Every finding on record at Elkins Rehabilitation & Care Center

Based on staff Interview and facility documentation, the facility failed to ensure that a resident residing on the facility's Alzheimer's unit was free from physical abuse, as described by nurse aide (NA) staff members who witnessed the incident. Using the reasonable person concept it can be determined that the average person would have experienced psycho-social harm as a result of the physical abuse, since an average person would not expect to be smacked in his/her own home or in a healthcare facility. This had the potential to affect a limited number of residents. Resident Identifier: Resident #1. Facility census 104.The facility's Abuse, Neglect, Exploitation policy, with a revision date of 06/23/25, outlined the following:--Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and misappropriation of resident property is more likely to occur with deployment of trained and qualified staff on each shift in significant numbers to meet the needs of the residents, and ensure that the staff assigned have knowledge of the individual residents care needs and behavioral symptoms. --Room or staffing changes, if necessary, to protect the resident from the alleged perpetrator.--Analyzing the occurrence to determine why abuse occurred, and what changes are needed to prevent further occurrences.--Defining how care provisions will be changed and improved to protect residents receiving services. --Training of Staff on changes made and demonstration of staff competency after training is implemented. --A licensed staff member suspected of abuse will be reported to his/her licensing board. The Reasonable Person Concept in Social WorkThe reasonable person concept is used to measure the severity of harm or potential harm a resident in long-term care suffers, even if the resident cannot express their feelings due to advanced dementia, focusing on what a reasonable person in that situation would experience. Abuse Involving Corporal PunishmentCorporal Punishment is the intentional application of physical force to cause bodily pain or discomfort, typically used as a disciplinary measure aiming to punish misconduct. WV State Code S61-2-29 states abuse of incapacitated adult is against the law. Findings included:a) Resident #1A facility reported incident was completed 08/23/25 at 2:05 PM with the following action notes: Allegation of physical abuse, Nurse Aide (NA) #100 reported that Licensed Practical Nurse (LPN) #200 smacked Resident #1's hand and then asked the resident how it felt to be slapped by someone. A review of a statement from NA #103 revealed that on 08/23/25 at 2:05 PM, Licensed Practical Nurse #200 touched Resident #1's hand very lightly and stated, no we don't do that, that is not nice. A continued review of the initial report of allegation revealed Resident #1 had discoloration to skin. Upon further review, the five-day follow-up investigation report stated:-No harm was noted or observed to Resident #1-The perpetrator was terminated-The incident was captured on security camera footage-Witnesses provided statements-The allegation was substantiated, with mandatory nurses training on abuse and neglect to be scheduled On 03/10/26, a review of the staff roster found LPN #200 employed at the facility. During an interview on 03/11/26 at 9:40 AM, Social Worker #103 reviewed the abuse reportable. The social worker stated she had watched the video and LPN #200 did smack Resident #1s hand. She verified her statements in the five-day follow-up investigation report. During an interview on 03/11/26 at 9:55 AM, LPN #101 stated she had watched the video for the day in question, and she observed LPN #200 smacking Resident #1s hand. She stated that there was slight discoloration to Resident #1's hand, but it went away shortly after. She stated that she sent LPN #200 home and sent in the initial abuse reportable to the appropriate state agencies. During a telephone interview on 03/11/26 at 12:55 PM, NA #100 revealed that she was in the hallway on the Reflections Hall (the facility's Alzheimer's Unit) and Resident #1 was trying to smack another resident when LPN #200 smacked Resident #1's hand and asked how does it feel to be smacked. NA #100 stated that she didn't feel Resident #1 was hurt in the incident indicating that Res #1 just walked off. During an interview on 03/11/26 at approximately 1:10 PM, the Director of Nursing (DON) verified that LPN #200 had been reinstated to the facility and continued to work on the facility's Alzheimer's unit. The DON also stated that LPN #200 was not reported for substantiated abuse and use of corporal punishment to the LPN Licensing Board. The DON stated she would confirm whether the individual received the required abuse training prior to returning to work. During an interview on 03/11/26 at approximately 1:25 PM, the DON and Administrator verified no abuse training was given prior to LPN #200 returning to work. The Administrator stated that LPN #200 was still in her 90 days from last date of employment and she was brought back as a continued employee.

Based on observation, staff interview, electronic medical record review, and review of the facility's Abuse, Neglect, Exploitation policy, the facility failed to take appropriate corrective action, as a result of investigation findings which substantiated physical abuse of a resident. The facility failed to provide additional training to staff as per their five-day follow-up of an abuse investigation. Additionally, the facility failed to report a licensed staff member to his/her licensing board. This was true of one (1) of four (4) residents reviewed for abuse during a complaint survey. Resident identifier #1. Census 104.The facility's Abuse, Neglect, Exploitation policy, with a revision date of 06/23/25, outlined the following:--Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and misappropriation of resident property is more likely to occur with deployment of trained and qualified staff on each shift in significant numbers to meet the needs of the residents, and ensure that the staff assigned have knowledge of the individual residents care needs and behavioral symptoms. --Room or staffing changes, if necessary, to protect the resident from the alleged perpetrator.--Analyzing the occurrence to determine why abuse occurred, and what changes are needed to prevent further occurrences.--Defining how care provisions will be changed and improved to protect residents receiving services. --Training of Staff on changes made and demonstration of staff competency after training is implemented. --A licensed staff member suspected of abuse will be reported to his/her licensing board. Findings included:a) Resident #1A facility reported incident was completed 08/23/25 at 2:05 PM with the following action notes: Allegation of physical abuse, Nurse Aide (NA) #100 reported that Licensed Practical Nurse (LPN) #200 smacked Resident #1's hand and then asked the resident how it felt to be slapped by someone. A review of a statement from NA #103 revealed that on 08/23/25 at 2:05 PM, Licensed Practical Nurse #200 touched Resident #1's hand very lightly and stated, no we don't do that, that is not nice. A continued review of the initial report of allegation revealed Resident #1 had discoloration to skin. Upon further review, the five-day follow-up investigation report stated:-No harm was noted or observed to Resident #1-The perpetrator was terminated-The incident was captured on security camera footage-Witnesses provided statements-The allegation was substantiated, with mandatory nurses training on abuse and neglect to be scheduled On 03/10/26, a review of the staff roster found LPN #200 employed at the facility. During an interview on 03/11/26 at 9:40 AM, Social Worker #103 reviewed the abuse reportable. The social worker stated she had watched the video and LPN #200 did smack Resident #1s hand. She verified her statements in the five-day follow-up investigation report. During an interview on 03/11/26 at 9:55 AM, LPN #101 stated she had watched the video for the day in question, and she observed LPN #200 smacking Resident #1s hand. She stated that there was slight discoloration to Resident #1's hand, but it went away shortly after. She stated that she sent LPN #200 home and sent in the initial abuse reportable to the appropriate state agencies. During a telephone interview on 03/11/26 at 12:55 PM, NA #100 revealed that she was in the hallway on the Reflections Hall (the facility's Alzheimer's Unit) and Resident #1 was trying to smack another resident when LPN #200 smacked Resident #1's hand and asked how does it feel to be smacked. NA #100 stated that she didn't feel Resident #1 was hurt in the incident indicating that Res #1 just walked off. During an interview on 03/11/26 at approximately 1:10 PM, the Director of Nursing (DON) verified that LPN #200 had been reinstated to the facility and continued to work on the facility's Alzheimer's unit. The DON also stated that LPN #200 was not reported for substantiated abuse and use of corporal punishment to the LPN Licensing Board. The DON stated she would confirm whether the individual received the required abuse training prior to returning to work. During an interview on 03/11/26 at approximately 1:25 PM, the DON and Administrator verified no abuse training was given prior to LPN #200 returning to work.

Based on observation, staff interview, electronic medical record review, and review of the facility's Abuse, Neglect, Exploitation policy, the facility failed to correctly implement their policy for a substantiated allegation of abuse. The facility failed to provide training to staff as per their five-day follow-up of an abuse investigation. Additionally, the facility failed to report a licensed staff member to his/her licensing board. This was true of one (1) of four (4) residents reviewed for abuse during a complaint survey. Resident identifier #1. Census 104.The facility's Abuse, Neglect, Exploitation policy, with a revision date of 06/23/25, outlined the following:--Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and misappropriation of resident property is more likely to occur with deployment of trained and qualified staff on each shift in significant numbers to meet the needs of the residents, and ensure that the staff assigned have knowledge of the individual residents care needs and behavioral symptoms. --Room or staffing changes, if necessary, to protect the resident from the alleged perpetrator.--Analyzing the occurrence to determine why abuse occurred, and what changes are needed to prevent further occurrences.--Defining how care provisions will be changed and improved to protect residents receiving services. --Training of Staff on changes made and demonstration of staff competency after training is implemented. --A licensed staff member suspected of abuse will be reported to his/her licensing board. Findings included:a) Resident #1A facility reported incident was completed 08/23/25 at 2:05 PM with the following action notes: Allegation of physical abuse, Nurse Aide (NA) #100 reported that Licensed Practical Nurse (LPN) #200 smacked Resident #1's hand and then asked the resident how it felt to be slapped by someone. A review of a statement from NA #103 revealed that on 08/23/25 at 2:05 PM, Licensed Practical Nurse #200 touched Resident #1's hand very lightly and stated, no we don't do that, that is not nice. A continued review of the initial report of allegation revealed Resident #1 had discoloration to skin. Upon further review, the five-day follow-up investigation report stated:-No harm was noted or observed to Resident #1-The perpetrator was terminated-The incident was captured on security camera footage-Witnesses provided statements-The allegation was substantiated, with mandatory nurses training on abuse and neglect to be scheduled On 03/10/26, a review of the staff roster found LPN #200 employed at the facility. During an interview on 03/11/26 at 9:40 AM, Social Worker #103 reviewed the abuse reportable. The social worker stated she had watched the video and LPN #200 did smack Resident #1s hand. She verified her statements in the five-day follow-up investigation report. During an interview on 03/11/26 at 9:55 AM, LPN #101 stated she had watched the video for the day in question, and she observed LPN #200 smacking Resident #1s hand. She stated that there was slight discoloration to Resident #1's hand, but it went away shortly after. She stated that she sent LPN #200 home and sent in the initial abuse reportable to the appropriate state agencies. During a telephone interview on 03/11/26 at 12:55 PM, NA #100 revealed that she was in the hallway on the Reflections Hall (the facility's Alzheimer's Unit) and Resident #1 was trying to smack another resident when LPN #200 smacked Resident #1's hand and asked how does it feel to be smacked. NA #100 stated that she didn't feel Resident #1 was hurt in the incident indicating that Res #1 just walked off. During an interview on 03/11/26 at approximately 1:10 PM, the Director of Nursing (DON) verified that LPN #200 had been reinstated to the facility and continued to work on the facility's Alzheimer's unit. The DON also stated that LPN #200 was not reported for substantiated abuse and use of corporal punishment to the LPN Licensing Board. The DON stated she would confirm whether the individual received the required abuse training prior to returning to work. During an interview on 03/11/26 at approximately 1:25 PM, the DON and Administrator verified no abuse training was given prior to LPN #200 returning to work.

