Every finding on record at Estrella Health And Rehabilitation Center

Based on clinical record review, observations, staff interviews and facility policy, the facility failed to ensure that an individualized on-going program of activities that met the interests and supported the well-being were consistently provided for 2 out of 2 sampled residents (#59 and #134). The universe was 148. The deficient practice could result in resident's interests, the physical, mental and psychosocial well-being, decreased socialization and stimulation not being met.Findings Include: -Regarding Resident #134: Resident #134 was admitted on [DATE] with diagnoses that included Cerebrovascular Disease, Spinal Stenosis, Dysphagia, Cerebral Infarction, Muscle Weakness, and Fusion of the Spine. The care plan revealed that the resident is dependent on staff for activities and is unable to physically participate due to poor mobility, one-on-one activities for cognitive stimulation, social interaction related to cognitive deficits, immobility and physical limitations. Interventions included 1:1 (one on one) Programming/Leisure check room visits 1 time per week, provide programming of activities that accommodate abilities, engage in simple, structured activities that avoid overly demanding tasks. A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a BIMS (brief interview of mental status) score of 7 which indicated that his cognitive skills were severely impaired. The resident preferences for customary routine and activities revealed that it was very important to have books newspapers and magazines to read, very important to listen to preferred music, somewhat important to be around animals, very important to keep up with the news, very important to do favorite activities, somewhat important to go outside to get fresh air, very important to participate in religious services and practices. Review of the 1:1(one to one) activity logs for January-March, 2026- revealed a note on January 28, 2026 that they played a game with resident #134 called 'guess' for 5 minutes. On February 20, 2026 there was a Pet visit for 5 minutes. No other 1:1 (one to one) visits were documented for the months of January 2026 to March, 2026. Review of Point Click Care documents in the Electronic Medical Record for the last 30 days revealed the following: 1:1(one to one) activity documented 3 days in March, no documented entertainment, no documented social activity, no documented creative activity, 12 days watching TV/Radio, 3 days observing surroundings, no documented mental activities, and no documented religious activities. An interview was conducted with resident #134 on April 7, 2026 at 10:06 a.m. which revealed resident #134 is a Spanish speaking resident. Resident #134 stated staff do not get him up out of bed to be in the wheelchair, he stated that he asks the Certified Nursing Assistants every day and they still do not get him up. He stated that they used to get him up and that he has the wheelchair by his bed. He further stated that there is no reason they can't get him up. He stated it has been approximately 3 or more months since he has been out of bed, except for his showers 2x per week. He is not able to participate in activities, just watch television (TV) that is in English, all day. The Resident stated that he would like to go outside to enjoy the sun and fresh air. He stated he likes music, news, and religious activities are very important to him. An observation was conducted on April 9, 2026 at 1:30 p.m. in the room of Resident #134. Resident #134 was observed to be in bed. The television (TV) was on but was observed to be playing in English. There were no activity items observed on the bedside table or anywhere else in the room. An observation was conducted on April 10, 2026 at 8:38 a.m. in the room of Resident #134. Resident #2 was observed to be in bed. There were no activity items observed on the bedside table or anywhere else in the room. An interview with Activity Director (staff #44). Staff #44 stated her role includes to plan calendars, assess new residents, and create care plans on what residents want to do each day. When asked how do you communicate with the Spanish speaking residents, she stated she has a new assistant that speaks Spanish. She further stated that to determine a resident's preferences, she would ask questions of the resident to put on the care plan. She stated that traveling bingo, word search, cards, coloring, crafts, and 1:1 (one to one) in resident rooms is provided to bedbound residents. She stated that we do not have any materials that are in Spanish. She stated that she had struggled to come up with activities for the Spanish speaking residents and especially the males. Regarding resident #134 she stated that they do 1:1 (one to ones) to talk with him about what he enjoys, but stated that she had not provided him any materials, and was not quite sure of what interest he has. An interview was conducted on April 10, 2026 at 1:06 p.m. with the Administrator (staff #167) and Director of Nursing (staff #147). Regarding activities for Spanish-speaking residents the DON stated he is Spanish speaking and does communicate with the residents that speak Spanish frequently. Staff #167 stated that the activities director would provide various activities throughout the day along with their staff that have been chosen by the residents and keep them engaged. Review of the Activity Programming Policy revised on April, 2025 stated that it is the policy of this facility to ensure that activities are available to meet resident needs and interests that support the physical, mental, and psychosocial well-being of the resident. Activities may be facility-sponsored groups or independent. Activities include any endeavor, other than routine activities of daily living, in which a resident participates that is intended to enhance her/his sense of well-being and to promote or enhance physical, cognitive, and emotional health. These include, but are not limited to, activities that promote self-esteem, pleasure, comfort, education, creativity, success, and independence. Attempts will be made to accommodate resident preferences, when safe to do so, for planning activities programs and calendars. Program considerations may include group offerings, independent offerings, or religious/spiritual offerings. Review of the facility policy titled, Delivery of Activity Services revised on July, 2022 revealed that it is the policy of this facility to ensure that residents have the right to choose the types of activities and social events in which they wish to participate. -Regarding Resident #59: Resident #59 was admitted to the facility on [DATE] with diagnoses of chronic kidney disease, gastrointestinal hemorrhage, hyperlipidemia, essential (primary) hypertension, muscle weakness, and need for assistance with personal care under Long Term Care (LTC). The Comprehensive Care Plan, revised March 17, 2026, stated that the Resident has little or no activity involvement, related to immobility and disinterest. Interventions of the facility included that the facility would explain the importance of social interaction and leisure activity time and invite the Resident to scheduled activities. A 5-day Medicare Minimum Data Set (MDS) assessment completed on March 10, 2026 revealed that the Resident had a BIMS score of 14 which indicated intact cognition, a report for mood showed the Resident presented with no severe moods and no behaviors exhibited. Review of 1:1 (one on ones) with the Activities team of the facility for the month of March 2026, revealed that the Activities team did not make contact or interact with Resident #59. On April 10, 2026, a review of Resident #59's Progress Notes showed no notes by Social Services regarding a discussion with Resident #59 or Resident #59's family regarding accommodations with the room or TVs. On April 10, 2026, a review of the Facility's 1:1 with residents revealed no 1:1 or any documentation contact with Resident #59 between January-March 2026. A review of the electronic health record revealed no documented evidence that the Resident had participated in the facility's activities. An interview and observation was conducted with the Resident on April 7, 2026 at 9:30 AM, which revealed that the Resident is Spanish-speaking only and has been at the facility for over a month. The Resident's room lacked a TV or radio, no activities were visible for the Resident to participate in, and the Resident revealed that she is very bored in her room with no one coming to speak with her or invite her to scheduled activities. The Resident stated that she likes to watch Spanish language television channels. The resident stated that when her son and daughter-in-law come to visit, it is the only time she is taken to activities and around the courtyard of the facility, otherwise she will lay in bed all day. The resident did not know to ask for a TV in her room. Another interview was conducted with the Resident's son over the phone on April 9, 2026 at 10:00 AM, which he confirmed that when he and his wife visit the Resident they do get the Resident out of the room. The son did not know why his mother did not have a TV in her room, or whether the facility would provide one, and stated she did not participate in creating his mother's care plan but that he would have liked to and would like a future invitation to be a part of the Resident's care plan. He was not aware if his mother participated in any activities, and was not contacted about the schedule of activities. He had not received any communication from Social Services about his mother's care. On April 9, 2026 12:32 PM, an interview was conducted with Staff #63, Maintenance, with regards to whether maintenance had any overall impact on a Resident's room set-up; specifically with setting up a TV for Residents in Long Term Care (LTC). Staff #63 stated that he does not initiate TV requests nor does he have a list of TV requests, but that he gets informed by Housekeeping about setting up TVs in rooms and general room set-up, maintenance with drywall, plugs, outlets, plumbing, and bed set-up. Staff #63 stated he believed Social Services is in charge of setting a resident up with a TV or making contact with the Resident's family. An interview was conducted on April 9, 2026 at 12:36 PM, with Staff #216, Social Services Director, who stated that the facility provides TVs for residents who cannot provide their own or if their families cannot provide a TV. Staff #216 stated that Certified nursing assistant (CNAs) let Social Services know of a TV issue or the family, but through the admission conference with the Resident and families the Concierge would inform Residents and family members about providing their own TVs. Staff #216 was unsure if providing a TV was the responsibility of the Resident or family and whether it was documented on the admission Agreement or if in a Policy. Staff #216 stated that Housekeeping is in charge of TV set-up. Activities Director, Staff #44, was interviewed April 9, 2026 at 1:00 PM and asked about current practice in reaching out to Spanish-speaking residents and how the Facility encourages participation in activities and offering activities. Staff #44 stated that she had within the last month hired a Spanish-speaking assistant Activities Director. She stated that the assistant aids in getting Spanish-speaking only residents to participate. In regards to bed-bound residents, Staff #44 stated that they try to offer certain activities that work well for bed-bound residents such as travel bingo, crafts, coloring, and puzzles. Staff #44 stated that there is 1:1 time with residents to better understand their likes and dislikes. She further stated that this is documented on 1:1 Sheets, which are currently being audited in-house. An observation was conducted of Resident #59's room on April 9, 2026 at 3:24 PM, to find no evidence of a TV in the Resident's room and the Resident laying on her side with no music or any type of entertainment/activity present. A phone-interview was conducted again with Resident #59's son on April 10, 2026 AM, to inquire if the Facility had informed him of providing a personal television for his mother's room. The son stated he had not been informed and that he had no prior knowledge of having to provide his mother with a TV. He stated that no paperwork was provided to him when his mother's care had transitioned to LTC, from skilled nursing care. A second interview was conducted with Staff #44, Activities Director, on April 10, 2026 at 9:31 AM, who stated that 1:1 documents which residents were contacted and their noted preferences. Staff #44 stated that she acquired this position in June 2025 and has since found deficits in the activities programs, especially with Spanish-speaking residents. She further stated that she had since hired a new assistant to aid in communicating activities and encouraging participation. Staff #44 stated that she makes a point to have 1:1's with residents that do not normally participate or who have not participated in activities. On April 10, 2026 at 10:03 AM an interview was conducted with Staff #71, Housekeeping Director, regarding residents who transition to LTC from the Skilled Nursing side of the Facility. When asked who ensures the rooms are ready and appropriately furnished for residents, she stated that CNAs (Certified Nursing Assistants) will inform Housekeeping about a Resident moving rooms or a new resident admittance. Housekeeping aids will clean and prep rooms for the Resident. Housekeeping does not ensure that a TV is provided to the Resident but if a Resident already has a TV in their possession then Housekeeping will inform Maintenance to connect the TV. Staff #71 stated that Social Services are in charge of TVs being provided and that they communicate with Housekeeping. Staff #71 further stated that Housekeeping does not contact families regarding a missing TV in a Resident's room. An interview was conducted April 10, 2026 at 11:50 AM with the Admissions Director, Staff #36, who stated that when newly admitted residents are arriving they are supplied with an Admissions Packet with welcome information and explanation of provided services and that all skilled nursing residents are supplied a TV within their room, but not Long Term Care (LTC) residents. Long Term Care resident's families are informed to bring their own TV, if one cannot be provided then the Facility will try to provide a TV. Staff #36 stated that they do not personally meet with the resident at arrival to the Facility until the Nurse does an evaluation for therapies and a care plan is created. The Case Manager and Social Services would be made aware of a resident who transitions over from skilled to LTC, any new admissions to LTC would be completed through clinical and management staff; Staff #36 only does the non-clinical initial admission of residents, case management does all the clinical ALTCS programs. Staff #36 stated again that she only reaches out to a resident's family pertaining to a TV being provided during a new admission, not when a resident transitions from skilled nursing to LTC. Staff #36 confirmed that Resident #59 did transition from skilled to LTC, and stated that Social Services takes that on. Another interview was conducted with Staff #216 on April 10, 2026 12:06 PM, Staff #216 stated that they do not have anything to do with a resident transitioning from skilled nursing to LTC in terms of providing a TV or setting up the room for the resident. Housekeeping has a checklist to ensure a room is prepared for the resident moving into LTC, and Maintenance is in charge of TV set-up, anything else is related to Admissions. Staff #216 stated that the family should have contacted the facility to inform them of the resident not having a TV in their room. An Interview was conducted with Staff #147, Director of Nursing (DON), who stated that if a resident is transitioning from skilled nursing to LTC, the process is done by Social Services. DON was informed that through previous interviews with Social Services stated that they are not involved in residents transitioning to LTC from skilled nursing and that Housekeeping, Concierge, Maintenance, and Admissions are all who could be in charge of setting up the room for the residents and anything regarding providing a TV. The DON stated that there is an issue with how this process is conducted. DON stated not being made aware of the lack of TV in Resident #59's room. DON acknowledged that Resident #59 should have been provided a TV and that the Facility has provided multiple TVs for Residents; DON stated that the facility missed this opportunity 100%. A final interview was conducted with Staff #44, Activities Director, and informed them that there was a resident who was not contacted through 1:1's or any documentation of contact regarding preferred activities and preferences. Staff #44 was asked what are the risks of a resident not participating in activities or being asked to participate, Staff answered that there is risk for isolation, depression, and not being able to continue their daily activities and promoting daily living. Staff #44 acknowledged that Resident #59 was never contacted and that the Resident had transitioned from nursing to LTC, and that nothing had been done for her in regards to activities. The Facility's Activities policy, revised July 2022, revealed that it is the policy of this facility to ensure that residents have the right to choose the types of activities and social events in which they wish to participate.

Based on review of clinical records, policy, and staff interviews the facility failed to ensure medications were administered per physician ordered parameters for two out of six sampled residents (Resident #167 and #3) regarding pain medication and medication for hypotension (low blood pressure). The Universe was 66. The deficient practice could result in undesirable medication-induced harm and uncontrolled pain. Finding Includes: -Regarding Resident #167: Resident #167 was admitted into the facility on November 13, 2022, and discharged on December 6, 2022, with diagnoses that included atherosclerotic heart diseases, pain in right shoulder, type II diabetes, depression, muscle weakness, and complete rotator cuff tear or rapture of left shoulder. Review of the physician orders revealed the following orders: -Oxycodone HCl tablet 5 milligram (mg), to give 1 tablet by mouth every 4 hours as needed for mild pain 1-3, with start date of November 13, 2022. -Oxycodone HCl tablet 5 mg, to give 2 tablets by mouth every 4 hours as needed for moderate pain 4-7, with start date of November 13, 2022. -Oxycodone HCl tablet 5 mg, to give 3 tablets by mouth every 4 hours as needed for severe pain 8-10, with start date of November 13, 2022. A care plan initiated on November 14, 2022, revealed that the resident was prescribed an opioid for pain and interventions included to administer medication as prescribed. A Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE], included a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. A November 2022, Medication Administration Records (MAR) revealed that Oxycodone HCl tablet 5 mg, to give 2 tablets by mouth every 4 hours as needed for moderate pain 4-7, was administered outside of physician ordered parameters and 2 tablets were administered when the pain level was either lower than 4 or higher than 7 on the following dates: -November 16, 2022, at 6:43 a.m., for a pain level of 8. -November 26, 2022, at 12:05 a.m., for a pain level of 3. A November 2022, Medication Administration Records (MAR) revealed that Oxycodone HCl tablet 5 mg, to give 3 tablets by mouth every 4 hours as needed for severe pain 8-10, was administered outside of physician ordered parameters and that 3 tablets were administered when the pain level was lower than 8 on the following dates: -November 15, 2022, at 12:35 a.m., for a pain level of 7. - November 16, 2022, at 5:52 p.m. for a pain level of 7. - November 17, 2022, at 12:21 a.m. for a pain level of 1 and at 5:49 p.m. for a pain level of 7. -November 18, 2022, at 9:45 a.m. for a pain level of 7 and at 3:12 p.m. for a pain level of 6. -November 20, 2022, at 5:24 a.m. for a pain level of 7, at 12:49 p.m. for a pain 7 and at 6:08 p.m. for a pain level of 7. - November 21, 2022, at 3:17 p.m. for a pain level of 7. - November 23, 2022, at 10:39 p.m. for a pain level of 7. - November 24, 2022, at 11:37 a.m. for a pain level of 7 and at 4:29 p.m. for a pain level of 7. - November 28, 2022, at 11:33 a.m. for a pain level of 7 and at 4:25 p.m. for a pain level of 7. - November 30, 2022, at 3:58 a.m. for a pain level of 3, at 11 a.m. for a pain level of 6 and at 4:07 p.m. for a pain level of 7. A December 2022, Medication Administration Records (MAR) revealed that Oxycodone HCl tablet 5 mg, to give 3 tablets by mouth every 4 hours as needed for severe pain 8-10, was administered outside of physician ordered parameters and that 3 tablets were administered when the pain level was lower than 8 on the following dates: -December 3, 2022, at 1:32 a.m. for a pain level of 6, at 11:51 a.m. for a pain level of 7 and at 4:12 p.m. for a pain level of 7. -December 4, 2022, at 11:59 a.m. for a pain level of 7, and at 4:12 p.m. for a pain level of 7. - December 3, 2022, at 12:21 p.m. for a pain level of 7, at 11:51 a.m. for a pain level of 7 and at 5:21 p.m. for a pain level of 7. An interview was conducted on April 9, 2026 at 12:31 p.m., with a Licensed Practical Nurse (LPN/ staff # 161), who stated that she provides medication administration to residents and before giving medications to residents, she verifies doctors order, dosage amount, and resident's name. Staff #161 then reviewed Resident #167 clinical record and stated that resident had an order of Oxycodone HCl tablet 5 milligrams, to give 1 tablet by mouth every 4 hours as needed for mild pain 1-3, then to give 2 tablets by mouth every 4 hours as needed for moderate pain 4-7, and to give 3 tablets by mouth every 4 hours as needed for moderate pain 8-10. LPN then reviewed the MAR for the month of November and December, 2022, and stated that pain level in MAR referred to resident's pain before medication was given to resident. The LPN stated that oxycodone 5 mg, to give 2 tablets for moderate pain 4-7, had been administered out of parameter on two occasions and then oxycodone 5 mg, to give 3 tablets for severe pain 8-10, had been administered out of parameter on seventeen occasions for the month of November 2022. The LPN further stated that risk if physician orders were not followed then residents would have medication side effects and could be lethargic and weak. An interview was conducted on April 9, 2026 at 1:35 p.m., with an LPN (staff # 108), who stated that she provided medication administration to residents. Staff #108 then stated that physician orders need to be followed before giving medications to residents because physicians are the ones who prescribe medication and know the dosage of medications. Staff #161 then reviewed the clinical record for Resident #167 and stated that resident had an order of Oxycodone HCl tablet 5 milligrams, to give 1 tablet by mouth every 4 hours as needed for mild pain 1-3, then to give 2 tablets by mouth every 4 hours as needed for moderate pain 4-7, and to give 3 tablets by mouth every 4 hours as needed for severe pain 8-10. The LPN then reviewed the MAR for the month of November and December, 2022, and stated that pain level in MAR referred to resident's pain before medication was given to resident. The LPN further stated that Oxycodone was not given within the parameter for the designated pain scale. The LPN further stated that if medication was administered outside of parameters and resident was given triple the dose, it would cause respiratory distress and dependency of narcotics. An interview was conducted on April 9, 2026 at 2:04 p.m., with a Director of Nursing (DON/staff # 147), who stated that her expectation from staff would be to administer medications as per physician order to the residents. DON then stated that unit managers follow up with nurses on the MAR to ensure medications were administered correctly as per the orders. The DON then reviewed the MAR for Resident #167 for the month of November and December, 2022, and stated that pain level in the MAR referred to resident's pain before medication was given to the resident. The DON stated that that resident had an order of Oxycodone HCl tablet 5 milligrams, to give 1 tablet by mouth every 4 hours as needed for mild pain 1-3, then to give 2 tablets by mouth every 4 hours as needed for moderate pain 4-7, and to give 3 tablets by mouth every 4 hours as needed for severe pain 8-10. The DON further stated that oxycodone 5 mg, to give 2 tablets for moderate pain 4-7, had been administered out of parameter on two occasions and then oxycodone 5 mg, to give 3 tablets for severe pain 8-10, had been administered out of parameter on seventeen occasions for the month of November 2022. Then, for December 2022, oxycodone 5 mg, to give 3 tablets for severe pain 8-10, had been administered out of parameter on six occasions and physician orders were not followed. The DON also stated that he would consider this a documentation error and this was concerning for him. -Regarding Resident #3: Resident (#3) was admitted to the facility on [DATE] with diagnoses that include encephalopathy, respiratory failure with hypoxia, organism pneumonia, type-2 diabetes mellitus without complications, essential (primary) hypertension, cognitive communication deficit, and need for assistance with personal care. The MDS dated [DATE] revealed a BIMS score of 13, which indicated that the resident is cognitively intact. The clinical record revealed the following physician order dated December 13, 2025: Midodrine HCI Oral Tablet 10 MG (Midodrine HCI) Give 1 tablet by mouth every 8 hours for hypotension HOLD if SB/P (systolic blood pressure) greater than 110 Review of the Medication Administration Record for the months of January 2026, February 2026, March 2026, and April 2026 revealed Midodrine HCI was administered by a nurse outside of physician ordered parameters on the following dates with the blood pressure (BP) reading at the time of administration noted as follows: January 12, 2026: Morning medication administration, BP 112/73, by RN Staff #222 January 17, 2026: Evening medication administration, BP 138/68, by RN Staff #222 January 19, 2026: Morning medication administration, BP 132/68, by RN Staff #222 January 24, 2026: Morning medication administration, BP 125/66, by RN Staff #222 January 24, 2026: Evening medication administration, BP 132/76, by LPN Staff #25 January 25, 2026: Evening medication administration, BP 118/59. by LPN Staff #194 January 26, 2026: Morning medication administration, BP 128/68, by LPN Staff #194 February 1, 2026: Evening medication administration, BP 120/69, by RN Staff #222 February 2, 2026: Morning medication administration, BP 120/69. by RN Staff #222 February 6, 2026: Morning medication administration, BP 112/72, by RN Staff #222 February 6, 2026: Evening medication administration, BP 142/69, by RN Staff #222 February 7, 2026: Morning medication administration, BP 124/76, by RN Staff #222 February 8, 2026: Evening medication administration, BP 116/67, by LPN Staff #160 February 9, 2026: Midday medication administration, BP 113/74, by LPN Staff #94 February 12, 2026: Morning medication administration, BP 123/82, by RN Staff #222 February 12, 2026: Midday medication administration, BP 116/72, by LPN Staff #160 February 13, 2026: Evening medication administration, BP 116/68, by LPN Staff #160 February 14, 2026: Evening medication administration, BP117/67, by RN Staff #222 February 15, 2026: Morning medication administration, BP 125/75, by RN Staff #222 February 18, 2026: Morning medication administration, BP 112/62, by LPN Staff #47 February 19, 2026: Evening medication administration, BP 118/73, by RN Staff #84 February 23, 2026: Morning medication administration, BP 115/68, by LPN Staff #47 February 25, 2026: Evening medication administration, BP 132/80, by LPN Staff #219 March 1, 2026: Morning medication administration, BP 125/71, by RN Staff #61 March 1, 2026: Evening medication administration, BP 122/80, by LPN Staff #219 March 2, 2026: Evening medication administration, BP 128/69, by LPN Staff #25 March 10, 2026: Evening medication administration, BP 123/63, by LPN Staff #47 March 15, 2026: Morning medication administration, BP 118/68, by LPN Staff #25 March 15, 2026: Evening medication administration, BP 123/75, by LPN Staff #215 March 24, 2026: Morning medication administration, BP 120/80, by LPN Staff #215 March 24, 2026: Evening medication administration, BP 125/66, by LPN Staff #117 March 27, 2026: Evening medication administration, BP 124/60, by LPN Staff #47 March 31, 2026: Evening medication administration, BP 125/55, by LPN Staff #46 April 4, 2026: Evening medication administration, BP 154/76, by LPN Staff #25 An interview was conducted on April 10, 2026 with RN (staff #98). Staff #98 stated the facility policy regarding following physician-ordered parameters for administering medications is that the provider/physician is contacted for clarification when parameters are noted to be outside of the administration window. Staff #98 stated that the consequences of not following physician-ordered medication administration parameters is that a patient is put into danger and an accident could occur. An interview was conducted on April 10, 2026 with LPN (staff #65). Staff #65 stated that the facility policy regarding following physician-ordered parameters for administering medications is to follow the parameters the physician stated in the order. Staff #65 stated that the consequences of not following physician-ordered medication administration parameters is that a medication error would occur. Staff #65 was asked to review the Medication Administration Record for the month of March 2026 and to identify dates where Midodrine HCI was administered outside of physician-ordered parameters for resident #3. Staff #65 identified a few dates through a brief record review that physician-ordered parameters were not followed on the dates of March 1, 2026 for the morning medication administration, March 15, 2026 for the morning medication administration, and March 24, 2026 for the morning medication administration. An interview was conducted on April 10, 2026 with DON (Director of Nursing, staff #147). Staff #147 stated that the facility policy regarding following physician-ordered parameters for administering medications is to follow the orders as written. Staff #147 stated that the consequences of not following physician-ordered medication administered parameters would be dependent upon the type of medication being administered. Staff #147 was asked to review the Medication Administration Record for the month of March 2026 and to identify if Midodrine HCI was administered to resident #3 following physician-ordered parameters. Staff #147 performed a record review and stated that the physician's orders were not followed and that a consequence of not following the orders is that the resident's blood pressure could increase by receiving the medication. Review of the facility's policy titled Physicians Orders with a review date of December 2024 revealed it is the policy of the facility that drugs shall be administered only upon the order of a person duly licensed and authorized to prescribe such drugs, and to accurately implement orders in addition to medication orders (treatments, procedures) only upon the order of a person duly licensed and authorized to do so in accordance with the resident's plan of care. A review of the policy titled Administration of Drugs with a revised date of June 2023, revealed that medications must be administered in accordance with the written orders of the attending physician. Review of the policy titled Unnecessary Drugs with a revised date of December 2024, revealed that Residents receive only those medications, in doses and for the duration clinically indicated to treat the resident's assessed condition(s).

