Every finding on record at Guam Memorial Hospital Authority

Based on observation, interview, record review, and policy review, the facility failed to implement a regular maintenance program to ensure bed systems, including bed rails, mattresses, and frames, were inspected for safety and potential entrapment hazards. The facility did not conduct routine assessments of mattress fit or measure potential entrapment zones in accordance with Food and Drug Administration (FDA) guidance. This had the potential to affect 14 of 19 sampled residents (Resident (R) R2, R3, R5, R8, R11, R12, R4, R9, R13, R22, R23, R25, R26 and R27) who used bed rails and had the potential to result in injury related to bed entrapment or bed system malfunction. Findings include: 1.Observation on 06/04/26 at 8:22 AM, R2 was in bed with 1/3 bed rails raised time (x) 3 (two rails at the head of his bed and one 1/3 rail at the foot of his bed. On 06/04/26 at 10:29 AM, 12:00 PM, 1:39 PM and 4:21 PM, R2 was in his bed with 1/3 bed rails raised x 2 at the head of his bed. On 06/05/26 at 9:49 AM, R2 was observed in his bed with two 1/3 bed rails at the head of his bed in the raised position. R2 stated he thought he had rails on his bed to keep him from falling out of bed. On 06/05/26 at 11:53 AM R2 was observed in bed with two 1/3 bed rails raised at the head of his bed. 2. Observation of R3 in bed with four 1/3 bed rails in the raised position at the head and foot of her bed on 06/01/26 at 12:45 PM, on 06/02/26 at 8:45 AM, 12:12 PM and 2:41 PM, on 06/03/26 at 8:40 AM and 1:44 PM, and on 06/04/26 at 10:30 AM, 12:01 PM and 1:39 PM. 3. Observation of R5 in bed with 1/3 bed rails in the raised position at the head of his bed on 06/01/26 at 12:40 PM, on 06/02/26 at 8:47 AM and 2:39 PM, on 06/03/26 at 8:38 AM and 1:33 PM, and on 06/04/26 at 8:36 AM, 10:28 AM and 1:37 PM with three 1/3 bed rails raised on his bed (two at the head of his bed and one at the foot of his bed). 4. Observation of R8 in bed with three 1/3 bed rails in the raised position on 06/01/26 at 10:48 AM, on 06/02/26 at 8:52 AM and 2:41 PM, on 06/03/26 at 8:40 AM and 1:21 PM and on 06/04/26 at 12:05 PM. 5. Observation of R11 in bed with four 1/3 bed rails in the raised position at the head and foot of her bed on 06/01/26 at 10:51 AM and with three 1/3 bed rails raised (two at the head of her bed and one at the foot of her bed) on at 06/01/26 at 1:05 PM, on 06/02/26 at 8:43 AM and 12:09 PM and on 06/04/26 at 11:07 AM. 6. Observation of R12 on 06/02/26 at 1:19 PM in bed with three 1/3 bed rails raised on her bed (two rails at the head of her bed on one rails at the foot of her bed). Observation of R12 on 06/04/26 at 10:26 AM, at 12:02PM, at 1:36PM and at 4:23PM of R12 in bed with two 1/3 bed rails raised at the head of her bed. 7. Observations on 06/01/26 at 11:45 AM and 1:23 PM and 06/02/26 at 2:14 PM, R4 was in bed with bilateral upper bed rails in place. On 06/04/26 10:46 AM R4 was in the commons area in bed with four bed rails (two upper [or towards the head of the bed] half rails and two lower [towards the foot of the bed]. On 06/05/26 at 12:25 PM in his room with all four bed rails up with padding attached to the bed rails. 8. Observations on 06/01/26 at 11:28 AM and 1:45 PM, 06/02/26 at 2:01 PM, and 06/05/26 at 12:31 PM, R9 was in bed with bilateral upper half bed rails raised; and on 06/04/26 at 10:54 AM R9 was observed in bed with bilateral upper bed rails and one lower bed rail raised. 9. Observations on 06/01/26 at 1:08 PM, 06/02/26 at 2:08 PM, 06/04/26 at 10:39 AM, and 06/05/26 at 12:15 PM, R13 was in bed with bilateral upper bed rails in the raised position. 10. Observations on 06/01/26 at 11:06 AM and 1:04 PM, 06/02/26 at 9:27 AM and 1:56 PM, 06/04/26 at 10:31 AM, and 06/05/26 at 11:53 AM, R22 was in bed with bilateral upper bed rails raised. 11. Observations on 06/01/26 at 11:08 AM, 06/02/26 at 1:58 PM, 06/05/26 at 12:02 PM, R23 was in bed with bilateral upper bed rails raised; and 06/04/26 at 10:33 AM, R23 was in bed with bilateral upper bed rails and one lower bed rail raised. 12. Observations on 06/01/26 at 11:30 AM, 06/04/26 at 10:38 AM, 06/05/26 at 12:13PM, R25 was in bed with bilateral upper bed rails raised, and on 06/02/26 at 2:07 PM, R25 was in bed with bilateral upper bed rails and one lower bed rail raised. 13. Observation on 06/01/26 at 11:36 AM and 06/04/26 at 10:45 AM, R26 was in bed with bilateral upper bed rails raised. 14. Observation on 06/01/26 at 1:25 PM, 06/04/26 at 10:46 AM, and 06/05/29 at 12:29 PM, R27 was in bed with bilateral upper bed rails raised. During an interview and record review on 06/05/26 at 3:01 PM, the Maintenance Leader (ML) stated bed inspections, consisting of testing the electrical components and the functionality of the bed were assessed annually. The ML stated the facility was aware of the Food and Drug Administration (FDA) recommendations regarding bed rails. The ML stated, The rails come standard to the bed. They can go down – we test them. They are not supposed to locked down. The ML was asked if mattresses were tested to ensure they fit the bed frame properly to limit entrapment zones. The ML stated they were not testing for entrapment zones as the bed rails were built into the bed. After review of the facility-provided binder of maintenance inspections, the Maintenance Leader confirmed that entrapment measurements were not performed. He stated, We do maintenance. The rails are on the bed when the resident arrives . No, we do not do any measurements. On 06/05/26 at 3:40 PM, the ML returned with a folder and stated they had done the testing as per FDA recommendations in 2023 but none since. There was no evidence the facility implemented an ongoing and consistent process to evaluate bed systems for entrapment risks in accordance with FDA guidance. During an interview on 06/06/26 at 9:54 AM, the DON was asked to provide a list of all residents that have bed rails. The DON stated, All the residents have bed rails because they came on the bed. Review of the facility's policy titled Safe and Effective Bed Rail Use, revised 07/,2021, revealed: Policy: It is the policy of this facility to identify and reduce safety risks and hazards commonly associated with bed rail use. A duo-faceted approach will be used to achieve sustainable quality outcomes, including 1) regular bed maintenance and 2) individual bed rail evaluations. In response to the requirement of providing for a safe, clean, comfortable, and homelike environment, the facility's regular maintenance program will include regular inspection of all bed systems (e.g., rails, frames, and mattresses, and operational components) to ensure they are clean, comfortable, and safe. The facility will also ensure individual resident bed rail evaluations are performed on a regular basis. It is the policy of this facility to conduct bed inspections.The facility will conduct regular bed inspections, utilizing an interdisciplinary, team-based approach (e.g., nursing and maintenance) to risk identification and prevention. The Director of Nursing and Maintenance Director (or qualified designees) will be responsible for completion of bed inspections on a regular basis. Background: .OVERVIEW OF THE U.S. FOOD AND DRUG ADMINISTRATION'S [FDA] POTENTIAL ZONES OF BED, The FDA provides dimensional recommendations for Zones 1-4, as 80% of reported entrapment cases have occurred in these zones. ZONE 1: Within the Rail, Any open space between the perimeters of the rail can present a risk of head entrapment. FDA recommended space: less than 4 3⁄4 ZONE 2: Under the Rail, Between the Rail Supports or Next to a Single Rail Support The gap under the rail between the mattress, may allow for dangerous head entrapment. FDA recommended space: less than 4 3⁄4 inch, ZONE 3: Between the Rail and the Mattress This area is the space between the inside surface of the bed rail and the mattress, and if too big it can cause a risk of head entrapment. FDA recommended space: less than 4 3⁄4 inches, ZONE 4: Under the Rail at the Ends of the Rail, A gap between the mattress and the lowermost portion of the rail poses a risk of neck entrapment. FDA recommended space is less than 2 3⁄8inches.ZONE 5: Between Split Bed Rails, When partial length head and split rails are used on the same side of the bed, the space between the rails may present a risk of either neck or chest entrapment. ZONE 6: Between the End of the Rail and the Side Edge of the Head or Foot Board A gap between the end of the bed rail and the side edge of the headboard or footboard can present the risk of resident entrapment. FDA recommended space is less than 2 5/8 inches. ZONE 7: Between the Head or Foot Board and the End of the Mattress When there is too large of a space between the inside surface of the headboard or footboard and the end of the mattress, the risk of head entrapment increases.