Based on record review and staff interview the facility failed to provide care and services in accordance with current standards of practice by administering Resident #115 a Benzodiazepines that she was not ordered. The State Agency (SA) confirmed that this failed practice caused harm to Resident #115. After Resident was given the Benzodiazepines she fell, resulting in a sprained hip. The incident occurred on 07/06/24 and was corrected on 07/08/24, therefore it is cited at past non-compliance.In a addition the facility failed to ensure it followed its policy and procedure for Resident #45 on weight management. This failed practice was found true for (2) of (27) residents investigated for quality of care during the Long-Term Care Survey Process. Resident identifiers #115 and #45. Facility Census #103.Findings Include: a) Resident #115A review 0N 08/27/25 at 1:40 PM of an Facility Reported Incident dated 07/08/25, revealed a description of an incident that is summarized as follows: On 07/06/25 at approximately 11:00 AM, Nurse administered narcotic without a physician's order to Resident #115. The medication belonged to another resident. Nurse reported that she was attempting to control the resident's behaviors. Resident #115 then fell and was sent to the local emergency room where it was determined that she had a sprained hip. The nurse was terminated on 07/08/24 after admitting to administering the medication. The facility substantiated the incident. A record review on 08/27/25 at 2:15 PM, revealed an incident report dated 07/06/24 that describes an incident as follows:Resident was standing in the doorway between hallway and common room when another resident attempted to come by in her wheelchair. Resident went to move and lost her balance and slid down the doorway onto the floor. Resident fall was witnessed by this nurse and (2) two Nursing Assistants (NA). Resident sent later in the day to emergency room for pain and a bruise to right elbow and hip. Further record review revealed a nurses note dated for 07/06/24 at 6:42 PM that reads as follows:Resident back to facility via stretcher with RCEMT from (local emergency room named). Resident skin warm pink dry and intact and shows no sign or symptoms of discomfort or distress. Residents D/C summary states that she has a right hip sprain and she should follow up with her doctor in 2 days. A review of Resident #115's orders for Ativan shows that at the time of the incident Resident #115 did not have an order for Ativan.During an interview on 08/27/25 at 2:49 PM, with the Director of Nursing (DON), The administrator, and the Licensed Social Worker (LSW), The DON stated, We did not put it all together that this had happened. A CNA came forward and we reviewed the cameras and found out that the resident was given this medication. On the video it shows the nurse getting the Ativan out of another resident's medications and then putting other medications out of the drawer in a strawberry ice cream and making a milkshake in which she had the resident drink. Not long after that (Resident #115 named) fell and had to go out. We immediately fired that nurse. b) Resident #45 A record review on 08/27/25 at 8:43 AM, revealed that Resident #45 weighed 166.6 pounds (lbs.) on 05/09/25 and on 08/17/25 weighed 143 lbs. A review on 08/27/25 at 9:15 AM of the policy titled {Weight Policy/Assessment/Interventions}, under procedure number, reads as follows: The resident's first weight will be obtained by CNA on admission and readmission. The next two weights will be obtained by the shower team. Resident will be weighed for a total of three days following admission/readmission. Then weekly for four weeks. Monthly after that by the shower team. If there is a weight difference of 5 lbs., shower team will weight the following day to verify if there has been a change in the weight.Further record review of Resident #45's weights, revealed that on 07/11/25 Resident #45 weighed 154.4 lbs. and on 07/24/25 weighed 150.5 lbs. Which is a (5) five pound weight loss. Resident #45 was not re-weighed until 07/27/25. During an interview on 08/27/25 at 9:42 AM, The Administrator confirmed that Resident #45 had not been re-weighed the next day for a (5) five pound weight loss like it says to do in the policy.

Based on staff and resident interviews, and observation The Facility failed to ensure residents knew they had the right to file grievances anonymously. This deficient practice had the potential to affect more than a limited number of residents. Facility Census 103: Findings included: a) During observation and resident interview on 08/25/25 at approximately 2:40 PM Resident #88 stated she did not know how to file a grievance anonymously, that she would just talk to the social worker if she had any complaints. In an interview with Resident #41 On 08/25/25 at 2:55 PM, the resident stated she did not know how to file a grievance/complaint anonymously but stated she would just talk to staff.Review of Section C of the most recent Minimum Data Set (MDS), revealed Residents #88 and #41 had capacity and were cognitively intact. A review of the facilities Grievance policy and Procedure revealed the residents have the right to file grievances without discrimination or reprisal. The policy stated the facility would notify residents individually and through postings on the right to file grievances verbally, in writing, or anonymously. During Residential council meeting on 08/26/2025 at 1:30PM, Resident #26, #36, and #44, were in attendance with capacity. They stated they did not know how to file a grievance form anonymously and stated they were never told how or where to file it. Based on record review of Section C of the most recent MDS record verified Residents #26, #36 and #44 had capacity and were cognitively intact. On 08/26/25 at 2:18 PM, during an interview with the Social Worker, she verified the facility had a locked box labeled complaints located on a shelf in the conference room hallway and acknowledged that residents in wheelchairs would not be able to reach it without staff assistance.

Based on observation and staff interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. This failed practice was a random opportunity for discovery.Resident identifiers: #51, #63 and #100. Facility Census: 101. a) Residents #51 and #63** On August 25, 2025, at 12:20 PM, the bathroom of Residents #51 and #63 was observed to have a very wet and slippery tile floor with standing water puddles around the toilet base. In an interview with Employee #55, she acknowledged the water puddles and slippery floor and stated she would report it to maintenance. In an interview with Maintenance #175 on 08/25/25, at 12:45 PM, he stated he had discovered the shower faucet was not completely turned off, which caused the standing water and slippery floor tiles in Residents #51 and #63's bathroom. b) Resident #101 On 08/25/25, at 3:46 PM, upon entering Resident #101's room, it was observed that she had a large pair of pink nail clippers in her hand with nail clippings in her lap. On 08/25/25, at 3:50 PM, in an interview with Employee #200, she acknowledged Resident #101 had nail clippers in her hands and stated she did not know where she got them or if it was permissible for her to have them. In an interview with LPN (Licensed Practical Nurse) #135 on 08/26/25, at 9:15 AM, she stated Resident #101 was not supposed to have the nail clippers in her room.

Based on observation and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide sanitary environment to help prevent the development and transmission of communicable diseases and infections with regards to the personal care equipment for two (2) residents. This failed practice was a random opportunity of discovery. Resident identifiers # 66 and #9. Facility census: 101. a) Resident # 66During facility entrance observation and interview on 08/25/25 at 3:40 PM, holes and exposed padding were observed on both Resident #66's wheelchair back rest and walker belt strap. b) Resident # 9In an interview with resident # 9 on 08/26/25 at 9:05AM, it was observed that her scooter chair had rips and tears on the right side back rest exposing the inner padding. During a facility walk through with the Infection preventionist on 08/27/25 at 9:35 AM she acknowledged both Resident #9's wheelchair and walker and Resident # 66's scooter chair had exposed inner padding. She stated they would be removed and repaired.

