8:37 a.m. immediately following the observation. The RN stated that the facility policy was to sanitize her hands between each resident care/interaction; and that, the wrist blood pressure cuff should also be sanitize after each resident use. However, the RN stated that she did not have any sanitizing wipes on her cart, so she could not sanitize the blood pressure cuff after she used it with the resident. She further stated that she did not have any sanitizing wipes on her cart since January 2023, and did not sanitize the blood pressure cuff. She also stated that she did not ask anyone for more wipes, or tell anyone that she did not have any. The RN stated that the risk of not sanitizing her hands or the blood pressure cuff between residents could result in transmission of infection. An interview with a licensed practical nurse (LPN/staff #53) was conducted on August 31, 2023 at 8:38 a.m. The LPN stated that blood pressure cuffs were to be sanitized between each resident use. In an interview with a certified nursing assistant (CNA/staff #45) conducted on August 31, 2023 at 8:43 a.m., the CNA said the wrist blood pressure cuffs should be sanitized between each resident use with an alcohol wipe or sanitizer wipe. An interview was conducted on August 31, 2023 at 8:47 a.m. with a restorative nurse aide (RNA/staff #77) who stated that the wrist blood pressure cuffs should be sanitized between each resident use; and that, she uses a sanitizing wipe or hand gel and a paper towel. During an interview with the Director of Nursing (DON/staff #32) conducted on August 31, 2023 at 8:50 a.m., the DON stated that her expectation was for staff to sanitize their hands upon entering and exiting resident rooms; and that, wrist blood pressure cuffs to be sanitized after each resident use. She stated that a nurse carrying a medication card into a resident's room and placing it on the bed did not meet her expectation as the bed would be considered dirty. She further stated that the medication would then be dirty and all the medications/card would need to be discarded. The DON also stated that sanitizing wipes should be available on each medication cart. Further, the DON stated that the risk of not sanitizing hands upon entering/exiting rooms, sanitizing blood pressure cuff after each patient use, and taking medication cards into resident rooms could result in transmission of infection. Review of a facility policy on Cleaning and Disinfection of Resident-Care Items and Equipment, revealed that non-critical items, including blood pressure cuffs, should be sanitized with an EPA registered disinfectant. Reusable resident care equipment is cleaned and disinfected or sterilized between residents. The facility policy on Handwashing/Hand Hygiene, revealed that the facility considers hand hygiene the primary means to prevent the spread of infections. Use an alcohol-based hand rub before and after direct contact with residents, before preparing or handling medications, after contact with objects in the immediate vicinity of the resident. Review of the facility policy titled, Administering Medications, revealed that staff follows established facility infection control procedures (e.g. hand washing, antiseptic technique) for the administration of medications.

Based on observations, clinical record reviews, resident and staff interviews, facility documentation and policy and procedures, the facility failed to ensure showers were provided for two residents (#14 and #230). Findings include: -Regarding Resident #14 Resident was admitted on [DATE] with diagnoses of COPD (chronic obstructive pulmonary disease) and major depressive disorder. The standard care plan dated July 7, 2023 included the resident needed help with daily activities, required assistance with mobility and transfers and further decline was expected. Interventions included assistance with ADLs (activities of daily living) as needed and to monitor that all needs are being met in a timely manner. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 13 which indicated the resident had intact cognition. The assessment also included the resident required extensive assist with dressing and personal hygiene, and was dependent for showers. Review of the shower schedule for the unit where resident #14 reside revealed that resident #14 had scheduled showers on Tuesdays and Fridays. The ADL sheet for August 2023 revealed that resident was provided with showers on August 3, 4 and 14; and that, the resident refused showers on August 20 and 21, 2023 Further review of the ADL sheet revealed that showers/bathing were refused on the following dates: -Sunday, August 20, 2023 - Refused -Monday, August 21, 2023 - Refused The clinical record revealed no evidence that a shower/bath was provided/offered and/or the resident refused on the following scheduled showers on August 8, 11, 18, 25, and 29, 2023. The progress notes from July 7 through August 30, 2023, revealed no documentation that resident refused showers on scheduled dates that were not marked or documented as provided. An interview with resident #14 was conducted on August 28, 2023 at 1:57 p.m. Resident #14 had greasy hair and she stated that she had one shower in two weeks. In an interview with a certified nursing assistant (CNA/staff #13) conducted on August 31, 2023 at 10:08 a.m., the CNA stated that showers were documented in the Activity of Daily Living (ADL) notebook; and that, showers were to be provided twice a week. She further stated that if a resident refused, she would notify the nurse, ask the resident again, and the nurse would document the refusal. The CNA further stated that CNAs would also document the refusal in the ADL notebook. During an interview with the Director of Nursing (DON/staff #32) conducted on August 31, 2023 at 11:11 a.m., the DON stated that showers were documented in an ADL book that was developed so that staff did not overlook showers. She said that showers were offered a minimum of two showers a week and as requested; and that, when a resident refuses the nurse and the physician were notified. A review of the ADL shower sheet for resident #14 was conducted during the interview. The DON stated the records showed that resident #14 did not receive showers twice a week on multiple occasions in August 2023. The DON stated that the risk of a resident not receiving showers twice a week could result in skin breakdown, resident not feeling well, infection, and odor. 47910 -Resident #230 was admitted on [DATE] with diagnoses of generalized muscle weakness, unsteadiness on feet, major depressive disorder and severe protein-calorie malnutrition. The care plan dated August 1, 2023 revealed the resident needed help with daily living activities related to declining condition manifested by decreased ADL participation and receiving therapy. Interventions included to assist with ADLs (activities of daily living) as needed, reinforce therapy following instructions given by PT/OT (physical-watch for fatigue The annual MDS (minimum data set) assessment dated [DATE] included a BIMS (brief interview for mental status) score of 15 indicating the resident had intact cognition. The assessment included the resident had no behaviors exhibited and required extensive assistance with one-person assistance with transfer and required limited assistance with one-person physical assistance with personal hygiene. The assessment coded bathing as support provided, ADL activity itself did not occur or family and/or non-facility staff provided care 100% of the time for that activity over the entire 7-day period. The facility documentation of the shower schedule revealed that resident #230 had scheduled showers on Tuesdays and Fridays. However, the ADL assistance and support documentation for August 2023 revealed the resident was not provided with showers multiple times on scheduled days. Further review of the documentation revealed that the resident was provided with bathing twice and had refused showers three times. An interview was conducted on August 30, 2023 at 3:04 p.m. with a certified nursing assistant (CNA staff #47) who stated that bed bath or shower days are divided by A and B beds. She stated that A-beds receive their showers on Mondays and Thursdays; B-beds receive showers Tuesdays and Fridays; and, Wednesdays and Saturdays were make-up days for residents who refused on their scheduled shower day. She stated if a resident refuses a shower it is written in the shower book and it is confirmed by the charge nurse. The CNA said that staff were to make different attempts throughout the day or on the make-up days. Regarding documentation of showers provided, she stated that code 8 on the bath sheet indicated the activity or bath did not happen; and, the letter R indicated the resident refused. An interview was conducted with Director of Nursing (DON/staff #32) on August 31, 2023 at 11:28 a.m. The DON stated resident showers were documented in two different ADL shower log books for each unit. She stated that the expectation was that residents are offered their showers at minimum 2 days per week; and, if resident requested for an additional shower, then it should be provided by staff. The DON stated if the resident refuses care the CNA was to notify the nurse and the physician; and that, if refusing care including showers was a continuing issue, then it should be care planned. During the interview, a review of the ADL shower sheet documentation was conducted with the DON who stated that based on the shower sheet, resident #230 did not receive showers as scheduled. She stated the risks of not receiving baths or showers would include infection, skin break down, resident odor and not feeling humanized. The facility policy on Supporting Activities of Daily Living, revealed that residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming and oral care.

