Every finding on record at Emerald Care Center Southwest LLC

Based on record review and interview, the facility failed to revise a care plan to include fall interventions for 1 (#3) of 3 sampled residents reviewed for fall interventions. The admissions coordinator identified 72 residents resided in the facility. Findings:A Fall Protocols Policy, dated 03/08/19, read in part, Residents experiencing an actual fall will have the following interventions: The care plan will be revised for any new fall prevention interventions.A care plan for Resident #3, dated 02/16/26, showed they were at risk for falls and would receive visual rounding from staff. The care plan showed Resident #3 would receive physical therapy or occupational therapy as needed. There were no additional fall interventions.An after visit summary for Resident #3, dated 05/03/26, showed they were seen in the emergency department for diagnoses of a closed head injury, contusion of the hip, and cervical strain sustained from a fall.On 07/13/26 at 12:37 p.m., LPN #1 stated the charge nurse would complete a fall data collection report after a resident had fallen. LPN #1 stated they could not locate any documentation for Resident #3's fall.On 07/13/26 at 2:30 p.m., the MDS coordinator stated they added fall interventions to care plans based on the fall data collection report. They stated all falls received interventions in the resident's care plan. The MDS coordinator stated they did not revise Resident #3's care plan to include a fall intervention for the fall on 05/03/26.

Based on record review and interview, the facility failed to ensure a resident was free from verbal abuse for 1 (#3) of 3 sampled residents reviewed for abuse.The admissions coordinator identified 72 residents resided in the facility. Findings:A policy titled Abuse, Neglect, and Exploitation, dated 11/17/24, read in part, Residents must not be subject to abuse by anyone.A quarterly comprehensive assessment for Resident #3, dated 05/23/26, showed they had a brief interview for mental status score of 14, which indicated they were cognitively intact.An incident report for Resident #3, dated 06/03/26, showed Resident #3 requested a peanut butter and jelly sandwich at lunch because they were not satisfied with the way their hamburger was cooked. The dietary manager yelled at Resident #3 stating, [They] should have asked for an alternative an hour ago! No, I won't make [them] a sandwich! The incident report showed another staff member intervened and Resident #3 received their peanut butter and jelly sandwich. Resident #3 took the sandwich to their room and cried. The dietary manager was immediately suspended pending the investigation and once verbal abuse was substantiated, they were terminated.A review of the abuse investigation for Resident #3 showed a sample of residents were asked to identify any experience with abuse in the facility. There were no additional reports of abuse.An in-service sign-in sheet, dated 06/05/26, showed all staff were educated on the facility's abuse policy and protocols.An Employee Status Report, dated 06/08/26, showed the dietary manager last worked on 06/03/26 and was terminated on 06/08/26.A quality assurance meeting agenda, dated 06/08/26, showed the quality assurance team met to discuss verbal abuse and measures to prevent future occurrence. On 07/13/26 at 12:10 p.m., CMA #1 stated they had not witnessed or heard any abuse and if they had, they would notify the DON or administrator immediately. They stated they were educated on abuse recently but could not recall the exact date.On 07/13/26 at 12:43 p.m., Resident #3 stated they remembered a cook was mean to them and made them cry. They could not remember the details.On 07/13/26 at 1:00 p.m., CNA #4 stated they were educated on abuse recently and often. They stated they had not witnessed or heard abuse and would report to DON or administrator immediately.On 07/13/26 at 2:21 p.m., the social services director stated they witnessed the dietary manager raising their voice at Resident #3 because they asked for an alternative at lunch time. They stated Resident #3 was tearful and they informed the dietary manager they would not speak to a resident in that manner. The social services director stated the dietary manager was immediately suspended and then terminated. They stated residents were asked about any potential abuse they may have experienced and there were no additional findings of abuse of any kind. The social services director sent their report into adult protective services who visited the facility shortly afterward and did their own investigation.On 07/14/26 at 9:00 a.m., CMA #2 stated they were educated on abuse routinely in the facility.On 07/14/26 at 10:44 a.m., CNA #3 stated they had not witnessed any abuse, but would report to charge nurse, administrator, or DON. They stated they were educated on abuse several times but did not recall specific dates.

Based on record review and interview, the facility failed to complete a Nursing admission Data Collection (an assessment used for elopement risk timely for 1 (#1) of 1 sampled resident reviewed for elopement.The administrator identified 71 residents resided in the facility. Findings:A policy for Elopement, Risk reduction strategies and management of missing resident, Wandering Missing Resident, dated 11/2022 and revised 01/2024, showed an elopement risk data collection was to be completed by the nursing staff on all residents at admission, if possible, otherwise no later than eight hours from admission.An undated admission Record showed Resident #1 was admitted to the facility on [DATE] at 11:14 a.m.Resident #1's electronic medical record medical diagnosis section showed the resident was admitted with vascular dementia.A nursing note, dated 12/24/25 at 3:46 p.m., showed Resident #1 was located by the police outside the facility down the road.Resident #1 had eloped from the facility within 4.5 hours of being admitted to the facility.Resident #1's Nursing admission Data Collection, signed as completed 12/29/25, showed the elopement risk data collection. The data collection was completed five days after admission and Resident #1 had eloped from the facility.On 12/31/25 at 12:45 p.m., the admission nurse stated they had been off for the holiday. They stated the nursing admission data collection was not completed until 12/29/25 and should have been completed within eight hours upon Resident #1's admission on [DATE].

Based on record review and interview, the facility failed to ensure a urinalysis order was completed and an antibiotic was transcribed as ordered for 1 (#5) of 3 sampled residents reviewed for care and treatment. The administrator identified 63 residents resided in the facility. Findings: An undated facility policy titled Medication orders, read in part, Written transfer orders (sent with a resident by a hospital or other health care facility): Implement a transfer order without further validation if it is signed and dated by the resident's current attending physician. A policy titled Laboratory Services and Reporting, dated 01/2024, read in part, The facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law .The facility is responsible for the timeliness of the services. Resident #5 had diagnoses which included other symptoms and signs involving cognitive functions following cerebral infarction. Resident #5's admission resident assessment, dated 11/07/24, showed the resident had moderate cognitive impairment with a BIMS of 09. A physician's order, dated 11/22/24, showed left hip X-ray, pelvis X-ray, urinalysis, and oxycodone (a narcotic) 15 mg every six hours. A nursing note, dated 11/22/24 at 5:53 p.m., read in part, UA with C&S one time only for lab for 1 day replied 'you get out of here' upon attempts to gather a sample. There was no documentation the urinalysis was completed or other attempts were made to obtain a urine specimen. A nursing note, dated 11/30/24 at 10:02 a.m., read in part, Called EMSA [emergency medical services] after observing resident on the floor, prone position. They were yelling out and c/o [complained of] pain everywhere. They had two abrasions on their face, one on their left eyebrow, one on their forehead. A nursing note, dated 11/30/24 at 9:59 p.m., read in part, Patient returned from the ER today on antibiotics for UTI. A hospital AFTER VISIT SUMMARY, dated 11/30/24, showed Keflex (an antibiotic medication) 500 mg, take one capsule by mouth in the morning, at noon, in the evening, and at bedtime for seven days. A physician's order, dated 12/01/24, showed Keflex oral capsule 500 mg, give 500 mg by mouth three times a day for UTI for seven days. A December 2024 medication administration record showed Resident #5 received Keflex 500 mg three times a day from 12/01/24 to 12/03/24. A nursing note, dated 12/04/24 at 11:40 a.m., showed insulin was held for resident blood sugar of 57. A nursing note, dated 12/04/24 at 1:41 p.m., showed the resident's blood sugar was 72. A nursing note, dated 12/04/24 at 2:32 p.m., read in part, Nurse was approached by CNA on duty who stated that resident was in room sitting in w/c [wheelchair] and nonresponsive. Upon entering room to assess resident, resident was sitting in w/c slumped over and drooling. Nurse sternal rubbed resident times 4 while calling out their name with no response or reaction. Nurse then contacted [name withheld] APRN [advanced practice registered nurse] and received an order to send resident to ER. Floor nurse on duty then came and checked patient FSBS which was 89 at that time. Resident VS [vital signs] were BP [blood pressure]- 138/79, P [pulse]-74, R [respiration]-12, O2 [oxygen]- 77% on RA [room air]. Nurse contacted EMS. Upon arrival of EMS resident FSBS was 77. Patient left the facility at 1430 [2:30 p.m.]. [Family member] was notified of the situation. A hospital Emergency Department record, dated 12/04/24, showed hypoglycemia and sepsis due to UTI with acute sepsis related organ dysfunction. On 04/07/25 at 9:54 a.m., the DON stated they could not locate lab results for the urinalysis ordered on 11/22/24. On 04/07/25 at 1:14 p.m., LPN #3 stated there was no documentation to show another attempt was made to obtain a urine specimen for the urinalysis. On 04/07/25 at 1:15 p.m., LPN #3 stated Resident #5 was sent to the ER for a fall on 11/30/24. On 04/07/25 at 1:17 p.m., LPN #3 stated the hospital diagnosis was UTI without hematuria. On 04/07/25 at 1:19 p.m., LPN #3 stated Keflex 500 mg one capsule by mouth in the morning, at noon, in the evening, and at bedtime for seven days was ordered. On 04/07/25 at 1:20 p.m., LPN #3 stated Resident #5 received Keflex 500 mg three times a day at the facility. On 04/07/25 at 1:40 p.m., the DON stated no other attempts were documented to obtain the urine specimen. On 04/07/25 at 1:48 p.m., the DON stated there was no documentation the facility provider changed the Keflex order upon returned. On 04/07/25 at 1:49 p.m., the DON stated the Keflex order was not transcribed accurately.

