Every finding on record at Emory Health and Rehab

Based on observation, interview, and record review, the facility failed 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 for 1 of 15 residents reviewed for infection control practices (Resident #20). The facility failed to ensure CNA C changed his gloves and performed hand hygiene while providing incontinent care to Resident #20. These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections. Findings included: Record review of the undated face sheet indicated Resident #2 was an [AGE] year-old male that admitted [DATE] with diagnoses that included: Dementia (a decline in mental abilities affecting daily life), cerebral infarction (a stroke, death of brain tissue due to lack of blood flow), and muscle wasting and atrophy (loss of muscle mass and strength). Record review of the quarterly MDS dated [DATE] indicated Resident #20 had a BIMS score of 8, indicating moderate cognitive impairment. He was always incontinent of bowel and bladder. Resident #20 required substantial/maximal assistance for toileting hygiene. Record review of the care plan dated 6/27/25 indicated Resident #20 had dementia and was at risk for increase in confusion and decline in ADL's as the disease progressed. Resident #20 had an ADL self-care performance deficit and required substantial assistance of 1 staff for toileting. During an observation on 8/05/2025 at 8:39 AM CNA C provided incontinent care, for Resident #20. CNA C cleaned Resident #20's backside and did not change his gloves or sanitize his hands before putting on Resident #20's clean brief, touching the clean bed pad, and the resident's pants. Then, he changed his gloves and sanitized his hands. During an interview on 8/05/25 at 8:51 AM, CNA C said he should have changed his gloves and sanitized his hands after cleaning Resident #20's backside and before touching clean things like his clean brief, bed pad, and his pants. He said there was a risk of cross-contamination and spreading infection. He said he was taught to always change his gloves and sanitize his hands when going from a dirty to a clean procedure. During an interview on 8/05/2025 at 12:32 PM, the ADON said staff should change their gloves and clean their hands anytime when going from a dirty procedure to a clean procedure. She said if a staff cleaned a resident's perineal area during incontinent care, they must change their gloves and wash their hands before touching anything clean. Otherwise, there was a risk of cross contamination and infection. During an interview on 8/05/2025 at 12:37 PM, the DON said staff should always change gloves when going from a dirty procedure to clean. He said if a staff was cleaning a resident during incontinent care and did not change gloves or clean their hands before touching clean items there was a risk of cross-contamination or infection. During an interview on 8/05/2025 at 12:42 PM the ADM said staff must change gloves after performing a dirty procedure before going to a clean procedure to prevent cross-contamination or infection to residents and staff. Record review of proficiency assessment dated [DATE] indicated CNA C was proficient in performing incontinent. Record review of a Perineal Care Policy with a revised date of February 2018 indicated: Purpose The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition.For a male resident:.m. Wash and rinse the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks.n. Dry area thoroughly. 9.Discard disposable items into designated containers. 10. Remove gloves and discard into designated container. 11. Wash and dry your hands thoroughly.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs, for 1 of 6 (Resident #19) residents reviewed.The facility failed to update Resident #19's care plans for her fall mat on 04/30/25. This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs.Findings included: Record review of Resident #19's face sheet, dated 08/05/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included, dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), hypertension (high blood pressure), and Osteoarthritis (OA) (a degenerative joint disease that causes cartilage breakdown, leading to pain, stiffness, and reduced mobility in affected joints). Record review of Resident 19's quarterly MDS assessment, dated 05/29/25, indicated Resident #19 was usually understood and was usually understood by others. Resident #19 BIMs score was 01 indicating she was severely cognitively impaired. The MDS indicated Resident #19 required maximum assistance with her ADLs. The MDS indicated she had a fall during the look-back period. Record review of Resident 19's Physician order dated 04/30/25 revealed Resident #19 had a Fall mat in place for safety precautions every shift. Record review of Resident #19's comprehensive care plan revision dated 07/31/25 revealed Resident #19 had a fall on 04/29/25, and 07/30/25. The interventions for staff were to assist resident with ambulation, transfers, utilizing therapy recommendations and increase rounding. The interventions did not indicate a fall mat. During an observation and interview on 08/05/25 at 2:49 p.m., the MDS nurse said she was responsible for the care plans. She looked in Resident #19's medical records and did not see a care plan for her fall mat. She said the care plan should have been updated when the quarterly MDS was done on 05/29/25 since the order was written before the MDS assessment. She said she was not employed at the time of the MDS assessment. She said care plan were done so the staff would know how to care for the resident. During an interview on 08/05/25 at 2:55 p.m., the DON said care plans were a team effort with the IDT. He said he was responsible for the acute care plans. The DON said the fall interventions should have been on the care plan for Resident #19. He said the purpose of care plans was for effective communication to the staff of the care the resident needed. He said without care plans proper care may not be given. During an interview on 08/05/25 at 3:29 p.m., the Administrator said the management nurses were responsible for the care plans. She said the MDS nurse was the overseer. She said fall intervention should have been on the Resident #19's care plans. She said care plans kept the staff aware of any changes or updates for the resident's care. Record review of the facility's policy titled, Care Planning, revised 09/2013, indicated, Policy: Our facilities care planning interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident. #13 assessment of residents are ongoing, and care plans are revised as information about the resident and the residents' condition change.

Based on observation, interview, and record review, the facility failed to ensure the environment was free of accidents and hazards for 1 of 6 (Resident #19) residents reviewed for accidents. The facility failed to ensure Resident #19's fall mat was beside her bed on 08/03/25. This failure could place residents at risk for fall related injuries.Findings included: Record review of Resident #19's face sheet, dated 08/05/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included, dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), hypertension (high blood pressure), and Osteoarthritis (OA) (a degenerative joint disease that causes cartilage breakdown, leading to pain, stiffness, and reduced mobility in affected joints). Record review of Resident #19's quarterly MDS assessment, dated 05/29/25, indicated Resident #19 was usually understood and was usually understood by others. Resident #19 BIMs score was 01 indicating she was severely cognitively impaired. The MDS indicated Resident #19 required maximum assistance with her ADLs. The MDS indicated she had a fall during the look-back period. Record review of Resident #19's Physician order dated 04/30/25 revealed Resident #19 had a Fall mat in place for safety precautions every shift. Record review of Resident #19's incident report dated 07/30/25 revealed she had a fall from her bed on 07/30/25. The incident report indicated she was sitting on her knees beside the bed on the fall mat holding onto the side rails. Record review of Resident #19's comprehensive care plan revision dated 07/31/25 revealed Resident #19 had a fall on 04/29/25, and 07/30/25. The interventions for staff were to assist resident with ambulation, transfers, utilizing therapy recommendations and increase rounding. The interventions did not indicate a fall mat. During an observation on 08/03/25 at 11:20 a.m., Resident #19 was in her bed without a fall mat beside her bed. During an observation on 08/03/25 at 1:02 p.m., Resident #19 was in her bed with the fall mat partially out at the head of the bed and the rest of the mat was under the bed. During an observation and interview on 08/03/25 at 3:42 p.m., CNA A walked into Resident #19's room and saw the fall mat was not on the floor beside her bed. CNA A said Resident #19 required a fall mat because she was at risk of falling. He said he was Resident #19's aide and should have made sure the fall mat was positioned beside her bed and not under the bed because she could have fallen and received an injury. During an interview on 08/05/25 at 1:39 p.m., LVN B said she was Resident #19's charge nurse. She said Resident #19 required a fall mat beside her bed. She said the aides were supposed to place the fall mat, but she was responsible for ensuring it was down by walking the halls. She said the fall mat was in place for safety. During an interview on 08/05/25 at 2:55 p.m., the DON said Resident #19 was supposed to have a fall mat beside her bed because she had a fall and was at risk for further falls. He said all staff was responsible for ensuring the fall mat was beside her bed. He said the fall mat was for fall prevention and to prevent an injury. During an interview on 08/05/25 3:27 p.m., the Administrator said if Resident #19 had an order for a fall mat, then she expected the fall mat to be beside her bed. She said the fall mat was for the prevention and safety of falls. Record review of the facility's policy titled, Fall and Fall Risk, Managing, revised 03/2018, indicated, Policy: based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risk and causes to try to prevent the resident from falling and try to minimize complications from falling. Resident-centered approaches to managing falls and fall risk #1 the staff with the input of the attending physician will implement a resident centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls.

Based on observation, interviews, and record reviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 of 1 medication room reviewed for pharmacy services. The facility failed to ensure the Medication Storage Room did not contain Resident #18's expired ondansetron (nausea medication) with an expiration date of 06/11/25 or an expired Tums bottle with an expiration date of 09/2024. This failure could place the residents at risk of not receiving the intended therapeutic benefits of prescribed medications and medications being used passed their effective or expiration date.Findings included: During an observation and interview on 08/04/25 at 12:26 PM, the medication storage room was reviewed and Resident #18's ondansetron 4mg medication card containing 26 tablets was noted with an expiration date of 06/11/25. A bottle of Tums was also located in the medication storage room that had an expiration date of 09/2024. MA F said she checked her side of the medication room weekly. She said she was unsure of when the bottle of tums was placed inside the medication room because she checked the medication room for expired medications on Wednesday of the prior week and the bottle of Tums was not there. She said MA G was responsible for the other side of the medication room where Resident #18's ondansetron was found. MA G said he checked the medication room for expired medications as least monthly. He said he was unsure how the medication was missed. MA F said failure to remove expired medications could place the resident at risk for receiving an expired medication and could cause them to get sick. MA G said anyone on the cart was responsible for ensuring expired medications were removed from the medication room and carts. During an interview on 08/05/25 at 2:00 PM, the Administrator said there should not have been any expired medications in the medication room. She said the medication aide was responsible for ensuring expired medications were removed from the medication room or cart and if they were not the resident could be given an expired medication. During an interview on 08/05/25 at 2:20 PM, the DON said he did not see an issue with having expired medications in the medication room because the medications were not on the medication cart. He said if the staff followed the medication rights, then the resident would never receive the expired medications. Record review of the facility's policy Storage of Medications revised April 2019, indicated . The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 5. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 medication carts (Nurse Cart) observed for medication storage. The facility failed to ensure the Nurse's cart did not contain Resident #2's undated NovoLog insulin bottle. This failure could place residents at risk for not receiving drugs and biologicals as needed and medications being used passed their effective or expiration date.Findings included: During an observation and interview on 08/04/25 at 11:00 AM, the Nurse's Cart was reviewed and a bottle of Resident #2's NovoLog insulin was noted to be opened and undated. LVN E looked at Resident #2's NovoLog insulin bottle and said there was not a date on it. She said the nurse who opened the insulin should have dated it. She said by not dating the insulin when opened the staff would not know if the insulin had gone past the shelf life. She said this could place the resident at risk for receiving a mediation that was out of date and not be strong enough. During an interview on 08/05/25 at 2:00 PM, the Administrator said she expected the insulin bottle to be dated when opened. She said the nurse who opened the insulin bottle was responsible for dating it. She said failure to date the insulin bottle could cause the insulin to be administered out of date. During an interview on 08/05/25 at 2:20 PM, the DON said he expected the insulin to be dated when opened. He said the nurse who first opened the insulin was responsible for dating it. He said by not dating the insulin the resident could have received a medication that was out of date. Record review of the facility's policy Administering Medications revised April 2019, indicated .When opening a multi-dose container, the date opened is recorded on the container.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure: 1. Food items were labeled and dated. 2. Hair restraints worn. 3. The microwave was clean and free of food debris. 4. The toaster was clean and free of food debris. 5. Expired food item was discarded. 6. Refrigerator/Freezer log was kept up to date. 7. Personal drinks were kept out of facility refrigerator. These failures could place residents at risk for foodborne illness. Findings included: During an observation and interview on [DATE] at 8:00 a.m., [NAME] C was in the kitchen without wearing a hair restraint. [NAME] C stated the one she had on her head had ripped. [NAME] C stated she was going to get another one but got sidetracked. [NAME] C stated it was important to wear a hairnet while in the kitchen to prevent food contamination. During the initial tour observation and interview with the [NAME] C on [DATE] between 8:21 a.m. and 8:50 a.m., the following was revealed: 1. Plastic storage bag that was identified by the Dietary Aide B as sliced turkey ham undated and unlabeled. 2. Plastic bottle labeled Ice Pop Prime Hydration drink noted in refrigerator. [NAME] C stated the drink belonged to her. [NAME] C stated she put the drink in the fridge to get cold. 3. Large serving pan labeled chicken dated [DATE]. [NAME] C stated the chicken should be discarded after 4 days. 4. [NAME] storage bin that was identified by Dietary Aide B as onions undated and unlabeled. 5. Toaster with food particles noted. 6. Microwave with several brown substance noted. 7. Refrigerator/Freezer temperature log was missing temperatures on [DATE], [DATE], [DATE]. During an interview on [DATE] at 1:16 p.m., Dietary Aide B stated all kitchen staff were responsible for labeling and dating food products. Dietary Aide B stated the cook was responsible for discarding the chicken after 3 days, cleaning the toaster/microwave and logging the temperature on every shift. Dietary Aide B stated personal drinks should go in the breakroom fridge. Dietary Aide B stated these failures could put residents at risk for food borne illness and contamination. During an interview on [DATE] at 1:24 p.m., [NAME] C stated whoever took the food products out the original package should have labeled and dated the item. [NAME] C stated she thought food should be discarded after 4 days until the Dietary Manager in-serviced her. [NAME] C stated the cooks were responsible for cleaning the toaster and microwave daily and as needed. [NAME] C stated the cooks were responsible for logging the refrigerator/freezer temperature right after breakfast. [NAME] C stated she should have put her personal drink in the back closet or in the staff breakroom. [NAME] C stated these failures could cause foodborne illness and contamination. During an interview on [DATE] at 1:46 p.m., the Dietary Manager stated cleanliness was important in the kitchen, so her staff are not spreading germs or contaminating anything. The Dietary Manager stated she was responsible for making sure the kitchen was cleaned appropriately. The Dietary Manager stated all food should be labeled with date received and the date it was opened. The Dietary Manager stated personal drinks should be kept in the staff refrigerator. The Dietary Manager stated that chicken that was in the serving pan should have been discarded after 3 days. The Dietary Manager stated cooks were responsible for cleaning the toaster and microwave daily and as needed. The Dietary Manager stated the refrigerator/freezer log should have been completed as soon as the cook got there in the morning and at the end of night shift. The Dietary Manager stated hairnets should be worn while in the kitchen. The Dietary Manager stated he was responsible for monitoring and overseeing by daily walk throughs and when there was an issue staff were verbally in serviced immediately. The Dietary Manager stated if the issues continued to happen a full in serviced was done by conducting a meeting with all kitchen staff. The Dietary Manager stated these failures could potentially put residents at risk for cross contamination, foreign debris getting into food and food borne illness. During an interview on [DATE] at 3:21 p.m., the Administrator stated she expected the kitchen to be clean and staff preventing cross contamination. The Administrator stated she expected all food to be labeled and dated. The Administrator stated she expected food to be discarded after day 3, microwave/toaster cleaned after each use and hairnets always worn. The Administrator stated the refrigerator/freezer log should be completed first thing in the morning and at the end of night shift. The Administrator stated she did walk throughs Monday-Friday and if she noticed an issue, it was addressed immediately. The Administrator stated the Dietary Manager was responsible for overseeing and monitoring. The Administrator stated it was important to ensure these things listed above were complying to ensure the health and safety of the residents. Record review of the facility's policy titled, Sanitization, revised ,d+[DATE] indicated, .the food service area shall be maintained in a clean and sanitary manner . 11. For fixed equipment or utensils that do not fit in the dishwashing machine, washing shall consist of the following steps: a. equipment will be disassembled as necessary to allow access of the detergent/solution to all parts; b. removeable components will be scraped to remove food particles accumulation and washed according to manual or dishwashing procedures . Record review of the facility's undated policy titled, Thaw Frozen Leftovers Safely, indicated, . this policy outlines the safe methods for thawing frozen leftovers to ensure food safety and prevent foodborne illness 1. Refrigerator Thawing . thawed food should be used within 3 days . Record review of the facility's policy titled, Food Receiving and Storage, revised ,d+[DATE] indicated, . food shall be received and stored in a manner that complies with safe food handling practices .7. Dry foods that are stored in bins will be removed from original packaging, labeled and dated .8. All foods stored in the refrigerator or freezer will be covered, labeled and dated . Record review of the facility's undated policy titled, Hair Restraint in Food Services, indicated, .the purpose of this policy to establish guidelines for employees to follow when it comes to hair restraint in food service kitchens. Hair restraint is an essential component of maintaining a safe and sanitary environment in a food service kitchen and is necessary to prevent contamination of food 1. All employees working in the kitchen or food preparation areas must always wear a hair restraint Record review of the facility's undated policy titled, Refrigerator and Freezer Log Maintenance indicated, . to ensure the safety and quality of food storage, this policy outlines the importance and procedures for maintaining a refrigerator and freezer log twice a day. Regular monitoring and documentation of temperatures are crucial in preventing food spoilage and ensuring compliance with food safety standards .maintaining a refrigerator and freezer log twice a day is mandatory in our establishment .5. Log Review . Logs will be reviewed daily by the kitchen supervisor to ensure compliance and to address any issues promptly

Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment for 4 of 4 resident's (Resident #'s 4, 17, 25, and 34) reviewed for a homelike environment. The facility failed to ensure Resident #25's wall behind her bed was free from deep gouges into the sheetrock measuring 4 inch wide and 2 feet long. The facility failed to ensure Resident #17's and Resident #34's bed linens were changed. The facility failed to ensure Resident #34 had hot water available in the bathroom. The facility failed to ensure Resident #34 had a toilet seat that was free from peeling paint. The facility failed to ensure Resident #34's toilet was flushing properly. The facility failed to ensure Resident #4's hot water in the bathroom sink was not running continuously, and Resident #4 had cold water available. These failures could place residents at risk for an uncomfortable, unhomelike environment, and a diminished quality of life. Findings included: 1. Record review of a face sheet dated 5/17/2024 indicated Resident #25 was a [AGE] year-old female who admitted on [DATE] with diagnoses of diabetes and high blood pressure. Record review of the Annual MDS dated [DATE] indicated Resident #25 was usually understood, and usually understood others. The MDS indicated Resident #25's decision making capacities were severely impaired, and she had a memory problem. The MDS failed to indicate Resident #25's BIMS score. During an observation on 7/07/2024 at 8:57 a.m., Resident #25 was lying in her bed awake, she was facing the wall. Resident #25's wall directly behind her bed had deep gouges down to the sheetrock measuring 3 inches wide and 2 feet in length behind her bed. Resident #25 was unable to be interviewed regarding the wall damage due to her cognitive state. During an observation and interview on 7/10/2024 at 2:29 p.m., the maintenance supervisor said when he observed the deep gouges in Resident #25's wall said he had not focused on resident rooms for maintenance problems, but relied on the nursing staff to inform him of the repair needs in specific resident rooms. The maintenance supervisor said not having a homelike environment could be a dignity issue. During an interview on 7/10/2024 at 2:44 p.m., the DON said resident rooms should be repaired, and maintained repaired. The DON said this was the resident's rooms and should be nice and homelike. The DON said the maintenance supervisor was responsible for repair of resident rooms. During an interview on 7/10/2024 at 3:41 p.m., the Administrator said she expected the maintenance supervisor to make rounds in the resident rooms monitoring for repairs, she expected empty rooms to be repaired prior to another resident occupying the rooms, and she expected all other staff to use the maintenance repair book to log needed repairs when they were found. The Administrator said she had made rounds in the facility but had not seen the gouges in Resident #25's wall. 2. Record review of a face sheet dated 06/28/2024 indicated, Resident #17 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included hypertension (high blood pressure), hyperlipidemia (high levels of fat particles in the blood), history of stroke, benign prostatic hyperplasia (prostate gland enlargement resulting in difficulty with urination) and acquired absence of limb. Record review of the quarterly MDS dated [DATE] indicated, Resident #17 was understood by others and understood others. The MDS indicated Resident #17 had a BIMS of 10 and was moderately cognitively impaired. The MDS indicated Resident #17 was independent with toileting, supervision and required touching assistance for lower body dressing, and putting on and taking off footwear. Resident #17 required set up/clean-up assistance with bathing and with upper body dressing. In section GG0120 Mobility devices the MDS indicated in the last 7 days Resident #1 used a wheelchair. Record review of the comprehensive care plan dated 05/19/2023 indicated, Resident #17 had an activities of daily living (ADL) self-care performance deficit. The care plan indicated interventions included Resident #17 required assistance with showering, dress according to climate, assist with daily hygiene, provide peri care as indicated. During an observation and interview on 07/07/2024 at 10:30 AM, Resident #17 said the linens on his bed had not been changed in two weeks. The linens had dirty yellow and orange stains on them, and the pillowcase was light brownish tinged. There were two large pinkish stains on the bottom half of the top linen. There was a musty odor in the room. Resident #17 said he should not have to ask the CNAs to change his linens they should be doing this as scheduled. During an observation on 07/08/2024 at 11:14 AM, Resident's #17 linens had dirty yellow and orange stains on them, and the pillowcase was light brownish tinged. There were two large pinkish stains on the bottom half of the top linen. There was a musty odor in the room. During an observation on 07/09/2024 at 01:30 PM, Resident's #17 linens had dirty yellow and orange stains on them, and the pillowcase was light brownish tinged. There were two large pinkish stains on the bottom half of the top linen. There was a musty odor in the room. 3. Record review of the face sheet dated 06/28/2024 indicated, Resident #34 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included acute kidney failure, hypertension (high blood pressure), deep vein embolism (blood clot), diabetes mellitus (a group of diseases that result in too much sugar in the blood. Record review of the quarterly MDS dated [DATE] indicated, Resident #34 was understood by others and understood others. The MDS indicated Resident #34 had a BIMS of 12 and was moderately cognitively impaired. The MDS indicated Resident #34 was independent with toileting, upper and lower body dressing, and putting on and taking off footwear, and he required set up/clean-up assistance with bathing. In section GG0120 Mobility devices the MDS indicated in the last 7 days Resident #34 used a wheelchair. Record review of the comprehensive care plan dated 11/16/23 indicated, Resident #34 had an activities of daily living (ADL) self-care performance deficit. The care plan indicated interventions included Resident #34 required assistance with showering, dress according to climate, assist with daily hygiene, provide peri care as indicated. During an observation and interview on 07/07/2024 at 10:40 AM, Resident #34 said his bed linens had not been changed in two weeks. Resident #34's linens had dirty brownish stains on the top portion, and the pillowcase had a light browning tinge to it. There was a strong urine smell in Resident #34's bathroom. There was dark yellow/orange colored water in the toilet. Resident #34's toilet seat lid had multiple areas that were peeling and multiple chipped paint areas which revealed the brown wood underneath it. Resident #34 said the toilet was hard to flush. He said he had to hold the handle down a long time to make it flush. Resident #34 said it always smelled like urine in his bathroom. An observation was made, and there was no hot water in Resident #34's bathroom sink (temperature of Resident #34's hot water was tested at 72 degrees), the sink would not drain the water timely, and the toilet was not flushing properly (urine remained in the toilet after flushed). Resident #34 said the toilet had not flushed and the sink had not drained for several months. Resident #34 said he told the Administrator a month or so ago about the clogged sink, not having hot water, and the bed linens not being changed. Resident #34 said the maintenance man had come in a few times and worked on the sink, but the water never got hot, the sink never drained right, and the toilet never flushed all the way. Resident #34 said the facility was his home, but it did not feel like a home when they did not have clean beds or a working bathroom. During an observation and interview on 07/08/2024 at 11:26 AM, Resident #34 said the bed linens did not get changed last night after he got a shower. Resident #34's sheets had dirty brownish stains on the top portion, and the pillowcase had a light browning tinge to it. Resident #34's toilet had light yellow water in the toilet bowl with a urine smell. There was no hot water in Resident # 34's bathroom sink. There was 1-2 inches of standing water in Resident #34's sink. During an observation on 07/09/2024 at 01:32 PM, Resident #34's sheets had dirty brownish stains on the top portion, and the pillowcase had a light browning tinge to it. There was no hot water in Resident # 34's bathroom sink. The sink would not drain the water timely and water was staying in the sink about 2 inches up. During an observation and interview on 07/09/2024 at 02:08 PM, the Maintenance Supervisor said he had not noticed the peeling and chipped paint on the toilet seat because the toilet lid was always closed when he was in Resident #34's bathroom. The Maintenance Supervisor stated he had unclogged Resident #34's sink before, but he was not aware of Resident #34 not having hot water. The Maintenance Supervisor took the temperature of Resident #34's bathroom sink water and it was 72 degrees Fahrenheit. The Maintenance Supervisor said the water temperature should be between 98-110 degrees Fahrenheit within 3 seconds. The Maintenance Supervisor said Resident #17 and Resident #34 should have a sink with hot water, a toilet that flushed, and a sink that would drain timely. The Maintenance Supervisor said it was important for the residents to have hot water for proper handwashing and to decrease the chances of spreading contaminants. The Maintenance Supervisor said the residents should have a working bathroom so that it feels like their own home. 4. Record review of the face sheet dated 06/28/2024 indicated, Resident #4 was an [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included dementia ( a group of thinking and social symptoms that interferes with daily functioning), atrial fibrillation(an irregular, often rapid heart rate that commonly causes poor blood flow), congestive heart failure (a chronic condition in which the heart doesn't pump as well as it should), hyperlipidemia (abnormally high concentration of fats in the blood). Record review of the quarterly MDS dated [DATE] indicated, Resident #4 was understood by others and understood others. The MDS indicated Resident #4 had a BIMS of 12 and was moderately cognitively impaired. The MDS indicated Resident #4 was independent with toileting, upper and lower body dressing, putting on and taking off footwear, and with bathing. In section GG0120 Mobility devices the MDS indicated in the last 7 days Resident #4 did not use a wheelchair. Record review of the comprehensive care plan dated 11/22/23 indicated, Resident #4 had an activities of daily living (ADL) self-care performance deficit. The care plan indicated interventions included Resident #4 required assistance with showering, dress according to climate, assist with daily hygiene, provide peri care as indicated. During an interview and observation on 07/07/2024 at 09:42 AM, Resident #4 said the hot water in his bathroom ran continuously. Resident #4 said he told the Maintenance Supervisor in May of 2024 about the running water. Resident #4 said he had complained about the running water in the Resident Council Meeting during the month of May 2024. Resident #4 said the Maintenance Supervisor told him he was busy painting the outside of the building but would fix the faucet once he finished painting. Resident #4 said it was aggravating that the water ran all the time because he worried about it since it was such a heavy stream of water flowing. An observation was made of the water faucet in Resident #4's bathroom running warm water at a continuous flow. During an interview on 07/10/2024 at 02:02 PM, CNA F said she was not he assigned CNA for resident #4. However, she said the CNAs were responsible for giving the residents their showers and for ensuring the bed linens were changed after showers/baths. CNA F said there was a shower schedule posted at the nurse's station to let the CNAs know who needed a shower on what day and shift and that included linen changes. CNA F said it was important for residents to receive their showers and have clean bedding to maintain the resident's cleanliness. CNA F said if a resident refused, or linens were not changed for a resident she reported to her charge nurse. CNA F said it was the charge nurse's responsibility to follow up on refusals or if linens were not changed after it was communicated to them by the CNAs. During an attempted phone interview on 07/10/2024 at 09:00 AM, 10:00 AM, 01:40 PM, Aide L. assigned to resident #4, was unable to be reached. During an interview on 07/10/2024 at 02:14 PM, LVN D said the CNA should report when a resident's linens were not changed to the charge nurse. LVN D said it was the charge nurse's responsibility to follow up on refusals or linens that were not changed after communicated by the CNAs. LVN D said the charge nurse should verify the shower sheets daily to ensure all showers were documented by the CNAs. LVN D said she expected the residents to receive their scheduled showers and linen changes to prevent infections, maintain skin integrity, and maintain hygiene. LVN D said there was a shower schedule and required linen changes posted at the nurse's station to let the CNAs know who needed a shower/linen change on what day and shift . LVN D said no staff reported a refusal of showering/bathing or linen changes to her. LVN D said ultimately if showers and bathing were not completed, she notified the ADON or DON. During an interview on 07/10/2024 at 2:24 PM, the DON said it was the CNAs responsibility to give the residents their showers and change the residents' linens at the time of their showers. The DON said there was a shower list that identified what resident received a shower/linen change on which day and shift. The DON said the CNAs performed showers and linen changes on the residents, but any of the nursing staff could and should perform showers and linen changes when needed. The DON said she expected the CNAs to communicate with the charge nurses daily to ensure the residents' needs were met. The DON expected the shower sheets to be completed by the CNAs daily, and for them to turn the shower sheets into the shower logbook daily. The DON said she expected the charge nurses to verify the showers/linen changes were completed by the CNAs daily by checking the shower logbook. The DON said if a resident refused, she expected staff to try again a couple times or send a different staff member to ask the resident. The DON said if a resident continued to refuse, she expected staff to report the refusal to the family and document the refusal. The DON said she was responsible for monitoring that the residents were bathed/showered, and that linens were changed appropriately according to the resident's plan of care. The DON said she expected the Maintenance Supervisor to inspect and fix the resident's rooms to promote a homelike environment. The DON said the importance of the residents receiving their scheduled showers and linen changes was to maintain dignity, hygiene, skin integrity, skin inspections and prevent skin infections. During an interview 07/10/2024 at 02:42 PM, the Administrator said she expected baths/showers/linen changes as scheduled or as requested by the resident. The Administrator said clinical staff were responsible for making sure the baths/showers/linen changes were provided for the residents. The Administrator said if the residents refused ADL care, the staff educated the residents. The Administrator said if a resident refused, she expected staff to try again a couple of times or send a different staff member to ask the resident. The Administrator said if a resident continued to refuse, she expected staff to report the refusal to the family and document the refusal. The Administrator said it was important for the residents to receive baths/showers/linen changes for hygiene purposes, to make the residents feel good, for infection control, and for their dignity. The Administrator said she expected the Maintenance Supervisor to maintain the building with working faucets and toilets and have access to hot and cold water at all times. The Administrator said it was the responsibility of all staff to take notice and report when there was a resident's room that required attention, so the resident had a homelike environment that promoted dignity and a healthy wellbeing. Record review of the Resident Council Meeting dated 05/24/2024 indicated a complaint of Resident #4's concerns regarding the leaking bathroom faucet. Record review of the Maintenance Logbook for 2024 did not indicate any repairs were needed for Resident #4's, Resident #17's, Resident #34's rooms. Record review of facility policy and procedure titled, Homelike Environment revised on February 2021, indicated . Residents are provided with a safe, clean comfortable and homelike environment and encouraged to use their personal belongings to the extent possible .a. clean, sanitary and orderly environment; .e. clean bed and bath linens that are in good condition .