Based on clinical record review, resident and staff interviews and policy review, the facility failed to ensure a care plan was revised regarding refusals for turning/repositioning and air mattress for one resident (#22). The deficient practice could result in resident not receiving appropriate treatment to meet their needs. Findings include: Resident #22 was admitted on [DATE] with diagnoses of pyonephrosis, sepsis, protein calorie malnutrition, and lack of coordination. Review of a care plan dated March 21, 2022 included the resident had the potential for skin breakdown. The wound assessment reports dated June 22, 29, and July 6, 2023 revealed the resident continued to refuse repositioning and air mattress; and that, the resident remained non-compliant. The care plan dated July 7, 2023 included that a skin breakdown was present. The quarterly Minimum Data Set assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. The assessment also revealed the presence of one stage 2 pressure ulcer. Review of wound assessment reports dated July 13 and 20, 2023 included that the resident continued to refuse repositioning and air mattress. Continued review of the clinical record revealed documentation in multiple progress notes that the resident refused to be turned/repositioned, and refused to use an air mattress. Review of the care plan reviewed on July 19, 2023 included the resident had a potential for skin breakdown; and that, a skin breakdown was present. Interventions included pressure relieving mattress, frequent repositioning, develop/monitor turning scheduled. However, there was no evidence that the care plan had been revised/updated regarding the resident's refusal for use of pressure relieving mattress and turning/repositioning. An interview was conducted on August 30, 2023 at 11:06 a.m. with a certified nursing assistant (CNA/staff #87) who stated that the facility policy was to turn/reposition resident's with pressure ulcers every 2 hours and as needed. She further stated that CNAs do not document this in the clinical record, but that, they would tell the nurses that they completed the task. An interview with resident #22 was conducted on August 30, 2023 at 11:33 a.m. Resident #22 stated she refuses to be turned/repositioned and to have a low air loss mattress on her bed. In an interview with a licensed practical nurse (LPN/staff #53) conducted on August 30, 2023 at 12:23 p.m., the LPN stated that resident #22 has a pressure on the coccyx and refuses to be turned/repositioned and also refuses to use an air mattress. She stated that the resident's care plan should be updated with interventions if a resident refused to be turned/repositioned, and refuse to use the air mattress. The LPN said that the risk of not updating interventions on a care plan could result in staff not knowing how to take care of a resident. During an interview conducted with an Assistant Director of Nursing (ADON/staff #72) on August 30, 2023 at 12:53 p.m., the ADON stated that care plans should be updated every 3 months; and that, if interventions include turning/repositioning and use of an air mattress, the care plan should be updated if the resident refuses these interventions. A review of the resident's clinical record was conducted with the ADON who stated that the resident's care plan was last updated on July 19, 2023 to include interventions to turn/reposition and use an air mattress. However, the ADON stated that the care plan was not revised to include the resident's refusals of the care planned interventions. Review of the facility policy titled, Comprehensive Person-Centered Care Plans, revealed that the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on clinical record review, staff interviews, facility documentation, policy and procedures, the facility failed to ensure adequate supervision was provided to prevent one resident (#13) from elopement. The deficient practice could result in residents being injured and/or harmed by others. Findings include: Resident #13 was admitted on [DATE] with diagnoses of unspecified psychosis, anxiety disorder, and hypertension. The care plan dated December 22, 2022 revealed the resident was confused and unsure of his new home. The goal was that the resident would not have any episodes of elopement. Interventions included a WanderGuard. This care plan was reviewed and updated on March 25, 2023, to included that resident eloped from the facility and a one-to-one staffing ratio was implemented for 7 days. The 15-minute checks dated March 25, 2023 included the following information: -From 9:30 a.m. to 10:15 a.m., the resident was walking and not following instructions; -At 10:15 a.m., the resident was in his room; and, -At 10:30 a.m., the resident could not be located; and that, the window in the room had been removed. A progress note dated March 25, 2023 at 12:33 p.m. revealed that a restorative nursing assistant (RNA) saw the resident in the dining room opening a window and getting up on a table to get out of the window; and that, the resident was brought back inside the facility by staff without difficulty. Per the documentation, the resident thought that his mother was in the hospital, was going to die and was attempting to go and see her. It also included that staff attempted to give the resident coffee and a snack and attempted to contact his mother; however, the resident remained restless and angry. The documentation that the staff attempted to administer Ativan (antianxiety) but the resident refused. The resident was placed on 15-minute checks. Further, the documentation included that at 10:45 a.m., the window frame had been removed in the resident's room and staff could not locate the resident. At 11:00 a.m., 911 was called while staff continued to look for the resident. According to the documentation, a certified nursing assistant (CNA) found the resident who was then transported to the emergency room . A progress note dated March 25, 2023 at 6:00 p.m. included the resident returned from the hospital, was still agitated and had an abrasion on the right side of his face. The Minimum Data Set, dated dated dated [DATE] included a brief interview for mental status (BIMS) score of 5 indicating a severe cognitive impairment. It also included an active diagnosis for Non-Alzheimer's dementia. The facility report dated March 28, 2023 included that the resident was able to remove the 18-inch wide window insert and exit outside as a result the wanderguard system did not alarm and the resident exited the facility through his bedroom window. The report further revealed that the allegation was verified by evidence collected during their investigation. Review of a care conference meeting note dated March 30, 2023 revealed the resident was able to ambulate on his own and continued to require a WanderGuard due to exit seeking behaviors. An interview was conducted on April 11, 2023 at 12:09 p.m. with a complainant who stated that the licensed practical nurse (LPN/staff #1) reported checking on the resident and nothing appeared wrong. The complainant said that the LPN checked on the resident a couple of hours later and he was gone; and that, staff noticed the resident was missing at 10:45 a.m. Further, the complainant stated the emergency room contacted the facility at 12:15 p.m. and reported that the resident had wounds on his face. During an interview with the resident's family conducted on April 11, 2023 at 1:19 p.m., the family member stated the resident was placed at the facility because the resident was wandering and was always agitated. She stated the facility told her the resident went out the window and made it to the parking lot where he fell . On April 11, 2023 at 2:48 p.m. an interview was conducted with a certified nursing assistant (CNA/staff #80) who stated the restorative aide saw the resident going out the window in the dining room. Staff #80 stated she found the resident in the parking lot and talked him into coming back into the facility. She stated that the nurse instructed her and another CNA (staff #68) to check on the resident every 15 minutes; however, she was sent to another hall to help. Staff #80 said that when she realized that it was going to take her longer than 15 minutes, she went back to tell the nurse and the other CNA (staff #68) that she was going to be gone for more than 15 minutes. Staff #80 stated that during this time, she passed by the resident's room and saw him standing by his bed; and, when she passed by the resident's room again and noticed the resident's door was shut. She said she opened the door and saw that the window frame had been removed and the resident was gone. Staff #80 said she reported the resident missing and went in her car to look for the resident and found the resident 0.9 miles away by the golf course. Staff #80 said the resident had gravel stuck to his face and hands and it looked like a rash on his hands. Staff #80 called 911 and had the resident transported to the hospital. In an interview conducted with the LPN (staff #1) on April 11, 2023 at 3:48 p.m the LPN said that the restorative aide (staff #27) found the resident in the dining room by himself and had opened and climbed out of the window. Staff #1 stated the resident made it to the parking lot. Staff #1 stated that the resident remained loud and agitated and kept saying that he needed to go to the hospital because his mother was dying. The LPN said that staff gave the resident coffee and snacks and was placed on every 15-minute checks. She stated that she thought the resident had calmed down; but then the resident crawled out his bedroom window. She stated that the resident was found at approximately 12:10 p.m.; and that, the resident had fallen down. An interview was conducted on April12, 2023 at 8:00 a.m. with a restorative aide (staff #27) who stated she was bringing dirty dishes from the second dining room to the kitchen when she saw the resident by himself standing in the window. She stated she told the resident to get down but the resident jumped out the window and headed towards the front parking lot. Staff #27 stated she called for help and two CNAs (#80 and #68) went outside to get the resident who was not injured and was brought back in. She stated the resident was agitated because his mother had been in the hospital and he wanted to go and see her. Staff #27 stated that later that morning, the resident crawled out of his bedroom window. During an interview with the acting Director of Nursing (staff #7) conducted on April 12, 2023 at 10:05 a.m., the DON stated the resident had behaviors that included exit seeking. She stated that the resident refused his antianxiety medications prior to his eloping the facility; and that, there was no documentation in the clinical record that the physician was notified. She stated tha resident jumped out of the dining room window and was placed on every 15-minute checks after he jumped out of the dining room window. However the acting DON said that the resident eloped the second time and was found approximately 0.5 miles away from the facility near a golf course on the ground with scrape to his face. Further, the acting DON stated that the 15-minute checks were not sufficient because the resident did get out. The facility policy on Elopement Precautions/Missing Resident included an objective of preventions of residents leaving facility without supervision when assessed to be an elopement risk and measures to take when a resident is found missing. The policy included that any resident that demonstrates or verbalizes elopement will immediately considered an elopement risk and immediate care interventions will be adopted to prevent unplanned elopement. Residents who are considered an elopement risk are to have their whereabouts confirmed at least every 30 minutes. Resident who are demonstrating agitation and elopement attempts are to are to remain under constant surveillance until the period of agitation resolves. Increased where about checks shall be maintained until staff is assured the resident is thoroughly redirected and it is safet to return to 30 minutes checks.

