Every finding on record at Haven of Sierra Vista, LLC

Based on observation, interviews, review of facility documentation and policies, the facility failed to ensure the dishwasher was operating at appropriate temperatures according to manufacturer's instructions. The deficient practice could increase the risk of residents consuming food that come into contact with non-sanitized food ware. The facility's census was 88. Findings include:An initial kitchen observation was conducted on December 7, 2025 at 10:47 A.M. of the dish machine temperature log. The temperature log had an entry for December 7, 2025 that indicated the temperature of the wash was 120 degrees and the rinse was 120 degrees. It also indicated PPM (parts per million) was 100. The log was initialed by Dietary Aide/Staff #93.An observation of the dish machine was conducted on December 7, 2025 at 11:15 A.M. The temperature of the dish machine was checked with Cook/Staff #44. Staff #44 indicated the temperature of the dish machine was 106 degrees. He stated that he was going to run the machine a few times and would recheck the temperature.A second observation of the dish machine temperature was done on December 7, 2025 at 11:36 A.M. with Staff #44. The dishwasher machine was observed to be running with dishware inside. Staff #44 removed the dishware and placed a dishwasher temperature puck onto the dish rack. At the end of the cycle, the puck was removed, by Staff #44, and he identified the temperature to be 101 degrees. Surveyor showed Staff #44 the dish machine temperature log and asked why there was a temperature discrepancy between the current reading and what was recorded on the log. Staff #44 indicated that the log must be incorrect because Staff #93 had not yet started their shift and hadn't been onsite yet. Staff #44 stated that the temperature should be 120 degrees or more since it was a low temperature dishwasher. He then stated that he was going to call his supervisor for directions on what he should do regarding the low temperatures. Staff #44 informed surveyor that they will be using disposable containers for the food service until maintenance fixes the dish machine.An interview was conducted on December 8, 2025 at 11:34 with the facility's Environmental Services Engineer/Staff #215. He stated that he was informed about the issue with the dish machine today and that there was an issue with the hot water mixing with the cold water which was causing the low water temperature to run through the dish machine. He shared that he was currently working on fixing the issue.An interview was conducted on December 8, 2025 at 3:15 P.M. with Dietary Manager/Staff #32. Staff #32 identified the dishwasher being a low temperature dishwasher with a wash/rinse temperature range of 120 - 150 degrees. She indicated that if the temperatures were out of range, staff are to stop the dishwasher and alert her and the maintenance team. If the issue comes up during the weekend or at night, they still are expected to alert her and the maintenance team. Staff #32 also shared that there was nothing in the policy that identifies the time-frame for her being notified about the malfunction. When reviewing the dishwasher temperature log, Staff #32 reviewed it and shared that she noticed the temperature of the dishwasher log indicated that the temperature on December 5th was 117 degrees. She stated that she was not notified about the low temperature of the dishwasher that day. Staff #32 indicated that residents could contract foodborne illnesses if the facility was not properly washing the dishes.An interview was conducted on December 8, 2025 at 3:40 P.M. with Staff #93. Staff #93 confirmed that she started her shift on December 7, 2025 at noon and worked until 8:00 P.M. She shared that part of her job duties is to take the temperature of the dishwasher and record it on the temperature log. She explained that the temperature needed to be 120 degrees or more and she obtains the temperature by placing the little square thing in the wash machine. Staff #93 shared that when she checked the temperature of the dish machine on December 6, 2025, the temperature was a little bit under 120 degrees but she went ahead and recorded 120 degrees on the dish machine temperature log so they wouldn't get mad at me. She also admitted that on December 6, 2025 she pre-filled out the log sheet for December 7, 2025. She added that the temperature of the dish machine had been inconsistent since the previous kitchen manager left and she did not know if the current kitchen manager knew about the issue. She also shared that she did not notify Staff #32 about the low temperature of the dish machine but did talk to some of her co-workers about it. Staff #93 indicated that having unsanitary dishes increases the risk of residents coming into contact with germs and bacteria which can make them sick.An interview was conducted on December 9, 2025 at 6:16 A.M. with Dietary Aide/Staff #80. She confirmed that she sometimes takes the temperature of the dish machine as part of her duties. She shared that she took the temperature of the dish machine on Friday, December 5, 2025 and that she recorded the temperature as 117 degrees. She shared that the temperature should have been 120 degrees or more and that she did not notify anyone about the low temperature of the dish machine. Staff #80 added that she should have told her supervisor about the low temperature. She indicated that the low temperature of the dish machine could lead to residents getting sick.Review of the facility's policy and procedure titled, Dish Machine Temperature Log, revealed a date of 2018. The policy stated Dishwashing staff will monitor and record dish machine temperatures to assure proper sanitizing of dishes. The procedure indicated that the temperature of the wash and rinse cycles are to be taken at each meal. The log is to be spot checked by the food director to ensure that temperatures are accurate. It also indicated that staff will be trained to report issues with the dish machine as soon as they occur.

Based on observations, interviews, and review of the facility's policies and procedures, the facility failed to ensure resident meals were served at appropriate temperatures. The sample size was five residents. The facility census was 88. The deficient practice could lead to residents receiving meals at unsafe temperatures which increases the risk of foodborne illnesses.Findings include:A complaint was received through the State Agency (SA) portal on November 25, 2025 at 2:37 pm alleging that food was served cold and was too spicy.Related to Resident #77-Resident #77 was admitted to the facility on [DATE] with diagnoses that includes pyothorax (infected pus pocket in the chest cavity) with fistula, pneumonia, and major depressive disorder.Review of the admission MDS, dated [DATE] revealed a BIMS score of 14 which indicated the resident is cognitively intact.An interview was conducted on December 7, 2025 with Resident #77 at 3:12 P.M. He shared that the food is cold and sometimes it was unidentifiable.Related to Resident #33-Resident #33 was admitted to the facility on [DATE] with diagnoses that includes chronic osteomyelitis (infection in the bloodstream) of the left ankle and foot, hypertension, and generalized muscle weakness.Review of the admission Minimum Data Set (MDS), dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident is cognitively intact.An interview was conducted on December 7, 2025 at 3:25 P.M. with Resident #33. He stated that the food was always cold.Related to Resident #32-Resident #32 was admitted to the facility on [DATE] with diagnoses that includes a fracture to the left femur, a large blood clot in the fork of the main lung artery blocking blood flow to both lungs, and muscle weakness.Review of the admission Minimum Data Set (MDS), dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident is cognitively intact.An interview was conducted on December 7, 2025 with Resident #32 at 3:51 P.M. He stated that the food is cold but it did taste better than his previous facility.Related to Resident #78-Resident #78 was admitted to the facility on [DATE] with diagnoses that includes pneumonia, acute kidney failure, and congestive heart failure.Review of the admission Minimum Data Set (MDS), dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident is cognitively intact.An interview was conducted on December 7, 2025 at 4:00 P.M. He expressed that the food was not great in temperature, texture, and flavor.An observation of the lunch meal delivery was conducted on December 8, 2025 with Staff #32. During this observation, a temperature check of the test tray was conducted with Staff #32 at 1:21 P.M. using the facility's food thermometer. The temperature check of the test tray was conducted in the dining/activity room in hallway 300. The temperature of the roast beef was 111 degrees. The temperature of the mashed potatoes was at 123 degrees. The temperature of the mixed vegetables was at 142 degrees.An observation of the breakfast tray line was conducted on December 9, 2025 at 6:56 A.M in the kitchen. During this observation, a temperature check, using the facility's food thermometer, of the food on the steam table was conducted with Cook/Staff #19 and staff #32. The temperature of the sausage patties was 129 degrees. Staff #19 shared that the food sometimes gets cold on the steam table because the air conditioning duct was directly over the steam table. She was observed putting parchment paper over the sausage patties. At 7:19 A.M. a second temperature check of the sausage patties was taken and the temperature was 131 degrees.A second observation of the meal delivery was conducted on December 9, 2025 with Staff #32 at 7:50 A.M. During this observation, a temperature check of the test tray was conducted with Staff #32 at 8:11 A.M. using the facility's food thermometer. Staff #32 indicated the temperature of the grits was 141 degrees. The temperature of the biscuit was 96 degrees and the sausage was 96 degrees. Staff #32 shared that the temperatures were acceptable if the food was palatable.An interview was conducted with the Staff #19 on December 10 at 10:11 A.M. When asked about safe temperatures for food being served to residents, she explained that she thought that the food on the steam table needed to be 145 degrees or higher in order to be safe to serve. However, she did not know what temperatures the hot food needed to be when residents receive it. She also added that sometimes the food gets cold because it takes too long to get delivered to the residents. Staff #19 shared that it wasn't okay for residents to eat hot food cold because they would not be happy with it.An interview was conducted with Staff #32 on December 10, 2025 at 10:16 A.M. She indicated that the food that was being held on the steamer needed to be maintained at 135 degrees. However, she added that when hot food is being delivered to residents, they need to be at palatable temperatures and it would be dependent on the resident's preferences. She also explained that if residents feel that the food is too cold, they are able to request a new tray and a new tray is given to them. Staff #32 reviewed the in-room dining policy and shared that the policy stated that it was preferred that food be at 120 degrees for palatability. She shared that she did not think she was meeting the temperature standard but they were meeting the palatability standard. Staff #32 indicated that hot food served at temperatures below 120 degrees increases the risk of residents developing foodborne illnesses.Review of the facility's policy and procedure titled, In-Room Dining indicates it was implemented in 2020. The policy explains that they do encourage residents to eat in the dining room to encourage socialization and monitoring. Number three of the procedure indicates that meals served in resident rooms can be checked at the point of service for palatable food temperatures. It identified the temperature of hot foods on room trays are preferred to be at 120 degrees or more for resident palatability. It also states that if there are concerns about the temperature of the food, a new meal is to be ordered from dining services. Number six of the procedure explains that the facility's nurses are to monitor residents when they are dining in their rooms. If there was an expressed concern about the food's temperature, they will offer appropriate meal substitutions.