Based on observation, staff interviews, and review of facility policies, the facility failed to ensure that confidential resident information was secured for 16 out of 148 residents. The deficient practice could lead to protected resident information being stolen or compromised.Findings include: During observation on April 9, 2026 at 3:41p.m. a laptop on a medication cart located by room [ROOM NUMBER] had an open computer screen facing the main hallway with resident confidential information for 16 residents. Health information for Resident #39 was identified due to 2 medications being left on the top of the medication cart in a medication cup when the nurse went into room [ROOM NUMBER]. The information was actively displayed on the laptop and was visible to anyone walking down the main hallway. The confidential resident information included the resident's name, resident's picture, and room number. The deficient practice could lead to resident protected health information being compromised or stolen.An interview was conducted on April 9, 2026 at 3:47 p.m. with the registered nurse (RN/staff #51). Staff #51 stated she was distracted and forgot to close the computer screen. She stated that the process would be to close out the computer screen if she leaves the medication cart, so no one is able to see the resident's information. The Registered Nurse stated that the patient's private information could be stolen and it would be a Health Insurance Portability and Accountability Act (HIPAA) violation. An interview was conducted on April 9, 2026 at 3:50 p.m. Certified nursing assistant (CNA/staff #34) Regarding HIPAA, staff #34 stated that it relates to the residents' private information. Staff #34 stated that in the effort to keep resident information private it is important to close out the resident record on the screens, utilized by the CNA's in the hallways, when staff walk away. Staff #34 also stated that the medication carts have laptop screens on them where resident information could be seen if the laptop is not closed when the nurses walk away from the medication cart. Staff #34 stated that the risk for not securing the screens could result in resident identity being taken.An interview was conducted with the director of nursing (DON/ staff #147) on April 9, 2026 at 3:50 p.m. Staff #147 stated that the nurse would need to lock the medication cart and make sure the laptop is closed as to not have any resident information displayed and viewed. The DON stated the risk would include resident information being viewed by others.Review of the facility policy titled Health Insurance Portability and Accountability Act Compliance Policy and Procedure revised December, 2024 revealed the Health Insurance Portability and Accountability Act Privacy Rule establishes national standards to protect individuals' medical records and other personal health information and applies to health plans, health care clearinghouses, and those health care providers that conduct certain health care transactions electronically. The Rule requires appropriate safeguards to protect the privacy of personal health information, and sets limits and conditions on the uses and disclosures that may be made of such information without patient authorization.

Based on observation, interviews, and review of facility policy and procedure, the facility failed to ensure medications were stored according to regulation and facility policy. The deficient practice could lead to overdose or unauthorized residents gaining access to medications.An observation conducted on April 9, 2026 at 3:41p.m. of the facility hallway by the resident room revealed that a medication cart was not locked. A clear medication cup on top of the medication cart had 2 white pills in it. There were no staff observed at the medication cart. During the 6 minute observation, there were 2 staff members and one resident that walked by the unlocked medication cart with the medication cup on top. The medication cart remained in observation until the Registered Nurse (RN/ staff# 51) returned to the cart at 3:47 p.m.An interview was conducted with staff #51, on April 9, 2026 at 3:47pm. A plastic medication cup with 2 white pills was observed on top of the medication cart, and staff #51 stated that the pills were Baclofen and Tylenol for resident #39. Staff #51 stated that she got busy and forgot to lock the medication cart. Staff #51 stated that the risk of an unlocked mediation cart and medications left on top of the cart could include that someone could steal the medications or someone could take someone else's medication and it could make them sick.An interview was conducted with the Director of Nursing (DON, staff #147) on April 9, 2026 at 3:50pm. The DON stated that medication carts need to be locked when staff step away from the cart. Staff #147 stated that the risk of leaving the medication cart unlocked included the potential for someone walking by taking the medications. Review of the facility policy titled Medication Access and Storage, Emergency Kit access revised July, 2024, revealed the facility is to store all drugs and biologicals in locked compartments under proper temperature controls. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

Based on observation, staff interviews, and policy review, the facility failed to store, prepare, distribute, and serve food in a manner that prevents foodborne illness to residents. The deficient practice could result in foodborne illness.Findings include:During the initial kitchen observation conducted on April 17, 2026 at 8:13 a.m., a comprehensive tour of the kitchen including the walk-in refrigerator and dry goods storage was performed with the Dietary Manager (staff #4).An observation of the contents of the walk-in refrigerator revealed an open container of ground beef on the bottom shelf. The open container of ground beef was stored with other unopened ground beef packages in the original cardboard box it had been delivered in. There was no evidence of a label or date on the open container of ground beef. Approximately 50% of the contents of the ground beef was found to remain in the plastic container/tubing that the product was originally packaged in. It was secured by having the open end of the product tied in a knot, and stored next to unopened ground beef packages in the same cardboard box.An observation of the dry goods storage room with staff #4 on April 7, 2026 at 8:25 a.m. revealed scoops used for bulk dry goods items, including oats and beans, to be stored in the open on a metal shelf next to assorted packaged food items. The scoops were observed to be visibly soiled, with dust remaining on them from previous use.An initial interview with the Dietary Supervisor (staff #4) was conducted at the facility at 8:30 a.m. on April 7, 2026. Staff #4 stated that ground beef should be dated after it is opened for use. Staff #4 reported a potential outcome for not dating and labelling ground beef after opening the package is that it can cause foodborne illness If used outside of applicable dates. Staff #4 stated that the observed storage of the bulk dry goods scoops is compliant with the facility policy.During a second interview with staff #4 conducted on April 10, 2026 at approximately 1:45 p.m., staff #4 stated that the facility policy regarding the labelling of food items varies depending on the food item. Staff #4 stated that opened food items should be stored in a separate container than unopened/unused food items per facility policy. Staff #4 stated a tub should be present next to the bulk dry goods containers to store the scoops when not in use. Staff #4 stated the scoops are cleaned on a daily basis. Staff #4 reported that cross contamination and foodborne illness could occur from not storing the dry goods scoops correctly.An interview with the Executive Director (staff #167) was conducted at the facility on April 10, 2026 at approximately 2:00 p.m. Staff #167 stated that the facility policy for storing, labelling, and dating food that has been opened and used is that every food item in the refrigerator should be labelled and dated. Staff #167 stated that he needed to review the facility policy to speak of the requirements for storing bulk dry goods scoops. Following policy review, staff #167 stated that the bulk dry goods scoops should be stored in a holder or washed beforehand.Review of the facility policy titled, Food Storage, revealed food is stored, prepared, and transported at appropriate temperatures and by methods designed to prevent contamination or cross contamination, following regulatory authority procedure for date marking. The facility food storage policy stated that date marking should indicate the date or day by which ready-to-eat, potentially hazardous food should be consumed, sold, or discarded and will be visible on all Time and Temperature Control for Safety (TCS) foods that is not for immediate use. Facility policy stated that TCS foods should be covered, labeled, and dated if stored and not for immediate use.Review of the facility policy titled, Food Storage, revealed scoops must be provided for bulk foods. Scoops may be stored in food as long as the handles do not touch the food, an alternative is to keep scoops covered in a protected area near the containers. Scoops are to be washed and sanitized on a regular basis.

Based on observation, interviews, record reviews and review of facility policy and procedures, the facility failed to ensure facility personnel handled and transported clean and soiled linens according to policy and followed appropriate room cleaning protocol to prevent the spread of infection. The deficient practice could result in the transmission of infection in the facility.Findings include:-Regarding LaundryAn observation of the laundry room was conducted on April 8, 2026 at 1:10pm. The observation revealed the Housekeeping Supervisor helping a resident get his clothes. They were going through racks of clothes hung up that were not covered and clothes were observed to be touching the ground.An observation was conducted of Floor Tech (staff #39) on April 8, 2026 at 1:12 p.m., who picked up the linen from the hallway soiled utility room and placed the soiled linens and clothes in the laundry room where they were separated. The observation revealed that staff #39 parked the cart outside the soiled linen laundry room door, which was open to the hallway. The cart he was pushing had a soiled linen bag on top of the cart and was otherwise not closed. Staff #39 stated that the soiled linen bag should be placed inside the cart with the lid on and not on the top of the cart without cover.An interview with the Housekeeping Supervisor (staff# 71) was conducted April 8, 2026 at 1:18p.m. Staff #71 stated that the process of handling soiled linens includes floor tech, housekeepers, and or care staff. She stated that the staff pick up the linen from the hallways soiled utility rooms in a cart that has a lid on it and then bring the linens and clothes to the soiled laundry room where they are separated and washed. Staff #71 stated that soiled linen carts should always be covered with a lid. She stated that the risk of 'parking' an uncovered soiled linen cart outside of the laundry room could cause contamination and the possibility of airborne illnesses to the residents and staff. Staff #71 further stated that the process of sorting contaminated linens from blood or contact isolation rooms included the use of red bags for transmission-based laundry. Staff #71 stated that the Floor Tech or nursing staff would transport the red bags and bring down the linens in the red bag within the bin or cart with a lid on the bin or cart. Staff #71 further stated that soiled linen is put in the yellow bin in the laundry room and that the red bag would go into the yellow bin with the rest of the soiled linen. Staff #71 stated that she was unsure how to deal with trash in a resident room where a resident was diagnosed with clostridioides difficile (C.diff). Staff #71 stated not transporting soiled linen in a covered cart with lid on could cause illness to the residents and bacterial issues that could spread to all staff and residents. She did state that the hallway soiled rooms also do not have a bin specific for red bags.An observation was conducted on April 9, 2026 at 3:25 p.m. with Lead Housekeeper (staff #99) who was folding and hanging clean linen and the clean linen was touching the floor. Staff did not place the linens that touched the floor back into dirty linens to wash. Staff #99 stated that she should have placed the linens that touched the floor back into the soiled linens to be rewashed or it could lead to a resident getting ill. Staff #99 further stated that they receive laundry training yearly on the computer and at the skills fair.An interview with the Housekeeping Supervisor was conducted on April 9, 2026 at 3:30 p.m. Staff #71 stated that staff should not be folding clothes against their body without having a gown on and that clean clothes should not be touching the floor. Staff #71 stated that the risks are bacteria and cross contamination.An interview with Licensed Practical Nurse (staff #65) was conducted on April 9, 2026 at 3:35 p.m. When asked how to handle soiled linen, she stated they place the linens in a clear bag and the process is not different for blood or a contact isolation rooms. She further stated that they do not have red bags and that all items are treated as contaminated. A staff interview with certified nursing assistant (CNA / staff #34) was conducted on April 9, 2026 at 3:40 p.m. Staff #34 stated that soiled linens are placed in a bag and the bag is tied. He stated that linens from a contact isolation room are put in a biohazard bag in a different container which is located in the resident's room.A staff interview with Licensed Practical Nurse (staff #14) was conducted on April 10, 2026 at 9:53 a.m. Staff #14 stated that when bagging soiled linens, we do not use colored bags and all soiled linens are put in the same covered bins. Staff #14 stated that staff should not be placing soiled linen on top of the bin and they should not be directly placing the soiled linens in a bag and walking down the hallway to the laundry room. Staff #14 stated that biohazard bags are used for bloody items and then most likely thrown away. She stated that the gray garbage cans are for trash and the yellow bins are for soiled linen. She stated that contaminated trash is disposed of the same way as regular trash.-Regarding HousekeepingAn Observation was conducted on April 10, 2026 at 10:36 a.m. Housekeeper (staff #181), was observed in a resident room sweeping up dirty gloves and wipes, soiled with brown matter which appeared to be fecal matter. She was observed to be sweeping from the inside of the room to the outside of the room doorway. An interview was conducted with staff #181 on April 10, 2026 at 10:40 a.m., Staff #181 stated that she was not sure of the facility process of cleaning contaminated items and did not understand what the risk would be. An interview with Licensed Practical Nurse (staff#14) was conducted on April 10, 2026 at 11:28 a.m. Staff #14 stated that the proper way to dispose of gloves/wipes contaminated with feces should be by picking them up and putting them in a bag. She stated that sweeping them is not permitted due to infection control concerns.An interview with Housekeeping Supervisor (staff #71) was conducted on April 10, 2026 at 11:29 a.m. regarding sweeping and removal of soiled gloves and or wipes. Staff #71 stated that the correct process for picking up soiled/ contaminated wipes or gloves is to pick them up and bag them. She stated she would re-educate the staff. An interview with Infection Control Preventionist (staff #14) was conducted on April 10, 2026 at 1:30 p.m. Staff #14 stated that staff were not following the process and procedure to minimize infections at the facility regarding soiled linen. Staff #14 also stated that the resident rooms should not be cleaned by sweeping contaminated gloves and wipes around the room. She stated they should be picked up with a glove on and put in a bag. She stated that the risk for not following identified processes could spread or cause infections throughout the facility.An interview was conducted with the Director of Nursing (staff #147) on April 10, 2026 at 1:45 p.m. Staff #147 stated that housekeeping did not clean the resident room in a safe manner by sweeping gloves and contaminated wipes across the floor. Staff #147 stated that this could cause residents and staff to get sick. Staff #147 further stated that the procedure for handling soiled linen was not followed and could cause infection to residents and staff.The Infection Prevention and Control Program Policy, reviewed on April 8, 2026, is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. The elements of the Infection Prevention and Control Program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. The policy further revealed that staff and resident education is done to identify risk of infection and promote practices to decrease risk. Policies, procedures and aseptic practices are followed by personnel in performing procedures, linen handling and disinfection of equipment. Linen Handling Policy, revised January, 2025, revealed that the facility is to take careful precautionary procedures and must be followed by laundry personnel to prevent the spread of infectious diseases to other staff members, residents and visitors. Clean and soiled linen shall be separated at all times. All soiled linen shall be treated as possibly infectious and handled as such. Any clean linen that falls on the floor or is touched with hands that have not been washed are also considered soiled. Clean linens should be carried and held away from the body.The Housekeeping Services Policy, revised December, 2024, stated it is the policy of the facility is to promote a sanitary environment.

Based on observations, staff and resident interviews, facility documentation, and policy review, the facility failed to ensure the smoking policy was implemented and followed for one resident (Resident #19) out of two sampled residents. The universe was 18. The deficient practice could increase the risk of smoking-related accidents. Findings include: Resident #19 was re-admitted to the facility on [DATE] with diagnoses that included a displaced fracture of medial condyle of right tibia, chronic pain syndrome, schizoaffective disorder, bipolar type, and depression. The care plan first initiated on May 6, 2022 revealed a focus indicating Resident #19 had the potential for injury related to smoking. Interventions for this focus included to provide education regarding safe smoking practices, maintain smoking materials at designated areas, and monitor and assess compliance with facility smoking policy. There was no evidence within the care plan indicating Resident #19 may keep smoking items on their person.The quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #19 had a brief interview for mental status (BIMS) score of 14 which indicated Resident #19 was cognitively intact. Further review of the MDS revealed Resident #19 was not utilizing oxygen. Review of the Smoking Evaluation-Version 2, dated February 8, 2026 revealed Resident #19 may light her own cigarette and had been provided education on safe smoking practices. However, there was no evidence in the smoking evaluation that stated Resident #19 may keep smoking items in her possession. Review of the Smoking Policy and Procedure form, signed by Resident #19 on July 10, 2022 revealed residents may not keep lighting materials, tobacco products, e-cigarettes, and smoking devices on their person or in their possession. An observation of the designated smoking patio was conducted on April 9, 2026 at 9:31 a.m. The Activities Supervisor (Staff #44), Administrator-in-Training (A.I.T./Staff #237), and Resident #19 were in attendance. Resident #19 was observed to remove a flame lighter and pack of cigarettes from her purse. Resident #19 proceeded to light a cigarette and place the lighter and pack of cigarettes back into her purse. An observation was conducted on April 9, 2026 at 9:41 a.m. of Resident #19's room. Resident #19 removed two 24/7 Red 100's brand cigarette packs and a blue flame lighter from her purse. An interview was conducted on April 9, 2026 at 9:41 a.m. with Resident #19. Resident #19 stated she had been at the facility for about two years and has been smoking prior to admission. Resident #19 stated the facility asked her questions about her smoking abilities and stated she may light her own cigarettes. Resident #19 stated there are no set smoking times and she can go out whenever she wants. Resident #19 stated she keeps her smoking materials with her in her purse at all times. An interview was conducted on April 9, 2026 at 9:57 a.m. with a housekeeping assistant/smoking attendant (Staff #127). Staff #127 stated he had been filling in as a smoking attendant but it is not normally a part of his job description. Staff #127 stated he will ensure the smoking residents are in the designated area, placing their trash in the correct bins, not passing cigarettes to other residents, and make sure residents are not taking smoking materials back to their rooms. Staff #127 stated residents should not be keeping smoking materials on their person as that would pose a safety risk. An interview was conducted on April 9, 2026 at 10:28 a.m. with a registered nurse (RN/Staff #51). Staff #51 stated there is a designated patio where residents may smoke and a smoking policy is signed upon admission. Staff #51 stated a smoking evaluation would be completed and the resident's care plan would reflect their smoking abilities. Staff #51 stated residents are not allowed to keep any lighters, cigarettes, or e-cigarettes in their possession and these must be given to the clinical staff or kept in a locker on the smoking patio. Staff #51 stated the risk of residents keeping smoking materials could lead to safety issues such as preventable fires. An observation of the designated smoking patio was conducted on April 9, 2026 at 10:49 a.m. where Resident #19 and the smoking attendant (Staff #237) was located. Resident #19 was observed to remove a cigarette and blue lighter out of her purse. Resident #19 proceeded to light the cigarette and place the lighter back into her purse. An interview was conducted on April 9, 2026, at 11:24 a.m. with Staff #44. Staff #44 stated that she, along with two unit managers, oversees the smoking patio. Staff #44 explained that the patio is open for smoking to residents who have been assessed as independent, while residents requiring assistance are assigned designated smoking times. Staff #44 reported that the facility does not employ designated smoking attendants; however, staff members are present on the patio when residents go out to smoke. Staff #44 further stated that independent residents are required to store their smoking materials in assigned lockers and are not permitted to keep these items on their person. Staff #44 indicated that if residents retain smoking materials in their possession, it poses a risk of injury to themselves or potential harm to the environment. She added that if she observes a resident with smoking materials that are not properly stored, she would provide education on the facility's policy and notify the unit managers. However, she clarified that she would not confiscate the items.An observation of Resident #19's room was conducted on April 9, 2026, at 11:59 a.m. with Staff #51. During the observation, Resident #19 removed two packs of 24/7 Red brand cigarettes and two blue flame lighters from her purse. Staff #51 informed the resident that she is not permitted to keep smoking materials in her possession and that the items would need to be secured. Staff #51 explained that designated lockers are available for storing cigarettes and lighters. Resident #51 was further advised that this policy is in place to reduce the risk of accidents. An interview was conducted on April 9, 2026 at 1:10 p.m. with the Director of Nursing (DON/Staff #147). Staff #147 stated that a resident or family representative signs the facility smoking policy upon admission and a smoking evaluation would be completed by the clinical staff to assess the resident's smoking abilities. Staff #147 stated if a resident was evaluated to smoke independently, the resident would be provided a locker and lock to store their smoking materials. Staff #147 stated lockers are provided because the residents are not allowed to keep their lighters and cigarettes in their possession as it poses a safety risk to all residents. Staff #147 stated if a resident was found with lighters or tobacco products in their possession the expectation would be to confiscate the items and report it immediately. Review of the Smoking Policy last revised January 2025, revealed residents who choose to smoke are provided with the means to do so in a way that does not put their safety or any others at risk. Review of the policy revealed no lighting materials, tobacco products, or smoking devices will be allowed to be kept in the possession of the residents, either on their person or in the facility. Further review of the policy revealed residents assessed to safely smoke independently will be provided a combination locker on the smoking patio where they will be able to store cigarettes.