Based on observation, record review and staff interview the facility failed to implement a resident's comprehensive person-centered care plan. This was discovered for one (1) of 28 care plans reviewed during the Long-Term Care Survey Process in the areas of hospice scheduling, application and removal of a hand splint and nutritional interventions for weight loss. Resident Identifiers: #17, #23, #89, #49 and #91. Facility Census: #103 Findings Included: a) Resident #17 On 10/24/23 a record review found Resident #17 has hospice services through (name of Hospice organization) Hospice. On 10/25/23 at 9:00 AM record review found the care plan for Hospice services states the Hospice nurse is to visit two (2) times weekly and as needed. There is no care plan in place for the number of Aide visits. The care plan is to state scheduled days the nurse and aide is to provide services. Review of the aide visit notes from 09/19/23 through 10/17/23 shows the aide is coming randomly on various days of the week. Aide visit records show a visit on 09/19/23 and not again until 09/29/23. No Aide visit records were available since 10/17/23. A review of the shower schedule shows Resident #17 has showers scheduled for Friday and Tuesday. Since the Aide comes on various days of the week, the facility Certified Nurse Aide does not know if the hospice aide is coming to provide care or not. Review of the Nursing Visit Records from 08/29/23 through 10/18/23 found there were no nurse visits for the week of 09/04/23 or 09/25/23. An interview on 10/25/23 at 1:30 PM with the Director of Nursing, confirmed the above information. b) Resident #23 On 10/24/23 a record review found Resident #23 had hospice services through (name of Hospice organization) Hospice. On 10/25/23 at 9:00 AM a record review found the care plan for Hospice services states the Hospice nurse is to visit two (2) times weekly and as needed and the Hospice Aide is to provide care three (3) times per week. The care plan is to state scheduled days for the nurse and aide to provide services. Review of the aide visit notes from 10/04/23 through 10/17/23 shows the aide is coming randomly on various days of the week. No Aide visit records were available since 10/17/23. A review of the shower schedule shows Resident #23 has showers scheduled for Wednesday and Saturday. Since the Aide comes on various days of the week, the facility Certified Nurse Aide does not know if the hospice aide is coming to provide care or not. Review of the Nursing Visit Records from 09/12/23 through 10/18/23 show there were nurse visits on 09/12/23 and 09/19/23 and not again until 10/04/23. On 10/25/23 at 10:05 AM during an interview with Licensed Practical Nurse #139 and Certified Nurse Aide #167 neither of them knew the scheduled nurse or aide visits from (Name of Hospice organization) staff, in addition, they did not know where to locate the schedule. An interview on 10/25/23 at 1:30 PM with the Director of Nursing, confirmed the above information. c) Resident #89 On 10/24/23 record review found Resident #89 has hospice services through (name of Hospice organization) Hospice. On 10/25/23 at 9:00 AM record review shows the care plan for Hospice services states the Hospice Aide is to provide care three (3) times per week and the Hospice nurse is to visit two times weekly and as needed. The care plan is to state scheduled days for the nurse and aide to provide services. Review of the aide visit notes from 08/16/23 through 08/30/23 and 10/02/23 through 10/11/23 shows the aide is only coming twice a week, on Mondays and Wednesdays. Furthermore, there were no Aide visit notes available for September 2023. According to the (name of Hospice organization) Aide Schedule posted at the nurses station for the house Certified Nurse Aides reference, Resident #89's shower days are Monday ad Friday. Therefore, the Hospice aide is not present to provide care on Fridays. During an interview on 10/25/23 at 1:30 PM with the Director of Nursing, she confirmed there is an issue with the hospice services provided with this company and she is aware of the missed visits. d) Resident #49 During an observation on 10/25/23 at 10:50 AM Resident #49 who has contractures of left hand was observed without his hand splint in place. A record review on 10/25/23 at 11:00 AM of Resident # 49's care plan found on 10/12/23 an intervention to Apply splints as ordered for his left hand contracture. A record review on 10/25/23 at 11:05 AM of Resident #49's found an active order for a Palm Protector to Left hand, Applies by FMP staff and removed by nursing. To be worn 10AM-4PM. During an observation on 10/25/23 at 1:00 PM Resident #49 was again observed asleep in his room, and his left hand splint not in place During an interview on 10/25/23 at 1:00 PM, CNA #167 stated, Therapy usually gets him ready, But I don't guess they did today. I will take care of it. e) Resident #91 A medical record review on 10/25/23 for Resident #91 indicated there was a significant weight loss. On 07/04/23 the resident's weight was 137 pounds and on 08/13/23 her weight was 115 pounds. This was calculated at a 16 percent weight loss of 22 pounds. There was no evidence the physician or the dietician was notified regarding the change in condition. The comprehensive person-centered care plan for Resident #91 had a nutritional intervention to alert the dietician and the physician to any significant weight loss or gain, this was not implemented. In an interview with the Nursing Home Administrator and the Director of Nursing on 10/25/23 at 9:40 AM, both verified the comprehensive care plan had not been implemented regarding notifying the dietician or the physician of the significant weight loss for Resident #91. 45171 49465

Based on medical record reviews and staff interviews, the facility failed to collaborate with hospice services to develop coordinated care plans for four (4) of four (4) residents reviewed for the care area of hospice during the Long-Term Care Survey Process. The care plans for Resident #18, #17, #23, and #89 did not specify when and what services were to be provided by the hospice staff. Resident identifiers: #18, #17, #23, and #89. Facility census: 103. Findings included: a) Resident #18 A medical record review on 10/25/23 revealed the person-centered care plan for Resident #18 was not developed to collaborate hospice services with the facility. In an interview with the Director of Nursing on 10/25/23 at 1:50 PM, she verified the care plan did not specify when and what hospice services were to be provided. b) Resdient #17 On 10/25/23 at 9:00 AM, a record review found the care plan for Hospice services states the Hospice nurse is to visit two times weekly and as needed. There is no care plan in place for Aide visits. The facility is required to collaborate with hospice services to develop a coordinated care plan and specify when and what services were to be provided by the hospice staff. An interview with the Director of Nursing on 10/25/23 at 1:50 PM, confirmed the above information. c) Resident #23 On 10/25/23 at 9:00 AM record review found the care plan for Hospice services states the Hospice nurse is to visit two (2) [NAME] weekly and as needed and the Hospice Aide to provide care three (3) times per week. The facility is required to collaborate with hospice services to develop a coordinated care plan and specify when and what services were to be provided by the hospice staff. An interview with the Director of Nursing on 10/25/23 at 1:50 PM, confirmed the above information. d) Resident #89 On 10/25/23 at 9:00 AM record review foun the care plan for Hospice services states the Hospice Aide is to provide care three (3) times per week and the Hospice nurse is to visit two times weekly and as needed. The facility is required to collaborate with hospice services to develop a coordinated care plan and specify when and what services were to be provided by the hospice staff. An interview with the Director of Nursing on 10/25/23 at 1:50 PM, confirmed the above information. 45171

Based on observation and staff interview, the facility failed to establish and maintain an effective infection prevention and control program. Staff failed to remove gloves after incontinence care contaminating the residents bed and surrounding areas. A bedpan and two triangle graduate cylinders were noted hanging on the commode with the toilet seat lifted. This is true for one of one reviewed for wound care and a random opportunity for discovery. Resident identifiers: #69, #94 and #39. Facility census: 103. Findings included: 1. Resident (R) #69 Incontinence care On 10/25/23 at 8:50 AM, Nurse Practitioner (NP) #32 and Licensed Practical Nurse (LPN) #74 were observed performing incontinence care after completing wound care on R #69. NP #32 wiped the stool off of R #69's behind and placed a new pad under the resident with the assistance of LPN #74. Without removing her soiled gloves, NP #32 assisted with repositioning the resident, pulled the sheet and blanket up to R #69's chin, and touched the upper bed rail. NP #32 removed one glove and carried the trash to the bathroom. NP #32 returned to the bedside table with one contaminated glove still on, cleaned off the bedside table and then removed the soiled glove. The above findings were reviewed with NP #32 immediately after this observation. NP #32 acknowledged she should have removed her gloves after providing incontinence care and agreed she contaminated multiple areas around R #69's bed and room. 2. Medical equipment storage. On 10/25/23 at 8:20 AM an observation in Resident (R) #94 and R#39's bathroom revealed two clear bags hanging on the back of the commode with the toilet seat up. Both bags were resting against the toilet bowel edge. One bag contained a triangle graduate cup for urine measurement and the other contained a bed pan and a triangle graduate cup. Licensed Practical Nurse (LPN) #164 confirmed the bedpan and urine measurement cups were improperly stored during an interview at 8:22 AM on 10/25/23.