Based on interviews, review of clinical records and facility policies and procedures, the facility failed to ensure two out of two sampled resident's (#10 and #81) medications were protected from diversion by one staff (#201). The deficient practice could result in residents not receiving prescribed medications, placing them at risk for unmanaged pain, withdrawal symptoms or other adverse outcomes.Findings include:Related to Resident #10-Resident #10 was admitted to the facility on [DATE] with diagnoses of malignant neoplasm of vulva, rheumatoid arthritis, and chronic pain syndrome.Review of the change of condition Minimum Data Set (MDS), dated [DATE] revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated she was cognitively intact. The MDS also revealed that she was receiving hospice care.Review of the physician's orders revealed an order for Oxycodone HCI (an Opioid analgesics) oral tablet 5 mg (milligrams) which was to be given to Resident #10 every 4 hours as needed for pain rating 6-10.Review of the care plan, initiated on October 20, 2025 revealed a goal of ensuring comfort care was provided due to her terminal illness and that she was receiving opioids. Interventions included administering medications as ordered to ensure resident's comfort and to document pain management.Related to Resident #81-Resident #81 was admitted to the facility on [DATE] with diagnoses of acute kidney failure, type 2 diabetes, and essential tremor.Review of the care plan, revised on July 12, 2024 revealed interventions to address her diabetes mellitus. Interventions included diabetes medications as ordered by the provider and monitoring side effects and effectiveness.Review of the quarterly MDS, dated [DATE], indicated Resident #81 had a BIMS score of 15 which indicated she was cognitively intact.Review of the physician's orders revealed an order for metformin HCI (antihyperglycemic agent) oral tablet 500 mg. Resident #81 was to take it by mouth twice a day for type 2 diabetes.Review of the State Agency's (SA) complaint portal revealed the facility made a self-report on December 2, 2025 at 4:36 P.M. Review of the facility's 5-day investigation report indicated that Staff #201 was observed, via security video, doing the counting (of medications) with the outgoing NOC (nocturnal) shift at the start of his 12-hour shift at 6:15 A.M. on November 29, 2025. The video revealed that around 5:00 P.M. Staff #201 was counting (medications) at the narcotic cart alone and removed a bottle with a red top indicating a narcotic. The report also noted that there was only one bottle of Oxycodone in the cart at the time which belonged to Resident #10. The report further noted that Staff #201 was observed taking the bottle down the hallway and returning to the hallway without the bottle. The video revealed him taking the narcotic sheet and putting it in his backpack and putting a bottle in his jacket, taking a pill, and putting another sheet and bottle in his backpack. The report indicated that both the Administrator/Staff #178 and Director of Nursing/Staff #52 contacted Staff #201 and requested that he return the narcotics to the facility. It also indicated that Staff #201 responded to both of them, verbally and via text messages, that he did not have the bottle of Oxycodone but he did send a picture, via text message, that he had taken another resident's (Resident #81) Metformin. The report explains the Staff #201 was then suspended on December 2, 2025 pending the outcome of the completed investigation. The facility reported the incident to the local police department and the police showed up to the facility on December 3, 2025 to investigate. It was noted that Staff #201 was booked into jail. On December 3, 2025 Staff #201 was terminated from the facility.An interview was conducted on December 10, 2025 at 8:31 A.M. with Licensed Practical Nurse (LPN/Staff #117). Staff #117 explained that controlled medications are kept in a lock box and when administering those medications, it is documented in the narcotic book the number of pills that are given. She added that they also sign their names next to the entry in the narcotic book. Staff #117 shared that it was not appropriate to take medications that you do not plan on administering because it would throw off the medication count and someone could get a hold of the medication and find themselves in a dangerous situation. Staff #117 indicated that diverting resident medications increases the risk of residents not receiving the medications they need or it might be given to the wrong resident who might not need the medication.An interview was conducted on December 10, 2025 at 8:42 A.M. with Registered Nurse (RN/Staff #49). She explained that medication diversion was not okay as it could be dangerous to those residents who might have allergies or drug addictions. She also added that it was not okay to take medications that you do not plan to administer to a resident.An interview was conducted on December 10, 2025 at 8:49 A.M. with LPN/Staff #16. Staff #16 explained that when medication is disposed of, a manager must be present as a witness. Staff further stated that if a second staff member is not present to witness the medication destruction, there is a risk the medication may not be destroyed correctly. Staff indicated that a nurse taking controlled substances for person use should never occur and would constitute medication diversion. Staff stated that diversion could result in residents not receiving prescribed medications or could lead to impaired nursing judgement, negatively affecting resident care and safety.An interview was conducted on December 10, 2025 at 9:06 A.M. with staff #178. She indicated that drug diversion was not acceptable because it hinders the residents' ability to get the proper pain medications or any other medications they might need. She added that it also goes against our policies and procedures and the clinical oath. When asked to describe the alleged incident, Staff #178 shared that on December 30, 2025 LPN/Staff #81 noticed there was a medication order for Oxycodone for Resident #10 however the controlled substance sheet was not in the book and the bottle with the medication was missing. Staff #81 then reported the missing medication to the Staff #52 and, in turn, Staff #52 then reported it to Staff #178. An investigation was initiated on December 1, 2025 and a full audit of all the medication carts was conducted and the medication was not found. Staff #178 further stated that the bottle containing the Oxycodone had a red top on it indicating that it was a controlled substance. It was the only medication in that specific medication cart that had a red top on it. Staff #178 and Staff #52 then reviewed the facility's security camera footage after making a self-report via the SA's complaint portal. Staff #178 explained that based on the report from Staff #81, the medication bottle was in the medication cart on November 29, 2025 but was missing on November 30, 2025. Her review of the security footage showed Staff #201 doing a medication count with Staff #81 during the shift change. She further explained that she saw the bottle and both staff members counting the medications. Staff #201 added that she observed Staff #201 acting different as he was rubbing his forehead a lot. Then around 5:45 P.M. on November 29, 2025 the video footage showed Staff #201 go to the medication cart and do the count by himself with no other nurse present. Staff #178 indicated that there was no reason for him to be doing a medication count alone and she confirmed this with Staff #52. Staff #178 further indicated that the video showed Staff #201 turning the pages in the narcotic count book and taking out two pages. Staff #201 was then seen with a bottle containing a red cap in his hand and he then walked down the hallway with the bottle in his hand. He then returned to the hallway with no bottle in his hand. The video also showed him going to the nurses' station and putting the bottle into his backpack and pull a sheet a paper from his hoodie pocket and throw the paper into the trash and going into the medication room. Staff #178 shared that the facility has a security camera in the medication room and upon review of that footage, they observed Staff #201 take a pill from a bottle, with a red cap on it, and put the pill into his mouth. Staff #178 shared that once she was able to call Staff #201, she told him that he was observed taking a medication bottle with a red top and destroying medication sheets and that he needed to return the medication bottle. She added that at that point she was under the impression that Staff #201 had only taken the Oxycodone from Resident #10, however, Staff #201 denied taking the medication bottle and had informed her that he only took Metformin from Resident #81. Upon review of Resident #81's medications, it was discovered that the facility had an extra bubble pack of Metformin that the family had brought in when she was admitted to the facility. Staff #178 shared that Resident #10 and Resident #81 have rooms that are right next to each other. The police were then called and they showed up to the facility on Wednesday, December 3, 2025 and the situation was explained to the police officers and video evidence was provided to them.A telephone call to RN/Staff #201 was placed on December 10, 2025 at 11:03 A.M. and the voicemail box was full.Review of the facility's policy titled, Medications: Controlled Substances revealed it became effective on January 1, 2024. The procedure states Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count. It also noted that the count is done by the on-coming nurse and the out-going nurse together and discrepancies are to be reported to the Director of Nursing. It further states that any major discrepancy or if it is apparent that any criminal activity had taken place, the Director of Nursing is to notify the administrator and consult with the pharmacist immediately and then determines if police or other enforcement personnel needs to be contacted.