Based on observation, interview, record review, review of the Food and Drug Administration (FDA) guidance, and policy review, the facility failed to ensure alternatives were attempted prior to the use of bed/side rails for 6 of 19 sampled residents (Resident (R) R2, R3, R5, R8, R11 and R12) reviewed for bed/side rails. This failure had the potential to increase the risk of resident accidental entrapment, suffocation, serious injury, or death. Findings include: 1. Review of R2's undated Patient Data located in the Electronic Medical Record (EMR) revealed the resident was admitted to the facility on [DATE] with diagnosis of stroke-like symptoms. Review of R2's quarterly Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 04/23/26 and found in a folder kept at the nurse's desk, revealed a behavior interview for mental status (BIMS) score of 14 out of 15, which indicated the resident was cognitively intact. The MDS indicated that the resident was independent with moving about in his bed but refused to transfer in and out of bed during the assessment reference period. The MDS indicated bed rails were not in use for the resident. Review of R2's Doctor's Orders Report dated 06/03/26 and found in the EMR revealed no physician's orders for the resident's bed rails. Review of R2's comprehensive care plan did not address the resident's specific use of bed rails. There was no specific information on the care plan related to the reason for the resident's use of bed rails or the type and size of rails in use on the resident's bed. The care plan did not address the use of bed rails nor any specific safety interventions for a resident that used bed rails. Review of R2's Bed Rail Risk assessment dated [DATE] and found in the EMR indicated the bed rails were being utilized for mobility and for safety per request of the resident. The assessment indicated the resident was at risk for injury related to the use of bed rails due to dementia, altered sensation and the use of a pressure reducing mattress on the resident's bed. The assessment indicated the bed rails were integral to the resident's bed and were to be used. The assessment did not address attempted alternatives to the resident's use of bed rails. Review of R2's clinical record, including nurses' notes, and progress notes revealed no documented evidence any alternatives were attempted prior to the use of bed rails or that education on the risks of bed rails was provided to the resident or family. Observation on 06/04/26 at 8:22 AM, R2 was in bed with 1/3 bed rails raised times (x) 3 (two rails at the head of the bed and one 1/3 rail at the foot of the bed). The rails on R2's bed were noted to be part of the manufacturer's original bed design, and there were no mechanisms to prevent staff from raising the bed rails. Observation on 06/04/26 at 10:29 AM, 12:00 PM, 1:39 PM and 4:21 PM, R2 was in his bed with 1/3 bed rails raised x 2 at the head of his bed. On 06/05/26 at 9:49 AM, R2 was observed in bed, which had been pulled into the facility's courtyard with two 1/3 bedrails at the head of his bed in the raised position. R2 stated he thought he had rails on his bed to keep him from falling out of bed On 06/05/26 at 11:53 AM R2 was observed in his room in bed with two 1/3 bed rails raised at the head of his bed. R2 was observed on 06/06/26 at 9:00 AM, Certified Nurse Aide (CNA)8 confirmed the resident was in bed with two 1/3 bed rails raised at the head of his bed and stated the resident had bed rails on his bed because he was afraid of falling out of bed. On 06/06/26 at 9:22 AM, R2 was observed along with the Director of Nursing (DON) who confirmed both of R2's bed rails were raised at the head of his bed. The DON stated the resident used the bed rails to move around in the bed. The DON confirmed no alternatives had been attempted prior to R2's use of bilateral bed rails and stated the rails were integral to the bed. 2. Review of R3's undated Patient Data located in the EMR revealed the resident was admitted to the facility on [DATE] with diagnosis of history of stroke. Review of R3's quarterly MDS with an ARD of 05/12/26 and found in a folder kept at the nurse's desk, revealed a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. The MDS indicated the resident was independent with moving about in her bed and required partial to moderate assistance from staff to transfer in and out of bed. The MDS indicated bed rails were not in use for the resident. Review of R3's Doctor's Orders Report dated 06/03/26 and found in the EMR revealed no physician's orders for the resident's bed rails. Review of R3's Safety Risk for Injury Related to Use of Side Rails Care Plan dated 05/14/26 and found in the EMR revealed the rationale for the resident's use of bed rails was hyperkalemia (elevated potassium levels in the blood). There was no specific information on the care plan related to the reason for the resident's use of bed rails or the type and size of bed rails in use on the resident's bed. The care plan did not address the use of bed rails nor any specific safety interventions for a resident that used bed rails. Review of R3's Bed Rail Risk assessment dated [DATE] and found in the EMR indicated the bed rails were being utilized per request of the resident because the resident felt safer when all four of her bed rails were raised on her bed. The assessment indicated that the resident was at risk for injury related to physical or clinical condition that increased the risk for entrapment. The assessment indicated the use of all four 1/3 bed rails. The assessment did not address attempted alternatives to the resident's use of bed rails. Review of R3's clinical record, including nurses' notes, and progress notes revealed no documented evidence any alternatives were attempted prior to the use of bed rails or that education on the risks of bed rails was provided to the resident or family. Observations of R3 in bed with four 1/3 bed rails in the raised position at the head and foot of her bed on 06/01/26 at 12:45 PM, on 06/02/26 at 8:45 AM, 12:12 PM and 2:41 PM, on 06/03/26 at 8:40 AM and 1:44 PM, and on 06/04/26 at 10:30 AM, 12:01 PM and 1:39 PM. The rails on R3's bed were noted to be part of the manufacturer's original bed design, and there were no mechanisms to prevent staff from raising the bed rails. R3 was observed along with CNA8 on 06/06/26 at 9:00 AM, CNA8 confirmed R3 was in bed with four 1/3 bed rails raised at the head of her bed. CNA8 stated the resident requested four bed rails because they made her feel safe. R3 was observed with the DON on 06/06/26 at 9:20 AM, who confirmed all four of R3's bed rails raised at the head of her bed and stated the resident requested all four bed rails be raised on her bed. The DON confirmed no alternatives had been attempted prior to R3's use of bilateral bed rails and stated the rails were integral to the bed. 3. Review of R5's undated Patient Data located in the EMR revealed the resident was admitted to the facility on [DATE] with diagnosis of history of stroke. Review of R5's quarterly MDS with an ARD of 03/22/26 and found in a folder kept at the nurse's desk, revealed a BIMS score was unable to be completed due to the resident's poor cognition. The MDS indicated R5 had both short and long-term memory problems. The MDS indicated the resident was dependent upon staff to move about in bed and transfer in and out of bed. The MDS indicated bed rails were not in use for the resident. Review of R5's Doctor's Orders Report dated 06/03/26 and found in the EMR revealed no physician's orders for the resident's bed rails. Review of R5's Safety Care Plan dated 05/14/26 and found in the EMR indicated the resident was using bed rails per his request. There was no specific information on the care plan related to the reason for the resident's use of bed rails or the type and size of rails in use on the resident's bed. The care plan did not address the use of bed rails nor any specific safety interventions for a resident that used bed rails. Review of R5'sBed Rail Risk assessment dated [DATE] and found in the EMR, indicated the bed rails were being utilized for safety and mobility. The assessment indicated the resident was at risk for injury related to the use of bed rails due to dementia. The assessment indicated the bed rails were integral to the resident's bed and were to be used. The assessment did not address attempted alternatives to the resident's use of bed rails. Review of R5's clinical record, including nurses' notes, and progress notes revealed no documented evidence any alternatives were attempted prior to the use of bed rails or that education on the risks of bed rails was provided to the resident or family. R5 was observed in bed with 1/3 bed rails in the raised position at the head of his bed on 06/01/26 at 12:40 PM, on 06/02/26 at 8:47 AM and 2:39 PM, on 06/03/26 at 8:38 AM and 1:33 PM, and on 06/04/26 at 8:36 AM, 10:28 AM and 1:37 PM with three 1/3 rails raised on his bed (two at the head of his bed and one at the foot of his bed). The rails on R5's bed were noted to be part of the manufacturer's original bed design, and there were no mechanisms to prevent staff from raising the bed rails. R5 was observed with CNA8 on 06/06/26 at 9:03 AM, who confirmed R5 was in bed with three 1/3 bed rails raised at the head and foot of his bed. CNA8 stated the resident had rails on his bed to move in bed because he was afraid of falling out of bed. R5 was observed with the DON on 06/06/26 at 9:23 AM who confirmed both of R5's rails were raised at the head of his bed, and one rail was raised at the foot of his bed. The DON stated the resident used the rails to move around in the bed. The DON stated she did not know why three rails were raised on R5's bed since he could not use rails at the foot of his bed for mobility. The DON confirmed no alternatives had been attempted prior to R5's use of bilateral bed rails and stated the rails were integral to the bed. 4. Review of R8's undated Patient Data located in the EMR revealed the resident was admitted to the facility on [DATE] with diagnoses of cellulitis and pressure sore to the sacrum. Review of R8's quarterly MDS with an ARD of 06/01/26 and found in a folder kept at the nurse's desk, revealed a BIMS assessment score of 15 out of 15, which indicated the resident was cognitively intact. The MDS functional abilities section was not complete, and the MDS did not indicate whether the resident was independent with moving about in his bed, transferring in and out of his bed or that he required assistance from staff for these tasks. The assessment indicated bed rails were not in use for the resident. Review of R8's Doctor's Orders Report dated 06/03/26 and found in the EMR revealed no physician's orders for the resident's bed rails. Review of R8's comprehensive care plan did not address the resident's specific use of bed rails. There was no specific information on the care plan related to the reason for the resident's use of bed rails or the type and size of rails in use on the resident's bed. The care plan did not address the use of bed rails nor any specific safety interventions for a resident that used bed rails. Review of R8's Bed Rail Risk assessment dated [DATE] and found in the EMR, indicated the bed rails were being utilized for safety and mobility. The assessment indicated the resident was at risk for injury related to the use of bed rails due to the need for the resident to get out of bed unsupervised. The assessment indicated the bed rails were integral to the resident's bed and were to be used. The assessment did not address attempted alternatives to the resident's use of bed rails. Review of R8's clinical record, including nurses' notes, and progress notes revealed no documented evidence any alternatives were attempted prior to the use of bed rails or that education on the risks of bed rails was provided to the resident or family. R8 was observed in bed with three 1/3 bed rails in the raised position on 06/01/26 at 10:48 AM, on 06/02/26 at 8:52 AM and 2:41 PM, on 06/03/26 at 8:40 AM and 1:21 PM and on 06/04/26 at 12:05 PM. The rails on R8's bed were noted to be part of the manufacturer's original bed design, and there were no mechanisms to prevent staff from raising the bed rails. R8 was observed in bed along with CNA8 on 06/06/26 at 9:01 AM, who confirmed two 1/3 bed rails were raised at the head of R8's bed and one 1/3 rail was raised at the foot of his bed. CNA 8 stated the resident had rails on his bed because he was afraid of falling out of bed. R8 was observed with the DON on 06/06/26 at 9:23 AM, who confirmed three rails were raised at the head and foot of R8's bed. The DON stated the resident used the rails to move around in the bed. The DON confirmed no alternatives had been attempted prior to R8's use of bilateral bed rails and stated the rails were integral to the bed. 5. Review of R11's undated Patient Data located in the EMR revealed the resident was admitted to the facility on [DATE] with diagnosis of history of femur fracture. Review of R11's admission MDS with an ARD of 04/01/26 and found in a folder kept at the nurse's desk, revealed a BIMS score of 14 out of 15, which indicated the resident was cognitively intact. The MDS indicated the resident was independent with moving about in bed and required partial to moderate assistance from staff to transfer in and out of bed. The MDS indicated bed rails were not in use for the resident. Review of R11's Doctor's Orders Report dated 06/03/26 and found in the EMR, revealed no physician's orders for the resident's bed rails. Review of R11's Use of Bed Rails Care Plan dated 05/18/26 and found in the EMR, indicated the resident was using bed rails because she was Coronavirus Disease (COVID) positive. There was no specific information on the care plan related to the reason for the resident's use of bed rails or the type and size of rails in use on the resident's bed. The care plan did not address the use of bed rails nor any specific safety interventions for a resident that used bed rails. Review of R11's Bed Rail Risk assessment dated [DATE] and found in the EMR, indicated the bed rails were being utilized for safety and mobility. The assessment indicated the resident was at risk for injury related to the use of bed rails due to physical or clinical condition, however the assessment indicated the bed rails were integral to the resident's bed and were to be used. The assessment did not address attempted alternatives to the resident's use of bed rails. Review of R11's clinical record, including nurses' notes, and progress notes revealed no documented evidence any alternatives were attempted prior to the use of bed rails or that education on the risks of bed rails was provided to the resident or family. R11 was observed in bed with four 1/3 bed rails in the raised position at the head and foot of her bed on 06/01/26 at 10:51 AM and with three 1/3 rails raised (two at the head of her bed and one at the foot of her bed) on at 06/01/26 at 1:05 PM, on 06/02/26 at 8:43 AM and 12:09 PM and on 06/04/26 at 11:07 AM. R11 was observed in bed along with CNA7 on 06/06/26 at 9:23 AM, who confirmed the resident was in bed with four 1/3 bed rails raised at the head and foot of her bed and stated the resident had bed rails on his bed to move in bed per her request. There were no mechanisms to prevent staff from raising the bed rails. R11 was observed in bed with the DON on 06/06/26 at 9:24 AM, who confirmed all four of R11's bed rails were raised at the head and foot of her bed. The DON stated the resident used the bed rails to move around in her bed, but that four rails should never be in the raised position on any resident's bed. The DON stated she did not know why all four bed rails were raised on R11's bed. The DON confirmed no alternatives had been attempted prior to R11's use of bilateral bed rails and that the rails were integral to the bed. 6. Review of R12's undated Patient Data located in the EMR revealed the resident was admitted to the facility on [DATE] with diagnosis of dementia. Review of R12's quarterly MDS with an ARD of 04/24/26 and found in a folder kept at the nurse's desk, revealed a BIMS score of five out of 15, which indicated the resident was severely cognitively impaired. The MDS indicated the resident required partial to moderate assistance from staff to move around within her bed and to transfer in and out of bed. The MDS indicated bed rails were not in use for the resident. Review of R12's Doctor's Orders Report dated 06/03/26 and found in the EMR revealed no physician's orders for the resident's bed rails. Review of R12's Use of Side Rails Care Plan dated 12/18/24 and found in the EMR, indicated upper bed rails were in use on the resident's bed bilaterally. There was no specific information on the care plan related to the reason for the resident's use of bed rails or the type and size of rails in use on the resident's bed. The care plan did not address the use of bed rails nor any specific safety interventions for a resident that used bed rails. Review of R12's Bed Rail Risk assessment dated [DATE] and found in the EMR, indicated the bed rails were being utilized for safety and mobility. The assessment indicated the resident was at risk for injury related to the use of bed rails due to dementia and physical or clinical condition (left knee contracture), however the assessment indicated the bed rails were integral to the resident's bed and were to be used. The assessment did not address attempted alternatives to the resident's use of bed rails. Review of R12's clinical record, including nurses' notes, and progress notes revealed no documented evidence any alternatives were attempted prior to the use of bed rails or that education on the risks of bed rails was provided to the resident or family. Observation on 06/02/26 at 1:19 PM, R12 was in bed with three 1/3 rails raised on her bed (two rails at the head of her bed and one rail at the foot of her bed). Observation on 06/04/26 at 10:26 AM, at 12:02 PM, and at 4:23 PM, R12 was in bed with two 1/3 bed rails raised at the head of her bed, and there were no mechanisms to prevent staff from raising the bed rails. R12 was observed in bed with CNA7 on 06/06/26 at 9:26 AM, in bed with two 1/3 rails raised at the head of her bed. CNA7 stated R12 had bed rails raised on her bed to assist with mobility in bed and because she was afraid to fall out of bed. R12 was observed with the DON on 06/06/26 at 9:27 AM, who confirmed both of R12's bed rails were raised at the head of her bed and stated the resident used the bed rails to move around in the bed. The DON confirmed no alternatives had been attempted prior to R12's use of bilateral bed rails and stated the bed rails were integral to the bed. Review of the facility's policy titled Safe and Effective Bed Rail Use revised 07/2021, revealed, Purpose: The objective of the bed rail use policy is to determine if resident use is safe and appropriate. The interdisciplinary team will use data collected from regular bed inspections and individual bed rail evaluations to bolster care planning and positive resident outcomes. The bed rail use policy will be reviewed annually or more frequently as needed and will be integrated into the facility Quality Assurance and Performance Improvement program (QAPI). Policy: It is the policy of this facility to identify and reduce safety risks and hazards commonly associated with bed rail use. A duo-faceted approach will be used to achieve sustainable quality outcomes, including 1) regular bed maintenance and 2) individual bed rail evaluations.the facility's regular maintenance program will include regular inspection of all bed systems (e.g., rails, frames, and mattresses, and operational components) to ensure they are clean, comfortable, and safe. The facility will also ensure individual resident bed rail evaluations are performed on a regular basis. Individual bed rail evaluations will include data collection analysis and determination of potential alternatives to bed rail use. When bed rail(s) are deemed necessary and appropriate, the facility will provide education to resident or resident's representative pertaining to the risk and benefits of bed rail use. The facility's priority is to ensure safe and appropriate bed rail use.Rationale for Completing Bed Rail Risk Assessment.BOX 2: alternatives to bedrails.

Based on record review and interviews, the facility failed to ensure Pre admission Screening and Resident Review (PASARR) Level 1 evaluation was completed for one (Residents (R)12) out of one resident reviewed for PASARR. The facility's failure to ensure the appropriate PASARR assessment was completed created the potential for residents to have unmet psychological/psychiatric needs while residing in the facility. Findings include:Review of R12's undated Patient Data located in the Electronic Medical Record (EMR) revealed the resident was admitted to the facility on [DATE] with diagnosis of dementia. Review of R12's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/24/26 and found in a folder kept at the nurse's desk revealed a Brief Interview for Mental Status (BIMS) score of five out of 15, which indicated the resident was severely cognitively impaired. Review of R12's EMR revealed no documentation that the PASARR Screening Level 1 had been completed prior to R12's admission to the facility, or at any time during the resident's admission, to ensure psychiatric services were not needed. During an interview on 6/03/26 at 3:48 PM, the Director of Nursing (DON) confirmed she was responsible for ensuring PASARR Level 1 evaluations were completed for each resident in the facility. She confirmed she was not able to locate R12's PASARR Level 1 Screening. The DON stated that each resident was expected to have a PASARR Level 1 screening in place prior to admission to the facility and then again with any change in psychiatric status or the addition of psychiatric medication to the resident's plan of care. The facility's policy regarding PASARR assessment was requested of the DON by the survey team on 06/05/26 at 4:00 PM and was not received prior to survey exit on 06/06/26.