Based on observation, record review, and interview, the facility failed to provide care consistent with professional standards of practice and in accordance with physician orders for: a. a PICC line for 1 (#1) of 3 sampled residents reviewed for infection control; and b. the administration of IV fluids for 1 (#12) of 3 sampled residents reviewed for medications as ordered. The DON identified six residents with IV lines resided in the facility. Findings: 1. On 04/02/25 at 2:21 p.m., Resident #1's PICC line dressing was dated 03/20/25. A policy titled Special Needs, dated 01/2024, read in part, To address special needs, this facility will provide the necessary care and treatment, including medical and nursing care, consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences. This policy pertains to the following needs: parenteral fluids .PICC/IV. Resident #1 had diagnoses which included encounter for orthopedic aftercare following surgical amputation and atherosclerosis of native arteries of extremities with left leg gangrene. A physician's order, dated 03/20/25, showed to change right arm PICC line dressing weekly and PRN. Change needleless connectors with dressing change, one time a day every Thursday. Resident #1's admission resident assessment, dated 03/26/25, showed the resident had moderate cognitive impairment with a BIMS of 12. An IV therapy care plan, revised 03/26/25, showed the resident had a PICC line to their right arm. On 04/02/25 at 2:23 p.m., Resident #1 stated they were not sure about PICC line dressing change. On 04/02/25 at 2:43 p.m., LPN #2 stated they last cared for the resident on 03/28/25. On 04/02/25 at 2:47 p.m., LPN #2 stated PICC line dressing change was done every seven days. On 04/02/25 at 2:48 p.m., LPN #2 stated Resident #1's PICC line dressing change order was for every Thursday and as needed. On 04/02/25 at 2:50 p.m., LPN #2 stated the resident's PICC line dressing was dated 03/20/25. On 04/02/25 at 2:51 p.m., LPN #2 stated the PICC line dressing should have been changed on 03/27/25. On 04/02/25 at 3:40 p.m., the DON stated PICC line dressing change was every seven days or per physician's orders. On 04/02/25 at 3:40 p.m., the DON stated they expected nurses to follow the physician's orders. 2. On 04/03/25 at 3:49 p.m., Resident #12's IV infusion was observed to be infusing at a rate of about 90 ml/hr. The dial was between the 80 and 100 markings. The 1000 ml fluid bag showed normal saline 0.9 and to infuse at 75 ml/hr. Resident #12 had diagnoses which included unspecified severe protein-calorie malnutrition and metabolic encephalopathy. Resident #12's admission resident assessment, dated 03/07/25, showed the resident had moderate cognitive impairment with a BIMS of 09. A physician's order, dated 03/27/25, showed normal saline flush IV solution 0.9% sodium chloride flush, use 75 ml intravenously two times a day continuous. On 04/03/25 at 3:49 p.m., Resident #12 stated they did not know what rate the intravenous infusion was running. They stated they did not adjust the rate on the pump. On 04/03/25 at 4:45 p.m., LPN #2 stated the intravenous infusion was going at a rate of 85 ml/hr and they adjusted the infusion rate to 75 ml/hr to match the resident's infusion order.

Based on observation, record review, and interview, the facility failed to follow the menu for one of one meal service observed. The DON identified 63 residents who received their meals from the kitchen. Findings: On 04/03/25 at 12:39 p.m., cook #1 was observed to plate four regular plates with each containing three chicken tenders, one scoop of coleslaw, one scoop of mashed potatoes, and one scoop of gravy. On 04/03/25 at 12:44 p.m., cook #1 was observed to plate a mechanical soft diet plate with one scoop grounded chicken tenders, one scoop of mashed potatoes, one scoop of gravy, and one scoop of cooked cabbage. On 04/03/25 at 1:06 p.m., cook #1 was observed to plate a pureed diet plate with one scoop pureed chicken tenders, one scoop mashed potatoes, and two scoops gravy. No pureed vegetables were served on the puree plate. A policy titled Menus and Adequate Nutrition dated 01/2024, read in part, The purpose of this policy is to assure menus are developed and prepared, based on reasonable efforts to meet resident choices and reflect the resident's nutritional, religious, cultural, and ethnic needs .Be followed. A week one extended menu Diet Spreadsheet, dated 2025, showed the following serving sizes: a. coleslaw 4 ounces, b. ground chicken tenders #8 scoop (equivalent to 4 ounces), c. pureed chicken tenders #6 scoop (equivalent to 5 ounces), and d. soft, cooked vegetables #16 scoop for pureed residents (equivalent to 2 ounces). On 04/03/25 at 12:36 p.m., cook #1 stated the ground chicken tenders should be served with 3 ounce spoon, pureed chicken tenders with 4 ounce spoon, and the coleslaw with 3 ounces scoop. On 04/03/25 at 1:09 p.m., cook #1 stated they did not puree any vegetables. They stated it was their fault. On 04/03/25 at 2:44 p.m., cook #1 stated the extended menu serving size for coleslaw was 4 ounces. They stated they served 3 ounces. On 04/03/25 at 2:45 p.m., cook #1 stated the extended menu serving size for ground chicken tenders was #8. They stated they served 3 ounces. On 04/03/25 at 2:46 p.m., cook #1 stated the extended menu serving size for pureed chicken tenders was #6 scoop. They stated they served 4 ounces. On 04/03/25 at 2:48 p.m., cook #1 stated they did not follow the menu.

Based on observation, record review, and interview, the facility failed to ensure infection control was maintained during the provision of incontinent care and PICC line dressing change for 2 (#1 and #9) of 3 sampled residents reviewed for infection control. The administrator identified 63 residents resided in the facility. Findings: 1. On 04/02/25 at 3:02 p.m., LPN #2 donned a gown, gloves, a mask, and entered Resident #1's room with a PICC line dressing change kit. They instructed Resident #1 to wear a mask. LPN #2 informed the resident they would be changing their PICC line dressing. A staff passing by the resident's room closed the door for privacy. The resident was sitting in their wheelchair. On 04/02/25 at 3:04 p.m., LPN #2 opened the PICC line dressing kit and placed it on the resident's bed. They removed their gloves and donned the sterile gloves from the kit. LPN #2 removed the resident's old PICC line dressing and the PICC line stabilization device. LPN #2 discarded their gloves and donned new gloves they retrieved from their pocket. They cleaned the PICC site with items from the kit. On 04/02/25 at 3:11 p.m., LPN #2 attached a new PICC line stabilization device, but could not apply the new dressing. They took off their gown, gloves, mask, and went out to get a new PICC line dressing kit. On 04/02/25 at 3:14 p.m., LPN #2 returned with a new PICC line dressing kit. They donned a gown, gloves, a mask, and provided privacy. They opened the new dressing kit on the resident's bed. They donned regular gloves and applied the new PICC line dressing. LPN #2 dated and initialed the new dressing. On 04/02/25 at 3:27 p.m., LPN #2 attached an alcohol cap to the PICC line. A policy titled Infection Prevention and Control, revised 01/2024, read in part, It is the policy of this facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections .Soiled linen shall be collected at the bedside and placed in a linen bag. When the task is complete, the bag shall be closed securely and placed in the soiled utility room. Resident #1 had diagnoses which included encounter for orthopedic aftercare following surgical amputation and atherosclerosis of native arteries of extremities with left leg gangrene. A physician's order, dated 03/20/25, showed to change right arm PICC line dressing weekly and PRN. Change needleless connectors with dressing change, one time a day every Thursday. Resident #1's admission resident assessment, dated 03/26/25, showed the resident had moderate cognitive impairment with a BIMS of 12. On 04/02/25 at 3:29 p.m., LPN #2 stated PICC line dressing change should be a sterile procedure. They stated they should have used the regular gloves to remove the old dressing and used the sterile gloves for the rest of the procedure. On 04/02/25 at 3:34 p.m., LPN #2 stated they did not perform a sterile dressing change and should have put the dressing kit on a clean working table. On 04/02/25 at 3:41 p.m., the DON stated if the PICC line dressing change was supposed to be sterile, then the nurse should have used sterile technique. They stated they were to follow standard regulation of practice. 2. On 04/03/25 at 11:03 a.m., CNA #1 entered Resident #9's room. They stated they would be performing incontinent care. The Resident's representative was at the bedside and the resident was lying in bed. CNA #1 had on gloves and they provided privacy. On 04/03/25 at 11:04 a.m., CNA #1 cleaned Resident #9's peri area. The Resident's peri area had redness. On 04/03/25 at 11:07 a.m., CNA #1 rolled Resident #9 to their right side and cleaned their buttocks. They applied cream to the resident's buttocks and coccyx area. CNA #1 turned the resident back and applied cream to the redness on the resident's peri area. CNA #1 discarded the wet brief in the trash. On 04/03/25 at 11:09 a.m., CNA #1 put a clean brief on the resident and clean clothing. CNA #1 did not change their gloves prior to putting cream on the resident. They did not change their gloves prior to putting clean clothing on the resident. On 04/03/25 at 11:09 a.m., CNA #1 with the same gloves, picked up the bed remote and adjusted Resident #9 in bed. On 04/03/25 at 11:15 a.m., CNA #1 with the same gloves, retrieved a brush and brushed Resident #9's hair. They put the resident's hair in a ponytail. On 04/03/25 at 11:19 a.m., CNA #1 took the trash and the resident's dirty clothes to the soiled utility room. Resident #9's clothes were not in a bag. CNA #1 discard their gloves. Resident #9 had diagnoses which included acquired absence of right leg below knee. Resident #9's Medicare 5 day resident assessment, dated 03/20/25, showed the resident had moderate cognitive impairment with a BIMS of 12. The assessment showed the resident was dependent on staff assistance for toileting and dressing. A self-care performance care plan, dated 04/03/25, showed the resident required one person substantial assist with toilet use. On 04/03/25 at 11:22 a.m., CNA #1 stated they should change their gloves once or twice during incontinent care. On 04/03/25 at 11:23 a.m., CNA #1 stated they did not change their gloves during the provision of incontinent care for Resident #9. They stated changing gloves would prevent cross contamination. On 04/03/25 at 11:25 a.m., CNA #1 stated dirty linens should be bagged during transportation. They stated they did not put the resident's dirty clothes in a bag during transportation. On 04/03/25 at 11:35 a.m., the DON stated staff should change their gloves when working from dirty to clean. On 04/03/25 at 11:36 a.m., the DON stated dirty linens should be put in a bag during transportation.