Based on observations, staff interviews and review of facility policy the facility failed to maintain comfortable water temperature to meet resident needs and food within a safe temperature for consumption. The deficient practice could have a negative psychosocial impact on residents. Findings include: The following resident interviews were conducted on October 10, 2024 care services provided in the facility: -Resident #10 stated that there was no hot water in the bathroom. -Resident #3 stated that food is cold not warm. Moreover stated there is no hot water; and that, her last shower was on September 30 because there is no hot water. -Resident #22 at 3:24 pm stated that there was no hot water for couple days. -Resident #30 stated that the soup is usually cold. There was no hot water today and Sunday. He was told that there is no hot water in the shower, their shower room is down by the hall, and the certified nursing assistant (CNA)/Staff #120 told him that there is no hot water today that he is supposed to receive a shower. Resident #30 family/visitor at bedside during interview. On October 11, 2024 at 08:38 am, Resident #33 stated that soup is cold; and that they have asked for reheating their food, however that the staff's expression appear to being bothered so residents just eat it cold. They stated that coffee was cold. On October 11, 2024 at 08:45am, human resources manager/Staff #6 was observed mopping the floor by the soiled room in station 2. She stated that they had a water back up this morning, they were notified by the night staff about the back up of water and they already had a plumber working on it. At 08:54 am, the director of nursing (DON)/Staff #22 stated that he had never seen flooding before, he stated that they have been working on their kitchen plumbing for a month ago, and he is not aware of any issues with plumbing or issues with water. Staff #300/executive director stated that they were remodeling their kitchen replacing pipes and their plumbers come at night so not to disturb care. An observation revealed white towels on the floor by the entrance door in room [ROOM NUMBER] and an air circulator is in the clean linen room next to the soiled room. Furthermore, observation revealed bathroom flooding in room [ROOM NUMBER]. On October 11, 2024 at 10:47am, shower sheets were requested for resident #30 which revealed shower sheets this week were missing. On October 11, 2024 at 1:09 PM, dietary manager/Staff #15 assissted with measuring the food temperature of a test tray ordered during investigation which revealed: temperature of turkey is at 117 degrees Fahrenheit, the stuffing temperature is at 128 degrees Fahrenheit, and the mixed veggies temperature is at 112 degrees Fahrenheit. The dietary manager stated that the food temperature when it reaches the resident should be around 110 degrees or higher. An interview was conducted with an LPN/Staff #149 on October 11, 2024 at 1:12pm who stated that they use Hoyer lift or Sara lift mechanical devices for transfers, one person assists or two person assist if resident able to stand up, and gait belt are used for transfers. Regarding showers, they have assigned showers for days and evening shift, and residents get at least a two showers a week. They use shower sheet every time even when a resident refuses a shower. They use the shower sheets for skin checks. He stated that he has not heard of any plumbing issues, but that there were toilet issues, and they have maintenance staff all the time. An interview was conducted with the DON on 10/11/2024 at 2:22pm. The DON stated that the meal times for delivering meals are on time according to posted meal times. The process for ordering food for the residents is they have a regular menu and an alternative menu, if they don't want the main dish they have alternative menu. A phone interview was conducted with staff #120/CNA. He stated that he gave a bed bath to a resident and one shower to another resident. He stated that they have issues with water and they are trying to fix it, and during the evening there is no warm water. A review of facility policy titled, Resident Rights, reviewed 3/2024 revealed (1) the resident has the right to be treated with consideration, respect, and full recognition of his or her dignity and individuality, and (5) to be encouraged and assisted throughout his or her stay in the center.

Based on observations, staff interviews and facility policy and procedure, the facility failed to there were no expired food items readily accessible for resident use; failed to follow proper food handling practices while preparing food; and, failed to ensure open food items were stored, labeled and dated in accordance with professional standards for food service safety. The deficient practice could result in food-borne related illness. Findings include: During the initial kitchen observation conducted with the dietary supervisor (staff #23) on [DATE] at 8:47 a.m., the refrigerator contained the following food items that were beyond their use by dates: -Grape jelly, use by date of [DATE]; -Mustard, use by date of February 24, 2024; and, -Clear package containing 5 impossible burgers, use by date of [DATE]. This package was also not sealed and was open to air. The refrigerator also had an 8-lb (pound) container of potato salad that was open; and, a metal serving pan with caked grease on the top containing cooked hotdogs in water, and was partially covered with a plastic wrap. The freezer contained a 5-lb bag of frozen green beans, impossible patties container and ,d+[DATE] count case of ground beef patties that were open and not sealed. The dry storage had one 16-oz package of Jet Puff Marshmallows was open and not sealed. Continued observation revealed that the cook (staff #7) was cleaning the meat preparation station with the cloth from the sanitizing bucket; and, returning the cloth back into the sanitizing solution with pieces of raw ground beef. The cook then grabbed the same cloth from the sanitizing solution and proceeded to clean and sanitize the meat preparation station with the same cloth. An observation of puree preparation conducted with the dietary supervisor (staff #23) and the cook (staff #7) on [DATE] at 10:54 a.m. The cook used his ungloved hand, scooped cheese sauce into the cooked macaroni and touched the cooked macaroni. He then wiped his ungloved hands onto his apron; and, he placed the cooked macaroni and cheese sauce into the blender and when finished, placed the cooked macaroni and cheese in the metal warming tray. The cook stated that he knew when the food was the right consistency and texture; and that, the pureed macaroni and cheese was ready to serve. The dietary supervisor (staff #23) tasted and tested the macaroni and cheese and told the cook that it was too thick and gritty and still had chunks that needed to be blended more. The cook placed and blended the cooked macaroni and cheese back into the blender and placed it into the serving tray without testing the consistency and texture. The dietary supervisor (staff #23) tasted and tested the macaroni and cheese and stated that the pureed food was still too thick and gritty and the cook had to blend it again. The cook placed the food back into the blender and the dietary supervisor told the cook that it needed to be thinned out. The cook then prepared chicken stock to add to the macaroni and cheese. The dietary supervisor stopped him and told him to add milk instead of the chicken stock as the macaroni and cheese was a cheese product. Immediately following the preparation of the macaroni and cheese, the cook took the same cloth from the same sanitizing bucket that used the meat preparation area and contained raw ground meat; and, clean the surface where the puree preparation was done. The dietary supervisor then told the cook to use the cloth from the new sanitizing bucket. In an interview with the dietary supervisor (staff #23) conducted on [DATE] at 9:44 a.m., the dietary supervisor stated that expectations were that the sanitizing concentration reading were according to the range that they were supposed to be. The dietary supervisor stated that the risks associated with using cleaning solution not at the right concentration include E-Coli (bacteria) and other underlying foodborne illnesses that would make the residents sick. Further, the dietary supervisor stated that it was an expectation that dietary staff follow proper storage, labeling and dating food items opened; and, discarding any food items after the expiration or use by date Review of the facility policy on Food Storage revealed that sufficient storage facilities will be provided to keep foods safe, wholesome, and appealing. Food will be stored in an area that is clean dry, and free from containments. Food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Food should be dated as it is placed on the shelves if required by state regulation. Date marking should be visible on all high-risk food to indicate the date by which a ready-to-eat, TCS food should be consumed, sold or discarded. Food will be stored and handled to maintain the integrity of the packaging until ready for use. Plastic containers with tight-fitting covers or sealable plastic bags must be used for storing grain products, dried vegetables and broken lots of bulk foods or opened packages. All containers or storage bags must be legible and accurately labeled and dated. Refrigerated and frozen foods should be covered, labeled and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. All refrigerated and frozen foods should be stored to allow air circulation.

Based on clinical record review, staff interviews, facility documentation, policy and procedure, the facility failed to ensure that accurate identification of one resident (#2) prior to transportation to an out of facility appointment; and, failed to ensure medical appointment was not missed for one resident (#1). The deficient practice resulted in one resident missing a scheduled appointment; and, the wrong resident was taken to an appointment. Finding include: -Resident #2 was readmitted at the facility on June 2, 2022 with diagnoses of metabolic encephalopathy, altered mental status, heart failure, sequelae of unspecified cerebrovascular disease and psychotic disorder with delusion. The care plan dated January 28, 2022 revealed the resident was at risk for impaired cognitive function/dementia or impaired thought processes. Intervention included to identify self at each interaction. Another care plan dated May 2, 2022 included the resident was dependent on staff for activities, cognitive stimulation, social interaction related to physical limitations, required transport and adapted materials. The monthly nursing summary dated May 11, 2023 revealed resident used a wheelchair for mobility and was totally dependent with 1-person assistance for wheelchair locomotion. It also included that the resident was incontinent with bladder and required 2-person assistance for transfers, bed mobility and toileting The NP (nurse practitioner) progress note dated May 12, 2023 included the resident was alert and forgetful. -Resident #1 was admitted on [DATE] with diagnoses of altered mental status, weakness, hemiplegia, unspecified sequelae of cerebrovascular disease and cognitive communication deficit. The care plan dated December 28, 2021 included that the resident exhibited or was at risk for cardiovascular symptoms or complications related to hypertension; and, had a decline in cognitive function or impaired thought processes related to a condition other than delirium, short/long term memory loss and dementia. The IDT (interdisciplinary team)-BIMS (Brief Interview for Mental Status) note dated September 29, 2022 included a BIMS score of 9 indicating the resident had moderate cognitive impairment. The consultation note dated October 5, 2022 included assessments of atrial fibrillation and carotid artery stenosis. The plan was for echocardiogram 2 weeks prior to the next follow-up in 6 months. The monthly nursing summary dated May 8, 2023 included that the resident required extensive assistance with one-person for mobility/ambulation, was incontinent with bladder and required one-person assist for transfers, bed mobility and toileting. The appointment list for May 8 through 12, 2023 revealed that resident #1 had an appointment scheduled for the heart clinic on May 12, 2023 at 11:15 a.m. Per the documentation, transportation with confirmation number was arranged to pick up resident #1 on May 12, 2023 between 10:15 and 10:45 a.m. The appointment list did not include any appointment scheduled for resident #2 on May 12, 2023. The grievance/complaint report dated May 12, 2023 revealed that the resident's family made a complaint and was upset that resident #1 had missed her cardiologist appointment. According to the report, the appointment was rescheduled and an investigation was completed. The facility investigation dated May 12, 2023 included that resident #1 missed her cardiologist appointment; and that, resident #2 was sent in resident #1's place. Per the documentation, shortly after the facility was made aware, resident #2 was returned to the facility safely. The investigation also included an interview with a licensed practical nurse (LPN/staff #25) who stated that transportation showed up just after medications were given to resident #1; and that, the LPN directed the transportation to resident #1 who was sitting in the dayroom. Per the report, the LPN reported that resident #2 was also in the day room and she clearly identified resident #1 to the transportation driver. Further, the investigation included that the NP was notified and the appointment was rescheduled for July 20, 2023. The quality team tracking form dated May 15, 2023 included identified problems that resident was sent out to the appointments without verification of appropriate resident; and that, transportation company was not verifying identification of residents being transferred to appointments. Causal factors included the following: staff lack of education on appointment process and proper identification of staff; staff lack of education to verify that name on doctor's appointment folder matches the name of resident; staff lack of education on location of appointment calendar and being aware of what resident was scheduled for appointments that day; and, vendor lack of education on facility's process for identification of residents prior to transporting to appointment. Interventions included education of staff regarding appointment process, resident rights; second identification to verify appropriate resident was sent to the appointment matches the appointment folder; calendar will be placed at the nurses desk daily with updated appointments; implemented audits to verify that appropriate resident s were sent to appointment and staff verifying correct resident was sent out; and, education of vendors on the facility's expectation on verification of residents identification and verifying with staff that appropriate resident was transferred. The facility also provided documentation of audits they completed to address these problems; and, copies of in-service training they completed with staff. However, at the time of the survey, the audits and in-service training presented were documented as ongoing; and, the quality team tracking form and the supporting documents submitted did not indicate that the identified issues have been resolved. An interview with an LPN (staff #10) was conducted on May 31, 2023 at 6:36 p.m. The LPN stated that when she comes for her shift in the morning, there is a list located at the nurse station; and, the list included all the residents that are scheduled for an appointment that day. She stated the unit secretary was responsible for scheduling the appointment, arranging the transportation and preparing the paperwork/packet for the appointment. She stated that when a resident has an appoint, she ensures that the CNA (certified nurse assistant) prepares the resident for the appointment. She said that the nurse on shift was responsible for ensuring that transportation will pick up the right resident for the appointment; and that, the nurses knows the residents so the nurses would know if transportation picked-up the wrong one for the appointment. The LPN stated that once transportation comes in to pick up the resident, she will give them the packet and will the resident for the appointment. Further, the LPN said that if the resident was not alert and oriented, there will be an escort assigned to go with the resident to the appointment. In an interview conducted with another LPN (staff #2) conducted on May 31, 2023 at 6:48 p.m., the LPN said that there was a staff responsible for scheduling appointment and arrange for transportation of the resident. He stated that staff will also prepare all the paperwork needed for the appointment. He said that scheduled appointments are found in the electronic record and in a list located at the nurse station. He stated that the list was an easy way to check which resident was going to an appointment. The LPN said that the resident will be picked up by transportation at the time scheduled and would also be brought back by the transportation arranged for that day. He stated that the information regarding the resident name and where the appointment will be is on the packet that was prepared for the appointment. He said that if the resident was not alert and oriented, an escort is assigned and will have the resident's packet. The LPN further stated that the nurse on shift the day of the appointment would know if the correct resident was taken by transportation because the transportation driver goes to the nurse station and would the nurse who they were picking up. An interview with the transportation specialist (staff #35) was conducted on June 1, 2023 at 11:18 a.m. Staff #35 stated that the nurses would place orders for appointments in the binder which she will check on a daily basis. She said that she would call the provider, schedule an appointment; and, once the schedule was confirmed, she will arrange for transportation. Staff #35 said that once a schedule and transportation was set, she will create a packet that includes the date/time/place of appointment, pick-up times, with or without escort, transportation company information. An interview with two clinical resource (staff #4 and #58) was conducted on June 1, 2023 at 1:00 p.m. Staff #4 stated that resident #1 missed the cardiology consult because there was a problem with transportation; and that, transportation picked up the wrong resident (#2) to the appointment of resident #1. Staff #4 stated that when transportation driver came to pick up resident #1 that day, the LPN (staff #25) was in the process of giving medication to another resident; and when the LPN got done with medication administration, the transportation driver was already gone. Staff #4 stated that both residents (#1 and #2) were two different rooms and were not roommate; and that, both residents were inside the activity room when transportation came. Staff #58 stated that the DON (director of nursing) instructed the transportation company to write an incident report; however, there was no incident report submitted because it was the transportation driver who reported the incident to the police. In an interview with another LPN (staff #41) conducted on June 1, 2023 at 1:55 p.m., the LPN stated that when she gets in for her shift, she will check the list of all the residents that will have an appointment for the day. She stated that the highlighted boxes in the list referred to the residents in the unit that has an appointment. The LPN stated that she will then instruct the CNA to prepared the resident for the appointment; and, when transportation arrives, she will hand them the packet and will direct transportation to the resident's room or the location of the resident. The LPN said that the nurse will identify the resident for the transportation staff; and that, as soon as she finds out that the wrong resident was taken by transportation, she will immediately call the transportation company and instruct them to come back. The LPN said that she will also notify management and ask them if she needed to document the incident; and if so, she will document it in the clinical record. She stated that will definitely call the resident's family and inform them of the incident, apologize and explain what happened. Regarding the incident, the LPN stated that she was aware that transportation took the wrong resident for the appointment of resident #1; however, she did not know the details of the event. An interview with the transportation company manager (staff #1) conducted on June 1, 2023 at 3:01 p.m., staff #1 stated that the transportation driver (staff #12) went to the facility to pick up a resident for an appointment. He stated that staff #12 informed the nurse who brought the resident out and told and identified the resident for staff #22; but that, the nurse had to give the resident her medication first. Staff #1 stated that staff #22 waited until the medication was given and took the resident to the appointment. Staff #1 said that shortly thereafter, someone from the facility called the dispatch and instructed to return the resident as it was the wrong resident. He stated that staff #22 came back at the facility and returned the resident. During an interview with the transportation driver (staff #12) conducted on June 1, 2023 at 3:09 p.m., staff #12 stated that he arrived at the facility and told the nurse that he was picking up resident #1 for an appointment. He stated the nurse gave him the room number for resident #1 who was not in the room; and that, he told the nurse who was at the medication cart at the station and told him that the resident was out and about. Staff #12 said that the nurse looked for the resident and came back and handed a female resident who was sitting in the wheelchair and told him here she is. He stated that the nurse told him that medications needed to be given so he waited; and then, he took the resident to the appointment site and gave the packet to the receptionist at the clinic and he left the resident at the reception area. he stated that shortly thereafter, dispatch called him and instructed him to pick the resident; however, he stated that dispatch did not tell him why so he assumed that the appointment was done. Staff #12 said than when he arrived at the clinic, the receptionist told him that it was a wrong resident that was taken to the appointment; and that, he returned to the facility and told the nurse that she sent him the wrong resident. he stated that the nurse appeared confused and denied the whole thing. Further, staff #12 stated that as he was leaving the facility, he met the resident's family at the front lobby and the resident's family told him this is resident #1 and pointed to resident #1. He further stated that the total time for the incident from pick up to return to facility was about an hour or a little over an hour. The facility policy on Appointments included that it was their policy to coordinate and arrange for appointments as ordered by the physician. The facility will maintain a system to monitor ordered appointments; and, the resident or responsible party will be notified of the appointment and of any changes/issues. The facility policy on Transportation to Diagnostic Appointment revealed that it was their policy to assist residents in arranging transportation to/from diagnostic appointments when necessary.

Based on clinical record review, staff interviews, and policy and procedure, the facility failed to ensure advance directive was accurate for one resident (#270). The sample size was 3. The deficient practice could result in residents' wishes not being honored. Findings include: Resident #270 was admitted to the facility on [DATE] with diagnoses that included end-stage renal disease, dependence on renal dialysis and age-related osteoporosis without current pathological fracture. Review of the physician's order dated [DATE] revealed an order for CPR (Cardio Pulmonary Resuscitation)/ Full code. Review of the PCC (Point Click Care) electronic record dashboard display revealed resident #270 was a full code. However, review of the advanced directive statement form revealed the resident advance directive was signed for a DNR (Do Not Resuscitate) on [DATE]. Further review of the clinical record revealed that an orange DNR code status advance directive form had been completed on [DATE]. An interview was conducted with a licensed practical nurse (LPN/ staff #161) on [DATE] at 10:59 am. She stated that an advance directive is obtained on admission and updated as the resident's status change; and, she will usually look for the advance directive in the facesheet in PCC and also look at the physician order. Staff #161 stated that an order is entered in PCC after the resident decide on their advance directive; and that, the advance directive in PCC should match to what the resident signed as the staff need to know resident's wishes when life saving measures are needed. An interview was conducted on [DATE] at 11:04 am. with another LPN (staff #86) who stated if the resident chooses to be DNR, an orange DNR paper is completed as soon as possible and signed by the resident, nurse and physician. Staff #86 said that the advance directive order is updated in PCC and the orange paper is scanned in PCC as well. He further stated that the advance directive signed and the physician order entered in PCC should match because in an emergency, nurses need to follow resident's wishes and not provide CPR when resident signed for a DNR. In an interview conducted with the Director of Nursing (DON/staff #132) on [DATE] at 11:49 a.m., the DON stated that his expectation was for staff to obtain advance directive during the resident's admission and ensure there is appropriate documentation in the electronic record. He stated if the resident chooses to be a DNR, there should be an orange DNR form signed. Further, the DON said that the advance directive in PCC and what the resident signed should match to avoid confusion and to let nurses know of resident's wishes during an emergency. Review of the facility policy titled Advance Directives and revised [DATE], stated that it is their policy that a resident's choice about advance directives will be recognized and respected. The policy stated once the advance directive or information regarding resident preferences regarding treatment options is received by the facility, it will be confirmed in the resident medical record and communicated to members of the care plan team. The facility will also notify the attending physician of advance directives so that, if necessary, appropriate orders can be documented in the resident's medical record and plan of care.