Based on clinical record review, staff interviews, and the facility policy and procedures, the facility failed to ensure that adequate documentation for one resident's (#40) nutritional intake was completed. The deficient practice could result in nutritional deficiencies not being monitored. Findings include: Resident #40 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included unspecified protein-calorie malnutrition, iron deficiency, chronic obstructive pulmonary disease, and acute kidney failure. Review of the care plan dated October 10, 2023 revealed that the resident is at risk for nutritional and hydration problems as evidenced by a low mini nutritional assessment (MNA) score of 6: malnourished. Interventions included fortified cereal, Med Pass nutritional shake two times daily, and to encourage intake. A mini nutritional assessment (MNA) dated October 11, 2023 revealed the resident's height was 68 inches and weight was 142 lbs and had a moderate decrease in food intake and lost more than 6.6 pounds over the last three months. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 14 indicating the resident was cognitively intact. The order summary revealed an order dated October 10, 2023 for a regular diet, regular texture, thin liquids consistency and fortified cereal. A progress note by the dietician dated November 12, 2023 revealed that the resident's weight was 133.5 lbs on November 3, 2023 and he had a 5.6% weight loss over the last 30 days. The resident is on a regular diet with 67% intake times one week, variable intake of fortified cereal, and an appetite stimulant is in place. The resident's weight is trending down despite interventions and will add Med Pass nutritional shake twice a day to maximize nutrition. Review of task for cereal intake revealed that there was no documentation on November 2, and 6, 2023 and documented as not applicable on November 10, 11, 12, 17, 18, 19, 23, 24, 25, 26, and December 1, 2, and 3, 2023. An interview was conducted on December 7, 2023 at 12:52 p.m. with a certified nursing assistant (CNA/staff #36), who stated that the percentage of food intake for every meal is documented for all the residents. She stated that if a resident refuses to eat, she documents the refusal on the task sheet and reports it to the nurse. She knows that the resident eats fortified cereal with a protein shake for breakfast and if it is a standing order, he should received the cereal every morning. She stated that if there is no documentation regarding the percentage of cereal eaten, it may mean that the cereal was not sent to the resident. During an interview conducted on December 7, 2023 at 1:14 p.m. with a registered nurse (RN/staff #81), she referred to the cereal order and stated that it was part of the dietary order, but was not sure how often the resident was supposed to receive it. She went to check with the Director of Nursing (DON/staff #100) and stated the DON told her the order for the fortified cereal was for every day shift. Then, staff #81 reviewed the task sheet for the fortified cereal and stated that some of the documentation was missing, and there were multiple times that not applicable was documented. She was not able to state why the staff hadn't documented the amount of cereal eaten and did not know what was meant by not applicable. An interview was conducted on December 7, 2023 at 1:24 p.m. with the Director of Nursing (DON/staff #100), who stated that it was the same CNA who documented not applicable on the task sheet and needed to be reeducated on how to complete the task sheet accurately. Then, staff #100 reviewed the progress notes and stated that she couldn't find anything showing that the resident refused to eat cereal on the days that the data was marked not applicable. She stated that there is a risk to not documenting the percentage of meal intake or the refusal to eat because we are not able to see if the resident is benefiting from the cereal. The facility's policy Resident Nutrition Services dated November 2015 states that the multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food likes, dislikes and eating habits. They will develop a resident care plan based on this assessment. Nursing personnel will evaluate food and fluid intake in residents with, or at risk for, significant nutritional problems. Nursing staff will assess and document the amounts eaten as indicated for individuals with, or at risk for, impaired nutrition.

Based on observations, staff interviews, and policy reviews, the facility failed to ensure a sanitary kitchen with regards to peeling paint over the tray line counter. The deficient practice could increase the risk of foodborne illness. Findings include: An observation was conducted of the kitchen on December 6, 2023 at 12:13 p.m. During this observation, peeling ceiling paint was noticed above the tray line counter. A follow-up observation was conducted on December 6, 2023 at 3:00 p.m. It was observed that the cracked and peeling ceiling paint spanned the length of the 3 vents on top of the tray line counter. An interview with the Nutrition Services Manager (staff #55) was conducted on December 6, 2023 at 2:55 p.m. Staff #55 stated that there are plans for a kitchen renovation. He said that the facility knows about the cracked/peeling ceiling paint in the kitchen but no action has been taken. He stated that the facility has assessed but nothing has been done. Staff #55 stated that it does bother him and that the crack/peeling ceiling paint is around the 3 vents. He said that potentially particles can get in the food they are preparing. Staff #55 noted that over 6-months ago, he placed a work order about the ceiling but it still has not been fixed. An interview was conducted with the Executive Director (ED/staff #11) inside the kitchen on December 6, 2023 at 3:02 p.m. Staff #11 admitted that all the times he has been at the kitchen he has never looked up. Now looking at it, he admitted that it is a concern that there is cracked/peeling ceiling paint over the tray line. Staff #11 stated that it has probably been months that the ceiling has cracked/peeling paint. He indicated that renovations for the kitchen is supposed to start next week. Staff #11 agreed that having cracked/peeling ceiling paint over the tray line is an issue. Review of the TELS work order log with the timeframe of May 1, 2023 through December 5, 2023 did not reveal a work order request regarding the peeling ceiling paint in the kitchen. On December 7, 2023 at 9:16 a.m., the ED (staff #11) and the Nutrition Services Manager (staff #55) showed the surveyor that the kitchen ceiling was fixed. Review of the facility policy titled Sanitation revised October 2008 indicated that the food service area shall be maintained in a clean and sanitary manner. The facility policy titled Maintenance Service revised December 2009 indicated that the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Furthermore, the policy stated that the functions include maintaining the building in good repair and free from hazards. The policy noted that the Maintenance Director is responsible for maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner.