Based on record review and interview, the facility failed to ensure a resident's: a. emergency contact and physician were notified of a resident's refusal of urine specimen collection for urinalysis for 1 (#5); and b. physician was notified of a resident's low blood sugar as ordered for 1 (#5) of 3 sampled residents reviewed for care and treatment. The administrator identified 63 residents resided in the facility. Findings: A policy titled NOTIFICATION OF CHANGES POLICY, dated 01/2024, read in part, It is the policy of this facility that changes in a resident's condition or treatment are immediately shared with the resident and/or the resident representative, according to their authority, and reported to the attending physician or delegate. Resident #5 had diagnoses which included other symptoms and signs involving cognitive functions following cerebral infarction. A physician's order, dated 11/02/24, showed to notify provider if blood sugar less than 60 or greater than 250 two times a day for diabetes mellitus. Resident #5's admission resident assessment, dated 11/07/24, showed the resident had moderate cognitive impairment with a BIMS of 09. A physician's order, dated 11/22/24, showed left hip X-ray, pelvis X-ray, urinalysis, and oxycodone (narcotic medication) 15 mg every six hours. A nursing note, dated 11/22/24 at 5:53 p.m., read in part, UA with C&S one time only for lab for 1 day replied 'you get out of here' upon attempts to gather a sample. There was no documentation the physician and the resident's emergency contact were notified of the resident's refusal to obtain a urine specimen. There was no documentation the urinalysis was completed. A nursing note, dated 12/04/24 at 11:40 a.m., showed insulin was held for resident blood sugar of 57. There was no documentation the physician was notified of the resident's low blood sugar. On 04/07/25 at 11:00 a.m., Resident #5's emergency contact stated they were not aware the resident had an order for an urinalysis on 11/22/24. They stated they were not aware the resident refused to let staff obtain the urine specimen. On 04/07/25 at 1:01 p.m., LPN #3 stated if a resident's blood sugar was low, they would notify the physician for further instructions. They stated if the resident was alert, they would offer snacks and recheck the blood sugar. On 04/07/25 at 1:08 p.m., LPN #3 stated they could not find documentation the physician was notified of Resident #5's low blood sugar on 12/04/24 at 11:40 a.m. On 04/07/25 at 1:09 p.m., LPN #3 stated they were to notify the physician if a resident refused urine specimen collection for urinalysis. On 04/07/25 at 1:12 p.m., LPN #3 stated the physician was not notified of the resident's refusal to obtain a urine specimen on 11/22/24. On 04/07/25 at 1:13 p.m., LPN #3 stated Resident #5's emergency contact was not notified of the resident's refusal to obtain a urine specimen on 11/22/24. On 04/07/25 at 1:14 p.m., LPN #3 stated there was no documentation to show another attempt was made to obtain a urine specimen for the urinalysis. On 04/07/25 at 1:31 p.m., the DON stated the facility did not have a protocol for low blood sugars. The DON stated the nurse would follow whatever the physician wants them to do. They stated it was a nursing judgement call unless there was a physician's order. On 04/07/25 at 1:34 p.m., the DON stated Resident #5's order was to notify the physician if blood sugar was less than 60 or greater than 250. They stated it must have been a hospital order. On 04/07/25 at 1:37 p.m., the DON stated there was no documentation the physician was notified of Resident #5's low blood sugar on 12/04/24 at 11:40 a.m. On 04/07/25 at 1:39 p.m., the DON stated nurses were to educate the resident, notify the family, physician, and re-attempt if the provider ordered a re-attempt at obtaining the urine specimen for an urinalysis. On 04/07/25 at 1:40 p.m., the DON stated there was no documentation the physician and the emergency contact were notified of the resident's refusal to obtain a urine specimen.

Based on record review and interview, the facility failed to ensure a urinalysis order was completed in a timely manner for 1 (#7) of 3 sampled residents reviewed for care and treatment. The administrator identified 63 residents resided in the facility. Findings: A policy titled Laboratory Services and Reporting, dated 01/2024, read in part, The facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law .The facility is responsible for the timeliness of the services. Resident #7 had diagnosis which included neuromuscular dysfunction of bladder. A physician's order, dated 02/18/25, showed urinalysis with culture and sensitivity one time only for lab for one day. A nursing note, dated 02/21/25, read in part, Resident's representative [name withheld] called and stated that resident is being very hateful and accusing everyone of stealing their belongings, [name withheld] informed this nurse that when [Resident #7] does this, it is usually because they has a UTI. This nurse notified the NP [nurse practitioner] of representative's concerns and residents' behaviors, new orders given for UA with C&S. [Name withheld] is aware of order for UA. [Lab company name withheld] notified. A Laboratory Report, dated 02/21/25, showed a urine specimen was collected on 02/21/25. There was no documentation a urine specimen was collected prior to 02/21/25. A Provider's Progress Note, dated 02/24/25, read in part, patient seen today for lab results returned. Urinalysis with culture returned with MRSA [Methicillin-resistant Staphylococcus aureus] in the urine. On 04/04/25 at 12:09 p.m., LPN #1 stated nurses were responsible for collecting urine specimens and notifying lab for pick up. On 04/04/25 at 12:10 p.m., LPN #1 stated the expectation was to obtain the ordered urine specimen immediately. On 04/04/25 at 12:21 p.m., the ADON stated the urinalysis ordered on 02/18/25 was put in their lab system on 02/18/25 and was collected on 02/21/25. On 04/04/25 at 12:24 p.m., the ADON stated there was no documentation to support why the urinalysis was not completed prior to 02/21/25. On 04/04/25 at 12:28 p.m., the DON stated they do not have specific time frames when an ordered urinalysis was to be completed. They stated the expectation was if the urinalysis was ordered today, then it should be completed today. The DON stated if nurses were unable to collect the urine specimen, they should document the reason in the residents' notes. On 04/04/25 at 12:30 p.m., the DON stated the urinalysis order was not completed in a timely manner.

Based on record review and interview, the facility failed include and update a careplan for one (#27) of eight sampled residents whose careplans were reviewed. The administrator identified 64 residents resided in the facility. Findings: A facility Care Plan Process policy, dated 10/10/21, read in part, The plan of care must describe the services the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and mental, and social well-being .b. High-risk areas such as fall, skin/wounds, pain, safety (i.e., smoking, elopement), and weight loss must be care planned immediately upon identifying risk via evaluation. Resident #27 had diagnoses which included autism. On 12/11/24 at 10:30 a.m., the facility's smoking list was reviewed with the DON. Resident #27 was listed as a smoker. Resident #27's care plan was reviewed and smoking was not included in care plan. On 12/11/24 at 10:32 a.m., the DON reported Resident #27 smoking was not included in the care plan. On 12/11/24 at 10:49 a.m., Resident #27 reported they smoke three to five times a day.

Based on record review and interview, the facility failed to ensure a smoking assessment was completed for one (#27) of 19 residents sampled for smoking assessments. The DON identified 64 residents who resided in the facility. Findings: A facility's Resident Smoking Policy-Physical Environment policy, dated 01/2024, read in part, 7. Resident who smoke will be evaluated , using the Smoking/Nicotine Devices , to determine adaptive equipment and level of supervision required for smoking, or if residents is safe to smoke at all .15. Documentation to support decision making will be included in the resident's medical record, including but not limited to: b. Assessment of relevant functional and cognitive factors affecting the ability to smoke safely. Resident #27 had a diagnoses which included autism. On 12/11/24 at 10:30 a.m., the facility's smoking list was reviewed with the DON. Resident #27 was listed as a smoker. There was no smoking assessment located in Resident #27's electronic medical record. On 12/11/24 at 10:32 a.m., the DON reported Resident #27 had no smoking assessment. On 12/11/24 at 10:49 a.m., Resident #27 reported they smoked three to five times a day.