Based on clinical record review and staff interview the facility failed to ensure that one resident's privacy (#322) was protected. The deficient practice could result in resident's right to privacy not respected and honored. Findings include: Resident #322 was admitted on [DATE] with diagnoses of fracture of unspecified metatarsal bone(s), left foot, subsequent encounter for fracture with routine healing, contusion of the right knee, subsequent encounter and abnormalities of gait and mobility. Review of the MDS (Minimum Data Set) discharge assessment dated [DATE] revealed the resident required extensive assistance with her activity of daily living and had a BIMS (Brief Interview for Mental Status) score of 15 indicating the resident was cognitively intact. The care plan with initiation date of January 9, 2022 included the resident was at risk for falls related to cognitive loss, lack of safety awareness and history of falls with fracture. Interventions included resident needed a safe environment. Review of facility documentation revealed that during the night of December 29, 2021, another resident wandered into the room of resident #322. According to the note, the other resident was crawling around on the floor and playing with the bed sheets of resident #322. Per the documentation, on December 30, 2021 resident #322 reported to staff that she did not feel safe being there because of the other resident's presence in her room. During an interview conducted with a licensed practical nurse (staff #86) on December 8, 2022 at 8:04 a.m., the LPN stated that he does not recall resident #322, but did remember the other resident who entered the room of resident #322. The LPN stated that the other resident was very cognitively impaired and wandered around her room and the unit on her hands and knees. The LPN stated that the other resident was being monitored every 15 minutes but staff could not redirect the resident from wandering. An interview was conducted on December 8, 2022 at 8:10 a.m. with a certified nursing assistant (staff #130) who stated that he knew resident #322 and the other resident whom he described as being a handful to care for. He also stated that other resident kept crawling around on the unit and when staff would try and redirect her or provide care she would scream, scratch and hit the staff. The LPN said that he was aware of the incident because resident #322 told him about it after resident #322 was moved to a new room in the facility. The LPN further stated that the other resident was eventually moved to another facility as the resident was unable to be redirected. In an interview conducted with the Director of Nursing (staff #132) on December 8, 2022 at 8:19 a.m., the DON stated that he was not present when the incident occurred and he was not aware of the details of the incident. However, he stated that his expectation was that staff would redirect and ensure resident safety and then notify himself and the provider. During an interview conducted on December 8, 2022 at 8:28 AM with the Executive Director (staff #41), he stated he vaguely recalls the incident which occurred prior to the facility take over. He said that he expects staff to redirect any resident from wandering and ensure resident safety. Review of the facility policy on Resident Rights included that it is their policy that all resident rights be followed per State and Federal guidelines as well as other regulatory agencies.

Based on the closed clinical record review, staff interviews, and review of facility policy and procedures, the facility failed to ensure resident's representative was informed of discharge for one resident (#273). The deficient practice could result in discharge/transfer requirements not being met. Findings include: Resident #273 was admitted on [DATE] with diagnosis that included encephalopathy, muscle weakness, cerebrovascular disease and aphasia; and, and discharged on [DATE]. The baseline care plan dated February 19, 2022 included the resident was at risk for impaired cognitive function/dementia or impaired thought processes related to stroke. Intervention included that the resident needed supervision/assistance with all decision making. A progress notes from social service dated March 9, 2022 at 4:56 pm stated that the social service staff spoke to the resident's son regarding upcoming discharge and per son, he stated he will be appealing and completed financial portion of AZLTC. The progress notes further stated that the writer spoke with the resident's son about group home option in the meantime of the pending AZLTC application. The note stated the son was open to the idea. The social service progress note dated March 9, 2022 stated referral was sent to placement agent for possible group home placement. Review of the NOMNC (Notice of Medicare Non-Coverage) form included that services will end on March 11, 2022. The form also revealed that on March 9, 2022 at 9:30 a.m., the family was provided via telephone the NOMNC information regarding the appeal process that included an instruction that to file an immediate appeal, the QIO (Quality Improvement Organization) must be called by noon on March 10, 2022. The NOMNC also stated the reason why member could not sign/understand was because the member was not alert and oriented. The social service progress note dated March 11, 2022 revealed that family was appealing the discharge and waiting on return call from the QIO. According to the note, the family was made aware that even with the appeal going on, the facility was still looking for a group home and was going to order all DME (Durable Medical Equipment) needed for discharge just in case the resident lose in the appeal. Another social service progress note dated March 11, 2022 included the family was informed that the resident's discharge was held due to the appeal. Review of physician's order dated March 11, 2022 revealed that DC (discharge) held due to appeal. A review of the result of the appeal revealed that the appeals process was started on March 11, 2022 at 5:53 p.m. and medical records were received on March 12, 2022 at 10:37 a.m. Per the documentation, the outcome included that the case had not progressed to a physician review and to call the helpline for more details. The social service progress note dated March 14, 2022 included that the family was informed that the facility was not sure what was going on with the appeal as it did not say denied or approved. Further, the note included the family called the QIO; and that, the facility was working on getting the resident moved over to the group home by March 15, 2022. However, the progress note did not indicate whether or not the family was informed of and agreed on the facility's plan to move the resident to a group home by March 15, 2022. The discharge summary and post-discharge plan of care dated March 14, 2022 revealed the resident was discharged to an assisted living/board and care. The summary stated the discharge instructions were given to the resident; and that, the discharge summary was signed on March 15, 2022 by the facility nurse. The discharge progress note dated March 15, 2022 included the resident was discharged on [DATE] via stretcher at approximately 2:10 p.m. accompanied by the medical transport company's personnel. It further stated that the resident's belongings, orders and medications were sent with the resident. The discharge MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 3 which indicated severe cognitive impairment. The MDS included the resident had a planned discharge to the community with return not anticipated. A nursing progress note dated March 16, 2022 revealed that the family, NP (Nurse Practitioner) and case manager were notified of the resident's discharge to group home. However, the clinical record revealed no evidence that the family/resident's representative was informed of and agreed on the resident's discharge to a group home prior to March 15, 2022. Further review of the clinical record revealed the facility was not aware of the result of the appeal; and that, the resident's representative for resident #273 was not informed of the delay in appeal. An interview was conducted with the case manager (staff #8) and the business office manager (staff #146) on December 8, 2022 at 9:15 a.m. They both stated that the discharge process happens upon admission and the IDT (Interdisciplinary team) meet weekly to discuss the skilled residents. Staff #8 stated when a discharge date has been decided, a NOMNC will be issued and appeal process is explained to the resident and/or resident representative. Staff #8 stated that after an appeal number is provided, the resident's clinical records are faxed to the QIO (Livanta); and, the result of the appeal can be viewed through the QIO portal. Staff #146 stated that sometimes the facility receive a letter from the QIO and sometimes the facility had to call them to know the outcome of the appeal. Further, staff #145 stated the facility would not discharge a resident without an appeal outcome. During another interview with staff #146 on December 8, 2022 at 9:42 a.m., she stated she spoke the QIO on December 8, 2022 and was informed the appeal for resident #273 was not done in a timely manner by the resident's representative; therefore, the appeal was not processed. An interview was conducted with the Director of Nursing (DON/ staff #132) on December 8, 2022 at 11:49 a.m. The DON stated that when a resident or their representative appeal their discharge, the facility should have the result from the appeal before discharging the resident. He stated if there is no result from the appeal, the facility should be reaching out to the QIO to ask for the outcome of the appeal. He stated the facility should also be coordinating with the resident representative about the process and follow up with discharge decisions if the appeal process is taking a long time. The facility policy titled Criteria for Transfer and Discharge revised on January 2022 stated that if the resident exercises his or her right to appeal a transfer or discharge notice, the facility shall not transfer or discharge the resident while the appeal is pending.

Based on resident and staff interviews, review of the clinical record, facility documentation and policy, the facility failed to ensure that one resident (#89) was provided a copy of their baseline care plan. The deficient practice could result in resident not receiving the needed care and services. Findings include: Resident #89 was admitted on [DATE] with diagnoses of quadriplegia C5-C7, fusion of spine unspecified, muscle weakness and need for assistance with personal care. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident wass cognitively intact. Review of the clinical record revealed that a baseline care plan was created September 13, 2022. However, further review of the clinical record revealed no evidence that resident #89 was provided a copy of the baseline care plan. An interview was conducted on December 09, 2022 at 09:03 a.m. with resident #89 who stated that he did not receive a copy of his care plan. During an interview with the Director of Nursing (DON/staff #132) on December 8, 2022 at 12:45 p.m., the DON stated that care plans are provided to the resident and/or representative during the care plan meeting; and that, the facility should provide a copy of the resident's care plan 72 hours after admission. In an interview with two social workers (SW/staffs #70 and #8) conducted on on December 8, 2022 at 1:45 p.m., Staff #70 stated she had not printed any copies of a baseline care plan because no one requested for a copy; and that, if a resident asked for one, she would print out a copy. Staff #70 also said that they are responsible for providing a copy of the care plan to residents. Staff #8 said that care plans are provided to residents within 48 hours of a care plan meeting; and, there should be a progress note in the electronic record that would indicate that a copy of the care plan was provided to the resident. In another interview conducted with DON on December 8, 2022 at 2:04 p.m., the DON stated that her expectation was for the care plan to be accurate and up to date. The DON also stated that several staff could provide a copy of the baseline care plan to the resident; and that, care plans should be provided within 48 hours after admission. The facility policy on Baseline Care Plan policy revised April 2022 revealed that a baseline care plan needs to be developed and implemented within 48 hours of admission. The facility team will provide a written summary to the resident or resident representative.

Based on clinical record review and staff interviews the facility failed to ensure adequate supervision was provided for one resident (#183) to prevent her from wandering into another resident's room. The deficient practice resulted in resident invading another resident's privacy. Findings include: Resident #168 was admitted on [DATE] with diagnoses of vascular dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety and altered mental status. The 5-day MDS (Minimal Data Set) assessment dated [DATE] revealed the resident had severe cognitive impairment, required extensive assistance with activities of daily living and did not exhibit any behaviors. Review of a genral note dated December 22, 2021 revealed resident came out of her room in a sitting position multiple times throughout the shift and was hard to redirect. A general note dated December 23, 2021 revealed resident came out of her room multiple times this pm, scooted on the floor, was not wearing a top several times, banged on the walls in the room disturbing other residents and yelled loudly, was hitting and scratching the CNA. A general note dated December 25, 2021 included the resident scooted around on the floor multiple times this pm; was assisted off the floor by staff either into bed or wheelchair. Per the documentation, resident was very confused-calling out Uncle Bill; and that, resident was banging on the wall in her room disturbing other patients. The note also included that the resident goes into other resident rooms and was redirected multiple times. A nurse practitioner (NP) follow-up note dated December 27, 2021 revealed resident had increased agitation and behaviors noted, continued to crawl on her own after rolling from the bed, as well as crawling on the floor fro her wheelchair. Despite documentation of behavior affecting other residents, there was no evidence found in the clinical record that resident #168 was provided with increased supervision. Review of facility documentation revealed that during the night, resident (#168) wandered into another resident's room on December 29, 2021 and was crawling around on the floor and playing with the other resident's bed sheets. The care plans initiated on January 3, 2022 included the resident was at risk for impaired thought processes related to dementia. It also included that the resident was dependent on staff for activities, cognitive stimulation, social interaction and was at risk for falls related to cognitive loss and lack of safety awareness. During an interview conducted with a licensed practical nurse (staff #86) on December 8, 2022 at 8:04 a.m., the LPN stated that he remembered resident #183 whom the LPN stated described as very cognitively impaired and wandered around her room and the unit on her hands and knees. The LPN also stated that resident #168 was monitored every 15 minutes but staff could not redirect the resident from wandering. An interview was conducted on December 8, 2022 at 8:10 a.m. with a certified nursing assistant (staff #130) who stated that resident #168 was a handful to care for; and that, resident #168 kept crawling around on the unit and when staff would try and redirect her or provide care she would scream, scratch and hit the staff. The LPN said that resident #183 was eventually moved to another facility as the resident was unable to be redirected. In an interview conducted with the Director of Nursing (staff #132) on December 8, 2022 at 8:19 a.m., the DON stated that he was not present when the incident occurred and he was not aware of the details of the incident. However, he stated that his expectation was that staff would redirect and ensure resident safety and then notify himself and the provider. During an interview conducted on December 8, 2022 at 8:28 AM with the Executive Director (staff #41), he stated he vaguely recalls the incident which occurred prior to the facility take over. He said that he expects staff to redirect any resident from wandering and ensure resident safety. Review of the facility's policy on Professional Standards revealed that it is their policy that services provided meet professional standards of quality and be provided by qualified persons in accordance with each resident's care plan. The policy on Fall Management System included a purpose that each resident is assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision as appropriate to prevent accidents.

Based on resident and staff interviews, clinical record reviews, and policies and procedures, the facility failed to ensure choices and preferences were honored for two residents (#12 and #16). The deficient practice could result in residents not provided with opportunity to exercise autonomy regarding their interests and preferences. Findings include: -Resident #12 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The social service progress notes dated April 1, 2022 revealed the resident was her own responsible party, with no power of attorney in place and had her family as emergency contacts. Review of a care plan initiated on April 1, 2022 revealed resident had an unstageable wound to right posterior gluteal fold. Interventions included that if the resident refuses treatment, to meet with interdisciplinary team (IDT), the resident, and family to determine why, try alternative methods to gain compliance, and to document alternative methods. The NP (nurse practitioner) progress notes dated April 12 and 21, 2022 included the resident was alert and oriented. Another NP progress note dated April 26, 2022 included an attempt was made to examine the resident due to chronic right gluteal fold unstageable pressure injury. According to the note, the resident was already up in the wheelchair and was out for the day. It also included the resident was notified that the wound team would see her; but, the resident told the staff that she did not want to wait. The clinical record revealed multiple changes were made to treatment orders for the pressure injuries to the right gluteal fold. Review of NP progress notes dated May 10, 2022, revealed the resident voiced concern with wound; was worried that it was not healing; and that, it had been a few weeks since the patient was seen due to patient being up in chair and/or out of the building. The skin/wound progress note dated May 24, 2022 revealed that an attempt to see the resident was made, but the resident stated she wanted to be seen first thing in the morning. A review of the clinical record revealed no evidence that wound treatment time had been changed after the resident had requested it. The NP progress note dated June 21, 2022 included that attempts to see the residents at various times of the day were made. Per the documentation, it had been asked that resident wait on bed, on Tuesdays, to allow for examination and offered to be seen first to accommodate; but the resident was not cooperative. The NP note dated July 1, 2022 included that it was the first examination on the resident in six weeks due to noncompliance. It also included the resident was argumentative and denied refusals. The grievance resolution form submitted by the resident on July 1, 2022 revealed the resident expressed concern with the wound NP regarding documentation that she had been refusing to be seen. Per the documentation, the resident only refused to be seen if it was too late; and that, it (referring to wound care) was never early. Further, the documentation included the resident requested to be seen for wound care as early as possible due to her school schedule and being out of the building. The grievance investigation notes documented the resident refused treatments; but, did not address the request of the resident to change wound dressing time due to her schedule. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The assessment revealed presence Stage IV pressure ulcer. According to the assessment, the resident had not refused care during the ARD date (Assessment Reference Date) which ended July 3, 2022. The IDT (interdisciplinary team) meeting note dated July 5, 2022, did not indicate the resident request to change wound dressing time was discussed or addressed. An interview was conducted on August 18, 2022 at 11:01 a.m. with a licensed practical nurse (LPN/staff #4) who stated the facility policy is to follow and implement orders including wound care treatment as ordered by the physician. An interview was conducted on August 18, 2022 at 11:41 a.m., with the Director of Nursing (DON/staff #71) who reviewed the grievance submitted by the resident on July 1, 2022 and stated that the IDT meeting held on July 5, 2022 did not address the resident's recent grievance regarding her choice of wound care treatment time. A review of the clinical record was conducted with the DON during the interview; and, he said that he could not see any documentation of the determination as to the reason for resident refusal and staff trying alternative methods to address resident refusal according to the care plan. He stated there was also no documentation the facility had worked with the resident to find alternative times for wound care treatments according to the resident's choice and preference. He further stated the grievance form for July 1, 2022 did not indicate that the facility had addressed the resident's concern regarding the time of wound care treatments. -Resident #16 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission MDS assessment dated [DATE], revealed a BIMS score of 15 indicating the resident had intact cognition. The assessment also revealed the resident had a stage 3 and 4 pressure ulcers. The IDT care plan review dated June 28, 2022 included the resident was alert and oriented x 4 and was able to make needs known. Review of the pressure ulcer care plan initiated on July 22, 2022 revealed resident had pressure ulcer or potential for pressure ulcer development. Interventions included to administer treatments as ordered and following facility policies and protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician order dated August 11, 2022 included for negative pressure wound therapy (NPWT) to the right ischium every Monday, Wednesday and Friday for stage 4 pressure ulcer. Review of IDT notes revealed no documentation regarding a resident's request for a change in his wound dressing time. Further review of the clinical record revealed no documentation the resident had requested a change in wound dressing time on August 15, 2022. During an interview conducted with the resident #16 on August 17, 2022 at 11:10 a.m., the resident stated he had asked the wound care nurse to administer the wound dressing in the morning and not at lunch time. However, the resident stated the facility has not complied with his request nor did they discuss it with him. Resident #16 also said he again discussed this request with a nurse on August 15, 2022; and that, the nurse told him that they would do the wound dressing in the morning on Wednesday, August 17, 2022. Resident #16 said that today was Wednesday, August 17 and the wound staff had not come to do his dressing treatment in the morning as he had requested and as the nurse had said she would. In an interview conducted on August 18, 2022 at 10:15 a.m. an LPN (staff #4) who stated that if a resident chooses to have care/treatment at a different time, they will try to accommodate within reason; and that, the patient centered care is important. He stated when a resident refuses treatment related to being out, he would notify the practitioner and let administration know He state that there would be a team meeting with the resident to address their choice, and establish a better routine. An interview was conducted with another LPN (staff #16) on August 18, 2022 at 11:01 p.m. The LPN stated that when a resident refuse care, she would notify the provider and would discuss the reason of the refusal with the resident. She stated when a resident chooses to have their wound care treatment done at a certain time, staff would need to rearrange things to accommodate the resident request. An interview was conducted on August 18, 2022 at 11:41 a.m. with the DON (staff #71) who stated that if a resident refused care he would want to know the reason why, notify the physician and find a way to get the care done because the resident needs it. He stated the process was for staff to talk with the resident and offer the treatment/care at a different time. Review of the facility policy on Resident Rights revealed that it is their policy that all rights be followed per State and Federal guidelines as well as other regulative agencies. The resident has the right to be treated with consideration and individuality, to voice grievances regarding treatment or care or recommend changes and to have prompt efforts undertaken by the center to resolve them. The facility policy on Grievances included that it is their policy to make prompt efforts to resolve grievances the resident may have. The facility policy titled, ADL (activities of daily living) Services to carry out, it included that it is the policy of the facility to involve residents in decision making and given choices related to ADL activities as much as possible. In the facility policy on Wound Management it revealed that it is the facility's policy to develop a care plan that is individualized and designed to meet the needs of the particular resident for whom they are being developed.