Based on clinical record reviews, resident and staff interviews, facility documentation and policy review, the facility failed to ensure one resident (#16) was free from neglect and failed to ensure that one resident (#41) was free from verbal abuse by a staff member. Findings include: -Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physician History and Physical dated 06/09/18, revealed the resident was admitted to the facility following hospitalization for a right distal femur fracture, multiple falls, a right ankle fracture and head contusion. The resident was complaining that his hands don't work and had upper extremity weakness. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Basic Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS also included the resident required total dependence with bed mobility, transfers, eating and toileting. Review of the care plan dated 6/13/18 revealed the resident had self-care deficit. Approaches included the resident is non ambulatory and requires extensive assistance of two staff for bed mobility and transfers. A physician note from the orthopedic physician office visit on 06/20/18 indicated the resident was being evaluated for a right distal fibula fracture that occurred from a fall. A CNA (Certified Nursing Assistant) accompanied the resident to the appointment from the facility. The resident was wearing a Controlled Ankle Movement (CAM) boot. The resident is to have repeat x-rays of the fracture around 7/11/18. The resident is to remain in the boot for another three weeks and follow-up again after the x-rays are completed in three weeks. A nurse's progress noted dated 7/16/18 at 8:40 a.m. documented the resident left the facility for an orthopedic physician appointment and was transported by a contracted transport company. Another nurse's progress note dated 7/16/18 revealed the nurse received a call from the driver of the transport company at 9:10 a.m. The nurse was advised by the driver that he had unhooked the front straps of the wheelchair and left to open up the ramp, then bent down to unhook the wheelchair straps from the rear and the wheelchair tipped backwards over on the driver. The note included that the resident slid out of the wheelchair onto the driver and he hit his head slightly on the side rail on the wheelchair ramp. The orthopedic office Nurse Practitioner requested emergency transport to take the resident to the hospital for x-rays. The incident occurred prior to the appointment, while attempting to get the resident out of the van. Review of the hospital emergency department records for resident #16 dated 7/16/18 revealed the resident reported that he was being pushed out of the van for an appointment when the wheelchair tipped backwards and he fell back and struck his head, but did not loose consciousness. The Computerized [NAME]ography (CT) results revealed the resident had a small acute subdural hematoma. The resident was transported to another hospital in a near by state for a neurosurgery specialty, which was not available at this hospital. Review of the facility's investigative report dated 7/21/18 revealed that on the morning of 7/16/18, resident #16 was transported to a local physician's office for an appointment by a transport company. A CNA (staff #64) from the facility accompanied the resident for assistance with Activities of Daily Living (ADL) as needed. Per the report, the transport driver parked the van facing the doctor's building, then released the front safety belt to the resident's wheelchair, proceeded to the back of the van to lower the ramp, and then released the back lower buckles to the wheelchair. When the driver released the lower safety belt, the resident began to go backward over the wheelchair. The transport driver and the CNA tried to grab the back of the chair, but the resident continued to fall over and hit the ramp. Paramedics arrived and transported resident #16 to the hospital. The resident sustained [REDACTED]. gate, and the weight of the resident caused an imbalance and the resident fell out of the wheelchair. Per the report, the CNA noted that the resident's legs were extended for comfort due to the fractured ankle. The report included that it was the responsibility of the transport driver to ensure the safety of patients when loading and unloading, and to ensure a safe entry to any building or facility. The report also included that the Maintenance Director of the facility visited the parking lot where the event occurred and noted that there was a slight incline in the front of the building where the van had parked, which could have contributed to the problem. An interview was conducted on 10/02/18 at 1:50 p.m. with the CNA (staff #64), who accompanied the resident to the doctor appointment. Staff #64 stated that on 7/16/18 she went on the transport because the resident couldn't push himself in the wheelchair. She said the transport driver placed the resident in the van, locked the chair and secured the straps, then put up the ramp and told the resident it might be a little uncomfortable, because the ramp was so close to the back of the resident's head. Staff #64 stated that usually residents are more forward in the van, but the resident had his leg extended. She stated the ride to the doctor's office was about 10-15 minutes and the wheelchair did not move during transport. Staff #64 stated when they arrived at the doctor's office, the driver parked on a slight incline with the back of the van lower than the front. Staff #64 stated she got out of the front passenger seat and the transport driver opened the driver's side sliding door and removed the front straps which were holding the front wheelchair wheels. She said the driver then went to the passenger side of the van, opened the sliding door, removed the straps from the right front wheelchair wheels, then went to the back of the van and lowered the ramp. She said when the driver removed the first strap, the wheelchair started to tip backwards. Staff #64 stated she tried to grab the chair, but it tipped and resident #16 slid out of the chair. She stated that the resident had a Hoyer lift sling under him and he slid out of the chair on the sling. She said that the wheelchair brakes were still locked and one of the straps was still in place leaving the resident's foot with the CAM boot stuck in the strap. She said the resident's head and body ended up on the ramp and his wheelchair was still partially in the van and was stuck. Staff #64 stated the transport driver was partially under the resident. Staff #64 further stated that if the resident's feet had been lowered, the resident could have been placed further inside the van. Staff #64 stated she has seen the transport drivers lower resident's legs in the past. Staff #64 stated the van was parked at an incline which caused the ramp to be at an incline. She said if the van would have been parked differently and the resident was further to the front he may not have tipped. An interview was conducted on 10/03/18 at 9:26 a.m. with the Licensed Nursing Assistant/Unit Coordinator (LNA/staff #24), who stated that some insurance companies contract with their own transport companies and some transports are done through the facility or through companies that they contract with. Staff #24 stated the facility used a transport company that the facility contracted with and paid for the transportation. Staff #24 stated if a resident needs assistance during the transport or during an appointment, a LNA or a CNA from the facility is designated to accompany the resident to the appointment. In an interview conducted on 10/03/18 at 10:08 a.m. with a CNA (staff #48), who stated that the driver of the transport van is responsible for getting the resident into and out of the van and securing the wheelchair. Staff #48 stated the company that transported resident #16 uses a mini van, and the vans have straps that are put on all 4 wheels. Staff #48 stated when he transported with resident #16 in the past, his leg was put down in the van. Staff #48 stated the vehicle is small and if the resident's leg was not lowered, he wouldn't fit up into the van correctly. An interview was conducted on 10/03/18 at 10:29 a.m., with the Director of Nursing (DON/staff #118). The DON stated the decision to accompany a resident to an appointment depends on the resident's condition, such as orientation, ability to communicate or to provide assistance during the appointment time. The DON stated the CNA's are never responsible for getting the resident into and out of the transport van, or securing or unsecuring residents, as the van driver is responsible for that. The DON stated that generally when a resident has a CAM boot on, the leg is elevated. In a telephone interview with the transport driver conducted on 11/03/18 at 11:50 a.m., the driver stated that when he transports a resident in a wheelchair, he gets the resident in and out of the van and secures them in the van. He stated the wheelchair is placed as far forward as possible, but the van has a second row of seats behind the driver's seat. The transport driver stated the resident's legs were not extended and he always warns them that the ramp is close to their head. The transport driver stated that he pulled in front of the doctors office facing the building. He stated there is an incline inside the van and the resident's wheelchair wheels were partially on the ramp. The transport driver stated he got out and opened up the side door and unclipped the front restraint on that side, then did the same on the other side. He stated then he went to the back and lowered the ramp and released the straps. He stated the wheelchair wheels were still locked, but the wheelchair tipped back and the resident came out on top of him, but he stopped the resident from falling to the ground. He stated the resident may have hit his head on the rail on the ramp. On 10/03/18 at 12:40 p.m., the transport company brought the same van (#285) that had transported resident to the facility. They demonstrated how a van is loaded and secured, including using the new blocking bar to prevent a wheelchair from rolling out. The floor of the van was more than 1/2 on an incline with the top being toward the front of the van and the lower part being toward the rear of the van. The transporter demonstrated the process to place a resident in a