Based on clinical record review, facility documentation, staff interviews, and policies and procedures, the facility failed to ensure one resident (#166) was free from resident to resident abuse, which resulted in physical harm as evidenced by a 5 x 4 cm bruise on the resident's right wrist. The deficient practice could result in other residents being abused. Findings include: -Regarding Resident #166 Resident #166 (alleged victim) was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, anxiety disorder, major depressive disorder, and schizoaffective disorder. A neurological care plan initiated on July 13, 2019 indicated that the resident has an alteration in neurological status related to dementia. Goals included: resident will be able to communicate daily needs, and will maintain optimal status and quality of life within limitations imposed by neurological deficits. Interventions included give medications as ordered, monitor/document for side effects and effectiveness, evaluate and treat as ordered. Review of a care plan initiated on July 25, 2019 revealed that the resident demonstrated physical behaviors related to his impaired cognition. The goal was resident will not harm self or others. Interventions included to analyze key times, place, circumstances, triggers, and what deescalates behavior and document. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS assessment indicated that at the resident was negative for psychosis, behavioral symptoms, rejection of care, and wandering. A nursing note dated November 4, 2021 revealed that the resident presented to the nursing office and showed a nurse a bruise to his right wrist. The nursing note stated that the resident reported that his roommate punched him causing the bruise which measured 5 x4 cm. The note documented that resident #166 stated that he was going to his room when his roommate grabbed then punched him. A follow-up nursing note dated November 4, 2021 indicated that resident #166 demonstrated exit seeking behavior after the incident. The note also noted that the resident wanted to talk to someone and kicked the exit door. The note documented that this occurred twice within a 30-minute period. A Health Status note dated November 4, 2021 indicated that during conversation with the resident regarding the incident, the resident stated that the man who hit him was standing next to him. Review of a progress note dated November 5, 2021 revealed that the incident which left a bruise on the resident's wrist was reported to Adult Protective Services (APS), non-emergency police, and the ombudsman. The note also stated that the residents were separated into different rooms. A weekly skin assessment dated [DATE] indicated that resident #166 had a new skin condition. It was described as right wrist bruise. Further review of the resident's clinical notes revealed a nursing note dated November 8, 2021 which indicated that resident had presented to the nurse's station multiple times stating he was being beat up in his sleep. The note indicated that the resident was reassured, redirected, and monitored. -Regarding resident #5 Resident #5 (alleged perpetrator) was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia without behavioral disturbance/psychotic disturbance/mood disturbance/anxiety, altered mental status, cerebrovascular disease, vascular dementia, anxiety disorder, and major depressive disorder. A cognition care plan initiated on April 30, 2018 revealed that the resident has impaired cognitive function/impaired thought process related to dementia. Interventions included to communicate with resident/family/caregivers regarding resident's capabilities and needs, review medications and record possible cause of cognitive deficit. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 5 indicating that the resident has severe cognitive impairment. Additionally, the MDS indicated that the resident has not exhibited psychosis or behavioral symptoms during the assessment period. A Health Status Note dated November 4, 2021 revealed that the resident # 5 was moved to another room in the secured unit. Review of a behavior note dated November 4, 2021 revealed that resident #5 stated that he did grab his roommate's arm and punched him with his fist. The note indicated that the incident occurred in the hallway and that the Director of Nursing (DON) was notified of the incident. A Social Services Progress note dated November 5, 2021 documented that per the DON, an Adult Protective Services (APS) report was submitted about a claim of a resident hitting roommate. The note indicated that residents have been separated into different rooms. It also noted that the incident was reported to the non-emergency police and that the ombudsman was notified. Review of the facility's investigation report dated November 9, 2021 revealed that according to Registered Nurse's statement, she was signing out medications in the nurse's office when resident #166 approached her and showed her his right wrist with a recent bruise. The report indicated that residents involved were unable to recall the event when interviewed. The investigation concluded that the allegation of abuse could not be substantiated due to lack of witnesses and inconsistency in resident statements. An interview with a Licensed Practical Nurse (LPN/staff #3) was conducted on December 7, 2023 at 1:52 p.m. Staff #3 stated that residents are supervised in order to mitigate resident to resident altercations. However, if it occurs, the staff will separate the residents immediately and report the incident. She indicated that she has not experienced such incidents in the facility. However, if it happens, it is reported to the Director of Nursing (DON), the social worker, physician, and family. Notification to the state and police is also done and the facility has to follow its protocol regarding abuse reporting and it is reported immediately. An interview with a Certified Nursing Assistant (CNA/staff #51) was conducted on December 7, 2023 at 2:08 pm. Staff #51 indicated that when they see a potential or actual resident to resident altercation, they try to redirect the residents. She noted that they get assistance to make sure the residents are separated and safe. Then they let the nurse know about the incident so it can be reported/documented. Staff #51 said that staff are provided abuse training. She said that it is provided as needed, when they do in-service training, and it is discussed during monthly meetings. An interview with the Director of Nursing (DON/staff #100) was conducted on December 7, 2023 at 3:07 p.m. Staff #100 stated that her expectation is for her staff to notify her immediately if an allegation of abuse occurs. She noted that she expects her staff to ensure that the resident(s) is safe. Notification regarding the allegation of abuse will then be accomplished by either the DON or the Executive Director (ED). The investigation is also usually done by the DON or the ED. Social Services assist with safety questions. The investigation involves interviewing anyone randomly where the incident occurred, interview the residents to see if they feel safe. With regards to the incident between residents #166 and #5, staff #100 noted that she remembers it. She noted that the incident was investigated and residents were assessed. Staff #100 noted that the residents were safe. She said to her recollection they were unable to unsubstantiated or substantiate due to the residents involved being in the dementia unit. The alleged victim was out in the hallway and it the timeframe could not be determined. Residents were not reliable historians. Regardless, she noted that the facility still must investigate, assess, separate the residents, and try to find out what happened. Review of facility policy titled Abuse Policy version dated 06/2022 indicated that the facility strive to prevent the abuse of all their residents. Furthermore, it noted that their objective is to provide a safe haven for our residents through preventive measures.

Based on clinical record reviews, staff interviews and facility policy and procedures, the facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) level I was completed accurately and a level II was sent to the state for determination for one resident (#2). The deficient practice could result in specialized services not being identified and provided to residents. Findings include: Resident #2 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included acute stress reaction, and suicidal ideations. A cognition care plan revised on November 7, 2019 revealed that the resident has impaired cognitive function or impaired thought process. Interventions indicated to use residents name and identify yourself at each interaction. Review of a medication care plan revised on November 4, 2019 revealed that the resident is on psychotropic medications related to schizoaffective disorder. Interventions included administer medications as ordered, monitor/record occurrence of target behavior symptoms, monitor/record/report to physician side effects and adverse reaction to medication, and psychiatric/psychological consult as ordered. A medication care plan initiated on September 23, 2020 indicated that the resident is on antidepressant medication related to depression. Interventions included to monitor/document/report to physician as needed ongoing signs/symptoms of depression that is unaltered by medication, give antidepressant medications as ordered by physician, and refer for psychiatric/psychological consult as ordered. Review of the resident's face sheet revealed the following new diagnoses and date of onset: major depressive disorder dated July 11, 2021, anxiety disorder dated September 26, 2020, and schizoaffective disorder dated August 21, 2021. A medication care plan revised on September 28, 2020 revealed that the resident is on anti-anxiety medication related to anxiety disorder. Interventions included to give anti-anxiety medications as ordered, monitor/record occurrence of target behavior symptoms, and psychiatric/psychological consult as ordered. Review of the PASRR Level I Screening Tool dated March 9, 2021 revealed the form was not adequately filled out. Section B. Mental Illness was left blank. The symptoms portion under the area interpersonal with the question has the individual exhibited interpersonal symptoms or behaviors was left unanswered. Additionally, the concentration/task related symptoms portion was left answered. The portion pertaining to History of Psychiatric Treatment was also left blank. The area titled Psychotropic Medications was also left blank. A communication care plan revised April 25, 2022 revealed that the resident has impaired hearing. Interventions included to be conscious of the resident's position when in groups, activities, and dining room to promote proper communication with others. It also recommended to use communication techniques which enhance interaction and to allow adequate time to respond. A care plan revised on April 25, 2022 indicated that the resident has a potential to demonstrate physical and verbal behaviors and refusal of care related to dementia. The goal was for resident not to injure self or others. Interventions included to administer and monitor the effectiveness of medications, assess and anticipate needs, evaluate for side effects of medication, intervene as needed to protect the rights and safe of others, remove from situation, when agitated-ensure safety and re-approach at a later time when less agitated. A medication care plan revised on February 17, 2023 revealed that the resident is on anti-psychotic medicates related to schizoaffective disorder. Interventions included to administer medications as ordered, and monitor for side effects. A behavioral care plan revised on July 26, 2023 revealed that the resident has behavior problems related to striking/swinging at staff during nursing care. Interventions included to administer medications as ordered, anticipate and meet needs, encourage to follow the care plan but respect choices, and explain all procedures to him before starting, allow time to adjust to changes. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating that the resident was unable to complete the assessment. Section I. Active Diagnoses indicated the resident's diagnoses included dementia, anxiety disorder, depression, and schizophrenia. Further review of the clinical record did not reveal a PASRR Level I after the PASRR Level I dated March 9, 2021. An interview with the Resident Relations Manager who functions as Social Services (staff #107) was conducted on December 7, 2023. Staff #107 stated that when a resident first comes into the facility, they come in with a PASRR which she reviews/updates. After the resident is here after 40-day admission they review and will do a PASRR or hospital stay or change they do a level II PASRR. Staff #107 noted that if there is a mental illness and intellectual disability they will do a new PASRR and initiate a level II. PASRR audit is accomplished by corporate and they check PASRR. However, the audit does not include residents that have been in the facility over 40-days, so long term care residents are not part of the PASRR audit complete by corporate. Staff #107 stated that every single spot of the PASRR sheet should be completed and that included section B. She noted that if schizoaffective disorder is a new diagnosis after a PASRR is completed then a new PASRR will be triggered. Staff #107 noted that if a new PASRR is not accomplished following a new mental illness/disorder diagnoses then the facility will not be able to provide effective care for the resident. She stated that a new PASRR is a great identifier to provide care for what a resident need so if it is not completed then it can be a problem. Staff #107 verified that the most recent PASRR for resident #2 was dated March 9, 2021. She stated that with the diagnoses of schizoaffective disorder in August 21, 2021, it should have triggered a new PASRR I and should include the medications that is related to the pertaining diagnosis. An interview with the Director of Nursing (DON/staff #100) was conducted on December 7, 2023 at 2:12 p.m. Staff #100 stated that her expectation is that PASRR is completed for each resident. She said that she also expects that when there is a new diagnosis related to mental illness/disorder a new PASRR is accomplished. Staff #100 stated that she has been made aware that a new PASRR should have been completed for resident #2 and that one will be done for him. Staff #100 stated that if a PASRR is not updated then the facility will not know how to properly care for the resident. Review of the facility's policy titled Pre-Admission Screening and Resident Review [PASRR]) version 0920 stated that the facility will strive to verify that a Level 1 PASRR screening has been conducted, in order to identify serious mental illness (MI) and/or an intellectual disability (ID) prior to initial admission of individual to the facility. Additionally, it stated that PASRR Level I screenings are used to determine whether the individual has a diagnosis or other presenting evidence that suggests the for MI or ID. If the resident is positive for potential MI or ID, a Level II PASRR referral must be submitted. The policy indicated that it is the responsibility of the facility to make referrals for a Level II PASRR, or that a referral is made by the ALTCs case manager, if a Level II is determined to be necessary. The policy also indicated that the facility will strive to submit an updated Level I Screening and Level II evaluation request within 14 days after the facility determines through the MDS assessment that there has been a significant change in the resident's physical or mental condition which may indicate the need for specialized MI or ID services, according to the Criteria for Level II Referrals. Furthermore, the policy stated that an updated Level I screening must be conducted for each resident of the facility who has serious mental illness or intellectual disability not less than annually.