Based on clinical record review, staff interviews, and policy and procedure, the facility failed to ensure pressure ulcer treatment was administered as ordered for two residents (#12 and #16). The deficient practice could result in treatment not being provided and development or worsening of pressure ulcers. Findings include: -Resident #12 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital discharge instruction dated March 31, 2022 revealed to follow-up with wound clinic for right ischial wound after discharge. Review of the initial admission record dated March 31, 2022 revealed the resident was admitted with a skin condition on the right gluteal fold. The Braden Scale dated March 31, 2022 included a score of 16 indicating the resident was low risk for pressure ulcer Regarding wound treatment to the right gluteal fold: The weekly skin evaluation dated April 1, 2022 revealed an unstageable pressure ulcer the right posterior thigh/gluteal, which measured 3 cm (centimeter) x 2 cm x 0.1 cm, with 50% eschar, 50% slough, small serosanguinous drainage. Per the documentation, plan was to continue current treatment order, cleanse with wound cleanser, pat dry, apply [MEDICATION(S)] and cover with dry or foam dressing, frequent turning and repositioning. However, review of the clinical record revealed no evidence that treatment was administered to the unstageable pressure ulcer from April 1, 2022 through April 3, 2022. The care plan initiated on April 4, 2022 included the resident was admitted with unstageable wound to the right posterior thigh/gluteal fold, stays up in her electric wheelchair for long periods of time and was at risk for breakdown related to [CONDITION(S)], cervical spinal cord injury. Interventions included to administer medications/treatment as ordered, wound care daily, follow facility policies/protocols for the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The weekly pressure ulcer note dated April 13, 2022 included a Stage 3 pressure ulcer to the right gluteal fold that measured 3.4 cm x 2.8 cm x 0.1 cm, with small serosanguinous exudate, slough on wound bed and defined wound edges. Per the documentation, the resident was seen by the wound NP (nurse practitioner), eschar was removed by sharp debridement; and that, there was new treatment order to clean with wound cleanser, pat dry, apply with [MEDICATION(S)] and cover with foam dressing. The weekly pressure ulcer assessment dated [DATE] included Stage 3 pressure ulcer to the right gluteal fold that measured 3.4 cm x 2.8 cm x UTD, with small serosanguinous exudate, slough on wound bed and defined wound edges. Per the documentation, the wound declined and treatment was changed from [MEDICATION(S)] back to [MEDICATION(S)]. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician orders dated April 22, 2022 and April 27, 2022 included to apply [MEDICATION(S)] to right gluteal fold and cover with foam dressing every day shift. The treatment administration record (TAR) for April 2022 revealed treatment were administered as ordered. A physician order dated May 5, 2022 included to pack loosely with [MEDICATION(S)] packing strip the wound to right gluteal fold, cover with foam dressing every day shift (discontinue date of July 12, 2022). Review of the clinical record revealed the documentation that the pressure ulcer to the right gluteal fold was assessed weekly and treatment was administered as ordered for May and June 2022. The weekly pressure ulcer assessment dated [DATE] included stage 4 pressure ulcer to the right gluteal fold that measured 0.5 cm x 0.5 cm x 2.9 cm, with small serosanguinous exudate, beefy red wound bed, defined wound edges. Plan was to continue with current treatment to pack loosely with [MEDICATION(S)] packing strip and cover with silicone dressing. A physician order dated July 12, 2022 included to cleanse right gluteal fold with wound cleanser, pat dry, pack loosely with AG (silver) alginate, cover with dry dressing every day shift for wound care. (start date of July 13, 2022). This order was transcribed onto the TAR for July 2022 and was documented as administered as ordered. It also included that the order was discontinued July 14, 2022. A physician order dated July 14, 2022 included to cleanse right gluteal fold with wound cleanser, pat dry, pack loosely with collagen and hydrogel, cover with gauze dressing and dry dressing every day shift for wound care. (start date of July 15, 2022 This order was transcribed onto the TAR for July 2022 and was documented as administered as ordered. It also included that the order was discontinued July 19, 2022. The weekly pressure ulcer assessment dated [DATE] included stage 4 pressure ulcer to the right gluteal fold that measured 0.6 cm x 0.6 cm x 3.2 cm, with moderate serosanguinous exudate, pink wound bed, defined wound edges. Plan was to continue with current treatment to pack loosely with [MEDICATION(S)] packing and cover with dry dressing. However, the physician order dated July 19, 2022 included to cleanse right gluteal fold with wound cleanser, pat dry, pack with collagen and packing strip (instead of [MEDICATION(S)] packing that was documented in the assessment). The start date for this order was July 20, 2022. This order was transcribed onto the TAR for July and revealed that treatment was not documented as administered on July 21, 2022. There was no documentation found in the clinical record for reason why treatment was not administered or whether or not resident refused treatment; and that, the physician was notified. The weekly pressure ulcer assessment dated [DATE] included stage 4 pressure ulcer to the right gluteal fold with measurements of 0.4 cm x 0.3 cm x 3 cm, with small serosanguinous exudate, normal for skin wound bed, defined wound edges. The assessment continued to document to continue with current treatment to pack loosely with [MEDICATION(S)] packing and cover with dry dressing. However, the documentation in the TAR from July 20 through 31, 2022 included transcribed treatment order for collagen and packing strip and not [MEDICATION(S)]. The weekly pressure ulcer assessment dated [DATE] included stage 4 pressure ulcer to the right gluteal fold with measurements of 0.4 cm x 0.3 cm x 2.7 cm, with scant serosanguinous exudate, pink skin wound bed, defined wound edges. The assessment continued to document to continue with current treatment to pack loosely with [MEDICATION(S)] packing and cover with dry dressing. The clinical record revealed no physician order to discontinue collagen and packing strip. Despite the discrepancies in treatment administered and treatment documented in the assessments, there was no evidence the treatment order for the right gluteal fold was clarified with the physician. The clinical record also revealed no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order dated August 3, 2022 included to cleanse right gluteal fold with wound cleanser, pat dry, pack loosely with [MEDICATION(S)] packing strip and cover with foam dressing or border gauze every day shift. The start date was August 4, 2022. This order was transcribed onto the TAR for August 2022 and had a discontinued date of August 9, 2022. A physician order was written on August 9, 2022 to cleanse right gluteal fold with wound cleanser, pat dry, pack loosely with [MEDICATION(S)] packing strip and cover with foam dressing or border gauze. The order indicated a change in the frequency of wound treatment to the right gluteal fold from every day shift to every shift. Review of the August 2022 TAR revealed no documentation for wound care on August 3 and 11, 2022. The TAR documented that treatment was administered on the night shift of August 16, 2022. An interview was conducted with resident #12 on August 17, 2022 at 10:45 a.m. Resident #12 stated that the facility was neglecting to change her wound dressing at night; and that, the wound nurse had come to see her sporadically between May 2022 and July 2022. In a wound treatment observation conducted with the infection preventionist (staff #82) on August 17, 2022 at 11:38 a.m., staff #82 stated that resident #12's dressing was not initialed and dated so she could not tell when the dressing was last changed. She stated that it is the facility's policy to write the date and initial on the outer dressing when treatment was administered applied, so that staff will know when it was last changed. During the observation, resident #12 stated the dressing to her right gluteal fold had not been changed during the night shift on August 16. The resident further stated that she asked for her dressing to be changed; but, the nurse never came in to change it. During an interview with the Director of Nursing (DON/staff #71) conducted on August 18, 2022 at 12:48 p.m., the DON stated the clinical record revealed no documentation that the received treatment to her right gluteal fold from March 31 through April 4, July 13, 19 and 21. He also said that based on the clinical record, resident #12 did not receive treatment/dressing change on August 3, 2022 because there was no order for treatment to the right gluteal fold. The DON stated that there should be an order; and that, there was no documentation the physician was notified regarding the lapse in wound care. He also stated that records showed the resident also did not receive treatment on August 11, 2022. The DON stated that staff did not follow their policy and did not meet his expectation by not providing treatment as ordered by the physician. Further, he stated that not providing treatment to the wound would include the risk that the wound could deteriorate. Regarding intervention for preventive care and pressure relief: A physician order dated March 31, 2022 included for low air mattress for wound care and to encourage to float heels while in bed. The care plan initiated on April 4, 2022 included the resident was admitted with unstageable wound to the right posterior thigh/gluteal fold, stays up in her electric wheelchair for long periods of time and was at risk for breakdown related to [CONDITION(S)], cervical spinal cord injury. Interventions included to administer medications/treatment as ordered, pressure reducing mattress and staff to assist resident to float heels. There was no evidence found in the clinical record the interventions for low air mattress and floating of heels were implemented from April 1 through 7, 2022. A physician order dated April 8, 2022 revealed and order for APL (alternating pressure loss) mattress to bed, check proper setting, function and inflation every shift. The order for the APL mattress was transcribed onto the TAR for April 2022 and was documented as administered as ordered. However, the clinical record revealed no evidence that the floating of heels were implemented as ordered from April 8 through May 16, 2022. A physician order dated May 17, 2022 included to float heels when in bed every shift for pink heels. On May 26, 2022, this order was changed to float heels when in bed every shift for prevention. The TAR for May and June 2022 revealed the APL mattress and floating of heels were documented as administered. However, the TAR for July and August 2022 revealed that the APL mattress and floating of heels were not documented as administered on the following shift and dates: -Night shift on July 2, 6, 27, 28; -Day shift on July 21; -Night shift on August 5 through 7, 11 and 17. The clinical record also revealed no evidence of reason why these interventions were not administered as ordered; and that, the resident refused. In an interview conducted with the DON (staff #71) on August 18, 2022 at 12:48 p.m., the DON stated the clinical record revealed no documentation that the APL mattress had been checked for proper setting, function and inflation or that the resident's heels had been floated while in bed as ordered for multiple dates in July and August 2022. He further stated the risk of improper offloading, or no offloading could result in a change in the resident's skin condition. -Regarding resident #16 Resident #16 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Braden scale dated June 14, 2022 included a score of 12 indicating the resident was high risk for pressure ulcer. The admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview of Mental Status (BMS) score of 15 which indicated resident had intact cognition. The assessment also coded for one Stage 3, one Stage 4 and one unstageable pressure ulcers. The IDT (interdisciplinary team) care plan review dated June 28, 2022 revealed the resident was alert and oriented x 4 and was able to make needs known. -Regarding pressure ulcer care treatment to left buttocks: The pressure ulcer care plan initiated on June 14, 2022 revealed the resident had pressure ulcer and potential for pressure ulcer development; and was admitted with wounds. Interventions included to administer treatments as ordered. The weekly pressure ulcer assessment dated [DATE] revealed stage 4 pressure ulcer to the right gluteal fold and the left buttocks and an unstageable pressure ulcer to the right anterior ankle. The care plan initiated on July 22, 2022 revealed the resident had pressure ulcer or potential for pressure ulcer. Interventions included to administer treatment as ordered, follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the physician order recap revealed treatment orders for the stage 4 pressure ulcer to the right gluteal fold and the left buttocks and an unstageable pressure ulcer to the right anterior ankle. The treatment orders were transcribed onto the wound team administration record for June and July 2022; and revealed that treatment to the following wounds was not documented as administered on these dates: -July 6, 2022 for the left buttock, right ankle and right gluteal fold; -July 21, 2022 right heel; and, -June 22, 2022 - left buttock. An interview was conducted with the DON (staff #71 on August 18, 2022 at 3:11 p.m. The DON stated the clinical record revealed no documentation that resident #16 received wound care treatment to the left buttocks, right ankle, right gluteal fold and right heel on different days in June and July 2022. He stated this did not meet the facility expectations; and, there was a risk that the wound could deteriorate. Regarding intervention for preventive care and pressure relief: The pressure ulcer care plan initiated on June 14, 2022 revealed the resident had pressure ulcer and potential for pressure ulcer development; and was admitted with wounds. Interventions included to administer treatments as ordered. A physician order dated June 16, 2022 included for APL mattress to bed, check proper setting, function and inflation every shift for skin maintenance. Review of the June 2022 TAR revealed the APL mattress check every shift was not documented as completed on June 28, and 30, 2022. An interview was conducted on August 18, 2022 at 10:15 a.m. with a licensed practical nurse (LPN/staff #4) who stated it is the facility policy to follow and implement orders including pressure ulcer/wound care/treatment as ordered by the physician. The LPN stated that if he had any questions regarding the order he would call the physician and document it in the clinical record. The LPN further stated wound care treatment provided to the resident should be documented on the TAR or MAR. Regarding interventions for pressure relief such as mattress checks and floating heels, the LPN said the expectation was to follow and implement these interventions as ordered by the physician and document implementation in the TAR. He further stated that if these interventions are not documented or initialed in the TAR, it indicates that it was not completed or administered. In an interview conducted with another LPN (staff #16) on August 18, 2022 at 11:01 a.m., staff #16 stated that it is the facility policy to follow physician orders as written. She also said that wound care treatments/dressings and interventions such as pressure relief mattress and floating heel checks are documented on the TAR. Staff #16 said if pressure relief mattress checks are not completed, the risk was not knowing or ensuring it is functioning or it is on the right pressure. She stated if wound care treatment is not administered as ordered there is the risk of further skin breakdown. During an interview conducted with the DON (staff #71) on August 18, 2022 at 11:41 a.m., the DON stated it is the facility policy and his expectation that physician orders would be followed as ordered, and that dressings would be documented on the TAR. He also said that the expectation was that orders for mattress checks and heel floating would be followed as written on the physician order and documented in the clinical record. In a later interview conducted with the DON/Staff #71 on August 18, 2022 at 3:11 p.m., the DON stated that resident #16's clinical record revealed no documentation the APL mattress had been checked as ordered on June 28, and 30, 2022. He stated this did not meet the expectation of the facility; and, there was a risk that the wound could deteriorate. The facility policy titled, Skin Management System-Prevention, revealed a treatment order will be obtained from the attending physician for areas requiring treatment (i.e., pressure injury, surgical wounds, open skin tears, abrasions, lacerations, etc.). The facility policy on Physician Orders included that it is their policy to accurately implement orders including treatment, procedures, and to do so in accordance with the resident's plan of care. It also included that other therapeutic interventions will be followed as ordered. Review of the facility's policy on Documentation and Charting revealed it is their policy to provide a complete account of the resident's care, treatment. The facility policy titled, Wound Management, revealed that a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable sores from developing. The nurse responsible for assessing and evaluating the resident's condition on admission and readmission is expected to take the following actions: -Once a wound has been identified, assessed, and documented, nursing shall administer treatment to each effected area as per Physician's order; and, -All wound or skin treatments should be documented in the resident's clinical record at the time they are administered. It also included that in order to prevent the development of skin breakdown or prevent existing pressure ulcers from worsening, nursing staff shall implement the use of pressure relieving/reducing and redistributing devices (including low air loss mattresses, etc.).

Based on clinical record review, staff interviews, review of facility documentation and policy, the facility failed to ensure sufficient preparation was provided to one resident to ensure a safe and orderly discharge. The deficient practice could affect the resident's continuity of care. Findings include: Resident #1 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan dated June 14, 2022 included the resident wished to return or be discharged home when skilled needs are met. Intervention included to make arrangement with required community resources to support independence post-discharge such as home care, therapy, physician and wound nurse Review of several fax cover sheets dated July 12, 2022 revealed referral to different home health agencies for the resident. The documentation also included the resident will be discharged to home on July 14, 2022 and to contact the resident's family. In one of the sheets was a handwritten note that read needs are assisted living or skilled nursing facility, completely dependent and too high acuity A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -Discharge to home July 14, 2022; -Home health therapy to evaluate and treat; -Home health nursing for medication management, safety evaluation and wound care. -DME to include Hoyer lift with Hoyer sling, semi electric hospital bed, low air loss mattress, wheelchair with elevating leg rests; -30-day supply of Ostomy supplies -Wound Vac for NPWT (negative pressure wound therapy); -Tube feeding: and, -Wound care. The nursing discharge summary note dated July 14, 2022 revealed that home health services for nursing and therapy has been arranged; and the facility had ordered wheelchair and specialty bed/mattress. A nursing note dated July 14, 2022 included discharge instructions were discussed and reviewed and remaining medication were sent with the resident. Per the documentation, the resident was transferred from bed to gurney without incident and had exited the facility on stable condition. A fax cover sheet dated July 14, 2022 included that a DME vendor was filling the DME orders and everything should be there late today .if possible, exception of 'low air loss mattress' which may take longer. Another fax cover sheet dated July 14, 2022 revealed a referral for DME (durable medical equipment) for resident #1. Per the documentation, the resident will be discharged today at about 2:00 p.m., needed low air loss mattress and to send it out to the resident's home at the earliest convenience of the vendor Another fax cover sheet dated July 14, 2022 revealed a referral to an agency for home health. Further, the hand written read that the facility just need the home health part of the order and that the facility had the DME taken care of. None of the fax cover sheets indicated whether or not the resident was accepted by the home health agency to which the referral was sent to. A discharge MDS (Minimum Data Set) assessment dated [DATE] included the resident required extensive assistance with bed mobility, dressing, eating, toileting, and personal hygiene; was totally dependent on assistance for transfers; and, had one unhealed stage 4 pressure injury. Per the MDS, there was an active discharge plan in place for the resident to return to the community. Review of the Discharge Summary and Post-Discharge Plan of Care dated July 14, 2022 revealed the resident was able to make needs known, health improved sufficiently and no longer needs the services of the facility. It also included that discharge instructions were provided to the resident/resident representative. Final summary of resident status revealed the resident was non-ambulatory, had swallowing problems, was on scheduled pain medications and needs total assistance with ADLs (activities of daily living). Continued review of the discharge summary included the resident was discharged to home with pressure wound to the coccyx that required ongoing treatment with a wound vac set at 125 mmHg (millimeters of mercury); will need home health services for nursing and therapy; and, outpatient therapy services for physical and occupational therapy (PT/OT). However, contact information for the home health and outpatient therapy services were left blank. List of medical equipment/devices ordered included wheelchair and specialty bed/mattress. However, the name of the agency the medical equipment had been ordered through were also left blank. During an interview with the resident's (#1) family conducted on July 28, 2022 at 10:42 a.m., she stated resident #1 was very upset, depressed and tearful because he had to be placed on hospice services to receive any nursing help. The family stated because no one would provide him with help, the resident felt he was put on hospice to help him die. According to the family, the hospital bed was never received; another family member had to place the wound vac on the resident's wound using an internet video; and, they purchased all supplies out of pocket. Further, the resident was taken to the emergency roiagnom on [DATE] because of increased pain in the stage 4 pressure ulcer to the coccyx. The family stated the wound vac was only delivered on July 25, 2022 by DME vendor who told family that no one told them where to deliver it. During an interview with a certified nursing assistant (CNA/staff #14) conducted on July 28, 2022 at 12:30 p.m., staff #14 stated when residents are discharge staff gathers all of the resident belongings and DME equipment and escorts the resident/family out to their car. Staff #14 stated wound vac used by the resident during their admission at the facility stays at the facility on discharge; and, residents would have wound vac in place when they get home. An interview was conducted on July 28, 2022 at 12:43 p.m. with a registered nurse (RN/staff #21) who stated that social services arrange for discharge equipment and services like home health and is documented in the discharge summary which is reviewed with the resident or representative on discharge. Staff #21 stated the nurse would instruct the resident or representative to sign the summary on discharge. Staff #21 also said DME and home health services are arranged prior to discharge i.e. few days before the discharge to make sure they are in place. During an interview with social services (SS/staff #88) conducted on July 28, 2022 at 1:27 p.m., staff #88 stated services are in place before discharge to help ensure a safe discharge. Regarding resident #1, the SS stated that home health services was in place on discharge; but, those services just fell through. He stated he thought services were in place but they didn't show up so he sent out an additional 15 packets to try and get services after the resident was home. Staff #88 stated the resident had many issues; was difficult to find a service that could handle his therapy, wound vac, and medical needs; and, the family was eager to get home. Staff #88 stated he had been following up with the resident/family, knew that resident was having some pain about a week after discharge; and, knew the resident had to go to the hospital. Staff #88 stated he was not sure if the resident had received services yet or started hospice. An interview was conducted on July 28, 2022 at 3:45 p.m. with the Director of Nursing (DON/staff #91) who stated that most of the time the facility likes to have the DME delivered to the facility if that is an option. The DON stated for larger items like hospital beds, the facility would wait to discharge the resident until those items are in place. The DON stated requests or referral for home health, therapy, and DME are sent out three days prior to discharge to ensure there is enough time to have a safe discharge. The DON also said that the floor nurse reviews the discharge summary with the resident or representative and have the resident or representative sign it prior to discharge. Regarding resident #1, the DON stated the family wanted for the resident to be discharged quickly; and that, the staff worked hard to meet those needs. A facility policy titled Discharge or Transfer included that it is their policy to provide the resident with a safe organized structured transfer and/or discharge from the facility to include but not limited to hospital, another healthcare facility or home that will meet their highest practical level of medical, physical and psychosocial well-being. Discharges to home will include obtaining orders for discharge from physician, including any medications at discharge; keeping resident/family involved with discharge planning; and, completing discharge instruction form and providing direction to resident/family as needed. The staff will obtain signature to verify directions, give copy to resident and maintain the original in clinical record. Social Services (or other designated individual) will initiate contact with a home health agency to ensure continuity of care as deemed appropriate.

Based on review of facility documents, staff interviews, and the glucometer user guide, the facility failed to act upon glucometer quality control testing results that were out of range. The deficient practice could result in residents having diabetic complications due to wrong glucometer readings. Findings include: Review of the glucometer test logs were reviewed for cart #1 and cart #2 on station 2 with a Registered Nurse (RN/staff #13) on September 15, 2021 at 1:06 PM. The glucometer test log for cart #1 and cart #2 revealed multiple days where the testing results were out of range for the month of September. Continued review of the glucometer logs for cart #1 revealed multiple times the testing results were out of range for the month of August 2021. An interview was conducted immediately with staff #13 who stated that the night shift nurse is responsible for performing the daily quality control testing on the glucometers. The RN stated she was not sure what happen but the testing result should be within the range listed on the glucometer test strip bottle used for the test. In an interview conducted with a Licensed Practical Nurse (LPN/staff #12) on September 16, 2021 at 12:26 PM, the LPN stated that the night shift is responsible for testing the glucometer daily. Staff #12 stated two controls, high and low, are used for the glucometer control test and the results are compared to the range listed on the test strip bottle to see if the results are in range. The LPN further stated that if the result is not within range, he will use a new glucometer. He stated it is important to make sure the testing result is within range to get an accurate reading on a resident's blood sugar. An interview was conducted with an LPN (staff #120/Station 2-Unit Manager) on September 16, 2021 at 1:06 PM. She stated glucometer control testing is done every night by the night shift nurse. The LPN stated the glucometer machine should be calibrated correctly. The Unit Manager further stated that she spoke to the night shift nurse who was performing the control test and found out that the nurse was not calibrating the glucometer properly. She stated that in order to perform a control test, the nurse needs to press a button on the glucometer when using high and low control solutions which will let the glucometer machine know that it is calibrating. She stated the nurse was not doing this step which resulted in out of range test results. The LPN stated she educated the nurse to let the supervisor know the next morning or use a new set of glucometers if the results are out of range. She stated the unit managers review the logs at the end of month. The LPN stated it is important to make sure the glucometer control test results are within range to ensure the glucometer machine is working properly. An interview was conducted with the Director of Nursing (DON/staff #117) on September 17, 2021 at 11:23 AM. The DON stated that her expectation is for the nurses to calibrate the glucometer every night and to follow up if the test results are out of range. She stated that in this case, it was the user error as the nurse was not performing the testing correctly. Staff #117 stated the nurse has been educated regarding glucometer testing. She stated if the testing results were out of range multiple days back to back then it would be a concern regarding the use of the device. She stated the glucometer should be tested correctly and the test results should be within range to make sure glucose readings are accurate. The DON stated her expectation is for the unit managers to check the glucometer testing logs daily or at least weekly. She stated new staffs are oriented to glucometer testing upon hire and checked off again on testing if there are any changes. The DON stated the facility did not have a policy regarding glucometer control testing but that they use the glucometer user guide. The user guide for the glucometer used by the facility revised January 2021 stated that the purpose of the control solution testing is to make sure the meter and the test strips are working properly. The user guide listed steps for performing control testing which stated to compare the reading on the screen to the low range and high range printed on the test strip bottle. If the reading falls outside the low range or high range printed on the test strip bottle, see Control Solution Troubleshooting. Possible causes listed under Control Solution Troubleshooting included meter malfunction. The guide included control solution test results will be stored in the meter memory and indicated by ctl icon.