wheelchair in the van, which included to place the wheelchair up as far as possible to the flat area on the floor of the van, lock the wheelchair wheels, add the block bar (new step since the event), apply the front wheel straps x 2, apply the rear straps x 2, raise the ramp, then close the doors. The transporter stated to remove a resident the process is to release the strap from the front drivers side, open the ramp and release the straps from rear wheels, open the side and release the strap from the front passenger side, then remove the block bar, and unlock the wheelchair and wheel backwards down the ramp. An interview was conducted on 10/04/18 at 8:14 a.m. with the Administrator (staff #119). Staff #119 stated that they expect the transport should be safe and provide a safe vehicle. Staff #119 said that he felt that the transport company had been negligent in how they handled the van and where they parked. He stated that he drove over to the place and there was a definite incline in the parking lot facing the office. Review of the Independent Services Agreement between the facility and the transport agency dated 12/19/17 revealed Service Provider staff shall be trained to meet and exceed the reasonable requirements of routine transportation services in accordance with Arizona state laws. -Resident #41 was readmitted to the facility on (MONTH) 7, (YEAR), with [DIAGNOSES REDACTED]. Review of a quarterly MDS assessment dated (MONTH) 6, (YEAR), revealed the resident had short term memory problems and required extensive assistance with bed mobility, transfers and dressing. Review of the facility's investigative report revealed that on (MONTH) 24, (YEAR) at 1:35 a.m., the resident reported to a certified nursing assistant (CNA/staff #116) that a CNA (staff #114) had been verbally abusive to her yesterday. Per the report, the resident stated that staff #114 mocks her when she complains of pain, and is quick tempered and throws things around her room sometimes. The resident reported that on the evening shift on (MONTH) 23, (YEAR), she put on her call light as she needed a pain pill and staff #114 answered it. The resident said that staff #114 started yelling at her in her face, so she told him to shut up and get out of her face or she would hit him. She reported that staff #114 said go ahead and hit me and you will get kicked out of here. The facility's report further included that staff #114 was suspended pending the investigation. Per the report, the allegation was substantiated and staff #114 was terminated on (MONTH) 27, (YEAR). An interview with former staff #114 was conducted on (MONTH) 3, (YEAR) at 9:46 a.m. He stated that he was on shift on (MONTH) 23, (YEAR) and was assigned to the resident. He stated that the resident was a little upset with him that day, but he did not understand why. Staff #114 denied yelling at the resident, or getting close to the resident's face and telling her to hit him, so he can get her kicked out of the facility. An interview was conducted on (MONTH) 3, (YEAR) at 12:34 p.m. with the licensed practical nurse (LPN/staff #117), who received the allegation of abuse from staff #116. Staff #117 stated the resident told her that staff #114 got too close to her face and yelled at her. She stated that by the time this was reported to her, staff #114 was already done for his shift. Staff #117 stated that this was abuse, so she reported this incident to her supervisor. An interview with resident #41 was conducted on (MONTH) 10, (YEAR) at 11:45 a.m. She stated that staff #114 was taking care of her that day and staff #114 was upset and yelled at her, because she was yelling at him, as she was in pain. She stated that staff #114 got close to her face. The resident placed her right hand about an inch from her face to demonstrate how close staff #114 had gotten. Resident #41 said she told staff #114 that if he gets close to her again, she will hit him. She said that staff #114 then told her to go ahead, so he can get her kicked out of the facility. Resident #41 further stated that staff #114 was always upset with her and called her selfish for asking for help. Review of the policy titled, Abuse Prevention Program revealed the resident has the right to be free from abuse and neglect. The policy included that the facility will protect our residents from abuse and neglect by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual.

Based on closed clinical record review, facility documentation, staff interviews and policy review, the facility failed to ensure the necessary care and services were provided, by failing to ensure a blister to one resident's (#176) left heel was thoroughly assessed and consistently monitored and by failing to ensure that preventative measures were in place to prevent further breakdown. Findings include: Resident #176 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Admission Nursing Evaluation dated October 25, 2016 included the resident had a large blister to posterior foot heel. No measurements or a description of the area was included. A nursing note dated October 25, 2016 documented the resident had a large blister to the left heel. No measurements or a description of the area was included. Review of a comprehensive care plan revealed the resident was at risk for pressure ulcers. A goal was that the resident would be free of pressure ulcers. Interventions included for weekly full body assessments and treatments as ordered. The care plan did not include any specific interventions for the heels, such as floating the heels when in bed. Review of the admission physician orders [REDACTED]. Despite documentation that the resident had a large blister to the left heel, there was no documentation that the left heel had been thoroughly assessed from admission through November 6, 2016. In addition, there was no documentation of any preventative measures that were implemented to prevent further breakdown to the left heel. Review of the admission MDS (Minimum Data Set) assessment dated [DATE], revealed the resident had a BIMS (brief interview for mental status) score of 14, which indicated intact cognition. The MDS also assessed the resident to require limited to extensive assistance with activities of daily living. Under the skin section of the MDS, the documentation included the resident was at risk for developing pressure ulcers, however, did not have any. A podiatry consultation note dated November 7, 2016 included full thickness desquamation to the posterior aspect of the left heel, which measured 4.0 cm (centimeters) x 3.5 cm x 0.2 cm with slough, necrotic tissue, and pink granular wound bed present, with malodor, [DIAGNOSES REDACTED] and moderate serosanguinous drainage. The documentation included a Stage III pressure ulcer to the left heel with [MEDICAL CONDITION]. The documentation also included that debridement was done and the left heel is in bad shape and a referral to the wound center should be considered. The treatment included daily wound care and to continue to use foam heel pads and change every 1-2 days, due to the level of drainage present in the wound. The recommendation included [MEDICATION NAME](antibiotic) 500 mg twice daily for 14 days. A physician's orders [REDACTED]. However, there were no orders for the use of the foam heel pads. A daily skilled nursing note dated November 8, 2016 included the resident had a large blister on the left posterior heel of the foot that had popped open and measured 4.0 cm x 4.0 cm x 0.1 cm. A review of the Weekly Non-Pressure Ulcer Healing assessment dated [DATE] revealed a popped blister Stage II (instead of a Stage III per the podiatry consultant) to the left heel, which measured 4.0 cm x 4.0 cm x 0.1 cm, with intact wound edges and surrounding skin, and with no drainage or undermining/tunneling present. The assessment did not include a description of the wound bed. A physician's orders [REDACTED]. Per the treatment administration record (TAR) for November 2016, the treatments were provided as ordered. Despite ongoing documentation of treatments being provided to the resident's pressure ulcer to the left heel, there was no evidence that the left heel wound had been thoroughly assessed after November 8. There was no documentation whether the pressure ulcer had improved or declined. In addition, there was no evidence that the referral to the wound center was followed up on. Per the clinical record, the resident was discharged on [DATE]. Review of the discharge instructions dated November 19, 2016 revealed a treatment order for the left heel. The documentation also included underlined instructions to follow up with wound care ASAP (as soon as possible). In an interview with the Assistant Director of Nursing (ADON/staff #25) conducted on July 12, 2017 at 9:05 a.m., she stated wound assessments include measurements and wound descriptions and are done weekly. Staff #25 said the assessments are documented on the wound tracking sheet, which is used by staff to check the progress of the wounds. An interview with a licensed practical nurse (LPN/staff #51) was conducted on July 13, 2017 at 8:42 a.m. Staff #51 stated that weekly skin checks are done by the third shift nurse, once a week. Staff #51 stated the third shift nurse is not a wound care nurse, but if the resident has a measurable wound, she is assigned to conduct the weekly skin assessments. She said the assessment should include the location of the wound, description of the surrounding skin and wound bed. During an interview with a registered nurse (RN/staff #29) conducted on July 13, 2017 at 9:37 a.m., she stated that she conducts a head to toe assessment which includes a skin assessment upon admission. She stated that each wound will be documented separately on the wound sheet and the nurses are to identify the type of wound, location of the wound and describe the wound, which includes the wound bed and edges. She also stated that wounds are assessed on a daily basis. Staff #29 further stated that a blister is considered a wound and must be documented on the wound sheet. She said that when a resident is admitted with a large blister, she will document this on a wound sheet, notify the physician, and apply the treatment as ordered to prevent the blister from bursting. Another interview with staff #25 was conducted on July 13, 2017 at 11:02 a.m. She stated that nurses are expected to