Based on policy review, record review and staff interview, the facility failed to develop, promote, and implement a facility-wide system to monitor the use of antibiotics. This was true for two (2) out of three (3) residents reviewed for antibiotic use during the Long-Term Care Survey Process. Resident identifiers: #47 and #204. Facility census: 103. Findings included: a) Antibiotic Stewardship Program Policy, revised on 02/25/22 Review of the facility's Antibiotic Stewardship Program policy, completed on 10/25/23 at 9:15 AM, revealed: -The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. -The program includes antibiotic use protocols and a system to monitor antibiotic use. -The facility uses the McGeer Criteria to define infections. -Attending physicians prescribe appropriate antibiotics in accordance with standards of practice and facility protocols. b) Resident #47 A record review, completed on 10/25/23 at 9:35 AM, revealed the following physician orders: -Amoxicillin-Pot Clavulanate Oral Tablet 875-125 MG (Amoxicillin & Pot Clavulanate) Give 875 mg by mouth two times a day for sinusitis for 10 Days. Start Date: 10/16/2023 Further medical review did not find an Infection Screening Evaluation / McGeer Criteria Checklist on file. -Amoxicillin-Pot Clavulanate Oral Tablet 875-125 MG (Amoxicillin & Pot Clavulanate) Give 875 mg by mouth two times a day for sinus infection for 5 Days. Start Date: 09/10/2023 Further medical review did not find an Infection Screening Evaluation / McGeer Criteria Checklist on file. c) Resident #204 A record review, completed on 10/25/23 at 9:50 AM, revealed the following physician orders: -Keflex Oral Capsule 500 MG (Cephalexin) Give 500 mg by mouth three times a day for UTI (Urinary Tract Infection) for 7 Days. Start Date:10/23/2023 Further medical review did not find an Infection Screening Evaluation / McGeer Criteria Checklist on file. d) Infection Preventionist Interview During an interview on 10/25/23 at 10:20 AM, the Infection Preventionist stated as part of the facility's Infection Prevention Control Program, the facility developed an antibiotic stewardship program that promotes the appropriate use of antibiotics and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance. The Infection Preventionist described the following protocol that should be followed (according to their antibiotic stewardship program) prior to a physician ordering an antibiotic for a resident: -When a nurse has identified a resident is experiencing a change in condition, the nurse should complete a SBAR (Situation, Background, Assessment, Recommendation) Report, -Then the nurse should complete an Infection Screening Evaluation to determine if the McGeer's Criteria is met, -Then the nurse should contact the doctor. The Infection Preventionist went on to confirm that having met the McGeer's Criteria is an indication it would be appropriate to prescribe antibiotics in accordance with standards of practice and with the facility protocols for antibiotic stewardship. When asked about the 10/16/23 order for Amoxicillin for Resident #47, the Infection Preventionist reported there was no Infection Screening Evaluation / McGeer's Criteria Assessment tied to this order. The nurse did not do it. When asked about the 09/10/23 order for Amoxicillin for Resident #47, the Infection Preventionist reported there was no Infection Screening Evaluation / McGeer's Criteria Assessment tied to this order. The nurse did not do it. When asked about the 10/23/23 Keflex order for Resident #204, the Infection Preventionist reported there was no Infection Screening Evaluation / McGeer's Criteria Assessment tied to this order. The nurse did not do it. When asked the Infection Preventionist confirmed that all facility doctors had been trained on the antibiotic stewardship program and that each physician should question if an Infection Screening Evaluation / McGeer's Criteria Assessment had indicated the need for an antibiotic prior to issuing an order. The Infection Preventionist agreed for a physician to not question if a McGeer's Criteria Assessment had been done was not in accordance with standards of practice and facility protocols. The Infection Preventionist reported she had noticed an uptick on the Infection Screening Evaluations / McGeer's Criteria Assessment not being completed and antibiotics still being prescribed in September 2023. The Infection Preventionist stated she reported these details at the October Quality Assurance (QA) meeting. Every month at the QA meeting, the Infection Preventionist notifies the QA Team what antibiotics were ordered, who the ordering physician was, and what met criteria and what did not. She vividly recalled questioning the overuse of antibiotics. To her knowledge no action had been taken on her report.

Based on observation and staff interview, the facility failed to provide care and treatment in a dignified manner. Staff signed and dated a dressing after it was affixed to Resident #69's body. This is true for one (1) of one (1) reviewed for wound care. Resident identifier: # 69. Facility census: 103. Findings included: a) Resident #69 On 10/25/23 at 8:50 AM Nurse Practitioner (NP) #32 was observed performing wound care and a dressing change on Resident (R) #69's buttocks. After cleaning the wounds, NP #32 applied two clean dressings onto R #69's buttocks. NP #32 signed and dated both dressings after they were affixed to the resident's body. An interview was conducted immediately after this observation with the wound care team: NP #32, Licensed Practical Nurse (LPN) #74 and LPN #124. All three nurses reported they were unaware they should not sign and date a dressing after it is applied to a resident's body. During an interview on 10/25/23 at 9:00 AM the Director of Nursing (DON) agreed staff writing on a dressing after it is affixed to the resident's body is a dignity concern. The DON acknowledged the dressing should be signed and dated before it is applied to the resident's body.

Based on medical record review and staff interview the facility failed to notify the physician and resident representative of a change in condition. This was discovered for one (1) of three (3) residents reviewed for the care area of nutrition during the Long-Term Care Survey Process. Resident # 91 had a significant weight loss and the physician and resident representative was not notified. Resident identifier: #91 Facility census: 103 Finding included: a) Resident #91 A medical record review on 10/25/23 for Resident #91 indicated there was a significant weight loss. On 07/04/23 the resident's weight was 137 pounds and on 08/13/23 her weight was 115 pounds. This was calculated at a 16 percent weight loss of 22 pounds. There was no evidence the physician or the resident representative was notified regarding the change in condition. In an interview with the Nursing Home Administrator and the Director of Nursing on 10/25/23 at 9:40 AM, both verified the physician and the Resident Representative had not been notified of the significant weight loss for Resident #91.

Based on record review and staff interview the facility failed to follow Physicians order for medication administration and failed to have an order for pressure ulcer care. Resident Identifiers: #17 and #12. Facility Census: #103 Findings included: a) Resident #17 On 10/24/23 at 10:22 AM record review of Resident #17's care plan found she had a stage IV pressure injury to her sacrum. Review of her current orders found no Physicians order for pressure ulcer treatment. During an interview on 10/25/23 at 10:00 AM Licensed Practical Nurse Wound Nurse Assistant #124 confirmed Resident #17 did have an open, stage IV pressure injury to her sacrum. She stated the wound care team failed to reassess a treatment order that was limited to fifteen (15) days for the pressure injury treatment. Wound care was provided on 10/18/23 and then the order fell off the Treatment Administration Record (TAR) due to the fifteen (15) day restriction on the antibiotic order. Therefore the pressure injury wound has not been treated for the last six (6) days. This was confirmed by documentation on the TAR for October. The pressure injury was being treated with an antibiotic. The original order stated: Flagyl Oral Tablet 500 milligrams. Apply to PI (pressure injury) topically every day shift for Stage IV. Crush med, place in wound bed, pack lightly with tegaderm alginate rope and cover with foam border dressing. The above information was confirmed with the Director of Nursing on 10/25/23 at 1:05 PM. b) Resident #12 On 10/23/23 at 3:13 PM, a brief record review completed on Resident #12's October 2023 Medication Administration Record (MAR) revealed the following physician orders and times the prescribed medications were not administered because Resident #12 was noted to be sleeping: -9:00 PM, Atorvastatin Calcium Tablet 40 MG, Give 40 mg by mouth one time a day Related to HYPERLIPIDEMIA - Not given 10/12/23 because Resident #12 was sleeping -9:00 PM, Mirtazapine Oral Tablet, Give 7.5 MG tablet by mouth at bedtime related to MAJOR DEPRESSIVE DISORDER RECURRENT, SEVERE WITH PSYCHOTIC SYMPTOMS - Not given on 10/12/23 because Resident #12 was sleeping -9:00 PM, Nortriptyline HCL Oral Capsule, Give 50 MG Capsule by mouth at bedtime related to HEREDITARY AND IDIOPATHIC NEUROPATHY - Not given on 10/12/23 because Resident #12 was sleeping -9:00 PM, Omeprazole Tablet Delayed Release, Give 20 MG by mouth one time a day related to GASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS - Not given on 10/12/23 because Resident #12 was sleeping -600 AM, Synthroid Tablet, Give 100 MCG by mouth one time a day related to HYPOTHYROIDISM - Not given on 10/12/23 because Resident #12 was sleeping -9:00 PM, [NAME] Petrolatum - Mineral Oil Ointment, Instill 1 application in both eyes one time a day for dry eyes - Not given 10/12/23 because Resident #12 was sleeping -9:00 PM, Ticagrelor Tablet, Give 90 MG Tablet by mouth two times a day related to ATHEROSCLERTOIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECOTORIS - Not given 10/12/23 because Resident #12 was sleeping -9:00 PM. Vitamin E Oral Tablet, Give 400-unit oral tablet by mouth two times a day for supplement - Not given 10/12/23 because Resident #12 was sleeping -9:00 PM, Atorvastatin Calcium Tablet 40 MG, Give 40 mg by mouth one time a day Related to HYPERLIPIDEMIA - Not given 10/17/23 because Resident #12 was sleeping -9:00 PM, Mirtazapine Oral Tablet, Give 7.5 MG tablet by mouth at bedtime related to MAJOR DEPRESSIVE DISORDER RECURRENT, SEVERE WITH PSYCHOTIC SYMPTOMS - Not given on 10/17/23 because Resident #12 was sleeping -9:00 PM, Nortriptyline HCL Oral Capsule, Give 50 MG Capsule by mouth at bedtime related to HEREDITARY AND IDIOPATHIC NEUROPATHY - Not given on 10/12/23 because Resident #12 was sleeping -9:00 PM, Omeprazole Tablet Delayed Release, Give 20 MG by mouth one time a day related to GASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS - Not given on 10/17/23 because Resident #12 was sleeping -600 AM, Synthroid Tablet, Give 100 MCG by mouth one time a day related to HYPOTHYROIDISM - Not given on 10/17/23 because Resident #12 was sleeping -9:00 PM, [NAME] Petrolatum - Mineral Oil Ointment, Instill 1 application in both eyes one time a day for dry eyes - Not given 10/17/23 because Resident #12 was sleeping -9:00 PM, Ticagrelor Tablet, Give 90 MG Tablet by mouth two times a day related to ATHEROSCLERTOIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECOTORIS - Not given 10/17/23 because Resident #12 was sleeping -9:00 PM. Vitamin E Oral Tablet, Give 400-unit oral tablet by mouth two times a day for supplement - Not given 10/17/23 because Resident #12 was sleeping During an interview on 10/24/23 at 2:40 PM, the Director of Nursing (DON) reported the professional standard of practice would be for the nurse to attempt to wake a sleeping resident gently, if no response it would be appropriate to temporarily move on to other residents, circle back to the sleeping resident and try again to wake them up. The DON went on to report that especially for scheduled nighttime medications it would be necessary to wake them up to ensure the physician order was followed. The DON noted if it was a pattern the resident could not be roused, the attending physician should be contacted to determine if they would like to change the time of the mediation administration. The DON agreed there was no documentation in the medical record that Licensed Practical Nurse (LPN) #23 had attempted to wake Resident #12 up nor did LPN #23 document the physician was notified of the fact that resident was sleeping through medication administration times. 45171