Based on observations, interviews, and record review the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain personal hygiene for 2 of 4 residents (Resident #'s 140 and 17) reviewed for ADLs. The facility failed to ensure Resident #140's face was free from facial hair. The facility failed to ensure Resident #17 received routine scheduled showers. These failures could place residents at risk for not receiving services/care and a decreased quality of life. 1) Record review of a face sheet dated 6/10/2024 indicated Resident #140 was a [AGE] year-old female who admitted on [DATE] with the diagnoses of profound intellectual disabilities (the inability to live alone, and care for themselves). Record review of the Admission MDS dated [DATE] indicated Resident #140 was rarely/never understood, and rarely/never understood others. The MDS indicated the BIMS assessment was not conducted. The MDS indicated Resident #140 had severely impaired daily decision-making cognitive skills. The MDS indicated Resident #140 had not displayed any rejection of care in Section E-Behavior. The MDS indicated Resident #140 was dependent on staff for personal hygiene. Record review of the Comprehensive Care Plan dated 6/19/2024 indicated Resident #140 required assistance with ADL's. The care plan goal was Resident #140 would maintain a sense of dignity by being clean, dry, odor free, well groomed, and dressed appropriately. The intervention of the care plan for Resident #140 was to assist with daily hygiene needs. Record review of the Daily CNA Shower Report Sheet for Monday-Wednesday-Friday indicated Resident #140 was to be routinely showered, shaved, provided hair and nail care. The Daily CNA Shower Report Sheet indicated: 6/12/2024: shower was provided, shaving, hair, and nails not completed. 6/14/2024: no shower sheet was provided. 6/17/2024: shower was provided, shaving, hair, and nails not completed. 6/19/2024: shower was provided, shaving, hair, and nails not completed. 6/21/2024: shower was provided, shaving, hair, and nails not completed. 6/24/2024: shower was provided, shaving, hair, and nails not completed. 6/26/2024: shower was provided, shaving, hair, and nails not completed. 6/28/2024: no shower sheet was provided. 7/03/2024: shower was provided, shaving, hair, and nails not completed. 7/05/2024: no shower sheet was provided. 7/08/2024: Shower, hair and nails was completed but not shaved . Record review of the CNA Flowsheet dated June 2024 indicated in the section of Shower on scheduled days there were no documented times Resident #140 was showered. The section of daily nail care indicated Resident #140 received nail care on June 10th, 11th, and 13th for the month of June. The CNA Flowsheet failed to have an entry for shaving. Record review of the ADL sheets dated July 2024 indicated Resident #140's shaving daily as needed was blank for July 1-7. The ADL sheets indicated Resident #140 received a shower on 7/02/2024. During an observation on 7/07/2024 at 9:31 a.m., Resident #140 was sitting in her reclining chair. She openeds her eyes when you touched her but she did has not have a verbal response. Resident #140 had facial hair 1/4 inches long to her upper lip and her chin area. During an observation on 7/07/2024 at 1:10 p.m., Resident #140 continues to have facial hair 1/4 inches long to her upper lip and her chin. Resident #140 appeared s to have dandruff (flaking white scalp material) to her scalp. During an observation on 7/08/2024 at 8:34 a.m., Resident #140 continues to have facial hair 1/4 inches long to her upper lip and chin. During an interview on 7/10/2024 at 1:21 p.m., CNA E said she provided care to Resident #140. CNA E said she was responsible for shaving residents of undesired facial hair. CNA E said the facial hair should be removed on shower days especially but any other day as well. CNA E said she thought a woman having facial hair was a preference . CNA E said she would not want to have facial hair, appearing to be a mustache. During an interview on 7/10/2024 at 1:35 p.m., LVN D said she expected residents to be free from undesired facial hair. LVN D said Resident #140 was showered by her on 7/08/2024 but she failed to shave Resident #140. LVN D said she would not want to have facial hair and having facial hair would not make her feel like a woman. LVN D said the CNAs were responsible for the ADLs and the nurses were responsible for monitoring. During an interview on 7/10/2024 at 2:26 p.m., the ADON said the CNAs were responsible for the provision of ADLs including shaving. The ADON said the nurses were responsible for monitoring the provision of ADLs. The ADON said facial hair should be removed if not desired. The ADON said Resident #140 should have been shaved to remove the facial hair. The ADON said not maintaining ADLs could be a dignity issue. During an interview on 7/10/2024 at 2:42 p.m., the DON said she expected the residents male or female to have undesired facial hair removed. The DON said the nursing staff were responsible for ensuring the ADLs were completed according to the schedule. The DON said she believed the system for the provision of ADLs was being monitored . The DON said not having facial hair removed when desired could be a dignity issue. The DON said monitored the bath sheets and made walking rounds to monitor ADLs. During an interview on 7/10/2024 at 3:33 p.m., the Administrator said the nursing staff should clarify with Resident #140's family member their desired outcomes as it related to shaving of facial hair. The Administrator said not shaving undesired facial hair could be a dignity issue. 30527 2. Record review of the face sheet dated 06/28/2024 indicated, Resident #17 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included hypertension (high blood pressure), hyperlipidemia (high levels of fat particles in the blood), history of stroke, benign prostatic hyperplasia (prostate gland enlargement resulting in difficulty with urination) and acquired absence of limb. Record review of the quarterly MDS dated [DATE] indicated, Resident #17 was understood by others and understood others. The MDS indicated Resident #17 had a BIMS of 10 and was moderately cognitively impaired. The MDS indicated Resident #17 was independent with toileting, supervision and touching assistance for lower body dressing, and putting on and taking off footwear, set up/clean-up assistance with bathing and with upper body dressing. In section GG0120 Mobility devices the MDS indicated in the last 7 days Resident #17 used a wheelchair. Record review of the comprehensive care plan dated 05/19/2023 indicated, Resident #17 had an activities of daily living (ADL) self-care performance deficit. The care plan indicated interventions included Resident #17 required showering, dress according to climate, assist with daily hygiene, provide peri care as indicated. Record Review of the Daily CNA (Certified Nurse Aide) Shower Report Sheet dated 06/01/2024 indicated Resident #17 was scheduled for showers 3 times weekly. Record review of the Daily CNA (Certified Nurse Aide) Shower Report Sheets dated 06/01/24, 06/04/2024, 06/11/2024, 06/15/2024, 06/18/2024, 06/20/24, 06/27/2024, 07/06/2024 indicated Resident #17 had not received a shower. Record review of the nursing notes dated 06/01/2024 through 07/06/2024 showed no refusals of showering/bathing. During an interview and observation on 07/07/2024 at 10:30 AM, Resident #17 said he had not received a shower in two weeks. Resident #17 said that he was supposed to receive a shower three times weekly on Tuesday, Thursday, and Saturday. Resident #17 said he had not refused to shower, but a shower had not been offered. Resident #17 said he could not recall the exact date of his last shower, but it was at least two weeks. Resident #17 said he should not need to ask for help with a shower because the staff was aware of the shower schedule. Resident #17 said it was degrading and he felt disrespected when his shower was not offered. Resident #17 was observed with oily hair and a strong musty odor lingered in the room. During an interview on 07/10/2024 at 02:02 PM, CNA F said the CNAs were responsible for giving the residents their showers. CNA F said there was a shower schedule posted at the nurse's station to let the CNAs know who needed a shower on what day and shift. CNA F said it was important for residents to receive their showers so staff could observe their skin and to maintain the resident's cleanliness. CNA F said if a Resident refused, or a shower/bath was not given to a resident she reported to her charge nurse. CNA F said it was the charge nurse's responsibility to follow up on refusals or baths that were not completed after communicated by the CNAs. During an interview on 07/10/2024 at 02:14 PM, LVN D said the CNA should report when a resident was not showered/bathed to the charge nurse. LVN D said it was the charge nurse's responsibility to follow up on refusals or baths not completed after communicated by the CNAs. LVN D said she expected the residents to receive their scheduled showers to prevent infections, maintain skin integrity, and maintain hygiene. LVN D said there was a shower schedule posted at the nurse's station to let the CNAs know who needed a shower on what day and shift. LVN D said no staff reported a refusal of showering/bathing to her. LVN D said ultimately if showers and bathing were un-resolved, she notified the ADON or DON. During an interview on 07/10/2024 at 2:24 PM, the DON said it was the CNAs responsibility to give the residents their showers. The DON said there was a shower list that identified what resident received a shower on which day and shift. The DON said the CNAs performed showers on the residents, but any of the nursing staff could and should perform showers when needed. During an interview on The DON said she expected the CNAs to communicate with the charge nurses daily to ensure resident's needs met. The DON expected the shower sheets to be completed by the CNAs and turned into the shower logbook daily. The DON said she expected the charge nurses to verify the showers given by the CNAs daily by checking the shower logbook. The DON said if a resident refused, she expected staff to try again a couple times or send a different staff member to ask the resident. The DON said if a resident continued to refuse, she expected staff to report the refusal to the family and document the refusal. The DON said she was responsible to ensure the oversight of resident 's bathed and showered appropriately according to the resident's Plan of Care. The DON said the importance of the residents receiving their scheduled showers was to maintain dignity, hygiene, skin integrity, skin inspections and prevent skin infections. During an interview 07/10/2024 at 02:42 PM, the Administrator said she expected baths/showers as scheduled or as requested by the resident. The Administrator said clinical staff were responsible for making sure the baths/showers were provided for the residents. The Administrator said if the residents refused ADL care, the staff educated the residents. The Administrator said if a resident refused, she expected staff to try again a couple times or send a different staff member to ask the resident. The DON said if a resident continued to refuse, she expected staff to report the refusal to the family and document the refusal. The Administrator said it was important for the residents to receive baths/showers for hygiene purposes and to make the residents feel good, infection control and dignity. Record review of the Shaving the Resident policy and procedure dated February 2018 indicated the purpose of the procedure was to promote cleanliness and to provide skin care. Preparations: 1. Review the resident's care plan to assess for any special needs of the resident. Documentation: 1. The date and time that the procedure was performed 5. If the resident refused thee treatment, the reasons why and the interventions taken. Reporting: 1. Notify the supervisor if the resident refuses the procedure. Record review of facility policy and procedure titled, Bath, Shower/Tub with a revised date of February 2018 indicated, The purposes for this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin .Documentation - 1. The date and time the shower/tub bath was performed .Documentation - of the resident refused the shower/tub bath, reason .Reporting - notify the supervisor if the resident refuses the shower/tub bath

Based on observation, interview, and record review the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 7 staff (Laundry Aides G, H, and K) reviewed for infection control practices on 2 of 4 halls ( halls 1 and 2). The facility failed to ensure that Laundry Aides G , H, and K covered the laundry cart while delivering the resident's clothing. This failure could place residents and staff at risk for cross-contamination and the spread of infection. Findings included: During an observation on 07/07/2024 at 8:17 AM., Laundry Aide K was observed in hall 2 pushing an uncovered laundry cart with clean clothes exposed. During an observation on 07/08/20244 at 9:20 AM., Laundry Aide K was observed in hall 1 pushing an uncovered laundry cart with clean clothes exposed. During an observation on 07/09/2024 at 10:00 AM, Laundry Aide H was observed in hall 2 pushing an uncovered laundry cart with clean clothes exposed. During an interview on 07/09/2024 at 4:07 PM, Laundry Aide G said the laundry cart should remain covered while transporting the residents' clean linens from the outside laundry facility to the inside of the facility. Laundry Aide G said the laundry cart could be uncovered while inside the facility delivering to residents. Laundry Aide G said the purpose of the covered laundry cart was to prevent contaminants from getting on the residents' clothing and linens. Laundry Aide G said she was educated at hire and in-serviced a month or so ago regarding transporting laundry. Laundry Aide G said soiled laundry should always be covered and clean laundry did not have to be covered inside the facility. During an attempted phone interview on 07/10/202 at 01:00 PM, Laundry Aide K was unable to be reached. During an interview on 07/10/2024 at 2:10 PM, Laundry Aide H said until the in-service on today's date (07/10/24), he thought the laundry cart should remain covered while transporting the residents' clean linens from the outside laundry facility to the inside of the facility and did not have to remain covered while delivering inside the building. Laundry Aide H said he was told on today's date that the laundry cart should remain covered at all times to prevent cross contamination by sneezing or residents touching the clothing while delivered to the residents. During an interview on 07/10/2024 at 1:34 PM, the Maintenance Supervisor said he was responsible for the laundry staff. The Maintenance Supervisor said he had educated the laundry aides and expected the staff to keep the clean laundry covered while it was transported from the laundry building outside. The Maintenance Supervisor said the laundry cart with clean clothing should be covered while clothing was delivered to the residents to prevent cross contamination. During an interview on 07/10/2024 at 2:42 PM, the Administrator said she expected the Maintenance Supervisor to provide oversight and education to the laundry staff on proper transport of clean and soiled linen. The Administrator said she was responsible to ensure the Maintenance Supervisor was doing his responsibilities. The Administrator said she expected the staff to keep the clean laundry covered while it was transported from the laundry building outside. The Administrator said she expected the staff to cover the laundry cart of clean clothing while clothing was delivered to the residents to prevent cross contamination. Record Review of in-service titled Infection Control and Laundry Services dated May 2024 indicated Laundry Aides G, H, and K had been in serviced. Record review of the facility's policy titled, Infection Control Policy and Procedure Manual, revised in October 2018, indicated, . Laundry and bedding shall be handled, transported and processed according to best practices for infection prevention and control Items being transported should remain covered .

Based on observations, interview, and record review, the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 3 of 31 residents (Resident #17, and Resident #14 and Resident #1) reviewed for comprehensive care plans. The facility failed to ensure Resident #17's care plan indicated he smoked. The facility failed to ensure Resident #14's care plan indicated he wandered. This failure could place residents at risk of not having individual needs met and a decreased quality of life. Findings included: 1. Record review of the face sheet dated 06/28/2024 indicated, Resident #17 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included hypertension (high blood pressure), hyperlipidemia (high levels of fat particles in the blood), history of stroke, benign prostatic hyperplasia (prostate gland enlargement resulting in difficulty with urination) and acquired absence of limb. Record review of the quarterly MDS dated [DATE] indicated, Resident #17 was understood by others and understood others. The MDS indicated Resident #17 had a BIMS of 10 and was moderately cognitively impaired. The MDS indicated Resident #17 was independent with toileting, supervision and touching assistance for lower body dressing, and putting on and taking off footwear, set up/clean-up assistance with bathing and with upper body dressing. In section GG0120 Mobility devices the MDS indicated in the last 7 days Resident #17 used a wheelchair. Record review of the care plan dated on 03/16/2023 did not indicate Resident #17 used tobacco or smoked cigarettes. Record review of the Smoking Risk Assessment completed on 06/12/2024 indicated Resident #17 used cigarettes and was a safe smoker. During and observation and interview on 07/08/2024 at 11:18 AM., Resident #17 was smoking a cigarette during the scheduled smoke break. Resident #17 said he had smoked cigarettes for as long as he could recall. During an interview on 07/10/2024 at 10:40 AM, the ADON said she was responsible for updating the care plans. The ADON said Resident #17's care plan should have reflected and included that he smoked. The ADON said it was important for his care plan to include that he smoked to make sure he was safe to smoke, and everyone knew that he smoked. During an interview on 07/10/2024 at 11:02 AM, the DON said the ADON was responsible for updating the care plans. The DON said Resident #17's care plan should have reflected and included that he smoked. The DON said Resident #17's care plan should have included that he smoked. The DON said she did not know why it was not in his care plan. The DON said it was important to include in the care plan that Resident #17 so that staff knew if he was eligible to smoke or if he failed the smoking assessment or if he needed a assistance with smoking. During an interview on 07/10/2024 at 2:42 PM, the Administrator said she expected the ADON to update and implement the care plans of the residents quarterly and yearly. The Administrator said Resident #17's should have had a care plan for smoking. The Administrator stated it was important for the care plan to be accurate to ensure all residents were provided with continuity of care. 2. Record review of the face sheet dated 06/28/2024 indicated, Resident #14 was an [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included chronic obstruction pulmonary disease (a group of lung diseases that block airflow making it difficult to breath), hypertension (high blood pressure), hypokalemia ((low potassium level in the blood). Record review of the quarterly MDS dated [DATE] indicated, Resident #14 was usually understood by others and usually understood others. The MDS indicated Resident #14 had a BIMS of 99 and was unable to complete the assessment. The MDS indicated Resident #14 was dependent with toileting, lower body dressing, and putting on and taking off footwear, bathing, and with upper body dressing. In section GG0120 Mobility devices the MDS indicated in the last 7 days Resident #14 used a wheelchair. Record review of the comprehensive care plan dated 09/14/2023 indicated Resident #14 had no care plan for wandering. During an observation on 07/07/2024 at 08:20 AM., Resident #14 was observed wandering into another resident's room and drinking from a cup on the bedside table. During an observation on 07/07/2024 at 10:11 AM., Resident #14 was observed wandering on hall 1 and exit seeking. During an observation on 07/07/2024 at 11:18 AM., Resident #14 was observed wandering in the front lobby and exit seeking. During an interview on 07/10/2024 at 10:40 AM, the ADON said she was responsible for updating the care plans. The ADON said Resident #14 wandered. The ADON said Resident #14's care plan should have reflected and included that he wandered and required redirection. The ADON said it was important for his care plan to include that he wandered to make sure he was safe. During an interview on 07/10/2024 at 11:02 AM, the DON said the ADON was responsible for updating the care plans. The DON said Resident #14 should have been care planned for wandering and wandering not being care planned place the residents at risk for getting out and getting lost and with them going in other residents' rooms the other residents could get upset. During an interview on 07/10/2024 at 2:42 PM, the Administrator said she expected the ADON to update and implement the care plans of the residents quarterly and yearly. The Administrator said Resident #14 should have had a care plan for wandering. The Administrator stated it was important for the care plan to be accurate to ensure all residents were provided with continuity of care as the care plan dictates the resident's care pathway. Record review of the comprehensive care plan last revised on 11/01/2023 indicated Resident #1 had no care plan for wound care to the left breast. Record review of Resident #1's order summary report with a date range of 11/01/2023 - 03/06/2024 indicated cleanse the non-pressure wound of the left breast with normal saline, pat dry, apply over the counter miconazole powder, cover with Calcium Alginate, and cover with border gauze every day, until healed every shift. Record review of Resident #1's progress note dated 11/01/2023 indicated left breast continues with a non-pressure wound related to cellulitis of the breast that has subsided. Wound measured as a cluster 9.5 x 6 x 0.3 cm with beefy red wound bed and a moderate amount of serious exudated . No improvements over the last 7 days. Continue calcium alginate and bordered gauze dressing daily. Record review of Resident #1's physician's wound evaluation management summary dated 11/08/2023 indicated non pressure wound of the left breast due to trauma/injury- full thickness. Wound size 10.5 x 5.5 x 0.2 cm, surface area of 57.76 cm, cluster wound open ulceration with moderate serous exudate. During an interview on 03/07/2024 at 01:00 PM, the MDS Coordinator stated she is responsible to update the care plans quarterly and yearly. The MDS Coordinator stated the ADONs, and DON were responsible for all other updates to the care plans. The MDS Coordinator stated it was important for the plan of care to accurately reflect the resident's needs for proper care. During an interview on 03/07/2024 at 01:32 PM, the DON stated the MDS Coordinator was responsible for ensuring everything for the resident's care was included in the care plans yearly and quarterly. The DON stated she was responsible for the updates for care plans. The DON stated Resident #1 should have had a care plan for wound care services being provided daily. The DON stated she did not know why it was not in the care plan. The DON stated it was important for Resident #1's wound care services to be included in her care plan because it is the map of providing care of the resident and resulted in continuity of care. Record review of the policy and procedure Comprehensive Assessment and the Care Delivery Process revised December 2016 indicated, a comprehensive, care planning and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring result and adjusting interventions .person-centered care plan that includes measurable objectives and timetables to meet he resident's physical, psychosocial and functional needs is developed and implemented for each resident. The services provided or arranged by the facility, as outlined by the comprehensive care plan, are provided by qualified persons, are culturally competent and trauma informed. 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 8. The comprehensive, person-centered care plan will: g. Incorporate identified problem areas, h. Incorporate risk factors associated with identified problems . Record review of the Care Plan and Care Area Assessments policy, revised on 05/06/2021, stated This identification and implementation of a plan of care will begin at admission with the initial care plan and be completed throughout assessment process for developing a comprehensive plan of care. The policy further indicated, Acute Care Plans o As acute problems or changes to intervention or goals are identified, an appropriate care plan will be developed or modified by a Nursing staff member. o CMMs are only responsible for care plans that relate to the MDS triggers at the time of assessment completion.

Based on observation, interview, and record review, the facility failed to ensure respiratory care was provided with professional standards of practice for 1 of 3 residents (Resident #7) reviewed for respiratory care and services. The facility failed to properly store Resident #7's nebulizer (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) mask while not in use. This failure could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory distress. Findings include: 1. Record review of Resident #7's order summary report, dated for the month of July 2024, indicated Resident #7 was a [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis which included diabetes mellitus (a group of diseases that result in too much sugar in the blood), chronic pulmonary edema (excessive fluid in the lungs), essential hypertension (high blood pressure), and atrial fibrillation (irregular, often rapid heart rate). Record review of Resident #61's order summary report, dated for the month of July 2024, indicated Resident #7 received albuterol 0.083% 1 via nebulizer every 4 hours as needed for wheezing and change Nebulizer tubing weekly. Record review of Resident #7's admission MDS assessment, dated 06/04/2024, indicated Resident #7 understood others and made herself understood. The assessment indicated Resident #7 was moderately cognitive impaired with a BIMS score of 9. The assessment indicated Resident #71 did not reject care necessary to achieve the resident's goals for health or well-being. The MDS indicated Resident #7 required partial/moderate assistance for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. Record review of Resident #7's care plan, with a revision date of 08/04/2022, indicated Resident #7 had an impaired respiratory status related to chronic pulmonary edema The care plan interventions included provide nebulizer therapy as ordered. During an observation and interview on 07/07/2024 at 10:05 a.m., Resident #7 was sitting in her bed. Resident #7 said she had not received a nebulizer treatment that she could recall. The nebulizer mask was laying on the table at bedside uncovered. During an observation on 07/08/2024 at 11:30 AM., Resident #7 was sitting in chair. The nebulizer mask was laying on the table at bedside uncovered. During an observation on 07/09/2024 at 3:43 PM., Resident #7 was asleep in bed. The nebulizer mask was laying on the table at bedside uncovered. During an observation, interview, and record review on 07/10/2024 at 2:06 PM., LVN D stated she was Resident #7's 6a-6p charge nurse, LVN A stated Resident #7 had an order for PRN nebulizer treatments. LVN D observed with the surveyor Resident #7's nebulizer mask on the bedside table not covered. LVN D stated Resident #7's nebulizer mask should be covered when not in use. LVN D stated she had not administered Resident #7 a breathing treatment this week on her shift . LVN D stated all nursing staff were responsible for ensuring infection control was provided for each resident. LVN D stated these failures could potentially put residents at risk for respiratory infection. During an interview on 07/10/2024 at 2:24 PM, the DON said she expected Resident #7's nebulizer mask be stored in a bag when not in use. The DON stated the 10 PM to 6 AM charge nurses were responsible for changing out nebulizer mask and oxygen tubing every Wednesday night. The DON stated the charge nurses were responsible for monitoring to ensure respiratory equipment was returned to designed bag after each use. The DON stated, she was responsible for monitoring the charge nurses. The DON stated these failures could potentially cause a decrease in respiratory status. During an interview on 07/10/2024 at 2:42 PM, the Administrator said she expected nebulizers stored in bags when not in use, tubing to be changed and dated per orders and filters to be placed on O2 concentrators. The Administrator stated this was monitored by the DON. The Administrator stated these failures put residents at risk for respiratory infection due to particles that could accumulate on the mask. Record review of the facility's Administering Medications through a Small Volume (Handheld) Nebulizer policy, revised October 2010, indicated, .29. When equipment is completely dry, store in a plastic bag with the resident's name and the date on it .

Based on observations, interview, and record reviews, the facility failed to ensure correct installation, use and maintenance of bedrails for 1 of 1 resident (Resident #21) reviewed for bedrails. 1.The facility failed to assess Resident #s 21 for the risk of entrapment from bed rails prior to installation. 2. The facility failed to document the attempt of alternatives to meet Resident #21's needs. These failures could place residents at risk for entrapment with serious injury and even death. Findings included: Record review of a face sheet dated 5/17/2024 indicated Resident #21 was a [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnosis of end stage dementia. Record review of the Consolidated Physician's orders dated July 2024 indicated Resident #21 was not ordered a bedrail device. Record review of the Significant Change MDS dated [DATE] indicated Resident #21 was rarely understood, and rarely understands others. The MDS indicated Resident #21's BIMS score was not determined due to his inability to understand. Section GG-Functional Abilities and Goals indicated Resident #21 was dependent on staff for rolling left and right, sit to lying, lying to sitting, sit to stand, chair/bed-to-chair transfers, and tub/shower transfers. The MDS in section P-Restraints indicated Resident #21 a bedrail restraint was not used. Record review of the Comprehensive Care Plan dated 3/20/2024 and updated on 6/25/2024 indicated Resident #21 required assistance with his ADLs. The care plan indicated Resident #21 required substantial assistance with sitting to lying, lying to sitting, sit to stand, chair to bed, and bed mobility. The interventions included Resident #21 would receive assistance with transfers, turning and repositioning, peri-care, daily hygiene, and meals. The comprehensive care plan indicated Resident #21 was transferred using a mechanical device. The goal of the care plan was Resident #21 would be out of the bed daily. The care plan interventions included staff to get resident #21 up out of bed daily and use two staff with the mechanical lift. The comprehensive care plan failed to address the use of a bedrail. Record review of a Side Rail assessment dated [DATE] indicated Resident #21 had a top left side rail available for use. The Side Rail Assessment indicated the side rail was used at all times. The Side Rail Assessment was not answered in the section does the side rail impede the resident's freedom. The Side Rail Assessment indicated the reason for the side rail use was the resident and responsible party requested. The Side Rail Assessment indicated clinical standards recommended side rails as an enabler. The Side Rail Assessment indicated the reason for the recommendation was to assist with transfers and bed mobility. The Side Rail Assessment in the section of medical symptom being treated was left blank. The Side Rail Assessment failed to indicate alternative measures implemented or considered prior to use of the side rail . The Side Rail Assessment was dated and signed by the ADON on 6/19/2024. During an observation on 7/07/2024 at 8:29 a.m., Resident #21 was lying on his left side in his bed facing the wall. Resident #21's bed had a half rail to the right side of his bed. Resident #21 was not able to be interviewed. During an observation on 7/08/2024 at 8:21 a.m., Resident #21 was lying in his bed facing the right side of his bed toward the half bed rail. During an interview on 7/10/2024 at 9:29 a.m., CNA E said Resident #21 had stopped over the last month using his bedrail for bed mobility or transfers. CNA E said Resident #21 was much weaker and could not use his bed rail. During an interview on 7/10/2024 at 1:35 p.m., LVN D said Resident #21 was unable to use a bed rail for bed mobility or transfers. LVN D said she expected the side rail assessment to accurately reflect the use of the side rail. LVN D said there was a risk Resident #21 could get injured from the use of a side rail since his inability to use the side rail over the last month. During an interview on 7/10/2024 at 2:26 p.m., the ADON said Resident #21 had a recent decline over the last month and had become unable to use his side rail for bed mobility and transfers. The ADON said she had not performed another assessment since Resident #21's decline in condition for the use of the side rail but should have. During an interview on 7/10/2024 at 2:42 p.m., the DON said Resident #21 used the side rail at one time for transfers and bed mobility but currently he was unable to use the side rail. The DON said the side rail assessment should be completed with the care plan. The DON said nursing was responsible for updating the assessment to accurately reflect the use of a side rail as an enabler. The DON said Resident #21 could be injured without an accurate assessment of the use of side rail. The DON said nurse managers were responsible for ensuring the side rail assessment was completed and completed accurately. During an interview on 7/10/2024 at 3:35 p.m., the Administrator said she expected the side rail assessment to be updated with changes in condition, as a part of the care planning process. The Administrator said nursing was responsible for updating the side rail assessment. The Administrator said the side rail should be removed from Resident #21's bed to prevent any injuries. Record review of a Bed Safety policy dated December 2007 indicated the facility shall strive to provide a safe sleeping environment for the resident .2. To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, foot board, and bed accessories), the facility shall promote the following approaches: .e. Identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment (altered mental status, and restlessness). 5. If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the attending physician, and input form the resident and/or legal representative. 8. Side rails may be used If assessment and consultation with the attending physician has determined that they are needed to help manage a medical symptom or condition or to help the resident reposition or move in bed and transfer, and no other reasonable alternative can be identified. 9. Before using the side rails for any reason, the staff shall inform he resident and family about the benefits and potential hazards associated with side rails.

Based on observation, interview and record review, the facility failed to ensure residents received therapeutic diets that were prescibed by the attending physician for 1 of 13 residents (Resident #28) reviewed for therapeutic diets. The facility did not ensure Resident #28 was given double protein portion as ordered by the physician. This failure could place residents at risk for poor intake, weight loss, unmet nutritional needs, and a loss of dignity. Findings Included: Record review of the face sheet, dated 05/17/2024, indicated Resident #28 was an [AGE] year-old male, originally admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes Mellitus (chronic condition that affects the way the body processes blood sugar) Record review of the physician orders dated 02/07/2024, indicated Resident #28 had an order, which started on 02/07/2024, extra portions of meat with meals. Record review of the quarterly MDS assessment, dated 02/20/2024, indicated Resident #28 usually made himself understood and rarely/never understood others. Resident #28 had short term/long term memory problems. Resident #28 had severely impaired decision-making skills. Resident #28 had no behaviors or refusal of care. Resident #28 did not have weight loss. Resident #28 was on a mechanically altered diet. Record review of the comprehensive care plan, dated 04/23/2024, indicated Resident #28 was on a pureed diet. The interventions included: serve diet as ordered and offer substituted if less than 50% was eaten, monitor intake, and supervision with meals. During an observation and record review on 07/07/2024 at 12:55 p.m., Resident #28 lunch meal ticket stated, extra meat portions. Resident #28 received a single serving of the entree which was steak fingers. During an interview on 07/07/2024 at 12:57 p.m., the Dietary Manager was asked by the surveyor if Resident #28 entree was considered double. The Dietary Manager stated no and went back to the kitchen to request for another serving of protein. During an attempted interview on 07/07/2024 at 1:02 p.m. with Resident #28, indicated she was non-interview able. During an interview on 07/07/2024 at 1:10 p.m., RN A stated nurses were responsible for checking trays prior to giving them out to residents. RN A stated Resident #28 should have gotten double protein serving. RN A stated, it was her mistake that Resident #28 did not receive double protein serving. RN A stated this failure could put Resident #28 at risk for further weight loss. During an interview on 07/10/2024 at 1:24 p.m., [NAME] C stated Resident #28 should have gotten two servings of steak fingers instead of one. [NAME] C stated she was nervous because the surveyor was present. [NAME] C stated it was the Dietary Manager and nursing staff responsibility to ensure the trays were correct before serving a resident. [NAME] C stated this failure could potentially put Resident #28 at risk for weight loss. During an interview on 07/10/2024 at 1:46 p.m., the Dietary Manager stated Resident #28 should have gotten two servings of steak fingers. The Dietary Manager stated he expected physician orders to be followed. The Dietary Manager stated the cook, himself and the nursing staff were responsible for checking the trays prior to the residents served. The Dietary Manager stated ultimately the nursing department were responsible for ensuring the trays were correct before serving a resident. The Dietary Manager stated he was responsible for overseeing and monitoring by checking the trays in the dining and residents' room at least five days a week. The Dietary Manager stated if he caught a tray incorrect before leaving the kitchen, he would have the staff to redo the tray or noticed an issue while making rounds he will have the cook to redo the tray. The Dietary Manager stated staff were verbally in-serviced immediately. The Dietary Manager stated this failure could put residents at risk for weight loss. During an interview on 07/10/2024 at 3:21 p.m., the Administrator stated she expected food trays to be checked and residents to receive the correct diet. The Administrator stated it was important for residents to receive the correct diet order to prevent weight loss. The Administrator stated the dietary was responsible for monitoring and overseeing. Record review of the facility's policy titled Food and Nutrition Services revised 10/2017 indicated each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident .7. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident .a. if an incorrect meal is provided to a resident . nursing staff will report it to the Food Service Manager so that a new food tray can be issued .

Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 1 resident (Resident # 21) reviewed for hospice services. The facility failed to obtain Resident #21's most recent updated hospice plan of care. The facility failed to ensure Resident #21's hospice plan of care accurately reflect his medication regimen. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. Findings included: Record review of a face sheet dated 5/17/2024 indicated Resident #21 was a [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnosis of end stage dementia. Record review of the Significant Change MDS dated [DATE] indicated Resident #21 was rarely understood, and rarely understands others. The MDS indicated Resident #21's BIMS score was not determined due to his inability to understand. Section O-Special Treatments, Procedures, and Programs was marked indicating Resident #21 received hospice care. Record review of the Comprehensive Care Plan dated 3/20/2024 and updated on 6/25/2024 indicated Resident #21 had been diagnosed with an end stage disease and had elected to have hospice services. The goal of the care plan indicated the facility would in accordance with the palliative care, implement measures to diminish the effects to the extent possible. The interventions of the care plan included to notify hospice of any significant changes in condition. Record review of the Hospice Comprehensive Assessment and Plan of Care Updated Report dated and printed on 5/13/2024 at 2:37 p.m., was the last Hospice Comprehensive Assessment and Plan of Care form in Resident #21's hospice medical record binder. The Hospice Comprehensive Assessment and Plan of Care indicated Resident #21 was started on hospice services on 3/11/2024 the diagnosis of senile degeneration of the brain (dementia). The Plan of Care indicated Resident #21's medication regimen included acetaminophen, bisacodyl suppository, hydrocodone, hyoscyamine, lorazepam, milk of magnesia, morphine, omeprazole, tamsulosin, and trazodone. The IDT Assessment and Plan of Care failed to reveal Resident #21's medication regimen included Zoloft, Alfuzosin, Zaditor, Robitussin, Zyrtec, Zofran, and Phenergan. Record review of the Consolidated Physician's Orders dated July 2024 indicated Resident #21 was ordered these medications but not indicated on the hospice plan of care: Zoloft 25 milligrams daily; Alfuzosin ER 10 milligrams twice daily; Zaditor eye drops one drop both eyes twice daily; Robitussin DM 2 teaspoons every 4 hours as needed for cough; Zyrtec 10 milligrams daily as needed for allergies; Zofran 4 milligrams one tablet every 4 hours as needed for nausea/vomiting; and Phenergan 25 milligrams one tablet by mouth every 6 hours as needed for nausea/vomiting. During an interview on 7/08/2024 at 10:56 a.m., the hospice nurse said Resident #21's hospice binder should have been updated with the current plan of care to ensure the continuity of care and the coordination of care with the facility and Resident #21. The hospice nurse indicated she was responsible for ensuring Resident #21's care was coordinated with the facility and the binder should be updated with the most recent plan of care coordination. During a telephone interview on 7/10/2024 at 10:34 a.m., the hospice program manager said she expected Resident #21's hospice binder to be current with the most recent hospice plan of care. The hospice program manager said the medication regimens should match and accurately reflect the medications Resident #21 received. The hospice program manager said when the Plans of Care were not readily available and were not accurately reflective of Resident #21's care there could be a risk of the care coordination. During an interview on 7/10/2024 at 1:35 p.m., LVN D said she was the nurse for Resident #21, and she expected the hospice records to be updated timely, and accurately. LVN D said when the hospice plan of care was not updated timely and accurately Resident #21 could receive care not desired or not according to his plan of care. LVN D said the hospice provider was responsible for ensuring the delivery of the hospice plan of care to ensure continuity of care. During an interview on 7/10/2024 at 2:30 p.m., the ADON said she expected the hospice plan of care to be current and available. The ADON said she expected the medication regimen and the care plans to match and coordinate the care Resident #21 desired. The ADON said she had not been monitoring the timely coordination of care with Resident #21's hospice provider. The ADON said the nursing staff were responsible for ensuring the continuity of care. During an interview on 7/10/2024 at 2:46 p.m., the DON said she expected the hospice plan of care to be provided to the facility timely and accurately to reflect and coordinate the care Resident #21 desired. The DON said she had not been monitoring the coordination of the care with Resident #21's hospice provider but would now implement monitoring. The DON said the nursing staff was responsible for the coordination of care with the hospice provider. During an interview on 7/10/2024 at 3:43 p.m., the Administrator said she expected the hospice provider to provide the coordination of care with the nursing staff for Resident #21. The Administrator said the coordination of care was important to ensure the continuity of care for Resident #21. The Administrator said nurse managers were responsible for ensuring the coordination of care. Record review of the Palliative Care Program policy dated 2001 indicated the 1. Palliative care was to provide to all resident with persistent or recurring health conditions that adversely affect daily functions or reduce life expectancy 2. The palliative care plan was based on a comprehensive interdisciplinary assessment of the resident and family. 3. The palliative plan of care is based on the expressed values, goals, and needs of the resident and family. 9. Community resources are identified and utilized to ensure continuity of care throughout the illness trajectory. This includes establishing ongoing collaborative relationships with hospice and acute care providers.