Based on record review and interview, the facility failed to ensure: a. the correct inhaler medication was provided to a resident for one (#21) of one sampeld resident reviewed for medication administration; b. medications were administered according to physicians orders for two (#37 and #116); and c. a resident's chart was updated with a new antibiotic order to be continued after an ER visit for one (#116) of two sampled residents reviewed for UTI's. Findings: The administrator identified 64 residents resided in the facility. A Medication Administration and General Guidelines, policy, dated 2021, read in part, Medications are administered in accordance with written orders of the attending physician. The policy also read, Residents are identified before medication is administered. The policy also read, The resident's MAR is initialed by the person administering the medication. The policy also read, The physician must be notified when a dose of medication has not been given. The policy also read, Medications supplied for one resident are never administered to another resident. 1. Resident #21 had diagnoses which included chronic obstructive pulmonary disease with acute exacerbation. On 12/11/24 at 11:21 a.m., LPN #2 was observed to take an inhaler to Resident #21 while they were in the therapy gym. They administered the inhaler. LPN #2 did not show the box to the surveyor prior to administering the inhaler. On 12/11/24 at 11:24 a.m., LPN was asked to see the box the inhaler came from. LPN #2 was observed to put the inhaler inside of a box and began to move boxes and look through the cart. LPN #2 was asked again to see the box the inhaler came from. LPN #2 then provided the box that read another residents name that was not Resident #21. The medication was Combivent 20/100 mcg/act. On 12/11/24 at 11:25 a.m., LPN #2 stated the inhaler was not Resident #21's. They stated the policy was to follow the five rights. LPN #2 stated they did not follow the policy. Upon review of Resident #21 orders there was no order for a Combivent inhaler found. 2. Resident #37 had diagnoses which included UTI, congenital occlusion of ureteopelvic junction, hydronephrosis, obstructive and reflux uropathy, crossing vessel, and stricture of ureter. A physician's order, dated 05/30/24, documented to give Macrobid (antibiotic medication)100 mg two times a day for UTI for five days. Completed on 06/04/24. A physician's order, dated 07/24/24, documented to give Keflex (antibiotic medication) 500 mg three times a day for UTI for 10 days. Completed on 08/03/24. A physician's order, dated 11/17/24, documented to give amoxicillin-pot clavulanate (antibiotic medication) 875-125 mg two times a day for UTI for three days. Completed on 11/20/24. Review of the July and August 2024 electronic medication administration record documented the resident received the first dose of Keflex 500 mg on 07/25/24 at 8:00 a.m. and the last dose documented was on 08/02/24 at 8:00 p.m. There was OF documented for the doses on 08/03/24 at 8:00 a.m. and 2:00 p.m. Review of Resident #37 progress notes documented the resident went to the ER for an elevated lab on 08/03/24 at 1:27 a.m. and returned to the facility on [DATE] at 1:30 p.m. The resident did not receive the last two doses of the antibiotic. On 12/12/24 at 11:57 a.m. the ADON stated Resident #37 received the Keflex up until they were sent out on 08/03/24. They stated Resident #37 returned on 08/04/24. The ADON stated the antibiotic was not continued through completion as they did not see an order to restart and did not see another order for the missed doses to be given. The ADON stated the charge nurse should have been notified so they would get an order to either continue or discontinue. They stated with the resident's kidney issues and recurrent UTI the medication should have been completed. 3. Resident #116 had diagnoses which included UTI, obstructive and reflux uropathy, hydronephrosis with renal and ureteral calculous obstruction, and unspecified hydornephrosis. A physician's order, dated 12/04/24, documented to give Macrobid 100 mg two times a day for UTI for seven days. Review of the December 2024 EMAR documented 9 on 12/05/24 for 7:00 a.m. - 11:00 a.m. The first dose was documented on 12/06/24 at 7:00 a.m. - 11:00 a.m. The last documented dose was on 12/11/24 at 7:00 a.m. - 11:00 a.m. The resident received five and a half days of medication when they were ordered to receive seven. On 12/11/24 at 1:46 p.m., CMA #1 stated blanks on the EMAR meant they did not get it. They stated 9 meant to see other/nurse notes. CMA #1 stated they put in their own note and told the nurses to put a note in. They stated the initials for 12/05/24 at 7:00 a.m. -11:00 a.m. were theirs and they recalled they let the nurse know the medication was not there. On 12/11/24 at 1:48 p.m.,CMA #1 stated Resident #116 was still receiving the medication and provided Resident #116's narcotic record. The record documented the amount of medication ordered was 14 and the amount received was 14. The first dose was signed out on 12/06/24 at 8:00 a.m. and it documented there were three pills remaining. On 12/11/24 at 2:12 p.m., the DON stated the process for new orders was the order would be given from the physician, entered into the electronic medical record or the appropriate system, and track for infection control. The DON stated they did not know why the resident did not receive the antibiotic when it arrived. The DON stated they did not know what happened and they extended the days by three days and had not figured out where the breakdown was. On 12/11/24 at 2:29 p.m., the DON stated the order was written at 5:45 p.m. on 12/04/24. They stated Resident #116 went to the emergency roiagnom on [DATE] so no dose should have been given. They stated the medication came in on 12/05/24. The DON stated the resident returned back to the facility before midnight on 12/04/24. They stated the UA results were on 12/05/24 and the antibiotic came in on 12/05/24. They stated they did not understand the second dose not being given. On 12/11/24 at 2:30 p.m., the DON stated the documentation was not an accurate reflection of the resident's medication and was not administered per physician order.

Based on observation and interview, the facility failed to ensure a medication cart was securely locked and attended to according to facility policy and procedure. The administrator identified 64 residents resided in the facility. Findings: An undated facility Medication Storage in the Facility policy, read in part, Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. On 12/10/24 at 11:43 a.m., the medication cart on the North end of the main lobby was found unlocked and unattended. On 12/10/24 at 11:44 a.m., LPN #2 reported the medication cart should have been locked.

Based on observation, record review, and interview, the facility failed to ensure: a. hair nets were worn appropriately; b. the kitchen was kept clean and maintained in good repair; c. food items were labeled, dated, and stored according to facility policy; and d. hand washing and glove usage were appropriate. The DON identified 60 residents ate from the kitchen. Findings: A Preventing Foodborne Illness-Employee Hygiene and Sanitary policy, dated [DATE], documented food and nutrition service employees would follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. It doucumented employees were to wash their hands after handling soiled equipment or utensils, during food preparation, and as often as necessary to prevent cross contamination when changing tasks. It documented hair nets or caps and/or beard restraints were to be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. A Food Receiving and Storage policy, revised [DATE], documented all foods were to be covered, labeled, and dated. On [DATE] at 8:40 a.m., dietary aide #1 and #2 were observed with their hair nets only covering the top area of their hair. Dietary aide #1 had the ends of their braids below the hair net and dietary aide #2 had hair outside of the hairnet all the way around their head. On [DATE] at 8:44 a.m., mouse droppings were observed across the tops of four baking soda boxes, a corn starch box was open and undated, and the Worcestershire sauce was found to be expired in the dry storage area. The floor of the kitchen had particles of dirt and debris all over. There were two plastic containers that had miscellaneous dishes. The containers had dirt and debris inside with the miscellaneous dishes. A cup of water with a straw was observed on the dish rack with the large pots and pans. On [DATE] at 8:54 a.m., the dietary manager stated they were unsure what the mouse droppings were, but stated it was not something that needed to be there. They stated they did not know why the corn starch box was open or undated. They stated the Worcestershire sauce had an expiration date of [DATE]. The dietary manager stated, I'm not going to act like I know how long it lasts. On [DATE] at 8:56 a.m., the dietary manager stated the two plastic containers on the bottom rack that had miscellaneous dishes looked like items they did not need. They stated if they were not using the items they needed to get rid of them. On [DATE] at 8:58 a.m., the dietary manager stated they had daily and weekly deep cleaning schedules. They stated, There should have been daily sweeping, but I have been on vacation. On [DATE] at 9:00 a.m., the freezer was observed to have no thermometer. the dietary manager stated that someone had broken the freezer thermometer, but they had new ones. When asked about the observed food with no label or date in the refrigerator, they stated I know these pineapples were from last Friday. I'm not going to make up no lies and waste your time. On [DATE] at 9:12 a.m., the dietary manager stated that hair nets were worn to keep hair from dropping in food. On [DATE] at 11:18 a.m., dietary aide #1 was observed touching the inside of the puree machine and replacing the blade with their bare hands. On [DATE] at 11:19 a.m., dietary aide #1 stated they were supposed to wear gloves all the time or when handling food. They stated they did not wear gloves when they touched the inside of the puree machine. On [DATE] at 12:03 p.m., the dietary manager was observed touching the serving cart with their gloved hands and then went directly back to making plates and touching the bread. They did not wash their hands or change gloves. On [DATE] at 12:26 p.m., the dietary manager was observed opening a new package of bread and then continuing to touch the bread without changing gloves or washing their hands. On [DATE] at 12:55 p.m., the dietary manager stated they were supposed to wash their hands and change gloves if they touched anything besides what was needed to serve the food. On [DATE] at 3:06 p.m., the administrator stated the kitchen was supposed to be cleaned daily, staff were to wear hair nets correctly, and food should be sealed, labeled, and dated.

Based on record review and interview, the facility failed to follow the antibiotic stewardship policy by ensuring a standardized tool for initiation of antibiotics was completed for the treatment of UTI's for one (#37) of three sampled residents reviewed for UTI's. The administrator identified 64 residents resided in the facility. Findings: A Antibiotic Stewardship Policy, dated 01/2024, read in part, The facility will track antibiotic use once ordered. The policy also read, The facility will utilize McGeer and or LOEB Criteria, a practical guide to use in nursing homes. Resident #37 had diagnoses which included congenital occlusion of ureteopelvic junction, hydronephrosis, obstructive and reflux uropathy, crossing vessel, and stricture of ureter. Resident #37's care plan, updated 04/06/24, documented the resident had a nephrostomy tube. The focus documented the resident would have no signs or symptoms of a urinary infection. A physician's order, dated 05/30/24, documented to give Macrobid (antibiotic medication) 100 mg two times a day for UTI for five days. Completed on 06/04/24. A physician's order, dated 07/24/24, documented to give Keflex (antibiotic medication) 500 mg three times a day for UTI for 10 days. Completed on 08/03/24. A physician's order, dated 11/17/24, documented to give amoxicillin-pot clavulanate (antibiotic medication) 875-125 mg two times a day for UTI for three days. Completed on 11/20/24. Review of the infection control book and Res #37's electronic medical record did not reveal a McGeer form was completed for the use of antibiotics in May 2024, July 2024, or November 2024. On 12/12/24 at 11:57 a.m., the ADON stated they were not able to locate the McGeer form for the use of the antibiotics in May, July, and November. They stated they should have been completed.

Based on record review and interview, the facility failed to provide documentation pneumococcal vaccines were offered and/or administered for two (#37 and #216) of five sampled residents reviewed for immunizations. The administrator identified 64 residents resided in the facility. Findings: An Infection Control Immunizations policy, dated 3/20/24, read in part, all residents will be offered pneumococcal vaccines. Assessments of pneumococcal vaccination status will be conducted within five working days of the resident's admission. A review of Resident #37's immunization record did not document the resident had received or been offered a pneumococcal vaccination. A review of Resident #216's immunization record did not document the resident had received or been offered a pneumococcal vaccination. On 12/12/24 at 10:57 a.m., LPN #1 stated they did not know how the vaccines got ordered, but if an order pops up we did it. They stated they did not skip the vaccinations if they were ordered to be done on their shift. On 12/12/24 at 11:01 a.m., the DON stated on admission, they were to document if the resident had the vaccines or not, and if not, then they were to get consent and provide the vaccination if the resident wanted it. On 12/12/24 at 11:43 a.m., the ADON/Infection Preventionist stated they were unable to locate the pneumococcal vaccination documentation for Res #37 or Res #216.