Based on observations, clinical record review, interviews, and policy review, the facility failed to ensure one resident (#23) received the necessary services to maintain good bathing and grooming hygiene. This deficient practice could result in bathing and grooming needs not being met. Findings include: Resident #23 was admitted on [DATE] with diagnosis including Parkinson's Disease, unspecified dementia, psychotic disturbance, mood disturbance, anxiety, arthritis, major depressive disorder, muscle weakness and need for assistance with personal care. A review of the MDS (minimum data set) dated November 07, 2023 revealed a BIMS (brief interview of mental status) of 5 and further noting that for personal hygiene the resident requires one-person physical assistance. A review of the care plan for resident #23 revealed that the resident is at risk for functional selfcare deficits and that facility staff is to communicate the resident and or family regarding the resident's needs. A observation was conducted on December 07, 2023 at 1:54 P.M. Resident #23 was observed to be seated in the communal area of the unit watching television. The resident was not clean shaven and was observed to exhibit facial hair. A telephone interview with the representative, Individual #203, of resident #23. She stated that the resident likes to be shaved but had not been. Individual #203 stated that the resident's presonal razor had been brought to the facility and it was requested that staff shave the resident; however, based on the representatives statement and per observation, the resident had not been shaven. An interview was conducted on December 7, 2023 at 2:02 P.M. with resident #23. The resident stated that he did not like facial hair and would like to have a shave. The CNA (certified nursing assistant), staff #31, had walked into the room and stated that the resident had not been shaven for 3 to 4 days, because she can't find his personal razor. She stated that facility razors were available but they tend to cause 'nicks' and that is why she had not shaved the resident. When asked about an electric razor, staff #31stated that the facility does have one but she would have to track it down; however, neither a bladed or electric razor had been utilized to shave the resident. She stated that the last time the resident had received a shower was on December 06, 2023. She further stated that anytime a resident wants to be shaved that he should be shaved. An interview was conducted with 2 additional CNA's, staff #94 and staff #202, on December 07, 2023 at 2:06 P.M. CNA #202 stated that residents generally bring their own razors, but if not, a facility razor would be utilized and CNA #94 if a resident prefers to be shaven, staff would shave the resident on a daily basis. An interview was conducted on December 07, 2023 at 2:27 P.M. with LPN (licensed practical nurse) staff #3. Staff #3 stated that personal hygiene tasks such as shaving are generally completed twice a week during showers and as needed. Staff #3 reviewed the shower schedule for the resident and stated that it was noted that the last documented shower was on November 15, 2023. An interview was conducted on December 07, 2023 at 2:39 P.M. with the DON (director of nursing) staff #100. Staff #100 stated that shaving is contingent on whether a resident would like to be shaved or not and that it is most frequently offered during showers twice weekly. However, staff #100 stated that the last documented time the resident had received a shower was on November 15, 2023 and the facility expectation is 2 showers per week; however, per facility documentation, the last reported shower had been approximately 3 weeks ago which did not meet the facility's expectation. A review of the facility's Activities of Daily Living (ADL) policy, with a revision date of March 2018, revealed that appropriate care and services would be provided to residents who are unable to carry out ADL's independently to include bathing and grooming. The bath and shower policy dated 2022 revealed that staff are to document the date and time that the shower/ bath had been performed and further document skin related observations and or refusals; however, the last documented shower was noted to be on November 15, 2023.

Based on documentation, staff and resident interviews, and the facility policy and process, the facility failed to ensure one resident (#40) had access to activities. The deficient practice could impact the psychosocial well-being of residents. Findings include: Resident #40 was admitted to the facility on [DATE] with diagnoses that included a displaced intertrochanteric fracture of the left femur, chronic obstructive pulmonary disease, dependence on oxygen, major depressive disorder and an anxiety disorder. The activities care plan dated October 10, 2023 stated that the resident enjoys being in his room watching TV and looking outside his window getting sunlight and included one intervention to offer a variety of activity types and locations. Note: resident #40 shares a room and his roommate's bed is located on the side of the room where the window is located. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 14 indicating the resident was cognitively intact. Review of the clinical record did not reveal any documentation of activities that the resident attended or refused to attend. During the initial interview conducted on December 4, 2023 at 1:07 p.m. with resident #40, he stated that he is not invited to activities and doesn't know what activities are being offered. An activity calendar was observed hanging on wall directly across from the resident's bed and was dated November 2023. An interview was conducted on December 7, 2023 at 2:07 p.m. with the Activities Manager (#staff 61), who stated that the purpose of activities is to get the residents out of their rooms, to distract them. She makes an activities calendar each month for the residents, so they know what activities are being offered. She stated that she goes to the residents' rooms and invites them to activities and she memorizes which residents are not participating. She stated that resident #40 usually doesn't want to attend activities because he is not interested. She stated that the prior Activities Manager trained her, which included tracking and documenting resident participation, but she has not done this. An interview was conducted on December 7, 2023 at 2:27 p.m. with the Executive Director (ED/staff #11), who stated that he supervises the Activities Manager (staff #61) and he has never required her to track resident participation in activities. He stated that there is a large activities calendar posted in the hallway, so residents know what activities are scheduled. During a second interview conducted on December 7, 2023 at 2:47 p.m. with resident #40, he stated that he can't get out of bed by himself, so he would need assistance to attend an activity. He also stated that he can read, but he can't see the activities calendar hanging on the wall across the room. The facility's policy Activity Programs dated January 2011 states that the activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. Activities participation for each resident is approved by the Attending Physician based on information in the resident's comprehensive assessment. Scheduled activities are posted on the resident bulletin board. Activity schedules are also provided individually to residents who cannot access the bulletin board (e.g. bed bound or visually impaired residents).