Based on interview and record review, the facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and providing written rationale, by the provider, when an antibiotic was used despite criteria, to determine the appropriate the use of an antibiotic for 1 of 4 residents (Resident #1) reviewed for antibiotic use. The facility failed to ensure Resident #1 had documented appropriate lab work and diagnoses to support the use of prescribed antibiotics. This failure could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections. Findings included: Record review of Resident #1's face sheet, dated 06/28/2024, indicated Resident #1 was an [AGE] year-old female, readmitted to the facility on [DATE] with a diagnosis which included multiple sclerosis (chronic, progressive disease involving damage to the sheaths of nerves cells in the brain and spinal cord causing numbness, impairment of speech, and of muscular coordination, blurred vison and sever fatigue). Record review of Resident #1's annual MDS, dated [DATE], indicated Resident #1 usually understood others, and usually sometimes made herself understood. Resident #1 had a BIMS score of 9, which indicated her cognition was moderately impaired. The assessment did not address Resident #1's current antibiotic use. Record review of Resident #1's care plan, reviewed on 02/21/2024, indicated Resident #1 was incontinent of bowel and bladder. The care plan interventions included, monitor for s/sx incontinent, provide peri care as indicated and report to physician or representative any complications. Record review of a progress note dated 06/05/2024 completed by the Medical Director indicated Resident #1 c/o burning with urination while making rounds. Record review of a progress note dated 06/05/2024 completed by LVN D indicated a new order was received from the Medical Director for Macrobid (antibiotic) 100 mg po twice a day x 7 days for UTI. Record review of the MAR dated 06/01/2024-06/30/2024, revealed Resident #1 received Macrobid on 06/05/2024, 06/06/2024, 06/07/2024, 06/08/2024, 06/09/2024, 06/10/2024 and 06/11/2024. Record review of a progress note dated 07/05/2024 completed by ADON indicated a new order was received from the Medical Director for Augmentin 875 mg po twice a day x 7 days for UTI. Record review of the MAR dated 07/01/2024-07/31/2024, revealed Resident #1 received Augmentin on 07/05/2024, 07/06/2024, 07/07/2024, 07/08/2024, and 07/09/2024. An attempted telephone interview on 07/09/2024 at 11:28 AM with the Medical Director, was unsuccessful. During an interview on 07/10/2024 at 2:08 p.m., the ADON stated her, and the DON were the Infection Control Preventionist for the facility. The ADON stated the process for antibiotic stewardship included the nurse that received the order must complete an infection report and initiate the antibiotic. The ADON stated her, or the DON would review the infection report and complete a facility map and color coordinating infection categories. The ADON stated there was no tool to determine whether an infection met criteria for starting an antibiotic. The ADON stated Resident #1 was given an antibiotic on 07/05/2024 due to increase anxiety and different behaviors. The ADON stated a urine specimen was not collected on 06/05/2024 or 07/05/2024. The ADON stated it was important to ensure residents meet the criteria so the resident would not get resistant to antibiotics. The ADON stated this failure put residents at risk for a multi drug resistant organism. During an interview on 07/10/2024 at 2:33 p.m., the DON stated her and the ADON were the Infection Control Preventionist. The DON stated ultimately, she was responsible for tracking and trending infections. The DON stated by monitored by reviewing the infection report and nurses notes daily. The DON stated if a lab or x -ray was done she would also review them. The DON stated there was no tool to determine whether an infection met criteria for starting an antibiotic. The DON stated a urine specimen/culture was not collected for Resident #1 on 06/05/2024 nor 07/05/2024. The DON stated it was important to ensure residents meet the criteria so they would not become resistant to antibiotic or put them at risk for multi drug resistant. During an interview on 07/10/2024 at 3:21 p.m., the Administrator stated the Infection Control Preventionist was responsible for monitoring and overseeing the infection control program. The Administrator stated this failure could potentially put residents at risk for a multi drug resistant organism. Record review of the facility's policy titled Antibiotic Stewardship Program, dated 11/2017, indicated, the facility has a formal antibiotic stewardship program to optimize the treatment of infections, reduce the risk of adverse events including the development of antibiotic-resistant organisms and employs a facility-wide system to monitor the appropriate use of antibiotics .2. A set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. This can be accomplished through improving antibiotic prescribing, administration and management practices, thus reducing inappropriate use to ensure that residents recue the right antibiotic for the right indication dose and duration .

Based on interview and record review, the facility failed to notify the resident's representative and consult the physician immediately when there was a significant change in the resident's physical, mental, or psychosocial status that is, a deterioration of health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 1 of 4 residents (Resident #30) reviewed for notification of changes. The facility failed to consult Resident #30's physician and notify the resident representative when Resident #30 refused to have a CMP (complete metabolic panel lab draw to provide information about the body's chemical balance) and a HBA1C (glycated hemoglobin test that measure the average amount of blood sugar) lab drawn on 05/09/24, 05/10/24, and 05/13/24. This failure could place residents' representative/physician at risk of not being aware of any changes in their conditions and could result in delay in treatment and decline in residents' health and well-being. Findings included: 1. Record review of a face sheet dated 06/28/2024 indicated, Resident #30 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included vascular dementia with other behavioral disturbance (a condition in which a person loses the ability to think, remember, learn and make decisions and solve problems), deep vein thrombosis (blood clot), hypertension (high blood pressure), and chronic pain. Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #30 was understood and was able to understand others. The MDS assessment indicated Resident #30 had a BIMS score of 11, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #30 required partial/moderate assistance for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. Record review of the physician orders dated July 2024, indicated Resident #30 had an order with a start date of 02/07/2024 for a CMP, HGBA1C every 3 months. Record review of the care plan dated 02/14/2024 indicated, Resident #30 had a history of stroke with interventions to give meds as ordered and monitor labs and report abnormal values to physician. Record review of Resident #30's medical record indicated no lab results for the May 2024 - July 2024. Record review of Resident #30's progress notes did not indicate Resident #30 had refused any labs from May 2024 - July 2024. The progress notes did not indicate Resident #30's representative or physician had been notified of Resident #30's lab refusals. During an interview on 07/09/2024 at 01:59 PM, the ADON said the facility failed to notify the family member and the physician of Resident #30's refusal of lab draws on 05/09/2024, 05/10/2024, and 05/13/2024 because she had not received any notification from the lab until today (07/09/2024) when surveyor inquired. The ADON said the resident's family and physician should have been notified of Resident #30's refusal to prevent any issues, delays in treatments and serve as coordination of care. During an interview on 07/10/2024 at 2:24 PM, the DON said Resident #30's family and physician should have been notified regarding Resident #30's refusal of the lab draws when it happened. The DON said the family members and physician of Resident #30 should have been notified of the lab draw refusal because it was a change in condition, and they should have been made aware of new areas of concerns, orders, etc. The DON said it was the responsibility of the charge nurse to notify the family of any changes in condition of the residents. During an interview on 07/10/2024 at 2:42 PM, the Administrator said she expected the residents' representatives and the physician to be notified of any changes in the resident's care. The Administrator said she expected the staff to document the notification of the family and the physician. The Administrator said Resident #30's family and physician should have been notified of the lab draw refusal because the residents' family could have communicated to Resident #30 and explained the needs of the lab draws being completed. The Administrator said the charge nurse was responsible for notifying the resident's representative and physician. Record review of the facility's policy Change in Resident's Condition or Status revised May 2017 indicated . Our facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and or status .1. F. refusal of treatment or medication two or more consecutive times .Notify resident's responsible party . 3. Document in the medical chart who was notified and when.

Based on observation, interview, and record review, the facility failed to ensure an environment that was free of accident hazards for 2 of 14 residents (Resident #17 and Resident #184) reviewed for accidents hazards from hot coffee. The facility failed to ensure safety measures were in place after Resident #184 received a second-degree burn (burns that involve the epidermis and part of the lower layer of skin, the dermis. The burn site looks red, blistered, and may be swollen and painful) from hot coffee that required treatment. The facility failed to ensure safety measures were in place to prevent Resident #17 from obtaining an injury from hot coffee. An Immediate Jeopardy (IJ) situation was identified on 05/09/23. The IJ template was provided to the facility on [DATE] at 11:14 a.m., While the IJ was removed on 05/10/23 at 4:14 p.m., the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for serious burns, infection and even death. Findings included: 1.Record review of Resident 184's face sheet dated 12/02/20 indicated she was a [AGE] year-old female admitted on [DATE] with diagnoses including transverse radius fracture (wrist break), cerebrovascular accident (stroke - when blood flow to the brain is blocked), Dementia (impaired ability to remember), and depression (feeling sad). Record review of Resident #184's significant change in status MDS assessment dated [DATE] indicated she was usually understood and usually understood others. The MDS indicated Resident #184 was severely impaired (BIMS score was 02). The MDS indicated Resident 184 required total assist with transfers, dressing, bathing, extensive assist with bed mobility and supervision with eating. The MDS indicated Resident #184 had other skin problems requiring treatment. Record review of Resident #184's physician order summary report dated for the month of November 2022 did not indicate a treatment order for right upper leg. Record review of Resident #184's comprehensive care plan dated 12/01/22 indicated she was at risk for skin breakdown as evidenced by incontinence, impaired bed mobility and cognitive impairment. The interventions were to assist with repositioning as needed, give medication as ordered, assess skin weekly and report any changes to the physician. Record review of an incident report dated 11/19/22 at 7:00 a.m., indicated Resident #184 obtained three reddened areas to right upper leg from coffee spill. Area #1 measured approximately 3cmx2cm, area #2 measured approximately 5cmX1cm, and area #3 measured approximately 8cmX2cm. Resident #184 did complain of pain and received Morphine (pain medication) 0.25ml for pain. Resident #184 received a new order to apply Silvadene cream (medication to help heal burns) to affected areas twice daily for seven days. The incident report indicated the DON was notified on 11/19/23 at 8:10 a.m. During an interview on 05/10/23 at 2:09 p.m., LVN B said she was the nurse who assessed Resident #184 after staff reported she had spilled coffee on herself. LVN B said Resident #184 originally had three reddened areas but after reassessing after breakfast she developed a blister to area #3. LVN B said she notified the physician and received new treatment orders. LVN B said she did not know this was a reportable incident, but she reported the incident to the DON on 11/19/22. During an interview and observation on 05/07/23 at 9:40 a.m., observed two coffee pots sitting on side table assessable to residents, visitors, and staff. Dishwasher BB tested temperature on both coffee pots. The first coffee pot temperature was 147-degree Fahrenheit and second coffee pot temperature was 140-degree Fahrenheit. Dishwasher BB said she did not test the temperature of the coffee before pouring into the coffee pots. During an observation and interview on 05/08/23 at 1:41 p.m., observed two coffee pots sitting on side table assessable to residents, visitors, and staff. Dishwasher CC tested temperature on both coffee pots. The first coffee pot temperature was 149- degree Fahrenheit and second coffee pot temperature was 142-degree. Dishwasher CC said she had never tested the temperature of the coffee. During an interview on 05/08/23 at 1:42 p.m., the dietary manager said coffee pots were assessable to everyone on the side table. He said the coffee temperature was not checked prior to leaving the kitchen. The dietary manager said he was aware a resident received a coffee burn sometime last year but could not remember who. He said he was unaware of Resident #17's hot coffee spill on 05/05/23. He said they did not implement any changes in the kitchen after the Resident #184 received burns from the hot coffee. The dietary manager said he was not aware the coffee should have been checked prior to leaving the kitchen. The dietary manager said he tested the coffee periodically but did not have a log. The dietary manager said he would start a temperature log for the coffee. During an interview on 05/08/23 at 4:22 p.m., the DON said she was aware Resident #184 obtained a coffee burn but did not realize it needed to be reported to HHS. The DON said she thought if they knew what happen it was not reportable. The DON said they put a plan in place for Resident #184 which included supervision for meals and a two handled cup for safety after the coffee spill. The DON said they did not do any in-services or implement a plan for other residents who might be at risk of coffee burns because she had implemented a plan for Resident #184 and did not think about any other residents who might had been at risk. During an interview on 05/08/23 at 4:28 p.m., the ADON said she was aware Resident #184 received a coffee burn the following Monday, 11/21/22 after the incident occurred. The ADON said she was not aware this type of incident needed to be reported since they were aware of how the incident occurred. The ADON said she did not look at any other residents who could have been at risk because they implemented a plan for Resident #189 During an interview on 05/08/23 at 4:39 p.m., the Administrator said initially she was not aware Resident #184 had a burn from the coffee. The Administrator said at some point later she became aware Resident #184 had a burn. She said she did not report to HHS because they had implemented a plan to protect Resident #184 from further burns and when they tested the coffee shortly after Resident #184 spilled the coffee on herself, the temperature was within their policy range of 133-degree Fahrenheit. The ADM said she did not think about the risk of other residents after she learned about Resident #184 because it was an isolated event and they had implemented a plan for Resident #184. During an interview on 05/10/23 at 10:39 a.m., the facility physician said Resident #184 had a second degree burn from the spilled hot coffee. 2. Record review of Resident 17's face sheet dated 03/20/20 indicated he was a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with diagnoses including psychotic disorders (severe mental disorders that cause abnormal thinking and perceptions), peripheral vascular disease {PVD} (problem with poor blood flow), arthritis (swelling and tenderness of joints), and Parkinson (a brain disorder that causes unintended or uncontrollable movements, such as shaking, and difficulty with balance and coordination). Record review of Resident #17's annual MDS assessment dated [DATE] indicated he was usually understood and usually understood others. The MDS indicated Resident #17 was moderately impaired (BIMS score was 08). The MDS indicated Resident 17 required limited assistance with personal hygiene, dressing and supervision with bed mobility, transfers, toileting, and eating. The MDS indicated Resident #17 was continent of bowel and bladder. Record review of Resident #17's comprehensive care plan dated 02/16/23 indicated he had cognitive impairment as evidenced by memory problems and impaired ability to make daily decisions. The interventions were to explain all procedures, allow time for task, and reorient as needed. Resident #17 was on a regular diet and needed supervision for eating. The interventions were to assist with setup, explain to Resident #17 where his food was using the clock method due to his blindness. Record review of Resident #17's incident report dated 05/05/23 at 8:15 p.m., revealed Resident #17 spilled his coffee on his left thigh and obtained a 3-inch X 1-inch reddened area to his left thigh area. During an observation on 05/09/23 at 7:21 a.m., several residents in dining room for breakfast and observed Resident #12 spilling coffee on his shirt while drinking. Resident #12 noted with tremors and had to have his other hand to help with mobility while drinking coffee. During an observation and interview on 05/09/23 at 08:25 a.m., Resident #17 was sitting up in a wheelchair in his room. Resident #17's left upper leg assessed with no injuries noted. Resident #17 said his left leg/thigh was fine. Resident #17 did not recall what happened 05/05/23 on the evening of the coffee spill. During an interview on 05/10/23 at 2:16 p.m., CNA F said she was the aide who took Resident #17 the coffee. CNA F said Resident #17 was sitting in his wheelchair when she brought in the coffee. CNA F said she was supposed to tell Resident #17 where his coffee was located because he was blind CNA F said before she could tell Resident #17 where his coffee was located on the table, he knocked it over spilling it on himself and the floor. CNA F said Resident #17 was wearing grey sweatpants when the coffee spilled. CNA F said she assisted Resident #17 to change his clothes, but she did not see any [NAME] because he covered himself up. CNA F said she notified the nurse and then left the room. During an interview on 05/09/23 at 8:34 a.m., LVN E said she was the nurse on duty when Resident #17 spilled coffee on himself. LVN E said she assessed his left leg and noted a small, reddened area to his left inner thigh. LVN E said she did not think much about the reddened area because it was small, and Resident #17 said it was fine and he did not complain of pain. LVN E said she made a note about the coffee spill in the physicians' book at the nurse's station. LVN E said the physician would check the book on his next rounds. LVN E said she did not report Resident #17's reddened area to the physician because he did not have any visual openings to his skin; he had no pain, and it was a minor change. LVN E said it was important to notify the physicians of changes, but she did not feel this was anything major, so she did not notify the doctor. LVN E said she did not report the coffee spill on 05/05/23 to the DON or administrator because it was a redden area, it was not serious, and she knew what happened. LVN E said she did not realize the redden area from the coffee spill was considered a first-degree burn. During an interview on 05/10/23 at 10:39 a.m., the facility physician said Resident #17 had a first degree burn from spilled hot coffee. Record review of Resident #17's nurses note charted by LVNE dated 05/05/23 at 9:00 p.m., revealed Resident #17 spilled coffee on his left thigh. Denied pain. Red area 3-inchX1-inch noted to front of left thigh. Record review of Resident #17's nurses note dated 05/05/23 at 9:00 p.m., did not indicate any notification to physician, nurse managers or administrator. During an interview on 05/10/23 at 2:36 p.m., the ADON said she was not aware of hot coffee spilling on Resident #17's left thigh until Monday 05/08/23. The ADON said she was not aware this type of incident needed to be reported to HHS since they were aware of how the incidents occurred. The ADON said she now knows this was a reportable event. The ADON said because they initiated the hot liquid safety assessment on 05/09/23 she did identify some residents who would benefit from some added safety such as: assist with hot liquids, drink hot liquids only at the table or drink hot liquids in a cup with a lid. During an interview on 05/10/23 at 2:53 p.m., the DON said when any abnormal incidents occur such as a burn the nurses were supposed to call her or the administrator. The DON said she was not aware of Resident #17's coffee burn on 05/05/23 but identified it on 05/08/23. The DON said she did not know it needed to be reported to HHS. The DON said she after reading the reporting letter she was aware of the criteria of what to report to HHS. The DON said failure to investigate incidents properly could delay safety for others. During an interview on 05/10/23 at 3:26 p.m., the administrator said she became aware on 5/8/23 of Resident #17's coffee burn that occurred on 05/05/23. The administrator said she was not aware why staff had not reported the incident on 05/05/23. The administrator said she was the abuse coordinator and should have been notified when Resident #17 obtained the coffee burn. The administrator said she reread the guidelines for reporting to HHS on 05/09/23 and realized she should have reported Resident #184's and Resident #17's coffee burn within 2 hours after learning about them both. Record review of the facility policy titled, Accidents, Incidents, investigating and reporting, dated July 2017, indicated All incidents or accidents involving residents .occurring on our premises shall be investigated and reported to the administrator. The nurse supervisor or charge nurse shall promptly initiate and document investigations of the or accident. The nurse supervisor or charge nurse shall complete a report of incident/accident form and submit the original to the director of nurse's services within 24 hours of the incident or accident. The director of nurse's shall ensure the administrator receives a copy of the report of incident/ accidents for each occurrence. Record review of the facility policy titled, Abuse prevention, dated May 2017, indicated The facility will assure that all residents are free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. #4 E all injuries to a resident will have an incident report completed. Injuries of unknown origin will be investigated. Administrator and director of nursing will determine what injuries are to be reported to HHS per regulation. #7 the administrator will report all abuse, neglect, misappropriation of resident property allegations to HHS per regulation. This was determined to be an Immediate Jeopardy (IJ) situation on 05/09/23 at 10:33 a.m. The Administrator was notified. The Administrator was provided with the IJ template on 05/09/23 at 11:04 a.m. and requested a Plan of Removal (POR). The Plan of Removal (POR) was accepted on 05/10/23 at 2:14 p.m. and indicated the following: Immediate action: Implement measures to prevent other coffee spills with burns. Immediate removal of coffee from dining room coffee will be kept in the kitchen completed 5/9/23 at 10:45 AM. Coffee temperature immediately lowered to 110 degrees by adding ice. Coffee temperature will be maintained in a thermos. All hot liquids will be served at a safe temperature from our kitchen, per our policy for the safety of all residents. Completed 5/9/23 at 10:45 AM. Kitchen staff will check temperature of all hot/warm liquids before it leaves the kitchen. Resident #17 was screened by physical therapy and a recommendation of a cup with lid, screen completed 5/9/23 at 11:00 AM. In service all staff on setting up meals/drinks for all residents started on 5/9/23 by DON. (All staff to have in service completed prior to working next scheduled shift) currently 33 out of 39 staff members have been in-serviced. To be completed by 5/9/23. All staff in-serviced on safety procedures for serving hot liquids/coffee completed 5/9/23 by DON. (All staff to have in service completed prior to working next scheduled shift) currently 33 out of 39 staff members have been in-serviced. To be completed by 5/9/23. Added in-service on safety procedures for serving hot liquids to hire pack for all new employees to complete prior to working. Completed by business office 5/9/23. Hot liquid assessments to be done today for all residents 5/9/23. Completed on 5/9/23. Hot liquid assessments to be completed quarterly and on all admission done by a licensed nurse. Monitor temperature of hot liquid served to resident. All hot liquids will have temperature checked in kitchen prior to being served. Completed by kitchen staff. All kitchen staff will be in-serviced on new hot/warm beverage requirement. Completed 5/9/23 at 11:00 AM. Identify at risk residents: 15 residents at risk, all residents accessed for hot liquid safety done by nurse management 5/9/23. -amended 5/10/2023 coffee temperature per facility hot beverage policy. In-services: Coffee/hot liquid safety Safety procedures for serving hot liquids/coffee Assisting the impaired with in room meals Assistance with meals/snacks Monitoring: Interviews on 05/10/23 from 1:30 p.m. until 4:00 p.m. revealed the following: Interviews with 2 RNs: DON and RN L (6am-6pm); 1 LVN PRN nurses, (6a-2p),1 LVN B(6a-2p), 2 nurses (2a-10p), LVN B and LVN E (2p-10p), LVN K and LVN G (10p-6a), 3 CNA's (6a-2p) CNA N, CNA P and CNA Q,3 CNA's (2p-10p) CNA O CNA R and CNA F and 2 (10-6p) CNA AA and CNA S, 1 laundry T, 3 Housekeepers (8a-4p) Housekeeper U, housekeeper V and housekeeper W, 4 dietary (1p-7p) Dietary X Dietary Y, Dietary Z and cook D, Dietary Manager, Activity Director, ADON, and Adm in-serviced on hot liquid process. All coffee will come from the kitchen. Kitchen staff must test coffee temperature before serving to the residents. All hot liquids must be below 140 degrees Fahrenheit. Residents who need lids will be provided a cup with a lid. Record review of the facility policy titled, Hot beverage, dated 05/09/23, indicated Our long-term nursing care facility is committed to providing a safe and comfortable environment for all our residents, including their enjoyment of hot beverages such as coffee and tea. In accordance with state regulations, we have established the following policy regarding the temperature of hot beverages served in our facility. #1 hot beverages served will be cooled to a temperature below 140 degrees Fahrenheit. #2 residents that have been assessed to need hot beverages with a lid will receive their beverages in one. It will be delivered on their tray. #3 the temperature of hot beverages must be checked using a calibrated thermometer to ensure compliance with company policy before being served. #4 the kitchen staff will log the temperature of hot beverages on a hot temperature log once the beverage it is below 140 degrees Fahrenheit. #5 all hot beverages will go out on trays from the kitchen. #6 hot beverages that are not 140 or below must be cooled to 140 degrees Fahrenheit before being served to the resident. #7 all staff members involved in preparing and serving hot beverages must receive training on the proper temperature requirement for coffee and the importance of maintaining these standards. #9 residents who request hot beverages must be served promptly, but only with hot beverages that meet the temperature requirements outlined in this policy. On 05/10/2023 at 4:14 p.m. the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to ensure food was prepared and served in a manner that prevented foodborne illness for 1 of 1 kitchen reviewed for food preparation and serving. The facility did not ensure hair restraints were worn appropriately by Dietary Cook C and Cook D while they prepared and served residents' food. This failure could place residents who ate food from the kitchen at risk of foodborne illness. Findings included: During an observation on 05/07/23 at 11:49 a.m., Cook C was not wearing a hair restraint appropriately while serving the lunch meal. Cook C's hair was visible outside of the hairnet at the ears and neck. During an observation on 05/08/23 at 11:23 a.m., Cook D was not wearing a hair restraint appropriately while preparing the lunch meal. Cook D's hair was visible outside of the hairnet at the base of her neck. During an interview on 05/08/23 at 1:45 p.m., Cook D said she wore a hair restraint to cover her hair and to prevent hair from falling into the food. Cook D touched her hair by the base of her neck and verbalized her hair was not appropriately in the hair restraint. Cook D said she had a lot of hair, and it was hard to keep all her hair in the hair restraint. Cook D said not having all her hair in the hair restraint could potentially cause food borne illness/contamination. During an interview on 05/08/23 at 1:48 p.m., the dietary manager said he saw Cook C and Cook D with partial hair out of their hair restraints. The Dietary Manager stated he was the overseer of the kitchen and he did daily spot checks and addressed any issues as needed. The dietary manager said he would do an in-service on the importance of wearing hair restraints and how to properly wear a hair restraint. The dietary manager said it was important to wear hair restraints to prevent hair from contaminating the food. During an interview on 05/10/23 at 11:30a.m., Cook C said the hair restraint should cover her whole head. Cook C was unable to say why her hair restraint was not covering her whole head. She said the dietary manager had talked with her on 05/09/23 and explained the importance of always keeping her hair in the hair restraint while in the kitchen. Cook C said there was a possibility for hair to get into the resident's food if all hair was not completely covered. Record review of in-service dated 05/09/23 revealed, Cook C and Cook D signed the in-service on hair restraints. Record review of policy hair restraint in food service kitchen indicated, The purpose of this policy was to establish guidelines for employees to follow when it comes to hair restraint in food service kitchens. Hair restraint was an essential component of maintaining a safe and sanitary environment in a food service kitchen and is necessary to prevent contamination of food. The policy applies to all employees who work in the kitchen or food preparation areas of the facility including cooks and dishwasher. #1 all employees working in the kitchen or food preparation areas must always wear a hair restraint. #2 hair restraints must be clean and in good condition. Hair restraints that are dirty torn or frail must be replaced immediately. #3 hair restraints must completely cover all hair on the head, including bangs and sideburns. #8 employees who fail to comply with a hair restraint policy may be subject to disciplinary action up to and including termination.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering, and securing of medications for 1 of 1 nurse's cart and 1 of 2 medication carts (#2 medication cart) reviewed for pharmacy services. The facility failed to ensure the nurse's cart was locked when left unattended in the hallway. The facility failed to ensure all medications on the nurses' cart and the #2 medication cart were labeled when opened. These failures could place residents at risk of not having the medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication. Findings Included: 1. During an observation and interview on 05/09/23 at 09:28 AM, the nurse's cart was on the 100 hall and was unlocked. There was no staff present. LVN B came out of a resident's room, and she said she was the one responsible for leaving the cart unlocked. LVN B said it was her responsibility to lock the cart when left unattended. LVN B said by leaving the cart unlocked and unattended, residents could open the cart and take medications. During an interview on 05/10/23 at 1:55 p.m., the ADON said she expected all carts to be locked when left unattended. The ADON said by not locking the cart, residents could be at risk for getting into the cart and obtaining anything they want or overdosing on medications. The ADON said the person who had the keys for the cart was responsible for ensuring the cart remained locked when unattended. During an interview on 05/10/23 at 2:29 PM, the DON said she expected the carts to be always locked unless the nurse was getting something from it. The DON said the nurse who had the keys was responsible for ensuring the cart remained locked when leaving unattended. The DON said leaving the cart unlocked the resident was at risk for getting into the cart and taking medications they were not supposed to. During an interview on 05/10/23 at 3:02 PM, the Administrator said she expected the carts to be locked when not in use. The Administrator said the nurse was responsible for ensuring the cart stays locked when not in use. The Administrator said by leaving the cart unlocked, the residents were at risk of getting ahold of something unsafe for them to have. 45879 2. During an observation and interview on 05/07/23 at 11:27 a.m., nurses' cart #1 revealed Resident #7's Lispro insulin was not dated when opened. LVN A said the insulin bottle should have been dated when it was opened. LVN A said he administered Resident #7 12 units of Lispro for her 6:30 a.m. medication pass on 05/07/23. LVN A said he did not notice the bottle was not dated during his 6:30 a.m. morning medication pass. LVN A said all medication should be dated when open. LVN A said without knowing when the insulin was opened it could cause residents to not receive effective medication. During an observation and interview on 05/08/23 at 10:10 a.m., medication cart #2 revealed Fluticasone Propionate 50mg (nasal spray) filled on 3/27/23 with no date when opened for Resident #24, Fluticasone Propionate (nasal spray) 50mg filled 2/1/23 with no date when opened for Resident #8, Debrox ear drops with no date when opened for Resident #27 and quadrivalent influenza (flu) vaccine in fridge with no date when opened. LVN B said she was not aware these medications did not have an opened date on them. LVN B said the nurse or medication aide who opened the medication should have dated them. LVN B said the night nurses usually checked for expired medication on the medication carts and or medication room but it was all nurse's responsibility. LVN B indicated expired medications given to a resident could affect the efficacy of the medication. During an interview on 05/08/23 at 2:08 p.m., the ADON said she expected all medication to be dated when opened. The ADON said the nurse who opens the medication were responsible for dating it. The ADON said by not dating the insulin or other medications when opened the staff will be unaware of when the medication expires. The ADON said residents were at risk for the medications not to work properly. During an interview on 05/08/23 at 4:22 p.m., the DON said she expected all medication to be dated when opened. The DON said the person who first opened the medication was responsible for dating it. The DON said the carts were to be checked daily by the night nurses, but it was her responsibility to oversee the process. The DON said the residents were at risk for ineffective medications. During an interview on 05/10/23 at 3:26 p.m., the Administrator said she expected all medication to be dated when opened and by not doing so, the staff would be unaware of when it expired. The Administrator said the carts were checked by the nurses and the nurse managers were to follow up. The Administrator said failure to date medication could lead to ineffective medication being received. Record review of the facility's policy titled Administering Medications revised April 2019, indicated, .Medications are administered in a safe and timely manner, and as prescribed .12. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. Record review of the facility's policy last revised April 2019, titled, Storage of Medications, indicated, The facility stores all drugs and biologicals in a safe, secure, and orderly manner . 8. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes containing drugs and biologicals are locked when not in use. 9. Unlocked medication carts are not left unattended .