Based on resident interview, record review, and staff interview, the facility failed to assist a resident in locating his lost hearing aide This was true for one (1) out of ( 2) residents reviewed for communication. Resident identifier #90. Facility census: 103. Findings included: a) Resident #90 During an initial interview on 10/23/23 at 11:15 AM, Resident #90 stated, Can you speak up, I can't hear without my hearing aide. Surveyor observed a hearing aide in Resident #90's left ear. Resident #90 stated, I am supposed to have hearing aides in both of my ears, they lost one of them. I haven't had it for a long time. When asked if he had reported it to anyone? Resident #90 stated, I have told all kinds of people I am not sure who they was. Resident #90 has a BIMS of 14 indicating he is cognitively intact. A record review on 10/24/23 at 9:00 AM, found on Resident #90's admission nursing assessment dated [DATE] the resident was admitted with hearing aides in both ears. During a record review on 10/24/23 at 9:15 AM Resident #90's admission MDS dated [DATE] section b300 was marked yes for hearing aides or other hearing devices. A review of Resident #90's care plan on 10/24/23 at 9:15 AM, found Resident #90's care plan did not contain any mention of hearing aides. During an interview on 10/24/23 at 10:00 AM with day shift Licensed Practical Nurse (LPN) #181 was asked how she know Resident #90 wears hearing aides and when to put them in and change the batteries? Employee #181 stated, It is listed on the TAR. A record review on 10/24/23 at 11:45 AM, Resident #90's TAR for September and October found no mention of hearing devices. During an interview with the Social Worker on 10/24/23 at 10:15 AM she stated, Resident #90 has never mentioned this to me, and I was not aware that he had 2 hearing aides. During an interview with the Director of Nursing (DON) on 10/24/23 at 11:00 AM she stated, I believe his hearing aide got sent to the VA to get fixed, I will check up on that. A record review on 10/24/23 at 2:00 PM, found a Nursing Progress note dated for 04/13/23 which read as follows, Mailed Hearing aides per residents request to {local VA} Attention: Audiology Services. During an interview on 10/24/23 with the DON at 3:45 PM, she stated, Here is a letter about residents hearing aids Letter read as follows, (Name of Resident #90)'s hearing aides were repaired and sent to a PO BOX. (Name of Resident #90)'s friend will be checking his box by the end of the week and will be bringing them in.

Based on record review and staff interview the facility failed to provide care to a pressure ulcer injury in order to promote healing. Resident Identifiers: #17. Facility Census: #103 Findings included: a) Resident #17 On 10/24/23 at 10:22 AM, a record review of Resident #17's care plan found she had a stage IV pressure injury to her sacrum. Review of her current orders found no Physicians order for pressure ulcer treatment. During an interview on 10/25/23 at 10:00 AM Licensed Practical Nurse Wound Nurse Assistant #124 confirmed Resident #17 did have an open, stage IV pressure injury to her sacrum. She stated the wound care team failed to reassess a treatment order that was limited to fifteen (15) days for the pressure injury treatment. Wound care was provided on 10/18/23 and then the order fell off the Treatment Administration Record (TAR) due to the fifteen (15) day restriction on the antibiotic order. Therefore the pressure injury wound has not been treated for the last six (6) days. This was confirmed by documentation on the TAR for October. The pressure injury was being treated with an antibiotic. The original order stated: Flagyl Oral Tablet 500 milligrams. Apply to PI (pressure injury) topically every day shift for Stage IV. Crush med, place in wound bed, pack lightly with tegaderm alginate rope and cover with foam border dressing. The above information was confirmed with the Director of Nursing on 10/25/23 at 1:05 PM.

Based on medical record review, resident interview, observation and staff interview, the facility failed to ensure the residents' environment remains as free of accident hazards as is possible. Morning medications were left in Resident #37's room unsupervised and not taken until hours later. Antifungal powder was left on R #90's dresser. These were random opportunities for discovery. Resident identifiers: R #37 and R #90. Facility census: 103. Findings included: a) Resident (R) #37 During an interview and observation on 10/23/23 at 12:22 PM, R #37 retrieved a medicine cup containing 12 pills/tablets from his desk. When questioned, R #37 reported they were his morning medications that the nurse left for him to take. R #37 stated he took one pill, the rest included psyche meds for his head so he didn't take them. On 10/23/23 at 12:27 PM, Licensed Practical Nurse (LPN) #179 acknowledged she left the pills in there this morning and added the resident stated he would take them. LPN #179 said she would go get the pills. Review of the medical record on 10/24/23 found LPN #179 signed out the following medications for R #37 at 9:00 AM: aspirin 81 milligrams (mg), Finasteride 5 mg, Metoprolol Succinate ER 25 mg (antihypertensive), Protonix 40 mg, two Venlafaxine Hydrochloride (HCL) (antidepressant) 150 mg each, vitamin D3 1000 international units (IU), Buspirone HCL 15 mg (antianxiety), Entresto 24-26 mg, mucinex 1200 mg, and one Super Beta Prostate tablet. The preadmission screening (PAS) form dated 08/31/23, states under section #28, R#37 in not capable of administering his own medications. The Director of Nursing confirmed the nurse should watch the resident take his medications and not leave them in the room, during an interview on 10/24/23 at 12:00 PM. b) Resident #90 During an observation on 10/23/23 at 12:30 PM, a bottle of Phytoplex anitfungal poweder was observed setting in the room of Resident #90 on the dresser underneath the TV. During an interview on 10/23/23 at 12:30 PM Resident #90 stated, I always have that in my room, they use it to put on my private area. During an obervation on 10/24/2023 at 9:30 AM, the same bottle of Phytoplex antifungal powder was still sitting in the room of Resident #90 on the dresser underneath the TV. During an observation on 10/24/23 at 10:00 AM the warning label on the back of the bottle of Phytoples anitfungal powder read under warnings { Keep out of reach of children. If swallowed get medical help or contact a Poision Control Center right away. A record review on 10/24/2023 at 11:00 AM revealed two (2) residents on the same hall as Resident #90 has Alzheimer's and wander. During an interview on 10/24/23 at 3:00 PM, the DON stated, Of course that bottle is in there. She then went in and removed the bottle. 49465

Based on record review and staff interview, the facility failed to ensure complete and accurate medical records. Resident #204's capacity status was incorrect in PointClickCare (the facility's electronic medical record software.) Resident #37's code status order was incorrect and did not match resident's Care Plan or resident's preference. This is true for two (2) of four (4) residents reviewed for Advanced Directives. Resident identifiers: Resident #204 and Resident #37. Facility census: 103. Findings included: a) Resident #204 When first opening Resident #204's electronic medical record, on 10/23/23 at 4:09 PM, the viewer immediately saw resident's name, gender, date of birth, age, physician, allergies, and code status. The code status was listed as DNR (Do Not Resuscitate), HAS Capacity. The Physician Determination of Capacity, dated 10/13/23, reflected Resident #204 LACKS capacity. During an interview on 10/24/23 at 1:22 PM, Licensed Practical Nurse (LPN) Clinical Supervisor #16 confirmed the error in the medical record and stated she felt it must have happened because two (2) people had worked on the admission. b) Resident #37 Review of the medical record on 10/24/23 revealed a social services note dated 09/01/23 stating R#37 requested to be a full code. The current physician orders include an order written on 09/09/23 stating Do Not Resuscitate. The medical record was reviewed with Social Worker (SW) #122 on 10/24/23 at 12:00 PM. SW #122 reported the social workers review the code status with each resident and family on admission. The resident's choice is documented in the initial social worker's note in the chart. SW #122 reported R#37 requested to be a full code. SW #122 stated the physician orders were incorrect, she would notify the nurse to change the orders. 43340