Based on clinical documentation, staff interviews, and the facility policy and process, the facility failed to complete baseline vital assessments upon one resident's (#116) admission. The deficient practice result in a change of condition not being recognized. Findings include: Resident #116 was admitted to the facility on [DATE] with diagnoses that included displaced intertrochanteric fracture of the left femur, hypothyroidism, and depression. The admission evaluation dated May 26, 2023 at 3:25 p.m. did not include vitals. An admission summary progress note dated May 26, 2023 at 7:38 p.m. revealed that the resident arrived at the facility around 1:30 p.m. The resident was admitted for a displaced intertrochanteric fracture of the left femur, subsequent encounter for a closed fracture with routine healing. The resident's weight was 158 pounds. Review of the weights and vitals summary revealed that the resident's blood pressure was 129/68 and temperature was 97.6 F. at 4:00 p.m. A health status progress note dated May 26, 2023 at 5:37 p.m. revealed that the resident felt warm and her temperature was 99.5 F. The resident was offered Tylenol and declined stating that it gives her diarrhea. The resident was checked again at 8:58 p.m. and stated that she was having chest pain and that she had called her husband and told him to call 911. The ambulance arrived at 9:05 p.m. to transport the resident to the hospital as per the resident's request. Saturation of peripheral oxygen (SPO2) was 95%. Staff attempted other vitals, but the emergency staff arrived and took vitals. The discharge/transfer assessment dated [DATE] at 9:23 p.m. did not include vital signs. An interview was conducted on December 6, 2023 at 10:14 a.m. with the reporting source (#200), he stated that the resident had surgery and was treated for infection at the hospital. He stated that the resident called him and said that she was hot and sweaty, warm to the touch, and having heart palpitations. He was concerned because staff did not take the resident's vitals when she was admitted and her temperature baseline was below average. He called 911 and had the resident transported to the hospital. An interview was conducted on December 6, 2023 at 11:17 a.m. with the Director of Nursing (DON/staff #100), she stated that when a resident is admitted , the staff establish a baseline, which includes: mentation, vitals, skin check, heart and lung sounds, and pedal pulses and the results are documented in the initial evaluation or could be found in a progress note. It is her expectation that the vitals are done within the first hour of the resident being admitted . She referred to the admission evaluation and acknowledged that the vitals were not included. Then, she referred to the clinical record and stated that the resident was admitted at 1:30 p.m., blood pressure was taken at 4:00 p.m., and temperature was taken at 4:00 p.m. She stated that if the vitals were not taken when the resident was admitted , we wouldn't have a baseline and then we wouldn't know if there was a change of condition. She also stated that she thinks it is common for the elderly to have a lower temperature. An interview was conducted on December 6, 2023 at 2:12 p.m. with a licensed practical nurse (LPN/staff #18), who stated that when a resident is admitted , the nurse completes a head-to-toe assessment, which includes a full set of vitals and the documented in the clinical record. She stated that the facility doesn't have a policy regarding vitals.

Based on staff interviews, and review of facility documentation and policies, the facility failed to ensure that the QAA (quality assessment and assurance) committee collected data and monitored it's performance regarding adverse events for performance improvement. Findings include: An interview was conducted on December 7, 2023 at 3:21 P.M. with the administrator, staff #11, and the director of nursing, staff #25. Staff #11 stated that the QAA comittee meets at least quarterly and that data for performance improvement is obtained from a variety of sources to include audits, staff and resident feedback. Some of the topics for PIP's (performance improvement plans) had included the facility census, pressure ulcers, weight loss, falls, psychotropic medications, call-light response and showers. Staff #11 stated that the data for each PIP is reviewed the following month during the QAPI (quality assurance and performance improvement program) meeting. Staff #11 stated that staff #25 utilizes audit forms and that data is kept in a specific binder. Status updates are then shared forward with staff and residents as applicable. She stated that two of the PIP's tracked included call-light response, which were stated to be ongoing and showers, which were stated as a completed PIP; however, when asked about the data tracking, the facility was unable to provide evidence of data tracking for either PIP. The administrator stated that both analysis of data and graphing of the data would be an expectation for any PIP. He stated that the risk of not tracking and appropriately documenting the data could include that the problem would not actually get fixed. A review of the Quality Assurance and Performance Improvement Meeting policy with a copyright date of 2016 revealed that the purpose of QAPI is to establish data-driven, facility-wide processes that improve the quality of care; however, for 2 of the performance measures, there was no evidence of data trend tracking for the identified PIP's.

Based on personnel file reviews, staff interviews, and the facility policy and procedures, the facility failed to provide evidence that 3 out of 10 staff (#98, #26, and #27) were provided resident rights training. The deficient practice could result in residents not being afforded their rights. Findings include: Review of the personnel file for staff #98, a physical therapist, revealed a hire date of June 1, 2023. Further review of the personnel file revealed no evidence that staff #98 had received training on resident rights. -Review of the personnel file for staff #26, a occupational therapist, revealed a hire date of June 1, 2023. Further review of the personnel file revealed no evidence that staff #26 had received training on resident rights. -Review of the personnel file for staff #27, a speech therapist, revealed a hire date of June 1, 2023. Further review of the personnel file revealed no evidence that staff #26 had received training on resident rights. An interview was conducted on December 6, 203 at 9:19 a.m. with the human resources (staff #201) all staff are required to complete training on resident rights. An interview was conducted on December 6, 2023 at 3:27 p.m. with a certified occupational therapy assistant (COTA)/Area Manager (staff #111. She stated that she doesn't have a sign-in sheet to show that staff (#98, #26, and #27) attended resident rights training. The facility policy Staff Development Program states all personnel must participate in initial orientation and regularly scheduled in-service training classes. DHS Mandatory topics include resident's rights.

Based on personnel file review, staff interviews, and the facility policy and procedures, the facility failed to provide evidence that 1 out of 10 staff (#98) was provided dementia training. The deficient practice could result in residents with dementia not receiving the care needed. Findings include: Review of the personnel file for staff #98, a physical therapist, revealed a hire date of June 1, 2023. Further review of the personnel file revealed no evidence that staff #98 had received dementia training. An interview was conducted on December 6, 203 at 9:19 a.m. with the human resources (staff #201) all staff are required to complete dementia training. An interview was conducted on December 6, 2023 at 3:27 p.m. with a certified occupational therapy assistant (COTA)/Area Manager (staff #111. She stated that she doesn't have a sign-in sheet to show that staff (#98) attended dementia training. The facility policy Staff Development Program states all personnel must participate in initial orientation and regularly scheduled in-service training classes. Topics did not include dementia training.

Based on staff interviews, clinical record reviews, and review of policy and procedure, the facility failed to ensure one resident who was identified with serious mental illness (#44) and one presumed short-stay resident (#26) who remained in the facility for longer than 40 days were referred to the State-designated authority for Level II pre-admission screening and resident review (PASRR) evaluation and determination. The sample size was 2. The deficient practice may result in residents being inappropriately placed into nursing homes and/or not receiving services they need. Findings include: -Resident #44 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Level I PASRR screening dated 02/04/21 indicated the resident had not been admitted for 30-day convalescent care and did not have a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The screening was signed by a Nurse Care Manager (NCM). Another Level I PASRR dated 03/12/21 was identified in the clinical record which included the resident's relevant diagnoses. However, a referral for a Level II evaluation and determination was not made. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the July 16 through 31, 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . However, review of the care plan did not include drug seeking and/or aggressive behaviors. Further review of the July 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 15 on the brief interview for mental status, indicating intact cognition. The assessment indicated the resident displayed no behaviors or symptoms of [CONDITION(S)], and required supervision/set-up for most activities of daily living. The August 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident displayed inability to sleep/stay asleep for 12 out of 31 nights. Per review, medications were administered in accordance with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A health status progress note dated 09/06/22 at 3:33 a.m. included the 2:00 - 10:00 p.m. shift reported the resident had an increase in self-isolation episodes. The note stated the isolation episodes were difficult to gauge at that time due to the resident resting in bed with eyes closed. Review of the September 1 through 7, 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . However, per review of the clinical record, a referral for a PASRR Level II evaluation and determination had not been done. -Resident #26 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A PASRR Level I screening document dated 10/04/21 revealed the resident was admitted to the facility from the hospital after receiving acute inpatient care, and that the physician had certified before admission that the resident required 30 days or less of nursing facility services. The document indicated that no referral for Level II services was necessary. However, further review of the clinical record did not reveal the PASRR Level 1 was updated and/or that the resident was referred to the State authority for Level II evaluation and determination after the resident continued to reside in the facility for longer than 40 days. On 09/08/22 at 11:13 a.m., an interview was conducted with the Social Services Director (SSD/staff #52). She stated that PASRR screening must be completed before residents are admitted to the facility or that she will complete the screening if the hospital has not provided it. She stated if the resident comes to the facility for 30-day convalescent care, but needs to stay longer, she will complete another Level I PASRR which would be good until the resident was discharged . She stated the resident would still be considered a Level I unless they were considered to be a danger to themselves or others. She stated that the clinical team is responsible to review for accuracy of diagnoses. She stated that she thought the MDS coordinator was responsible for making referrals to the State agency for Level II evaluation. She stated that the facility would not be appropriate for residents with Level II designation. She stated that she was not really aware of the PASRR screening process and that she would be sure to correct it as soon as she could. An interview was conducted on 09/08/22 at 11:44 a.m. with the Director of Nursing (DON/staff #27). She stated that upon admission the resident will have a PASRR which would be completed by the discharging facility/hospital. She stated that either she or the MDS coordinator will review it for accuracy. She stated that if the resident was admitted for a 30-day convalescent stay, but stayed for a longer period of time, a PASRR Level II must be completed upon day 40 by the SSD (staff #52). She stated that when a resident is identified as having an evident or possible mental disorder, intellectual disorder, or related condition staff #52 must make a referral. She stated that it would not meet her expectations not to screen the residents appropriately. The facility policy titled Pre-Admission Screening and Resident Review, dated 2020 stated the facility will strive to verify that a Level I PASRR screening has been conducted, in order to identify serious mental illness (MI) and/or intellectual disability (ID) prior to initial admission of individuals to the facility. A new PASRR Level I screening is not required for readmission to the facility. PASRR Level I screenings are used to determine whether the individual has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . If the resident is positive for MI or ID, a PASRR Level II referral must be submitted. It is the responsibility of the facility to make referrals for a Level II PASRR.