Based on observation, interview, and record review the facility failed to immediately consult with the resident's physician when there was significant change in the resident's physical, mental, or psychosocial status for 1 of 2 residents (Resident # 17) reviewed for notification of changes. The facility failed to notify the physician for Resident #17 after LVN E assessed redness on his left inner thigh from spilled hot coffee. This failure could place residents at risk of their physicians not being aware of the resident conditions and delay treatments for the residents' conditions. Findings included: Record review of Resident 17's face sheet dated 03/20/20 indicated he was a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with diagnoses including psychotic disorders (severe mental disorders that cause abnormal thinking and perceptions), peripheral vascular disease {PVD} (problem with poor blood flow), arthritis (swelling and tenderness of joints), and Parkinson (a brain disorder that causes unintended or uncontrollable movements, such as shaking, and difficulty with balance and coordination). Record review of Resident #17's annual MDS assessment dated [DATE] indicated he was usually understood and usually understood others. The MDS indicated Resident #17cognition was moderately impaired (BIMS score was 08). The MDS indicated Resident 17 required limited assistance with personal hygiene, dressing and supervision with bed mobility, transfers, toileting, and eating. The MDS indicated Resident #17 was continent of bowel and bladder. Record review of Resident #17's comprehensive care plan dated 02/16/23 indicated he had cognitive impairment as evidenced by memory problems and impaired ability to make daily decisions. The interventions was to explain all procedures, allow time for task, and reorient as needed. Record review of the physicians' book revealed a note dated 05-05 with no year or time. Resident #17 spilled hot coffee on his left thigh, area red. Record review of nurse note dated 05/05/23 at 9:00p.m., revealed, Resident #17 spilled coffee on his left thigh. Denies pain. Red area 3 X 1 inch noted to front of thigh. Record review of nurses noted dated 05/05/23 at 9:00p.m., did not indicate the physician had been notified. During an interview on 05/10/23 at 2:16 p.m., CNA F said she was the aide who took Resident #17 the coffee. CNA F said Resident #17 was sitting in his wheelchair when she brought in the coffee. CNA F said before she could tell Resident #17 where his coffee was located on the table, he knocked it over spilling it on himself and the floor. CNA F said Resident #17 was wearing grey sweatpants when the coffee spilled. CNA F said she assisted Resident #17 to change his clothes but she did not see any [NAME] because he covered himself up. CNA F said she notified the nurse and then left the room. During an interview on 05/09/23 at 8:34 a.m., LVN E said she was the nurse on duty when Resident #17 spilled coffee on himself. LVN E said she assessed his left leg and noted a small, reddened area to his left inner thigh. LVN E said she did not think much about the reddened area because it was small and Resident #17 said it was fine and he did not complain of pain. LVN E said she made a note about the coffee spill in the physicians' book at the nurse's station. LVN E said the physician would check the book on his next rounds. LVN E said she did not report Resident #17's reddened area to the physician because his skin was not opened; he had no pain and it was a minor change. LVN E said it was important to notify the physicians of changes, but she did not feel this was anything major, so she did not notify the doctor. LVN E said she did not report the coffee spill on 05/05/23 to the DON or administrator because it was a redden area, it was not serious and she knew what happened. LVN E said she did not realize the redden area from the coffee spill was considered a first-degree burn (affects the epidermis, or outer layer of skin). During an observation and interview on 05/09/23 at 08:25 a.m., Resident #17 was sitting up in a wheelchair in his room. Resident #17 said his left leg/thigh was fine. Resident #17 did not recall what happened 05/05/23 on the evening of the coffee spill. During an interview on 05/10/23 at 2:36 p.m., the ADON said the physician should have been notified of the redness to Resident #17's leg from the coffee spill. The ADON said she expected the nurses to pick up the phone and notify the physician of any changes. She said it was important to notify the physician of any resident's changes so they would be aware and in case they wanted to order something new or stop something. During an interview on 05/10/23 at 2:53 p.m., the DON said she expected nurses to notify the physician of all changes whether minor or major. The DON said the charge nurses were responsible to notify the physician of any changes and her and the ADON were to follow up. The DON said without notification, the physician would not know if a resident had a change. During an interview on 05/10/23 at 3:26 p.m., the Administrator said she expected nursing staff to notify the physicians of any changes to the residents. The Administrator said administration nurses were to follow up on notifications. The Administrator said failure to notify the physician could impede the resident's care. Record review of facility policy change of condition, observing, reporting and recording dated May 2017 indicated, It is the policy of this home to inform the resident, the resident's physician and if indicated the residents responsible party of the following: #1 an accident or incident involving the resident which results in injury as it has the potential for requiring physician intervention. #2 a significant change in the residence physical, mental, or psychosocial status, such as a deterioration in health, mental, or psychosocial status, and life-threatening conditions or clinical complication. #4 A need to alter treatment significantly.

F880 S/S L Based on observation, interview and record review the facility failed to ensure an effective infection control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections including COVID-19 (a new respiratory disease which can cause mild to severe illness with most severe illness in adults [AGE] years and older) were maintained for the facility. The facility did not quarantine Resident #1 after her roommate tested positive for COVID-19. The facility did not move Resident #1 to the warm zone of the building after her exposure. Staff worked on halls with residents who were COVID-19 negative and on halls with residents who were COVID-19 unknown status during the same shift. Staff did not wear appropriate PPE on the COVID-19 positive unit. An Immediate Jeopardy (IJ) situation was identified on 12/1/20. While the IJ was removed on 12/2/20, however, the facility remained out of compliance at no actual harm with a potential for more than minimum harm that is not immediate jeopardy with a scope of widespread, due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk for being exposed to COVID-19, health complications, and death. Findings included: The website, https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html, accessed on 12/2/20 stated .Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for [DIAGNOSES REDACTED]-CoV-2 14 days after their last exposure (e.g., date their roommate was moved to the COVID-19 care unit) . The COVID-19 RESPONSE FOR NURSING FACILITIES dated 10/8/20 indicated . NF providers should designate HCWs for each cohort and staff should not work with more than one cohort. Once staff are designated to work with a given cohort, staff should not change designation from one day to another, unless required in order to maintain adequate staffing for a cohort .To avoid transmission within facilities, NFs should use separate staffing teams for COVID-19-positive residents to the best of their ability, and designate separate facilities or units within a facility to separate residents into three categories: those who are COVID-19-negative, those who are COVID-19-positive, and those with unknown COVID-19 status .NFs must identify whether the following concerns exist and specifically address them through education and training: lack of understanding of proper use of each type of PPE; .Improper donning and doffing procedures .Cross contamination .lack of understanding of cold, warm and hot zones within a facility .cold zone - area with no COVID-19 infection present .warm zone - area used to monitor residents probable of COVID-19 infection .hot zone - area where COVID-19 infection is present . An Emergency Response Policy dated 11/2/20 indicated .When a resident tests positive for COVID 19 and has a roommate, the roommate will be placed on the quarantine hall for endurance of 14 days .staff working the hot area must stay in full PPE (gowns, gloves, mask, and face shield/goggles) the entire time on the unit. Staff going into warm rooms must don full PPE and PPE must be removed upon exiting the room .adherence to infection control policies is critical. Adherence to droplet precautions during the care of a resident with symptoms or a confirmed case is a must .infection control policies require staff to use standard and droplet precautions with symptomatic residents or staff . A resident roster provided by the administrator on 11/30/20 indicated there were thirteen residents who were positive for COVID-19 that resided on the COVID-19 positive unit (hall 100). A resident roster provided by the administrator on 11/30/20 indicated there were three residents who resided on the warm/unknown zone (hall 200). 1.Consolidated physician orders [REDACTED].#2 was [AGE] years old, readmitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated Resident #2 usually understood others and was usually understood. The MDS indicated Resident #2 required supervision with ADLs. A care plan revised on 11/29/20 indicated Resident #2 required isolation due to a positive COVID 19 test. The care plan indicated Resident #2 was readmitted to the COVID positive unit for isolation. A Hospital and Nursing Facility Transfer Record dated 11/23/20 at 9:55 a.m. indicated Resident #2 was transferred to the hospital for decreased oxygen saturation and increased temperature. The transfer record indicated Resident #2's vitals at the time of transfer were temperature 97.8, pulse 121, respirations 24, blood pressure 127/83, and oxygen saturation of 87%. The record indicated Resident #2 was given Tylenol at 7:30 a.m. on 11/23/20. The record indicated Resident #2 had an increased temperature earlier in the morning of 102.4 degrees Fahrenheit and oxygen saturation of 81%. A nursing note dated 11/23/20 at 6:30 a.m. indicated Resident #2 had a temperature of 102.4 degrees Fahrenheit and oxygen saturation of 84% on room air. The nursing noted indicated Resident #2 had wheezing throughout both lungs and a cough was noted. A nursing note dated 11/23/20 at 7:30 a.m. indicated an order to send Resident #2 to the emergency room for evaluation was received but Resident #2 refused. A nursing note dated 11/23/20 at 9:45 a.m. indicated Resident #2 had fallen in her room. The nursing note indicated Resident #2 agreed to go to the hospital and 911 was called for Resident to be sent to emergency room for respiratory symptom evaluation. A physician notification form dated 11/23/20 at 9:55 a.m. indicated Resident #2 was sent to the emergency room for evaluation of increased temperature and decreased oxygen saturation. The nurse practitioner was notified. Hospital records dated 11/23/20 indicated Resident #2 was admitted to the hospital due to being positive for COVID 19. She was discharged back to the facility on [DATE]. 2.Consolidated physician orders [REDACTED].#1 was [AGE] years old, readmitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated Resident #1 understood others and was understood. The MDS indicated Resident #1 required limited assistance with ADLs. A care plan revised on 10/15/20 indicated Resident #1 had cognitive impairment and required limited assistance with ADLs. The care plan revised 12/1/20 indicated Resident #1 required isolation due to a possible exposure to COVID 19. The care plan indicated Resident #1 was moved to the warm hall for isolation. The 24 hour report indicated the following: *11/23/20 - Resident #2 was admitted to the hospital and had tested positive for COVID 19. Resident #1 had a [DIAGNOSES REDACTED]. *11/24/20 - Resident #2 was at the hospital. Resident #1 had a [DIAGNOSES REDACTED]. She was on warm isolation. *11/25/20 - Resident #2 was at the hospital. Resident #1 had a [DIAGNOSES REDACTED]. She was on warm isolation. *11/26/20 - Resident #2 was at the hospital. Resident #1 had a [DIAGNOSES REDACTED]. She was on warm isolation. *11/27/20 - Resident #2 was at the hospital. Resident #1 had a [DIAGNOSES REDACTED]. She was on warm isolation. *11/29/20 - Resident #2 was at the hospital. Resident #1 had a [DIAGNOSES REDACTED]. *11/30/20 - Resident #1 had a [DIAGNOSES REDACTED]. During an observation on 11/30/20 at 3:15 p.m. the name plates on room [ROOM NUMBER] indicated Resident #1 and Resident #2 shared a room. There was no signage on the door indicating isolation precautions. There was no isolation cart outside of her room. During an observation on 11/30/20 at 2:30 p.m., LVN A went into the warm zone on the 200 hall. She went into rooms [ROOM NUMBER]. She changed her PPE appropriately on the warm zone and went on the cold zone on hall 300. She went into room [ROOM NUMBER] and then room [ROOM NUMBER] (Resident #1's room). She obtained Resident #1's vitals and exited the room. She did not change her gown when she exited Resident #1's room. During an interview on 11/30/20 at 2:48 p.m., LVN A said she worked both the cold zones (hall 300 and hall 400) and warm zone (hall 200). She said she changed her PPE when she went in the rooms on the warm zone. She said she did not change her PPE for anyone on the cold zone. She said Resident #1 was not on isolation that she was aware of. She said she just found out today that Resident #2 had tested positive for COVID 19. LVN A said she did not know why Resident #1 was not moved to the warm unit. LVN A said Resident #1 should have been moved immediately. LVN A said the facility did not have dedicated staff for the warm zone (hall 200). During an interview on 11/30/20 at 3:49 p.m., CNA B said she worked both the cold zones (hall 300 and hall 400) and warm zone (hall 200). She said Resident #1 was on the cold zone (hall 300). She said she did not change her PPE after she cared for Resident #1. She said Resident #1 was not on isolation precautions. During an interview on 12/1/2020 at 11:45 a.m., CNA C said she worked both the cold zones (hall 300 and hall 400) and warm zone (hall 200). She said she changed her PPE between each resident on the warm zones but not the cold zones. She said she did not change her PPE after providing care for Resident #1. She said Resident #1 was not on isolation precautions. CNA C said she worked the day Resident #2 was sent to the hospital. She said Resident #2 complained of feeling tired and had a cough. CNA C said she was off work for the next 2 days, but when she returned she was told that Resident #2 had tested positive for COVID 19. She said she asked someone why Resident #1 had not been moved to the warm zone but was told there were no rooms available. CNA C could not recall who she had asked. CNA C said there was never any signage placed on Resident #1's room indicating she was on isolation precautions. She said there was never an isolation cart placed outside of Resident #1's room. During an interview on 12/2/20 at 9:50 a.m., CNA D said she worked both the cold zones (hall 300 and hall 400) and warm zone (hall 200). She said she did not change her gown after providing care to Resident #1. CNA D said she found out Resident #2 had tested positive for COVID 19 on 11/27/20. She said she knew Resident #1 should have been moved to the warm zone, but she did not ask anyone about it. During an interview on 12/2/20 at 10:19 a.m., CNA E said she worked both the cold zones (hall 300 and hall 400) and warm zone (hall 200). She said they did not have staff dedicated to just the warm zone. CNA E said she did not change her PPE after providing care to Resident #1. She said Resident #1 was not on isolation. CNA E said she found out Resident #2 had tested positive for COVID 19 around 11/26/20. She said she asked her charge nurse about moving Resident #1 to the warm zone but was just told we'll get to it. CNA E said Resident #1 was never moved and she was not placed on isolation precautions. During an interview on 12/1/2020 at 11:07 a.m., the ADON said they did not have dedicated staff for the warm zone (hall 200). She said staff worked the cold zones (hall 300 and hall 400) and warm zones (hall 200). The ADON said Resident #1 was not on isolation precautions. She said Resident #1's roommate (Resident #2) had fallen and was sent to the hospital. She said Resident #2 had tested positive for COVID 19 at the hospital. The ADON said she was not sure when they were notified Resident #2 had tested positive. She said she believed they were notified the next day (11/24/20). The ADON said whoever was notified about Resident #2, should have moved Resident #1 to the warm zone immediately. During an interview on 12/1/20 at 4:00 p.m., the administrator said she did not have dedicated staffing for her warm zone (hall 200) She said staff worked the cold zones and warm zones. She said she did not know she had to have dedicated staff for each cohort. The administrator said normally the nurse would call the hospital and get an update about resident who were sent out. She said she did not know who received the update that Resident #2 had tested positive. She said the staff knew they were supposed to move Resident #2's roommate to the warm zone immediately. She said she did not know why Resident #1 was not moved. She said she had plenty of rooms on the warm zone. During an interview on 12/2/20 at 12:05 p.m., the DON said Resident #2 had a fever and decreased oxygen saturation the morning of 11/23/20. She said they had tried to send her to the hospital, but she refused at that time. She said approximately an hour later Resident #2 had fallen. She said Resident #2 was still wheezing, coughing and was short of breath. She said she agreed to go to the hospital. The DON said she called the hospital either that evening (11/24/20) or the next day and was notified that Resident #2 had tested positive for COVID 19. The DON said she did not move Resident #2's roommate (Resident #1) to the warm zone. She said she did put her on precautions. She said she put boxes in her room. The DON said she did not put signage on the door and did not place an isolation cart outside of her door. She said staff were already wearing PPE (gowns, gloves, and N95 masks). She said she did not think about them needing to change the gowns after providing care to Resident #1. She said she thought they could wear the same gown. The DON said it was her responsibility to move Resident #2 to the warm zone. 3. During an observation on 11/30/20 at 2:43 p.m., there was a sign on the door of the COVID positive hall that indicated staff are to wear full PPE at all times when on the COVID 19 hall. During an observation on 11/30/20 at 2:55 p.m., RN F was working on the COVID 19 positive hall. She was standing in the hall at the medication cart. She was wearing a surgical mask. She was not wearing a N95 mask, gown, or face shield/goggles. She walked to the end of the hall and opened the door for another staff. She walked back to the medication cart. During an observation on 11/30/20 at 3:00 p.m., CNA G was working on the COVID 19 positive hall. She was wearing a N95 mask and gown. She went into resident room [ROOM NUMBER] and resident room [ROOM NUMBER]. She was not wearing a face shield or goggles. During an observation on 11/30/20 at 5:46 p.m., CNA H entered the back door on the COVID 19 positive hall wearing a N95 mask. She went to the middle of the hall and obtained her gown and walked back to the door to don her gown. CNA H did not put on a face shield or goggles. She walked into resident room [ROOM NUMBER]. During an observation on 11/30/20 at 5:47 p.m., there was no donning station at the entry of the COVID 19 hall. The PPE was stored on a table in the middle of the hall. During an interview on 11/30/20 at 5:50 p.m., CNA G said she never wore a face shield or goggles. She said the face shield and goggles were available, but she did not usually put them on. She said she was supposed to wear full PPE when she was on the COVID 19 positive hall which included gown, mask, gloves, and face shield/goggles. During an interview on 11/30/20 at 5:54 p.m., RN F said she worked all halls, but today she had worked the COVID 19 positive unit. RN F said full PPE should always be worn when on the COVID positive hall which included N95 mask, gown, and gloves. She said she did not have on a N95 mask because she already had COVID 19 and was more relaxed with her PPE. She said the surgical mask was easier to wear. RN F said she should have had a gown on when she was in the hallway. She said, that is my bad. RN F said she never wore the face shield or goggles. She said that was just her preference and personal choice. During an interview on 11/30/20 at 5:59 p.m., CNA H said she never wore the face shield or goggles. She said the face shields were available, she just had not put one on. During an observation on 11/30/20 at 3:33 p.m., RN F was standing with the door to the COVID 19 positive hall cracked open while she talked with the administrator and ADON. She was wearing a surgical mask. She was not wearing a N95 mask, gown, or face shield/goggles. She closed the door and returned to the medication cart on the hallway. She was not instructed to don her appropriate PPE. The administrator was notified on 12/1/20 at 1:56 p.m. an Immediate Jeopardy situation was identified due to the above failures. The administrator was provided the Immediate Jeopardy template on 12/1/20 at 2:19 p.m. The facility's Plan of Removal was accepted on 12/1/20 at 7:01 p.m. and included: *All staff will be in serviced on proper use of PPE for isolation and quarantined residents given by Administrator and ADON. This will include the appropriate donning and doffing of PPE. Proper PPE for quarantine and isolation is to don gloves, N95 Mask, gown and eye protection (face shield or goggles) that must be worn the whole time while in COVID-19 Unit. *Staff will be in-serviced on 12-2-20 at 9:00 a.m. on notifying the administrator and DON immediately of a COVID-19 positive resident and moving a roommate of a COVID positive resident to the quarantine/isolation hall immediately, due to potentially being exposed. * Staff will be designated for working cold/warm/hot. No staff working in warm/hot zones will be permitted to cross over to cold zones. Agency was contacted on 12-1-20 to assist with covering shifts. *Resident who was exposed to her roommate who tested positive for COVID-19 was moved to quarantine hall on 12/1/20 at11:45am. *The COVID-19 policy was updated on 12/1/20 to include reporting positive Covid-19 residents immediately to the administrator and DON. *All staff in-service was held at 9:00 a.m. on 12/2/20 conducted by administrator and ADON. Staff who were unavailable for the mandatory in-service will not work until they have completed the in-services. On 12/2/20 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Six LVNs (on all shifts - 6 a.m. to 6 p.m.; 6 p.m. to 6 a.m.;6 a.m. to 2 p.m.; 2 p.m. to 10 p.m.; 10 p.m. to 6 a.m.; and weekends), 8 CNAs (all shifts), 1 MA (double weekends) one NA (10 p.m. to 6 a.m.), three housekeeping staff, and one maintenance supervisor and two laundry aides said they were in-serviced on the proper use of their PPE for isolation and quarantined residents (gloves, N95 Mask, gown and eye protection (face shield or goggles), reporting COVID positive residents immediately to the administrator and DON, moving roommates of COVID positive residents immediately to the warm hall, and dedicated staffing for each cohort. All staff were able to answer the questions with correct information to the above in-service training topics. Staff were observed to be wearing the appropriate PPE and wearing it correctly. Resident #1 was moved to the warm hall. On 12/2/20 at 12:35 p.m., the administrator was informed the IJ was removed; however, the facility remained out of compliance at no actual harm with a potential for more than minimal harm that is not immediate jeopardy with a scope identified as widespread due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review the facility failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest, practicable physical, mental, and psychosocial well-being for 2 of 24 residents reviewed for care and services regarding COVID-19 (a new respiratory disease which can cause mild to severe illness with most severe illness in adults [AGE] years and older). (Resident #1 and Resident #2) The administrator and DON did not develop an appropriate plan to provide nursing care for Resident #1 after he tested positive for COVID-19 and was moved to the hot (COVID-19 positive) unit. The facility did not review their existing plan to mitigate staffing shortages as required per CDC guidelines. The administration and DON did not direct staff to quarantine Resident #2 after his roommate tested positive for COVID-19. An Immediate Jeopardy (IJ) situation was identified on 11/2/20. While the IJ was removed on 11/4/20, the facility remained out of compliance at no actual harm with the potential for more than minimal harm that is not an immediate jeopardy with a scope identified as isolated, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for being exposed to COVID-19, health complications, and death. Findings included: The website, https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, accessed on 11/6/20 stated, .Develop (or review existing) plans to mitigate staffing shortages from illness or absenteeism. CDC has created guidance to assist facilities with mitigating staffing shortages . Residents with COVID-19 should, ideally, be cared for in a dedicated unit or section of the facility with dedicated HCP (see section on Dedicating Space) . If a resident requires a higher level of care or the facility cannot fully implement all recommended infection control precautions, the resident should be transferred to another facility that is capable of implementation . The website, https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html, accessed on 11/6/20 stated .Assign dedicated HCP to work only on the COVID-19 care unit. At a minimum this should include the primary nursing assistants (NAs) and nurses assigned to care for these residents . Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for [DIAGNOSES REDACTED]-CoV-2 14 days after their last exposure (e.g., date their roommate was moved to the COVID-19 care unit) . Increase monitoring of ill residents, including assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam, to at least 3 times daily to identify and quickly manage serious infections . The Texas Health and Human Services COVID-19 RESPONSE FOR NURSING FACILITIES version 3.5 dated 08/18/2020 stated, . Caring for someone with COVID-19 requires additional time and resources, including PPE, to maintain infection control and protect other residents and staff . Quarantine residents with exposure or symptoms . Any roommates (of COVID-19 positive residents) should be moved and monitored for fever and symptoms twice daily for 14 days . 9. Facility Activities Required for LTC COVID-19 Response In Advance .Develop a staffing contingency plan in case a large number of staff must self-quarantine or isolate because of potential exposure, being probable of, or positive for COVID-19 . Extended (24-72 hours) . Maintain resident care .Attachment 1: Immediate Response Guidelines Immediate Actions (0-24 hours) . Provide adequate staff with training, skills, and competencies for COVID- 19 care . The facility's policy titled, COVID Senior Suite Care and Rehab Emergency Response Policy for COVID-19, updated on 6/1/20, did not address the disposition of residents with known exposure to COVID-19 or the care to be provided to COVID-19 positive residents. 1. Consolidated physician orders dated November 2020, indicated Resident #1 was [AGE] years old, readmitted on [DATE] with [DIAGNOSES REDACTED]. The physician orders indicated Resident #1 was to be checked by a nurse and assessed for pain by a nurse every shift and was to receive the following medications: [REDACTED] *Aspirin 81 mg (milligrams) 1 tablet by mouth daily for [DIAGNOSES REDACTED]. *[MEDICATION NAME] 75 mg 1 tablet by mouth daily for [DIAGNOSES REDACTED]. *Dilitia XT 180 mg 1 capsule by mouth daily for [DIAGNOSES REDACTED]. *[MEDICATION NAME] 1000 mg 1 tablet by mouth twice a day for [DIAGNOSES REDACTED]. Physician orders dated 10/30/20 at 3:15 p.m., indicated Resident #1 was admitted to Medicare A, Skilled nursing due to [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated Resident #1 was severely impaired cognitively, usually understood others and usually made himself understood. The MDS indicated Resident #1 had no behavior of rejecting care, he required supervision with bed mobility, transfers, walking, dressing, eating, toilet use and personal hygiene. Resident #1 was occasionally incontinent of bladder and always incontinent of bowel. The MDS indicated Resident #1 had active [DIAGNOSES REDACTED]. A care plan revised on 10/30/20 indicated Resident #1 was COIVD-19 positive and moved to the hot area of the building for isolation. The care plan indicated Resident #1 had a [DIAGNOSES REDACTED]. The interventions included give medication as ordered and monitor for signs and symptoms of stroke. The care plan indicated Resident #1 was at risk for bleeding due to medications and the interventions included monitor for abnormal/unexplained bruising and monitor for abnormal bleeding. Resident #1 had a history of [REDACTED]. Resident #1 had a [MEDICAL CONDITION] disorder, the interventions included, administer medication as ordered, and if signs of [MEDICAL CONDITION] activity are observed ensure safe position. During an interview on 11/1/20 at 2:45 p.m., RN A indicated Resident #1 was on the hot hall, she said he came from room [ROOM NUMBER]. RN A said the 100 hall was divided by a plastic barrier, the front of the 100 hall was the warm area and behind the barrier was the hot area. RN A said all the other halls in the building (200, 300 and 400) were cold halls. RN A said there were no other residents in the building on isolation or quarantine. During an interview on 11/1/20 at 2:50 p.m., MA C said she was the MA for the entire facility during the current shift. She said she did not enter the hot area, she handed medications to the staff on the hot hall at the plastic barrier that divided the warm and hot area. MA C said the staff on the hot hall administered medication to Resident #1. During an interview on 11/1/20 at 3:40 p.m., the maintenance director said he was the only one on the hot hall with Resident #1, he said there was no nurse or CNA with him. He said he was taking Resident #1's vital signs and reporting them to LVN B via text message. The maintenance director said he had been with Resident #1 on the hot hall by himself for about 45 minutes, he said someone was supposed to relieve him at 6:00 p.m. The maintenance director said he had not given Resident #1 any medication, he said he would call LVN B if there was an emergency. During an interview on 11/1/20 at 4:10 p.m., RN A said there was not a nurse on the hot hall, she said LVN B was the nurse responsible for Resident #1 and she was also the primary nurse for the rest of the building. RN A said she provided the wound care and any assistance LVN B needed on the weekend. During an interview on 11/1/20 at 4:12 p.m., LVN B said she was the primary nurse for the building, she said she worked double weekend shifts. LVN B said she worked 10/31/20 from 6:00 a.m. to 10:00 p.m. and worked 11/2/20 since 6:00 a.m. LVN B said staff on the hot hall would text her the vital signs of Resident #1 and keep her updated via text message. LVN B said prior to the maintenance director being on the hot hall with Resident #1, CNA G had taken care of him. LVN B said she had not seen or assessed Resident #1 since the afternoon of 10/30/20, prior to him being transferred to the hot hall. LVN B said the DON came to the building sometime yesterday (10/31/20) afternoon and assessed Resident #1. LVN B said she had no reason to go to the hot hall. During an interview on 11/1/20 at 4:15 p.m., LVN E said Resident #1 was assessed on Saturday (10/31/20) by the DON, she said she was not sure of the time. LVN E said the documentation of the assessment had not yet been assessed. During an interview on 11/1/20 at 4:20 p.m., the DON said she assessed Resident #1 Saturday (10/31/20) evening. The DON said the documentation of the assessment was not yet completed, she said there had not been a nurse assigned on the unit with Resident #1 since he was moved to the hot unit. The DON said they had trouble finding staff to care for Resident #1 after he was moved to the hot hall. During an interview on 11/1/20 at 4:22 p.m., the administrator said there had been a CNA staffed on the hot unit with Resident #1 but not a nurse. The administrator said staff texted information to the nurse regarding Resident #1, she said the maintenance director was on the hot hall with Resident #1 at this time. The administrator said she had trouble getting staff to care for Resident #1. During an interview on 11/2/20 at 1:32 p.m., the administrator said the plan for staffing formed in July was to utilize the facilities PRN (as needed) nurses. She said there had been several PRN nurses who indicated they would care for COVID-19 positive residents at that time. The administrator said when we contacted them to work Friday (10/30/20), none of them could work or were working for other facilities. The administrator said there had been no evaluation of the COVID-19 staffing plan since it was formed in July 2020. During an interview on 11/2/20 at 1:35 p.m., the DON said she had not and was not instructed to check with PRN nursing staff to update the emergency staffing plan. The MAR indicated [REDACTED] *Aspirin 81 mg 1 tablet by mouth on 10/31/20 at 6:00 a.m. and 11/1/120 at 6:00 a.m.; *[MEDICATION NAME] 75 mg 1 tablet by mouth on 10/31/20 at 6:00 a.m. and 11/1/120 at 6:00 a.m.; *Dilitia XT 180 mg 1 capsule by mouth on 10/31/20 at 6:00 a.m. and 11/1/120 at 6:00 a.m.; *[MEDICATION NAME] 1000 mg 1 tablet by mouth on 10/31/20 at 6:00 a.m. and 6:00 p.m.; and *[MEDICATION NAME] 1000 mg 1 tablet by mouth on 11/1/20 at 6:00 a.m. and 6:00 p.m. During an interview on 11/2/20 at 10:00 a.m., CNA G said she worked Saturday (10/31/20) from 6:00 a.m. to 6:00 p.m. and Sunday (11/1/20) from 6:00 a.m. to 2:00 p.m. CNA G said she was the only staff member on the hot hall during those times. CNA G said she checked Resident #1's vital signs every four hours and notified the nurse via text message. She said Resident #1 had received medication once each day she was there, she said MA C brought the medications to her in a medication cup and then stood at the plastic barrier while she gave the medications to Resident #1. CNA G said she did not know the indication or side effects of the following medications, [MEDICATION NAME], and Dilitia. CNA G said a nurse did not come back to the hot unit during the time she worked the past two days. The nurse MAR indicated [REDACTED] *10/31/20 between 6:00 a.m.-2:00 p.m.; *10/31/20 between 2:00 p.m.-10:00 p.m.; *10/31/20 between 10:00 p.m.-6:00 a.m.; *11/1/20 between 6:00 a.m.-2:00 p.m.; *11/1/20 between 2:00 p.m.-10:00 p.m.; and *11/1/20 between 10:00 p.m.-6:00 a.m. 2. Consolidated physician orders dated November 2020, indicated Resident #2 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The physician orders did not address Resident #2's need for quarantine due to exposure of COVID-19. The MDS dated [DATE] indicated Resident #2 was severely impaired cognitively, was sometimes understood and sometimes made himself understood. The MDS indicated Resident #2 had no behaviors of rejecting care, was totally dependent on staff for bed mobility, transfers, locomotion in his wheelchair, dressing, eating, toileting personal hygiene and bathing. A care plan dated prior to 11/1/20 did not address Resident #2's need for quarantine due to exposure of COVID-19. During an interview on 11/1/20 at 2:45 p.m., RN A indicated Resident #1 was on the hot hall, she said there were no other residents in the building on isolation or quarantine. RN A said Resident #1 was moved from room [ROOM NUMBER] and Resident #2 had been his roommate, she said Resident #2 was not in quarantine. During an interview on 11/1/20 at 2:50 p.m., MA C said she was the MA for the entire facility during the current shift. She said she passed medication to all of the residents on the cold halls including hall 200. MA C was wearing an N95 mask, she did not wear any additional PPE when entering Resident #2's room because he was on a cold hall. MA C said she did not cover her N95 with a hospital mask while giving medication to Resident #2. MA C said she did not change her mask after giving medication to Resident #2 and before giving medication to other residents. During an observation on 11/1/20 at 2:55 p.m., staff on the cold halls were wearing surgical masks only. Resident #2 was laying in his bed in room [ROOM NUMBER]. The door was open to the room. There was no signage to indicate Resident #2 was in quarantine. There was no PPE outside of the room. During an interview on 11/1/20 at 3:00 p.m., CNA F was wearing a surgical mask. CNA F said she wore a surgical mask while providing care to residents on the cold halls including Resident #2. CNA F said she did not change her mask after providing care to Resident #2 and before going into another resident's room. CNA F said she did not wear any additional PPE while providing care to Resident #2 because he was not quarantined. During an observation on 11/1/20 at 4:24 p.m., LVN E entered Resident #2's room wearing only a surgical mask. The door was left open and the medication cart was left in the door way while LVN E was in the room. LVN E exited Resident #2's room with her medication cart, wearing the same surgical mask entered Resident #3's room. During an interview on 11/1/20 at 4:35 p.m., LVN E said she did not change her mask after exiting Resident #2's room or wear any additional PPE while administering his medication because he was not in quarantine. During an interview on 11/1/20 at 4:20 p.m., the DON said Resident #2 was not in quarantine because his results from the mass testing on 10/26/20 were negative. The DON said Resident #1 and #2 were tested on the same day. During an interview on 11/1/20 at 4:22 p.m., the administrator said Resident #2 should have been quarantined because of his exposure to Resident #1. The administrator was notified on 11/2/20 at 2:18 p.m., an IJ situation was identified due to the above failures. The administrator was provided the IJ template on 11/2/20 at 2:30 p.m. The facility's Plan of Removal was accepted on 11/3/20 at 3:19 p.m. and included: Resident who was exposed to his roommate who tested positive for COVID-19 was moved to quarantine hall on 11/2/20 @10:30am. The COVID-19 policy was updated on 11-2-20 to include moving a roommate of a COVID positive resident to the quarantine/isolation hall, due to potentially being exposed. All staff in-service on proper PPE for isolation and quarantined residents given by DON and ADON. Proper PPE for quarantine and isolation is to don gloves, N95 Mask or higher-level respirator (or face mask if those are not available), gown and eye protection (face shield or goggles) that must be worn the whole time while in COVID.19 Unit. DON and ADON will monitor staff on using proper PPE. The COVID-19 positive resident will be assessed by a licensed nurse per shift, per CDC. Licensed nurse assessment q shift began 11/1/2020 at 6 PM. Licensed nurse was working our COVID-19 unit from 6PM 11/1/2020 through the time IJ was issued. The assessment will be documented in the residents' chart. Nursing in-service was conducted by DON, ADON, and Administrator on 11-3-20 at 9am about assessing COVID residents per shift. All staff in-service will be held at 9am on 11-3-20 conducted by Administrator, DON, and ADON. Staff will not work till all in-services for the Plan of Removal are complete. QUAPI will be held on 11-3-20 to review updated COVID policy, updated Emergency Plan, and In-services. On 11/4/20 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: During an observation on 11/4/20 at 9:30 a.m., Resident #2 was quarantined on the warm hall. During interviews on 11/4/20; 1RN; 7 LVN's (4 on the 6 a.m.-2p.m. shift; 1 on the 2 p.m.-10 p.m. shift and 2 from the 10 p.m.-6 a.m. shift); 9 CNAs (4 on the 6 a.m.-2 p.m. shift; 3 on the 2 p.m.-10 p.m. shift and 2 from the 10 p.m.-6 a.m. shift); 2 CMAs (1 on the 6 a.m.-2 p.m. shift; and 1 on the 2 p.m.-10 p.m. shift) and 4 additional staff a PTA, kitchen, maintenance director, and housekeeper were interviewed. The staff indicated they received in-service training regarding wearing the proper PPE for isolation and quarantined residents (gloves, N95 Mask or higher-level respirator (or face mask if those are not available), gown and eye protection (face shield or goggles); and moving a roommate of a COVID positive resident to the quarantine/isolation hall, due to potentially being exposed. The nurses indicated a COVID-19 positive resident must receive an assessment by a licensed nurse every 8 hours and documented in the residents' chart. During an interview on 11/4/20 at 10:00 a.m., the DON said she has been monitoring staff every two hours to ensure the proper PPE was worn on the warm hall and the PPE was donned and doffed correctly. The DON said all staff, who had not yet received the in-service over; quarantining the roommates of COVID-19 positive residents; PPE requirements for the care of isolated/quarantined residents; and the assessment of COVID-19 residents every eight hours by a licensed nurse would not be able to return to work until the in-services were completed. Resident #1's medical record was reviewed and indicated, he had received a complete assessment every eight hours by a licensed 11/1/2020 at 6:00 p.m. The facility COVID-19 policy, updated on 11/2/20 indicated a roommate of a COVID-19 positive resident must be moved to the quarantine/isolation hall, due to potentially being exposed. The QAPI sign in sheet, dated 11/3/20 indicated all necessary members of the QAPI committee, including the medical director, addressed the facilities plan of removal, updated COVID-19 policy, and updated Emergency Plan. On 11/4/20 at 11:42 a.m., the administrator was informed the IJ was removed; however, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as a isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections was provided for 2 of 36 residents reviewed for infection control related to COVID-19 (a new respiratory disease which can cause mild to severe illness with most severe illness in adults [AGE] years and older). (Resident #1 and Resident #2) The facility did not provide appropriate nursing care to Resident #1 after he tested positive for COVID-19 and was moved to the hot (COVID-19 positive) unit. The Facility did not review their existing plan to mitigate staffing shortages as required per CDC guidelines. The facility did not quarantine Resident #2 after his roommate tested positive for COVID-19. The facility did not move Resident #2 to the warm zone of the building after his exposure. An Immediate Jeopardy (IJ) situation was identified on 11/2/20. While the IJ was removed on 11/4/20, the facility remained out of compliance at no actual harm with the potential for more than minimal harm that was not an immediate jeopardy with a scope identified as isolated, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for being exposed to COVID-19, health complications, and death. Findings included: The website, https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, accessed on 11/6/20 stated, .Develop (or review existing) plans to mitigate staffing shortages from illness or absenteeism. CDC has created guidance to assist facilities with mitigating staffing shortages . Residents with COVID-19 should, ideally, be cared for in a dedicated unit or section of the facility with dedicated HCP (see section on Dedicating Space) . If a resident requires a higher level of care or the facility cannot fully implement all recommended infection control precautions, the resident should be transferred to another facility that is capable of implementation . The website, https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html, accessed on 11/6/20 stated .Assign dedicated HCP to work only on the COVID-19 care unit. At a minimum this should include the primary nursing assistants (NAs) and nurses assigned to care for these residents . Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for [DIAGNOSES REDACTED]-CoV-2 14 days after their last exposure (e.g., date their roommate was moved to the COVID-19 care unit) . Increase monitoring of ill residents, including assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam, to at least 3 times daily to identify and quickly manage serious infections . The Texas Health and Human Services COVID-19 RESPONSE FOR NURSING FACILITIES version 3.5 dated 08/18/2020 stated, . Caring for someone with COVID-19 requires additional time and resources, including PPE, to maintain infection control and protect other residents and staff . Quarantine residents with exposure or symptoms . Any roommates (of COVID-19 positive residents) should be moved and monitored for fever and symptoms twice daily for 14 days . 9. Facility Activities Required for LTC COVID-19 Response In Advance .Develop a staffing contingency plan in case a large number of staff must self-quarantine or isolate because of potential exposure, being probable of, or positive for COVID-19 . Extended (24-72 hours) . Maintain resident care .Attachment 1: Immediate Response Guidelines Immediate Actions (0-24 hours) . Provide adequate staff with training, skills, and competencies for COVID- 19 care . The facility's policy titled, COVID Senior Suite Care and Rehab Emergency Response Policy for COVID-19, updated on 6/1/20, did not address the disposition of residents with known exposure to COVID-19 or the care to be provided to COVID-19 positive residents. 1. Consolidated physician orders dated November 2020, indicated Resident #1 was [AGE] years old, readmitted on [DATE] with [DIAGNOSES REDACTED]. The physician orders indicated Resident #1 was to be checked by a nurse and assessed for pain by a nurse every shift and was to receive the following medications: [REDACTED] *Aspirin 81 mg (milligrams) 1 tablet by mouth daily for [DIAGNOSES REDACTED]. *[MEDICATION NAME] 75 mg 1 tablet by mouth daily for [DIAGNOSES REDACTED]. *Dilitia XT 180 mg 1 capsule by mouth daily for [DIAGNOSES REDACTED]. *[MEDICATION NAME] 1000 mg 1 tablet by mouth twice a day for [DIAGNOSES REDACTED]. Physician orders dated 10/30/20 at 3:15 p.m., indicated Resident #1 was admitted to Medicare A, Skilled nursing due to [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated Resident #1 was severely impaired cognitively, usually understood others and usually made himself understood. The MDS indicated Resident #1 had no behavior of rejecting care, he required supervision with bed mobility, transfers, walking, dressing, eating, toilet use and personal hygiene. Resident #1 was occasionally incontinent of bladder and always incontinent of bowel. The MDS indicated Resident #1 had active [DIAGNOSES REDACTED]. A care plan revised on 10/30/20 indicated Resident #1 had a [DIAGNOSES REDACTED]. The care plan indicated Resident #1 had a [DIAGNOSES REDACTED]. The interventions included give medication as ordered and monitor for signs and symptoms of stroke. The care plan indicated Resident #1 was at risk for bleeding due to medications and the interventions included monitor for abnormal/unexplained bruising and monitor for abnormal bleeding. Resident #1 had a history of [REDACTED]. Resident #1 had a [MEDICAL CONDITION] disorder, the interventions included, administer medication as ordered, and if signs of [MEDICAL CONDITION] activity are observed ensure safe position. During an observation on 11/4/20 at 12:00 p.m., Resident #1 was sitting in a chair in his room on the hot unit. Resident #1 was not interviewable and was unable to answer the surveyor's questions. During an interview on 11/1/20 at 2:45 p.m., RN A indicated Resident #1 was on the hot hall, she said he came from room [ROOM NUMBER]. RN A said the 100 hall was divided by a plastic barrier, the front of the 100 hall was the warm area and behind the barrier was the hot area. RN A said all the other halls in the building (200, 300 and 400) were cold halls. RN A said there were no other residents in the building on isolation or quarantine. During an interview on 11/1/20 at 2:50 p.m., MA C said she was the MA for the entire facility during the current shift. She said she did not enter the hot area, she handed medications to the staff on the hot hall at the plastic barrier that divided the warm and hot area. MA C said the staff on the hot hall administered medication to Resident #1. During an interview on 11/1/20 at 3:40 p.m., the maintenance director said he was the only one on the hot hall with Resident #1, he said there was no nurse or CNA with him. He said he was taking Resident #1's vital signs and reporting them to LVN B via text message. The maintenance director said he had been with Resident #1 on the hot hall by himself for about 45 minutes, he said someone was supposed to relieve him at 6:00 p.m. The maintenance director said he had not given Resident #1 any medication, he said he would call LVN B if there was an emergency. During an interview on 11/1/20 at 4:10 p.m., RN A said there was not a nurse on the hot hall, she said LVN B was the nurse responsible for Resident #1 and she was also the primary nurse for the rest of the building. RN A said she provided the wound care and any assistance LVN B needed on the weekend. During an interview on 11/1/20 at 4:12 p.m., LVN B said she was the primary nurse for the building, she said she worked double weekend shifts. LVN B said she worked 10/31/20 from 6:00 a.m. to 10:00 p.m. and worked 11/1/20 since 6:00 a.m. LVN B said staff on the hot hall would text her the vital signs of Resident #1 and keep her updated via text message. LVN B said prior to the maintenance director being on the hot hall with Resident #1, CNA G had taken care of him. LVN B said she had not seen or assessed Resident #1 since the afternoon of 10/30/20, prior to him being transferred to the hot hall. LVN B said the DON came to the building sometime yesterday (10/31/20) afternoon and assessed Resident #1. LVN B said she had no reason to go to the hot hall. During an interview on 11/1/20 at 4:15 p.m., LVN E said Resident #1 was assessed on Saturday (10/31/20) by the DON, she said she was not sure of the time. LVN E said the documentation of the assessment had not yet been documented. During an interview on 11/1/20 at 4:20 p.m., the DON said she assessed Resident #1 Saturday (10/31/20) evening. The DON said the documentation of the assessment was not yet completed, she said there had not been a nurse assigned on the unit with Resident #1 since he was moved to the hot unit. The DON said they had trouble finding staff to care for Resident #1 after he was moved to the hot hall. During an interview on 11/1/20 at 4:22 p.m., the administrator said there had been a CNA staffed on the hot unit with Resident #1 but not a nurse. The administrator said staff texted information to the nurse regarding Resident #1, she said the maintenance director was on the hot hall with Resident #1 at this time. The administrator said she had trouble getting staff to care for Resident #1. The MAR indicated [REDACTED] *Aspirin 81 mg 1 tablet by mouth on 10/31/20 at 6:00 a.m. and 11/1/20 at 6:00 a.m.; *[MEDICATION NAME] 75 mg 1 tablet by mouth on 10/31/20 at 6:00 a.m. and 11/1/20 at 6:00 a.m.; *Dilitia XT 180 mg 1 capsule by mouth on 10/31/20 at 6:00 a.m. and 11/1/20 at 6:00 a.m.; *[MEDICATION NAME] 1000 mg 1 tablet by mouth on 10/31/20 at 6:00 a.m. and 6:00 p.m.; and *[MEDICATION NAME] 1000 mg 1 tablet by mouth on 11/1/20 at 6:00 a.m. and 6:00 p.m. During an interview on 11/2/20 at 10:00 a.m., CNA G said she worked Saturday (10/31/20) from 6:00 a.m. to 6:00 p.m. and Sunday (11/1/20) from 6:00 a.m. to 2:00 p.m. CNA G said she was the only staff member on the hot hall during those times. CNA G said she checked Resident #1's vital signs every four hours and notified the nurse via text message. She said Resident #1 had received medication once each day she was there, she said MA C brought the medications to her in a medication cup and then stood at the plastic barrier while she gave the medications to Resident #1. CNA G said she did not know the indication or side effects of the following medications, [MEDICATION NAME], and Dilitia. CNA G said a nurse did not come back to the hot unit during the time she worked the past two days. The nurse MAR indicated [REDACTED] *10/31/20 between 6:00 a.m.-2:00 p.m.; *10/31/20 between 2:00 p.m.-10:00 p.m.; *10/31/20 between 10:00 p.m.-6:00 a.m.; *11/1/20 between 6:00 a.m.-2:00 p.m.; *11/1/20 between 2:00 p.m.-10:00 p.m.; and *11/1/20 between 10:00 p.m.-6:00 a.m. 2. Consolidated physician orders dated November 2020, indicated Resident #2 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The physician orders did not address Resident #2's need for quarantine due to exposure of COVID-19. The MDS dated [DATE] indicated Resident #2 was severely impaired cognitively, was sometimes understood and sometimes made himself understood. The MDS indicated Resident #2 had no behaviors of rejecting care, was totally dependent on staff for bed mobility, transfers, locomotion in his wheelchair, dressing, eating, toileting personal hygiene and bathing. A care plan dated prior to 11/1/20 did not address Resident #2's need for quarantine due to exposure of COVID-19, the care plan was updated after surveyor identified intervention. During an interview on 11/1/20 at 2:45 p.m., RN A indicated Resident #1 was diagnosed with [REDACTED]. She said there were no other residents in the building on isolation or quarantine. RN A said Resident #1 and Resident #2 had been roommates and Resident # 2 remained in room [ROOM NUMBER]. She said Resident #2 was not in quarantine. During an interview and observation on 11/1/20 at 2:50 p.m., MA C said she was the MA for the entire facility during the current shift. She said she passed medication to all cold halls (COVID-19 negative) including hall 200. MA C was wearing an N95 mask, she did not wear any additional PPE when entering Resident #2's room because he was on the cold hall. MA C said she did not cover her N95 with a surgical mask while giving medication to Resident #2. MA C said she did not change her mask after giving medication to Resident #2 and before giving medication to other residents. During an observation on 11/1/20 at 2:55 p.m., staff on the cold halls were wearing surgical masks only. Resident #2 was laying in his bed in room [ROOM NUMBER]. The door was open to the room. There was no signage to indicate Resident #2 was in quarantine. There was no PPE outside of the room. During an interview on 11/1/20 at 3:00 p.m., CNA F was wearing a surgical mask. CNA F said she wore a surgical mask while providing care to residents on the cold halls including Resident #2. CNA F said she did not change her mask after providing care to Resident #2 and before going into another resident's room. CNA F said she did not wear any additional PPE while providing care to Resident #2 because he was not quarantined. During an observation on 11/1/20 at 4:24 p.m., LVN E entered Resident #2's room wearing only a surgical mask. The door was left open and the medication cart was left in the door way while LVN E was in the room. LVN E exited Resident #2's room with her medication cart, wearing the same surgical mask and entered Resident #3's room. During an interview on 11/1/20 at 4:35 p.m., LVN E said she did not change her mask after exiting Resident #2's room or wear any additional PPE while administering his medication because he was not in quarantine. During an interview on 11/1/20 at 4:20 p.m., the DON said Resident #2 was not in quarantine because his results from the mass testing on 10/26/20 were negative. The DON said Resident #1 and #2 were tested on the same day. During an interview on 11/1/20 at 4:22 p.m., the administrator said Resident #2 should have been quarantined because of his exposure to Resident #1. The administrator was notified on 11/2/20 at 2:18 p.m., an IJ situation was identified due to the above failures. The administrator was provided the IJ template on 11/2/20 at 2:30 p.m. The facility's Plan of Removal was accepted on 11/3/20 at 3:19 p.m. and included: Resident who was exposed to his roommate who tested positive for COVID-19 was moved to quarantine hall on 11/2/20 @10:30am. The COVID-19 policy was updated on 11-2-20 to include moving a roommate of a COVID positive resident to the quarantine/isolation hall, due to potentially being exposed. All staff in-service on proper PPE for isolation and quarantined residents given by DON and ADON. Proper PPE for quarantine and isolation is to don gloves, N95 Mask or higher-level respirator (or face mask if those are not available), gown and eye protection (face shield or goggles) that must be worn the whole time while in COVID.19 Unit. DON and ADON will monitor staff on using proper PPE. The COVID-19 positive resident will be assessed by a licensed nurse per shift, per CDC. Licensed nurse assessment q shift began 11/1/2020 at 6 PM. Licensed nurse was working our COVID-19 unit from 6PM 11/1/2020 through the time IJ was issued. The assessment will be documented in the residents' chart. Nursing in-service was conducted by DON, ADON, and Administrator on 11-3-20 at 9am about assessing COVID residents per shift. All staff in-service will be held at 9am on 11-3-20 conducted by Administrator, DON, and ADON. Staff will not work till all in-services for the Plan of Removal are complete. QUAPI will be held on 11-3-20 to review updated COVID policy, updated Emergency Plan, and In-services. On 11/4/20 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: During an observation on 11/4/20 at 9:30 a.m., Resident #2 was quarantined on the warm hall. During interviews on 11/4/20; 1RN; 7 LVN's (4 on the 6 a.m.-2p.m. shift; 1 on the 2 p.m.-10 p.m. shift and 2 from the 10 p.m.-6 a.m. shift); 9 CNAs (4 on the 6 a.m.-2 p.m. shift; 3 on the 2 p.m.-10 p.m. shift and 2 from the 10 p.m.-6 a.m. shift); 2 CMAs (1 on the 6 a.m.-2 p.m. shift; and 1 on the 2 p.m.-10 p.m. shift) and 4 additional staff a PTA, kitchen, maintenance director, and housekeeper were interviewed. The staff indicated they received in-service training regarding wearing the proper PPE for isolation and quarantined residents (gloves, N95 Mask or higher-level respirator (or face mask if those are not available), gown and eye protection (face shield or goggles); and moving a roommate of a COVID positive resident to the quarantine/isolation hall, due to potentially being exposed. The nurses indicated a COVID-19 positive resident must receive an assessment by a licensed nurse every 8 hours and documented in the residents' chart. During an interview on 11/4/20 at 10:00 a.m., the DON said she has been monitoring staff every two hours to ensure the proper PPE was worn on the warm hall and the PPE was donned and doffed correctly. The DON said all staff, who had not yet received the in-service over; quarantining the roommates of COVID-19 positive residents; PPE requirements for the care of isolated/quarantined residents; and the assessment of COVID-19 residents every eight hours by a licensed nurse would not be able to return to work until the in-services were completed. Resident #1's medical record was reviewed and indicated, he had received a complete assessment every eight hours by a licensed nurse 11/1/2020 at 6:00 p.m. The facility COVID-19 policy, updated on 11/2/20 indicated a roommate of a COVID-19 positive resident must be moved to the quarantine/isolation hall, due to potentially being exposed. The QAPI sign in sheet, dated 11/3/20 indicated all necessary members of the QAPI committee, including the medical director, addressed the facilities plan of removal, updated COVID-19 policy, and updated Emergency Plan. On 11/4/20 at 11:42 a.m., the administrator was informed the IJ was removed; however, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as a isolated, due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents reviewed for accidents. (Resident #1) The facility did not ensure Resident #1's Broda chair was locked properly while being lifted in the van lift. Resident #1 fell from the van lift with the Broda chair landing on top of the resident resulting in the resident having a left hip fracture requiring surgical intervention. This failure could place 8 residents who required assistive devices when traveling in the facility van at risk of injury. Findings included: Physician orders [REDACTED].#1 was [AGE] years old and admitted [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 09/26/17 indicated Resident #1 required 2 staff to use a mechanical lift for transferring and could not help with transfers. Resident #1 was at risk for falls and staff should assist appropriately for transfers. The MDS dated [DATE] indicated Resident #1 was moderately cognitively intact, usually understood others, and usually made herself understood. Resident #1 was dependent on staff for transfers, toilet use, bathing, and locomotion off unit. Resident #1 was incontinent of bowel and bladder. Hospital records dated 09/21/17 indicated Resident #1 was being transported by nursing home staff when they lost control of the chair lift and Resident #1 fell . X-rays dated 09/21/17 indicated Resident #1 had a left femoral neck fracture. A CAT scan dated 09/21/17 indicated Resident #1 had an acute fracture of the left femoral neck with mild impaction and mild anterior and lateral displacement of the distal fracture fragment. Surgery records dated 09/23/17 indicated Resident #1 had surgery on her left femoral neck fracture to control pain. During an interview on 09/27/17 at 10:25 a.m., CNA A said she transported Resident #1 to a dermatology appointment on 09/21/17 in the facility van. She said they arrived to the appointment and from inside the van, she loaded Resident #1 onto the lift in her Broda chair and secured the locks on the Broda chair. CNA A said she exited the van and began to walk around to the back of the van when Resident #1 complained that she was urinating and began to wiggle in her chair. CNA A said she noticed both front brakes were not locked and the back wheels of Resident #1's Broda chair rolled off the lift. She said Resident #1 fell on to the pavement and the Broda chair landed on Resident #1. CNA A said Resident #1 used her Broda chair to commute to appointments and was bed bound the rest of the time. She said there was no check off form for using the lift or facility van. During an observation on 09/27/17 at 10:23 a.m., Resident #1's Broda chair, used during her transport on 09/21/17, was checked by the surveyor. The front brakes on the Broda chair were locked and the surveyor pulled, pushed, and aggressively shook and slid the chair and the front brakes stayed securely locked. During an observation and interview on 09/27/17 at 10:56 a.m., Resident #1 was lying in her bed with an approximately 1 foot long incision to her lateral left thigh. Resident #1 said she was in pain if her leg was touched. She said on 09/21/17, she had a dermatology appointment and CNA A transported her alone to the appointment. She said she remembered CNA A standing on the side of the lift holding a drink in one hand and her other hand was on the arm of the chair. She said she began to urinate and she asked CNA A if she was urinating through the chair. She said CNA A looked under the Broda chair and said she was urinating through the chair. Resident #1 said she began to feel the chair moving and thought to herself that she hoped CNA A would grab the chair before it fell off the lift. She said she remembered falling onto the pavement from the lift. She said she remembered being in pain when she tried to move. Resident #1 said she was unable to see the wheels when she was in the Broda chair and did not know if CNA A locked the wheels before she was placed on the lift. She said she did not feel safe riding in the facility van and was relieved when she found out she was going to be transported back to the facility by ambulance. CNA A's employee file indicated she was hired on 11/05/13 and did not include any trainings or check offs regarding transporting residents on the facility van. During an interview on 09/27/17 at 11:32 a.m., the administrator said the facility did not have a transporting policy or a policy on assistive device checks. The administrator said the facility van was at a repair shop to ensure the lift was working properly. During an interview on 10/03/17 at 11:52 a.m., the administrator said 8 residents who required assistive devices when traveling rode the facility van.