assess, describe and document each wound separately on the wound sheet. She also stated that staff #51 conducts weekly wound measurements, but the floor nurses are expected to assess the wound, do treatments as ordered and document. She further stated that a blister is considered a Stage II pressure ulcer and must be assessed and documented in the clinical record. Immediately following the interview, a review of the clinical record was conducted with staff #25. She confirmed that the resident had a large blister on the left heel on admission. She stated that the facility had no knowledge of the findings of the podiatrist note regarding a Stage III pressure ulcer to the left heel, until the podiatry notes were requested by the survey team. A follow up interview was conducted with staff #25 on July 13, 2017 at 1:05 p.m. The ADON stated that she could not locate any documentation that the blister to the left heel was assessed and monitored after admission. She acknowledged that despite staff providing wound treatments, there was no evidence that the pressure ulcer to the left heel was thoroughly assessed at least weekly. She said she could not explain why the Stage III pressure ulcer to the left heel was missed by the nurse, when treatment was being provided daily. She also said that the facility did not receive the podiatry consultation note dated November 7, 2016, and that the floor nurses are supposed to follow up with the physician's clinic regarding orders. Review of the facility's policy regarding Wound Assessments and Documentation revealed that all wounds are thoroughly assessed upon admission or upon occurrence of the wound. The policy included that the wound nurse will complete the comprehensive weekly wound assessment, which includes any drainage, description of the periwound and wound bed, if any odor is present and measurements, and to document the findings. The policy also noted that all wounds are assessed for changes, with each dressing change.

Based on clinical record reviews, staff and resident interviews, hospital documentation and review of policies and procedures, the facility failed to ensure that interventions were in place for one resident (#68), who was non compliant with smoking, and failed to ensure one resident (#25) was transferred safely. Findings include: -Resident #68 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed documentation that a family member/responsible party had signed the facility's non-smoking policy on June 27, 2014, acknowledging that they had been informed of the facility's non smoking policy and adherence to the policy. A quarterly MDS (Minimum Data Set) assessment dated [DATE], assessed the resident with moderate cognitive impairment and had poor decision making skills, which required cues and/or supervision. The MDS also noted that the resident had range of motion limitations to the upper and lower extremities, which included impairment on one side. Review of a care plan conference summary dated April 1, 2015 revealed the resident had gone outside of the facility to smoke. A social services note date April 14, 2015 included that the resident was observed in front of the entrance bumming cigarettes off visitors, as they entered the building. The resident was reminded of the non smoking policy and that he could not smoke on campus and voiced understanding. An activity note dated April 17, 2015 documented that an activity staff member gave the resident an electronic cigarette kit, with two cartridges. Review of a social services note dated April 25, 2015 revealed the resident was overheard bumming cigarettes from visitors. The resident was reminded of the facility's non smoking policy and that his family member/POA (power of attorney) did not want him to smoke. The resident verbalized that he understood. Another activity note dated April 28, 2015 included that activity staff had purchased an additional cartridge for the resident's electronic cigarette. An activity note dated May 29, 2015 included that a family member had given the resident a vapor electronic cigarette kit, which had a charger and liquid and that the family had asked if activity staff had the charger and liquid, however, they did not have either one of the items. A social services note dated May 29, 2015 documented that the social worker had over heard the resident asking visitors if he could have a cigarette. The social worker confronted the resident outside and told him that he could not bum cigarettes and that he could not smoke on campus. Per the note, the resident denied the actions and the social worker told the resident that she could see him as he sits right outside her office. The resident stated that he was sorry. Review of the resident's care plans revealed that they had not been revised to address the resident's non compliance with smoking, nor were there any interventions to address this behavior. In addition, further review of the clinical record revealed there was no documentation of any ongoing interventions that were implemented, despite the resident's known behavior of being non compliant with smoking. A nurse's noted dated June 4, 2015 at 5 p.m. included that the resident was found outside in front of the building, by activity staff. The resident's hair was on fire, so staff poured water on the resident and he was brought inside and wet towels were applied to his face and head. The resident was assessed by nursing staff and had burns to his right ear, cheek, forehead, and the top of his head and scalp. Staff called 911 and the physician was notified. According to the hospital records dated June 4, 2015, the resident had three percent total body surface area burns to the right side of his face, forehead, and right ear. The resident's right ear appeared to be a second degree deep thickness burn. Per the hospital documentation, the resident stated that while lighting a cigarette, the wind blew his hair into the lighter and his hair caught on fire, causing burns to his forehead, right ear and right neck area. An interview was conducted on August 17, 2016 at 2:30 p.m., with resident #68. The resident stated he was smoking out in front of the building and his hair caught fire. He stated that he had smoked previously out by the dumpster, but did not remember where he got the cigarettes. The resident further stated that he did not remember if he was told that the facility was a non smoking building. On August 18, 2016 at 11:30 a.m., an interview was conducted with activity staff #61. Staff #61 stated that she had witnessed the resident smoking outside the building in April 2015. Staff #61 stated that she was leaving work with another staff on June 4, 2015 at approximately 5:00 p.m., when she saw the resident outside the building entrance area. She stated the resident's hair was on fire, so she took her bottle of water and dumped it on the resident, while another staff member went inside and got some wet towels. Staff #61 stated that the resident had a lighter and cigarettes with him. Staff #61 further stated that she had given the resident an electronic cigarette kit with cartridges, and that the family had purchased another vapor type electronic cigarette that required a charger and liquid, however; the family did not provide refills for the liquid, nor did they bring in the charger. An interview was conducted with a licensed practical nurse (LPN/staff #8) on August 18, 2016 at 11:47 a.m. Staff #8 stated that she had witnessed the resident smoking outside the building numerous times from April through June 2015. She stated the resident's behavior had been discussed in care plan meetings, but nothing more was done other than to redirect the resident. Staff #8 stated that a family member had supplied the resident with smoking materials and that the resident was allowed to go off property to smoke with other residents. Staff #8 stated she was with staff #61 on June 4, and witnessed the resident outside in the front of the building, with his hair on fire. Staff #8 stated that staff #61 dumped water on the resident, while she ran into the building to get wet towels and notify nursing staff. On August 18, 2016 at 1:10 p.m., an interview was conducted with social services (staff #66) and the Director of Nursing (DON/staff #86). Both stated that the resident had been witnessed numerous times smoking outside of the building, and had been overheard asking visitors for cigarettes. According to both staff, no interventions had been implemented to prevent the resident from obtaining smoking materials or to prevent the resident from smoking. Staff #66 was not aware of any additional information which was provided to the family to remind them not to provide smoking materials to the resident. During an interview with the Administrator (staff #85) on August 18, 2016 at 1:26 p.m., staff #85 stated that social services had made administrative staff aware that the resident had been observed smoking outside the building, but no interventions had been implemented. Staff #85 stated that the resident could have been issued a 30-day notice, but because there was a family member working at the facility, staff decided not to issue one. Staff #85 stated that no notices had been sent to the family to remind them to not provide smoking materials to the resident. Staff #85 further stated that the only time the non smoking policy was discussed was upon admission, when the resident and/or family/responsible party signed the non smoking policy. A review of the facility's non smoking policy revealed that upon admission to the facility, you or your responsible party are being advised that the building is a non smoking facility. By signing the following, you agree to adhere to the non smoking policy. According to the Admission policy, residents are not to keep matches or lighters in their possession and those residents who fail to comply with the smoking regulations are to be referred to the Administrator for possible discharge. -Resident #25 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a therapy transfer assistance form dated July 25, 2016 revealed the resident required maximum assistance with transfers (which indicated that the resident does 25% of the transfer). Review of the admission MDS assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 12, which indicated the resident had moderate cognitive impairment. The resident was