Based on record review, interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure the Minimum Data Set (MDS) assessments were transmitted within the timeframes specified in the RAI manual for nine of 19 residents (Resident (R)1, R4, R7, R9, R22, R27, R2, R3 and R12) MDSs reviewed during the survey. This failure had the potential for inaccurate or incomplete care planning and/or provision to the resident, the resident being discharged may not be able to receive services elsewhere because Medicare was not aware of the discharge status, and/or a lack of appropriate payment for services to the facility. Findings include: 1.Review of R1's facility provided undated Patient Data revealed an admission date of 01/20/26. Review of the validation report provided by the MDS Coordinator (MDSC) revealed a quarterly MDS with an assessment reference date (ARD) of 04/27/26 found in a folder kept at the nurse's desk, was not transmitted until 06/02/26. 2. Review of R4's facility provided undated Patient Data revealed an admission date of 05/27/26. Review of the validation report provided by the MDSC showed a discharge return anticipated MDS with an ARD of 05/04/26 found in a folder kept at the nurse's desk was not transmitted until 06/02/26. 3. Review of R7 facility provided undated Patient Data revealed a facility admission date of 01/15/26. Review of the validation report provided by the MDSC showed a quarterly MDS with an ARD of 04/22/26 found in a folder kept at the nurse's desk was not transmitted until 06/02/26. 4.Review of R9's facility provided undated Patient Data revealed an admission date of 10/23/24. Review of the validation report provided by the MDSC showed a quarterly MDS with an ARD of 04/20/26 found in a folder kept at the nurse's desk was not transmitted until 06/02/26. 5. Review of R22's facility provided undated Patient Data revealed an admission date of 04/12/26. Review of the validation report provided by the MDSC revealed an admission MDS with an ARD of 04/19/21 found in a folder kept at the nurse's desk was not transmitted until 06/02/26. 6. Review of R27's facility provided undated Patient Data revealed an admission date of 04/13/26. Review of the validation report provided by the MDSC revealed an admission MDS with an ARD of 04/20/26 and found in a folder kept at the nurse's desk was not transmitted until 06/03/26. 7.Review of R2's undated Patient Data located in the Electronic Medical Record (EMR), revealed the resident was admitted to the facility on [DATE]. Review of R2's quarterly MDS with an ARD of 04/23/26 found in a folder kept at the nurse's desk was not transmitted until 06/02/26. 8.Review of R3's undated Patient Data located in the EMR revealed the resident was admitted to the facility on [DATE]. Review of R3's quarterly MDS with an ARD of 05/12/26 found in a folder kept at the nurse's desk was not transmitted until 06/02/26. 9. Review of R12's undated Patient Data located in the EMR revealed the resident was admitted to the facility on [DATE]. Review of R12's quarterly MDS with an ARD of 04/24/26 found in a folder kept at the nurse's desk was not transmitted until 06/02/26. Review of the facility's MDS Submitter Final Validation Report dated 06/03/26 provided by the MDSC indicated for R1, R4, R7, R9, R22, R27, R2, R3 and R12's, Record Submitted Late: The submission date was more than 14 days after the assessment. During an interview on 06/03/26 at 10:13 AM, the MDSC confirmed MDS Assessments were expected to be transmitted within 14 days of assessment completion. During an interview on 06/06/26 at 1:19 PM, the Director of Nursing (DON) confirmed MDS assessments were expected to be transmitted timely. During an interview on 06/03/26 at 4:02 PM, the MDSC confirmed all the assessments were submitted late and that she used the RAI Manual as a reference. Review of the October 2025 RAI Manual page 5-1 revealed: Transmitting Data: Providers must transmit all sections of the MDS 3.0 required for their State-specific instrument, including the Care Area Assessment (CAA) Summary (Section V) and all tracking or correction information. Transmission requirements apply to all MDS 3.0 records used to meet both federal and state requirements. Care plans are not required to be transmitted. Assessment Transmission: Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (V0200C2 [MDS section] + 14 days). All other MDS assessments must be submitted within 14 days of the MDS Completion Date (Z0500B [MDS section] + 14 days). Tracking Information Transmission: For Entry and Death in Facility tracking records, information must be transmitted within 14 days of the Event Date (A1600 [MDS section] + 14 days for Entry records and A2000 [MDS section] + 14 days for Death in Facility records).

Based on record review and interviews, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for one of 19 residents (Resident (R) 12) reviewed. The MDS did not accurately reflect the resident's receipt of antipsychotic medication during the look-back period. This failure had the potential to result in inaccurate information being used for care planning an clinical decision-making. Findings include: Review of R12's undated Patient Data located in the Electronic Medical Record (EMR) revealed the resident was admitted to the facility on [DATE] with diagnoses of dementia and Failure to Thrive. Review of R12's Doctor's Orders Report revealed an order, with an initial order date of 07/18/25, for the resident to receive Quetiapine (an antipsychotic medication) 25 milligram (mg) once daily at bedtime. Review of R12's quarterly MDS with an Assessment Reference Date (ARD) of 01/24/26 and found in a folder kept at the nurse's desk, indicated a Brief Interview for Mental Status (BIMS) score of five out of 15, which indicated the resident was severely cognitively impaired. The MDS indicated the resident was not receiving an antipsychotic medication. Review of R12's Medication Administration Record/Treatment Administration Record (MAR/TAR) for 01/2026 revealed R12 received Quetiapine daily during the seven day look-back period (01/17/26 through 01/24/26) for the 01/24/26 quarterly MDS. During an interview on 06/03/26 at 10:13 AM, the MDS Coordinator (MDSC) confirmed R12's quarterly MDS was inaccurate related to the administration of an antipsychotic medication for the resident. During an interview on 06/06/26 at 1:19 PM, the Director of Nursing (DON) confirmed MDS assessments were expected to be accurate.

Based on record review, interview, and policy review, the facility failed to ensure residents were assessed for COVID-19 vaccination status and offered and/or provided the COVID-19 vaccine, or that refusal, contraindication, or prior vaccination status was documented for two of five residents (Resident (R) 13 and R19) reviewed for vaccinations out of a total sample of 19. This failure had the potential to increase the risk of COVID-19 infection and serious illness. Findings include: Findings include: 1. Review of R13's facility provided undated Patient Data revealed an admission date of 09/07/25. Review of R13's quarterly MDS with an Assessment Reference Date (ARD) of 03/14/26 and found in a folder kept at the nurse's desk revealed a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15, indicative of being cognitively intact. Review of the Infection Preventionist (IP) Nurses Note dated 09/17/25 at 3:55 PM provided by the IP revealed, COVID-l9 VACCINATION: Offered and educated resident on the importance, significance, and common side effects of the vaccine. He agreed to receive the vaccine when available. Review of R13's entire clinical record revealed no documentation to indicate the vaccine was administered following the resident's agreement, nor was there documentation of refusal, contraindication, or prior vaccination status. During an interview on 06/04/26 at 5:15 PM, the IP confirmed there was no record R13 had received the COVID vaccine. During an interview on 06/06/26 at 1:27 PM, the Director of Nursing (DON) stated, Upon admission, verify if the resident had it or not. If not, we will educate on the vaccine and offer it within a week of admission. The DON confirmed R13 should have received whichever COVID vaccine he was due for. 2. Review of R19's undated Patient Data located in the Electronic Medical Record (EMR) revealed the resident was admitted to the facility on [DATE]. Review of R19's admission MDS with an ARD of 04/21/26 and found in a folder kept at the nurse's desk, revealed a BIMS score of 12 out of 15, which indicated the resident was moderately cognitively impaired. Review of R19's Immunization Records dated 06/04/26 and located in the EMR revealed no documentation the facility assessed, offered, or provided the COVID-19 vaccine, nor documented refusal, contraindication, or prior vaccination status. During an interview on 06/04/26 at 2:57 PM, the IP indicated COVID vaccines were to be offered to the resident upon admission to the facility or at the hospital prior to transfer to the facility. The IP stated she was not sure how R19's immunization status had been missed upon admission to the facility. During an interview on 06/06/26 at 1:19 PM, the DON confirmed COVID immunizations were expected to be offered and administered or documented as refused prior to or upon admission to the facility and that it was the facility's responsibility to ensure this was done. Review of the facility's policy titled Protocol for Provision of COVID-19 Vaccination for SNF Residents dated 02/2022, revealed, Purpose: The COVID-19 vaccination has been shown in clinical trials to prevent hospitalizations and deaths. This protocol provides the process for ensuring provision of COVID-19 vaccination for residents that opt-in for vaccination. By executing this, the Skilled Nursing Facility (SNF) will be protecting part of the community population who are the most vulnerable.

Based on interview, record review, observation and document review, the facility failed to ensure appropriate sized incontinence products were available for one (Resident (R) 13) of 19 residents in the survey sample. This failure had the potential to negatively affect R13's dignity and skin integrity. Findings include:During an interview on 06/01/26 at 1:08 PM, R13 queried if the facility had any large size briefs as the mediums briefs did not fit. The request was passed on to the Director of Nursing (DON) on 06/01/26 at 1:30 PM. During a follow-up interview and observation on 06/04/26 at 10:39 AM regarding whether large briefs had been provided, R13 stated, No and asked if he could show what was being used. R13 lowered the sheet to show an incontinence brief under him attached to an absorbent bed pad (also known as chux) tucked in over the top of the groin area. R13 stated, this has been going on for a while now. Review of R13's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/14/26 and found in a folder kept at the nurse's desk revealed a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15, indicative of being cognitively intact. Observation of the Clean Utility Room on 06/04/26 at 10:57 AM with Registered Nurse (RN) 3 revealed two bags of medium sized briefs and stacks of chux. RN3 stated, There's another supply room in the back.With RN3 on 06/04/26 at 11:01 AM observation of the back supply room, RN3 stated, This is the PAR level room and confirmed the presence of four large plastic bags each containing ten packages of Dr. P medium briefs. RN3 stated, the room next to the PAR level room was the CSR room where we have the charges [charge items]. RN3 clarified items like gauze, abdominal dressings (ABD) pads, and kerlix were in this room and that there are no briefs in there.During an interview on 06/04/2026 at 11:00 AM regarding brief sizes, the DON stated, They normally have them, but CSR is out. A request was made for the last delivery invoice for small and large sized briefs. During an interview on 06/05/26 at 11:30 AM, Certified Nurse Aide (CNA) 6 stated an awareness that they have had medium sized briefs for the past couple of months. When asked who was to be advised if out of stock of something. CNA6 stated, Actually, someone is assigned to do the inventory for the supplies [named three names, one per shift] then they advise the [NAME] Clerk to order supplies. When asked who instructed the CNAs to use a chux along with a brief. CNA6 stated, It's used to extend. I guess it's a practice for the CNAs, I guess nobody instructed. At least we can close the diaper. CNA6 stated that the chux supports the skin for no skin tears and extra absorption.During an interview on 06/05/26 at 11:12 AM, the Administrative Officer (AO) stated, Yes, those are the inventories. The AO confirmed she had been told that it was January when they had the large size. A policy regarding the sizing of briefs, inventories, and who was to be advised of stock inventories was requested and not provided prior to survey exit on 06/06/26.Review of the facility provided brief inventories documentation revealed the last supply of large incontinence briefs was documented on 02/02/26.A follow-up interview on 06/05/26 at 12:15 PM, R13 stated large briefs had now been provided. R13 stated, he hasn't had them since February. R13 stated that he had advised his therapist who told the charge nurse and the head nurse. He was just told they were out of stock. R13 stated that the bed pad was uncomfortable, it was embarrassing and undignified to have it [brief] be so small and not fit. It's embarrassing to have to wear a diaper anyway, then to have it fit like a speedo and have something tucked in that was uncomfortable. It just is not right. During an interview on 06/05/26 at 5:12 PM, the Medical Director stated, Yes of course they should have appropriate sizes. We shouldn't deny anyone their rights. They have a right to have their size.During an interview on 06/06/26 at 1:30 PM, the DON stated, Different sizes should be available. Lately, only providing the medium. They [hospital] said they stopped ordering anything but the mediums. The DON stated, I called the day before and was told they only had medium and when I followed up, they sent over large briefs.

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure a comprehensive admission Minimum Data Set (MDS) assessment was completed within the time frame required by the RAI Manual for one of 19 sampled residents (Resident (R) 21). This failure had the potential for inaccurate or incomplete care planning and/or provision of care to the resident, and/or inaccurate reimbursement for services.During the tour of the facility, R21 was observed in his room on 06/01/26 at 11:02AM. Review of the facility provided resident matrix document did not indicated that R21 was a new admission admitted within the past 30 days. Review of the facility provided Patient Data sheet revealed R21 was admitted to the facility on [DATE]. During an interview on 06/03/26 at 3:45PM when inquiring about a list of names that needed MDS assessment reviews, the MDS Coordinator (MDSC) provided a note that indicated that R21's admission (comprehensive) MDS with an assessment reference date (ARD) of 04/21/26 was still incomplete. During the interview, the MDSC stated she used the RAI manual as a reference. Review of the RAI Manual dated October 2025 page 5-1 revealed: Transmitting Data: Providers must transmit all sections of the MDS 3.0 required for their State-specific instrument, including the Care Area Assessment (CAA) Summary (Section V) and all tracking or correction information. Transmission requirements apply to all MDS 3.0 records used to meet both federal and state requirements. Care plans are not required to be transmitted. Assessment Transmission: Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (V0200C2 [MDS section] + 14 days). All other MDS assessments must be submitted within 14 days of the MDS Completion Date (Z0500B [MDS section] + 14 days).

Based on record review, interviews, and policy review, the facility failed to ensure two Residents (R)2 and R12) out of five residents reviewed for unnecessary medication was free from potential chemical restraints. The facility's failure to ensure residents were free from unnecessary chemical restraints created the potential for this and other residents to receive medication that is not necessary or desired related to their psychiatric/mental health care. Findings include: 1.Review of R2's undated Patient Data located in the Electronic Medical Record (EMR) revealed the resident was admitted to the facility on [DATE] with diagnoses of stroke-like symptoms and type 2 diabetes. Review of R2's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/23/26 and found in a folder kept at the nurse's desk revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident was cognitively intact. The MDS indicated that the resident was receiving an antidepressant medication daily and that the resident did not exhibit any behaviors during the assessment reference period. Review of R2's Doctor's Orders Report dated 06/03/26 and found in the EMR revealed an order, with an initial order date of 05/30/26, for the resident to receive Trazadone (an antidepressant medication) 25 milligrams (MG) three times daily. There was no diagnosis or rationale for the resident's Trazadone order. Review of R2's Medication Administration Records (MARs) dated 06/01/26 through 06/06/26 and found in the Medication Administration Book on the medication cart revealed the resident was receiving his Trazadone per physician's orders. The MARs revealed agitation was being monitored related to the administration of the medication. There was no documentation of side effect tracking related to the Trazadone in the resident's record. Review of R2's Coping Care Plan dated 08/15/25 and found in the EMR revealed nothing specific related to the administration of antidepressant medication. Review of R2's EMR revealed no documentation to indicate any attempt had been made by the facility to address the resident's agitation with the use of non-pharmaceutical methods prior to initiating the Trazadone order for. 2.Review of R12's undated Patient Data located in the EMR revealed the resident was admitted to the facility on [DATE] with diagnoses of dementia and Failure to Thrive. Review of R12's quarterly MDS with an ARD of 04/24/26 and found in a folder kept at the nurse's desk revealed a BIMS score of five out of 15, which indicated the resident was severely cognitively impaired. The MDS indicated the resident was receiving antipsychotic medication daily and did not exhibit any behaviors during the assessment reference period. Review of R12's Doctor's Orders Report dated 06/03/26 and found in the EMR revealed an order, with an initial order date of 05/30/26, for the resident to receive Quetiapine (an antipsychotic medication) 25 mg once daily at bedtime. There was no diagnosis associated with the Quetiapine order. Review of R12's MARs dated 06/01/26 through 06/06/26 and found in the Medication Administration Book on the medication cart revealed the resident received the Quetiapine per physician's orders. The MARs revealed the resident was being monitored for confusion related to the administration of the medication, however, there was no documentation of tracking side effect related to the usage of Quetiapine. Review of R12's Antipsychotic Medication Use Care Plan dated 08/08/24 and found in the EMR indicated the resident was receiving Quetiapine related to minor outbursts. Interventions included monitor side effects related to the use of the medication and monitor the resident's behaviors related to the administration of the medication. No specific behaviors related to the administration of the Quetiapine were indicated in the plan of care. Review of R12's EMR revealed no documentation to indicate any attempt had been made by the facility to address the resident's minor behavioral disturbance by non-pharmaceutical methods prior to initiating the order for Quetiapine. During an interview on 06/06/26 at 1:19 PM, the Director of Nursing (DON) confirmed specific behaviors and side effects related to the administration of psychotropic medications were expected to be monitored, non-pharmacological interventions should be attempted prior to the administration of psychotropic medication, and a clear diagnosis/rationale was expected to be in place for each psychotropic medication ordered for a resident. Review of the facility's policy titled, Psychotropic Medication Use dated 02/2016 revealed, Residents of the facility who are prescribed psychotropic medication, such as antipsychotic, antidepressants, etc. will be monitored.Attending physicians must indicate that a psychotropic medication is necessary to treat a specific condition/behavior.Licensed nurses will be aware of potential side effects of psychotropic medications and report any side effects to the resident's attending physician.Attempts for non-pharmacological interventions must be clearly documented in the resident's chart.