Based on observation, interview, and record review, the facility failed to prohibit misappropriation of resident's property for 2 of 2 residents reviewed for misappropriation of property. (Resident #1 and #2) The facility did not prevent exploitation of Resident #1's money and of Resident #2's property. This failure could place the census of 39 at risk for exploitation and misappropriation of personal property. Findings included: 1. Physician orders [REDACTED].#1 was [AGE] years old and admitted on [DATE]. Her [DIAGNOSES REDACTED]. A Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 usually understood others and usually made her needs known. Her BIMS (brief interview for mental status) score was 7. She required extensive assistance with transfers, dressing, toilet use, and personal hygiene. A care plan dated 04/20/17 indicated Resident #1had impaired vision and impaired daily decision making and interventions included to announce self by name when entering room, encourage independence, and do not rush resident. During an interview on 04/20/17 at 8:47 a.m., the administrator said CNA A was Resident #1's power of attorney. She said the power of attorney was dated 01/17/17 but Resident #1 did not leave the facility in January 2017. She said Resident #1's signature on the power of attorney did not resemble Resident #1's signature when she signed to get her hair styled. She said Resident #1 received Medicaid benefits and was unsure how the transfer of property would affect her Medicaid eligibility. The administrator said the facility had Resident #1's will and it said all her property went to her grandson. During an interview on 04/20/17 at 11:14 a.m., Resident #1 said she did not know CNA A until she started working at the facility. She said CNA A asked to be her power of attorney. She said she did not know that her grandson could be her power of attorney and said she would prefer her grandson to be her power of attorney. She said she left everything to her grandson in her will. Resident #1 said she owned her house and land. She said her house and land should not be in CNA A's name because she did not transfer the property to her. She said she would not want anybody except her grandson to get her house and land. During an interview on 04/20/17 at 12:36 p.m., CNA A said she started working at the facility in May 2016 and met Resident #1. She said she was not Resident #1's power of attorney. CNA A said she was only Resident #1's responsible party at the facility. She said she had nothing to do with Resident #1's finances. She said in November 2016, she and Resident #1's grandson took Resident #1 out of the facility to an attorney's office to transfer Resident #1's house to her grandson. She said while they were sitting in the attorney's office, Resident #1's grandson said to put the house in her (CNA A's) name. She said Resident #1's house and land was transferred to her name. She said she did not know if the property transfer would affect Resident #1's Medical eligibility. The county deed history for Resident #1's property indicated Resident #1 was the owner of the property until 11/18/16. Resident #1's property was transferred into CNA A's name. The property was appraised for $30,440 in 2017. A durable power of attorney dated 01/17/17 indicated CNA A and Resident #1's grandson were her power of attorney. During an interview on 04/20/17 at 1:41 p.m., the DON said she remembered CNA A and Resident #1's grandson taking Resident #1 out of the facility in November 2016. She said Resident #1 did not leave the facility during January 2017. 2. Physician orders [REDACTED].#2 was [AGE] years old and admitted on [DATE]. His [DIAGNOSES REDACTED]. A MDS dated [DATE] indicated Resident #2 understood others and made his needs known. His BIMS score was 11. He required limited assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. During an interview on 04/20/17 at 8:47 a.m., the administrator said on 04/18/17, Resident #2 came to her after he opened his mail and noticed his check that he wrote to the facility bounced. She said Resident #2 said he gave CNA A and CNA B his debit card to do some personal shopping for him and the resident believed that both CNAs took out unauthorized money from the ATM. The administrator said he also loaned CNA B $840 that he did not get back. She said a few months ago the business office manager accidently opened Resident #2's bank statements and showed it to her. She said she noticed the multiple ATM withdraws and knew Resident #2 did not leave the facility to make the cash withdraws. She said she confronted Resident #2 about the ATM withdraws but the resident denied that staff was taking any money from him. She said staff was in-serviced about not shopping for residents and she personally went to CNA B and asked her if she was shopping for Resident #2 and she said she was. The administrator said she told CNA B to stop shopping for Resident #2 and the activity director was the only staff member that could shop for residents. She said Resident #2 did not have enough money in his bank account to pay for stay at the facility. During an interview on 04/20/17 at 11:38 a.m., Resident #2 said he only gave his debit card to the activity director, CNA B, and CNA B's husband. He said the activity director gave him receipts when she bought anything for him. He said two months ago CNA B told him she was 2 months behind on her rent and asked to borrow $800. He said he liked CNA B and she went to the store for him so he let her borrow the money. He said he gave CNA B his debit card with his pin number and she took out the money. He said CNA B came to him last week and asked him for another $40 and he gave her his debit card for her to take out the money from the ATM. He said CNA B did not give him receipts after any of the purchases. He said he gave his debit card to CNA B's husband once when he came to the facility. He said he did not get a receipt from CNA B's husband. Resident #2 said when he gave his debit card to CNA B and CNA B's husband; he did not receive any cash from them. Resident #2 said he was out on pass during the Easter weekend but had not left the facility since the later part of 2016. Resident #2 said he did not meet CNA B until she started working at the facility. He said CNA B introduced him to her husband. During an interview on 04/21/17 at 7:52 a.m., CNA B said she began working at the facility in December 2015. She said she did not borrow money from Resident #2. She said she did take Resident #2's debit card and buy him food but she did not take money out of the ATM when she had Resident #2's debit card. CNA B said Resident #2 gave her the pin number to his debit card. She said she knew she was not supposed to take Resident #2's debit card. CNA B said she did not know Resident #2 before she worked at the facility. During an interview on 04/20/17 at 10:27 a.m., the activity director said Resident #2 told her that he let CNA B borrow $800 and she did not pay him back. She said she thought CNA B probably borrowed more than $800 because CNA B would ask staff if she could borrow money. The activity director said she reported the allegation to the administrator. She said she heard the administrator tell CNA B not to buy Resident #2 items and not to take his debit card. She said she was the only authorized staff that could buy personal items for residents. She said she took money out of the ATM for Resident #2 four times and two of the times was during Easter weekend. She said she got Resident #2 to sign his receipts for the purchases when she returned to the facility. During an interview on 04/20/17 at 1:41 p.m., the DON said she saw Resident #2's bank account balance about a year ago and it was $40,000. She said CNA B was seen taking Resident #2 food and personal items to his room. The DON said Resident #2's truck was parked at the facility but Resident #2 was unable to drive. She said CNA B's husband came to the facility and drove Resident #2's truck multiple times. She said CNA B borrowed money from her and did not pay it back. She said CNA B owed her more than $1000. During an interview on 04/20/17 at 11:53 a.m., MA C said she was concerned that CNA B was taking advantage of Resident #2 because she saw CNA B going to the store for Resident #2. She said the administrator told all the staff not to make purchases for the residents. During an interview on 05/01/17 at 10:48 a.m., Resident #3 said her room was across the hall from Resident #2's room. She said she often saw CNA B bringing Resident #2 food and personal items to his room. During an interview on 04/20/17 at 2:06 p.m., LVN D said CNA B asked to borrow money from her several times. During an interview on 05/01/17 at 10:41 a.m., LVN E said CNA B asked to borrow money from her several times. During an interview on 04/21/17 at 9:09 a.m., a local police chief said CNA B's husband came to the police station to give a statement regarding Resident #2. He said the husband said he met Resident #2 at the facility in December 2016 and began running errands for the resident. The police chief said CNA B's husband said Resident #2 needed money to make a deposit on a house and he used Resident #2's debit card and withdrew $1750 and also bought him snacks, drinks, and clothes. The husband told the police chief that the last time he used Resident #2's debit card was 04/16/17 when he withdrew $200 and bought some personal items. A bank statement for the period of 12/28/16 to 01/29/17 indicted Resident #2 withdrew a total of $2600 from the local ATM, with the first unauthorized withdraw on 12/30/16. A bank statement for the period of 01/30/17 to 02/27/17 indicated Resident #2 withdrew $100 from the local ATM. A bank statement for the period of 02/28/17 to 03/27/17 indicated Resident #2 withdrew $1300 from the local ATM. A bank statement from the period of 03/28/17 to 04/19/17 indicated Resident #2 withdrew $1800 from the local ATM. The CMS 672 dated 04/20/17 indicated the census was 39.