Based on resident and staff interviews, a food test tray, and policy review, the facility failed to ensure food was provided that was palatable and attractive. The deficient practice has the potential for residents who disliked a meal to experience nutritional problems or dissatisfaction with their meals. Findings include: On 9/13/21 at 10:44 AM, one resident stated that the food offered and prepared at the facility does not even look cooked. On 9/13/21 at 12:13 AM, a resident stated that the food tastes terrible, both the Macaroni & Cheese and the alternate bologna sandwich appear un-appetizing. On 9/13/21 at 12:17 AM, a resident stated that the food offered and prepared at the facility appears poor and tastes terrible. A resident council meeting was conducted on 9/16/21 at 10:00 AM. In the council meeting 6 out of 7 residents stated that food served and prepared by the facility looked and tasted bad. They added that alternate plates were just as bad. Review of the lunch menu for 09/16/21 revealed the following: -Pepperoni Pizza -Parsley Garnish -Assorted beverage -Chocolate Chip cookies -Zesty Cucumber salad On 09/16/21 at 12:30 PM a test tray of the lunch meal was evaluated: - The Pepperoni Pizza looked thin and stale, it appeared like old frozen pizza. It tasted stale, dry, and was not flavorful. - The Chocolate Chip cookies were with descent flavor, but without appeal. - The Zesty Cucumber salad was unidentifiable as a salad and had little zest. It was served in a plastic cup covered with plastic wrap. The test tray was sampled by the survey team and everyone agreed the food appeared unappetizing and had poor flavor. An interview was conducted with the district manager (staff #166) on 9/16/21 at 01:25 PM. Staff #166 stated that she has not had many complaints about the food before and that the residents are also offered alternates. An interview was conducted with the Director of Nursing (DON/staff #117) on 9/16/21 at 02:08 PM. Staff #117 stated that she had spoken with the manager and it had come to her attention over the past month that there were weaknesses and insufficiencies in their food and service. The DON stated that she has not had complaints about food appearance, but has heard some residents' concerns about the taste of the food served. Review of the facility policy titled Food and Nutritional Services (revised 6/15/18) stated the purpose is to provide food and nutrition services to meet the physiological and psychosocial needs of residents. The policy included food is prepared in a wholesome, appetizing, and sanitary manner.

Based on observations, clinical record review, staff interviews, facility documentation, review of the Center for Disease Control (CDC) 2007 Guideline for Isolation Precautions and policies and procedures, the facility failed to maintain an effective infection control program, by failing to ensure that contact precautions were followed for one resident (#63) with active [MEDICAL CONDITIONS], and an immunocompromised resident (#122) was cohorted with a resident (#63) who had active [MEDICAL CONDITION]. As a result, the Condition of Immediate Jeopardy (IJ) was identified. The deficient practice increased the potential for the transmission of the [MEDICAL CONDITION] infection and placed residents and staff at risk. Findings include: On (MONTH) 29, 2019 at 2:36 p.m., the Condition of Immediate Jeopardy (IJ) was identified. The Administrator was informed of the facility's failure to implement infection control procedures for resident #63, who was on contact precautions for active [MEDICAL CONDITION]. Observations were conducted of one certified nursing assistant (CNA/staff #85), who did not remove gloves upon exiting the room, and when the CNA re-entered the room, the CNA did not don a gown or gloves and provided personal care to the resident. In addition, resident #63 was observed sharing a room with another resident (#122), who did not have [MEDICAL CONDITION] and was not being treated for [REDACTED].#122 was immunocompromised (diagnosed with [REDACTED]. The Administrator presented a plan of correction on (MONTH) 29, 2019 at 6:05 p.m. The Administrator was informed that the plan of correction needed to include in-service training and education on contact precautions for [MEDICAL CONDITION], handwashing, the wearing of PPE (personal protective equipment) while disposing of soiled trash, the cohorting of resident #63 with resident #122, and the facility's process for determining who can cohort with residents who have [MEDICAL CONDITION]. A revised plan of correction was presented and was accepted at 7:15 p.m. The plan included all staff education on donning/doffing of PPE and proper handwashing for residents on contact precautions including [MEDICAL CONDITION]; and cohorting residents needing contact precautions according to the Centers for Disease Control guideline. The plan further included that resident #122 was removed to another room. Multiple observations were conducted on (MONTH) 29 and 30, 2019 of the facility implementing their plan of correction, which included staff in-services were being done regarding infection control and contact precautions for [MEDICAL CONDITION]; staff interviewed were knowledgeable of infection control procedures including contact precautions for [MEDICAL CONDITION], observations were conducted of staff implementing contact precautions when entering and exiting resident #63's room, and resident #122 was moved to another room. As a result, the Condition of Immediate Jeopardy was abated on (MONTH) 30, 2019 at 3:13 p.m. -During an observation conducted on (MONTH) 29, 2019 at 11:55 a.m., an isolation cart which contained personal protective equipment (PPE/gowns, gloves etc.) was outside of resident #63's room. At this time, a CNA (staff #85) removed his gown and disposed of it in the resident's room prior to exiting. Staff #85 then exited the room, while still wearing the gloves which were worn in the resident's room and walked out of the room with a bag of soiled linen. Staff #85 then opened the soiled utility room door, which was next to the resident's room with the same gloves on. Approximately 5 seconds later, staff #85 exited the soiled utility room door, without gloves on. Staff #85 then entered the clean utility room, which was adjacent to the soiled utility room. Staff #85 exited the clean utility room carrying clean linen. Staff #85 was then observed to enter resident #63's room with the clean linen and did not apply a gown or gloves. Shortly thereafter, staff #63 exited the resident's room holding a soiled incontinent pad in a plastic bag, without gloved hands. Staff #63 then entered the soiled utility room and disposed of the plastic bag. An interview was conducted with the CNA (staff #85) on (MONTH) 29, 2019 at 11:59 a.m. Staff #85 stated that when he entered the resident's room with the clean linen he did not put gloves or a disposable gown on, because he just had to put a sheet on the resident. Staff #85 stated the plastic bag which he was holding without gloves had an incontinent pad with bowel movement on it. Another interview was conducted with staff #85 on (MONTH) 29, 2019 at 1:55 p.m. In clarifying what care was provided when staff #85 entered the resident's room carrying the clean linen and without donning a gown or gloves prior to entering, staff #85 said that he placed a clean sheet under the resident's buttocks and did not wear gloves or a gown. Staff #85 stated that when he went into the soiled utility room to dispose of the soiled linen he washed his hands real quick, not long, just a little soap and water. An interview was conducted with a CNA (staff #50) on (MONTH) 30, 2019 at 8:58 a.m. Staff #50 stated that if a resident was on isolation, a gown and gloves should be put on before entering the room. Staff #50 stated that prior to exiting the room, the gown and gloves should be removed and disposed of in the resident's room. Staff #50 further stated that it was facility policy to wash hands with soap and water. An interview was conducted with a CNA (staff #91) on (MONTH) 30, 2019 at 9:00 a.m. Staff #91 stated that before she enters an isolation room she dons gloves and a disposable gown. Staff #91 stated that before she leaves the room, she would remove the PPE and dispose of it in the resident's room. Staff #91 said she would then wash her hands with soap and water for thirty seconds. An interview was conducted with a CNA (staff #122) on (MONTH) 30, 2019 at 9:05 a.m. Staff #122 stated that before she went into an isolation room, she would put a gown and gloves on. Staff #122 stated that after caring for the resident, she would remove the protective equipment and place it in the container in the resident's room. Staff #122 further stated that she would then wash her hands with soap and water for twenty to thirty seconds. -Resident #63 was admitted to the facility on (MONTH) 25, 2019, with [DIAGNOSES REDACTED]. A care plan dated (MONTH) 26, 2019 revealed the resident required assistance with activities of daily living (ADL) (bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion and toileting) related to weakness, [MEDICAL CONDITION] and end stage [MEDICAL CONDITION]. Interventions included to provide the resident with total assistance of 2 for bed mobility and transfers using a hoyer lift. Review of the clinical record revealed that resident #63 was moved to the same room as resident #122 on (MONTH) 22, 2019. A quarterly Minimum Data Set (MDS) assessment dated (MONTH) 1, 2019 included a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. The MDS included the resident required total assistance with toilet use and transferring, and extensive assistance with dressing, personal hygiene and bed mobility. The MDS also included the resident was always incontinent of bowel and bladder. Review of ADL documentation revealed no evidence that the resident was having loose stools from (MONTH) 6, 2019 through (MONTH) 13, 2019. The documentation indicated the resident was having soft formed stools. Review of the clinical record revealed the resident had a change in condition on (MONTH) 13, 2019, related to altered mental status and fever, and the resident was transferred to the hospital. The hospital records included a final infectious disease progress note dated (MONTH) 18, 2019, which stated the resident tested positive for [MEDICAL CONDITION], continue [MEDICATION NAME] for 14 more days and continue contact precautions. Review of the clinical record revealed the resident was readmitted to the facility on (MONTH) 19, 2019 at 3:30 p.m. Resident #63 was placed back into the same room with resident #122. A nursing note dated (MONTH) 20, 2019 included that resident #63 was a readmitted with [DIAGNOSES REDACTED]. Another nursing note dated (MONTH) 20, 209 revealed the first dose of [MEDICATION NAME] was given this morning with no adverse reaction noted. Continues with precaution. A physician's orders [REDACTED]. Review of ADL documentation for (MONTH) 20, 2019 revealed the resident had a medium soft/formed stool. For (MONTH) 21, the documentation showed that the resident had one medium soft/loose stool. A care plan dated (MONTH) 22, 2019 revealed the resident was at risk for complications of infection related to [MEDICAL CONDITION]. A goal was for the infection to resolve within 14 days. Interventions included to administer medication as ordered, use contact precautions, encourage hand washing, monitor for any signs and symptoms of pain and notify provider as indicated, monitor for skin breakdown and report to physician as indicated, and to monitor vital signs and report any abnormalities. A nurse practioner note dated (MONTH) 22, 2019 included the resident was being seen for a return from the hospital where she was treated for [REDACTED]. The plan included to monitor [MEDICAL CONDITION], continue [MEDICATION NAME] and when the resident had 2 to 3 soft stools, do a repeat stool sample. A physician's orders [REDACTED]. According to a general progress note dated (MONTH) 24, 2019, the resident continues with antibiotic for [MEDICAL CONDITION] and to continue with infection contact precautions. A nurse practitioner note dated (MONTH) 24, 2019 included the resident was being seen for follow up related to [MEDICAL CONDITION]. The note included the resident stated that she had one bowel movement this day. The plan included to monitor for [MEDICAL CONDITION], continue [MEDICATION NAME] and to repeat stool sample when antibiotic is completed. Review of (MONTH) 2019 ADL documentation regarding bowels revealed the following: July 24: the resident had 3 medium soft/loose stools July 25: the resident had one medium soft/loose stool and 3 small soft/loose stools July 26: the resident had 3 small soft/loose stools and one large soft/loose stool July 27: the resident had one medium soft/loose stool and 2 small soft/loose stools July 28: the resident had one medium soft/formed stool and 3 soft/loose extra large stools July 29: the resident had 2 large soft/loose stools, 1 medium soft formed stool, and 1 large soft/loose stool A nurse practitioner note dated (MONTH) 29, 2019 at 5:28 p.m. (after the IJ was called) included the resident was being seen for a follow up for [MEDICAL CONDITION]. The note stated the resident had reported that she was having 3 to 4 normal stools per day, with an increase amount of stool due to the food she ate. The plan included to monitor for [MEDICAL CONDITION], continue [MEDICATION NAME] until (MONTH) 2, 2019 and stools are at resident's baseline, and to continue contact precautions per facility policy. Regarding the cohorting of residents: -Resident #122 was admitted to the facility on (MONTH) 15, 2019, with [DIAGNOSES REDACTED]. A care plan dated (MONTH) 17, 2019 included the resident requires assistance for ADL care with bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfers and toileting related to weakness. Interventions included to provide resident with extensive assistance of 1 for bed mobility and extensive assistance of 1 to 2 for transfers using a gait belt. According to a nursing note dated (MONTH) 21, 2019, the resident was under hospice services with a [DIAGNOSES REDACTED]. Another care plan dated (MONTH) 22, 2019 included the resident was receiving hospice care services starting (MONTH) 21, 2019, due to end stage [DIAGNOSES REDACTED]. Interventions were to provide ADL support and companionship, and other interventions as desired by resident to promote comfort, and provide emotional and social support to patient and family, address anticipatory grief and end of life wishes and planning. A physician's note dated (MONTH) 23, 2019 revealed the resident's status was poor, due to a terminal illness. The note included the resident will be admitted to hospice once paperwork is completed and per oncology, they are unable to provide treatment for [REDACTED]. A significant change MDS assessment dated (MONTH) 25, 2019 included the resident was severely cognitively impaired, with disorganized thinking. The MDS included the resident required total staff dependence for toilet use and dressing, and had impairment in functional limitation in range of motion in bilateral upper and lower extremities. A nurse practitioner note dated (MONTH) 10, 2019 included the resident had a 20 pound weight loss since February, and continues to not be a candidate for [MEDICAL CONDITION] or [MEDICAL CONDITION] treatment for [REDACTED]. She is being followed by hospice with a terminal prognosis of [MEDICAL CONDITION]. An observation was conducted on (MONTH) 29, 2019 at 9:08 a.m. of the room shared by resident #63 and #122. Outside of the room, was an isolation cart and a sign which indicated to see the nurse before entering the room. There were also two resident names (resident #63 and resident #122) listed on the outside of the room. At this time, resident #122 was observed lying in the bed by the window, however, resident #63's bed was unable to be seen from the doorway. An interview was conducted with a licensed practical nurse (LPN/staff #37) immediately following this observation. Staff #37 stated there were two residents in this room and only bed A (resident #63) was on contact isolation for [MEDICAL CONDITION]. In an interview with a LPN (staff #71) on (MONTH) 29, 2019 at 11:50 a.m., she stated that she was the nurse assigned to this room today. She stated that resident #63 was on contact isolation for [MEDICAL CONDITION] and the other resident (resident #122) did not have [MEDICAL CONDITION]. She stated that resident #63 came back from the hospital with [MEDICAL CONDITION] and is still currently receiving antibiotics for the infection. An interview was conducted with the Infection Preventionist (staff #192) on (MONTH) 29, 2019 at 2:26 p.m. Staff #192 stated that it was facility policy for resident's who have a [MEDICAL CONDITION] infection to be placed in an isolation room. Staff #192 stated that if a private room was not available, the resident should be placed in a room (cohort) with another resident who had [MEDICAL CONDITION]. Staff #192 further stated that if a resident had a [DIAGNOSES REDACTED]. Review of the CDC guidelines updated in (MONTH) 2019 revealed that [MEDICAL CONDITION] is a spore forming bacterium that causes inflammation of the colon known as [MEDICAL CONDITION]. Risk factors include antibiotic use, serious underlying illness and age over 65. [MEDICAL CONDITION] spores are shed in feces and transferred to patients mainly via the hands of people who have touched a contaminated surface or item. [MEDICAL CONDITION] spores can live for months or sometimes years on surfaces. For prevention of transmission of [MEDICAL CONDITION] in healthcare settings, use contact precautions for patients with known or suspected [MEDICAL CONDITION]. Contact precautions are intended to prevent transmission of infectious agents, which are spread by direct or indirect contact with the patient or the patient's environment. The CDC guidelines further included to use gloves and gowns when entering patient rooms and during care, and for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. Before exiting the patient room, discard gowns and gloves to contain pathogens, especially those that have been implicated in transmission through environmental contamination (e.g. [MEDICAL CONDITION] .and other intestinal tract pathogens). The CDC guidelines also included the following: Cohorting is the practice of grouping together patients who are colonized or infected with the same organism to confine their care to one area and prevent contact with other patients. Cohorts are created based on clinical diagnosis, microbiologic confirmation when available, epidemiology and mode of transmission of the infectious agent. A single patient room is preferred for patients who require contact precautions. It is generally preferred not to place severely immunosuppressed patients in rooms with other patients. When a single patient room is not available, consultation with infection control personnel is recommended to assess the various risks associated with other patient placement options (e.g. cohorting, keeping the patient with an existing roommate). Review of the facility's Infectious Disease Management policy dated 5/1/18 revealed the facility will use appropriate infection control, environmental decontamination and prevention measures for the prevention and management of infectious diseases and communicable diseases. Patients who have evidence of an infectious disease will be treated according to physician/provider orders and current guidelines. Contact precautions will be followed when there is a high risk for transmission. Review of a facility policy regarding Contact Precautions dated (MONTH) 15, 2019 revealed that in addition to standard precautions, contact precautions will be used for diseases transmitted by direct or indirect contact with the patient or the patient's environment. The purpose is to reduce the risk of transmission of epidemiologically important microorganisms by direct or indirect contact. Instruct staff regarding precautions and the use of PPE. Staff must use barrier precautions when entering the room, including gowns and gloves. Change gown and gloves during care if they come in direct contact with infectious material. Before exiting the room, remove and bag gown and gloves, and wash hands upon exiting the room. Remove bagged PPE from the room and discard in soiled utility and wash hands. The policy further included to place patient in private room, if possible. Patient may cohort with an individual who has the same organism. Do not place colonized or infected patient with another patient who has severe immunosuppression (e.g. cancer .etc.) A policy titled, Clostridioides Difficile Infection (CDI) dated (MONTH) 15, 2019 revealed .Place patient in private room. If private rooms are not available, place patient in room (cohort) with other CDI patient. If no private room or cohorting with another CDI is not possible, then do not place patient with another patient who has severe immunosuppression (e.g., cancer). The policy also included to maintain stringent hand washing procedures.