Based on interview, record review and policy review, the facility failed to ensure residents were assessed for influenza and pneumococcal vaccination status and offered and/or provided indicated vaccines, or that refusal, contraindication, or prior vaccination status was documented, for 1 of 5 residents (Resident (R) 19) reviewed for vaccinations. This failure had the potential to increase the risk for R19 to contract influenza and/or pneumococcal disease and experience adverse health outcomes. Findings include:Review of R19's undated Patient Data located in the Electronic Medical Record (EMR), revealed the resident was admitted to the facility on [DATE] and was over the age of 65 at the time of admission. Review of R19's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/21/26 and found in a folder kept at the nurse's desk, revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated the resident was moderately cognitively impaired. Review of R19's Immunization Records dated 06/04/26 and located in the EMR revealed no documentation the facility assessed, offered, or provided influenza or pneumococcal vaccines, nor documented refusal, contraindication, or prior vaccination status. During an interview on 06/04/26 at 2:57 PM, the Infection Preventionist (IP) indicated influenza and pneumococcal vaccines were to be offered upon admission to the facility or at the hospital prior to transfer to the facility. The IP confirmed that there was no documentation of R19 influenza and pneumococcal immunization status. The IP stated she was not sure how R19's immunization status had been missed upon admission to the facility. During an interview on 06/06/26 at 1:19 PM, the Director of Nursing (DON) confirmed influenza and pneumococcal immunizations were expected to be offered and administered prior to or upon admission to the facility and that it was the facility's responsibility to ensure this was done. Review of the facility's policy titled, Administering Pneumococcal Vaccine dated 04/2023 indicated, Upon admission, the assigned licensed nurse will assess every resident for inclusion in the high-risk target group. The criteria for inclusion in this group is as follows: Previously unvaccinated adults age [AGE] years and older.Upon one week of admission, the resident or authorized resident representative will be given a copy of the Vaccine Information Sheet (VIS). Review of the facility's policy titled, Administering Influenza Vaccine dated 04/2023 indicated, Vaccination will be administered by the licensed nurse as a standing order for those individuals who are assessed and are determined to meet the criteria for high-risk target groups.Upon admission, the assigned licensed nurse will assess every resident for inclusion in the high-risk target group. The criteria for inclusion in this group is as follows:Persons aged > 50 years Have any condition (e.g., cognitive dysfunction, spinal cord injuries, seizure disorders, or other neuromuscular disorders) that can compromise respiratory function or the handling of respiratory secretion or that can increase the risk for aspiration .Upon one week of admission, the resident or authorized resident representative will be given a copy of the Vaccine Information Sheet (VIS).

Based on record review, interviews, and policy review the facility failed to ensure require Notification of Medicare Non-Coverage (NOMNC advisements were provided to two of three residents (Resident (R) 29 and R30) to ensure that residents were give two days in advance notice of Medicare A services ending. This failure had the potential for residents to incur unauthorized expenses and/or forfeit the time granted for an appeal to Medicare. Findings include:1. Review of R29's facility provided Patient Data revealed an admission date of 01/19/26 with diagnosis of post-surgical right femur fracture. Review of the facility provided NOMNC worksheet indicated for R29 the Medicare A services start date was 01/19/26 with the last covered day of services was 02/02/26. Review of the facility provided NOMNC form showed the last covered day noted was 02/02/26 and that R29 signed the form on 02/02/26. During an interview on 06/06/26 at 2:59PM, the Hospital Utilization Specialist ([NAME]) confirmed the NOMNC was to be issued two days in advance of the last covered day and confirmed for R29 that it was not provided two days prior to the last day of Medicare A services end date. 2. Review of R30's facility provided Patient Data revealed an admission date of 04/12/26 with diagnosis of oxygen dependence. Review of the facility's provided NOMNC worksheet indicated for R30 the start date of Medicare A services and the last covered day of Medicare A services was 04/12/26. Review of the facility provided NOMNC form showed the last covered day was 04/12/26 and R30 signed that she did not consent, along with a facility representative signature dated 04/21/26. During an interview on 06/06/26 at 3:09 PM, the [NAME] stated that R30 was transferred to the skilled nursing facility because of the typhoon and needing hospital beds [NAME] confirmed that R30 required no skilled care and that the NOMNC was signed on 04/21/26 which was nine days after the end of the service date. Review of the facility's policy titled Skilled Nursing Facility ABN/NOMNC effective date 11/10/2022, revealed: .III. Policy. 1. Skilled Nursing Facility may issue Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) . to Medicare fee-for service inpatients if they plan to hold the patient financially liable. These notices may be issued during admission or at any point during an [sic] skilled nursing stay if it is determined that the care the patient is receiving, or is about to receive, is not covered because it is:.b. Custodial care (not a covered level of care) (S1862(a)(9) of the Act) . B. The Notice of Medicare Non-Coverage (NOMNC) (CMS-10123). 1. Must be delivered at least two calendar days before Medicare covered services end or the second to the last day of service if care is not being provided daily.

Based on interview, record review, and policy review, the facility failed to advise one of five residents (R12) reviewed for unnecessary medications of the risks and benefits for psychotropic medication use. This failure had the potential to affect the care provision, discharge planning, and/or informed consent for psychotropic medications. Findings include: Review of R12's undated Patient Data located in the EMR revealed the resident was admitted to the facility on [DATE] with diagnoses of dementia and Failure to Thrive. Review of R12's quarterly Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 04/24/26 and found in a folder kept at the nurse's desk revealed a Brief interview of mental status (BMS) score of five out of 15, which indicated the resident was severely cognitively impaired. Review of R12's Doctor's Orders Report dated 06/03/26and d in the EMR revealed an order, with an initial order date of 05/30/26, for Quetiapine (an antipsychotic medication) 25 milligram (mg) once daily at bedtime. There was no diagnosis for the Quetiapine order in the EMR. Review of R12's Medication Administration Records (MARs) dated 06/01/26 through 06/06/26 and found in the Medication Administration Book on the medication cart, revealed the resident received the Quetiapine per physician's order. Review of R12's EMR revealed no documentation to indicate informed consent had been obtained for the administration of the resident's antipsychotic medication. During an interview on 06/06/26 at 1:19 PM, the DON stated she was not aware informed consent was to be obtained for the administration of any psychotropic medication. The facility's policy related to informed consent for the administration of psychotropic medication was requested on 06/05/26 at 4:00 PM. The survey team was provided with a facility policy related to the administration of psychotropic medication prior to survey exit; however, the policy did not address informed consent for the administration of the medication.

Based on record review, interviews, and policy review, the facility failed to ensure routine dental services were provided for one (Resident (R)5) out of two residents reviewed for dental services in the sample of 19 residents. The facility's failure to ensure dental services were provided for R5 created the potential for the resident to experience complications and/or pain related poor dentition. Findings include: Review of R5's undated Patient Data located in the Electronic Medical Record (EMR) revealed the resident was admitted to the facility on [DATE] with diagnosis of history of stroke. Review of R5's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/22/26 and found in a folder kept at the nurse's desk revealed a Brief Interview for Mental Status (BIMS) score that was not able to be completed due to the resident's poor cognition. The MDS indicated no oral or dental problems. Review of R5's Doctor's Orders Report dated 06/03/26 and found in the EMR revealed no physician's orders for the resident to see an oral health professional. Review of R5's Dental Care Care (sic) Plan dated 06/15/25 and found in the EMR indicated the resident was expected to maintain good oral health. Interventions included, Referral to oral health professional. Review of R5's EMR revealed no documentation to indicate the resident had been seen by a dentist/oral health professional for routine dental care since his admission to the facility on [DATE]. During an interview on 06/03/26 at 2:58 PM, the Social Services Director (SSD) stated that all residents were to be offered/receive routine dental services at least every six months as part of their plan of care. The SSD confirmed R5 had not been offered routine dental services since his admission on [DATE]. During an interview on 06/03/26 at 3:57 PM, the Director of Nursing (DON) confirmed R5 did not have a physician order to receive routine dental care. She stated her expectation was that all residents should be offered routine dental care at least once every six months. Review of the facility's policy titled Dental Services dated 02/2016 revealed, [The Facility] must provide or obtain from outside resources routine or emergency dental services to meet the need of each resident.

Based on record review, observation, interview, and policy review, the facility failed to ensure two of 19 residents (Resident (R) R4 and R22) had comprehensive person-centered care plans for each resident, with measurable objectives and timeframes to meet the resident's medical, nursing, mental, and/or psychosocial needs as identified during a comprehensive assessment. This failure had the potential to affect the care and/or quality of life experienced by the resident while at the facility. Findings include:1. Review of R4's facility provided undated Patient Data revealed a readmission date of 05/27/26 with diagnoses of history of cerebral vascular accident (stroke), fever from urinary tract infection, and bedbound.Observations of R4 on 06/01/26 at 11:45 AM and 1:23 PM; and 06/02/26 at 2:14 PM in bed with bilateral upper half rails in the up position with blue pads wrapped around them; and on 06/05/26 at 12:25 in bed with all four bed rails in the up position with the blue padding attached to all four rails.Observation on 06/06/26 at 9:12 AM with the Director of Nursing (DON) revealed R4 in bed with all four rails in the up position with blue padding attached on the interior of the rail.Review of the facility provided Care Plan revealed the use of R4's bed rails was not care planned. During an interview on 06/06/26 at 1:20 PM, the DON stated an expectation that Bed rail use should be care planned.2. Review of R22's facility provided undated Patient Data revealed an admission date of 04/12/26 with diagnoses of depression and undiagnosed mental disability. Observations on 06/02/26 at 10:58 AM, 06/02/26 at 1:56 PM, 06/04/26 at 10:31 AM, and 06/05/26 at 11:53 AM revealed R22 in bed. Review of R22's facility provided Activity Assessment revealed, Interventions: 1:1 [one to one] activity: conversation, exercise and music therapy, group activity: bingo social, outdoor sunshine/ socialization. Frequency: Resident will be seen 5 to 7x [times] / week for 1:1/group activity. Review of R22's facility provided Care Plan did not reveal any personalized activity care plan based on the assessment. During an interview on 06/06/26 at 1:38 PM, the DON confirmed activities should be care planned. Review of the facility's policy titled Comprehensive Care Plans reviewed 02/2016 revealed:Purpose: To ensure that resident will receive a comprehensive care plan so that resident will be in a best possible, physical, mental, psychological well-being.Policy: A facility must develop a comprehensive care plan for each resident that includes measurable objective and timetables to meet a resident's medical, nursing, mental, and psychological needs that are identified on a comprehensive assessment.The services that are to be furnished to attain or maintain the resident highest possible, physical, mental, and psychological well-being. A comprehensive care plan should develop after the comprehensive assessment. Must be prepared by the other disciplinary team that includes physician, and registered nurse with responsibility for the resident and other appropriate staff in discipline. Procedures: The facility must use the result of the assessment to develop, review and revise the comprehensive care plan.

Based on interview, document review, policy review and review of the Guam Code Annotated (GCA), the facility failed to ensure its governing body appointed a Licensed Nursing Home Administrator (LNHA) who was licensed and responsible for the management of the facility, reporting and being accountable to the governing body. This failure had the potential to result in ineffective oversight and lack of accountability and to affect all the residents of the facility. Findings include: During an interview during entrance conference on 06/01/26 at 10:06 AM with the Director of Nursing (DON), the Administrative Officer (AO), and Medical Director, the DON confirmed she was the Acting Administrator and did not have an Administrator's licensed. Review of the file provided on 06/02/26 by the Hospital Quality, Patient Safety and Regulatory Compliance Administrator (QPSRCA) revealed a LNHA job posting was done in January 2025 with one qualified applicant. The file included that the Board of Trustees Human Resources Subcommittee had the LNHA opening topic on their agenda for 01/13/25, 02/10/26, 03/17/26, 04/28/26 and 05/13/26 Board of Trustee meetings. During an interview on 06/06/26 at 4:40 PM, the QPSRCA confirmed the LNHA position opening was also included on the facility's Quality Assurance agenda. Review of the facility's policy titled Governing Body, reviewed 11/2023 revealed, Policy: The facility must have a governing body that is legally responsible for establishing andimplementing policies regarding the management and operation of the Skilled Nursing Unit.Procedures: The governing body appoints the Administrator that is responsible for the management of the facility. Review of the GCA Chapter 15 Nursing Home Administrators located at https://guamcourts.gov included under S 15102. Administrator's License Required, No nursing home shall operate except under the supervision of a nursing home administrator, and no person shall be a nursing home administrator unless he is the holder of a sufficient nursing home administrator's license issued pursuant to this Chapter.

Based on interview, the facility failed to present a Disclosure of Ownership during the extended survey. This failure could affect the accuracy of records for Centers of Medicare and Medicaid Services (CMS) and has the potential to affect all of the residents in the facility. Findings include:On 06/04/26 at 10:18 AM, the Disclosure of Ownership document was requested from the Administrative Officer (AO). During the exit conference on 06/06/26 at 6:00 PM, the AO stated the department that would complete and provide the Disclosure of Ownership document was closed and the document would be emailed on Monday. As of 06/10/26 at 5:30 AM the Disclosure of Ownership document has not been provided by the facility.