Based on observation, interview, and record review, the facility failed to develop and implement written policy and procedures to prohibit misappropriation of resident's property for 2 of 2 residents reviewed for misappropriation of property. (Resident #1 and #2) The facility did not prevent exploitation of Resident #1's money and of Resident #2's property. This failure could place the census of 39 at risk for exploitation and misappropriation of personal property. Findings included: The facility's undated abuse policy defined exploitation as .if it belongs to a resdient or is placed here for a resident's benefit, then you connot posses it, buy it, trade for it, steal it, receive it as a gift, or any other way control it, to do so is exploitation . and .if you, an employee, borrow money or items from a resident, you have committed an offense of our policy and SSC&R interprets this as exploitation . 1. Physician orders [REDACTED].#1 was [AGE] years old and admitted on [DATE]. Her [DIAGNOSES REDACTED]. A Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 usually understood others and usually made her needs known. Her BIMS (brief interview for mental status) score was 7. She required extensive assistance with transfers, dressing, toilet use, and personal hygiene. A care plan dated 04/20/17 indicated Resident #1had impaired vision and impaired daily decision making and interventions included to announce self by name when entering room, encourage independence, and do not rush resident. During an interview on 04/20/17 at 8:47 a.m., the administrator said CNA A was Resident #1's power of attorney. She said the power of attorney was dated 01/17/17 but Resident #1 did not leave the facility in January 2017. She said Resident #1's signature on the power of attorney did not resemble Resident #1's signature when she signed to get her hair styled. She said Resident #1 received Medicaid benefits and was unsure how the transfer of property would affect her Medicaid eligibility. The administrator said the facility had Resident #1's will and it said all her property went to her grandson. During an interview on 04/20/17 at 11:14 a.m., Resident #1 said she did not know CNA A until she started working at the facility. She said CNA A asked to be her power of attorney. She said she did not know that her grandson could be her power of attorney and said she would prefer her grandson to be her power of attorney. She said she left everything to her grandson in her will. Resident #1 said she owned her house and land. She said her house and land should not be in CNA A's name because she did not transfer the property to her. She said she would not want anybody except her grandson to get her house and land. During an interview on 04/20/17 at 12:36 p.m., CNA A said she started working at the facility in May 2016 and met Resident #1. She said she was not Resident #1's power of attorney. CNA A said she was only Resident #1's responsible party at the facility. She said she had nothing to do with Resident #1's finances. She said in November 2016, she and Resident #1's grandson took Resident #1 out of the facility to an attorney's office to transfer Resident #1's house to her grandson. She said while they were sitting in the attorney's office, Resident #1's grandson said to put the house in her (CNA A's) name. She said Resident #1's house and land was transferred to her name. She said she did not know if the property transfer would affect Resident #1's Medical eligibility. The county deed history for Resident #1's property indicated Resident #1 was the owner of the property until 11/18/16. Resident #1's property was transferred into CNA A's name. The property was appraised for $30,440 in 2017. A durable power of attorney dated 01/17/17 indicated CNA A and Resident #1's grandson were her power of attorney. During an interview on 04/20/17 at 1:41 p.m., the DON said she remembered CNA A and Resident #1's grandson taking Resident #1 out of the facility in November 2016. She said Resident #1 did not leave the facility during January 2017. 2. Physician orders [REDACTED].#2 was [AGE] years old and admitted on [DATE]. His [DIAGNOSES REDACTED]. A MDS dated [DATE] indicated Resident #2 understood others and made his needs known. His BIMS score was 11. He required limited assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. During an interview on 04/20/17 at 8:47 a.m., the administrator said on 04/18/17, Resident #2 came to her after he opened his mail and noticed his check that he wrote to the facility bounced. She said Resident #2 said he gave CNA B his debit card to do some personal shopping for him and the resident believed that CNA B took out unauthorized money from the ATM. The administrator said he also loaned CNA B $840 that he did not get back. She said a few months ago the business office manager accidently opened Resident #2's bank statements and showed it to her. She said she noticed the multiple ATM withdraws and knew Resident #2 did not leave the facility to make the cash withdraws. She said she confronted Resident #2 about the ATM withdraws but the resident denied that staff was taking any money from him. She said staff was in-serviced about not shopping for residents and she personally went to CNA B and asked her if she was shopping for Resident #2 and she said she was. The administrator said she told CNA B to stop shopping for Resident #2 and the activity director was the only staff member that could shop for residents. She said Resident #2 did not have enough money in his bank account to pay for stay at the facility. During an interview on 04/20/17 at 11:38 a.m., Resident #2 said he only gave his debit card to the activity director, CNA B, and CNA B's husband. He said the activity director gave him receipts when she bought anything for him. He said two months ago CNA B told him she was 2 months behind on her rent and asked to borrow $800. He said he liked CNA B and she went to the store for him so he let her borrow the money. He said he gave CNA B his debit card with his pin number and she took out the money. He said CNA B came to him last week and asked him for another $40 and he gave her his debit card for her to take out the money from the ATM. He said CNA B did not give him receipts after any of the purchases. He said he gave his debit card to CNA B's husband once when he came to the facility. He said he did not get a receipt from CNA B's husband. Resident #2 said when he gave his debit card to CNA B and CNA B's husband; he did not receive any cash from them. Resident #2 said he was out on pass during the Easter weekend but had not left the facility since the later part of 2016. Resident #2 said he did not meet CNA B until she started working at the facility. He said CNA B introduced him to her husband. During an interview on 04/21/17 at 7:52 a.m., CNA B said she began working at the facility in December 2015. She said she did not borrow money from Resident #2. She said she did take Resident #2's debit card and buy him food but she did not take money out of the ATM when she had Resident #2's debit card. CNA B said Resident #2 gave her the pin number to his debit card. She said she knew she was not supposed to take Resident #2's debit card. CNA B said she did not know Resident #2 before she worked at the facility. During an interview on 04/20/17 at 10:27 a.m., the activity director said Resident #2 told her that he let CNA B borrow $800 and she did not pay him back. She said she thought CNA B probably borrowed more than $800 because CNA B would ask staff if she could borrow money. The activity director said she reported the allegation to the administrator. She said she heard the administrator tell CNA B not to buy Resident #2 items and not to take his debit card. She said she was the only authorized staff that could buy personal items for residents. She said she took money out of the ATM for Resident #2 four times and two of the times was during Easter weekend. She said she got Resident #2 to sign his receipts for the purchases when she returned to the facility. During an interview on 04/20/17 at 1:41 p.m., the DON said she saw Resident #2's bank account balance about a year ago and it was $40,000. She said CNA B was seen taking Resident #2 food and personal items to his room. The DON said Resident #2's truck was parked at the facility but Resident #2 was unable to drive. She said CNA B's husband came to the facility and drove Resident #2's truck multiple times. She said CNA B borrowed money from her and did not pay it back. She said CNA B owed her more than $1000. During an interview on 04/20/17 at 11:53 a.m., MA C said she was concerned that CNA B was taking advantage of Resident #2 because she saw CNA B going to the store for Resident #2. She said the administrator told all the staff not to make purchases for the residents. During an interview on 05/01/17 at 10:48 a.m., Resident #3 said her room was across the hall from Resident #2's room. She said she often saw CNA B bringing Resident #2 food and personal items to his room. During an interview on 04/20/17 at 2:06 p.m., LVN D said CNA B asked to borrow money from her several times. During an interview on 05/01/17 at 10:41 a.m., LVN E said CNA B asked to borrow money from her several times. During an interview on 04/21/17 at 9:09 a.m., a local police chief said CNA B's husband came to the police station to give a statement regarding Resident #2. He said the husband said he met Resident #2 at the facility in December 2016 and began running errands for the resident. The police chief said CNA B's husband said Resident #2 needed money to make a deposit on a house and he used Resident #2's debit card and withdrew $1750 and also bought him snacks, drinks, and clothes. The husband told the police chief that the last time he used Resident #2's debit card was 04/16/17 when he withdrew $200 and bought some personal items. A bank statement for the period of 12/28/16 to 01/29/17 indicted Resident #2 withdrew a total of $2600 from the local ATM, with the first unauthorized withdraw on 12/30/16. A bank statement for the period of 01/30/17 to 02/27/17 indicated Resident #2 withdrew $100 from the local ATM. A bank statement for the period of 02/28/17 to 03/27/17 indicated Resident #2 withdrew $1300 from the local ATM. A bank statement from the period of 03/28/17 to 04/19/17 indicated Resident #2 withdrew $1800 from the local ATM. During an interview on 04/20/17 at 8:47 a.m., the administrator said Resident #2 left the facility during the Easter weekend but did not leave the facility when the other ATM withdraws occurred. The CMS 672 dated 04/20/17 indicated the census was 39.

Based on observation, interview, and record review, the facility failed to implement interventions to prevent worsening of pressure injuries (ulcers) for 1 of 1 residents reviewed for pressure injuries. (Resident #1) The facility did not provide treatment or perform assessments as ordered. Resident #1 was admitted with 2 stage 4 pressure injuries, these increased in size over a month when he was not receiving the ordered treatment. This failure could place 19 residents who are in the bed or chair all or most of the time at risk for developing new pressure injuries. Findings included: Physician orders [REDACTED].#1 was [AGE] years old and admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. A Braden Scale form for predicting pressure injuries dated 10/18/16 for Resident #1 indicated he was at high risk for pressure injuries. A Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 understood others and made his needs known. He was totally dependent on staff for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. He had a urinary catheter and [MEDICAL CONDITION] bag. The MDS indicated Resident #1 had 2 stage 4 pressure injuries. A care plan dated 02/22/16 (sic) indicated Resident #1 required total assistance with activities of daily living (ADLs) and had pressure injuries to his left and right buttock. Interventions included to notify the physician if treatment was not effective after 2 weeks, provide wound treatment as ordered, and to document location, size, and appearance of pressure injuries weekly. The care plan did not address Resident #1 refusing pressure injury treatments. During an interview on 11/28/16 at 6:03 p.m., the DON said she was not aware of the incorrect date of Resident #1 ' s care plan. She said she did not why the care plan was not updated. She said Resident #1 did not admit to the facility until 03/29/16. During an interview on 11/28/16 at 4:45 p.m., Resident #1 said he did not get his pressure injury treatment daily as it was ordered. He said the nurses told him that they did not have time to treat his pressure injuries. He said he had gone 4 days without a treatment before. Physician orders [REDACTED].#1 ' s left and right buttock pressure injuries were to be cleaned every 8 hours with normal saline and pack with 4 inch by 4 inch gauze with Dakin ' s solution (an antiseptic solution to treat wounds) and cover with an ABD pad (to cover large wounds) until resolved. During an interview on 11/28/16 at 7:34 p.m., RN A said Resident #1 ' s pressure injuries were to be packed with a dry dressing once a day. The Treatment Administration Record (TAR) for October 2016 indicated Resident #1 received treatment to his 2 pressure injuries once a day on 10/18/16, 10/19/16, 10/21/16, 10/24/16, 10/25/16, 10/26/16, 10/27/16, and 10/29/16. He did not receive treatment on 10/20/16, 10/28/16, and 10/30/16. Physician orders [REDACTED]. Resident #1 was to receive weekly skin assessments. During an interview on 11/28/16 at 6:03 p.m., the DON said they did not have Resident #1 ' s TAR for November 2016. The most recent skin assessment dated [DATE] indicated Resident #1 ' s left buttock pressure injury measured 7 cm by 5 cm with 1.5 cm of undermining. Resident #1 ' s right buttock pressure injury measured 16 cm by 10 cm with 3.5 cm of undermining. During an observation on 11/28/16 7:08 p.m., RN A provided treatment to Resident #1 ' s pressure injuries. Resident #1 ' s left buttock pressure injury measured 5.5 cm by 5 cm and was 0.5 cm deep. The pressure injury had 2 cm of undermining. Resident #1 ' s right buttock pressure injury measured 12 cm by 16 cm and was 1 cm deep. The pressure injury had 6 cm of undermining. The pressure injuries were red in color with a small amount of eschar in the center of the wound bed. RN A cleaned Resident # ' 1 pressure injuries with Dakin ' s solution, packed the pressure injuries with dry gauze, and covered them with a dressing. During a telephone interview on 11/28/16 at 6:22 p.m., LVN B said worked all shifts at the facility. She said she sometimes did not provide pressure injury treatment to Resident #1 because he refused the treatment. She said she did not document in the nursing notes that Resident #1 refused treatment. She said she did not have time to do weekly skin assessments for residents that were assigned to her. A weekly skin assessment schedule indicated Resident #1 was to receive his skin assessment on Tuesdays on the 2:00 p.m. to 10:00 shift. During a telephone interview on 11/30/16 at 4:37 p.m., CNA D said Resident #1 stayed in his electric wheelchair most of the time. She said Resident #1 did not refuse wound care. She said Resident #1 was easy going and was not resistant to care. Nursing notes dated 11/01/16 to 11/28/16 did not address Resident #1 ' s pressure injuries or refusal of treatments. The CMS form 672 dated 11/28/16 indicated 1 resident had pressure injuries.

Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit neglect for 1 of 6 residents reviewed for neglect (Resident #1). CNA A, LVN B, and a hospice aide did not perform an appropriate transfer on Resident #1. The resident was transferred by staff lifting under her arms resulting in a fracture. This failure could place 28 residents who required assistance with transfers at risk of injury. Findings included: Physician orders [REDACTED].#1 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 could sometimes understand others, sometimes make herself understood, and was totally dependent on two staff for transfers. Her cognition was severely impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 0. A care plan dated 2/10/16 indicated Resident #1 required total assistance with all activities of daily living including transfers. The care plan required staff to assist with transfer as needed. An incident report dated 3/1/16 indicated a CNA came to the nurses station and asked LVN C to look at Resident #1 ' s arm. Resident #1 ' s left upper inner arm was bruised. Resident #1 stated it happened last night while they were putting me in bed. Resident #1 was interviewed again a short time later and said her son and his wife were putting Resident #1 in bed last night and hurt her arm. Another CNA stated to LVN C Resident #1 did not have any visitors the night before. Resident had two bruises to her left upper inner arm, one measuring 3.8 cm by 1 cm and was reddish, purple in color, and another 3 cm by 1.5 cm blue in color. An attempt was made to contact LVN C during the investigation on 3/22/16 at 12:44 p.m. She did not answer and did not return the phone call. During an interview on 3/22/16 at 3:14 p.m., the DON said she interviewed Resident #1 after the bruises were found on Resident #1 and did not suspect abuse or neglect. She said Resident #1 said the bruises were caused from her son and his wife, and she denied abuse from the facility. The DON said it was possible Resident #1 sustained the bruising during a transfer. An incident report dated 3/3/16 indicated Resident #1 ' s bruising was larger and darker, and spread to her inner arm. The incident report indicated the physician was contacted, an x ray was ordered. An x-ray report dated 3/4/16 indicated Resident #1 had a nondisplaced [MEDICAL CONDITION] neck of the left humerus. During an observation and interview on 3/22/16 at 9:57 a.m., Resident #1 was sitting on a lift pad in a geri chair in the front lobby. She was leaned to her right side, and her left arm was under her shirt in a sling. Resident #1 said she did not know what happened to her arm, and she did not recall ever being handled roughly by the staff or injured during transfers. During an interview on 3/22/16 at 9:21 a.m., the DON said she suspected Resident #1's fracture was caused from the hospice aid who came to the facility on [DATE] and admitted to transferring Resident #1 without assistance. During a telephone interview on 3/22/16 at 4:04 p.m., the hospice aide said when she arrived to the facility, Resident #1 was in the front lobby. The hospice aid said she told CNA A she needed to give Resident #1 a shower, and CNA A told her to ask for help if she needed it. The hospice aide said she took Resident #1 into her room, transferred her alone to the shower chair, took her to the shower and bathed her, took her back to her room and put on the call light for assistance. She noted Resident #1 had bruising to her left upper arms prior to her transferring Resident #1. She said Resident #1 was not dropped and did not struggle during the transfer. She said she did not use a gait belt, and lifted Resident #1 from her pants and underneath her left arm. The hospice aid said after she turned on her call light, CNA A and LVN B came to transfer Resident #1 back to her geri chair. She said they did not use a gait belt, and lifted Resident #1 by the back of her pants and underneath her arms. During a telephone interview on 3/22/16 at 2:17 p.m., CNA A said on 3/1/16, she and LVN B assisted Resident #1 back to the geri chair after Resident #1 ' s shower was completed by the hospice aid. She said they did not lift Resident #1 from under her arms because she knew better than that, and said they lifted Resident #1 from the back of her pants. She said she did not know why they did not use a gait belt. She said Resident #1 did not complain of any pain during the transfer. During an interview on 3/22/16 at 2:05 p.m., LVN B said on 3/1/16 after Resident #1 ' s shower, she assisted CNA A transfer Resident #1 from the shower chair to the geri chair. She said Resident #1 did not bear weight well, and she informed CNA A Resident #1 needed to be a Hoyer transfer from that point forward. She said Resident #1 was not able to pivot herself during the transfer. LVN B said she and CNA A lifted Resident #1 under her arms. She said she did not know why they did not use a gait belt. An undated Two Person Total Lift policy indicated staff were to safely get resident from one surface to another when the resident is unable/unwilling to bear weight on his or her lower extremities. The policy indicated two staff members were required for residents requiring total assistance and the procedure included one staff member will place gait belt on resident and standing behind the resident grabs the gait belt on the sides to support the trunk of the body .second staff member squats and supports the resident's legs at the thighs and calves .on the count of three, both staff members, simultaneously lift the resident. A Safe Resident Handling policy revised August 2007 indicated mechanical lifting equipment or other approved resident handling aids would be used to prevent manual lifting and handling of residents except when absolutely necessary such as in a life-threatening, emergency or otherwise exceptional circumstance. An undated Abuse Prevention Policy required the facility to assure that all residents are free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, neglect and misappropriation of property. The CMS 672 dated 3/22/16 indicated 5 residents were dependent on staff for transfers and 23 residents required assistance with transfers.

Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit neglect for 1 of 6 residents reviewed for neglect (Resident #1). CNA A, LVN B, and a hospice aide did not perform an appropriate transfer on Resident #1. The resident was transferred by staff lifting under her arms resulting in a fracture. This failure could place 28 residents who required assistance with transfers at risk of injury. Findings included: An undated Abuse Prevention Policy required the facility to assure that all residents are free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, neglect and misappropriation of property. A Safe Resident Handling policy revised August 2007 indicated mechanical lifting equipment or other approved resident handling aids would be used to prevent manual lifting and handling of residents except when absolutely necessary such as in a life-threatening, emergency or otherwise exceptional circumstance. Physician orders [REDACTED].#1 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 could sometimes understand others, sometimes make herself understood, and was totally dependent on two staff for transfers. Her cognition was severely impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 0. A care plan dated 2/10/16 indicated Resident #1 required total assistance with all activities of daily living including transfers. The care plan required staff to assist with transfer as needed. An incident report dated 3/1/16 indicated a CNA came to the nurses station and asked LVN C to look at Resident #1 ' s arm. Resident #1 ' s left upper inner arm was bruised. Resident #1 stated it happened last night while they were putting me in bed. Resident #1 was interviewed again a short time later and said her son and his wife were putting Resident #1 in bed last night and hurt her arm. Another CNA stated to LVN C Resident #1 did not have any visitors the night before. Resident had two bruises to her left upper inner arm, one measuring 3.8 cm by 1 cm and was reddish, purple in color, and another 3 cm by 1.5 cm blue in color. An attempt was made to contact LVN C during the investigation on 3/22/16 at 12:44 p.m. She did not answer and did not return the phone call. During an interview on 3/22/16 at 3:14 p.m., the DON said she interviewed Resident #1 after the bruises were found on Resident #1 and did not suspect abuse or neglect. She said Resident #1 said the bruises were caused from her son and his wife, and she denied abuse from the facility. The DON said it was possible Resident #1 sustained the bruising during a transfer. An incident report dated 3/3/16 indicated Resident #1 ' s bruising was larger and darker, and spread to her inner arm. The incident report indicated the physician was contacted, an x ray was ordered. An x-ray report dated 3/4/16 indicated Resident #1 had a nondisplaced [MEDICAL CONDITION] neck of the left humerus. During an observation and interview on 3/22/16 at 9:57 a.m., Resident #1 was sitting on a lift pad in a geri chair in the front lobby. She was leaned to her right side, and her left arm was under her shirt in a sling. Resident #1 said she did not know what happened to her arm, and she did not recall ever being handled roughly by the staff or injured during transfers. During an interview on 3/22/16 at 9:21 a.m., the DON said she suspected Resident #1 ' s fracture was caused from the hospice aid who came to the facility on [DATE] and admitted to transferring Resident #1 without assistance. During a telephone interview on 3/22/16 at 4:04 p.m., the hospice aid said when she arrived to the facility, Resident #1 was in the front lobby. The hospice aid said she told CNA A she needed to give Resident #1 a shower, and CNA A told her to ask for help if she needed it. The hospice aid said she took Resident #1 into her room, transferred her alone to the shower chair, took her to the shower and bathed her, took her back to her room and put on the call light for assistance. She noted Resident #1 had bruising to her left upper arms prior to her transferring Resident #1. She said Resident #1 was not dropped and did not struggle during the transfer. She said she did not use a gait belt, and lifted Resident #1 from her pants and underneath her left arm. The hospice aid said after she turned on her call light, CNA A and LVN B came to transfer Resident #1 back to her geri chair. She said they did not use a gait belt, and lifted Resident #1 by the back of her pants and underneath her arms. During a telephone interview on 3/22/16 at 2:17 p.m., CNA A said on 3/1/16, she and LVN B assisted Resident #1 back to the geri chair after Resident #1 ' s shower was completed by the hospice aid. She said they did not lift Resident #1 from under her arms because she knew better than that, and said they lifted Resident #1 from the back of her pants. She said she did not know why they did not use a gait belt. She said Resident #1 did not complain of any pain during the transfer. During an interview on 3/22/16 at 2:05 p.m., LVN B said on 3/1/16 after Resident #1 ' s shower, she assisted CNA A transfer Resident #1 from the shower chair to the geri chair. She said Resident #1 did not bear weight well, and she informed CNA A Resident #1 needed to be a Hoyer transfer from that point forward. She said Resident #1 was not able to pivot herself during the transfer. LVN B said she and CNA A lifted Resident #1 under her arms. She said she did not know why they did not use a gait belt. An undated Two Person Total Lift policy indicated staff were to safely get resident from one surface to another when the resident is unable/unwilling to bear weight on his or her lower extremities. The policy indicated two staff members were required for residents requiring total assistance and the procedure included one staff member will place gait belt on resident and standing behind the resident grabs the gait belt on the sides to support the trunk of the body .second staff member squats and supports the resident's legs at the thighs and calves .on the count of three, both staff members, simultaneously lift the resident. The CMS 672 dated 3/22/16 indicated 5 residents were dependent on staff for transfers and 23 residents required assistance with transfers.

Based on observation, interview, and record review, the facility failed to ensure the necessary care and services were provided in accordance with the comprehensive assessment for 1 of 5 residents reviewed for assessments. (Resident #20) CNAs M and H pulled Resident #20 up in bed by her brief and under her arms; the CNAs heard a pop and notified LVN D. Resident #20 was not properly assessed. The resident complained of pain for 2 days before she was assessed. The incident resulted in Resident #20 receiving a fractured shoulder. This failure could place 24 residents who required assistance with transfers at risk for not being properly assessed to prevent further decline and injury. Findings included: Physician orders [REDACTED].#20 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #20 required two person assistance with bed mobility and transfers. Resident #20 was able to understand others. A care plan dated 01/04/16 indicated Resident #20 was a total assist with activities of daily living, bed mobility, and transfers. An Incident Report dated 02/19/16 indicated Resident #20 was repositioned in bed with her brief and under the arms by CNAs M and H on 2/17/16. The incident indicated CNA M and CNA H heard a pop while pulling Resident #20 up in bed. The report indicated Resident #20 complained of pain for 2 days and had swelling to the left chest/shoulder area. The report indicated an x-ray was performed on 02/19/16 and a mild left acute humeral fracture was identified. An x-ray report dated 02/19/16 documented Resident #20 had a mild displaced acute-appearing left humeral neck fracture and proximal forearm soft tissue swelling. Nursing notes dated 2/17/16 and 2/18/16 did not indicate Resident #20's left arm/shoulder was assessed. A nursing note dated 02/18/16 indicated Resident #20's daughter was notified the resident was complaining of pain. A nursing note dated 02/19/16 indicated Resident #20 had an x-ray to the left shoulder. During an observation and interview on 02/20/16 at 11:20 a.m., Resident #20 was lying in bed with discoloration and swelling to her left arm. Resident #20 said CNA M pulled her up under her left arm to reposition her in the bed on Wednesday (2/17/16). The resident indicated the CNA hurt her left arm. Resident #20 said, it hurt it hurt. Resident #20 said she was given 2 Tylenol tablets. Resident #20 said the CNAs usually pulled her up using a draw pad. Resident #20 said an x-ray was not completed until Friday (2/19/16). During an interview on 02/19/16 at 11:45 p.m., the administrator said she was not informed about Resident #20's incident until the afternoon of 02/19/16 and the incident occurred on 02/17/16. She said they started the in-house investigation on 02/19/ 2016. During an interview on 02/20/16 at 12:15 p.m. CNA H said she and CNA M pulled Resident #20 up in bed by the incontinent brief and under the resident's arms. CNA H said she heard a pop and Resident #20 started to cry and said, it hurts. She said CNA M informed LVN D what happened. During an interview on 02/20/16 at 12:45 p.m., the ADON said LVN D informed her Resident #20 was complaining of pain in the left upper arm after being pulled up in the bed under her arms and by her brief on 2/17/16. She said Resident #20 was offered Tylenol for pain and the doctor was notified of the change in condition on 02/19/16. The ADON indicated she did not assess the resident's arm/shoulder on 2/17/16. During an interview on 02/20/16 at 1:35 p.m., CNA M said she and CNA H pulled Resident #20 up by her incontinent brief and under the resident's arms. She said there was a pop and Resident #20 said ouch. She said LVN D was informed of the incident. CNA M said she should have not pulled Resident #20 up under her arms. During an interview on 02/20/16 at 2:00 p.m., LVN D said she was informed by the CNAs that Resident #20 complained of left arm pain on 2/17/16. She said the arm was not assessed, she just eyeballed it. She said the physician was not called on 02/17/16. During an interview on 02/20/16 at 3:20 p.m., CNA C said she attempted to roll Resident #20 to her side on 2/19/16 and the resident screamed out and she immediately informed the nurse. She said they were to use a draw sheet when repositioning a resident and never pull them up by the arms. During an interview on 02/20/16 at 3:10 p.m., the DON said the ADON notified her of the incident on 2/17/16. The DON said she notified the administrator on 2/19/16 and an investigation was started on 02/19/16. She said the resident's arm/shoulder was assessed on 2/19/16. An undated Positioning and Moving Residents in Bed Policy indicated .roll draw sheet up until hands are touching resident ' s body. Grasp sheet and pull resident toward head of bed . An undated Incident/Accident Report Procedure Policy indicated .a licensed nurse shall assess, interview, and document anytime an incident or accident occurs. The nurse should get the witness (es) name, including the resident and their account of the incident . An undated Change of Condition Policy indicated . when a resident condition changes the charge nurse will complete the appropriate forms and assess, intervene, notify the family and physician . The CMS 672 dated 02/20/16 indicated 24 residents required assistance with transfers.

Based on interview and record review, the facility failed to consult the physician and notify the family immediately for changes in condition for 1 of 5 residents reviewed for changes in condition. (Resident #20) Resident #20 complained of pain to her left arm on 2/17/16 after being pulled up in bed by her shoulder/arm and brief. The physician was not notified until 02/19/16. An x-ray was ordered and the resident was noted to have a fracture to her left arm. The family was not notified until 2/18/16. This failure could place 24 residents who required assistance with transfers at risk for not receiving care and treatment to meet their needs. Findings included: Physician orders [REDACTED].#20 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #20 required two person assistance with bed mobility and transfers. Resident #20 was able to understand others. A care plan dated 01/04/16 indicated Resident #20 was a total assist with activities of daily living, bed mobility, and transfers. An Incident Report dated 02/19/16 indicated Resident #20 was repositioned in bed with her brief and under the arms by CNAs M and H. The incident indicated CNA M and CNA H heard a pop while pulling Resident #20 up in bed. The report indicated Resident #20 complained of pain for 2 days and had swelling to the left chest/shoulder area. The report indicated an x-ray was performed on 02/19/16 and a mild left acute humeral fracture was identified. An x-ray report dated 02/19/16 documented Resident #20 had a mild displaced acute-appearing left humeral neck fracture and proximal forearm soft tissue swelling. During an observation and interview on 02/20/16 at 11:20 a.m., Resident #20 was lying in bed with discoloration and swelling to her left arm. Resident #20 said CNA M pulled her up under her left arm to reposition her in the bed on Wednesday (2/17/16). The resident indicated the CNA hurt her left arm. Resident #20 said, it hurt it hurt. Resident #20 said she was given 2 Tylenol tablets. Resident #20 said the CNAs usually pulled her up using a draw pad. Resident #20 said an x-ray was not completed until Friday (2/19/16). A nursing note dated 02/18/16 indicated Resident #20's daughter was notified the resident was complaining of pain. An x-ray report dated 02/19/16 noted Resident #20 had a mild displaced acute-appearing left humeral neck fracture and proximal forearm soft tissue swelling. During an interview on 02/19/16 at 11:45 p.m., the administrator said she was not informed about Resident #20's incident until the afternoon of 02/19/16 and the incident occurred on 02/17/16. She said they started the in-house investigation on 02/19/ 2016 and reported it to the regulatory agency on 02/19/16. She said the CNAs are to use draw sheets when repositioning residents. She said the Providers Investigation report was not complete. During an interview on 02/20/16 at 12:15 p.m. CNA H said she and CNA M pulled Resident #20 up without a draw pad. CNA H said Resident #20 was pulled up in bed by the incontinent brief and under the resident's arms. CNA H said she heard a pop and Resident #20 started to cry and said, it hurts. She said CNA M informed LVN D what happened. During an interview on 02/20/16 at 12:45 p.m., the ADON said LVN D informed her Resident #20 was complaining of pain in the left upper arm after being pulled up in the bed under her arms and by her brief on 2/17/16. She said Resident #20 was offered Tylenol for pain and the doctor was notified of the change in condition on 02/19/16. During an interview on 02/20/16 at 2:00 p.m., LVN D said CNA M informed her Resident #1 complained of pain to the left arm after they pulled her up in the bed by her arm and brief. LVN D said she informed the ADON of the incident on 2/17/16. The LVN indicated she did not notify the physician of the incident. During an interview on 02/20/16 at 3:10 p.m., the DON said Resident #20's family was notified of the incident on 02/18/16. The DON said the physician was notified of the incident on 2/19/16. She said the physician ordered an x-ray on 02/19/16. An undated Change of Condition Policy indicated . when a resident condition changes the charge nurse will complete the appropriate forms and assess, intervene, notify the family and physician . The CMS 672 dated 02/20/16 indicated 24 residents required assistance with transfers.

Based on observation, interview and record review the facility failed to ensure adequate supervision was provided during care for 1 of 5 residents reviewed for accidents. (Resident #20) CNAs M and H pulled Resident #20 up in bed without a draw sheet and Resident #20 sustained a fracture of the arm/shoulder. This failure could place 24 residents who required assist with transfers and repositioning at risk of injury. Findings included: 1. Physician orders [REDACTED].#20 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #20 required two person assistance with bed mobility and transfers. Resident #20 was able to understand others. A care plan dated 01/04/16 indicated Resident #20 was a total assist with activities of daily living, bed mobility, and transfers. An Incident Report dated 02/19/16 indicated Resident #20 was repositioned in bed with her brief and under the arms by CNAs M and H. The incident indicated CNAs M and H heard a pop while pulling Resident #20 up in bed. The report indicated Resident #20 complained of pain for 2 days and had swelling to the left chest/shoulder area. The report indicated an x-ray was performed on 02/19/16 and a mild left acute humeral fracture was identified. An x-ray report dated 02/19/16 documented Resident #20 had a mild displaced acute-appearing left humeral neck fracture and proximal forearm soft tissue swelling. During an observation and interview on 02/20/16 at 11:20 a.m., Resident #20 was lying in bed with discoloration and swelling to her left arm. Resident #20 said CNA M pulled her up under her left arm to reposition her in the bed on Wednesday (2/17/16). The resident indicated the CNA hurt her left arm. Resident #20 said, it hurt it hurt. Resident #20 said she was given 2 Tylenol tablets. Resident #20 said the CNAs usually pulled her up using a draw pad. Resident #20 said an x-ray was not completed until Friday (2/19/16). During an interview on 02/19/16 at 11:45 p.m., the administrator said she was not informed about Resident #20's incident until the afternoon of 02/19/16 and the incident occurred on 02/17/16. She said the CNAs were to use draw sheets when repositioning residents. During an interview on 02/20/16 at 12:15 p.m. CNA H said she and CNA M pulled Resident #20 up without a draw pad. CNA H said that Resident #20 was pulled up in bed by the incontinent brief and under the resident's arms. CNA H said she heard a pop and Resident #20 started to cry and said, it hurts. She said CNA M informed LVN D what happened. During an interview on 02/20/16 at 12:45 p.m., the ADON said the CNAs are to use a draw pad when repositioning a resident. During an interview on 02/20/16 at 1:35 p.m., CNA M said she and CNA H pulled Resident #20 up by her incontinent brief and under the resident's arms. She said there was a pop and said Resident #20 said ouch. She said LVN D was informed of the transfer. CNA M said she should have not pulled Resident #20 up under her arms. During an interview on 02/20/16 at 3:20 p.m., CNA C said she attempted to roll Resident #20 to her side and the resident screamed out and she immediately got the nurse to inform her. She said they were to use a draw sheet when repositioning a resident and never pull them up by the arms. During an interview on 02/20/16 at 3:10 p.m., the DON said the CNAs should have used a draw sheet to reposition Resident #20. An undated Positioning and Moving Residents in Bed Policy indicated .roll draw sheet up until hands are touching resident ' s body. Grasp sheet and pull resident toward head of bed . An undated Incident/Accident Report Procedure Policy indicated .a licensed nurse shall assess, interview, and document anytime an incident or accident occurs. The nurse should get the witness (es) name, including the resident and their account of the incident . An undated Change of Condition Policy indicated . when a resident condition changes the charge nurse will complete the appropriate forms and assess, intervene, notify the family and physician . An in-service dated 02/19/16 noted positioning and moving residents in bed and the use of a draw sheet for all dependent residents. The CMS 672 dated *** indicated 24 residents required assistance with transfers.