Based on clinical record reviews, resident and staff interviews, facility documentation and policies and procedures, the facility failed to ensure one resident (#237) was free from neglect, by failing to provide the necessary nursing services when changes of condition occurred. The deficient practice resulted in a lack of nursing care being provided when a resident experienced a change of condition. The facility also failed to ensure one resident (#36) was free from physical abuse by another resident (#124). The deficient practice could result in residents being subjected to physical abuse. Findings include: -Resident #237 was readmitted to the facility on (MONTH) 23, 2019, with [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident was a full code status. The annual MDS (Minimum Data Set) assessment dated (MONTH) 25, 2019 included a BIMS (Brief Interview for Mental Status) score of 14, indicating the resident was cognitively intact. The MDS included the resident was totally dependent on one person for assistance with bed mobility, toilet use and personal hygiene, and required extensive assistance of one person for dressing. Per the MDS, the resident was receiving oxygen therapy and was on a [MEDICAL CONDITION] (Bi-level Positive Airway Pressure) machine. A care plan for cardiovascular complications (with an initiation date of (MONTH) 22, 2014) revealed the resident was at risk for cardiovascular symptoms/complications. Interventions included checking oxygen saturation every shift; assessing/monitoring vital signs as ordered and reporting abnormalities to the physician; and for oxygen at ,[DATE] LPM (liters per minute) via nasal cannula as needed to keep oxygen saturation greater than 90%. A respiratory care plan (with an initiation date of (MONTH) 8, (YEAR)) revealed the resident was at risk for complications related to [MEDICAL CONDITION] and was non-compliant with oxygen and [MEDICAL CONDITION] placement. A goal was that the resident would have no signs and symptoms of respiratory distress. Interventions included the following: administer medications and [MEDICAL CONDITION] as ordered; monitor and report oxygen saturation levels via pulse oximetry as ordered and as needed; and observe for signs and symptoms indicating respiratory distress and report to physician. Review of the physician recapitulation orders for (MONTH) and (MONTH) 2019 included the following orders: -Oxygen saturation every day and night shift -Pulse oximetry to keep oxygen saturations greater than or equal to 90% -Oxygen ,[DATE] LPM per nasal cannula to keep oxygen above 88% every day and night shift -[MEDICAL CONDITION] at 3 LPM oxygen to be applied at bedtime and removed in the morning. These orders were transcribed onto the (MONTH) 2019 MAR (medication administration record) and the TAR (treatment administration record). Further review of the MAR/TAR for (MONTH) 2019 revealed that the oxygen saturation levels were done every day and night shift. The scheduled times were 7 a.m. and 7 p.m. The documentation showed the following oxygen saturation levels for resident #237: Date 7 am 7 pm [DATE]: 89% 95% [DATE]: 98% 97% [DATE]: 90% 92% [DATE]: 90% 91% [DATE]: 91% 93% [DATE]: 98% 96% [DATE]: 90% 95% [DATE]: 90% 95% [DATE]: 95% 96% [DATE]: 90% 92% [DATE]: 92% 93% [DATE]: 90% 90% [DATE]: 90% 95% [DATE]: 98% 92% [DATE]: 90% 93% [DATE]: 93% 91% [DATE]: 93% 90% [DATE]: 90% 92% [DATE]: 97% 93% [DATE]: 92% 90% In addition, the MAR indicated [REDACTED]. The SVN treatments were given on the following days at various times as follows: (MONTH) 1, 5, 6, 7, 8, 11, 13, 14, 15, 19 and 20, and the oxygen saturation levels ranged between 90%-96%. A medication nursing note dated (MONTH) 20, 2019 at 7:03 p.m., revealed the resident was administered [MEDICATION NAME] (antianxiety) 0.25 mg (milligrams) by mouth for anxiety as evidenced by panic attacks. Further review of the (MONTH) 2019 MAR indicated [REDACTED]. A nursing note at 8:35 p.m. by a LPN (licensed practical nurse/staff #30) revealed that [MEDICATION NAME] 325 mg 2 tablets by mouth was administered to the resident for general discomfort. The MAR indicated [REDACTED]. A general nursing note dated (MONTH) 20, 2019 at 10:15 p.m., by staff #30 revealed that she answered the resident's call light and the resident complained of shortness of breath. Per the note, the resident's oxygen saturation was 56%, and the resident was on oxygen at 6 LPM per nasal cannula. The intervention documented was that staff #30 gave the resident a breathing treatment. Further review of the clinical record revealed there was no documentation of any other interventions which were done at that time other than a breathing treatment, there was no documentation of a thorough assessment of the resident which was done at that time, including a thorough respiratory assessment, and there was no documenation of any change of condition charting that was done. In addition, there was no documentation that the resident's physician/provider was notified of the resident's change in condition/low oxygen level. The clinical record documentation also showed that the resident's oxygen saturation level was not checked again until 40 minutes later. According to a general nursing note dated (MONTH) 20, 2019 at 10:55 p.m. by staff #30, the resident's oxygen saturation level was 79% on 6 LPM of oxygen per nasal cannula, with no signs and symptoms of respiratory distress or shortness of breath at this time. Per the note, the resident was sleeping. Continued review of the clinical record revealed no evidence that the physician/provider was notified that the resident's oxygen saturation level continued to be low, and there was no documentation that additional interventions were implemented to address the resident's ongoing low oxygen saturation levels. Also, there were no nursing notes or other documentation regarding the resident's status or that the resident's oxygen saturation levels were rechecked between 10:56 p.m. and 12:53 a.m. A general nursing note dated (MONTH) 21, 2019 at 12:54 a.m. included the nurse (staff #30) went into the resident's room to recheck the resident's oxygen saturation and the resident looked pale, fingernails were turning blue but resident was warm to touch. The resident was not responding, CPR (cardiopulmonary resuscitation) was started and 911 was called. Another general nursing note dated (MONTH) 21, 2019 at 1:05 a.m. included the physician was notified. Review of the facility's investigative report dated (MONTH) 26, 2019 included that a licensed practical nurse (LPN/staff #30) was the nurse on shift (on (MONTH) 20 evening shift through (MONTH) 21 night shift) and took care of resident #237. The report included that on (MONTH) 20, 2019 at 7:00 p.m., the resident complained of not feeling well (shortness of breath) and a breathing treatment was administered. (Although there is no clinical record documentation of this.) At 10:00 p.m., the resident complained of shortness of breath and oxygen saturation was 56% on 6 LPM of oxygen via nasal cannula. The resident was administered a breathing treatment. At 10:55 p.m., resident's oxygen saturation was rechecked and was 79% on 6 LPM of oxygen via nasal cannula. At 12:52 a.m. on (MONTH) 21, 2019, the resident was observed to be pale with blue fingers and unable to get an oxygen saturation level and no heartbeat. At approximately 12:57 a.m., code blue was called and CPR was initiated. The EMS (Emergency Medical Services) came at 1:10 a.m. and at 1:28 a.m., the EMS medical director pronounced the death of resident #237. Continued review of the facility's investigative report revealed that staff #30 failed to document the SVN treatment at 7 p.m. and 10:15 p.m., failed to complete a change in condition for respiratory distress, did not place the [MEDICAL CONDITION] on the resident and admitted that she was unable to notify physician/provider until after the resident was pronounced dead. The report also included that staff #30 failed to adhere to Cardio [MEDICAL CONDITION] Resuscitation policy and procedure by delaying the initiation of Cardio [MEDICAL CONDITION] Resuscitation. The investigative report further included a written statement from staff #30 titled Station 2 on evening of (MONTH) 20, 2019 to (MONTH) 21, 2019, which included that a certified nursing assistant (CNA) reported the resident wanted to see her. The resident told her (staff #30) I can't breathe. Vital signs were as follows: RR (respiratory rate) was 24 per minute, PR (pulse rate) was 66 per minute and oxygen saturation level was 56% on 6 LPM of oxygen per nasal cannula. A breathing treatment was administered at 10:15 p.m. She rechecked the resident's oxygen saturation level at 10:55 p.m. and was 79% on 6 LPM of oxygen per nasal cannula, with no signs and symptoms of respiratory distress or shortness of breath and that the resident was resting at this time. The statement further included that she (staff #30) continued with nursing work at this time. Staff #30 stated the CNA informed her that the resident was sweating. She returned to the resident's room at 24:52 midnight (which is 12:52 a.m.) on (MONTH) 21, 2019 and observed that the call light was pulled out of the wall and the resident's bed was in a flat position. The resident's oxygen saturation was rechecked and nothing came up. The resident's face was pale with mouth opened and fingernails were blue. She (staff #30) tried to arouse the resident, but was unsuccessful. The report included a witness statement dated (MONTH) 21, 2019 by a CNA (staff #121), who reported that at 7:00 p.m., the resident reported she did not feel well and did not have any evidence of distress. Staff #121 reported that at 9:00 p.m. the resident felt she was hot, at 12:00 a.m. the resident was banging on her table, another CNA assisted her with a pitcher of water and at 12:56 a.m. code blue was called. Another witness statement dated (MONTH) 21, 2019 by a CNA (staff #58) included that at 1:00 a.m. on (MONTH) 21, 2019, she heard an overhead page for Code Blue in the resident's room. She responded immediately and a LPN (staff #112) initiated CPR to the resident and she assisted the nurse (the statement did not include the identity of this nurse) with calling 911 at 1:02 a.m. EMS responded around 1:10 a.m. and continued CPR. A witness statement by a CNA (staff #28) dated (MONTH) 22, 2019, revealed that on (MONTH) 20, 2019 between 11:30 p.m. and 12:00 a.m., resident #237 had her call light on to be changed. After changing the resident, she said that she could not breathe. She notified staff #30 who replied that she would see resident when she is done with her medication pass. Per the statement, the resident was heard pounding the bedside table with her call light and another CNA (staff #121) went in to assist the resident. The resident turned her call light on again and staff #30 was informed. A witness statement by a LPN (staff #112) dated (MONTH) 25, 2019, revealed that on (MONTH) 21, 2019 at 1:00 a.m., an overhead page for Code Blue was heard and she responded immediately, she assessed the resident and initiated CPR. EMS responded around 1:10 a.m. and continued CPR. At 1:28 a.m., EMS stopped the code and pronounced the resident's death. Further review of the investigative report revealed that staff #30 was terminated. During an interview with a CNA (staff #121) conducted on (MONTH) 31, 2019 at 9:11 a.m., she stated that she worked the evening/night shift on (MONTH) ,[DATE], 2019 and throughout her shift, the resident kept pressing the call light and kept banging on her bedside table with the call light for help. She said that after providing assistance, she would leave the room and the resident would start banging on the table again. She stated it was crazy that day because so many things were going on. She stated right after dinner that day, she noticed the resident's bedside table was pushed away, the resident had oxygen on, and was sitting straight up in her bed and was pale and sweaty. She said this was not normal for the resident, because the resident's room was freezing cold and the resident did not look good. She stated when she exited the resident's room, she informed staff #30 and the MDS (Minimum Data Set) Coordinator (staff # 35) who were standing outside of the resident's room about the resident's condition. In an interview with the MDS Coordinator (staff #35) conducted on (MONTH) 31, 2019 at 11:29 a.m., she stated that she worked the day shift on (MONTH) 20, 2019 and throughout that day the resident kept turning the call light on and kept banging her bedside table. She stated that she had answered the resident's call light multiple times that day and the resident wanted to have regular water or just wanted some company. She stated there was a time that day when a CNA reported the resident did not look good. She said the day shift nurse came into the resident's room and administered a breathing treatment to the resident. A phone interview with a LPN (staff #30) was conducted on (MONTH) 1, 2019 at 8:03 a.m. Staff #30 stated the outgoing day shift nurse gave a report that the resident had a low oxygen saturation and a breathing treatment was administered, resulting in the resident's oxygen saturation going back to 95%. She denied receiving reports from a CNA around dinner time that the resident was sweaty and was not looking good. She stated at 10:00 p.m., she went into the resident's room as requested and she checked the resident's oxygen saturation, which read 56%. She stated the resident was breathing normal and there were no signs and symptoms of respiratory distress. She said that she gave the resident a breathing treatment but did not call the physician, because the resident's oxygen saturation usually runs low and after treatment it will go back to normal. She said at 10:55 p.m., she went to check on the resident and the resident was comfortable and resting in bed, with no signs and symptoms of respiratory distress. She stated the resident had the oxygen on and the resident's color and breathing were fine. She stated the [MEDICAL CONDITION] was not on the resident and was not in the room, because it was broken. She said she checked the resident's oxygen saturation and it read 79%, which is normal for the resident so she went back to work and did not call the physician. She said at 12:52 a.m. (on (MONTH) 21, 2019) she checked on the resident and the resident's bed was in a flat position and the call light was off the wall. She said the CNA informed her then that the resident was sweaty, so she checked the resident's blood sugar and oxygen saturation. She stated that when she placed the pulse oximetry machine on the resident, there were no numbers registered on the machine and she noticed the resident's fingers were blue. She said she then went to grab the chart to check the resident's code status, called a code and called 911. However, she stated that when she called 911 she was not successful, because the facility's phone was not working properly. She said the nurses from the other station came to help and CPR was started. She said a CNA was able to call 911 on her personal cell phone. She stated that she called the physician three times at this time, but the physician did not return the call until 3:00 a.m. Multiple attempts were made to conduct a phone interview with a CNA (staff #28), who reported to staff #30 that the resident could not breathe on (MONTH) 20, 2019 between 11:30 p.m. and 12:00 a.m., however were unsuccessful. An interview with the Director of Nursing (DON/staff #113) was conducted on (MONTH) 2, 2019 at 8:52 a.m. Staff #113 stated that on (MONTH) 21, 2019 at 1:00 a.m., she received a call from staff #30 who was flustered and reported that paramedics were at the facility performing CPR to the resident. She stated staff #30 told her the physician was not notified and that 911 was not called when the resident's oxygen saturations were 56% and 79%, because staff #30 thought the oxygen saturations would go back up, after the breathing treatment. She stated the resident's oxygen saturation levels ranged between 88% and 90% and can go as low as 79%. However, staff #113 said staff #30 is expected to call the physician or 911 after treatment is provided and a resident's oxygen saturation does not go back up to normal range. She stated the breathing treatment takes 10 to 15 minutes and that a nurse is expected to take the oxygen saturation after the treatment is done and call the physician or 911 as appropriate. Further she stated that staff #30 did not do what she was supposed to do given the circumstances of the events that day. She said staff #30 called the physician only when the resident was coding, not when the resident's oxygen saturations were low. Review of the Abuse Prohibition policy revealed the facility prohibits abuse and neglect for all residents. The policy defined neglect as the failure of the facility, its employees or service providers to provide goods and services to a patient that is necessary to avoid physical harm, pain, mental anguish or emotional distress. The policy regarding Notification of Change in Condition included the facility must immediately consult with the patient's physician when there is a significant change in the patient's physical, mental, or psychosocial status. A policy titled, Physician/Advanced Practice Provider (APP) Notification included the purpose was to communicate a change in the resident's condition to the physician/AAP. Upon identification of a resident who has clinical changes, change in condition, or abnormal lab values, trained staff will perform appropriate clinical observations and data collection and report to physician as indicated. Staff observations and resident baseline should always be the primary determinate of the timing of physician notification. If the resident's condition indicates urgent physician notification, staff is to notify the physician immediately with the vital signs information, report all pertinent data and obtain and implement specific orders for intervention. -Resident #36 was admitted to the facility on (MONTH) 26, (YEAR) with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated (MONTH) 7, 2019 included a BIMS score was 15, which indicated the resident was cognitively intact. In an interview with resident #36 on (MONTH) 30, 2019 at 9:09 a.m., she reported that she had recently been physically abused by another resident. She stated a resident (#124), whose name she did not know, came into her room and wanted to use her bathroom. She said the other resident had her wheelchair sideways in the doorframe, so she was unable to get past her to go into the hallway. When she asked the resident to leave her room, she stated that it was not her room and she then hit her with the back of her hand. She stated this incident was about a month ago and this resident had previously tried to come into her room and use the bathroom. She stated after this incident she was finally able to get into the hall to go ask for help. She reported this incident to the nurse who was on duty, staff #16. She further stated that the police came out to speak with her. She said she has had no further incidents with this resident. -Resident #124 was admitted to the facility on (MONTH) 13, 2019 with [DIAGNOSES REDACTED]. A quarterly MDS assessment dated (MONTH) 21, 2019 revealed the resident had a BIMS score of 4 out of 15, which indicated the resident was severely cognitively impaired. No wandering behavior was noted. The resident required extensive assistance by staff for activities of daily living and used a wheelchair for mobility. Per the MDS, the resident had impairment on one side to the upper extremity which interfered with daily functions. Review of the facility's investigative documentation revealed that on (MONTH) 10, 2019, resident #36 reported to a LPN (staff #16) that she was assaulted by resident #124. Staff #16 immediately approached resident #125 and brought her to the nurses station for close monitoring. Staff #16 assessed both residents and no injury was noted to either resident. Resident #36 was interviewed and explained that she was in her room sitting in her chair, and noticed a shadow and then fingers on her bathroom door. She observed resident #124 halfway into her bathroom and approached her by telling her that she did not feel comfortable with her using the bathroom. Resident #124 then stated that she owned the building and was going to get rid of resident #36. Resident #36 told resident #124 to get out of the bathroom and attempted to pull resident #124's wheelchair out of the bathroom, when resident #124's wheelchair became lodged between the bathroom door and the room door. Resident #36 then began to seek staff assistance but was unable to get into the hallway. Resident #124 then struck resident #36 with the back of her right hand against resident #36's right side of her face. Resident #124 then self-propelled her wheelchair out of the room and stated to resident #36, you're mean and crazy. Just hit me. Hit me already. Resident #36 explained that she did not strike out and did not hit resident #124, and did not have any type of stick and/or object in her hand. Resident #36 explained that resident #124 wandered into her room approximately ,[DATE] times before. Further review of the investigation documentation revealed resident #124 was interviewed and explained that she went into her room and into her bathroom and saw the lady in the wheelchair (resident #36) in her room. Resident #124 explained that she then tried to go into the bathroom when resident #36 would not let her in because resident #36 told her it wasn't her bathroom. Resident #124 stated that resident #36 had a stick and was pushing her shoulder with it and she was trying to defend herself because resident #36 continued to poke her with the stick. She said she then struck out and swung her hand out to hit resident #36. Resident #124 became tearful and stated, I'm sorry. I know this is childish but she provoked me to swing at her. I'm not a fighter. I don't bother anyone. I just needed to go to the bathroom and she wouldn't let me. Resident #36 is always in my room at night after dinner. The facility investigation also includes staff who were working the night of (MONTH) 10, 2019 were interviewed and there were no witnesses. Staff reported that resident #124 has wandered towards other rooms and is easily redirected, but entering into other rooms is not a common behavior that she exhibits. Staff #16 reported resident #124 had been toileted 30 minutes prior to this incident. The investigation concluded that resident #36 has continued with her activities of daily living without any changes. Staff are to monitor for any changes in mood and/or behavior and notify the provider as indicated. Resident #124 has requested a room change, which will be completed when a room/bed becomes available. Resident #124's chart was reviewed by the nurse practitioner and labs were ordered. Based on the results of the labs, resident #124 was started on an antibiotic for a urinary tract infection. Psych services also followed up with resident #124 and noted that the incident appeared to have been an isolated event due to confusion and this was out of character for resident #124. Social serviced followed up with both residents and no concerns were noted. A psychiatric follow up note dated (MONTH) 12, 2019 indicated resident #124 was seen for an urgent visit after a recent altercation with resident #36. Staff reported that resident #124 appeared to be confused and tried to use resident #36's bathroom. Resident #36 reportedly got upset with resident #124 and pushed resident #124's wheelchair so resident #124 slapped resident #36. Resident #124 admits to the altercation with resident #36. Staff reported that resident #124 was easily redirected after the incident and that this incident was very out of character for her and there were no other concerns at that time. The note continues that resident #124 has not previously had trouble with aggression or agitation and it is believed that this was an isolated incident, but her behavior will be monitored. In an interview with staff #16 on (MONTH) 30, 2019 at 1:46 p.m., she stated she is familiar with residents #36 and #124 and the incident between them. She stated that it was shift change when resident #36 came out of her room to the nurses station and stated that she had been assaulted. She said that resident #36 reported resident #124 came into her room to use the bathroom and wouldn't leave. She stated that resident #36 may not have understood how confused resident #124 might have been and resident #36 began pulling on resident #124's wheelchair, which may have been what caused the altercation. She also stated the residents were immediately separated and assessed. She stated that resident #36 did not have any red marks to her face, and there were no injures noted to either resident. She stated there were no witnesses and she had not seen that kind of behavior from resident #124 before. She stated resident #124 was known to be very confused, but not violent or aggressive. She stated the Director of Nursing (DON/staff #113) was informed right away of this incident. In an interview with staff #113 on (MONTH) 1, 2019 at 1:21 p.m., she stated she was unaware of this behavior of resident #124 going into resident #36's room. She stated their rooms were right across the hallway from each other when this incident happened. She said that resident #124 could have mistaken resident #36's room for hers. The DON stated there had been no prior reports of this type of behavior. She said after this incident, resident #36 reported that there had been several other incidents of resident #124 coming into her room and trying to use the bathroom. She stated that if they would have known about this behavior by resident #124 before the incident, perhaps it could have been prevented. Review of a facility policy regarding Abuse revealed the definition of physical abuse is: hitting, slapping, pinching, kicking, etc., as well as controlling behavior through corporal punishment. Staff will identify events .and determine the direction of the investigation. This also includes patient to patient abuse. If the suspected abuse is resident to resident, the resident who has in anyway threatened or attacked another will be removed from the setting or situation and an investigation will be completed .options for room changes will be provided based on the situation.

Based on closed record reviews, staff interviews, and review of policy and procedure, the facility failed to ensure one resident (#1) was transferred safely without falling and sustaining a significant injury. Findings include: The resident was admitted to the facility [DATE] with the [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS) dated [DATE] Quarterly assessment Section C included resident had severely impaired cognition, and Section G indicated the resident required two person physical assist for transfers, walk in room and walk in corridor, and one person physical assist for locomotion on unit. A review of the residents careplan indicated [DATE] and revised [DATE] revealed the resident requires extensive assistance with Activities of Daily Living, (ADL's) that included transfer with two person physical assist, as well as walking in room and corridor, locomotion on unit was extensive assist with one person physical assist due to cognitive loss/dementia. The [DATE] careplan also included the resident is at risk of falls: [MEDICAL CONDITIONS], cognitive loss, and lack of safety awareness. Interventions revealed that the resident was a one to two person assist for transfers with a gait belt. A review of nursing progress notes dated [DATE] revealed a new physician's orders [REDACTED]. Resident ambulates a short distance with certified nurse assistant (CNA) assist. Her baseline was independent ambulation. Nursing progress notes [DATE], documented resident gait somewhat unsteady, required assist of one to ambulate to the dining room. Another nursing note dated [DATE], the resident required assistance of one with bed mobility and transfers. A nursing progress note dated [DATE], revealed the resident's gait was slightly unsteady, requires the assistance of one to two with ADL's and walking. Another progress note dated [DATE], revealed the resident's gait was slightly unsteady, requires the assistance of one to two with walking. A later nursing note dated [DATE], revealed the resident's gait was slightly unsteady, requires the assistance of one to two with gait belt for safety. Another nursing note observation dated [DATE], documented the resident was assisted times one with gait belt to dining room for meals, gait slow and steady. A change of condition progress note dated [DATE], at 5:10 p.m. revealed the resident had a witnessed fall in her bedroom when getting up for dinner. The note indicated the resident had lost her balance fell and struck her head resulting in a hematoma to the right side, laceration to the right side of her eye with bleeding. The physician was notified and the resident was transferred to the hospital. Review of facility's investigation dated [DATE], revealed a CNA (staff #4) providing care to the resident let go of the resident's gait belt during her transfer to reach for an article of clothing for the resident. The resident fell , striking the right side of her head. The resident was transferred to the hospital by ambulance for evaluation as per the physician's orders [REDACTED]. An interview was conducted with the facility administrator (staff #1) on [DATE], at 1:08 p.m. He stated the facility's investigation of the incident revealed the CNA (staff #4) providing care for the resident was preparing the resident to ambulate to the dining room for dinner. The resident was transferred to a standing position when the CNA realized the resident would need her jacket. When the CNA let go of the gait belt, the resident fell striking her head. The administrator stated her head injury resulted in a subdural hematoma. The resident did not return to the facility and expired. The administrator reported that all CNA staff receive education in use of gait belts and transferring residents. The training is provided on initial hire and through continued education. The administrator further stated the CNA involved was terminated after the facility's internal investigation and was subsequently reported to the State Board of Nursing. Attempts to contact the CNA (Staff #4) who had provided care for the resident when she fell on [DATE], were unsuccessful. An interview was conducted on [DATE], at 1:02 p.m. with a random CNA. She stated she was required to have her gait belt available at all times and use it it on residents needing mobility assistance. She described checking a CNA Kardex for the residents current mobility needs and also staff shift reports. Another interview was conducted on [DATE] at 1:30 p.m. with the Physical Therapy Supervisor (staff #2) who stated the resident had a fear of falling . She stated on [DATE], the resident was able to ambulate 100 feet with minimal assistance with the aid of a walker. An additional interview was conducted on [DATE] at 2:10 p.m. with Human Resources (staff #3) who stated the direct care staff receive training in the use of mechanical lifts and gait belts. Policy's are reviewed and all are expected to follow. The training is reviewed every six months with required demonstration of proficiency. Individual concerns are identified and addressed with further inservicing and retraining as needed. A review of the employee file of the CNA involved in the incident revealed inservice's were documented on transfer and gait belt training. In addition the facility's dress code stated the CNA's were required to wear their gait belts as part of their uniform. The facility policy titled Safe Resident Handling program stated all residents/patients will be assessed upon admission, readmission, with significant change in condition and quarterly by a licence nurse for assistance with transfer activities, mobility, or repositioning in accordance with MDS procedures and requirements. Assessments will include the need for lift/transfer equipment, friction reducing aids, and gait/transfer belts. The Policy stated : Staff will follow the Center's Nursing policies and procedures related to the use of lifts and transfers and positioning devices. Maintain hands on back and side of gait belt at all times. Appropriate staff will receive training on safe patient/resident handling and demonstrate competency on use of lifts and transfer devices. Transfer assistance , mobility, and other resident handling tasks are to be carried out in accordance with the Lift/Transfer Assessment and care plan.