Based on clinical record review, resident and staff interviews, and the facility's policies and procedures, the facility failed to assist one resident (#3) in obtaining hearing aids. The sample size was 2. The deficient practice could result in residents not being provided with devices to maintain hearing ability. Findings include: Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the audiological record dated March 9, 2022 stated minimal response levels for pure tone. Review of the pure tone audiogram revealed a downward slope in hearing frequency. The audiological record included a prescription that stated to consider hearing aids if dementia, and also stated severe hearing loss bilaterally. Review of a quarterly Minimum Data Set, dated dated dated [DATE] revealed a Brief Interview of Mental Status score of 7, which indicated the resident had severe cognitive impairment. The MDS stated the resident had adequate ability to hear (with hearing aid or hearing appliances if normally used), understood verbal and non-verbal expressions, and understood verbal content (with hearing aid or device if used). An interview was conducted with the resident on September 9, 2022 at 12:57 p.m. Resident #3 was lying in bed looking at the television. Resident #3 answered interview questions appropriately but had to be spoken to loudly. Resident #3 stated she was hard of hearing in both ears. An interview was conducted on September 8, 2022 at 8:42 a.m. with a social service (staff #52). Staff #52 stated this was the first time she heard about the resident needing hearing aids, and that she did not know anything about the audiology recommendation. Staff #52 stated the process when a resident returns from an audiology appointment included the driver handing the doctor's paperwork to the receptionist who was also responsible with scheduling appointments. Staff #52 stated the nurses input the orders, then give the paperwork to the medical records to be scanned to resident's electronic records. Staff #52 stated she would follow up and make the appointment happen. An interview was conducted on September 8, 2022 at 1:50 a.m. with the DON (director of nurses/staff #27). Staff #27 stated the process when a resident returns from an audiology appointment includes giving the physician paperwork to the nurse, who inputs the physician orders, then the family or the facility can make arrangements for transportation. Staff #27 stated social services was responsible for following up on hearing aids prescriptions. The DON stated if a resident did not get the recommended hearing aids, the resident could have difficulty with communication. A facility policy, Hearing Impaired Resident, Care of, stated staff will assist hearing impaired residents to maintain effective communication with clinicians, caregivers, other residents and visitors. The policy also stated the staff will assist the resident (or representative) with locating available resources, scheduling appointments, and arranging transportation to obtain needed services.

Based on clinical record review, observations, resident and staff interviews, and policy and procedure, the facility failed to ensure a suprapubic catheter was secured and positioned below the level of the bladder for one resident (#46). The sample size was 2. The deficient practice could result in adverse effects to residents. Findings include: Resident #46 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing admission summary dated August 7, 2022 at 6:22 p.m., stated the resident was admitted following urosepsis with a suprapubic catheter related to chronic obstructive urinary issues. Review of the care plan initiated on August 8, 2022 included a problem for obstructive [CONDITION(S)], and stated the resident was at risk for developing complications due to the catheter. The interventions included keeping the catheter drainage bag below the level of the bladder. Review of the admission Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 10, which indicated the resident had moderately impaired cognition. The assessment also revealed the resident had an indwelling catheter. An observation was conducted on September 6, 2022 at 9:42 a.m. The resident was observed lying in bed, eyes closed, the head of the bed was flat, and the resident's head was resting on a white pillow. Resident #46 was observed with a urinary catheter bag attached on the middle part of the bed frame, aligned with the resident's left hip, not below the bladder. A second observation was conducted on September 8, 2022 at 8:30 a.m. The resident was lying in bed with the head of the bed slightly elevated to approximately 20 degrees. A urinary catheter was observed hung on the upper right side of the bed, on the movable frame. The urinary catheter had approximately 1300 cc (cubic centimeter) of urine, and the tubing had visible sediments. An immediate interview was conducted with resident #46 who stated he had just finished eating breakfast. The resident stated the urinary catheter was emptied by the nurses once a day. Resident #46 exposed the urinary catheter, and stated he did not know if the nurse emptied it last night because he was asleep. The urinary catheter tubing was not secured on the resident's body, and the drainage bag was not placed below the resident's bladder. An interview was conducted with the resident on September 8, 2022 at 11:00 a.m. The resident stated he was showered and a nurse put a new dressing on the catheter. The resident exposed the suprapubic catheter site and it was observed the stoma was covered with a 4X4 gauze. However, further observation of the urinary catheter revealed the urinary tubing was not secured. An interview was conducted on September 8, 2022 at 1:50 a.m. with the DON (director of nurses/staff #27). Staff #27 stated her expectation related to the placement of a supra pubic catheter included the collection bag being placed below the level of the bladder, and securely anchored to prevent tugging. The facility policy, Urinary Continence and Incontinence-Assessment and Management revealed urinary catheters will be used sparingly, for appropriate indications only. The policy also revealed the staff and physician will treat symptoms of urinary tract infections or urosepsis as indicated but that eradication of all bacteria may not always be feasible (e.g., in a resident who has an indwelling urinary catheter). The policy did not include catheter placement and securement to prevent potential injury and recurrent urinary tract infections.