Based on observation, record review, and interview, the facility failed to maintain effective pest control. The administrator identified 64 residents resided in the facility. Findings: A Pest Control Program policy, dated 11/17/24, read in part, Facility will maintain an effective pest control program that eradicates and contains common household pests. On 12/09/24 at 8:44 a.m., upon initial tour of the kitchen multiple mouse droppings were observed across the tops of four boxes of baking soda in the dry storage area. On 12/09/24 at 8:49 a.m., the dietary manager denied knowing what the mouse droppings were, but stated it was not something that needed to be there. They then threw four boxes of baking soda away. On 12/09/24 at 11:04 a.m., a cockroach was observed crawling on Resident #216's hand and prosthetic leg while sitting in the dining room. On 12/10/24 at 2:01 p.m., housekeeper/CNA #1 stated every once in a while, you see a roach. I know they have someone out for that pretty frequently. On 12/10/24 at 2:03 p.m., CNA #1 stated they had seen roaches and bedbugs. They spray and they go away, but they come back. On 12/10/24 at 3:06 p.m., the administrator stated pest control was just there last week. They denied seeing pests and stated it could take from 24-48 hours for the treatments to take effect. They stated, The residents come in with them, all you can do is keep calling pest control to come out.

Based on record review and interview, the facility failed to ensure medications were administered as ordered for one (#10) of three sampled residents reviewed for misappropriation of property. The DON identified 58 residents resided in the facility. Findings: The Medication Administration and General Guidelines policy, dated 2021, read in part, Medications are administered in accordance with written orders of the attending physician. Resident #10 had diagnoses which included pain. A physician's order, dated 08/07/24, documented oxycodone HCL (narcotic medication) oral tablet 15 mg give 0.5 tablet via peg tube every four hours for pain. The September 2024 TAR documented a nine on the following days and times; a. 09/03/24 at 8:00 p.m., b. 09/06/24 at 12:00 a.m., 4:00 a.m., 8:00 p.m., and c. 09/24/24 at 4:00 a.m., 8:00 a.m. The September 2024 TAR documented blanks on the following days and times; a. 09/10/24 at 8:00 p.m., and b. 09/24/24 at 4:00 p.m. The September 2024 TAR documented a six on 09/13/24 at 4:00 p.m. A progress note, dated 09/24/24 at 2:02 p.m., documented oxycodone HCL oral tablet 15 mg give 0.5 tablet via peg tube every four hours for pain: awaiting from pharmacy. On 10/09/24 at 6:05 p.m., the DON stated the nine on the September TAR meant other/see nurses notes. They stated they did not know if the medication was administered or not for the nine and the blanks on the TAR. On 10/09/24 at 6:09 p.m., the DON stated the six meant no insulin required per orders. They stated they did not know if the medication was administered or not.

Based on record review and interview, the facility failed to ensure residents were free from abuse for one (#2) of two sampled residents reviewed for abuse. The DON identified 58 residents resided in the facility. Findings: The Abuse, Neglect and Exploitation policy, dated 11/17, read in part, Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The policy also read, .Physical Abuse includes, but not limited to hitting, slapping, pinching and kicking. Resident #2 had diagnoses which included other specified depressive episodes. An Initial State Reportable Incident form, dated 07/10/24, documented an allegation of abuse/mistreatment. It was documented Resident #2 was noted standing outside of the BOM doorway yelling [gender withheld] slapped me. It was documented Resident #2 was escorted out of the hallway. It was documented the BOM suspended was immediately pending investigation. A Final State Reportable Incident form, dated 07/29/24, documented an allegation of abuse/mistreatment. It was documented Resident #2 stated the BOM wagged their index finger in their face telling them to shush during their interaction. It was documented Resident #2 pointed their finger at the BOM as well. It was documented the BOM slapped the resident's hand and the resident immediately began yelling for the administrator and stated, [gender withheld] slapped me. It was documented the BOM stated Resident #2 would not let them speak, so they told them to shush. It was documented the BOM stated the resident had their hand pointed near their face. It was documented the BOM stated they swatted Resident #2's finger, like they would a fly. On 10/08/24 at 3:05 p.m., Resident #2 stated the BOM slapped their hand during their interaction on 07/10/24 and they yelled for help. On 10/08/24 at 3:29 p.m., the BOM stated Resident #2 was yelling at them and had their hand close to their face. The BOM stated they brushed the resident's hand aside. On 10/08/24 at 3:40 p.m., the BOM stated the incident could fall under the category of abuse because they touched the resident. They stated they did not abuse the resident.

Based on observation, record review, and interview, the facility failed to provide ulcer care as ordered by the physician for two (#1 and #3) of three residents sampled for ulcer care. LPN #1 identified 61 residents resided in the facility. Findings: The Wound Care LPN identified 13 residents received wound care in the facility. 1. Resident #1 admitted to the facility on [DATE] with diagnosis which included non pressure chronic ulcer with unspecified severity (back and right thigh). A Physician's Order, dated 05/25/24, documented, Hibiclens External Solution (Chlorhexidine Gluconate) Apply to back and thighs topically every day shift for use with each dressing change. A May 2024 TAR, had no documentation on 05/26/24 and 05/30/24 for the above treatment. A June 2024 TAR, had no documentation on 06/09/24 for the above treatment. A Physician's Order, dated 05/25/24, read in part, Non-pressure wound of the right flan: cleanse with hibiclense, pat dry, apply calcium alginate sprinkled with collagen powder, cover with island dressing daily and prn every day shift A May 2024 TAR, had no documentation on 05/26/24 for the above treatment. A June 2024 TAR, had no documentation on 06/08/24 for the above treatment. A Physician's Order, dated 05/25/24, read in part, Non-pressure wound of the right posterior thigh: cleanse with hibiclense, pat dry, apply calcium alginate sprinkled with collagen powder, cover with island dressing daily and prn every day shift A May 2024 TAR, had no documentation on 05/26/24 for the above treatment. A June 2024 TAR:, had no documentation on 06/09/24 for the above treatment. A Physician's Order dated 05/16/24, read in part, Nystatin External Powder 100000 UNIT/GM (Nystatin Topical) Apply to buttocks topically one time a day. A May 2024 TAR, had no documentation on 05/26/24 for the above treatment. 2. Resident #3 admitted to the facility on [DATE] with diagnosis which included pressure ulcer of sacral region, stage four. A Physician's Order, dated 06/05/24, documented, Cleanse bilateral buttocks with ns, pat dry, apply triad to bilateral buttocks BID and prn. A June 2024 TAR, had no documentation on 06/07/24 for the above treatment. A Physician's order, dated 06/05/24, documented, Hydrophillic Paste apply to bilateral buttocks topically two times a day for prevention. A June 2024 TAR, had no documentation on 06/07/24 for the above treatment. A Physician's Order, dated 06/07/24, documented, Floor Nurse: cleanse area to LFA with ns, pat dry apply xeroform and cover with dry dressing daily and prn. Every day shift related to other skin changes. A June 2024 TAR, had no documentation on 06/07/24 for the above treatment. On 06/17/24 at 11:56 a.m., the Wound Care LPN stated the blanks on the TAR meant the treatment was no done. On 06/17/24 at 11:58 a.m., the Wound Care LPN stated the treatments above had not been done. They stated treatments are to be done by the end of your shift.