also assessed to require extensive assistance of two staff members for transfers. An interim care plan indicated that the resident required assistance with transfers. According to a nursing note dated July 28, 2016, the resident sustained [REDACTED]. The physician was notified. A physician's orders [REDACTED]. Another nursing note dated July 28, 2016 indicated that the resident had returned to the facility, with dissolving stitches and sutures. Review of the weekly wound assessment dated [DATE] revealed the laceration to the resident's right leg was 13 cm in length and had 16 staples and 5 stitches. physician's orders [REDACTED]. Review of the facility's investigation revealed that on July 28, 2016, the resident sustained [REDACTED]. The incident occurred around 7:30 p.m., during a transfer. Per the report, a certified nursing assistant (CNA/staff #32) assisted the resident off the toilet and pivoted her back into the wheelchair, but when the resident was about to sit down, her right ankle hit the pedal of the wheelchair and all of her weight was on her ankle, which was pressing up against the foot pedal of the wheelchair. The report included that the CNA should have repositioned the foot pedals on the wheelchair, before transferring the resident. The CNA was suspended for five days and was educated on following facility protocol. The report further included that the wheelchair was inspected by maintenance for any defects and none were found. Review of the medication administration record (MAR) for July and August 2016 revealed the resident received narcotic pain medication on multiple occasions. The resident's pain level ranged from 6-8 out of 10 (with 10 being the worst). A nursing note dated August 8, 2016 revealed the resident went to the emergency room to have the staples removed, and while in the hospital, the hospitalist suggested a wound care consult. physician's orders [REDACTED]. Review of the wound clinic notes dated August 11, 2016 revealed the resident's right leg had swelling and the treatment was changed. physician's orders [REDACTED]. Also, there was an order to elevate the resident's feet. A physician's orders [REDACTED]. During an interview with the resident at 9:30 a.m. on August 17, 2016, she said that when this incident happened, the CNA took her to the bathroom and when she was finished, she went to sit back down onto her wheelchair, but her leg hit the foot pedal on the wheelchair and caused the injury. She stated that the injury has caused her a lot of pain. An interview was conducted at 11:00 a.m. on August 17, 2016, with the CNA (staff #32), who transferred the resident. He stated that when he was lifting the resident from the toilet to her wheelchair, she grabbed the grab bar in the bathroom, as he was easing her back to her chair. He said the resident slid against the foot pedal and when she sat down, all of her weight rubbed against the foot pedal causing the laceration. He stated that the incident was his mistake, because he should have taken the foot pedals off of the wheelchair. He stated when this happened, the foot pedals were on the wheelchair and were moved out of the way slightly, but were not moved far enough out of the way, as they could have been. He stated that the foot pedals that were on her chair did not have the soft backing like some pedals, but were hard plastic and they had the metal bar, which attached to the wheelchair. He said the foot pedal was flipped up, exposing the hard backing of the foot pedal, which is what caused the injury. He stated that he had been taught that it was okay to transfer a resident with the foot pedals on the wheelchair, if the pedals were swung all the way out. He said the other option is to take them off completely. During an interview with a CNA (staff #48) at 11:30 a.m. on August 17, 2016, she said that when she is transferring a resident from the toilet to the wheelchair, she removes the foot pedals. She said the bathrooms in the facility are small and there is not enough room to swing the foot pedals out, so she removes them so she has more room. She said there is no written policy or protocol, it just goes back to her training as a CNA. She said that sometimes the therapists in the building do training on transferring, but they do not mention the foot pedals. She stated that she has not received any education from the facility regarding foot pedal use. During an interview with the Assistant Director of Nursing (ADON/staff #29) at 8:55 a.m. on August 18, 2016, she stated that there is no facility protocol in regards to foot pedal usage while transferring residents, but the facility relies on the training that the CNAs receive to get their license. She stated the CNA should have removed the foot pedals prior to the transfer, based on the training he had received as a CNA. In an interview with a LPN (staff #58) at 9:20 a.m. on August 18, 2016, she stated that foot pedals need to be folded back to the side or taken off completely before doing a transfer, from the toilet to the wheelchair. She stated that if they are swung out, they need to be all the way to the side. She stated that the bathrooms are on the smaller side in the facility and that it is difficult to find enough room to swing the foot pedals out all the way. She stated that CNAs are trained to transfer in this manner. An interview was conducted with a CNA (staff #37) at 12:00 p.m. on August 18, 2016. She stated that foot pedals should be taken off prior to transferring a resident to their wheelchair. She stated that the bathrooms are not big enough to swing the foot pedals all the way out and so to be safe, she removes the foot pedals prior to transfers. She stated that she learned this in her CNA training course. During an interview with the DON (staff #86) at 11:30 a.m. on August 18, 2016, she stated that CNAs receive training on transfers, as part of their schooling to become CNAs and should know to remove or swing the foot pedals all the way out, prior to transferring a resident. She stated that she feels the CNA did not transfer the resident properly, because he did not remove the pedals or swing them all the way out. In an interview with a physical therapy assistant (PTA/staff #80) at 1:00 p.m. on August 18, 2016, he stated that the therapy department had not addressed foot pedal use with staff, as there had been no issues. He stated the resident bathrooms are small and he would like to see the foot pedals removed, prior to going into the bathroom. In an interview with the Administrator (staff #85) at 3:00 p.m. on August 18, 2016, she stated that she could not locate any policy in regards to foot pedals and transfers.

Based on clinical record review, staff interview, and policy review, the facility failed to thoroughly assess a pressure ulcer upon admission and consistently provide wound care for one resident (#158). Findings include: Resident #158 was admitted on [DATE], with [DIAGNOSES REDACTED]. The resident discharged on [DATE]. Review of the physician's orders dated September 10, 2014 revealed wound care orders to cleanse coccyx open area with normal saline, pat dry, apply hydrogel, and cover with island dressing daily until healed. Review of the resident assessment data collection form dated September 10, 2014 revealed a pressure ulcer to coccyx. No staging or measurements were noted. Review of the nurse's note dated September 10, 2014 revealed coccyx pressure ulcer dressing was dry and intact. A review of the Braden scale dated September 10, 2014, scored the resident at a 15 which indicated a mild risk for pressure ulcers. Review of the treatment administration record revealed the treatment was not provided until September 12, 2014. Review of the nurse's notes dated September 14, 2014 revealed the first documentation that the pressure ulcer was a stage 4. A review of the wound evaluation dated September 14, 2014 included the pressure ulcer on the coccyx measured 4 centimeters (cm) x 4 cm, that slough and necrotic tissue was present, wound margins intact, surrounding tissue pink, no odor, no drainage and positive for pain. Review of an undated care plan for pressure ulcers included the following interventions: apply dressing per physician orders, observe dressing for any signs of exudate, assess for color and amount, monitor wound status - include weekly the size of the wound, measurements of depth width, skin color, and the surrounding skin assessment. An interview was conducted on April 28, 2015 at 3:15 p.m., with the director of nursing (DON). She stated a resident assessment should be conducted upon admission which included a complete skin assessment and if there are any skin issues, the doctor should be contacted for orders. The DON further stated it is not appropriate for the resident to go for 4 days without a completed skin assessment or appropriate for treatment not to be administered as ordered. She continued to state the admission nurse should initiate an immediate plan of care. The DON was unable to provide any documentation of the condition of the pressure ulcer upon admission. During an interview conducted on April 28, 2015, a licensed staff stated when a resident is admitted a complete assessment is completed and it includes a skin assessment. She stated if there are no wound orders, she would call the doctor to obtain the orders. The licensed staff then stated an initial care plan would be developed. She continued to state all orders are followed immediately upon admission. Review of the facility policy Skin assessment stated the resident will have a complete assessment of the skin upon admission and weekly during the stay. The skin assessment is documented in the admission nurse note and on the admission assessment. If a wound is present it is assessed and documented according to the Wound Assessment policy and procedure. Review of the facility policy Wound assessment and documentation stated all wounds are thoroughly assessed upon admission of the resident to the facility or upon occurrence of the wound. The initial wound assessment is to include the location, stage, and measurement in centimeters, appearance of peri-wound, appearance of wound bed, drainage, color, amount, consistency, and odor. This initial assessment is to be charted in the nurse's notes noting all the information. A skin assessment, including measurements, is completed weekly by the nurse.