Based on clinical record reviews, observation, staff interviews, facility and hospital documentation and policy and procedures, the facility failed to ensure that one resident (#131) was transferred safely and failed to ensure that one resident (#18) was reassessed for the continued use of side rails. Findings include: -Resident #131 was admitted on [DATE], with [DIAGNOSES REDACTED]. A review of the MDS (Minimum Data Set) quarterly assessment dated [DATE], revealed the resident had no cognitive impairment and required extensive assistance of two persons with bed mobility and transfers. A fall care plan identified that the resident was a fall risk related to decreased mobility. A goal included that the resident would have no falls with injury through the next review. Interventions included to place call light within reach at all times, remind resident to use call light when attempting to ambulate or transfer and assist with toileting needs. Review of the ADL care plan revealed the resident was dependent on staff for bed mobility, transfers, dressing and toileting. The goal included that the resident's ADL care needs will be met. Interventions included to encourage residents participation while providing care, monitor for pain or discomfort and maintain good body alignment. According to the Kardex Report (a reference for Certified Nursing Assistants/CNAs which documents the level of assistance that each resident requires), the resident required extensive assistance of two persons for transfers. However, documentation on the Activities of Daily Living (ADL) Record, which is completed by CNAs revealed that resident #131 was frequently provided the assistance of one person with bed mobility and transfers in November 2015. The documentation further included that the resident was provided the assistance of two persons with transfers only on three occasions (November 2, 3 and 24). Review of the ADL Record for December 2015 revealed the resident was a one person physical assistance with bed mobility, dressing and toilet use. The documentation further included that the resident was provided two person assistance with transfers only on December 1, 2, 3, 6, 8 and 9. Review of a Situation Background Assessment/Appearance Request (SBAR) Communication form dated December 12, 2015, revealed the resident had a witnessed fall during a transfer from the bed to the wheelchair by a CNA. The facility's investigative documentation revealed that the resident had a fall while being transferred by CNA #1 from the bed to the wheelchair on December 12, 2015. The CNA placed the resident's wheelchair next to the bed at an angle, with the wheelchair brakes locked. The CNA then placed her arms underneath the resident's underarms and transferred the resident to the wheelchair. The resident was on the edge of the wheelchair, so the CNA attempted to reposition the resident further back into the wheelchair. Per the documentation, the resident made a body movement which appeared as a hop causing the CNA to lose her stance. This resulted in the resident falling off the wheelchair onto his buttocks, with both legs bent to the resident's right side. CNA #1 also fell to the floor and landed in a sitting position, with her arm still underneath the resident's arm. The documentation also noted that the CNA did not have a gait belt on. The resident was transferred to a hospital. The investigative report also included that the care plan was updated to reflect the need of two persons when getting the resident in and out of bed. According to the hospital records, the resident was admitted on [DATE], due to bilateral thigh pain. The documentation showed that the resident sustained [REDACTED]. An interview was conducted on February 3, 2016 at 1:17 p.m. with a licensed practical nurse (LPN), who stated that CNA #1 informed her of the resident's fall during a transfer on December 12. She stated that she found the resident with his buttocks on the floor, with both legs bent and the resident's hand was on the wheelchair and the other hand was on the bed. She said that CNA #1 transferred the resident from the bed to the wheelchair by herself. The nurse stated the resident was assessed and an x-ray was done, which showed fractures, so the resident was transferred to the hospital. An interview was conducted on February 3, 2016 at 2:02 p.m. with CNA #2, who stated that she was assisting another resident when CNA #1 called out for help. She said when she entered the resident's room, CNA #1 was trying to prevent the resident from falling, so she helped put the resident to the floor and instructed CNA #1 to get the nurse. An interview with CNA #1 was conducted on February 3, 2016 at 2:20 p.m. She stated that she placed the resident's wheelchair by the edge of the bed, then placed her forearm under the resident's arm and lifted the resident. She stated that the resident was on the edge of the wheelchair, so she lifted the resident again, which resulted in both she and the resident falling. She said that the resident was a two person assist with transfers, but she was the only CNA in the resident's room at the time of the incident. Further, she stated that the resident has always been a two person assist as written in the resident's Kardex. CNA #1 stated that she was also supposed to use a gait belt, but she did not use the gait belt when she transferred the resident on December 12. Multiple interviews with different CNAs were conducted on February 4, 2016 and they all stated that it is the facility policy to use a gait belt when doing a one person transfer. They also stated that they refer to the resident's Kardex for guidance regarding the type of assistance that the resident needs in performing ADLs. An interview with the Unit Manager was conducted on February 4, 2016. She stated that the Kardex Report is a reference for the CNAs to assist them in providing assistance with the residents. She said that this information is generated from the resident's MDS assessments and is revised as needed to reflect resident's needs. Review of the facility's policy regarding Fall Management revealed that Patients will be assessed for fall risk as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. The purpose is to reduce fall risk and minimize the actual occurrence of falls. The policy also included to develop an individualized plan of care. Review of the Safe Resident Handling/Transfer Equipment policy revealed the purpose was to provide safe transfers, ambulation and/or repositioning to residents who have a loss of functional abilities. The policy included that the use of two staff members may be care planned for safety as indicated. -Resident #18 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the nursing admission assessment dated [DATE], revealed the resident had unclear speech, was oriented to self only, had short and long term memory problems and was severely impaired with decision making skills. The assessment included the resident had a left hand contracture and needed two persons for transfers. Under the section for Devices/Restraints, it was noted that the resident utilized two half side rails. A review of the interdisciplinary progress notes dated May 22, 2015 revealed the resident had two half side rails in place for mobility and positioning. According to a Device Evaluation dated May 22, 2015, the resident had a history of [REDACTED]. Review of a Restrictive Device Consent dated May 22, 2015 and signed by the resident's responsible party revealed that bilateral half side rails to bed were in place for mobility and positioning, while in bed. A care plan dated May 24, 2015 identified that the resident was at risk for falls. An intervention included for half side rails to bed for repositioning and mobility. Review of the 14 day MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had severe cognitive impairment and was totally dependent on two staff for bed mobility. Also, the area to check that side rails were being utilized was left blank. An interdisciplinary progress note dated July 7, 2015 continued to document the use of two half side rails for mobility and positioning. Review of the Device Evaluation form dated August 25, 2015 revealed the resident was re-evaluated for side rail use. Per this assessment, there were no changes and the side rails remained part of the resident's plan of care. Review of the monthly nursing summaries from September through October 2015 revealed that the resident continued to utilized two half side rails. A physician's order dated November 3, 2015 included for the resident to have half rails up for turning and repositioning. According to the significant change MDS assessment dated [DATE], the resident had severe cognitive impairment and was totally dependent on two staff for bed mobility. Also, the area to check that side rails were being utilized was left blank. During observations conducted on February 2, and February 4, 2016, the resident was observed lying in bed, with bilateral half side rails in the up position. Further review of the clinical record revealed that there was no documentation that the resident was re-evaluated after August 25, 2015 for the continued use of side rails, in order to determine if the devices posed any safety concerns with ongoing use. An interview was conducted on February 2, 2015 at 9:42 a.m. with a unit manager, who stated that two half side rails are used for the resident, but the resident is not physically capable of getting in and out of bed on his own. In an interview with a licensed practical nurse (LPN) conducted on February 5, 2016 at 1:19 p.m., she stated that the resident uses half side rails for positioning and mobility. She stated that a resident is initially assessed for use of side rails on admission, and then reassessed quarterly thereafter. She said that assessments and reassessments of side rail use are documented on the Device Evaluation form and maintained in the resident's clinical record. Review of the clinical record with the LPN was conducted immediately following the interview and she stated that the last evaluation for the use of the side rails was in August 2015. Review of the facility policy regarding Bed Rails revealed that the use of bed rails may act as a restraint for one individual, but not another depending on the patient's condition and circumstance. Always evaluate the situation and consider risks and benefits of bed rail use, whether being used as an enabler or a restraint. The policy further included to reassess the need to use bed rails on a frequent, regular basis.

Based on clinical record reviews, staff interviews, and policy review, the facility failed to ensure that two residents (#271 and #155) were provided care and services to prevent the development of pressure ulcers. Findings include: -Resident #271 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Admission assessment dated [DATE], revealed no documented evidence that the resident had any pressure ulcers on the buttocks or coccyx area. The Braden Scale for Predicting Pressure Sore Risk dated November 25, 2014, identified that the resident was at moderate risk. Review of the Interdisciplinary Progress Notes dated November 25, 2014, revealed the resident was incontinent of bowel and bladder, and required maximum assistance of two staff members for activities of daily living. Review of the care plan for risk of skin breakdown, as evidenced by limited mobility dated November 26, 2014, revealed the following interventions: Apply barrier cream with each cleansing, assist resident in repositioning and turning frequently with cares, evaluate for localized skin problems, evaluate for skin risk factors per protocol, monitor skin for signs/symptoms of skin breakdown, utilize positioning devices as appropriate to prevent pressure over bony prominence's, and weekly skin assessments by licensed nurse. A nurse practitioner's (NP) progress note dated November 28, 2014, documented for an air mattress for the resident's buttocks wounds. Another NP progress note dated November 29, 2014, documented for an air mattress for tissue off load/buttocks wounds. Despite the documentation that the resident had buttocks wounds, there was no clinical record documentation regarding any assessments of the wounds, including measurements or description of the wound beds, nor any documentation as to when the wounds were first identified. There was also no physician's orders for any wound treatments from the time of admission through December 1, 2014. The first documented thorough assessment of the pressure ulcers were noted in a wound physician's progress note dated December 2, 2014. The note included the following: coccyx - stage III pressure ulcer that measured 3.0 centimeters (cm) by 3 cm., with a depth of 0.2 cm and had a small amount of serous drainage, right buttock - stage III pressure ulcer that measured 7 cm by 3.5 cm, with a depth of 0.2 cm, with a small amount of serous drainage noted, and a left distal buttock/upper posterior thigh - stage II pressure ulcer that measured 2.5 cm by 3.0 cm, with a scant amount of serous drainage. Physician's orders dated December 2, 2014 included the following treatment orders: coccyx pressure ulcer - Santyl, apply nickel thick layer to wound bed and cover with dry protective dressing daily and as needed (PRN), right buttock - Santyl, apply nickel thick layer to wound bed and cover with a dry protective dressing daily and PRN, and left distal buttock/upper posterior thigh - Hydrogel, cover with dry protective dressing daily. According to the admission Minimum Data Set (MDS) assessment dated [DATE], the resident had severe cognitive impairment and was totally dependent on staff for activities of daily living. The assessment also included that the resident had one stage II and two stage III pressure ulcers. In addition, review of the December 2014 TARs (Treatment Administration Record), which are kept in a book and staff initial when treatments are done, revealed that the physician ordered treatment for [REDACTED]. A wound care observation was conducted on December 5, 2014, with a licensed practical nurse (LPN) and an RN/supervisor. The pressure ulcers on the buttocks/coccyx were treated and measured with the following results: coccyx - 4 cm by 2.3 cm with a pink wound bed and an area of slough that was approximately 1 cm in diameter; right buttock - 8.2 cm by 2.9 cm with a pink wound bed with granulation tissue; and left posterior upper thigh - 1.9 cm by 3.0 cm with a pink wound bed and an area of slough that was approximately .4 millimeters. The dressings were changed and care was provided, per physician's orders. An interview was conducted with a RN, who stated that this resident had no pressure ulcer orders until December 2, 2014. She stated that the Hydrogel treatment did not get done, as the order did not get printed off the computer and it was not placed in the TAR book. She stated the process for wound orders is that the wound doctor e-mails the orders, the nurse prints the orders from the computer and then they go in the TAR book. She stated that no one noticed that one of the wound orders had not been printed. An interview was conducted with an LPN/unit manager on December 5, 2014. The LPN stated that there are no measurements for the pressure ulcers on the resident's buttocks/coccyx, prior to the wound doctor's measurements. He also stated that he does not know when the pressure ulcers were first identified. -Resident #155 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Admission assessment dated [DATE], revealed the resident had multiple bruises, and a left mushy heel, but there was no documentation the resident had a pressure ulcer to the right heel. The Braden Scale for Predicting Pressure Sore Risk dated June 23, 2014, identified that the resident was at mild risk. According to the admission MDS assessment dated [DATE], the resident was identified to be cognitively intact and required extensive assistance with most activities of daily living. The resident was also assessed to be at risk for pressure ulcer development, however; did not have any pressure ulcers upon admission. Review of the care plan for the potential for skin breakdown related to decreased mobility included the following interventions: elevate heels off of bed, keep skin clean and dry, observe skin every shift for signs and symptoms of potential skin breakdown, and weekly skin assessments. A quarterly MDS assessment dated [DATE], included the resident was at risk for developing pressure ulcers, however; did not have any. Further review of the clinical record revealed there was no documentation that the resident had any pressure ulcers to the right heel, until September 30, 2014. A wound physician's progress note dated September 30, 2014, now documented that the resident had a right heel unstageable pressure ulcer that measured 0.6 centimeters (cm) by 1.0 cm, with a small amount of serous drainage noted. The wound bed was described as having 26-50% slough, and 26-50% pink granulation tissue. A physician's order dated September 30, 2014, included the following wound treatment to the right heel: Santyl, apply nickel thick layer to wound bed, cover with dry protective dressing daily, and float heels while in bed. The wound physician's progress notes for October 2014 documented the following measurements of the right heel pressure ulcer: October 7 - measured 0.4 cm by 1 cm; October 14 - measured 0.2 cm by 0.7 cm; October 21, was noted to be a stage III and measured 0.2 cm by 0.5 cm, with a depth of 0.1 cm. Review of the TAR for September 30, through October 21, 2014, revealed there was no documented evidence that the physician ordered treatment was provided to the right heel pressure ulcer, during this time frame. Review of the wound progress notes dated October 28, 2014, revealed the wound on the right heel was a stage III pressure ulcer and measured 0.4 cm by 0.5 cm, with a wound bed that was 76-100% eschar. A physician's order was written on October 31, 2014, to cleanse the right heel with normal saline, apply skin prep, and leave open to air. Review of the Braden Scale for Predicting Pressure Sore Risk dated November 26, 2014, revealed a score of 20; indicating the resident was at mild risk, despite having a pressure ulcer. Per the wound physician progress notes [REDACTED]. During the survey, a wound observation was attempted, however; the resident declined. An interview was conducted on December 5, 2014, with a LPN/unit manager. The LPN stated that she was unable to find the TAR for October 2014, that would show that the right heel pressure ulcer was treated per physician's orders through October 21. She also stated that this would not be documented anywhere else. Review of the facility's policy on Skin Integrity Management revealed "...The purpose is to provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment, and promote healing of all wounds...Implement Special Wound Care treatments/techniques, as indicated and ordered..." Review of the facility's policy on Pressure Ulcer Guidelines revealed "... Recommend and obtain treatment order based on the patient's goals and wound condition...Implement prevention interventions...Transcribe order and document treatment on Treatment Administration Record (TAR)..."

Based on closed clinical record review, facility documentation, former and current staff interviews, and policy review, the facility failed to ensure that one resident (#1) was transferred safely during a mechanical lift transfer by staff #1, who neglected to transfer the resident, per facility policy. Findings include: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment completed on October 10, 2013, revealed in Section G. that the resident required extensive assistance with transfers, with two plus persons physical assistance. Review of the self care deficit care plan related to dementia revealed that the resident required extensive to dependent assistance for transfers. Review of the facility's investigative documentation revealed that on November 14, 2013 at approximately 1:30 p.m., resident #1 fell during a mechanical lift transfer by staff #1. The resident sustained [REDACTED]. Per the investigation, staff #1 had placed another resident on the toilet and decided to transfer resident #1 from her wheelchair to her bed using the mechanical lift, without another staff member present. As staff #1 lifted the resident in the mechanical lift, one of the straps came undone and the resident fell . Staff #1 attempted to catch the resident, but could not. Staff #1 admitted that she had violated the facility's mechanical lift policy and procedure when she attempted this transfer without another nursing staff member. Staff #1 also admitted that she did not properly secure the sling. Physician orders [REDACTED].#1 to the emergency room by ambulance. Review of the hospital emergency room records dated November 14, 2013, revealed the resident sustained [REDACTED]. The resident was treated in the emergency room and returned to the facility. Review of the nursing notes dated November 14, 2013, revealed that the resident returned to the facility from the hospital. An interview was conducted with a licensed practical nurse (LPN) on March 4, 2014. The LPN stated that staff #1 reported to him that resident #1 had fallen face first from the mechanical lift and that she had transferred the resident by herself. An interview was conducted with staff #1 on March 4, 2014. Staff #1 stated that she had just put another resident on the toilet, and while he was on the toilet, she decided to put resident #1 to bed, using the mechanical lift. Staff #1 stated that she tried to get help, but could not find anyone, so she hooked the resident up and lifted the resident in the sling. She stated that while the lift was going up, the front strap came loose, causing the resident to fall face first, hitting her head on the floor. She also stated that the facility's policy requires two staff members for all mechanical lifts, and what she did was wrong. An interview was conducted with the facility educator who stated that staff #1 did not follow the facility's policy requiring two staff members for all mechanical lift transfers. She further stated that the sling to the lift was not hooked correctly, causing the resident to fall face first to the floor. An interview was conducted with a certified nursing assistant (CNA) on March 4, 2014. The CNA stated that he always uses two staff members for a mechanical lift transfer. He also stated that if the other CNA's are busy, he gets a nurse to help him. Review of the facility's policy on Safe Resident Handling Equipment revealed "...Staff may use Safe Resident Handling equipment, such as lifts or repositioning equipment, for patients when needed...Staff will be trained in the use of each type of equipment...The Total Lift will be used as the primary intervention to manual lifting, transferring, and repositioning, and requires a minimum of two persons to perform the lift..."

Based on observations, clinical record review, staff and resident interviews, and facility policy review, the facility failed to ensure that one resident (#6) was provided care and services to prevent the development of a pressure ulcer. Findings include: Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed a Nursing assessment dated [DATE], that documented the resident had no skin/wound conditions present. Review of the Braden Scale dated January 24, 2014, revealed a score of 14; which indicated the resident was at moderate risk for developing pressure ulcers. Despite this, no interim skin care plan was developed. There was also no documentation of any preventative measures that were implemented to prevent skin breakdown. The admission Minimum Data Set (MDS) assessment completed on January 30, 2014, included in Section V., that the resident was at risk for pressure ulcers and to proceed to care planning. In Section G of the MDS, it noted that the resident was totally dependent on staff for bed mobility, toilet use, and personal hygiene. According to the Change of Condition documentation dated February 11, 2014, the resident now had a new right heel fluid filled blister, which measured 6 centimeters (cm) by 5 cm. Review of the Interdisciplinary Progress Notes dated February 11, 2014, revealed that a new wound was identified to the right heel and was described as a suspected deep tissue injury. The treatment included to float the heels. A comprehensive care plan for skin breakdown was not developed until February 11, 2014. The care plan documented the resident had a right medial heel, suspected deep tissue injury. Interventions included to float the heels, apply skin prep to the right medial heel suspected deep tissue injury, cover with dry protective dressing twice daily, and provide a low air loss mattress. Physician orders [REDACTED]. The orders included to cleanse the right medial heel blister with normal saline, apply skin prep, cover with dry protective dressing twice per day, and for the wound doctor to follow weekly. Physician orders [REDACTED]. Continued review of the clinical record revealed there was no documented evidence that thorough weekly wound assessments were completed from February 12, through 26, 2014. Review of the Interdisciplinary Progress Note dated February 27, 2014, revealed that the right heel was unstageable, and to continue the prescribed treatment. However, the note did not include any measurements or a thorough description of the wound bed. In addition, the facility was unable to provide any documentation that the wound treatments to the right heel were consistently provided, as ordered. An observation of wound care was completed on March 5, 2014, with a licensed practical nurse (LPN). The resident was observed lying supine in bed, with his heels touching the mattress. The resident's heels were not observed to be floated, as ordered. Wound care was provided by the LPN. The wound measured 5 by 5.5 cm, and had black eschar covering the entire area. An interview was conducted with the LPN immediately following the observation. The LPN stated that the resident's heels are supposed to be floated while in bed. Another observation was conducted on March 6, 2014, of the resident. At this time, the resident's heels were not being floated. An RN who was present during the observation stated that the heels should be floated, as ordered by the physician. An interview was conducted with the resident on March 6, 2014. The resident stated that no precautions were done to prevent the pressure ulcer prior to the blister on his heel. An interview was conducted with an LPN on March 6, 2014. The LPN stated that there should have been interventions done prior, but there was not. She also stated that there was no care plan for skin breakdown, prior to the development of the pressure ulcer. Review of the facility's policy on Skin Integrity Management revealed "...To provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment, and promote healing of all wounds...Develop comprehensive, interdisciplinary plan of care including prevention and wound treatments as indicated...Implement pressure ulcer prevention for identified risk factors..."