Based on observation, interview and record review, it was determined the facility failed to ~ perform weekly skin assessments for three (#2, #4 and #5); ~ obtain a physician's orders [REDACTED]. ~ complete wound treatments according to the physician's orders [REDACTED].#2) of five sampled residents who were reviewed for pressure ulcers. Resident #2 was readmitted to the facility on [DATE] with one stage II pressure ulcer. On 04/07/21 she had developed an unstageable deep tissue pressure injury wound on her sacrum. On 04/15/21 the pressure wound on the sacrum had deteriorated and was observed to be open during observation of wound care provided by the staff. She had also developed a dark purple area on her right hip/trochanter area. The facility identified three residents who had wounds and physician ordered wound care treatments in the facility. The facility identified 51 residents who resided in the facility. Findings: 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's care plan, dated 12/10/19, documented to observe the skin for changes during routine care and report to the physician as needed. The resident's care plan, dated 01/13/20, documented to perform weekly skin observation sheets as scheduled. A physician's orders [REDACTED]. The weekly skin assessments dated 02/2021 documented the resident did not have skin breakdown. A Braden Scale for Predicting Pressure Sore Risk, dated 03/07/21, documented, .Score: 9 .Category .VERY HIGH RISK . An Admit/Readmit Screener, dated 03/08/21 at 6:06 p.m., documented, .Integrity . Site .upper left buttocks .Pressure .Length .2 cm .Width .3 cm .Stage .II . Site .lower left buttocks .Pressure .Length .3 cm .Width .4 cm .Stage .II . Res has two separate open areas to left buttocks . It was not documented the physician or the resident's representative had been notified. No new treatment order was documented for the pressure ulcers. From 03/13/21 through 04/07/21, no weekly skin assessments or other documentation of an assessment of the resident's skin, including the two stage II pressure ulcers on the left buttocks as documented on 03/08/21 after she had returned from the hospital, was documented. A Braden Scale for Predicting Pressure Sore Risk, dated 03/14/21, documented, .Score: 11 .Category .HIGH RISK . The resident's care plan, dated 03/17/21, documented to provide treatment per current orders. A nurse's note, dated 04/07/21, documented, .wound to coccyx/right buttocks 5.8 cm x 10.5 cm. Wound doctor to see this week . This was the first documentation of the pressure wound on the coccyx/right buttocks. An initial wound evaluation and management summary, dated 04/08/21, documented the wound care physician assessment of the pressure ulcer on the sacrum was an unstageable deep tissue injury of more than one day. It documented the measurements as 7.5 cm x 11 cm x 0.1 cm. The periwound radius had odor, [DIAGNOSES REDACTED] and induration. There was moderate serous exudate with 10% granulation tissue, 20% dermis and 70% skin. It documented additional wound detail: concern for skin failure with skin slough and rapidity of development, co-morbidities, recent hospital stay, wound to evolve. The primary dressing order was to apply santyl, [MEDICATION NAME] ointment and calcium alginate and cover with a dry protective dressing twice a day for 30 days. A weekly wound observation tool, dated 04/08/21, documented the resident had an acquired pressure ulcer on the sacrum staged as a deep tissue injury. It was documented as the first observation with granulation tissue present, foul odor and redness to the surrounding tissue. The measurements were 75 mm x 11 mm x 1 mm. The current treatment plan was documented to cleanse with NS, pat dry, apply santyl/[MEDICATION NAME] ointment with calcium alginate, and cover with bordered dressing twice a day. The treatment administration record, dated 04/2021, documented to cleanse the coccyx/right buttocks with NS, pat dry, apply calcium alginate and cover with a bordered gauze daily for wound care. It was documented the treatment had been completed from 04/08/21 through 04/15/21. On 04/14/21 at 3:00 p.m., the resident was observed asleep in her bed. On 04/15/21 at 10:48 a.m., LPN #1 was asked what interventions were provided to prevent the developement/worsening of pressure ulcers. He stated they provided timely incontinent care and repositioning, ensured good nutrition, performed wound care and had the wound care physician assess the residents weekly for wound measurements. LPN #1 stated he had first observed resident #2's skin the previous Monday or Tuesday (04/05/21 or 04/06/21). He stated the resident had three areas on her bottom and it looked bad so he had informed the ADON. He stated the treatment order had not matched what he observed on her bottom. At 11:20 a.m., LPN #1 was observed to perform wound care for the resident while LPN #2 assisted with positioning. LPN #1 removed the dressings from the resident's bottom. The right buttocks was observed to have an area approximately 4 cm x 3 cm with pink tissue around the edges and a dark thicker center. The upper left buttocks was observed to have an area approximately 2 cm x 3 cm with minimum bleeding. The lower left buttocks was observed to have an area approximately 1 cm x 2 cm with minimum bleeding. The right hip/trochanter area was observed with dark purple/black skin approximately 5 cm x 3 cm. The sacrum was observed to be open in the center. LPN #1 stated the sacrum had not been open last week when he had provided the wound care to the resident. He was asked if the area on the right hip/trochanter was present last week. He stated no, it was also new to him. He stated he was going to bring the DON in to observe the new skin breakdown. At 11:25 a.m., the DON observed the pressure ulcers. She stated the open area on the sacrum was new and they would notify the wound care doctor. LPN #1 measured the sacrum and stated the length was 5.5 cm with 4 cm open and the width was 2 cm. He stated he could not determine the depth without having a Q-tip. At 3:25 p.m., the DON was asked if the resident had skin breakdown when she was readmitted from the hospital on [DATE]. She stated yes. She was asked if an order had been obtained for a treatment for [REDACTED]. She stated there was an order dated 02/13/21 to cleanse the left inner buttocks, but not a new order since the readmit. The DON was asked if they had a physician's orders [REDACTED]. She stated they had an order dated 2/19/21 for weekly skin assessments. She was asked if weekly skin assessments had been completed since 03/12/21. She stated it was not documented. She was asked if the resident currently had the pressure ulcers on her left buttocks. She stated yes. She was asked what the condition of the resident's skin was between 03/13/21 and 04/07/21, the time period no skin assessment was documented. She stated she could not answer that. The DON was asked what the condition of the resident's skin was on 04/07/21. She stated she had a deep tissue injury on her sacrum that measured 75 mm by 11 mm x 1 mm with a foul odor and redness. At 3:40 p.m., LPN #1 was asked to describe the condition of the resident's bottom when he had assessed it this date. He stated the area was red with open areas. The left buttock was 25% breakdown and the middle area was 50% breakdown stage II with a foul odor which was not present the previous week. The sacrum was open, which was a decline from the previous week. The clinical record was reviewed on 04/16/21 for new wound care orders related to the assessment of the skin on 04/15/21. There were no orders to address the pressure ulcers on the left and right buttocks and the discolored area on the right hip/trochanter. On 04/16/21 at 11:28 a.m., the DON was asked what the current treatment was for the left and right buttocks and the right hip/trochanter. She stated they did not have an order yet for the right hip. She stated they had notified the wound doctor about the areas and she would assess the resident today. She stated they had an order for [REDACTED]. She stated to apply santyl, [MEDICATION NAME] ointment and calcium alginate two times a day. She was asked if they had applied the santyl and [MEDICATION NAME] ointment and performed the wound care two times a day per the physician's orders [REDACTED]. 2. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The clinical record did not include a weekly skin evaluation for the month of April, 2021. On 04/16/21 at 3:45 p.m., the DON stated they had not performed a weekly skin evaluation for the resident in April. 3. Resident #5 was admitted on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The clinical record did not include a weekly skin assessment for the months of March and April, 2021. On 04/16/21 at 3:45 p.m., the DON stated they had not performed a weekly skin assessment for the resident in March and April.

Based on observation, record review and interview, it was determined the facility failed to assess, monitor, and intervene for a resident with surgical wounds for one (#1) of three residents reviewed for surgical wounds. Resident #1 became septic seven days after admission post aortobifemoral bypass surgery. The facility identified seven residents with surgical wounds. Findings: Resident #1 was admitted on [DATE]. His admission [DIAGNOSES REDACTED]. The resident was admitted with three surgical incisions with staples. One incision was on the abdomen and two were in the groin areas. A physician's orders [REDACTED]. The resident's care plan was reviewed and there was no plan for surgical incision care. Medication administration records and treatment administration records were reviewed. There was no monitoring noted or dressing changes noted to the groin or the abdominal incisions. An admission note, dated 07/23/20 at 16:42 p.m., documented the resident had a swollen scrotum, discoloration to bilateral upper extremities, and buttock with slight redness. There was no mention of the incisions to the abdomen or groin. An admission skin integrity assessment, dated 07/23/20, documented the resident had a swollen groin. No surgical incisions were mentioned in the assessment. A skilled nurse assessment, dated 07/24/20, documented the resident had an abdominal incision, The note did not describe the incision. There was no documentation of the groin incisions. A physicians note, dated 07/24/20, documented the resident had a midline abdominal incision with staples intact and swelling to left lower extremity. The note did not document the groin incisions. A skilled nurse assessment, dated 07/25/20, documented the resident had a surgical wound, swollen scrotum, and abdominal incision. The note did not describe the incision. There was no documentation of the groin incisions. A skilled nurse assessment, dated 07/26/20, documented the resident's skin was intact, had a swollen scrotum, and an abdominal incision. The note did not describe the incision. There was no documentation of the groin incisions. A skilled nurse assessment, dated 07/27/20, documented the resident had a surgical wound, swollen scrotum, and an abdominal incision. The note did not describe the incision. There was no documentation of the groin incisions. There was no assessment documented on 07/28/20. A skilled nurse assessment, dated 07/29/20, documented the resident had a surgical wound, a swollen scrotum, and an abdominal incision. The note did not describe the incision. There was no documentation of the groin incisions. A physician note, dated 07/29/20, documented, the patient had scrotal [MEDICAL CONDITION] which was noted to have during hospitalization . The note documented the resident had a midline abdominal incision with staples. The note did not document the groin incisions. There were no thorough assessments of the wounds on admit and/or during the resident's seven day stay at the facility. A nurse note, dated 07/30/20, documented the physician ordered the resident to be sent to the hospital related to an enlarged prostate. The hospital physician note, dated 07/30/20, documented, .chief complaint: scrotal swelling .was discharged on ,[DATE] with some scrotal swelling at this time, but has significantly worsened .noted dressings still in place in bilateral groins from previous surgery, left side with purulent discharge and open wound in groin. Right groin with dressing with some purulent discharge on dressing .Active Diagnoses: [REDACTED]. scrotal [MEDICAL CONDITION] 3. Fungating scrotal mass 4. Vascular disease 5. Left leg [MEDICAL CONDITION] 6. Chronic pain with opioid dependence . A surgical physician note, dated 07/31/20, documented, .S/P aortobifemoral bypass, now with superficial wound infection .He states that his bilateral groin dressings have not been changed since he left the hospital. He now presents with increased [MEDICAL CONDITION] of the lower extremities, particularly the left and of the scrotum. He has purulent drainage from his bilateral groin incisions and [DIAGNOSES REDACTED] of his midline abdominal incision. He had fever on arrival .Plan to take patient to OR today to open and debridement surgical incisions with placement of [DEVICE] . A physicians note, dated 08/01/20, documented, .Pt has had increased pain and swelling in groin area along with fevers .presented with elevated WBC, fever, and lactic acid of 2 .I&D with washout and b/l muscle flaps with [DEVICE] placed on 07/31. During procedure he was found to have infection at graft site along with abdominal infection .Assessment .Sepsis likely due to below .fever leukocytosis, elevated lactic acid, B/I post-surgical graft infection w/abdominal infection .Scrotal [MEDICAL CONDITION], likely due to groin infection, Scrotal US possible abscess or hematoma deep to wall, urine culture pending . In November 2020 the new director of nursing (DON) started reviewing pressure ulcers/skin assessments during quality assurance (QA) meetings. On 11/16/20 nursing staff were in-serviced on assessments of wounds and wound care. On 11/20/20 all staff were in-serviced on assessments, documentation, and notification of changes in status. In December 2020 the DON started a wound summary report for any wounds or suspected wounds. This report was being reviewed weekly and during QA meetings. This report helped to recognize skin issues and ongoing monitoring of skin conditions. The wound nurse or nurse on staff were to complete skin assessment on admission. The wound care nurse's working schedule had changed to have her present for the majority of new admissions. The wound nurse would turn in weekly skin condition reports to determine if treatments are effective. On 12/09/20 an in-service on assessments for new admissions and all charting was provided. In December 2020 during the QA meeting, the daily documentation of wounds was discussed. On 12/22/20 a weekly skin condition report was initiated by the DON. There were two reports, one report for pressure ulcers, and one report for non-pressure skin conditions. It was to be filled out by the wound nurse and turned in to the DON for review. The facility provided weekly documentation for skin conditions since 12/22/20. On 01/12/21 an in-service was provided on wound healing and documentation. On 01/18/21 an in-service was provided on wound care plans. The DON and administrator said inservices would continue to be provided on assessments, wound care, and proper wound care charting. The facility provided evidence of weekly monitoring of wounds and inclusion in the monthly QA meetings. On 02/19/21 at 10:10 a.m., the DON was asked what type of documentation should be in an admission assessment. She said there should be a full skin assessment with details on the condition of the skin. She was asked was there an admission assessment on this resident. She said there was an admission assessment but it did not identify any of the surgical wounds. She was asked if a resident had surgery would you expect dressing changes and monitoring of incisions. She stated, Yes, unless the wounds were healed. At 1:34 p.m., the surgeon was asked should the facility have been monitoring and changing the dressing on the surgical wounds. She said, they should have been monitoring the sites and changing the dressings several times a day. She said the resident was retaining fluid and it was leaking at the wound sites. The surgeon said the dressings were soiled every time we changed them at the hospital and the dressings needed to be kept clean and dry. The surgeon was asked what could happen if the dressings were not changed. She stated it could cause skin break down and infection. At 4:27 p.m., the facility physician was asked if he knew the resident had surgical incisions in the groin. He stated, I did not document on any surgical incisions in the groin area but with the type of surgery I would have known there were surgical incisions. My main concern was the groin swelling increasing and not getting any better. This was the first time I had seen the resident and I sent him back to the hospital to be seen by a urologist.