Based on observation, interview, and record review, the facility failed to ensure 3 of 5 CNAs (CNAs G and H) demonstrated competency in techniques to care for 2 of 3 residents reviewed for incontinent care (Resident #2) and transfers (Resident #20) CNAs M and CNA H did not re-position Resident #20 properly and the resident sustained [REDACTED]. CNAs G and H failed to thoroughly clean Resident #2 during incontinent care. This failure could place 30 residents who required assistance with incontinent care and 24 residents who required assistance with transfers and repositioning at risk for injury, discomfort, skin breakdown, and urinary tract infections. Findings included: 1. Physician orders [REDACTED].#20 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #20 required two person assistance with bed mobility and transfers. Resident #20 was able to understand others. A care plan dated 01/04/16 indicated Resident #20 was a total assist with activities of daily living, bed mobility, and transfers. An Incident Report dated 02/19/16 indicated Resident #20 was repositioned in bed with her brief and under the arms by CNAs M and H. The incident indicated CNAs M and H heard a pop while pulling Resident #20 up in bed. The report indicated Resident #20 complained of pain for 2 days and had swelling to the left chest/shoulder area. The report indicated an x-ray was performed on 02/19/16 and a mild left acute humeral fracture was identified. An x-ray report dated 02/19/16 documented Resident #20 had a mild displaced acute-appearing left humeral neck fracture and proximal forearm soft tissue swelling. During an observation and interview on 02/20/16 at 11:20 a.m., Resident #20 was lying in bed with discoloration and swelling to her left arm. Resident #20 said CNA M pulled her up under her left arm to reposition her in the bed on Wednesday (2/17/16). The resident indicated the CNA hurt her left arm. Resident #20 said, it hurt it hurt. Resident #20 said she was given 2 Tylenol tablets. Resident #20 said the CNAs usually pulled her up using a draw pad. Resident #20 said an x-ray was not completed until Friday (2/19/16). During an interview on 02/19/16 at 11:45 p.m., the administrator said she was not informed about Resident #20's incident until the afternoon of 02/19/16 and the incident occurred on 02/17/16. She said the CNAs were to use draw sheets when repositioning residents. During an interview on 02/20/16 at 12:15 p.m. CNA H said she and CNA M pulled Resident #20 up without a draw pad. CNA H said that Resident #20 was pulled up in bed by the incontinent brief and under the resident's arms. CNA H said she heard a pop and Resident #20 started to cry and said, it hurts. She said CNA M informed LVN D what happened. During an interview on 02/20/16 at 12:45 p.m., the ADON said the CNAs are to use a draw pad when repositioning a resident. During an interview on 02/20/16 at 1:35 p.m., CNA M said she and CNA H pulled Resident #20 up by her incontinent brief and under the resident's arms. She said there was a pop and said Resident #20 said ouch. She said LVN D was informed of the transfer. CNA M said she should have not pulled Resident #20 up under her arms. During an interview on 02/20/16 at 3:20 p.m., CNA C said she attempted to roll Resident #20 to her side and the resident screamed out and she immediately got the nurse to inform her. She said they were to use a draw sheet when repositioning a resident and never pull them up by the arms. During an interview on 02/20/16 at 3:10 p.m., the DON said the CNAs should have used a draw sheet to reposition Resident #20 especially since she was bed bound. An undated Positioning and Moving Residents in Bed Policy indicated .roll draw sheet up until hands are touching resident ' s body. Grasp sheet and pull resident toward head of bed . An undated Incident/Accident Report Procedure Policy indicated .a licensed nurse shall assess, interview, and document anytime an incident or accident occurs. The nurse should get the witness (es) name, including the resident and their account of the incident . An in-service dated 02/19/16 noted positioning and moving residents in bed and the use of a draw sheet for all dependent residents. 2. During an observation and interview on 2/17/16 at 9:05 a.m., CNAs G and H provided incontinent care to Resident #2. CNA G said Resident #2's pants, brief, and socks were soaked with urine. CNAs G and H did not clean Resident #2's urine soaked legs and feet. During an interview on 2/17/16 at 9:16 a.m., CNA G said she forgot to clean Resident #2's legs and feet. During an interview on 2/17/16 at 9:18 a.m., CNA H said she was nervous and forgot to clean Resident #2's legs and feet. During an interview on 2/17/16 at 11:15 a.m., the DON said staff should clean any part of a resident's skin that was soiled with urine or feces. The undated incontinent care policy provided by the DON did not address cleansing other parts of a resident's body that was soiled with urine or feces. 3. During an observation on 2/16/16 at 9:35 a.m., CNA C provided incontinent care to Resident #18. Resident #18's bed sheets had a brown ring from urine down to feet and up to shoulders and had two pads underneath her. CNA C cleansed only the bilateral groin areas. She did not spread and clean Resident #18's labia area. CNA C did not clean Resident #18 ' s legs and back. During an interview on 2/16/16 at 9:52 a.m., CNA C said Resident #18 ' s the labia was not cleaned. She said she did not clean Resident #18 ' s back or legs. She said it was a normal practice for the labia to be cleaned. During an interview on 2/16/16 at 9:56 a.m., CNA C said Resident #18's care could have been better and she should have cleaned her labia. She said she should have wiped her back and legs. The CMS 672 dated 2/15/16 indicated 9 residents were occasionally or frequently incontinent of bladder and 30 required assistance with transfers.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 of 7 residents reviewed for pain. (Resident #1) Resident #1 developed a pressure sore to his left heel and experienced recurring excruciating pain during ADL care and dressing changes. Although he could receive pain medication prn (as necessary), his pain was not controlled. His pain medication was increased to routinely every 6 hours with prn medication. The resident continued to cry out in pain, yell with pain during care, and complained daily of pain for 17 days. Staff did not develop and implement new interventions, modify a pain management plan to try to relieve his pain, did not ensure he was pre-medicated prior to treatments, and did not notify the physician of his unrelieved pain until after surveyor intervention. An Immediate Jeopardy situation was identified on 01/20/15. The Immediate Jeopardy was removed on 01/21/15. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure contributed to Resident #1 experiencing excrutiating, unrelieved pain. This failure could place the 24 residents receiving routine pain management at risk for unrelieved pain, anxiety, and incapacitating distress. Findings included: Physician orders [REDACTED].#1 was [AGE] years old, admitted on [DATE] with the [DIAGNOSES REDACTED]. The physician orders [REDACTED]. The comprehensive care plan dated 10/31/14 indicated Resident #1 was at risk for skin breakdown and increased pain from contractures. The goal was for Resident #1 to be relieved of pain within one hour of the interventions provided. The interventions included staff to administer pain medications to Resident #1 as ordered, monitor after the pain medications were given for effectiveness, and reassess the resident's pain quarterly and as needed. The most recent MDS dated [DATE] indicated Resident #1 was able to make himself understood, usually understood others, and required cueing. Resident #1 required extensive assistance with ADLs of bed mobility, transfers, dressing and personal hygiene. He required total assistance with locomotion, toileting, and bathing. Resident #1 was occasionally incontinent of bowel and bladder. The MDS indicated Resident #1 was not on scheduled pain medications, did not receive any as needed pain medications, or receive any non-medication pain interventions. The assessment indicated Resident #1 had 2 unstageable deep tissue wounds. The most recent Pain Evaluation dated 9/19/14 indicated Resident #1 did not have a [DIAGNOSES REDACTED]. Skin condition reports for Resident #1 indicated the following: * 1/5/15 - A left heel pressure sore (developed 10/27/14) measuring 8.5 centimeters (cm) x 6 cm, black in color with odor and no drainage. The note indicated Resident #1 complained of pain from the pressure sore. *1/12/15 - A left heel pressure sore measuring 8.5 cm x 7.5 cm, black in color with an odor and had no drainage. The note indicated Resident #1 complained of pain from the pressure sore. During an observation and interview on 1/19/15 at 10:00 a.m., Resident #1 cried out loudly in pain while CNAs C and D provided incontinent care. CNA D said Resident #1 screamed out with any care provided. She said she had notified the nurses. During an observation on 1/19/15 at 10:10 a.m., Resident #1 cried out loudly as though he was in severe pain when LVN E elevated his left leg and foot. LVN E continued removing the dressing from his left leg without stopping to evaluate Resident #1's pain level and need for intervention. After surveyor intervention, LVN E asked Resident #1 about his pain and he replied "It hurts like a son of a [***] !" Resident #1 expressed how severe his pain was, but LVN E continued providing wound care and did not provide interventions for his pain. During an interview on 1/19/15 at 10:10 a.m., LVN E said she was not sure how much of Resident #1's screaming out "was not just habit now." She said he had routine [MEDICATION NAME] ordered. A nursing note by LVN E dated 1/15/15 at 10:30 a.m., indicated Resident #1 "...continues to complain of pain, the routine pain medication administered with little effectiveness, will continue to monitor ..." A nursing note by LVN E dated 1/16/15 at 9:30 a.m., indicated Resident #1 continued to complain of pain to his heel and leg. The routine pain medication was administered with little effect. During an observation and interview on 1/20/14 at 8:45 a.m., CNAs A and D transferred Resident #1 from the Geri-chair to the bed using the Hoyer-lift (mechanical lift). During the transfer Resident #1 cried out multiple times; however, the CNAs continued providing care without stopping to notify the nurse or to provide the resident with any pain relief . Resident #1 said the pain terrorized him all the way to his shin. CNA D said Resident #1 had pain with any movement. CNAs A and D did not notify the nurse of Resident #1's complaining of pain, but let her know he was in bed awaiting wound care. During an interview on 1/20/15 at 9:05 a.m., CNA D said she forgot to tell RN F of Resident #1's verbal expressions of pain. During an observation on 1/20/2015 at 10:55 a.m., RN F initiated wound care for Resident #1's left heel pressure sore. She informed Resident #1 to say "STOP" if the treatment was uncomfortable. During the treatment Resident #1 began to cry out loudly several times and then he said, "Stop". The treatment nurse continued treatment until the surveyor alerted her Resident #1 said "stop." RN F stopped briefly and informed Resident #1 she was almost finished and proceeded again with care. RN F said Resident #1 had pain medications ordered routinely, but she was not sure what time he received the routine medication or if he was administered any prn pain medication prior to this wound treatment. She said she was unsure if Resident #1 had a prn pain medication ordered. RN F said she thought about pre-medicating Resident #1 prior to wound care, but did not. The MAR indicated [REDACTED] *1/2/15 - once for general discomfort, effective *1/3/15 - twice for hollering out when moved, good relief *1/4/15 - once for yelling out in pain, the note indicated non-effective *1/5/15 - twice for yelling out with foot pain, the note indicated non-effective *1/6/15 - once for complaint of heel pain and; *1/7/15 - for heel pain, the note indicated helpful. The MAR indicated [REDACTED]. A physician telephone order dated 1/6/15 indicated Resident #1 received [MEDICATION NAME] 50 mg routinely every 6 hours. The MAR indicated [REDACTED]. A pain record dated January 2015 indicated Resident #1 complained of pain daily from 01/04/15 - 01/20/15. A nursing note by LVN L dated 1/15/15 at 11:40 p.m., indicated Resident #1 " ...continued to scream with ADLs provided, will continue to monitor ..." A nursing note by LVN L dated 1/19/15 at 11:30 p.m., indicated Resident #1 continued to scream when staff adjusted his left heel and she would continue to monitor. During an interview on 1/20/15 at 11:05 a.m., LVN L said she provided care to Resident #1. LVN L said Resident #1 screamed out in pain anytime staff turned him or provided care for him. LVN L said Resident #1 took [MEDICATION NAME] for pain, but it was not effective. LVN L said Resident #1's screaming out had gotten worse. LVN L said she had never attempted to contact Resident #1's physician about his pain, but said she probably should have. A physician's telephone order dated 1/20/15 (obtained after surveyor intervention) indicated Resident #1 received Tylenol #3 one tablet every 4-6 hours as needed for pain. A nurse note dated 1/20/15 at 5:30 p.m., LVN O indicated Resident #1's pain score was a 10 on a scale of 1 - 10 with 10 being the worst pain. The note indicated Resident #1 was administered Tylenol #3. At 6:30 p.m., LVN O indicated Resident #1 denied pain. During an interview on 1/20/15 at 10:45 a.m., the DON said he was unaware Resident #1 had severe pain with care. The DON said he expected the nurses to inform the physician if the pain medications were ineffective. During an interview on 1/20/15 at 12:08 p.m., the administrator said she was aware Resident #1 had pain on January 2. The administrator said she discussed Resident #1's needs with the DON. She said Resident #1's pain medication was adjusted on 1/7/15. The administrator said she was unaware Resident #1 was having severe pain. A Pain Assessment Policy and procedure dated March 2013 indicated a pain assessment's purpose was to assess pain presence, intensity, to medicate according to intensity, and to evaluate effectiveness of the pain medication. The policy indicated the pain level should be assessed every shift using the verbal pain scale or the PAINAD (pain scale used for residents with dementia) and give medications according to level of pain. The policy and procedure indicated the administrator would receive a daily pain assessment report. The administrator and DON were notified on 1/20/15 at 12:12 p.m.,that an Immediate Jeopardy (IJ) situation was identified due to the above failures. The facility's Plan of Removal was accepted on 1/20/15 at 3:33 p.m. and included: "*Facility will notify physician of Resident #1's pain level immediately. *Physician orders [REDACTED]. Resident #1's pain will be pre- medicated thirty minutes prior to wound care. Resident #1 will be assessed each shift by in-serviced charge nurses for effectiveness of changes. Physician will be notified promptly if new order is not effective. Nurse mangers will review assessments daily. Weekend RN supervisors will review assessments and monitor during rounds. Care Plan team will develop and implement a care plan for resident #1's pain management to include pain medication and non-pharmacological interventions. *Director of nurses and nurse managers will assess all residents by 01-21-2015 (8 a.m.) for pain by using the pain evaluation form that includes 0-10 scale and PAINAD scale and notify physician as appropriate. *All charge nurses will be re-in-serviced starting now, on assessing pain by using nursing policy and procedure on pain assessment, notification of physician, pain management and interventions by 01-21-2015 by 3pm. Nurses that may provide wound care will be in-serviced by nurse management on pre medication prior to wound care and assessment of pain. *PRN nurses will be in-serviced on above before starting a shift. *All staff will be in-serviced by nurse managers on whom to report resident pain and the signs and symptoms of pain by using a guideline form on pain by 01-21-2015 (2pm). *D.O.N will provide administrator with a daily pain assessment report and proof of notifications to physician by copy of fax, telephone order. If physician does not respond facility Medical Director will be called for orders. On weekends, on call physician will be contacted for orders. If there is no response facility will send to emergency room for treatment. *QA team will monitor through quarterly meetings." The surveyors confirmed the plan of removal was implemented sufficiently to remove the IJ by: *14 CNAs were interviewed and said they were aware of the signs and symptoms of pain and would report those findings to the charge nurse immediately. The CNAs said if the charge nurse did not act on their notification they would notify the ADON, DON or administrator. *5 LVNs and 2 RNs said they were aware of the two different pain scales to identify pain for interviewable and non-interviewable residents. The nurses said they would administer pain medications 30 minutes prior to wound care and anytime they suspected or a resident complained of pain. They said they would re-evaluate the pain 45 minutes to 1 hour later and if not relieved, they would notify the primary physician. The nurses said if the primary physician did not respond then the medical director would be contacted and if unable to contact a physician and the pain persisted the resident would be sent to the local emergency room . On 1/21/15 at 3:28 p.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. A list provided by the DON on 1/20/15 at 3:15 p.m. indicated there were 24 residents on routine pain medications which included Resident #1.

Based on observation, interview, and record review, the facility failed to provide care and services to ensure indwelling urinary (Foley) catheter tubing was secured for 1 of 1 residents sampled with Foley catheters. (Resident #4) Resident #4's Foley catheter tubing was not secured to prevent pulling and tension. He had a stage II pressure sore at the catheter insertion site. This failure could place 1 resident with a Foley catheter at risk for further discomfort, urethral trauma, and UTIs. Findings included: Physician orders [REDACTED].#4, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. Resident #4 had a Foley catheter and catheter care was to be provided each shift. The transport calendar indicated Resident #4 went for cystoscopy on 02/19/13 at 8:45 a.m., two days before the area to the penis was identified. The skin report for Resident #4 indicated the area to his penis was identified on 02/21/13 (2 days after cystoscopy). It was described as a 1 by 2 cm area on penis where catheter was and had a tan/gray colored wound bed. The most recent MDS assessment dated [DATE] indicated Resident #4 was totally dependent with ADLs and had a Foley catheter. A nursing care plan dated 02/27/13 did not address securing Resident #4's catheter tubing. During an observation and interview on 03/11/13 at 3:10 p.m., Resident #4 was lying on his right side. His penis and catheter tubing was tucked between his legs. Incontinent care was provided and the catheter tubing was pulled taut during care and repositioning. The opening to the penis was red and irritated with an approximate 0.4 cm blister. At the completion of care, his penis was tucked between his legs with the tubing pulled over his left thigh. CNAs F and G said they did not secure tubing to the resident. During an observation and interview on 03/12/13 at 9:35 a.m., Resident #4's catheter tubing was not secured and his penis and the tubing was tucked between his legs. The blister observed on 03/11/13 had ruptured leaving a raw, open area. His penis and the tubing were again tucked between resident's legs. The DON said the irritation to the opening of the penis was caused by the doctor when a cystoscopy (scope exam of urethra and bladder) was performed. The undated facility catheter care policy did not address securing catheter tubing to prevent trauma to the urethra. The Lippincott manual of Nursing Practice (7th edition) Pg. 695 Procedural Guidelines for " Management of a Patient with an Indwelling Catheter and Closed Drainage System" (Foley), page 694; General Considerations: "Action: Secure the indwelling catheter (a)...Male: Tape the catheter to the patient's thigh; (b) Allow some slack of the tubing to accommodate the patient's movements; (c) Keep the tubing over the patient's leg". "Rational: Properly securing the catheter prevents catheter movement and traction on the urethra. (c) This tubing position helps prevent kinking or forming of loops of stagnant urine". The CMS 672 dated 03/11/13 indicated 1 resident had an indwelling catheter.

Based on observation, interview, and record review, the facility failed to provide care and services to ensure indwelling urinary (Foley) catheter tubing was secured for 1 of 1 residents sampled with Foley catheters. (Resident #4) Resident #4's Foley catheter tubing was not secured to prevent pulling and tension. He had a stage II pressure sore at the catheter insertion site. This failure could place 1 resident with a Foley catheter at risk for further discomfort, urethral trauma, and UTIs. Findings included: Physician orders [REDACTED]. Resident #4 had a Foley catheter and catheter care was to be provided each shift. The transport calendar indicated Resident #4 went for cystoscopy (looking into the bladder with a lighted scope) on 02/19/13 at 8:45 a.m., two days before the area to the penis was identified. The skin report for Resident #4 indicated the area to his penis was identified on 02/21/13 (2 days after cystoscopy). It was described as a 1 by 2 cm area on penis where catheter was and had a tan/gray colored wound bed. The most recent MDS assessment dated [DATE] indicated Resident #4 was totally dependent with ADLs and had a Foley catheter. A nursing care plan dated 02/27/13 did not address securing Resident #4's catheter tubing. During an observation and interview on 03/11/13 at 3:10 p.m., Resident #4 was lying on his right side. His penis and catheter tubing was tucked between his legs. Incontinent care was provided and the catheter tubing was pulled taut during care and repositioning. The opening to the penis was red and irritated with an approximate 0.4 cm blister. At the completion of care, his penis was tucked between his legs with the tubing pulled over his left thigh. CNAs F and G said they did not secure tubing to the resident. During an observation and interview on 03/12/13 at 9:35 a.m., Resident #4's catheter tubing was not secured and his penis and the tubing was tucked between his legs. The blister observed on 03/11/13 had ruptured leaving a raw, open area. His penis and the tubing were again tucked between resident's legs. The DON said the irritation to the opening of the penis was caused by the doctor when a cystoscopy (scope exam of urethra and bladder) was performed. The undated facility catheter care policy did not address securing catheter tubing to prevent trauma to the urethra. The Lippincott manual of Nursing Practice (7th edition) Pg. 695 Procedural Guidelines for " Management of a Patient with an Indwelling Catheter and Closed Drainage System" (Foley), page 694; General Considerations: "Action: Secure the indwelling catheter (a)...Male: Tape the catheter to the patient's thigh; (b) Allow some slack of the tubing to accommodate the patient's movements; (c) Keep the tubing over the patient's leg". "Rational: Properly securing the catheter prevents catheter movement and traction on the urethra. (c) This tubing position helps prevent kinking or forming of loops of stagnant urine". The CMS 672 dated 03/11/13 indicated 1 resident had an indwelling catheter.

Based on observation, interview, and record review, the facility failed to provide care and services in accordance with the comprehensive assessment to ensure: a. indwelling urinary (Foley) catheter tubing was secured for 1 of 1 resident reviewed for Foley catheters. (Resident #1) b. pain was assessed, evaluated, and interventions were revised to ensure adequate pain relief for 2 of 2 residents reviewed for pain. (Resident #s1 and 3) 1. Resident #1 had erosion of his penis caused from pressure from his unsecured Foley catheter (a tube to drain urine from the bladder). The wound deteriorated from 1.0 cm x 0.5 cm on 04/16/13 to 1.0 cm x 2.0 cm with a 0.3 cm area of white slough (dead, necrotic tissue) on 04/20/13. The wound had torn through the urethral opening into the penile shaft. The facility did not: assess the penis during weekly skin assessments; postion and secure the urinary catheter tubing to prevent pressure on his penis; and evaluate the effectiveness of the treatment. 2. Resident #3 was not premedicated for pain relief prior to daily wound care. This failure could place 1 resident with a Foley catheter at risk for further discomfort, urethral trauma, and UTIs and could place 9 residents receiving pain management at risk for unrelieved pain. Findings included: Consolidated physician orders [REDACTED]. The orders indicated Resident #1 had a Foley catheter. A physician order [REDACTED].#1's penis every shift or as needed during peri care. Resident #1's MDS dated [DATE] indicated his cognition was severely impaired, he was totally dependent for all of his ADL care, had a Foley catheter and was incontinent of bowel. This MDS assessment indicated Resident #1 had a Stage II pressure sore and an unstageable pressure sore. There was no documentation of pressure sore on the resident's penis. Resident #1's care plan dated 2/27/13 indicated he had a 1.0 cm x 2.0 cm area on his penis. Interventions included to apply skin treatment until healed, monitor skin, weekly skin assessments, and notify physician of any sign or symptom of infection. A Foley catheter care plan dated 3/13/13 indicated to provide Foley catheter care per facility policy, secure the Foley catheter tubing to the resident's leg with a catheter strap, and the nurse manager to check for proper placement on daily rounds. A physician progress notes [REDACTED]. There was no mention of skin breakdown or erosion to his penis. The weekly pressure ulcer log dated 4/16/13 indicated Resident #1 had a Stage II pressure sore to his right outer foot, that measured 1.0 cm by 0.5 cm. There was no mention of skin breakdown to his penis. Resident #1's TAR dated April 2013 documented that his Foley catheter was assessed as secured to his leg to prevent pulling, and [MEDICATION NAME] was applied to the tip of his penis every shift and as needed. These two treatments were documented as provided every shift to current date except for 7 shifts that were not initialed by staff. During an observation on 4/29/13 at 1:30 p.m., Resident #1 was in bed. A deep pink groove the size and shape of the unsecured catheter tubing was noted on the back of his right leg. A leg strap was in a basin with supplies on a bedside table. CNA E said his catheter tubing had not been positioned or secured on top of his right thigh, and was placed downward, so he could wear his pants. There was a 1.0 cm x 2.0 cm erosion on the tip of the resident's penis at the urethra at the 3 o'clock position, and an approximate 1 cm erosion at the 1:00 o'clock position. The eroded areas were red and inflammed and an approximate 0.3 cm area of white slough was noted at the 1:00 o'clock erosion site. The wound had torn through the urethral opening into the penile shaft. RN B said the area was inflammed and new to him. He said it looked as though the catheter had pulled against the urethra. RN B said the treatment for [REDACTED].#1's urethra, so he was going to call the physician. During an observation on 4/29/13 at 3:15 p.m., Resident #1 was lying in bed, and his Foley catheter was not secured. During an interview on 4/29/13 at 10:40 a.m., the administratorshe said that RN B was newly assigned to perform skin assesments weekly on residents but was unsure if he had started assessing the residents. During an interview on 4/29/13 at 10:55 a.m., the ADON said their plan was to have RN B perform weekly skin assessments but that had not started. The ADON said different charge nurses on each shift were currently responsible for residents' skin assessments. She said they had not had a DON in the facility since 4/5/13. During an interview on 4/29/13 at 11:05 a.m., the ADON said Resident #1's skin assessment should be in the treatment book. A skin assessment sheet was located that addressed the foot but there was no assessment regarding the breakdown on his penis. Resident #1's nursing notes dated 4/29/13 at 11:00 a.m. indicated the urethral catheter site had two small excoriations. The left side of the urethral opening had .25 cm x .50 cm excoriation and the right side of the urethral opening had a .25 cm x .25 cm excoriation. Both sites had pink/red tissue beds that blanched. The treatment included to clean with normal saline, pat dry and apply [MEDICATION NAME] ointment two times a day till healed. There was no documentation that the primary physician or the urologist was notified of the erosion on Resident #1's penis. During an interview on 5/4/13 at 10:28 a.m., Resident #1's urology PA said according to their office notes, they had not seen Resident #1 since 2/29/13, and during that visit there had not been anerosion to the resident's penis. The PA said facility staff contacted their office this week on 4/30/13 regarding the erosion on Resident #1's penis, and this was the first time they had been notified of any issues. The facility's directed inservice dated 4/5/13 indicated that staff had been instructed on the negative outcomes associated with catheter use, prevention of serious outcomes with catheter use, proper securing of Foley catheter tubing and what needs to be documented and where to find the documentation. There was no evidence observed or written that indicated the facility had implemented this inservice training. 2. Consolidated physician orders [REDACTED]. Her orders indicated she did not receive any routine pain medication. She received Aspirin 81 mg daily for stroke. Resident #3's physician orders [REDACTED]. Resident 3's MDS dated [DATE] indicated her cognition was severely impaired, she was totally dependent for all of her ADL care, and was incontinent of bowel and bladder. She was assessed as having one Stage II pressure sore with pink granulation tissue. Her assessment indicated she was not on pain management and she had no pain. The weekly pressure ulcer log dated 4/26/13 indicated Resident #3 had a Stage II pressure sore to her right hip that measured 2.5 cm x 1.0 cm. The wound bed was white, with a small amount of yellow drainage. Resident #3's care plan dated 3/27/13 indicated she had a Stage II pressure sore to her right hip and an abrasion to her toe. The interventions included treatment as ordered by physician, notify MD of change or worsening of wound, resident is on pressure relieving mattress, change gloves in between taking off old dressing and replacing new dressing. Resident #3's April 2013 MAR indicated she had not received any PRN pain medication for the month of April. Her pain management flowsheet for April 2013 was blank. During an observation on 4/29/13 at 11:15 a.m., RN B and CNA E turned Resident # 3 on her left side, and a pressure sore on her right hip measured approximately 2.0 cm x 1.0 cm with yellow slough noted on the 1-2 o'clock region. RN B said the wound bed contained 30% yellow slough. When RN B began cleaning Resident #3's right hip with normal saline, Resident #3 grimaced and gasped as RN B cleaned the wound bed. During an interview on 04/29/13 at 2:40 p.m. RN B was asked if he provided pain medication before he provided treatments. He said he usually worked the 2:00 p.m. to 10:00 p.m. shift and generally did not provide wound care. He said if he did treatments more often, he would assess them for pain. During an interview on 4/30/13 at 8:23 a.m., LVN A said she was not premedicating residents prior to providing wound care. LVN A said two residents that needed pain medication were Residents #1 and #3. LVN A said these residents both expressed signs of pain during wound care. LVN A reviewed both Resident #1 and #3's April 2013 MAR and stated if they were receiving pain medication it would have been documented. The undated Pain Assessment policy indicated the purpose was to assess pain presence and to use the PAINAD scale for non-verbal or cognitively impaired residents. Some non-verbal signs of pain on the scale were short period of hyperventilation, facial grimacing and moaning or groaning. The CMS 672 dated 4/29/13 indicated 1 resident had a Foley catheter and 9 residents received pain management.