Based on observation, interview, and record review, the facility failed to honor the rights of one of one resident (Resident(R)28) reviewed for choices to make decisions about their care. Specifically, staff failed to provide showers for R28 prior to going to dialysis treatments due to lack of available linens.This failure resulted in R28 experiencing psychosocial harm as exhibited by decreased engagement in social activities, apathy and withdrawal, and refusal of care. Findings:On 08/18/25 at 10:58 AM, R28 was observed lying in bed in her room, watching television. R28 was alert and stated she wanted to share her concerns; however, she is going to dialysis so would like to speak the next day. Transport arrived after a couple of minutes. On 08/19/25 at 09:35 AM, a follow-up interview was conducted with R28, inside her room. R28 stated the facility had been short of linens. R28 reported that she goes to dialysis three times a week and, on dialysis days, she prefers to take a shower. However, on most days, staff told her that there were no linens available, so showers could not be provided. Instead, the Certified Nursing Assistants (CNAs) would provide a wipe down. R28 stated this occurred frequently, like yesterday, I only got a wipe down.I am also speaking for other residents, because if it's just a wipe down, you still get sticky. R28 stated when she returns from dialysis, she becomes irritated because she feels more uncomfortable. R28 further stated that when she is irritated, she does not want to do anything and will refuse to eat or take her medications. R28 stated if it's not dialysis days, it's okay I just wash down there.but not during dialysis.Review of the electronic health record (EHR) revealed R28 is a [AGE] year-old resident readmitted to the facility on [DATE], with diagnoses including end stage renal disease on hemodialysis, sacral pressure ulcer, and seizure disorder.Review of the Minimum Data Set (MDS, a standardized assessment tool) with assessment reference date of 08/04/25, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R28 had no cognitive impairment. R28 required substantial/maximal assistance from staff for shower/bathing and personal hygiene.Review of the Physician Progress Note dated 08/06/25, revealed documentation of R28's refusal of care and medication. The note showed, In reviewing nursing notes patient has had multiple refusals of medications and care plan for her wound care. This is not specific to Depakote or to midodrine. Referred to Guam behavioral [sic] Health. Patient seen by Guam behavioral [sic] Health. Seen by psychiatry. Diagnosis of MDD [Major Depressive Disorder] Increase risperidone to .5 mg b.i.d.[twice a day]. On 08/19/25 at 01:17 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1, who stated R28 goes to dialysis on Monday, Wednesday, and Friday and likes to take showers before going to dialysis. CNA 1 stated R28 receives shower from the night shift staff early in the morning on dialysis days. CNA 1 stated that R28 is picked up by transport at around 11 AM and comes back in the afternoon shift (3:00 PM to 11:00 PM). On 08/19/25 at 01:31 PM, an interview was conducted with CNA 3, who stated that R28 likes to go out and participate in group activities. CNA 3 stated, however, that there are days when R28 suddenly becomes quiet, does not want to do anything, and refuses to eat.Review of the SNU shower schedule showed R28 was scheduled to receive showers on the night shift (11:00 PM to 07:00 AM) every Sunday, Tuesday, and Thursday. Shower is given early the following morning (Monday, Wednesday, and Friday).Review of the night shift's SNF CNA Patient Care (CNA's shower documentation) for August 2025 revealed that showers were not provided to R28 on 8/1, 8/4, 8/8, 8/13 and 8/18/25 as scheduled.On 08/21/25 at 10:38 AM, an interview was conducted with Registered Nurse (RN) 2, who stated she was aware that residents, including R28, were not consistently provided showers due to lack of linens. RN 2 stated, sometimes they [CNAs] report to me they cannot shower the resident because there are no linens, or sometimes we cannot change the bed because there are no linen, so sometimes I tell them just to change the lifter [lift sheet]. RN 2 verified that after R28 returns from dialysis, she often hears reports from nurses and CNAs that the resident refuses care and refuses to eat.On 08/21/25 at 03:34 PM, a telephone interview was conducted with CNA 2, who stated she worked the night shift and was regularly assigned to R28. CNA 2 explained that R28 receives her showers in bed, meaning her body and hair are washed while she remains in bed, which requires the linens to be changed afterward. CNA 2 stated that R1 prefers to have showers early morning on her dialysis days, which are Monday, Wednesday, and Friday. CNA 2 verified that on 08/08 and 08/13/25, where she documented a shower did not occur; it was because there were no linens available. CNA 2 stated that when showers are done in bed, both towels and linens are needed, but most of the time these were not available. In those instances, CNA 2 stated they would provide only a wipe-down and perineal care. CNA 2 stated that R28 verbalized a wipe down was not enough and that she wanted a shower, but staff could not provide one due to the linen shortage. CNA 2 added, she [R28] has no choice.we have no choice also.we want to shower them [residents] but we have no linens.On 08/22/25 at 09:36 AM, R28 was observed participating in group coloring activity with other residents. R28 was smiling and had her hair in pigtails. R28 stated she had shower today and was happy.On 08/22/25 at 02:08 PM, an interview was conducted with the Director of Nursing (DON), who verified that linen shortage has been ongoing. The DON stated that when she brings the concern up in the meetings, she is told the issue is being addressed. The DON stated that, at times, she has had to purchase wash cloth and hand towels for residents, as these items are not included in the linen delivery. The DON further stated she is aware that staff have also brought in and donated linens from their own homes. When asked about her expectations, the DON stated she hopes the issue will be resolved soon, as the current situation is not acceptable. The DON added, I feel for our residents.On 08/22/25 at 03:01 PM, an interview was conducted with the DON, Medical Director (MD), Compliance Officer (CO). When asked how linen inventory is tracked and what process ensures adequate supply is maintained for all resident care needs, including showers, MD stated he was not aware of a linen shortage. The DON stated Environmental Services staff had been reporting linen shortages during meetings with hospital leadership and were told, that's all we have. The DON further stated this issue was brought up in their QAPI last July 22,2025, where the reason provided was that linens were damaged and stained. The CO stated Environmental Services is part of the QAPI committee at the hospital and confirmed that linen shortages have been discussed during meetings with hospital leadership. The CO stated the Assistant Administrator at the hospital has been seeking a contract to replace the damaged linens. When asked how staff and resident feedback, such as R28's reports of not receiving showers due to linen and colostomy bag shortages, are incorporated into QAPI monitoring for quality of life, the CO stated I don't have an answer. I don't know when QAAs happen or what is discussed. What usually happens is it goes from the QA committee then back out to staff but not from resident and staff in.The facility was unable to provide a policy specific to resident showers.Cross reference to F584 and F867.

Based on interview and record review, the facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program by not conducting quarterly meetings for three consecutive quarters, and when a meeting was held in July 2025, the team failed to address an ongoing supply concern. In addition, there was no system in place for obtaining feedback and input for direct care staff and residents, including how such input would be used to identify and address problems. These failures limited the facility's ability to identify systemic problems, implement corrective actions, and monitor effectiveness, placing residents at risk for unmet needs.Findings:Review of the QAPI plan submitted during the entrance conference titled QAPI Plan 2024, revealed indicators and measures derived from survey results spanning 2019 through 2023. The QAPI plan did not contain indicators, measures, or performance improvement projects for 2025.On 08/22/25 at 03:01 PM, an interview and concurrent review of the facility's QAPI program was conducted with the Director of Nursing (DON), Medical Director (MD), and Compliance Officer (CO). The DON stated the Skilled Nursing Unit (SNU) had not held QAA committee meetings because there was no administrator in place to oversee the process. The CO stated she played a supportive role to the SNU and had discussed QAPI at the hospital level, and that she had offered to chair the committee moving forward.The DON further stated that when the MD was on leave in July 2025 and the former Medical Director was covering, the covering physician learned the facility had not been holding QAPI meetings, so he called for a QAPI meeting on07/22/25. When asked when the last QAPI meeting had been held before that, the DON stated there had been none for the past three quarters prior to the July meeting.When asked how linen inventory is tracked and what process ensures adequate supply is maintained for all resident care needs, including showers, MD stated he was not aware of a linen shortage. The DON stated Environmental Services staff had been reporting linen shortages during meetings with hospital leadership and were told, that's all we have. The DON further stated this issue was brought up in their QAPI last July 22,2025, where the reason provided was that linens were damaged and stained. The CO stated Environmental Services is part of the QAPI committee at the hospital and confirmed that linen shortages have been discussed during meetings with hospital leadership. The CO stated the Assistant Administrator at the hospital has been seeking a contract to replace the damaged linens. When asked how staff and resident feedback, such as R28's reports of not receiving showers due to linen and colostomy bag shortages, are incorporated into QAPI monitoring for quality of life, the CO stated I don't have an answer. I don't know when QAAs happen or what is discussed. What usually happens is it goes from the QA committee then back out to staff but not from resident and staff in.Review of the QAPI Agenda dated 07/22/25, did not include documentation of review of discussion of ongoing facility concerns, including linen and colostomy bag shortages.Cross reference to F561, F584, F691, F837, and F868.

Based on observations and interviews, the facility failed to ensure food safety standards when:1. The box of dishwasher heater booster and the storage cart were rusty.2. The hinge and handle of the food steam table had a thick whitish, black and brownish build-up.3. Staff food items were stored inside the kitchen walk-in refrigerator where the residents' food items were stored.4. Tray line or plating was not performed in a sanitary manner and food items were not measured accordingly.Failure to provide a food production environment that is safe and sanitary may result in foodborne illness, cross contamination of food and equipment and use of expired ingredients that may affect flavor and/or texture of food. Foodborne illness and cross contamination may result in gastrointestinal distress and in severe instances may result in death. This had the potential to affect 17 residents who received meals from the facility. Findings:1.During the initial tour of the kitchen with the Food Service Supervisor (FSS) on 08/18/25 at 9:00 AM, the box of dishwater heater booster and the two-tier stainless-steel storage cart were rusty. In addition, the hinge and handle of the food steam table had a thick whitish, blackish, brownish build up. 2.During observation on 08/19/25 at 09:25 AM, inside the walk-in refrigerator, several food items were placed on the top of one of the shelves labeled as EMPLOYEE BIN. FSS stated that the food items are staff personal food brought from home and added that local public health told them that they can keep staff food item as long as it's separated from the resident's food item.Review of facility policy titled, Outside Food Policy at Skilled Nursing Unit dated 03/2016 indicated, Food brought in from the outside are to be stored in separate refrigerators or storage areas from residents' food storage areas.The U.S. Food and Drugs Administration 2022 Food Code 6-403.11 Designated Areas indicated, Because employees could introduce pathogens to food by hand-to-mouth-to-food contact and because street clothing and personal belongings carry contaminants, areas designated to accommodate employees' personal needs must be carefully located. Food, food equipment and utensils, clean linens, and single-service and single-use articles must not be in jeopardy of contamination from these areas.3.On 08/20/25 at 09:56 AM, Food Service Worker (FSW) 1 was observed entering the kitchen from the common dining area without washing their hands. In an interview at 09:57 AM, FSW1 acknowledged that he did not wash his hands before entering the kitchen and stated that he will wash his hand in the sink located at the back of the kitchen.Review of undated in-service information provided by the facility titled, Food Safety In-Service Personal Hygiene & Handwashing indicated, Although handwashing seems like an easy task, it is often one in which many people take shortcuts. We need to be vigilant when it comes to handwashing. Handwashing with soap and water is the single most effective way to prevent the spread of bacteria and viruses, the major causes of foodborne illness. Further, Bacteria and viruses can travel easily from one person to another or from people to food and food contact surfaces. Therefore, it is important to wash hands frequently and after any task that may potentially contaminate your hands. 4.During the food tray line and food distribution on 08/20/25 at 11:16 AM the following was observed:i. FSW1 was wearing a glove on his left hand and no glove on his right hand while dishing out the food. In between the scooping of regular diet, FSW1 was cutting and chopping the food items for trays with mechanically chopped diet. FSW1 was observed touching the food with his gloved hands. FSW1 moved one scooped of rice to another plate using his gloved hands, directly touching the rice. In addition, FSW1 was observed going in and out at the washing area to wash the chopping board without changing the glove or performing hand hygiene.ii. Observed food scoopers and serving utensils handle were touching and resting inside the food tray.iii. After FSW1 hand over the food tray, FSW2 was observed adding extra scoop of salmon in the tray.iv. FSW1 was using kitchen tongs to dish out spaghetti and stated, we don't have enough [measuring] scoops.At 11:54 AM, the Hospital Food and Beverages Manager (HFBM) observed the above findings and went to the back of the kitchen to get a measuring cup to measure the spaghetti. HFMB advised FSW1 measure the food items according to the meal ticket and not to add additional food items on top of what FSW1 had already scooped in the tray. HFBM also told FSW1 to perform hand hygiene and not to let the scooper rest in the food. HFBM stated prepping the chopped dishes should not be done on the spot. All food items should be prepared beforehand (before the tray line). HFBM added, [FSW1] should not be touching the food, and they should be using the proper scooper or measuring cup at least.

Based on interview and record review, the facility failed to ensure its governing body appointed an administrator who is licensed pursuant to Guam Code Annotated (GCA), and responsible for the management of the facility, reporting to and being accountable to the governing body. The facility had no Administrator since April 2024. This failure had the potential to result in ineffective oversight and lack of accountability, leading to supplies not being consistently available to residents, including essential items such as linens and colostomy bags placing residents at risk for unmet care needs and diminished quality of life.Findings:On 08/18/25 at 08:50 AM, during the entrance conference attended by the Director of Nursing (DON) and the Medical Director (MD), both stated that the facility did not have an administrator. Without being prompted, the MD introduced himself as overseeing clinical work, with no administrative oversight of the facility. When asked, when the facility had been without an administrator, the DON stated that this had been the case since April 2024.On 08/18/25 at 11:35 AM, the hospital Chief Executive Officer (CEO), introduced herself to the survey team and stated she oversaw the Skilled Nursing Unit (SNU) because it was still under the hospital. When asked, the hospital CEO acknowledged she did not have a Nursing Home Administrator license as required by the Guam Code Annotated, Chapter 15, governing nursing home administrators. The hospital CEO further stated that the SNU had been without a licensed administrator for some time and that efforts were ongoing to recruit one.On 08/22/25 at 03:01 PM, an interview was conducted with the DON, MD, and Compliance Officer (CO). The CO stated she sat on the governing board and verified the SNU did not have an administrator. The CO stated Human Resources had announced the position and there had been several rounds of interviews, but the challenge was that the facility was too small for the salary expectations of those applying.Review of the Guam Code Annotated (GCA) Chapter 15 Nursing Home Administrators included under S 15102. Administrator's License Required, No nursing home shall operate except under the supervision of a nursing home administrator, and no person shall be a nursing home administrator unless he is the holder of a sufficient nursing home administrator's license issued pursuant to this Chapter.Cross reference to F584, F561, F691, F837, F838