Based on closed record review, hospital records, staff interviews, and facility policy review, the facility failed to ensure that one resident (#12) received care and services to prevent pressure ulcers from developing and failed to implement measures to prevent further breakdown. Findings include: Resident #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the pressure ulcer care plan dated May 31, 2013, revealed that the resident was at risk due to incontinence of bowel and bladder and poor nutrition. The following interventions are noted: check, change and cleanse every two hours and as needed; apply barrier cream after each incontinent episode; and full body assessment weekly. According to the Risk Scoring Guide for Pressure Ulcers dated June 5, 2013, the resident was identified to be at high risk for developing pressure ulcers. In addition, the Braden Scale for Predicting Pressure Sore Risk dated June 12, 2013, also identified the resident was at severe risk. Despite this, there was no documented evidence that thorough weekly skin assessments were completed for the month of June 2013. Review of the clinical record revealed there was no documentation that thorough weekly skin assessments were completed for the month of July 2013. A physician's order dated July 16, 2013, included to cleanse the left buttock open area with wound cleanser, pat dry, and apply [MEDICATION NAME] Ag (silver) and Duoderm; and to change every other day until resolved. Review of the TAR (Treatment Record) for July 2013, revealed no documentation that the treatment was done as ordered on July 18 or 20, 2013. Despite the above documentation regarding an open wound to the left buttocks area, the clinical record had no evidence or documentation that the wound had been assessed. A physician's order dated July 20, 2013, included to send the resident to the emergency room for an unrelated health condition. According to the Minimum Data Set (MDS) discharge assessment completed on July 20, 2013, the resident did not have any pressure ulcers. The resident was readmitted to the facility on [DATE]. Review of the Resident Admission Assessment Data Collection form dated July 23, 2013, revealed the resident had two stage 2 pressure ulcers on the coccyx. The assessment did not include any measurements or description of the wounds. Review of the pressure ulcer care plan revealed it was not updated to reflect the two stage 2 pressure ulcers. The care plan did not include any additional interventions, despite having two pressure ulcers. Review of the admission orders [REDACTED]. The Risk Scoring Guide for Pressure Ulcers updated on July 31, 2013, included the resident was identified to be at moderate risk for pressure ulcer development. Continued review of the clinical record revealed there was no documented evidence of any thorough skin assessments that were completed from July 24 through 31, 2013. There was also no further documentation regarding the two stage 2 pressure ulcers to the coccyx, as identified upon readmission to the facility. A quarterly MDS assessment dated [DATE], included the resident was totally dependent and required two plus persons for physical assistance with bed mobility, transfers, and toilet use. Also, Section M. noted that the resident had no pressure ulcers. Review of the Braden Scale for Predicting Pressure Sore Risk dated August 31, 2013, revealed the resident was at moderate risk. For the Month of August 2013, there was no clinical record documentation of any thorough weekly skin assessments that were completed. A physician's order was written on September 8, 2013, to cleanse the coccyx with wound cleanser, pat dry, apply [MEDICATION NAME] Ag and cover with Duoderm every other day and as needed. According to the Weekly Pressure Ulcer Healing assessment dated [DATE], the resident now had a stage 2 pressure ulcer. According to the body diagram, the coccyx and left and right buttocks areas were circled. There was no written documentation as to the location of the wound. The wound was labeled as wound #1 and measured 4 centimeters (cm) by 1 cm, no depth or undermining noted, with a scant amount of serosanguineous drainage. The date of onset was September 8. Review of the TAR for September 2013, included the above treatment order, however, it was dated September 3, instead of September 8. The treatment was also transcribed to be done daily, instead of every other day. No physician's order was found for September 3, or for the change in frequency. In addition, the treatment was not documented as being done on September 11, 12 and 13. The next pressure ulcer assessment was done on September 15, 2013. Per the Weekly Pressure Ulcer Healing Assessment, wound #1 was a stage 2, measured 2 cm by 1 cm., with no depth and no tunneling, and had a scant amount of serous drainage. There was no written documentation as to the specific site of wound #1, other than on the body diagram in which the coccyx area and left and right buttocks area were circled. The next wound assessment was not completed until eight days later. According to the Weekly Pressure Ulcer Healing assessment dated [DATE], wound #1 was now a stage 4 and measured 4 cm by 2 cm, with no depth or tunneling, and a scant amount of serous drainage. The wound bed was described as "pink." The wound was noted to have deteriorated. There was no written documentation as to the site of the wound, other than the body diagram in which the coccyx area and left and right buttocks area were circled. A physician's order was obtained on September 24, 2013, which included to discontinue the previous treatment to the coccyx and right gluteal fold. The orders were as follows: cleanse coccyx with wound cleanser, pat dry, cover with [MEDICATION NAME] Ag, then [MEDICATION NAME] foam, and cover with an opsite, change every other day until resolved; for the right gluteal fold - cleanse with wound cleanser, pat dry, cover with [MEDICATION NAME] Ag, then [MEDICATION NAME] foam, cover with opsite and change every other day until resolved. Review of the Weekly Pressure Ulcer Healing Assessment for September 30, 2013, revealed that wound #1 was a stage 4, and measured 4 cm by 2 cm. The wound bed was described as having slough, with a small amount of serosanguineous drainage. The documentation included the wound had deteriorated. Again, there was no written documentation as to the site of the wound, other than the body diagram in which the coccyx area and left and right buttocks area were circled. The Weekly Pressure Ulcer Healing Assessment for October 7, 2013, included wound #1 was a stage 4, measured 4 cm by 2 cm. with a depth of 1 cm., the wound bed was pink and now had "some eschar." Despite the resident developing a stage 4 pressure ulcer, the pressure ulcer care plan was not updated to reflect this change, nor any additional interventions that were implemented. A physician's order was written on October 7, 2013, to discontinue the previous treatment orders to the coccyx. Change treatment to left buttocks; cleanse with wound cleaner, pat dry, apply cover with [MEDICATION NAME] foam and cover with opsite and paper tape every other night. Review of the nurse's notes dated October 9, 2013, revealed that the coccyx area was cleansed and re-dressed per physician's orders. The note also included that the left buttocks area had a foul odor emitting from the decubitus, with some drainage noted and will continue to monitor. There was no clinical record documentation that the physician was notified. Review of the TAR for October 2013, revealed no documented evidence that the physician ordered treatment was done on October 10. According to the Weekly Pressure Ulcer Healing assessment dated [DATE], the resident now developed a stage 2 pressure ulcer to the coccyx, identified by the facility as wound #2. The wound measured 1 cm by 1 cm, and the wound bed was pink. A physician's order was written on October 13, 2013, to discontinue all treatments to coccyx, left buttocks, and right gluteal. The order included the following change in treatment; cleanse coccyx with wound cleaner, pat dry, apply [MEDICATION NAME], cover with Hydroplex every day; cleanse left buttocks with wound cleaner, pat dry, apply Santyl, cover with Hydroplex daily. The orders also included the right gluteal area was resolved. Review of the Weekly Pressure Ulcer Healing assessment dated [DATE], revealed that wound #1 was a stage 4, measured 4 cm by 2 cm with a depth of 1 cm., had a small amount of serous drainage, and the wound bed was pink with some eschar. The documentation on this assessment conflicted as to the site of wound #1. On the body diagram the right buttocks area was circled, however, under the section site/location, it was written that the wound was on the left buttock A nurse's note dated October 15, 2013, included the resident's left buttocks had an area that was black with eschar, was very reddened and had a hard area that was approximately one inch in circumference around the wound. The nurse practitioner was called and new orders were received to change the dressing two times per day. A physician's order was written on October 15, 2013, to change the dressing to the left buttocks, two times per day. On October 17, 2013, a physician's order was written for a wound clinic appointment for the left buttocks. Review of the October 2013 TAR revealed that the wound treatment order was rewritten on October 19, 2013, for the right buttocks wound to be cleansed with wound cleaner, apply [MEDICATION NAME] AG, cover with foam dressing and change every day. However, no documented evidence of a physician's order was able to be found for this date. Review of the Weekly Pressure Ulcer Healing assessment dated [DATE], revealed that wound #1 was unstageable