Based on observation, interview, and record review, the facility failed to assess, obtain timely treatments, and implement interventions to prevent the development and worsening of pressure sores for 2 of 4 residents reviewed for pressure sores. (Resident #s 4 and 9) 1. Resident #4 was admitted with 2 unstageable pressure sores, 1 to his left heel and 1 to his right outer foot. The resident developed 2 additional stage II pressures sores, 1 to his right heel and 1 to his penis. The facility did not: * obtain orders for treatments for 2 days after Resident #4 was admitted ; * off-load his heels to remove pressure; and * position urinary catheter tubing to prevent pressure on the tip of the penis. 2. Resident #9 developed 2 stage II pressure sores to his left buttock. The facility did not assess the pressure sores or obtain treatment orders for approximately one week. This failure likely contributed to the development and worsening of pressure sores for Resident #s 4 and 9. This failure could place the 20 residents at high risk of pressure sores at risk for developing pressure sores. Findings included: 1. Physician orders dated February 2013 indicated Resident #4, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The orders indicated Resident #4 had a Foley catheter. The orders required staff to off load Resident #4's heels with pillow under his calves at all times while he was in the bed. There were no orders for treatment of [REDACTED]. The Admission Nursing assessment dated [DATE] indicated Resident #4 had a 2 cm x 2 cm unstageable pressure sore on his left heel and a 1 cm x 1 cm unstageable pressure sore on his right outer foot. There was no indication of a pressure sore on Resident #4's right heel or penis. A physician telephone order dated 02/04/13 (2 days after admission) required staff to clean the area on Resident #4's right outer foot (eschar) and use hydrogel-santyl (for [MEDICATION NAME] necrotic tissue) and foam dressing daily. The orders required staff to "use skin prep to a blister on Resident #4's right heel and cover with foam daily". The orders did not address Resident #4's left heel or penis. Physician telephone order dated 02/05/13 (3 days after admission) required staff to use skin prep to the deep tissue injury on Resident #4's left heel. The transport calendar indicated Resident #4 went for cystoscopy (look in the bladder with a lighted scope) on 02/19/13 at 8:45 a.m. (two days before the area to the penis was identified). The skin report dated 02/21/13 indicated Resident #4 had a 1 cm x 2 cm area with a tan/gray colored wound bed on penis where the catheter tubing was. A physician telephone order dated 02/21/13 required staff to apply [MEDICATION NAME] (moisture barrier/skin protectant) to the tip of Resident #4's penis every shift and after incontinent care. The most recent MDS assessment dated [DATE] indicated Resident #4 was totally dependent with ADLs, had one stage I and one unstageable pressure sore, and had a Foley catheter. The Braden scale (tool used to assess risk of developing pressure sores) dated 02/26/13 indicated Resident #4 was at moderate risk for developing pressure sores. A nursing care plan dated 02/27/13 indicated Resident #4 was admitted from hospital with a 1 cm x 2 cm area on his penis, an unstageable 1.2 cm x 0.8 cm area on his right outer foot that had eschar and a 3 cm x 3 cm Stage II on his right heel. The care plan did not include pressure relief interventions. The care plan did not address preventing pressure from the catheter tubing to the penis opening. During observations on 03/11/13 at 3:10 p.m. with CNAs F and G and on 03/12/13 at 9:35 a.m. with the DON, Resident #4 was in bed and had dressing on his right heel. His heels were on the mattress. Resident #4's catheter tubing was tucked between his legs creating pressure against the bottom of the penis opening. During an observation and interview on 03/11/13 at 3:10 p.m., Resident #4 was lying on his right side. The resident's right outer foot was pressed against the mattress. The low air loss mattress was set at 7 (range of 1-8) and the mattress was hard. His penis and catheter tubing was tucked between his legs. CNAs F and G provided incontinent care for Resident #4. During incontinent care the catheter tubing was pulled taut against the penis opening. The opening to the penis was red and irritated with an approximate 0.4 cm blister on the left side of the penis opening. At the completion of care, his penis was tucked between his legs with the tubing pulled over his left thigh. The CNAs did not apply [MEDICATION NAME] following incontinent care. CNAs F and G did not float the heels after care. During an observation and interview on 03/12/13 at 9:35 a.m., Resident #4's catheter tubing and penis were tucked between his legs. The blister observed on 03/11/13 had ruptured leaving a raw open area. During an observation and interview on 03/12/13 at 9:35 a.m., Resident #4 had the following skin issues: *The left heel was intact. The DON said it was 'mushy', but had been black. *The right heel had an approximately 4 cm x 4 cm closed dry pale area. The bottom 1 cm edge of the area was dark purple. The DON said it was a blister and it was "re-absorbing". *The right outer side of his foot had an approximate 2 cm hard thick brown crusty area. *The left side of the penis opening was an approximately 0.4 cm x 0.2 cm open area where the blister was on 03/11/13. After completion of skin observations, the DON placed a pillow under Resident #4's knees. Resident #4's heels continued to remain on the bed. Resident #4's penis and catheter tubing was placed between his legs. The most recent skin assessment for Resident #4 indicated the following: * 03/04/13 - left heel 1.8 cm x 1.8 cm black, unstageable. * 03/11/13 - right heel 3 cm x 3 cm stage II, wound bed tan/clear. * 03/11/13 - right outer foot 1 cm x 1 cm brown with serous drainage. * 03/11/13 - penis opening 1 cm x 0.5 cm brown with small amount of serous drainage. There were no assessments for Resident #4's left heel. The National Pressure Ulcer Advisory Panel, Clinical Practice Guideline, 2009, indicated a Stage II pressure sore was a partial thickness skin loss or blister. The National Pressure Ulcer Advisory Panel, Clinical Practice Guideline, 2009, indicated an unstageable pressure was a full thickness tissue loss in which the base of the ulcer was covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) tissue in the wound bed. The guidelines indicated until enough slough and/or eschar was removed to expose the base of the wound, the true depth, and therefore stage, could not be determined. 2. Physician orders dated February 2013 indicated Resident #9, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The physician orders did not include any treatments for open areas on the resident's buttock. The most recent MDS dated [DATE] indicated Resident #9 had no speech, was rarely understood, and rarely understood others. He had both short- and long-term memory problems, and his decision making skills were severely impaired. He was totally dependent on two staff members for bed mobility and transfers, and incontinent of both bowel and bladder. A care plan dated 02/20/13 indicated Resident #9 was at risk for skin breakdown related to incontinence, impaired bed mobility, history of pressure sores, fragile skin, alteration in nutrition, and cognitive impairment. Care plan approaches included: "monitor for skin breakdown and report to M.D. and responsible party; assess weekly and record; monitor for incontinence every 2 hours and prn; change promptly; and prevent shearing forces and friction during transfers". During an observation on 03/11/13 at 10:40 a.m., Resident #9 had a 2 x 2 inch dressing on his left buttock. Two areas were noted to the left buttock; one open area was 0.2 cm and had a Q-tip depth. The second area was a dark area approximately 0.5 cm. LVN A removed the dressing for surveyor observation. She said she was not aware the resident had any skin concerns and would contact the physician. Resident #9 had a pressure relieving mattress on his bed and a pressure relieving pad in his chair. The treatment record dated March 2013 did not indicate any treatments for open areas on Resident #9's left buttock. The weekly skin report dated 03/08/13 did not indicate any skin concerns for Resident #9. During an interview on 03/11/13 at 3:45 p.m., LVN A said she was not aware of the areas on Resident #9's buttocks until after surveyor intervention. She said at 11:00 a.m., she notified the physician and obtained treatment orders. LVN A said she did not know who had put the dressing on Resident #9's buttock. During an observation and interview on 03/12/13 at 9:15 a.m., LVN A said there were two areas on Resident #9's left buttock. During an interview on 03/12/13 at 9:20 a.m., CNA E said Resident #9 had the areas on his buttock since last week and she had informed the charge nurse. During an interview on 03/12/13 at 10:30 a.m., CNA D said Resident #9 had two areas on his buttocks since the 03/08/13 or 03/09/13. She said she was not sure which day, but remembered seeing the area and telling the nurse. During an interview on 03/12/13 at 10:35 a.m., the DON said all residents had a head to toe skin assessment completed weekly by the charge nurse. She said charge nurses on each shift did skin assessments with exception of the weekend shifts. During an interview on 03/13/13 at 7:30 a. m., the DON said she observed Resident #9's skin last week on 03/05/13 or 03/06/13, and there were no open areas. During an observation and interview on 03/13/13 at 7:40 a.m., LVN A measured the wounds on Resident #9's left buttock and said the measurements were 0.5 cm x 0.4 cm and the open area 0.4 cm x 0.2 cm with the depth of a Q-tip. Nurse notes dated 03/11/13, after surveyor intervention, indicated the physician was notified of the areas on Resident #9's buttock. A new order was obtained to clean the area with normal saline, pat dry, apply hydrogel (water-based gel that aids tissue repair) and foam dressing, and secure with clean dressing. The undated Assessment and Reporting of Skin Condition policy and procedure indicated it was "For the purpose of data gathering and evaluation of the quality of care, the three elements to this procedure - the 'Weekly Skin Assessment' , the 'Skin Report', and the 'Weekly Skin 'Condition Report' will be completed." The procedure included instructions for completing the forms. The section "New sites" - included, "the doctor will need to be notified". During an interview on 03/13/13 at 2:45 p.m., The DON provided a list of 20 residents on who were at risk for developing pressure ulcers.

Based on observation, interview, and record review, the facility failed to provide treatment and services in accordance with the comprehensive assessment to promote healing, prevent infection, and prevent new sores from developing for 6 of 10 residents reviewed for pressure sores. (Resident #s 1, 2, 3, 4, 6, and 7) 1. Resident #1 had erosion of his penis caused from pressure from his unsecured Foley catheter (a tube to drain urine from the bladder). The wound deteriorated from 1.0 cm x 0.5 cm on 04/16/13 to 1.0 cm x 2.0 cm with a 0.3 cm area of white slough (dead, necrotic tissue) on 04/20/13. The wound had torn through the urethral opening into the penile shaft. The facility did not: assess the penis during weekly skin assessments; postion and secure the urinary catheter tubing to prevent pressure on his penis; and evaluate the effectiveness of the treatment. 2. Resident #3 had a stage III pressure sore to her right hip. The facility did not assess the pressure sore correctly nor provide the physician's orders [REDACTED]. 3. Resident #4 developed three stage II pressure sores to both buttocks. The facility did not obtain treatment orders, notify the physician of new sores, or put interventions in place to prevent worsening of sores. 4. Resident #2 developed stage II pressure sores to his left buttock and both ears. The facility did not provide padding to his ears or reposition him every 2 hours as ordered. 5. Resident #6 developed a stage I pressure sore to her left heel. The facility did not identify the area, off load the heel, or contact the physician until after surveyor intervention. 6. Resident #7 was admitted with a stage II pressure sore on his sacrum and was assessed at high risk for developing pressure sores. He was not provided a pressure relieving device for his chair. These failures likely contributed to the development and worsening of pressure sores for Resident #s 1, 2, 3, 4, and 6 and could place the 20 residents at high risk of pressure sores at risk for developing pressure sores. Findings included: 1. Consolidated physician orders [REDACTED]. The orders indicated Resident #1 had a Foley catheter. A physician order [REDACTED].#1's penis every shift or as needed during peri care. Resident #1's interdisciplinary updated care plan dated 02/27/13 indicated he had a 1.0 cm x 2.0 cm area on his penis. Interventions included to apply skin treatment until healed, monitor his skin, perform weekly skin assessments, and notify the physician of any sign or symptom of infection. A Foley catheter care plan dated 03/13/13 indicated to provide Foley catheter care per facility policy, secure the Foley catheter tubing to the resident's leg with a catheter strap, and the nurse manager was to check for proper placement on daily rounds. Resident #1's most recent MDS dated [DATE] indicated his cognition was severely impaired, he was totally dependent for all of his ADL care, had a Foley catheter, and was incontinent of bowel. This MDS assessment indicated Resident #1 had a stage II pressure sore and an unstageable pressure sore. There was no documentation of a pressure sore on the resident's penis. A physician progress notes [REDACTED]. There was no evidence of skin breakdown or erosion to his penis. The weekly pressure ulcer log dated 04/16/13 indicated Resident #1 had a stage II pressure sore to his right outer foot that measured 1.0 cm by 0.5 cm. There was no documentation of breakdown to his penis. Resident #1's TAR dated April 2013 noted his Foley catheter was assessed as secured to his leg to prevent pulling, and [MEDICATION NAME] (barrier/skin protectant cream) was applied to the tip of his penis every shift and as needed. These two treatments were documented as provided every shift from April 1-30 2013. During an observation and interview on 04/29/13 at 1:30 p.m., Resident #1 was in bed. A deep pink groove the size and shape of the unsecured catheter tubing was noted on the back of his right leg. A leg strap was in a basin with supplies on a bedside table. CNA E said his catheter tubing had not been positioned or secured on top of his right thigh, and the tubing was placed downward so he could wear his pants. There was a 1.0 cm x 2.0 cm erosion on the tip of the penis at the urethra at the 3:00 o'clock position and an approximate 1.0 cm erosion at the 1:00 o'clock position. The eroded areas were red, inflamed, and an approximate 0.3 cm area of white slough (dead, necrotic tissue) was noted at the 1:00 o'clock erosion site. The wound had torn through the urethral opening into the penile shaft. RN B said the area was inflamed and new. He said it looked as though the catheter had pulled against the urethra. RN B said the treatment for [REDACTED].#1's urethra to treat the open areas. He was going to call the physician. During an observation on 04/29/13 at 3:15 p.m., Resident #1 was lying in bed and no catheter leg strap was on his leg. During an interview on 04/29/13 at 10:40 a.m., the administrator said RN B was newly assigned to perform skin assessments weekly on residents, but was unsure if he had started. During an interview on 04/29/13 at 10:55 a.m., the ADON said their plan was to have RN B perform weekly skin assessments, but that had not started. The ADON said different charge nurses on each shift were currently responsible for residents' skin assessments. She said they had not had a DON since 04/05/13. During an interview on 04/29/13 at 11:05 a.m., the ADON said Resident #1's skin assessment should be in the treatment book. A skin assessment sheet was located that addressed the foot, but there was no assessment regarding the breakdown on his penis. Resident #1's nursing notes dated 04/29/13 at 11:00 a.m. indicated the urethral catheter site had two small excoriations. The left side of the urethral opening had 0.25 cm x 0.50 cm excoriation and the right side of the urethral opening had a 0.25 cm by 0.25 cm excoriation. Both sites had pink/red tissue beds that blanched. The treatment included to start with normal saline, pat dry, and apply [MEDICATION NAME] (antibiotic) ointment two times a day until healed. There was no documentation that the primary physician or the urologist was notified of Resident #1's penile erosion. During an interview on 05/04/13 at 10:28 a.m., Resident #1's urology PA said according to their office notes, they had not seen Resident #1 since 02/29/13. During that visit, there had not been any penile erosion. The PA said facility staff contacted their office on 04/30/13 regarding his penile erosion, but that was the first time they were notified of any complications. A directed in-service dated 04/05/13 indicated were instructed on the negative outcomes associated with catheter use, prevention of serious outcomes with catheter use, proper securing of Foley catheter tubing, what needs to be documented, and where to find the documentation. 2. Consolidated physician orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #3's cognition was severely impaired. She was totally dependent for all of her ADL care and was incontinent of bowel and bladder. She had one stage II pressure sore with pink granulation (healing) tissue. A care plan dated 03/27/13 indicated Resident #3 had a stage II pressure sore to her right hip and an abrasion to her toe. The interventions included to provide treatment as ordered by the physician, notify the MD of change or worsening of the wound, resident is on a pressure relieving mattress, and to change gloves in between taking off the old dressing and replacing a new dressing. Physician orders [REDACTED]. A physician order [REDACTED]. Resident #3's right great toe with normal saline (salt water), pat dry, apply hydrogel (water-based gel to aid in tissue repair), and a foam dressing. The weekly pressure ulcer log dated 04/26/13 indicated Resident #3 had a stage II pressure sore to her right hip that measured 2.5 cm x 1.0 cm. The wound bed was white with a small amount of yellow drainage. During an observation on 04/29/13 at 11:15 a.m., RN B and CNA E turned Resident #3 on her left side, and there was a pressure sore on her right hip that measured approximately 2.0 cm x 1.0 cm with yellow slough (dead/necrotic tissue) noted on the 1:00 to 2:00 o'clock region. RN B said the wound bed contained 30% yellow slough RN B placed Resident #3's pressure sore dressing in the resident's bed and a piece of wax paper as a barrier. All the supplies slipped off the paper, into her bed. He cleaned his gloves with an alcohol swab and cleaned the wound bed with normal saline. He applied a piece of collagen matrix (biological material used for soft tissue repair), applied Santyl to the yellow slough in the wound, and cut a piece of foam dressing which CNA E held with an ungloved hand. RN B removed the unclean piece of foam and cut another piece of foam. RN B instructed CNA E to wear gloves and RN B reapplied the foam and secured the dressing with tape. The National Pressure Ulcer Advisory Panel (NPUAP) website http://www.npuap.org/resources/educational-and-clinical-resources/pressure-ulcer-categorystaging-illustrations/ accessed (date) indicated: "Category/Stage II: Partial thicknessPartial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous (serum and blood) filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising*. This category should not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration or excoriation.*Bruising indicates deep tissue injury." "Category/Stage III: Full thickness skin lossFull thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput (back of the head), and malleolus (ankle) do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable." 3. Consolidated physician orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #6 was severely cognitively impaired, required total care for all ADLs, was incontinent of both bowel and bladder, and had a feeding tube for nutrition. A care plan dated 12/05/12 indicated Resident #6 was at risk for pressure ulcers and the goal was she would not develop pressure sores in the next 90 days. Interventions included: *elevate heels off bed surface and use pillow between knees; *assess skin daily for reddened, dark, or discolored areas; and, *keep skin clean and dry. During an observation and interview on 04/29/13 at 11:20 a.m., Resident #6 was turned to her right side. Her heels were not elevated and were on the bed surface. During an observation and interview on 04/29/13 at 11:55, the ADON touched Resident #6's left heel and said it was mushy and soft. She identified the heel as a stage I pressure sore. She said the heels should be off-loaded and she would contact the physician. A physician order [REDACTED].#6's left heel. During an observation on 04/29/13 at 3:45 p.m., Resident #6's heels were lying directly on the mattress surface and not off-loaded. During an observation and interview on 04/30/13 at 8:20 a.m., Resident #6's heels were lying directly on the mattress surface and not off-loaded. LVN A said staff would off load the resident's heels. 4. Consolidated physician orders [REDACTED]. A skin report dated 03/11/13 indicated Resident #2 developed a stage II pressure sore on the left buttock measuring 0.2 cm x 0.2 cm x 0.1 cm. Nursing notes dated 03/26/13 indicated the area on the left buttock was healed. A physician order [REDACTED]. The most recent MDS dated [DATE] indicated Resident #2 required total assistance for all ADLs, was not ambulatory, was incontinent of bowel and bladder. The MDS indicated he was at risk for pressure sores, had two stage II pressure sores with one present on re-admission. A care plan dated 04/02/13 indicated Resident #2 had a stage II pressure sore behind his ear due to his oxygen tubing and a stage II pressure sore on his buttock. Interventions included: *treatment as ordered; *place padding on oxygen tubing; *monitor for signs of infection; and *weekly skin assessment. A care plan dated 04/03/13 indicated Resident #2 was at risk for skin breakdown related to incontinence, impaired bed mobility, history of pressure sores, fragile skin, alteration in nutrition, and cognitive impairment. The goal was for skin to remain clean, dry and intact for the next 90 days. Care plan approaches included: "monitor for skin breakdown and report to M.D. and responsible party; *assess weekly and record; *monitor for incontinence every 2 hours and as needed; *change promptly; *prevent shearing forces and friction during transfers; *encourage fluids by mouth and fluid intake; and, *provide pressure relieving and positioning devices." A nursing note dated 04/06/13 indicated Resident #2 developed a stage II pressure sore on the left buttock measuring 1.2 cm and a stage II pressure sore on the right buttock measuring 1.0 cm x 1.0 cm. A physician order [REDACTED]. A skin report for Resident #2 indicated the following: *04/11/13 Stage II - 3.0 cm x 2.0 cm x 0.1 cm left buttock; *04/11/13 Stage II - 3.0 cm x 3.0 cm x 0.1 cm left buttock; and, *04/18/13 Stage II - 3.5 cm x 5.0 cm x 0.1 cm left buttock. A weekly skin report dated 04/26/13 indicated Resident #2 had a stage II pressure sore to his left buttock measuring 3.5 cm x 5.0 cm. During observations on 04/29/13, Resident #2 was lying on his back and there was no padding to the oxygen tubing behind his ears at: *11:30 a.m.; *12:25 p.m.; *1:00 p.m.; or, *3:45 p.m. During an observation and interview on 04/29/13 at 4:15 p.m., CNA H and CNA I turned and repositioned Resident #2 after surveyor request. They said he had not been repositioned since their shift began at 2:00 p.m. CNAs H and I said the resident was to be turned every 2 hours. During an observation and interview on 04/29/13 at 1:00 p.m., RN B measured Resident #2's stage II pressure sore to his left buttock. The sore measured 1.5 cm x 0.25 cm. The RN said it was continuing to heal. RN B said all the charge nurses were responsible for the skin assessments and treatments. Resident #2's bed had a pressure reduction mattress. During an observation on 04/30/13 at 8:25 a.m., Resident #2's bed had a low air loss mattress after surveyor intervention. He was positioned on his right side with a pillow to his back and did not have padding to his oxygen tubing. During an observation on 04/30/13 at 8:45 a.m., two CNAs positioned Resident #2 on his right side, facing the wall supported by a pillow to his back. There was no padding on his oxygen tubing behind his ears. During an observation on 04/30/13 at 11:30 a.m., Resident #2 was lying on his right side facing the wall LVN A said she would ask the CNAs to turn him. 5. Consolidated physician orders [REDACTED]. An undated telephone order for Resident #4 indicated: clean both stage II pressure sores on the right buttock with normal saline, apply hydrogel and foam, secure with tape daily. Resident #4's April 2013 MAR indicated [REDACTED]. The skin protocol policy dated 03/03/2012 for the treatment of [REDACTED]. The most recent MDS dated [DATE] indicated Resident #4 required supervision for ADLs and mobility and required physical help from staff for bathing. Resident #4 required supervision for toileting and was frequently incontinent of urine. A pressure sore care plan dated 3/30/13 indicated she was at risk for skin tears, rashes and pressure sores. A nursing note 4/18/13 indicated there were 2 stage II pressure sores on Resident #4's right buttock. The physician was notified and treatment orders received. There was no documentation in the entire clinical record that the physician was notified or a treatment order was received for the pressure sore on the left buttock. A skin report dated 04/18/13 indicated Resident #4 had a stage II pressure sore to the right buttock measuring 0.2 cm x 1.0 cm x 0.2 cm, wound bed pink and no drainage. A treatment record for Resident #4 dated April 2013 indicated: *04/18/13, Clean #1 area on left buttock with normal saline, pat dry, apply hydrogel, and foam daily till healed; and *04/18/13, Clean #2 area on left buttock with normal saline, pat dry, apply hydrogel, and foam daily until healed. A skin report dated 04/24/13 indicated Resident #4 had a stage II pressure sore to the right buttock measuring 2.0 cm x 2.0 cm x 0.2 cm. The wound bed was pink, with bloody drainage. There was no odor, no physician notification, and no treatment change documented. A weekly skin report dated 04/26/13 indicated Resident #4 had: *a stage II pressure sore to the right buttock measuring 2.0 cm x 2.0 cm pink; and *a stage II pressure sore to the right buttock measuring 2.0 cm x 2.0 cm, bloody drainage. During an interview on 04/30/13 at 9:30 a.m., LVN A said the documentation on Resident #4's treatment record was a transcription error; the wounds were on the right buttock. During observation and interview on 04/29/13 at 10:45 a.m., the surveyor asked to observe wound care for the wound on Resident #4's buttocks. RN B said he was not aware the resident had a wound on the buttocks. Resident #4 told RN B she had a sore on her bottom. RN B removed the dressing from Resident #4's right buttock and noted a stage II pressure sore on the left buttock as well. The two stage II pressure sores on the right buttock both measured 2.0 cm x 2.0 cm. The stage II pressure sore on the left buttock measured 0.5 cm x 0.5 cm. A red rash and discoloration on the right buttock measured 10.0 cm x 10.0 cm. He performed the same treatment on all the pressure sores. No physician notification or request for treatment to the left buttock was found in the entire medical record regarding the decline in Resident #4's wounds. During an interview on 04/29/13 at 2:45 p.m., the FSS said he notified the dietitian of Resident #4's skin concerns by phone call or fax when notified by the nursing department. The administrator said all residents with weight loss and skin problems were reviewed by the dietitian. The FSS said he was not aware of Resident #4's pressure sores until after surveyor intervention. The ADON said she had not given the FSS a copy of the skin report. The administrator said their system for communicating skin concerns had failed. She said she did not understand the difference between pressure reduction mattresses and low air loss mattress. During an interview on 04/30/01 at 9:58 a.m., the RD said the facility had her cell phone number, home number, and fax number to notify her of resident concerns. The RD said she reviews the skin and weight loss reports and makes recommendations as needed. The RD said she was not aware of Resident #4's pressure sores until after surveyor intervention. 6. Consolidated physician orders [REDACTED]. Resident #7's most recent MDS dated [DATE] indicated he required limited to extensive assistance for his ADL care and was continent of bowel and bladder. He had two stage II pressure sores with pink granulation tissue. Resident #7's care plan dated 03/20/13 indicated he was at risk for skin breakdown related to impaired mobility, history of pressure ulcers, and cognitive impairment. The interventions included: assist with repositioning, and use padding between pressure areas, monitor for skin breakdown, and provide pressure relieving devices. Resident #7's physician orders [REDACTED]. The weekly pressure ulcer log dated 04/26/13 indicated Resident #7's pressure sores had healed. During an observation and interview on 04/29/13 at 8:35 a.m., Resident #7 was seated in his wheelchair on a pillow. CNA E said he had a sore on his bottom when he was admitted , but it had healed. Resident #7 said his bottom was better, but still got sore and he wanted a pad for his wheelchair. During an observation on 04/30/13 at 8:40 a.m., Resident #7 was seated in his wheelchair on a pillow. During an interview on 04/30/13 at 8:42 a.m., the ADON said after surveyor intervention, she contacted the physician and a pad was ordered for Resident #7's wheelchair. The Medical Director's Skin Protocol dated 03/09/12 indicated: Stage I pressure sores: *notify MD by phone or fax; and *apply [MEDICATION NAME] every shift until healed. Stage II pressure sores: *Notify MD by phone or fax; *cleanse skin with normal saline; apply safe gel or equivalent; *cover with Coversite (non-adherent gauze-type dressing) or equivalent; *do all treatments until pressure sores are healed; and *notify physician if worsens. Support care for all stage II - IV pressure sores: *vitamin C 500 mg twice daily; *zinc 220 mg every day; *[MEDICATION NAME] (supplement to aid with wound healing) extra 8 ounces every day: *multivitamin with minerals every day; and *house supplement every day. A list provided by the ADON on 04/30/13 indicated 20 residents at risk for pressure sores. The CMS 672 dated 04/29/13 indicated there were 8 residents with pressure sores.

Based on observation, interview, and record review, the facility failed to provide care and services in accordance with the comprehensive assessment to ensure indwelling urinary (Foley) catheter tubing was secured for 1 of 1 residents reviewed for Foley catheters. (Resident #1) Resident #1 had erosion of his penis caused from pressure from his unsecured Foley catheter (a tube to drain urine from the bladder). The wound deteriorated from 1.0 cm x 0.5 cm on 04/16/13 to 1.0 cm x 2.0 cm with a 0.3 cm area of white slough (dead, necrotic tissue) on 04/20/13. The wound had torn through the urethral opening into the penile shaft. The facility did not: assess the penis during weekly skin assessments; postion and secure the urinary catheter tubing to prevent pressure on his penis; and evaluate the effectiveness of the treatment. This failure could place 1 resident with a Foley catheter at risk for further discomfort, urethral trauma, and UTIs. Findings included: Consolidated physician orders [REDACTED]. The orders indicated Resident #1 had a Foley catheter. A physician order [REDACTED].#1's penis every shift or as needed during peri care. Resident #1's MDS dated [DATE] indicated his cognition was severely impaired, he was totally dependent for all of his ADL care, had a Foley catheter and was incontinent of bowel. This MDS assessment indicated Resident #1 had a Stage II pressure sore and an unstageable pressure sore. There was no documentation of pressure sores on the resident's penis. Resident #1's care plan dated 2/27/13 indicated he had a 1.0 cm x 2.0 cm area on his penis. Interventions included to apply skin treatment until healed, monitor skin, weekly skin assessments, and notify physician of any sign or symptom of infection. A Foley catheter care plan dated 3/13/13 indicated to provide Foley catheter care per facility policy, secure the Foley catheter tubing to the resident's leg with a catheter strap, and the nurse manager to check for proper placement on daily rounds. A physician progress notes [REDACTED].. There was no mention of skin breakdown or erosion to his penis. The weekly pressure ulcer log dated 4/16/13 indicated Resident #1 had a Stage II pressure sore to his right outer foot, that measured 1 cm x 0.5 cm. There was no mention of skin breakdown to his penis. Resident #1's TAR April 2013 documented that his Foley catheter was assessed as secured to his leg to prevent pulling, and [MEDICATION NAME] was applied to the tip of his penis every shift and as needed. During an observation on 4/29/13 at 1:30 p.m., Resident #1 was in bed. A deep pink groove the size and shape of the unsecured catheter tubing was noted on the back of his right leg. A leg strap was in a basin with supplies on a bedside table. CNA E said his catheter tubing had not been positioned or secured on top of his right thigh, and was placed downward, so he could wear his pants. There was a 1 cm x 2 cm erosion on the tip of the penis at the urethra at the 3 o'clock position and an approximate 1 cm erosion at the 1:00 o'clock position. The eroded areas were red and inflammed and an approximate 0.3 cm area of white slough was noted at the 1:00 o'clock erosion site. The wound had torn through the urethral opening into the penile shaft. RN B said the area was inflammed and new to him. He said it looked as though the catheter had pulled against the urethra. RN B said the treatment for [REDACTED].#1's urethra, so he was going to call the physician. During an observation on 4/29/13 at 3:15 p.m., Resident #1 was lying in bed, the Foley catheter was not secured. During an interview on 4/29/13 at 10:40 a.m. the administrator said RN B was newly assigned to perform skin assesments weekly on residents but was unsure if he had started assessing the residents. During an interview on 4/29/13 at 10:55 a.m., the ADON said their plan was to have RN B perform weekly skin assessments but that had not started. The ADON said different charge nurses on each shift were currently responsible for residents' skin assessments. She said they had not had a DON in the facility since 4/5/13. During an interview on 4/29/13 at 11:05 a.m., the ADON said Resident #1's skin assessment should be in the treatment book. A skin assessment sheet was located that addressed the foot but there was no assessment regarding the breakdown on his penis. Resident #1's nursing notes dated 4/29/13 at 11:00 a.m. indicated the urethral catheter site had two small excoriations. The left side of the urethral opening had 0.25 cm x 0.50 cm excoriation and the right side of the urethral opening had a 0.25 cm x 0.25 cm excoriation. Both sites had pink/red tissue beds that blanched. The treatment included to clean with normal saline, pat dry and apply [MEDICATION NAME] ointment two times a day till healed. There was no documentation that the primary physician or the urologist was notified of erosion to Resident #1's penis. During an interview on 5/4/13 at 10:28 a.m., Resident #1's urology PA said according to their office notes, they had not seen Resident #1 since 2/29/13, and during that visit there had not been erosion to the resident's penis. The PA said facility staff contacted their office this week on 4/30/13 regarding the erosion on Resident #1's penis and this was the first time they had been notified of any skin issues. The facility's directed inservice dated 4/5/13 indicated that staff had been instructed on the negative outcomes associated with catheter use, prevention of serious outcomes with catheter use, proper securing of Foley catheter tubing and what needs to be documented and where to find the documentation. There was no evidence observed or written that indicated the facility had implemented this inservice training. The website, http://www.public.asu.edu/~cbaldwi1/swborderlands/Stabilizing_the_Urinary_Catheter.pdf, accessed 4/30/12, read "The indwelling urinary catheter is secured or stabilized to prevent accidental removal, reduce trauma to the urethra and bladder, and reduce inflammation of urinary tissues. The goal of stabilization is to prevent excessive pull or traction on the catheter...The lower abdomen site is preferred for long-term use of catheters for men as it reduces the tissue damage to the urethra." The CMS 672 dated 04/29/13 indicated 1 resident had a Foley catheter.

Based on observation, interview, and record review, the facility failed to prevent the development and worsening of an avoidable pressure sore for 1 of 2 residents sampled for pressure sores. (Resident #1) Resident #1 was admitted without pressure sores but developed a Stage II pressure sore that worsened to a Stage III. The facility did not: *provide pressure relief for pressure sore prevention (low air loss mattress); *notify the physician of the pressure sore and obtain an order for [REDACTED]. *perform weekly skin assessments per facility policy. These failures contributed to the development and deterioration of Resident #1's pressure sore and could place 27 residents at risk for pressure sore development at increased risk for skin breakdown. Findings included: Physician orders [REDACTED]. Resident #1's MDS dated [DATE] indicated he usually understood others, was incontinent of bowel and bladder, and dependent on staff for bed mobility, transfers, dressing and bathing. The MDS indicated he was non-ambulatory, and did not have current or recent pressure sores. Resident #1's care plan updated 5/24/11 noted he was at risk for pressure sores based on his Braden scale (scale for predicting pressure sore risk). The most recent Braden Scale dated 6/4/11 indicated Resident #1 was at moderate risk for skin breakdown. The last physician progress notes [REDACTED]. A dietary progress note dated 2/28/12 noted Resident #1 was receiving treatment for [REDACTED]." The dietitian recommended [MEDICATION NAME] (used to promote wound healing) 1 packet daily, zinc 220 mg daily, and liquid protein 30 ml daily. Physician orders [REDACTED]. The physician order [REDACTED]. An undated care plan indicated Resident #1 had a Stage II pressure sore on his coccyx. The interventions included: *assist with repositioning *assess skin on a weekly basis *provide pressure relieving and positioning devices on bed/wheel chair as indicated. The weekly pressure ulcer log dated 3/2/12 indicated Resident #1 had a 3 cm Stage II pressure sore on his coccyx, white and pink in color. There were no other entries regarding Resident #1. During observations of Resident #1 the following was noted: *at 3/5/12 at 11:05 a.m., was lying on his back, on a [MEDICATION NAME] foam mattress. *at 3/5/12 at 4:35 p.m., was in bed lying on his back, on a [MEDICATION NAME] foam mattress. *at 3/6/12 at 9:35 a.m., was in bed lying on his back, on a [MEDICATION NAME] foam mattress. *at 3/6/12 at 11:25 a.m., Resident #1 was in bed lying on his back, on a [MEDICATION NAME] foam mattress. During an observation and interview on 3/6/12 at 3:15 p.m., Resident #1 had a pressure sore on his coccyx. The open area was pink and measured 2.5 x 3 cm. There was a 1.5 x 1 cm area of gray, moist slough near the gluteal fold. The skin, surrounding the wound bed was red and inflamed and measured 4.5 x 4.5 cm. The DON said the pressure sore had worsened since she had seen it on 3/1/12. She said when she last saw the wound it was the size of a nickel and pink. She said she would call the physician and get new orders because of the slough in the wound bed. During an observation and interview on 3/6/12 at 3:33 p.m., the DON said she did not know what type of mattress Resident #1 was on. She pushed down on the mattress and said it felt firm, the mattress tag noted it was a [MEDICATION NAME] mattress. She said they had better mattresses and she would get the resident an air mattress. During an observation on 3/7/12 at 8:55 a.m., after surveyor intervention, Resident #1 had a low air loss mattress on his bed. During an interview on 3/7/12 at 9:45 a.m., the DON said the mattress on Resident #1's bed was a [MEDICATION NAME], foam spring mattress. She could not provide additional information about the mattress. The DON said she was unaware of Resident #1's pressure sore until last Friday, 3/2/12. She said she did not know when the pressure sore was originally found, as there was nothing in the nursing notes to indicate when it was identified. She said the charge nurse, should have assessed the resident's skin weekly, notified the physician when the pressure sore was found and should have begun wound care. The DON said a physician order [REDACTED]. During an interview on 3/7/12 at 11:06 a.m., Resident #1's physician said he expected the nurses to inform him of new pressure sores. He said he was not aware of Resident #1's pressure sore. The National Pressure Ulcer Advisory Panel at <http://www.npuap.org/pr2.htm>, accessed 10/06/11, noted the following pressure ulcer definitions: Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The facility's undated policy regarding pressure sores stated the following: *Assess any new decubitus ulcer as soon as discovered. *Include all pertinent information on pressure sore/decubitus record. *Notify physician and obtain orders for treatment. On 3/7/12 at 7:00 p.m., the DON provided a list of 27 residents at risk for developing pressure sores.