Based on observation, record review and interview, it was determined the facility failed to ensure one (#9) of one sampled resident was free from abuse. The resident reported her roommate, another facility resident, verbally abused and physically threatened her. The facility identified 60 residents who resided in the facility. Findings: A policy and procedure titled, Abuse Protection, dated August 1, 2019, documented: Policy The resident has the right to be free from verbal, sexual, physical, and mental abuse . Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents . Resident #9 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A significant change assessment, dated 12/07/19, documented the resident's cognition was intact and she required extensive assistance with her ADLs. The resident had episodes of feeling depressed and feeling bad about herself seven to eleven days during the two week look back period. A care plan, dated 12/19/19, documented the resident was on antidepressant medications for depression, suicidal ideation and self isolation. On 02/25/20, at 8:46 a.m., the resident stated she needed something for her nerves. As she tried to continue, her roommate, resident #45 was rambling and raising her voice. The resident was observed to rub her head then she stopped speaking, looked down and took a deep breath. She stated her roommate had been making her anxiety worse. She had requested a new roommate but nothing had been done. At 5:13 p.m., the DON stated the resident had been fine until today when she started hallucinating. She stated the resident had been in the hospital prior to re-admission and had all of her previous antipsychotic medications discontinued. The DON stated, We have just been waiting for something to happen. On 02/26/20 at 8:44 a.m., the resident stated her roommate had been going off on her the past three days but the previous night she stated, if I had a gun I would blow your head off. The social services director stated the roommate was being moved to different room. The resident stated it had not been fair to her. Resident #45 had made her feel very low and she was not sure how she would pick herself back up. The resident stated the roommate had made her feel inadequate for her inability to care for herself. She stated the nurse aides on the night shift would listen to resident #45 and say they did not know what could be been done about her. The resident was asked where resident #45 had been moved. She stated somewhere across the hall because she could still hear her. At 9:03 a.m., CNA #1 stated the problem with resident #45 started yesterday, although resident #9 had expressed concerns two days ago. The CNA stated she told the resident not to worry about it because it was not directed toward her. The CNA stated resident #9 made a comment about the night shift staff having told her the same thing. At 9:07 a.m., the social services director stated the move of resident #45 was only temporary. The resident had no history of behaviors or aggression toward someone until now. The facility was waiting on the mental health services provider to see the resident and put her back on her antipsychotic medications. The social services director stated resident #9 had other roommates in the past but the changes had not necessarily been due to her. The last roommate of resident #9 had moved due to a request for a bed next to the window. The social services director was asked if she had spoken to resident #9 regarding the incident which had occurred with resident #45. She stated no. At 9:12 a.m., CNA #2 stated resident #45 had been acting out toward resident #9 for the past two days, she thought it had been reported. The CNA stated the resident needed to have been on her psych medications. At 10:02 a.m., the DON was asked if anyone had interviewed resident #9 regarding the incident and how they had ensured her safety. She stated the social services director had spoken to the resident. The DON was informed of the conversation with social services earlier in the morning when she stated she had not spoken directly with the resident. The DON then stated the mental health services provider was contacted for resident #45 but nothing had been addressed with resident #9. On 02/27/20 at 8:32 a.m., resident #9 stated resident #45 had been back in the room and slept there the previous night. The resident stated she needed something stronger for her nerves. She began to cry and stated she was not even hungry for breakfast. At 9:17 a.m., CNA #3 stated when she had come on duty the previous night, resident #45 was found in the room with resident #9. She was in bed watching television. The CNA verified with staff the resident had not been moved back into the room at that time, then redirected her out of the room. At 10:37 a.m., the mental health services provider stated resident #9 was worried resident #45 would find a weapon and come after her. The provider stated she reassured the resident no one had access to weapons and assisted her with calming exercises.