Based on observation, record review and staff interview the facility failed to develop and implement an infection control program designed to prevent the spread of communicable diseases. The laundry room door would not stay closed, hand hygiene was not provided to residents before meals, infection control standards were not followed during wound care, soiled linen was placed on the floor and staff did not don PPE (personal protective equipment) before entering a droplet precaution room. This failed practice had the potential to effect more than an isolated number of residents. Resident identifiers: #136, #70, #47, #20, #23, and #80. Facility census 86. Findings Included: a) Laundry room On 07/27/22 at 8:53 AM, this surveyor observed the door between the potentially contaminated linen and clean linen side of the laundry room to be open. Environmental Service Aide (ESA) #73 stated that the door between the dirty and clean laundry rooms will not stay closed. ESA #73 stated I feel the breeze today. On 07/27/22 at 9:20 AM, the Administrator acknowledged the door between the dirty and clean side of the laundry room should stay closed. A review of a facility provided policy labeled laundry process with no effective date found the following reference: Centers for Disease Control and Prevention (CDC), Guidelines for Environmental Infection Control in Health-Care Facilities, Recommendations of CDC and the Health care Infection Control Practices Advisory committee (HICPAC)https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5210a1.htm revealed the following information: II. Laundry Facilities and Equipment .Maintain the receiving area for contaminated textiles at negative pressure compared with the clean areas of the laundry b) Reflections dining room - no hand hygiene during mealtime During an observation of lunch being served on the Reflections dining room on 07/26/22 at 12:00 PM, found there were 11 residents seated in the dining room. Staff passed out clothing protectors and meal trays. The staff failed to offer hand hygiene to any of the 11 residents. On 07/26/22 at 12:10 PM, Registered Nurse #206 and Nurse Aide #49 both agreed they did not provide any hand hygiene prior to serving lunch. On 07/26/22 at 12:42 PM, Administrator informed of the above findings. c) Resident #136 Observation of wound care on 07/26/22 at 3:09 PM, with LPN #14 found LPN #14 obtained a bottle of hand sanitizer from the top of the treatment cart. LPN #14 entered the the room of Resident #136. LPN #14 placed the bottle of hand sanitizer on the table without placing it on a barrier or cleaning the table prior to placing the bottle on the table. While applying the medication, which was in a paste form to the buttocks of Resident #136, LPN #14 moved her glasses on the top of her head and back on her nose three times while wearing the soiled gloves that were used to apply the paste. LPN #14 was asked if she was aware she had handled her glasses throughout the procedure? LPN #14 said, No I didn't even think about it. LPN#14 said she was planning on putting the hand sanitizer back on the treatment cart. On 07/26/22 at 3:15 PM, Administrator was informed of the above observations. d) Resident #70 - Wound Care Observation of wound care for Resident #70 on 07/27/22 at 1:42 PM, with Licensed Practical Nurse (LPN) #14 found the following: LPN #14 began by placing the wound treatment supplies on the bedside table without cleaning the table first. LPN #14 removed the dressing to the right hip, dated 07/25/22. It was noted the right hip had a healing bruise greenish/yellow in color and approximately 10 centimeters (cm) by 10 cm in size. Inside of the bruise boarders were three (3) opened wounds. LPN #14 pointed to the smallest wound and said this is the one she was treating. LPN #14 poured normal saline on one 4x4 gauze. With one single wiping motion across the right hip, LPN #14 wiped all three (3) opened wounds at once. LPN #14 again wiped all three (3) wounds with a single dry 4x4 gauze. Then LPN #14 opened one premedicated single use skin prep and wiped it over all three open wounds before applying the dressing. LPN #14 removed the dressing dated 07/25/22 from the left hip and revealed two opened wounds with discolored dark skin around the wounds. Once again LPN #14 did not clean or treat each wound separately, wipping both wounds with the same gauze. LPN #14 removed one glove from her right hand, put a very small amount of hand sanitizer on the tips of the fingers on the right hand and rubbed her fingers and thumb together for 3 seconds before putting on one new glove to the right hand. Using her left hand, she held the Calcium Alginate (this was ordered for the right hip and was applied to the left hip) to the two open wounds while applying the foam dressing on the wounds. On 07/27/22 at 2:30 PM, Administrator was informed of the observation. The Administrator stated she was in the process of have a group come into the facility to provide wound care. 44981 e) Resident #47 On 07/25/22 at approximately 1:20 PM, an observation was made during incontinence care for Resident #47. Nurse Aide (NA) #72 and NA #78 were observed throwing dirty linen and a soiled brief on the floor without a barrier leaving a wet spot directly on the floor. On 07/25/22 at 1:27 PM, NA #78 stated, I forgot, when asked about using a barrier during incontinence care. NA #72 made no statement. Licensed Practical Nurse (LPN) # 77 confirmed the dirty linen and the soiled brief should not be put directly on the floor and the items were not discarded into a designated container. The facility policy entitled Perineal Care, step #11 states, Discard disposable items into designated containers . On 07/25/22 on 1:44 PM, the Director of Nursing (DON) was notified. The DON stated I'm embarrassed .I'm sorry. No further information was obtained during the survey process. f) Resident #20 On 07/25/22 at 11:26 AM, Resident #20 was found to be in a transmission-based precaution room for droplet precautions for observation due to the resident being a new admission to the facility. On 07/25/22 at 11:40 AM, NA #61 did not put any personal protective equipment (PPE) on prior to entering the droplet precaution room. NA #61 stated I don't have to if I'm just picking up a tray. LPN #34 confirmed PPE was not worn into the droplet precaution room. The signage placed on the door of room [ROOM NUMBER]-P, has illustrations of what preferred PPE should be worn during droplet precautions. These include face shield or goggles, an N95 face mask or higher, one pair of clean, non-sterile gloves and an isolation gown. On 07/25/22 at approximately 12:00 pm, the Administrator was notified of the breach of infection control in a transmission-based precaution room. No further information was obtained during the survey process. g) Resident #23 On 07/27/22 at 12:35 PM, wound care was observed for Resident #23. LPN #14 did not wear a gown upon entering the enhanced barrier precaution room. LPN #14 was asked why the isolation gown was not worn? LPN #14 said, It's a new policy .I forgot. The signage on the door of Resident #23's room states, wear gloves and gown for the following high-contact resident care activities .wound care: any skin opening requiring a dressing. On 07/27/22 at 12:48 PM, the Administrator notified. No further information was obtained during the survey process. h) Resident #80 On 07/27/22 at 2:12 PM, wound care to the sacrum was performed by LPN #124. The bedside table was not cleaned prior to placing the barrier on the bedside table. The resident's personal belongings were left on the table. These personal belongings could contaminate the surrounding field. The personal belongings left were a crumbled up napkin, water pitcher, open pop can, a water bottle and a box of tissues. The bed control was on the floor and LPN#124 picked it up with a gloved hand and did not remove the glove or complete hand hygiene after placing the bed control back on the bed. LPN #124 also moved the bedside table and opened the door with a gloved hand. LPN #124 did not remove the glove or complete hand hygiene after touching these items. On 07/27/22 at 2:40 PM, wound care to the right heel was performed by LPN #14. While wound care was being completed to the sacrum by LPN #124, LPN #14 placed the wound care supplies on a chest of drawers without cleaning the chest of drawers. LPN #14 then moved the wound supplies to the bedside table without cleaning the table. The resident's personal belongings were left on the table. These personal belongings could contaminate the surrounding field. The personal belongings left were a crumbled up napkin, water pitcher, open pop can, water bottle, and a box of tissues. Throughout the process of wound care to the right heel, LPN #14 touched her eye glasses multiple times with unclean and ungloved hands. On 07/27/22 at 3:05 PM, LPN #14 and LPN #124 stated, do we have to move the personal belongings? LPN #124 stated, I didn't realize I picked up the bed control with the same gloves. LPN #14 stated, Did I touch my glasses? On 07/27/22 at approximately 3:30 PM, the Administrator was notified of the findings during wound care for Resident #23 and #80. No further information was obtained during the survey process. 45173

Based on observation and staff interview, the facility failed to ensure two (2) of 28 sampled residents had a dignified dining experience. Staff stood over residents while assisting them to eat. Resident identifiers: #70 and #57. Facility census: 86. Findings included: a) Resident #70 Observation at 11:42 AM on 07/26/22, found the resident received his noon meal. The resident was in his room, in bed when the meal was served. Nurse Aide (NA) #118 was standing beside the bed looking down on Resident #70 while feeding him. NA #118 was asked if she should sit down when feeding the Resident? NA #118 replied, he's a feeder and I stand up when I feed him. b) Resident #57 On 07/26/22 at 11:45 AM, NA #17 was observed standing by Resident #57's bed looking down on the resident while feeding him the noon meal. Resident #57 was in bed. NA #17 said she usually doesn't sit down when feeding Resident #57. On 07/26/22 at 1:25 PM, the administrator said a nursing assistant should sit down when feeding a resident. The administrator asked if the residents were eating in their rooms? The surveyor replied yes, and the administrator said, Well I don't know if they need to sit down if the residents are eating in their rooms. The surveyor asked if feeding residents in their rooms was different than feeding a resident in the dining room? The administrator replied, No, I didn't really mean what I said.

Based on observation, medical record review, staff interview, and policy review, the facility failed to provide the necessary care and services to attain the highest practicable physical, mental and psychosocial well-being in accordance with the resident's plan of care for one (1) of three (3) Stage 2 residents reviewed for pressure ulcers. The facility failed to provide pain medication to a resident who expressed pain either verbally or nonverbally during activities of daily living (ADL) care and/or wound treatment. Resident identifier: #142. Facility census: 64. Findings include: a) Resident #142 During a Stage 1 interview on 12/29/14 at 1:10 p.m., Employee #62, a licensed practical nurse (LPN), related Resident #142 had pressure ulcers on her heels. Review of the medical record, on 12/29/14 at 5:09 p.m., revealed a pressure ulcer assessment, which indicated the resident had an unstageable pressure ulcer (PU) on her right heel and an unstageable pressure ulcer on her left heel. In an interview with Employee #141, a nursing assistant (NA), on 01/06/15 at 2:46 p.m., she related she observed indications of pain when providing ADL care with Resident #142. She indicated the resident expressed pain when staff provided incontinence care. The NA said she wiped around the areas on the resident's buttocks, because they were sore. Employee #53, a NA, interviewed on 01/06/15 at 2:50 p.m., also indicated Resident #142 had pain with ADL care related to skin issues. A wound dressing change was observed on 01/06/15 at 9:45 a.m. Employee #127, a registered nurse (RN) prepared to change the resident's pressure ulcer dressings with the assistance of Employee #34 (NA). The NA said, "I don't think she likes this," and the RN replied, "I do think she has some pain with this." When Employee #127 cleansed the resident's right heel, the resident furrowed her eyebrows, but did not verbalize pain. After completing the heel dressings, the RN provided treatment to the open areas on the resident's buttocks, which were identified as skin acquired moisture damage (MASD). Each buttock had three (3) open areas with defined borders, and appeared as shallow craters. When the nurse made a large swipe with a 4x4 gauze pad which contained wound cleanser across the resident's right buttock, Resident #142 cried out, "Oh, stop, stop." The RN continued with the treatment. She obtained another 4x4 gauze with wound cleanser and wiped across the resident's left buttock. The resident again cried out "Stop," and reached back to push away the nurse's hand. The nurse continued with the treatment and applied cream to each buttock, then asked the resident, "Now, doesn't that feel better?" During an interview with Employee #130, a licensed practical nurse (LPN), on 01/06/2015 10:45 a.m., the nurse reviewed the medical record and related pain medication had not been administrated to Resident #142 since her admission. The LPN said "... if staff knew it (pain) was an issue, pain medication would be administered one half (1/2) hour before the dressing change." She related no one had ever asked her to medicate the resident. Progress notes, reviewed on 01/06/2015 12:19 p.m., revealed no evidence the resident expressed pain either verbally or nonverbally. In addition, pain flow sheets indicated the resident had "0" pain. An interview with the director of nursing (DON), in the presence of Employee #127, on 01/06/15 at 12:45 p.m., revealed she "... would expect a nurse to stop the treatment and provide pain intervention or provide intervention prior to starting a treatment if pain is anticipated." Employee #127 confirmed the resident grimaced during previous dressing changes, as an expression of discomfort. After discussion, the RN related she had not thought to give the resident anything for pain, because she believed the cream would help. .