Based on observation, interview and record review the facility failed to maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection, when the facility did not prevent the development of infections for 3 of 15 residents (sampled Resident 6, 3, and unsampled Resident 14.); failed to provide adequate supplies of PPE to prevent cross contamination where seven resident rooms had contact isolation precautions in place; Staff inconsistently follow infection control techniques; and the infection control designee was not trained for infection control management nor given the time to conduct infection control assignments and the facility did not have an effective tracking and monitoring system to ensure the vaccination status of all residents. Findings include: 1. Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a gastrostomy tube ([DEVICE]) for feeding and a urinary catheter for elimination. The resident required total assistance for activities of daily living (ADLs). The resident's family member was with the resident most of the time. During the initial tour on 1/23/2012 at 4:30 PM, Resident 6 was observed lying in bed. Her family member was sitting next to the resident's bed without wear Personal Protective Equipment (PPE). When asked what the facility had taught him about the use of PPE, and he looked at the sign, he said he had not noticed the sign and though he did notice the staff usually wore a yellow gown and gloves, they told him he did not need to, just to wash his hands frequently. He stated the staff taught him to feed the resident through the feeding tube and how to clean the resident's privates, and how to change the dressing on the wound. When he did those things he stated he wore gloves, but not a gown. The resident stated he did interact with other residents and visitors and sat in common areas of the facility. There was a sign on the resident's door indicating the resident was on: Contact Precautions Isolation an Standard Precautions; Gown and Glove When Entering (these are called (PPE)); Clean hands before entering room and upon exiting, wash hands thoroughly for at least 15 seconds or use Alcohol hand foam. A staff member was seen exiting the resident's room wearing a yellow gown, she took off the gown and hung it on a pole attached to the drawers where the clean PPE were outside the door of the room. Then she reentered the room to wash her hands in the resident's bathroom. The resident's urinary catheter bag was on the floor. During observations of care provided on 1/24/2012 at 1:30 PM, a licensed nurse (LN) and a certified nursing assistant (CNA) donned PPE then went into Resident 6's room to provide care. The resident was positioned on her right side. The CNA removed the resident's soiled brief. The urinary catheter bag was attached to the right side of the bed, causing the catheter tube to pull from the resident's urethra over the stool and down to the collection bag. Neither the LN nor the CNA moved the collection bag to the left side of the bed, nearer to the resident and out of area where the staff were working. The CNA used a gloved hand to clean the resident while pouring water over the perineum and the catheter tubing- spreading the stool over the entire perineum including the opening of the urethra, which increased the risk of urinary infection. After the area was cleaned the LN removed the dressing from a Stage 4 pressure ulcer on the resident's sacrum. She cleansed the wound, and dressed it as ordered by the physician; however when she tried to secure the dressing, she taped the lower end of the dressing very near the anus and the tap would not stick. The LN stuffed extra gauze under the tape, "to prevent any stool from getting in the wound." The staff stated they had completed the resident's care. Resident 6's heels were covered with socks and heel protectors (a foam bootie). The surveyor asked to see the resident's heels. The right heel had a black circular pressure ulcer with reddened area surrounding the ulcer. The measurements were 4.0 cm x 2.0 cm. The wound bed could not be visualized as it was covered with hard black necrotic (dead) tissue termed Eschar. No treatment was provided for the heel pressure ulcer. The LN and CNA removed their gloves, washed their hands then exited the room where they removed their gowns. The CNA threw away the gown and the LN hung her gown on the pole attached to the drawers where clean PPE was stored. When asked about the method of cleaning the resident, the CNA stated "We do not have enough wash cloths to go around." When asked about the catheter pulling the CNA and the LN stated, "We should have moved it to the other side." When asked why she hung the soiled gown on the pole outside the resident's room, the LN stated they run out of gowns if they throw them out each time. Review of the record revealed the following: A summary of the review of the staff and physician notes revealed the following: 10/22/2011 - Admission; 10/28/2011 - minimal amount of drainage around the feeding tube; 10/29/2011- greenish discharge from the feeding tube site. On 11/9/11- staff collected C&S from [DEVICE] site results showed infection with MDROs- [DIAGNOSES REDACTED] pneumoniae and Pseudomanas aeruginosa; On 11/8/2011 LN noted there was pus at the Peripherally inserted central catheter (PICC) site on the resident's right upper arm. In the physicians notes and orders dated 11/30/2012 the MD ordered RN to remove the PICC and send the tip for C&S. The physician also ordered IV fluids for two days. However there was no order for replacement of the PICC or to insert any other type of IV. On 12/5/2012 and MD ordered at 9 PM, "Please remove PICC now- send cath (catheter) tip for C&S. Lab result showed C&S collected 12/6/11 with PICC site infection with MDRO - [DIAGNOSES REDACTED] pneumonia. During an interview on 1/24/2011 at 3: 35 PM, when asked about the infection of the PICC site and why the PICC was removed five days after the MD's order, a LN familiar with the patient stated the infection was bad at the site and there was pus all around it. "The MD ordered antibiotics on the same day and (the LN on duty) was afraid to remove it (the PICC)." Review of the laboratory reports also revealed the following time lines of infections for Resident 6: [DEVICE] site - staff collected Culture and Sensitivity (C&S) on 11/9/2011 results showed infection with MDROs- [DIAGNOSES REDACTED] pneumoniae and Pseudomanas aeruginosa; Two urinary tract infections (UTI) collected C&S 11/16/11 with Escherichia coli (E.coli- an organism found in feces) and 12/6/11 with Pseudomanas aeruginosa; and Peripherally inserted central catheter (PICC) site infection C&S collected 12/6/11 with [DIAGNOSES REDACTED] pneumonia. The sacral wound was infected 12/29/2011 with two of the bacterium found in three other sites of the body. A swab sample of the sacral wound drainage was collected on 12/29/2011 source: deep wound sacral pressure ulcer Stage 4. A C&S final results dated 1/3/2012 showed infection with four multi-drug resistant organisms (MDROs): Pseudomonas aeruginosa, Cirtobacter freundii, Acinetobacter baumannii, and [DIAGNOSES REDACTED] pneumoniae. Two of these organisms, [DIAGNOSES REDACTED] pneumoniae and Pseudomanas aeruginosa, were found in the infections of the three sites listed above. The resident had been on numerous antibiotics since admission: 11/ 9/2011 -[MEDICATION NAME] mg via feeding tube daily for two weeks. 11/19/2011 - [MEDICATION NAME] 1 Gram (gm) IV daily for 7 days; 12/8/11 [MEDICATION NAME] 3.375 mg IV every 12 hours for two weeks and [MEDICATION NAME] 500 mg IV daily for 2 weeks; 12/10/11 Impenem 250 mg IV every 12 hours for 7 days and Amikrein 240 Mg IVPB every 24 hours for three days. 12/29/11 [MEDICATION NAME] 3.375 gms in 50 ml of normal sa IV every 12 hours for 7 days; 12/30/11 [MEDICATION NAME] 1 gm IV daily for 7 days; and 1/2/12 [MEDICATION NAME] 1 gm IV every 12 hours for 10 days and Imipenem 250 mg IV every 6 hours for six weeks. 2. During a tour of the residents rooms with the acting administrator and the head nurse on 1/26/2012 beginning at 8:45 AM, the following was observed: room [ROOM NUMBER] a contact precaution sign for a resident infected with Clostridium Difficile (C.Diff)- the sign instructed those entering and exiting to wear PPE and to wash hands with soap and water. There was a yellow gown hanging on the pole attached to the drawers where the clean PPE were located outside the resident's room. room [ROOM NUMBER] the resident was infected with MDRO infections; room [ROOM NUMBER] the resident was infected with Methicillin Resistant Staphylococcus Aureus (MRSA); room [ROOM NUMBER] the resident was infected with [DIAGNOSES REDACTED] (flesh eating bacteria) and C.Diff. The contact precaution signs outside each of these rooms were the same, "Contact Precautions Isolation an Standard Precautions; Gown and Glove When Entering (these are called Personal Protective Equipment (PPE)) Clean hands before entering room and upon exiting, wash hands thoroughly for at least 15 seconds or use Alcohol hand foam." On 1/26/2012 at 8:50 AM, room [ROOM NUMBER] the resident was infected with MRSA. There was an occupational therapist (OT) working with the resident in the room. The OT had on a yellow gown that was loosely tied at the neck and not at the waist potentially exposing parts of the OT's personal clothing to the MRSA organism. A CNA exited the room, removed her yellow gown and hung it on the pole attached to the drawers where the clean PPE were located outside the resident's room; she then washed her hands. room [ROOM NUMBER] - the resident was infected with MRSA - the contact precaution sign indicated visitors did not need to wear PPE. The assistant administrator and the head nurse stated the resident had a wound so the visitors did not need to wear PPE. room [ROOM NUMBER] - the resident was infected with MDRO, and had a different contact precaution sign. room [ROOM NUMBER] - the resident was infected with MRSA and had the following sign: "Contact Precautions Isolation an Standard Precautions; Gown and Glove When Entering (these are called Personal Protective Equipment (PPE)) Clean hands before entering room and upon exiting, wash hands thoroughly for at least 15 seconds or use Alcohol hand foam." During interviews 1/26/2012 beginning at 8:45 AM, When asked why the staff hung the contaminated yellow gowns on the pole outside the residents' rooms that had isolation precautions, the acting administrator and the head nurse stated the facility had limited resources. The acting administrator stated if they threw away the gowns after each use they would run out in one day. He stated the hospital administration was aware of this problem, however no changes had been made. When asked why the LN continued to instill IV fluids into an infected PICC site, the acting administrator stated the LN should have removed the PICC the first time the MD order the removal or obtained a clarification order to continue IV fluids via the PICC site or to insert a peripheral IV . 3. Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The hospital history and physical record dated 1/8/12 revealed the resident was admitted due to "sepsis" Recent admission with urinary tract infection, dysuria and infected left leg. Urine cultures showed Escherichia (E.) Coli and leg wounds with heavy growth of pseudomonas aeruginosa (1/17/12). Review of the Patient Progress Notes record dated 1/12/12 revealed the left leg wounds were debrided. On the same day, the physician ordered "wound care daily alternate wet to dry with [MEDICATION NAME]. On 1/23/12 at 3:10 PM, during the initial tour, a posting outside the resident's room stated "Contact Isolation." Resident 3's left lower leg dressing was observed soaked with bright red drainage. The licensed nurse stated that the physician has just changed the resident's leg ulcer dressing at the bedside. The licensed nurse went inside the resident's room without wearing an isolation gown. With a pair of gloves on, the licensed nurse repositioned the resident's leg to check the dressing moderately saturated with fresh blood. She changed her gloves, and without washing her hands, the licensed nurse proceeded to get a new disposable pad from the resident's closet. She placed the disposable pad under the resident's left leg to protect to line the resident's linen be saturated with the drainage. She then checked on the resident who was pointing to her disposable diaper. The resident is a known deaf and mute to the facility staff. The licensed nurse continued to check on the resident's diaper for tightness without changing her gloves. Review of the resident's plan of care showed no evidence of precautions to be taken while resident is on contact isolation. 4. On 1/23/12 at 3 PM, during the initial tour non-sample Resident 14's room had a posting, "Contact isolation" A licensed nurse was observed inside the resident's room wearing gloves and no isolation gown. Interview with the nurse revealed that she was assisting and cleaning the resident's face to wipe off the sputum. When asked what kind of infection the resident has, the licensed nurse stated the resident has methicillin-resistant staphylococcus aureus (MRSA) of the sputum. Review of sputum culture dated 7/17/11 revealed heavy growth of MRSA. Interview with the charge nurse on 1/25/12 revealed that the physician does not want to re-culture. Review of the resident care plan showed no evidence of precautions to be taken while the Contact Isolation is still being enforced. On the same day and time, Resident 14's Foley catheter drainage bag was also observed lying on the floor. There was no effort to get the bag off the floor in the presence of a licensed nurse in the room. 5. Interview with nursing administrative staff revealed that the facility did not have a qualified infection control coordinator responsible for investigating, controlling, and preventing infections in the facility. Review of the facility's infection control manual revealed several duties of the infection control representative including the ability to demonstrate knowledge of complete infection control process in the healthcare setting; demonstrating understanding of standard and isolation precautions set forth by the CDC; attending continuing education program and maintaining current knowledge of all aspects of infection control; demonstrating knowledge of microbiology and modes of transmission of disease entities, conferring with staff nurses on a regular basis to determine occurrence of healthcare associated infections; and communicating infection control activities to the infection control practitioner at the hospital. During an interview on 1/25/12, an administrative staff member stated that the facility's infection control coordinator was a licensed nursing staff who worked full-time on the evening shift (3:00 PM - 11:00 PM). When asked if the number of hours allocated for infection control duties and responsibilities by the staff could be determined, the administrative staff stated that the time was not captured because the licensed staff, when regularly scheduled, provided direct patient care. The administrative staff added that the licensed nursing staff could not work during her days off to conduct infection control activities because overtime pay was not being authorized. In the same interview, the administrative staff stated that the facility's infection control coordinator did not have training in infection control but that she consulted with the hospital infection control coordinator on a regular basis. When asked if meeting minutes were maintained during these consultation, the staff stated that he was not aware. During a separate interview on 1/25/12, the hospital's infection control coordinator stated that there were regular consultations between her and the facility's infection control representative. When asked if documentation was maintained detailing when these consultations occurred and what topics were discussed, none was provided. 6. The facility did not have an effective tracking and monitoring system to ensure that the vaccination status of residents in the facility could be determined so that the influenza and pneumococcal vaccines could be offered. In addition, the facility did not have policy and procedures that included provisions required under 483.25(n)(1)&(2). (Cross-refer to F334.)