Based on observation, record review and interview, it was determined the facility failed to: ~ assess, monitor and intervene for a resident who had a change in condition for one (#124) of one sampled residents with a change in condition; ~ ensure a thorough wound assessment was completed of a surgical wound for one (#57) of one sampled resident with a surgical wound; and ~ ensure catheter care was provided for two (#118 and #124) of three sampled residents with indwelling urinary catheters. The facility failed to complete neurological assessments per their policy after resident #124 hit her head during a fall, and failed to assess, monitor and intervene in a timely manner as the resident experienced a change in condition. The resident was unresponsive except to a sternal rub when transferred to the hospital and was found to have severe [CONDITION(S)], acute kidney injury, hypothermia, pneumonia, and urinary tract infection, The facility identified four residents who had a urinary catheter in the facility. Sixty-one residents resided in the facility. Findings: A neurological evaluation policy, dated March 2010, documented a neurological evaluation was used to establish a baseline neurological status upon which subsequent evaluations may be compared and changes in neurological status may be determined. It documented to use the neuro evaluation following a fall when a patient has hit their head. It documented, after the completion of the initial neuro evaluation with vital signs, continue evaluations every 30 minutes x 4, then every one hour x 4, then every 8 hours x 9 (for the next 72 hours). The facility's Weekly Wound Reports Policy, reviewed 09/07/14, documented, .Weekly wound reports will be maintained by each nursing unit to monitor the development, healing and progress of wounds. Guidelines .the nursing management designee is responsible to ensure that all wounds are measured weekly and recorded on the medical record's weekly wound flow sheet .The flow sheet is completed as part of the wound round process. .Wound rounds will be completed on a weekly basis. Wound rounds are visual assessments of all Stage II or greater sites and complicated non-pressure sites. Assessment includes measuring of site, determination of improvement or deterioration, evaluation of effectiveness of current treatment, presence of infection, and recommendations for continued treatment . The weekly wound report will include all areas of skin breakdown: Pressure Ulcers Wounds (surgical sites, skin tears, scratches, abrasions, etc) Stasis Ulcers Other areas . The weekly wound report will include the following information for each site: Resident's name . Sites of skin breakdown Date of origin Place of origin Stage (for pressure ulcers) Treatment Preventive measures . Measurements (length, width, depth, tunneling, etc) . Description of wound (drainage, color, odor) Sites that are healed will be noted on the wound report for 4 weeks . 1. a. Resident #124 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan, dated 10/23/18, documented, The resident has had an actual fall with minor injury r/t non-complaince communication/comprehension .Interventions .For no apparent acute injury, determine and address causative factors for the fall .PT consult for strength and mobility . An incident report, dated 10/24/18 at 1:45 p.m., documented the resident was found sitting up in front of her chair in the floor. The resident stated she was going to the bathroom and scooted out of the chair and hit the floor. Neuro checks were initiated. The resident was instructed on using the call light. An incident report, dated 10/25/18 at 7:49 a.m., documented the resident was found on the floor on the side of the bed. The resident was observed sitting on her bottom. The resident had two skin tears to the left arm. The resident was very confused. The resident started yelling and screaming after she was assisted to the bed. The resident was saying she was leaving and she started scooting to get off the bed. The resident was then placed in the wheelchair. A nurse's note, dated 10/26/18 at 3:08 p.m., documented the resident threw herself forward to her knees and hit her head on the floor. The resident had a goose egg over her left eye turning purple. The resident's pupils were equal and reactive after the fall. The resident was sent to the ER. An incident report, dated 10/26/18, documented the resident had attempted to enter the staff bathroom from the hall. The resident was looking for something and when she was unable to find it, she became agitated and pushed herself back and fell forward out of the wheelchair. It was documented she was sent to the ER for altered mental status. The state report form, dated 10/26/18, documented, .Resident was observed by staff throwing herself forward and hitting her head on the floor. Upon assessment resident has rom to all extremities. Resident denied any pain of discomfort. Resident was noted to have a raised area noted to the left side of her head. Neurological checks were initiated. Resident was sent out for hospital evaluation .Resident was sent out for further evaluation and returned to the facility with new orders for [CONDITION(S)]. Residents urinary tract infection may have contributed to her cognitive status which resulting in the fall . The neurological record documented an entry for a neuro check on 10/26/18 at 8:30 p.m. No other neuro checks were documented for 10/26/18 after 8:30 p.m. A nurse's note, dated 10/26/18 at 11:07 p.m., documented, resident returned to facility from hosp visit r/t fall with head injury .has n/o for [MEDICATION(S)] [antibiotic] .for [CONDITION(S)] .resident alert and oriented to self .frequent checks made by staff . The next nurse's note was dated 10/27/18 at 11:28 a.m. The note documented, Focused nurses note r/t change in condition of SNF patient admitted with generalized weakness/ESKD/chronic [CONDITION(S)] continues with increased confusion/agitation/anxiety moving about the floor in her room unable to contain in bed or chair answers some simple questions appropriately unable to carry on meaningful conversation vital signs within limits foley cath intact/patent has new order for ABT pending arrival from pharmacy second toe on Lt. foot red/painful placed call to Dr. [name deleted]/received t.o to x-ray Lt. foot et add [MEDICATION(S)] twice daily for anxiety .fed self breakfast requires 1-2 person max assist with ADL's The neurological record documented entries for neuro checks on 10/27/18 at 4:30 a.m. and 8:30 p.m. No other neuro checks were documented for 10/27/18. The next nurse's note was dated 10/27/18 at 9:12 p.m. The note documented, Patient continues to have disoriented mentation resting quietly at this time X-ray results negative initial urinalysis negative Stat CBC results pending, will continue to monitor/insure safety . The next nurse's note was dated 10/28/18 at 11:46 a.m. The note documented, Focused nurses note r/t Patients recent decline/change in condition of mental status observed on bed with eyes closed able to arouse with sternum rub opens eyes for 30 second intervals still unable to communicate effectively CBC results indicate [CONDITION(S)] (on-going) admitted with [CONDITION(S)] diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .placed call to Dr. [name deleted] staff with these findings/received T.O to transport to E.R Patient left per stretcher with [ambulance] . An EMS billing summary, dated 10/28/18, documented, Dispatch: 12:07 At patient: 12:15 .Transport 12:22 .Pt was seen on Friday at [hospital name deleted] after a fall where she hit her head. PT was then released. Although PT has dementia, she is normally alert and fairly orientated .Pt found alert only to painful responses and maintaining her airway. PT was laying on a mattress on the floor. Pt had multiple bruises and contusions, as well as was covered in multiple bandages preventing IV access. PT was picked up using her bed sheet and placed onto the cot and then brought out to the ambulance for further care and assessment .Pt placed onto cardiac monitor and found to be bradycardic and hypotensive . An emergency room record, dated 10/28/18 at 12:51 p.m., documented, .Pt was found down on the tile floor in her nursing home today with altered mental status. Pt has mild dementia but nursing home reports that she talks and ambulates at baseline Pt was hypoxic with oxygen saturation 80 on room air on arrival to ED. Pt was also hypothermic at 28 [C] [82.4 F] on arrival .CXR with pneumonia. UA revealing [CONDITION(S)]. Will admit .Clinical Impression Primary Impression: Severe [CONDITION(S)] Secondary Impressions: AKI (acute kidney injury), Bruising, Hypothermia, Infectious [CONDITION(S)], Pneumonia, [CONDITION(S)] . A History and Physical report, dated 10/28/18 at 4:55 p.m., documented, .Problem List 1. Severe [CONDITION(S)] 2. Pneumonia 3. AKI (acute kidney injury) .Found to be septic in ER with [CONDITION(S)], started on warmer. Required [MEDICATION(S)] dosing per [ambulance company] due to significant [CONDITION(S)]. Patient found to be in the 70s on RA On 12/20/18 at 12:52 p.m., the DON was asked what time the resident was found on 10/28/18 when they observed a change in condition. She stated at 11:46 a.m. per the nurses' notes. She was asked what interventions the staff did before the arrival of EMS. She stated it looked like they assessed the resident and took her vital signs. She was asked in what position the resident was found. She stated, It says on the bed. She was asked if the resident's position was ever changed before EMS arrived. She stated, It does not say her position was changed. She was asked if she could explain why the EMS records documented the resident was found on a mattress in the floor. She stated she could not explain. She stated she did not know anything about it. She stated maybe because the resident had an altered mental status and had been getting out of the bed. She was asked why the resident being on the floor on a mattress would not be documented in her clinical record. She stated, I honestly can not tell you. She was asked if the resident had fallen prior to the arrival of EMS. She stated no, she did not know anything about her falling on 10/28/18. She was informed of the dispatch time on the EMS records as 12:07 p.m. She was asked why the nurse's note was documented at 11:46 a.m. for the change in condition, which included EMS arrival to the facility. She stated she did not know how that had occurred. She was asked if there was a time discrepancy in the documentation. She stated yes. The DON was asked what time the staff had last documented on the resident prior to the staff observing the change in condition on 10/28/18. She stated, The day before at 2112. She was asked if the resident had been assessed between 10/27/18 at 9:12 p.m. and 10/28/18 at 11:46 a.m. She stated, According to the nurse's notes, no. The DON was asked what their policy was for performing neurological checks after a fall with a head injury. She stated they performed neuro checks for 72 hours after the fall. She was asked when the resident had fallen on 10/26/18. She stated at 3:08 p.m. She was asked when they had started neuro checks. She stated on 10/26/18 at 8:30 p.m. She was informed it was documented the resident had not returned to the facility from the hospital until 11:07 p.m. per the nurse's note. She was asked when they had performed the last neuro check per the documentation. She stated on 10/27/18 at 8:30 p.m. She was asked if they had performed neuro checks on the resident until she went to the hospital on 10/28/18. She stated, No. She was asked if they would have performed the neuro checks on the resident per their policy, was it possible they would have observed the change in condition sooner. She stated, Possibly. b. Resident #124 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The admission assessment, dated 09/20/18, documented the resident was admitted from the hospital with a catheter with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A nurse's note, dated 10/05/18, documented the catheter was discontinued on 10/04/18. Review of the closed clinical record revealed no documentation the resident had received catheter care from 09/20/18 through 12/04/18. On 12/20/18 at 1:19 p.m., the DON was asked when the staff normally provided catheter care for the residents who had a catheter. She stated every shift and as needed. She was asked why they provided catheter care. She stated to prevent infection and make sure they were clean. She was asked when the staff had provided catheter care for resident #124. She stated she did not see an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated, No. 2. Resident #57 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] An admission progress note, dated 11/21/18 at 3:47 p.m., documented, .Lumbosacral wound with exposed surgical hardware present, redness surrounding site, no odor or drainage noted . The admission nursing assessment, dated 11/21/18, documented the resident had a surgical incision measuring 6.8 cm length x 1.6 cm width x 1.7 cm depth in the lumbosacral area. A skilled nursing note, dated 11/30/18 at 9:39 p.m., documented, .Wound care provided to lumbosacral dehiscent wound per orders, no odor/drainage noted, pt tolerated well. Continue on ABT/[MEDICATION(S)] r/t infection to Lumbosacral wound . A progress note, dated 12/01/18 at 3:04 p.m., documented, .Wound care provided this shift skin continue red to area not bright red as it was yesterday will continue to observe . A skin note, dated 12/02/18 at 8:10 p.m., documented, Res has surgical wound to lower back with rod in place, area measuring 5cm X 0.1cm X 1.5cm, 100% granulation tissue and wound is improving. Area is red around wound with slightly pink wound bed. Cleanse area with ns, pat dry, apply dakins soaked sterile 4X4, pack lightly and cover with alevin foam dressing. Res tolerated treatment well . An admission skin observation tool, dated 12/14/18, documented the resident had a lumbosacral surgical incision measuring 5.0 cm length x 0.1 cm width x 1.3 cm depth. The assessment contained no further documentation regarding the wound. On 12/19/18 at 12:51 p.m., ADON #1 was asked about the resident's wound care. She stated she was not the wound care nurse, however, she does wound care on residents when asked. The ADON stated she usually just does pressure ulcers but will look at surgical wounds etc if asked. The ADON was asked about the admission documentation which contained only the location and measurements of the wound with no description of what the wound looked like and asked if that was a complete wound assessment. She stated, No, it should say if sutures are present, what the edges look like, etc. She continued, stating, I first saw her and documented on her wound the first week of December. The ADON was informed of the resident having had documentation of just the location and measurements of the wound when she came in on 11/21/18 and there was no documentation found of a complete assessment until she saw her on 12/2/18, 11 days later. She was then asked if that was following the facility's policy. She stated, I'd have to look and see. At 1:05 p.m., ADON #1 returned, stating, It looks like it should have been me. She then gave the surveyor a copy of the Weekly Wound Reports Policy and stated, But they were looking at it twice a day. 3. Resident #118 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan, dated 11/22/18, documented a problem related to a foley catheter for urinary retention. The goal was the resident would be free of complications through the next review date. An intervention, dated 12/04/18, included cath care frequently. The admission assessment, dated 11/27/18, documented the resident was independent in cognitive skills for daily decision making. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/13/18 at 1:53 p.m., the resident was asked how often the staff had provided catheter care including cleaning the insertion site of the catheter. She stated every other day. She stated she did not have signs and symptoms of a urinary tract infection currently. She stated she was having some pain at the insertion site until they cleaned it. There was no documentation for a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/17/18 at 10:14 a.m., the resident was asked when the staff had last provided catheter care. She stated they had provided catheter care the previous night and they had changed the catheter because the other catheter started irritating her. She was asked how often the staff provided catheter care. She stated every other day. On 12/17/18 at 2:15 p.m., LPN #2 was asked if the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She was asked what that order consisted of. She stated they were to make sure the catheter was draining. She stated they usually had a specific foley care order, however she did not see a foley care order. She was asked where the catheter care would be documented. She stated it would be documented twice a day in the progress notes. She was asked if the catheter care had been documented twice day in the progress notes. She stated no, not twice a day. She was asked if the resident had an order specific to catheter care. She stated, No. She was asked if staff had provided catheter care twice a day per the clinical record. She stated, No. At 2:42 p.m., the DON was asked what physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated when to change the catheter, when to provided catheter care and to document intake and output. She was asked if they had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She was asked if the staff had provided catheter care for the resident. She stated since there was no order, she would say no. She was asked if catheter care had been documented. She stated she did not see it.