Based on facility record review, hospital record review, staff interview, and anonymous information received during a complaint investigation, the facility failed to provide adequate amounts of fluid to maintain proper hydration for one (1) of ten (10) sampled residents. The resident experience a change in health status and was subsequently hospitalized . An admitting [DIAGNOSES REDACTED]. Resident identifier: #105. Facility census 103. Findings include: a) Resident #105 A review of the medical record revealed this [AGE] year old male was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. He had a Foley catheter placed to facilitate healing of the pressure ulcers. At 4:00 p.m. on 03/03/12, after transferring himself from the wheelchair into bed, Resident #103 complained to nursing that his Foley catheter was hurting him. He had 200 cc of amber urine in his drainage bag. At 9:00 p.m. the nurse's note, written by Nurse #4, stated, "...resident was c/o (complaining of) pain upon exam. It was noted cath (catheter) was clamped - and there was some blood in the cath bag." The physician was notified and the catheter was discontinued at the resident's request. The nurse also noted, "Resident voided X 3 lg amts of cl (large amounts of clear) amber urine since." The nurse's note by Employee #115 (Registered Nurse) stated at 2:00 p.m. on 03/04/12, "Resident c/o burning with urination. Will obtain clean catch UA (urinalysis) with resident's next void." There was no evidence a urine specimen was obtained or sent for testing. The medical record contained no entries for 03/05/12 or 03/06/12. The last nurse's note which contained any reference to intake or output was 03/03/12. There were no further entries in the nurse's notes indicating either intake or output until four (4) days later, on 03/07/12 at 11:00 p.m. Nursing notes, dated 03/07/12 at 11:25 a.m., described the resident had an unwitnessed fall in the bathroom. He sustained a two (2) inch scratch to the top of his head. The physician was notified and the resident was sent to the emergency room for examination. A CAT scan failed to identify any acute injury and the resident was returned to the facility at 4:30 p.m. While in the emergency room , a urinalysis was done. The resident was diagnosed with [REDACTED]. At 11:00 p.m. on 03/07/12, the nurse's notes stated, "Resident rested most of evening taking clothes off - throwing empty cups and other items on floor - ". This was the first entry of these behaviors in either the nurses' notes or the social service notes since admission. The nurse included, "Nutritional intake fair." There was no other intake and output information in the nurse's note. At 12:45 a.m. on 03/08/12, the notes indicted the resident "...had emesis X 1." At 7:35 p.m. on 03/08/12, the resident was described as, "...very quiet this evening..." At 11:00 p.m. on 03/09/12, the resident, "...refused to eat supper.. had 360 cc of H2O....Very hard to wake resident up tonight. Temp (temperature) was taken at 11p 100.5 ax (axillary) - cool wash cloths applied at this time..." The medical record contained no evidence of any follow up nursing assessment until an entry at 4:00 p.m. on 03/11/12 (forty-one (41) hours later), which noted the resident had "difficulty swallowing pills..." At 2:30 p.m. on 03/12/12, Nurse #109 notified the physician the resident had a temperature, was lethargic, and "was still not doing well." Orders were received to stop the antibiotic and obtain urine for testing "in the morning." At 10:30 p.m. on 03/12/12, the notes indicated, "Resident refuse meals....lethargic." At 7:30 p.m. on 03/13/12, the notes indicated, "Resident lethargic - combative..." He was visited by the attending physician and sent to the emergency room at 7:00 p.m. The attending physician's progress notes of 03/13/12 stated, "Unresponsive, Shook him several times. Doesn't wake up. Nurses report pt (patient) has been sleeping for 2 days now. Refuses to take meds. Does not want to eat. Plan to send to ER for evaluation." Review of the facility's investigation of an allegation, made by the resident's son, revealed signed statements from three (3) nursing assistants, NAs, (#9, #97, and #107). The son alleged the facility failed to ensure adequate fluid intake to prevent dehydration, prior to the resident's hospital admission on 03/13/12. The statements from the NAs each described the resident had stopped eating and/or drinking in the days before his transfer, although none of them could recall exact dates. Their statements, all taken on 03/20/12, included the following (typed as written): -- NA #9: "He stop eating and drinking. We reposition him every 2 hrs. He just mumbled when we did it. When in room stop responded. He would let drinks run out of his mouth. " -- NA #97: "The last 2 times I worked with (resident #105) he would not eat or drink that much for me. I tried to feed him but he said he just couldn't do it and the nurse tried to and she couldn't get anything in him . He would not get up or out of bed either." -- NA #107: "(Resident) had refused to eat or drink. Stop talking just mumbled while we were repositioning him. When asking him a question he wouldn't respond." NAs #9 and #97 verified their statements when interviewed at 10:45 a.m. on 05/24/12, but could not explain the amounts entered by them on the 'Fluid Intake Detail Report' and the 'I/O Detail Report'. These reports showed a total, on 03/12/12, of 1140 cc, on a day when there was documentation, by nurses, which stated the resident was not eating or drinking. During an interview with the administrator, at 2:30 p.m. on 05/24/12, she had no comment about the resident's inaccurate intake record. She acknowledged the resident had no follow-up assessment after a health status change which included complaints of urinary pain, finding the resident's Foley catheter clamped off and blood in his urine, removal of the catheter, and further complaints of pain. The nurse's notes reflected this information on 03/04/12. There were no nurse's notes from 03/04/12 at 2:00 p.m. until 03/07/12 at 11:25 a.m. when the resident had a fall and was sent to the emergency room for evaluation. The resident's hospital record was reviewed. The hospital History and Physical, dated 03/14/12, was completed by the same attending physician who cared for the resident at the facility. The following assessment was made at the hospital by this physician: "The patient had been less responsive since about 4 days prior to this admission and over the past 2 days had become even more unresponsive. He had stopped taking all of his medications and had not eaten or drunk much of anything since then ... He was then admitted for further evaluation, hydration and treatment." The Admitting Impression was: 1. Severe dehydration. 2. Electrolyte abnormality. 3. Acute [MEDICAL CONDITION] on chronic. 4. [MEDICAL CONDITION] secondary to urinary tract infection. The final discharge [DIAGNOSES REDACTED]. 1. Dehydration - corrected (BUN now is 24 and creatinine 1.2 from BUN 132 and creatinine 8.1 on admission). 2. Acute [MEDICAL CONDITION], resolved. 3. Electrolyte imbalance (sodium 145 and potassium 3.6 now from sodium of 166 and potassium of 5.7 on admission). 6. Urinary tract infection, resolved. This information collected during the survey was presented to the administrator and Employee #5 during an interview at 2:30 p.m. on 05/24/12. They had no comment about the missing assessments of the resident's intakes and outputs. The administrator denied the resident was dehydrated when he was admitted to the hospital. The hospital record, written by the resident's attending physician at the nursing facility, stated the resident was dehydrated. The resident's nursing facility medical record did not reflect adequate comprehensive nursing assessments to verify the resident was taking in food and fluids in the days prior to the transfer to the hospital. Resident #105 had several risk factors for becoming dehydrated. These included [MEDICAL CONDITION], unresponsiveness, fever, and refusal to eat or drink. Additionally, on 03/03/12 the resident had amber urine, and on 03/07/12 the resident was diagnosed with [REDACTED]. There was no evidence the risk factors for dehydration or the potential indicators of dehydration were identified and assessed by the facility. .