Based on observation , interviews, and record review, the facility failed to ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they are unavoidable for one of 10 sampled residents, (Resident 4) and one of 5 unsampled residents (Resident (11); and failed to provide necessary treatment to promote healing and prevent infection for one of 10 sampled residents (Resident 6) a resident who entered the facility with pressure ulcers. Findings include: 1. Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a gastrostomy tube ([DEVICE]) for feeding and a urinary catheter for elimination. The resident required total assistance for activities of daily living (ADLs). The resident's family member was with the resident most of the time. Review of the facility Pressure Ulcer Management Policy # 6301-II C-15 identifies pressure ulcers as follows: Stage 1: An observable, pressure-related alteration of intact skin. Skin changes in one or more of the following parameters: a. Skin temperature (warmth or coolness) b. Tissue consistence (firm or boggy) c. Sensation (pain, itching) d. A defined area of persistent redness in lightly pigmented skin, whereas in darker skin-tones, the ulcer may appear with persistent red, blue or purple hues. Stage 2: Partial thickness skin loss involving epidermis, dermis or both. the ulcer is superficial and presents clinically as an abrasion, or shallow crater. Stage 3: full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through underling fascia. The ulcer presents clinically as a deep crater with or without undermining adjacent tissue. Stage 4: full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures (e.g., tendon, joint capsule). Undermining an sinus tracts also may be associated with Stage 4 pressure ulcers. unstageable: When the wound is mostly covered with necrotic tissue, it can not be staged until it is debrided. During observations on 1/24/2012 at 1:30 PM, a licensed nurse (LN) and a certified nursing assistant (CNA) were providing care to Resident 6. The resident was positioned on her right side. The CNA removed the resident's soiled brief. The urinary catheter bag was attached to the right side of the bed, causing the catheter tube to pull from the resident's urethra over the stool and down to the collection bag. Neither the nurse nor the CNA were observed moving the collection bag to the left side of the bed, nearer to the resident and out of area where the staff were working. The CNA used hand that was gloved to clean the resident while pouring water with the other hand over the perineum and the catheter tubing- spreading the stool over the entire perineum including the opening of the urethra, which increased the risk of urinary infection and infection of the sacral pressure ulcer. After the area was cleaned, the nurse removed the dressing from a Stage 4 pressure ulcer on the resident's sacrum. She cleansed the wound, and dressed it as ordered by the physician; however when she tried to secure the dressing, she taped the lower end of the dressing very near the anus where the tape would not stick. The dressing was not secure to prevent fecal cross contamination. The staff stated they had completed the resident's care. Resident 6's heels were covered with socks and heel protectors (a foam bootie). The surveyor asked to see the resident's heels. The right heel had a black circular pressure ulcer with reddened area surrounding the ulcer. The measurements were 4.0 cm x 2.0 cm. The wound bed could not be visualized as it was covered with hard black necrotic (dead) tissue termed Eschar. No treatment was provided for the heel pressure ulcer. When asked why the heel wound was not treated the LN stated she did not know. When asked the Head Nurse, she stated she did not know, however she would contact the doctor to find out. When asked about the method of cleaning the resident, the CNA stated "We do not have enough wash cloths to go around." When asked about the catheter pulling the CNA and the LN stated, "We should have moved it to the other side." Review of the electronic medical record "Wound Assessment" revealed the following: 10/22/2011 - Right heel- Stage 1 pressure ulcer, size 1 cm Length (L) x 0.75 cm Width (W) appearance -black skin noted. Treatment- Heel protectors and elevate heels. Sacrum- Stage 3 pressure ulcer size 6 cm L x 7 cm W appearance - 70% red, 30 % brown. Treatment - wet to dry (dressing) with normal saline. 11/8/2011- Right heel- Stage 1 size 1 cm L x 1 cm W appearance - black hard necrotic. Treatment- heel protectors and elevate heels. Comment- improvement. However the size had increased and necrotic tissue was present. Sacrum - Stage 2 size 6 cm L x 4.7 cm W appearance - pinkish/read surrounding, serous (yellowish fluid) discharge center of the wound is yellow brown color. Treatment- wet to dry dressing with normal saline. The standard of practice is not to down Stage a pressure ulcer - 11/25/2011 - Right heel - Stage 2 size 2 cm L x 1 cm W appearance - blackish. Treatment heel protectors and leg elevated. Sacrum- Stage 3 size 6.5 cm L x 5 cm W appearance- center - yellow/surrounding red. Serosanginous (yellowish/bloody) drainage. Treatment- wet to dry dressing with normal saline. 12/16/2011 - Right heel - Stage 2 size 2 cm L x 2.5 W cm hard black scab. Treatment heel protectors and leg elevated. Note - patient unable to reposition leg. Sacrum- Stage 3 size 7 cm L x 5.5 cm W x 2 cm D (deep), appearance- center - pinkish/ grayish yellow. yellowish drainage, mild odor and with grayish necrotic tissue. Treatment- wet to dry dressing with normal saline. Reposition every 2 hours side to side. The type of treatment to the sacral wound was not changed despite evidence that the wound was getting worse. 12/22/2011 - Right heel - No assessment documented. Sacrum - Stage 3 size 5.2 cm L x 7.7 cm W x 2.5 cm D appearance pinkish with yellowish tissue - wound debrided. Treatment- hydrogen dressing. 12/31/2011- Right heel - Stage 2 size 2 cm L x 2.3 cm W, appearance blackish, hard and dry. Treatment elevate on the pillow, heel of the bed. Sacrum - Stage 4 size 5.2 cm L x 7.7 cm W x 3.2 cm D with 2.5 cm undermining at 8 o'clock. Appearance - pinkish with yellowish tissue, yellowish drainage, mild odor. Treatment- hydrogel and [MEDICATION NAME] dressing after cleaning with normal saline. 1/24/2012 - (Observed by surveyor) Right heel- Stage 2 size 4 cm L x 2 cm Appearance - black with reddish surrounding. Treatment: heel protector, heel off the bed. Comment both lower extremities elevated on the pillow. Sacrum - Stage 3 size 4.6 cm L x 6 cm W x 3 cm D. No appearance documented. Treatment - wet to dry clean with normal saline, [MEDICATION NAME] wash and hydrogel applied to inner area of the wound. The heel wound was unstageable due to the presence of eschar covering the entire wound. There was no documentation as to why the right heel wound was not treated. The sacral wound started out as a Stage 3 and progressed to a Stage 4 involving bone and muscle. Undermining was documented one time. Review of the laboratory reports for the sacral wound were as follows: A swab sample of the sacral wound drainage was collected on 12/29/2011 source: deep wound sacral decubiti Stage 4 - Culture and Sensitivity (C&S) final results dated 1/3/2012 showed infection with four multi-drug resistant organisms (MDROs) Pseudomonas aeruginosa, Cirtobacter freundii, Acinetobacter baumannii [DIAGNOSES REDACTED] pneumoniae. The resident had prior infections of the [DEVICE] site collected C&S 11/9/11 with [DIAGNOSES REDACTED] pneumoniae and Pseudomonas aeruginosa; Two urinary tract infection [MEDICAL CONDITION] collected C&S 11/16/11 with Escherichia coli (E.coli- an organism found in feces) and 12/6/11 with Pseudomonas aeruginosa; and Peripherally inserted central catheter (PICC-line) infection C&S collected 12/6/11 with [DIAGNOSES REDACTED] pneumonia. The sacral wound was infected 12/29/2011 with two of the bacterium found in three other sites of the body. Review of the Care Plan Conference Summary dated 12/5/2011 and 12/7/2011 revealed the resident had a stage 3 pressure ulcer on 12/5/2011 and 2 pressure ulcer on 12/7/2011. A summary of the Interdisciplinary care conference and the staff's recommendations were faxed to the physician on 12/9/2011. The summary did not include complete or accurate identification or treatment of [REDACTED]. There was no documentation of discussion of the location of the pressure ulcers, or the progression in size or the infections of the pressure ulcers or the treatment of [REDACTED]. Review of the facility Pressure Ulcer Management Policy # 6301-II C-15 under section III. Wound Prevention/Management Interventions part C. reads as follows: For patients who have a pressure ulcer, document on the weekly Braden Scale Assessment, or when there is a change in the pressure ulcer and intervene appropriately (based on the stage level of the wound), as follows: "...Stage II - Air [MEDICATION NAME] Cleansing Spray... [MEDICATION NAME] Cream (moisture barrier)[MEDICATION NAME], changed every 3 days or as needed, OR Transparent film dressing, changed every 2 days or as needed, turning schedule every 2 hours. Stage III - Air Mattress,[MEDICATION NAME] Cleansing [MEDICATION NAME] Cream... Normal Saline wet to dry dressing 2-3 times per day, cover with gauze using [MEDICATION NAME] tampe to secure to skin. [MEDICATION NAME] gel (to keep wound bed moist and promote (new cell growth), cover with gauze using [MEDICATION NAME] tape to secure to skin...Turning schedule every 2 hours...Stage III with necrotic tissue...Santyl Ointment (enzymatic Debridement) daily application, cover with guaze using [MEDICATION NAME] tape to secure to skin." Stage IV- Same as Stage III. There were no guidelines for how to manage unstageable pressure ulcers. There were no guidelines for Deep Tissue injury. The facility did not follow their policy in using [MEDICATION NAME] Cleansing Spray, [MEDICATION NAME] Cream, [MEDICATION NAME] or Transparent film dressing for Resident 6's right heel Stage II pressure ulcer (This pressure ulcer was unstageable because it was covered with Eschar) The Facility did not follow their policy in using Santyl (or any other enzymatic [MEDICATION NAME] agent) for Resident 6's Sacral Stage III pressure ulcer when eschar formed. Surgical debridement ended up revealing a deep Stage IV pressure ulcer. 2. Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The hospital history and physical record dated 1/8/12 revealed the resident was admitted due to "[MEDICAL CONDITION] " Recent admission with urinary tract infection, dysuria and infected left leg. Urine cultures showed Escherichia (E.) Coli and leg wounds with heavy growth of pseudomonas aeruginosa (1/17/12). Review of the Patient Progress Notes record dated 1/12/12 revealed the left leg wounds were debrided. On the same day, the physician ordered " wound care daily alternate wet to dry with [MEDICATION NAME]. On 1/23/12 at 3:10 pm, during the initial tour, Resident 3's left lower leg dressing was observed soaked with bright red drainage. The licensed nurse stated that the physician has just changed the resident's leg ulcer dressing at the bedside. The Wound Care Flowsheet dated 1/8/12 revealed the resident's left lower leg had an irregular size pressure sore with a length of 25 cm x 4 cm in width with sero-sanguinous, odorless drainage. On 1/24/12 the left lower leg Stage II pressure sore was described as pale/pink in color and measured 19 cm L x 6 cm W with no depth. On the same day, the flowsheet also revealed a new pressure area in the left ankle described as Stage II with a length of 1 cm x 1 cm in width, yellow in color, with no drainage and no odor. The management was to elevate the legs on a pillow, and wet to dry dressing as prescribed. On 1/25/12, in an interview, the morning charge nurse indicated that the leg treatments were done by the night shift nurses because wound treatment and dressing changes can be done after the showers. On 1/26/12 at 8:15 a.m. Resident 3 was observed up in wheelchair eating breakfast in the common dining room. Upon surveyor request, a treatment observation was done after the resident finished breakfast meal and returned to the room. The treatment nurse assessed the multiple sites of debrided pressure sores: Left inner leg with irregular shaped open areas: upper area measured 11.5cm L x 4 cm W x 1 cm in depth (D); the middle area measured 4 cm L x 2 cm W with undermining and lower area measured 9.5 cm L x 3 cm W. The Stage II left ankle pressure sore measured 1.5 cm L x 1.0 cm W The black eschar on the lower lateral side of the left ankle measured 3.0 cm L x 2.0 cm W A dry scab on the upper lateral side of the left ankle measured 05. cm L x 0.5 cm W After the treatment nurse measured the pressure sore areas, she indicated that accuracy in measuring the debrided areas was inconsistent due to irregular open areas. Also the three open areas were measured as one in length as documented in the wound care. However, the undermining in the middle portion of the left inner leg was not identified. The black eschar area in the left ankle was not identified in the assessment on 1/24/12, two days prior to assessment conducted by the day shift treatment nurse. On the same day at 9:30 a.m., the director of nurses (DON) was made aware of the inaccuracies of pressure sore assessments and observed the newly discovered black eschar on the lateral side of the left ankle. 3. Resident 11 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The initial assessment nursing notes revealed no skin breakdown. On 1/25/12 at 9 a.m. Resident 11 was observed during morning care rendered by a certified nursing assistant. During the bedbath, the resident's back had three areas of persistent redness: a raised reddened area in the mid-back, flat reddened area on the right side of the back and a blackish red abraded area on the sacrum. The licensed nurse indicated that A&D ointment is applied as a preventive measure, however, the CNA did not apply the ointment because it was unavailable. The nurses' notes dated 1/24/12 revealed that the certified nursing assistant notified the licensed nurse of redness on the buttocks, raised reddish patches on the sacral area. On 1/25/12 on 11 pm-7 am shift, a licensed nurse documented " red raised area mid-upper back still present, hard to touch. Charge nurse (CN) made aware. " On 1/25/12, the 7 am-3 pm shift nurses notes revealed a " reddened tender area size-like a quarter still present at mid upper back. Notified CN. " There was no documented evidence in the medical record that the physician was notified of the reddened skin areas at the back. On 1/25/12 at 4 p.m. interview with the resident's husband revealed a concern of the reddened raised area on the resident's back if it was a growing cyst. He was also concerned about the resident's peeling skin in the hands and feet from the allergic reactions incurred from antibiotics infused in the hospital. On 1/25/12 after discussions with the licensed nurse about Resident 11's skin condition, the charge nurse notified the physician and obtained orders for warm compress to mid-upper back. The physician also held the [MEDICATION NAME] and [MEDICATION NAME] doses for that day. 4. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of initial assessment dated [DATE] identified the resident as totally dependent on staff with all activities of daily living except eating. The resident had surgery to repair the fractured left hip (open reduction internal fixation) on 12/18/11. The initial assessment identified the resident with frequent hip pain daily. The admission notes dated 12/21/12 at 22:41 revealed the resident had a surgical wound that measured 15 ? centimeters (cm) scar incision in the left hip/thigh and a sore in the left hand in between the second and third finger. The Braden scale for pressure sore identified the resident as moderate risk to develop pressure sores. Upon admission the resident did not have any pressure sores but the resident was bedfast and required moderate to maximum assistance. Review of the nurses' progress notes revealed that on 12/25/11, the " left inner buttock 3 small 1-0.5 cm next to the sacrum, about an inch below it, small 0.5 cmx0.6 cm and the larger one at the bottom 2.0 cm L(length) x 1.0 cm W(width). dry, no drainage. [MEDICATION NAME] applied. " The Wound Assessment form confirmed that on 12/25/11 , the resident's left inner buttock had an open area next to the sacrum, measured " 0.5 cm. below the first 1.0 cm x 0.5 cm down below the next one 2.0 cm x 1.0 cm W " On 12/29/11 the Stage II pressure sore in the left inner buttock increased in size 2.0 cm to 7.0 cm in length and from 1.0 cm to 4 cm in width. Also, on 12/29/11 two other pressure sores were identified: A Stage II pressure sore in the right inner buttock that measured 5 cm in length and 4 cm in width and Stage II pressure sore in the sacrum that measured 3 cm L x 0.5 cm W. On 1/25/12 at 4:00 p.m. the licensed nurse who documented the pressure sore discovery revealed that she reported the skin breakdown to the charge nurse and was verbally told to apply the [MEDICATION NAME]. Review of the physician's orders [REDACTED]. On 1/26/12 at 7:20 a.m., interview with the charge nurse revealed that she might have told the other licensed nurse to apply the [MEDICATION NAME] and she was not sure if [MEDICATION NAME] required a physician's orders [REDACTED]. Review of the plan of care dated 12/29/11 revealed the resident was assisted to turn to sides; explained to resident the importance of repositioning and turning to sides every two hours. The social service designee notes revealed the resident has mood problems, feisty and needs special approach. On 1/25/12 at 2:45 p.m. during a treatment observation, Resident 4's sacral pressure sore was noted dry without drainage. The treatment nurse stated that the other pressure sores healed because the resident started getting out of bed and goes to the courtyard most of the time.