with undermining present, measured 4 cm by 4 cm by 2 cm, with serous drainage that was foul and purulent. The documentation included that the site of the location of wound #1 was the left buttocks, however, on the body diagram the right buttocks was circled. According to the clinical record documentation, wound #2 was not assessed until eight days later on October 21, 2013. Per the Weekly Pressure Ulcer Healing Assessment, wound #2 was a stage 2 and measured 1 cm by 1 cm, and had a pink wound bed. A physician's order was written on October 21, 2013, to send the resident to the emergency room for a decubitus pressure ulcer stage 4 on the "left hip." Review of the hospital records revealed the resident was admitted with stage 3 and 4 decubitus ulcers of bilateral hips. The documentation included the resident was transferred due to worsening wounds that were getting worse. The hospital documentation further included that there was a deep wound at the greater trochanter of the left hip, which measured 5 x 6 cm wide and circular and 1.5 cm deep, covered with black, necrotic slough, with foul odor. On the right side at the greater trochanter area, there is a small wound stage 3, 2 by 2 cm with necrotic slough. The notes also stated that the bilateral deep decubitus ulcers appear to be infected. An interview was conducted on February 5, 2014, with a licensed practical nurse (LPN). The LPN stated that this resident was compliant with care. She also stated that skin assessments are done by nursing and documented on the MAR, and on the weekly skin assessment form. An interview was conducted on February 5, 2014, with a registered nurse (RN). She stated that nurses do the weekly skin assessments and it is documented on the MAR when done. An interview was conducted on February 5, 2014, with the director of nursing (DON). The DON stated that some of the interventions that should be on a resident's pressure ulcer care plan are positioning and nutrition. She also stated that she thinks this resident did not have a pressure relieving mattress, but instead had a scoop mattress because she was a fall risk. An interview was conducted on February 6, 2014, with the wound nurse. The wound nurse stated that weekly skin assessments should have been done and nursing had "dropped the ball." She further stated the pressure ulcer care plan should have been updated. The wound nurse also stated that this resident would scoot around in the bed a lot and that may have contributed to the pressure ulcer getting worse. She stated that she works part time and measures and assesses wounds in the facility one day per week and that the nurse is responsible for the wound care on all other days. A second interview was conducted with the DON on February 6, 2014. The DON stated that she was not aware of any additional documentation for this resident. She also stated that the care plan should have been updated and the weekly skin assessments should have been done. Review of the facility's policy on Skin Assessments revealed "...Residents will have a complete assessment of skin on admission and weekly during their stay at the facility...Any resident with a Braden score of 12 or below, will be placed on a pressure relieving mattress and chair cushion...The permanent day shift nurse performs a weekly assessment including measurements. This is documented on the weekly assessment sheet located on the MAR..." Review of the facility's policy on Pressure Ulcers revealed "...The purpose: to provide guidelines for the assessment and identification of residents at risk of developing pressure ulcers...Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown. Immediately report any signs of a developing pressure ulcer to the supervisor...Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated...Because a resident at risk can develop a pressure ulcer within 2-6 hours of the onset of pressure, the at risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers...The admission evaluation helps to define those initial care approaches..."

Based on clinical record review, observations, resident and staff interviews, and review of the facility's policies and procedures, the facility failed to ensure that one resident (#106) was transferred in a safe manner to avoid injury, and that hazardous waste and chemicals were stored safely. Findings include: -Resident #106 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed a quarterly MDS (minimum data set) assessment dated [DATE], documented that the resident was a one-person, limited assist for transfers. Resident care plans documented the resident had difficulty with transfers and required one person assistance for transfers. They also included the resident was a fall risk due to weakness, that the resident was non-ambulatory and was to be encouraged to stand and pivot with assistance and transfers. A review of facility investigative documentation revealed that on October 6, 2012, during a transfer from a wheelchair to the resident's bed, the resident sustained [REDACTED]. The resident was sent to the hospital for treatment. According to the hospital documentation, the resident had a 15 centimeter (6 inch) bone deep laceration to her left lower extremity. Documentation included that the resident's leg was sutured and dressed and was released back to the facility on [DATE]. An interview was conducted with resident #106 on November 8, 2012. The resident stated that staff #12 was assisting her with a transfer from the wheelchair to her bed and had assisted her to stand, and then lifted her to the bed. The resident stated that she yelled that her leg was hurting, but staff #12 continued with the transfer and her leg was injured on the bed frame. She further stated that staff #12 was in a hurry and did not safely transfer her. A telephone interview was conducted with staff #12 on November 8, 2012. Staff #12 stated that she remembered the incident on October 6. She stated that she was transferring the resident from the wheelchair to the bed and that the resident's wheelchair was locked and the resident had a gait belt on. She said that she assisted the resident to stand and the resident pivoted and moved her left leg back towards the bed, and as she lifted the resident to the bed, the resident began yelling that her leg was hurting. Staff #12 stated that she continued with the transfer, even though the resident was yelling for her to stop. She said that she did not call for help and didn't think she had any other choice but to continue to transfer the resident to the bed. She stated when she got the resident onto the bed, she saw the laceration on the resident's leg. Staff #12 further stated that there was a gap in the resident's bed frame and that was how she believed, the resident sustained [REDACTED]. On November 8, 2012, an observation was made of the resident's bed, with the Director of Nursing (DON) and maintenance staff present. The upper bed frame, under the mattress, was covered with a Styrofoam type tubing. Maintenance staff removed the tubing to reveal a metal bed frame, with an approximate 4 inch gap between the head and body area of the bed frame. The edges appeared blunted and smooth with no rough or jagged edges. During the observation, the DON stated that the resident was tiny and frail, probably got her left calf area caught in the gap of the bed frame, causing the laceration when the staff lifted the resident onto the bed. A review of the facility policy for moving a resident from a chair to a bed, revealed documentation that the policy was to ensure safe transfers of residents. The policy further documented that should a resident become weak, pale, begin to perspire, complain of chest pain, feel dizzy, or show any other signs of acute distress, cease the procedure and summon the nurse supervisor. -An observation was conducted on November 8, 2012 at 7:50 a.m of an unlocked door to shower room #2 on the east wing. Located on a waist high wall divider was a spray bottle containing a pink liquid labeled, "Germicidal Cleanser." The label on the spray bottle contained a warning that the chemical was hazardous. An interview was conducted with a housekeeping staff member at the time of the observation of who stated that the cleanser should not have been left out and that it should have been put away in the overhead cabinet. The maintenance director stated that the cleanser should not have been left out and accessible to residents. An additional interview was conducted with the environmental services director at 8:15 a.m. and she stated that the germicidal cleanser should not have been left out. Another observation was conducted at this same time of a soiled utility room with the door ajar, which contained a trash bin labeled, "Hazardous waste." The resident population with access to the shower room and the soiled utility room included residents who were ambulatory and wheelchair bound, as well as residents with dementia. An interview was conducted with the assistant Director of Nursing regarding the open door to the soiled utility room immediately following the observation. He stated that there was hazardous waste stored in the room and that he would not have expected the door to be open. The maintenance director provided a copy of the material safety data sheet (MSDS) for the ProClean Premium Germicidal cleanser. In section II it documented that the cleanser had hazardous ingredients. Section V of the MSDS documented that eye contact "may cause, severe permanent damage to eyes" and that ingestion was, "Harmful or fatal if swallowed." A review of the facility's policy on Hazardous and Toxic Substances documented "Storage of all hazardous/toxic materials will be in locked storage areas accessible by maintenance, housekeeping and nursing."