Based on record review, staff interview, and policy review, the facility failed, for one (1) of four (4) sampled residents, to ensure a resident admitted with a pressure sore received necessary treatment and services to promote wound healing, by failing to: (1) monitor, assess, and record the characteristics of the pressure sore in accordance with physician orders [REDACTED]. integrity on the resident assessment instruments; and (4) develop a resident-specific care plan to address the wound, and revise the care plan when the status of the wound declined. Resident #103 was admitted on [DATE] and discharged on [DATE]. The pressure sore on Resident #103's coccyx declined from a Stage II area measuring 7.5 cm x 0.2 cm x 0.1 cm (present on admission), to a Stage III area measuring 3.0 cm x 5.0 cm x 0.2 cm on 03/24/11. There was no documentation to reflect any assessment / monitoring of this area between 03/01/11 and 03/24/11, nor was the documentation to reflect any assessment / monitoring of this area after 03/24/11 or prior to her discharge on 04/01/11. Resident identifier: #103. Facility census: 96. Findings include: a) Resident #103 1. Review of the nursing assessment completed on admission (dated 03/01/11) revealed Resident #103, a [AGE] year old female who weighed 124 pounds, had skin breakdown located in the "split in crease of buttocks 7.5 (centimeters or cm) by 0.2 (cm) by 0.1 (cm)". The nursing admission note, also dated 03/01/11, described the area of skin breakdown as: "Long split in skin in crease of buttocks 7 1/2 cm x 0.2 (cm) x 0.1 (cm) (sic) [MEDICATION NAME] applied." Further record review revealed the following descriptions in a Skin Report / Weekly Update for Non-Pressure Related Areas dated 03/01/11: "red center /c (with) yellow edges" and "skin is split". The treatment plan recorded on this form included measuring the area every six (6) days until healed and applying [MEDICATION NAME] Cream to the area every shift and as needed. Documentation on the Skin Report / Weekly Update dated 03/01/11 also provided the following dimensions of the wound: length - 7.5 cm, width - 0.2 cm, and depth - 0.1 cm. Only one (1) other measurement of the resident's pressure sore was completed during this resident's month long stay at the facility, which was recorded in a late entry nursing progress note written on 03/28/11 for 03/24/11. This entry stated, "Resident exhibits Stage III area to coccyx. Area measures 3.0 cm by 5.0 cm x 0.2 cm (sic) Center of wound dark red /c small amount serosanguinous drainage. Surrounding skin bright red & irritated. Area cleansed /c NS (normal Saline), Fiboral packed to coccyx area & Allevyn dressing applied." Documentation on the Wound / Skin Healing Record dated 03/24/11 also revealed provided the following measurements for this pressure ulcer on the resident's coccyx: length - 3.0 cm, width - 5.0 cm, and depth - 0.2 cm. The date of onset of the wound was left blank on the form, and the "original stage" was identified as "Stage II". -- 2. Review of the treatment administration record (TAR) revealed a physician's orders [REDACTED]." The TAR was marked with rectangular boxes to prompt the nurse to initial after obtaining wound measurements on the 3-11 shift on 03/01/11, 03/07/11, 03/13/11, 03/19/11, 03/25/11, and 03/31/11. However, review of the TAR found it was initialed to indicate this order was carried out only on 03/01/11, and not on any of the other dates. Further record review found the wound was measured only on 03/01/11 (upon admission) and again on the 7-3 shift by a wound care nurse on 03/24/11. As cited above, the wound care nurse described the wound in nurse's progress notes as a Stage III area to the coccyx on 03/24/11. -- 3. In an interview with a wound care nurse (Employee #136) on 04/14/11 at 12:15 p.m., she said the floor nurses typically initiate a Wound / Skin Healing Record form whenever a pressure ulcer is identified, and they place that form in the Medication Administration Record, [REDACTED]. However, this form was not initiated for Resident #103 upon her admission to the facility. When asked about the documentation on the TAR, she agreed the order on the TAR was initiated on 03/01/11 to measure the wound every six (6) days until healed and that the TAR was not marked to indicate this order was carried out on 03/07/11, 03/13/11, and 03/19/11. She acknowledged that wound measurements were not taken on those three (3) dates. She also acknowledged that her assessment and measurement of the wound on 03/24/11 was the only one (1) completed during the resident's stay at the facility since the day of her admission on 03/01/11. When asked why the wound was not measured again after 03/24/11 and why it was not measured on 04/01/11 (prior to the resident's discharge to home), she said any of the nurses can and do measure and record information about a resident's pressure ulcers. She reported that she was the individual who used to measure all of the residents' wounds weekly, but it was decided instead that the floor nurses would do measurements on their own residents. She said sometimes the floor nurses forego measuring the wounds if they know a wound care nurse will be there to assess in the near future. -- 4. During an interview with the nurse manager (Employee #141) on 04/14/11 at 5:20 p.m., she reviewed Resident #103's nurse's progress notes and found an entry dated 03/08/11, which stated the area in the crease of the Resident's buttocks was not improving. She also found an entry dated 03/18/11, which cited the physician was in the facility and a new dressing was started for the wound "due to worsening". Review of the physician's medication / order sheet dated 03/18/11 found an area to record the indication or [DIAGNOSES REDACTED]. -- 5. Review of physician's orders [REDACTED]. Review of the TAR revealed that, after the treatment was completed on 03/18/11, the dressing was due to be changed again on 03/21/11. The treatment was not completed as ordered on [DATE], as signified by a rectangular box with an "x" through it; instead, the dressing change occurred on 03/22/11. Review of the reverse side of the TAR found no explanation as to why this treatment was not completed timely as ordered by the physician. Also, review of the reverse side of the TAR found a Treatment Record for staging the pressure area, recording the dimensions and appearance of the area, and any other comments; however, nothing was completed on the reverse side of any of the three (3) TARs, as they were all left blank. -- 6. Review of physician's orders [REDACTED]. Review of the TAR revealed it was initialed to indicate the wound was measured on 03/24/11. Boxes were drawn in which to initial that measurements were obtained on the 7-3 shift on 03/30/11 and 03/31/11; however, both boxes had "x's" in them, signifying the coccygeal wound was not measured on these dates. Review of the reverse side of the TAR found a Treatment Record for staging the pressure area, recording the dimensions and appearance of the area, and any other comments; however, nothing was completed on back of the TAR, leaving it blank. -- 7. Review of the admission minimum data set (MDS) with an assessment reference date (ARD) of 03/08/11 found the assessor coded Resident #103 as having no unhealed pressure ulcers upon admission and no other skin problems other than the surgical wound from the [MEDICAL CONDITION] repair. In the 14-Day MDS with an ARD of 03/16/11, the assessor coded her as having no unhealed pressure ulcers but having an open lesion other than an ulcer. In comparison, in the 30-Day MDS with an ARD of 03/30/11, the assessor coded her as having a Stage 3 pressure ulcer measuring 3.0 cm in length, 5.0 cm in width, and 0.2 cm in depth, which the assessor now noted was present on admission. Similarly, the discharge MDS dated [DATE] also coded her as having a Stage 3 pressure ulcer that was present upon admission. During an interview with the staff development nurse (Employee #143) on 04/14/11 at 3:40 p.m., she agreed that the 14-Day MDS (dated 03/16/11) coded the resident as having no pressure ulcers and the 30-Day MDS (dated 03/30/11) coded her as having a Stage 3 pressure ulcer that was present on admission. During an interview with the assessment nurse (Employee #120) on 03/14/11 at 4:00 p.m., she said she did not encode the admission MDS (dated 03/08/11) to reflect the resident had a pressure ulcer on admission, because it seemed to be a crack between her buttocks. She looked at the Wound / Skin Healing Record dated 03/24/11, noting the wound was identified as a Stage 2 pressure ulcer to the coccyx on that form, and said it looks like the pressure ulcer developed in house and got worse while she was here, because the wound was not assessed as having been a pressure ulcer on admission. Employee #120 agreed it was not coded as a pressure ulcer on the 14-Day MDS, and she did not see any other measurements of the wound's dimension from admission until 03/24/11. The administrator, who was present at this time, agreed that whatever type of wound it was, it should have been measured and documented every week, and it was not. Review of the Care Area Assessment - Pressure Ulcer(s) Worksheet, dated 03/08/11, found "existing pressure ulcer(s)" was not marked, with the following notation: "No pressure ulcers present." Review of extensive risk factors in the Pressure Ulcer(s) Worksheet also found no mention that Resident #103 was admitted with an open area in the crease of her buttocks measuring 7 1/2 cm x 0.2 cm. x 0.1 cm. -- 8. Review of the comprehensive care plan revealed, on pages 10 and 11, the resident's skin problem consisted of a "small open area between buttocks due to moisture" and also noted the resident was: "At risk for additional skin breakdown secondary to need for extensive assistance with bed mobility, non-amb (ambulatory) at this time; frequent urinary and occasional bowel incontinence." Further review of the care plan revealed no care plan revisions or notations that identified the stage of the pressure ulcer or the changing size or character of the pressure ulcer. Care plan review also revealed no specific interventions targeted at healing or monitoring the existing pressure ulcer. -- 9. On 04/14/11 at 3:00 p.m., concerns related to assessment and monitoring of pressure ulcers, the coding of ulcers on the minimum data set assessments (MDS), and care planning were discussed with the administrator, who then offered to provide policies on wound assessments and monitoring. Review of the Wound Care / Documentation form, produced by the administrator on 04/14/11 at 3:30 p.m., found that wounds were to be assessed on admission and measured, orders for dressing(s) were to be placed on the treatment record, appropriate preventative measures were to implemented, and the instruction listed under Item #7 identified the need to address the wound in the resident's care plan. Review of the wound care policy revealed the Wound / Skin Healing Record and/or the Skin Report / Weekly Update must include documentation addressing the following: - what kind of wound - measurements - dressing and frequency to change - location - odor - amount of drainage - type of drainage - surrounding tissue - wound edges - wound bed During an interview with the administrator on 04/14/11 at approximately 3:30 p.m., she said measurements of all wounds were supposed to be done weekly and as needed.