Based on observation, interview and record review the facility failed to maintain acceptable parameters of nutrition for weight for 2 of 10 sampled residents ( resident 2 and 6); when 1.) Resident 6 lost 18.5 % of her body weight due to a leaking gastrostomy tube ([DEVICE]) and 2.) Resident 2 did not receive follow up care for weight maintenance. Findings: 1. Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a gastrostomy tube ([DEVICE]) for feeding and a Urinary catheter for elimination. The resident required total assistance for activities of daily living (ADLs). The resident's family member was with the resident most of the time. Observations of the resident on 1/24/2012 during personal care revealed the resident was cachectic (ill health and very thin). During an interview on 1/24/2011 at 10 AM, the resident's family member stated the resident had a feeding tube that leaked for a long time before the facility replaced it. The family member stated the resident lost a lot of weight. During an interview and record on 1/24/2011 at 10:45 AM, the day shift charge nurse stated the [DEVICE] had been leaking almost from admission to Christmas. She stated she was not sure why it took so long for the tube to be changed. Review of Resident 6's record from the Monthly Weight Log read as follows: 10/22/2011 - 103 pounds (lbs) 11/14/2011 - 89.6 lbs 12/10/2011 - 85 lbs ([DEVICE] replaced 12/14/2011) 01/10/2012 - 87.9 lbs The resident lost 18 lbs in approximately 2 months. A summary of the review of the staff and physician notes revealed the following time line: 10/22/2011 - Admission; 10/28/2011 - minimal amount of drainage around the feeding tube; 10/29/2011- greenish discharge from the feeding tube. 11/15/2011 - MD noted added suture at the [DEVICE] site to help reduce leakage. 11/16/2011 - MD noted to request surgeon to revise or change the [DEVICE]. 11/28/2011- feeding tube leaking; 11/30/2011- MD noted the [DEVICE] needed to be changed. 12/3/2011 - feeding tube still leaking, 12/9/2011 - feeding tube still leaking. 12/14/2011- Surgeon replaced [DEVICE] with same size tube, 24 french. 12/27/201 - MD noted [DEVICE] still leaking. Resident to have tube replaced again the next day (12/28) with a 28 french [DEVICE]. 1/13/2012 - MD noted [DEVICE] leak is fixed. During this time frame the MD began the resident on [MEDICATION NAME] one half can every 6 hours then increased to one can every 6 hours. Nurses notes between 10/22 and 11/6/2011 revealed the resident did not tolerate one can, so the feeding was reduced to [MEDICATION NAME] one half can every 6 hours on 11/6/2011 - 31 days after the [DEVICE] leak began. A physician's orders [REDACTED]. On 12/19/2011 the dietician recommended pleasure feeding 1/2 teaspoon puree food and 1/2 teaspoon water at a time. There was no documentation whether or not the resident received this oral feeding or how/if the resident tolerated it. On 12/31/2011 the dietitian recommended and the physician changed the feeding to Nepro 1/2 can every 4 hours. On 1/7/2012 - the physician changed the feeding to Fibersource 1/2 can every 4 hours. Review of the registered dietician (RD) notes dated 1/18/2012 revealed the residents lab results for Serum [MEDICATION NAME] was low at 2.0 grams/deciliter (gms/dcl)- Normal range was 3.4 - 5.0 gms/dcl. Decreased [MEDICATION NAME] may occur when your body does not get or absorb enough nutrients and reduces the body's ability to heal. During an interview on 1/25/2011 at 2 P.M., the RD stated the resident developed diarrhea from the Nepro, therefore the feeding was changed to Fibersource. She stated the weight loss was due to the leaking [DEVICE]. She said the resident was receiving maybe 60% of what was fed to her. When asked if any other means of nutrition was discussed or considered, she stated no. When asked if she was involved in the interdisciplinary care conferences, she stated no, the dietary manager attended and let her know if there were problems. Review of the Care Conference notes dated 12/5&7/2011 indicated the current type and amount of feeding, and a note that the [DEVICE] was leaking. There was no other Care Conference noted provided and no other documentation on what the facility would do to enhance the resident's nutrition to prevent weight loss and improve wound healing during the 69 days that the [DEVICE] was leaking. 2. Resident 2 was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. Review of the "Mini Nutritional Assessment" dated 1/07/12, revealed that Resident 2 was "nutritionally at high risk" and "with increased nutrient needs related to severe [MEDICAL CONDITION] (as evidenced by) severe protein depletion with [MEDICATION NAME], and cachexia..." The assessment also noted that weighed 96 lbs and had a height of 5 feet and 5.75 inches. Recommendations made by the dietitian dated 1/07/12 included providing Resident 2 with enteral feedings of [MEDICATION NAME] 1 can every 6 hours for 24 hours increasing to 1 can every 4 hours, and 150 ccs water for flush. This, according to the recommendation would provide the resident with 1500 kcal and 61 gms of protein per day. The recommendation also included monitoring of tube feeding residuals, monthly weights, weekly laboratory tests, and hydration status. During an interview on 1/25/12, a nutritional support staff stated that because of Resident 2's [MEDICAL CONDITIONS] and consideration for a carbohydrate controlled formula, that [MEDICATION NAME] was an appropriate substitute for another solution he was to receive but was unavailable. Review of the medical record however revealed the lack of monitoring of Resident 2 to ensure that identified nutritional risks were being addressed or that interventions were effective. While the resident, for example, was described in a dietary note dated 1/16/12 as being "underweight" (weight noted on admission on 1/07/12 was 96 lbs), no other weight measurements were obtained until 1/25/12 when a weight of 95.2 was recorded. In addition, there was no documentation if the current enteral feeding regimen, calculated to provide 1500 kcal per day, allowed for weight gain or maintenance of current weight. While the enteral feeding was to provide 61 gms of protein, no measurements of protein stores ([MEDICATION NAME] level) were available following Resident 2's admission to the facility. Review of laboratory results dated [DATE] when Resident 2 was in the hospital revealed an [MEDICATION NAME] level of 2.2 gms/dl (normal limit 3.4 - 5 gms/dl). Further review of the medical record revealed that while a care plan was written for "special needs--providing nutritional support," the plan however was developed relative to the risk for aspiration. The care plan, for example, did not identify nutritional goals that needed to be met or indicators that needed to be monitored to help ensure that Resident 2 met established nutritional benchmarks such as weight and/or [MEDICATION NAME] levels. Further review of the care plan revealed the lack of identification of a desired or target weight as a baseline from which the effectiveness of nutritional interventions can be measured.

Based on record review and interview, the facility did not ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections [MEDICAL CONDITION] and to restore as much normal bladder function as possible; 1. When the facility did assess or refer a resident for bladder training or adaptive equipment resulting in accidental incontinence for one of 10 residents (Resident 2), and 2. When the facility did not prevent the development of UTIs for one of 10 residents (Resident 6). Findings include: 1. Resident 1 was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. Review of the minimum data set ((MDS) dated [DATE] revealed that the resident was alert and oriented, dependent on staff for most activities of daily living, and continent of bladder function. The care area assessment (CAA) summary for the current admission noted that urinary incontinence will not be care planned because the resident "is continent." Review of the medical record revealed that on 1/16/12, Resident 2 was described in nurses notes as being incontinent of bladder. On 1/18/12, the resident was also documented in nurses notes as "incontinent of bladder and bowel," and on 1/20/12, as being "incontinent of urine." In addition, SNU (skilled nursing unit) nurse aide flowsheets dated 1/20/12 through 1/23/12 described Resident 2 as being incontinent of bladder function. Notwithstanding the documentation, review of the medical record revealed the lack of documented evidence that the physician was notified and that an assessment of the resident's bladder status was conducted to identify the cause of the incontinence and determine whether or not the resident could benefit from a bladder training program. In addition, review of the medical record revealed the lack of indication that a care plan was developed to address the change in bladder status which included goals and outcomes as well as interventions to prevent further diminishment of function. During an interview on 1/24/11, Resident 2 stated that while he had been having episodes of urinary incontinence which required him to wear briefs, that he however still feels the urge if he has to urinate. The resident added that he had been having accidents because of the increasing urgency and the delay and difficulty of getting him to the bathroom. In light of this, there was no documentation of any referral to determine if the resident could benefit from therapy services or use of adaptive equipment. 2. Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a gastrostomy tube ([DEVICE]) for feeding and a urinary catheter for elimination. The resident required total assistance for activities of daily living (ADLs). The resident's family member was with the resident most of the time. During observations and subsequent interviews on 1/24/2012 beginning at 1:30 PM, a licensed nurse (LN) and a certified nursing assistant (CNA) were providing care to Resident 6. The resident was positioned on her right side. The CNA removed the resident's soiled brief. The urinary catheter bag was attached to the right side of the bed, causing the catheter tube to pull from the resident's urethra over the stool and down to the collection bag. Neither the nurse nor the CNA moved the collection bag to the left side of the bed, nearer to the resident and out of area where the staff were working. The CNA used a gloved hand to clean the resident while pouring water over the perineum and the catheter tubing- spreading the stool over the entire perineum including the opening of the urethra, increasing the risk of urinary tract infection [MEDICAL CONDITION]. When asked how often catheter care was provided to Resident 6 and about the method of cleaning the resident, the CNA stated "We do it (catheter care) every shift and we not have enough wash cloths to go around so we just use our gloved hand and water." When asked about the catheter pulling the CNA and the LN stated, "We should have moved it to the other side." When asked what the procedure was to "do catheter care", the LN stated they cleaned the perineum beginning close to the body using soap and water, cleaning around the catheter and then clean the tube from close to the body down the tube. The LN stated they usually use some gauze if a wash cloth was not available. When told of the surveyors observation of potential contamination of the Urethra (opening of the urinary tract) due to the method of cleaning and allowing the catheter tube to be in touch with the anus and stool. The LN stated she would be sure to observe the resident for signs of infection. Review of laboratory results revealed the resident had two previous urinary tract infections [MEDICAL CONDITION] collected C&S 11/16/11 with Escherichia coli (E. coli- an organism found in feces) and 12/6/11 with Pseudomanas aeruginosa; The resident had prior infections of the [DEVICE] site collected C&S 11/9/11 with [DIAGNOSES REDACTED] pneumoniae and Pseudomanas aeruginosa; Review of the Care Plan for SNU-Foley Catheter Use initiated 10/22/2011 and updated 1/20/2012, included the following direction: Clean urinary meatus (opening of the Urethra)...every shift.

Based on observation, interview, and record review of one (1) of three (3) residents identified as having an indwelling catheter, the facility did not ensure that a resident who entered the facility without a catheter was not catheterized unless the resident's clinical condition demonstrated that catheterization was necessary; and that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections as possible. Finding includes: Resident 3 was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. Review of the medical record revealed that the resident was admitted from the hospital where she was treated for [REDACTED]. The minimum data set ((MDS) dated [DATE] described the resident as having short-term memory problem, with moderately impaired cognitive skills for decision-making, and was dependent on staff for all activities of daily living (ADL). Review of hospital records revealed that Resident 3 had an indwelling catheter inserted because of [MEDICAL CONDITION]. Once the retention resolved however, the catheter was subsequently removed. Upon admission on 8/14/10, Resident 3 was not noted to have an indwelling catheter and the MDS (minimum data set) dated 8/21/10 did not indicate the presence of a catheter noting instead that Resident 3 was incontinent of bladder function. During the initial tour on 9/15/10, Resident 3 was observed in bed with a urinary bag at the bedside containing dark amber urine with sediments. A facility staff on the tour verified that the resident had a urinary catheter. Review of the medical record revealed a physician's orders [REDACTED]. A nurses note dated 8/23/10 at 2:07 p.m. described the foley catheter as "draining well to amber colored urine (which was) very cloudy." Further review of the medical record however revealed the lack of indication for the use of the urinary catheter. Prior to this, the resident was described in nurses notes, including on 8/14/10 as "incontinent of bladder" and was "using adult diapers." On 8/24/10, a physician's orders [REDACTED]. Result of the C&S made available on 8/26/10 revealed the presence of infection. On 8/24/10, a physician's orders [REDACTED]. Review of the MAR (medication administration record) revealed however that Resident 3 was given the antibiotic only once daily on 8/29/10, 8/30/10, 8/31/10, and 9/02/10. Medical record review further revealed that another physician's orders [REDACTED]. During the survey on 9/16/10, results of the tests could not be located in the record. When asked, a facility staff stated that the neither specimen was collected or sent on 9/10/10 as ordered. The following day on 9/17/10, review of test results of urine sent for analysis at 9:00 p.m. on 9/16/10 revealed among others, a "large" presence of blood; white blood cells from 30 - 49 (normal range 0 - 5); and red blood cells of 15 - 29 (normal range 0 - 5). No urine C&S results were available because of insufficient time. Further review of the medical record revealed that while a care plan was available for the "Problem with Urinary Incontinence," none however was developed for the use of the indwelling catheter that addressed indications as well as the length of time for its use, interventions to prevent urinary tract infections, monitoring of urine output, and protection from accidental removal that may injure the resident. Review of nurses notes for example, revealed the lack of documentation of urinary output or of catheter care rendered, if any. Review of the medical record also revealed the lack of evaluation of the catheter in light of the lack of documented indication for its continued use. During skin care observation on 9/17/10, the treatment nurse stated that the catheter was inserted because of stage 2 pressures sores which the staff explained were healing. This notwithstanding, there was no analysis of risks and benefits particularly relating to the urinary tract infection. Review of the record also revealed a nutrition assessment dated [DATE] noting that Resident 3 "triggered for nutrition and hydration" because of "poor appetite." A recommendation was made to "offer fluids with and between meals." While a care plan was available for "Imbalance Nutrition," none however was developed for Resident 3's risk for dehydration. During the survey, a sign posted inside the resident's room noted that "Patient Must Drink Water" and that Resident 3 must have 2 cups on the day and evening shifts, and one cup during the night shift (for a total of 5 cups or 1200 ccs/day). During the survey however, staff were not observed offering water or other liquids outside of regular meal times. Review of intake and output sheets including on 9/06/10, 9/07/10, 9/08/10, 9/14/10, 9/15/10, 9/16/10, revealed that Resident 3 was not consuming the desired amounts. On 9/16/10, for example, Resident 3 only had 370 ccs documented as total water intake for all 3 shifts. On 9/15/10, only 225 ccs; on 9/14/10, only 450 ccs; and on 9/13/10, only 550 ccs. During the skin care observation on 9/17/10, blood-tinged urine was observed along the tubing leading to Resident 3's urinary drainage bag. The treatment nurse who also made the observation stated that the blood-tinged drainage had not been noted prior.