Based on clinical record review, observations, staff interviews, and review of policy, the facility failed to provide oxygen as ordered for one resident (#3). The sample size was 2. The deficient practice could result in residents not receiving ordered oxygen. Findings include: Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan problem with a revision date of December 9, 2021, stated the resident had oxygen therapy as needed related to [CONDITION(S)]. The interventions stated to provide oxygen therapy per physician order. Review of the weights and vital signs records dated August 2022 revealed resident #3's oxygen saturation ranged between 90%-95% approximately 60 times. Review of the treatment administration record (TAR) for August 2022, revealed checked marks for all shifts which indicated oxygen was administered. Review of quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 07, which indicated the resident had severe cognitive impairment. The assessment did not reveal the resident had received oxygen therapy. Further record review of weight and vital signs records dated September 5, 2022 at 10:28 a.m. revealed the resident's oxygen saturation was 90%, and at 5:33 p.m. it was 93%. The record for September 6, 2022 revealed at 1:55 p.m. and 6:28 p.m., the resident's oxygen saturation was 95%. The record also revealed that on September 7, 2022 at 1:46 a.m., the oxygen saturation was 90%. Review of TAR dated September 2022 revealed checked marks for all shifts which indicated oxygen was administered. An observation of resident #3 was conducted on September 6, 2022 at 12:57 p.m. Resident #3 was lying in bed and was able to participate with the interview when spoken to loudly. It was noted that the resident's room did not include oxygen set up to administer oxygen, including concentrator, emergency oxygen tank, and nasal cannula. The resident was not observed wearing oxygen. On September 8, 2022 at 8:53 a.m., a registered nurse (RN/staff #69) visited resident #3's room and stated the resident did not have oxygen on. The RN reviewed the TAR and stated the nurses signed off on the oxygen administration but the resident did not have oxygen on. A follow up interview was conducted with the RN (staff #69) on September 8, 2022 at 8:58 a.m. Staff #69 stated resident #3 has not received oxygen for a while, and the last time oxygen was used was when it was ordered in 2020, when the resident had respiratory episodes. Staff #69 stated the nurses signed off on oxygen administration indicating it was administered but there is no oxygen concentrator or oxygen set up in the resident's room. The RN stated the nurses were signing the oxygen administration on the TAR because they were used to providing oxygen to maintain the resident's saturation greater than 90%. An interview was conducted on September 8, 2022 at 1:50 a.m. with the DON (director of nurses/staff #27). Staff #27 stated resident #3 has an oxygen order in point click care (PCC). Staff #27 stated the staff documents the oxygen administration in PCC if ordered, and her expectation is for staff to follow the order. The DON stated if a resident with an oxygen order is not followed, the resident could be at risk for [CONDITION(S)] or shortness of breath. A facility policy, Medication and Treatment Orders, stated orders for oxygen will be prescribed and managed according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, clinical record review, resident and staff interviews, and facility policies, the facility failed to ensure one of 16 sampled residents (#49) received the necessary services to maintain good grooming and personal hygiene. The census was 63. The deficient practice could result in residents not receiving Activities of Daily Living (ADL) care. Findings include: Resident #49 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan initiated on September 30, 2020 revealed resident #49 had an ADL self-care performance deficit related to weakness. The goal was that the resident would improve current level of function in bed mobility, transfers, dressing, and toilet use. Interventions included the resident required the assistance of 2 staff participation for toilet use, transfer, and mobility; and required the assistance of one staff participation with bathing, personal hygiene and oral care, and dressing. The quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 8, indicating the resident had moderate cognitive impairment. The assessment also revealed the resident was total dependent for bathing and transfers, and required the assistance of two persons. The assessment included the resident required extensive assistance of two persons for bed mobility, dressing, personal hygiene, toilet use and bathing. A review of the POC (Point of Care) Legend Reports and Shower Sheets for February 20, 2021 through May 6 2021 revealed the resident was offered bathing care once a week February 22 through 28, March 8 through 14, March 29 through April 4, April 5 through 11, and April 12 through 18. This report also revealed the resident did not receive bathing care the weeks of March 1 through 7, and April 26 through May 2. During an interview conducted with the resident on May 3, 2021 at 12:03 PM, the resident was observed to have a white flaky and crusty appearance on his face, scalp and neck; and very dry flaky skin on his arms. The resident stated that he does not receive bathing assistance on a daily basis. The resident stated he was due for bathing and was sure how often he is supposed to get bathed or showered. In an interview conducted with a Certified Nursing Assistant (CNA/staff #76) on May 5, 2021 at 9:12 AM, the CNA stated sometimes they are unable to provide all the showers during their shift and that they will put that on the shower sheet and hand it off to the evening shift. Staff #76 stated residents' showers are documented in their electronic health records. During an interview conducted with a Registered Nurse (RN/staff #23) on May 5, 2021 at 1:26 AM, the RN stated that CNAs mostly handle bathing and that nurses only get involved with showers when they are asked. She said the CNAs will ask the nurse for assistance if the resident refused bathing, and that the nurse will go talk to the resident about bathing. An interview was conducted on May 6, 2021 at 2:07 AM with a CNA (staff #53), who stated residents are scheduled twice a week for bathing. She stated that there are not enough staff and that she would not be surprised to hear that a resident did not receive their showers. The CNA said that they try to get the showers done but sometimes it is just the two CNAs for this long hall. Staff #53 said that if a resident had refused the shower, it would be documented. The CNA stated the CNAs chart resident bathing in the resident electronic health record. An interview was conducted on May 6, 2021 at 3:37 PM with the Director of Nursing (DON/staff #47), who stated most residents receive their showers twice a week, however they can receive a shower 3 times a week if they want. She stated that she thinks twice a week is the standard. The DON said this resident should have been offered a shower twice a week. She stated that when the staff reported that showers were not able to be given, the management team would go and give residents showers. The DON stated if the shower sheet was out, then she would document the shower. The DON further stated that she was not always great about documenting and that was her fault. Review of the facility's policy titled Shower/Tub Bath revised October 2010 stated the purpose of the procedure is to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. The policy also stated the following information should be recorded on the resident's ADL record and/or in the resident's medical record: the date and time the shower/tub bath was performed, the name and title of the individual(s) who assisted the resident with the shower/tub bath, all assessment data obtained during the shower/tub bath, how the resident tolerated the shower/tub bath, if the resident refused the shower/tub bath, the reason(s) why and the intervention taken, and the signature and title of the person recording the data.

Based on clinical record review, resident family and staff interviews, and policy review, the facility failed to ensure adequate supervision was provided on the secured dementia unit/Special Care Unit (SCU) including for two residents (#5 and #27) who were involved in a resident to resident altercation that resulted in an injury to resident #5. The secured unit census was 13. The facility census was 63. The deficient practice could result increased risk for accidents or hazards related to inadequate resident supervision. Findings include: -Resident #5 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included [CONDITION(S)] disorder, anxiety disorder, and muscle weakness. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 2, which indicated that the resident had severe cognitive impairment. The assessment included the resident had rejection of care and wandering 1 to 3 days of the assessment period. Review of the behavior Care Area Assessment (CAA) revealed the resident was noted to be exit seeking, wanting to go home and for the staff to have measures in place to keep the resident safely within the facility. A fall report dated February 4, 2021 revealed the resident was found on the floor in an adjacent, empty room and was looking for an exit. The report included that wandering was a predisposing situation factor. A care plan revised February 9, 2021 (initiated 1/23/2021) revealed: The resident was at risk for falls related to impaired gait/balance, weakness, wandering, and impaired cognition. Review of the Care Unit Evaluation for the Special Care Unit dated April 13, 2021 revealed the resident had diagnoses of [CONDITION(S)] disorder and anxiety. The evaluation included the resident had wandering on 4-6 days and required the Special Care Unit (SCU). Review of the quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 3, which indicated the resident had severely impaired cognition. The assessment included the resident wandered on 1 to 3 days of the assessment period. Review of a nursing progress note dated April 26, 2021 at 6:34 p.m. revealed the resident continued with exit-seeking behavior and wandering into other residents' rooms. Redirected. Continue to monitor. A nursing note dated April 27, 2021 at 3:22 a.m. revealed the resident had a fall that occurred in the TV/Dining area of the SCU. The note included the resident was assessed, assisted to a standing position, and that the resident was able to ambulate to bed. Review of an IDT (Interdisciplinary Team) fall review note dated May 1, 2021 at 10:38 a.m. revealed the resident sustained a fall on May 1, 2021 at 12:00 a.m. and sustained a laceration to the head. Review of a nursing progress dated May 3, 2021 at 6:00 a.m. revealed: Screaming was heard coming from a resident's room (resident #27). Both resident #27 and this resident are in the room standing, Certified Nursing Assistant (CNA) staff reports as she entered the room she witnessed a physical altercation and this resident fell backward onto her head. Resident #27 continued to yell at this resident while receiving care, this resident is slid out into the hallway. Resident is having a hard time opening her eyes and has noticeable weakness to her left grip, pain in left lower extremity with range of motion. Respirations are even and unlabored. Hematoma is felt on the back of patient's scalp. Emergency Medical Services was contacted to transport the resident related to head injury with neurological deficits. Review of a nursing progress note dated May 3, 2021 stated that since returning from the hospital, the resident is very restless, wandering the hallways, into other residents' rooms and hallucinating. Continue to monitor. A physical incident report dated May 3, 2021 revealed the patient had wandered into a resident's room and the CNA reported hearing arguing and entered the room. The CNA witnessed resident #27 placing her hands on resident #5 and resident #5 fell backwards. The CNA described it as a push. Predisposing factors included resident #5 was an active exit seeker and ambulating without assist. Review of a provider note dated May 3, 2021 included that nursing reported the resident with disturbed sleeping patterns, [CONDITION(S)], exit-seeking behavior and wandering. The patient was in an altercation today May 3, 2021, and fell and hit the back of her head. Nurse reports to patient having a hematoma. Patient is poor historian. Monitor behavior and redirect as needed. A care plan initiated on May 4, 2021 included the resident had impaired decision making and was at risk for altercations related to wandering and impaired cognitive function. The goals included that the resident would be able to communicate basic needs on a daily basis. The interventions included to keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Goals for wandering and altercations with other residents, and interventions to decrease the risks with wandering and altercations were not included. -Resident #27 was admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)]. A care plan that was initiated on August 4, 2016 stated the resident had the potential to demonstrate physical behaviors related to anger and had threatened staff with a walking stick. The goal was that the resident would not injure self or others. Interventions included to analyze key times, places, circumstances, triggers, and what de-escalated behavior and to document; to establish limits for inappropriate behaviors; to intervene as needed to protect the rights and safety of others; monitor and modify environment for external contributors to behavior including other residents. An annual MDS assessment dated [DATE] revealed the resident had a BIMS score of 99 as the resident was unable to complete the interview. The staff assessment for mental status included the resident had short- and long-term memory problems and poor decisions requiring cues/supervision. The assessment included that the resident had delusions and hallucinations, daily rejection of care, and wandering. Review of a Care Unit Evaluation dated April 13, 2021 for the Special Care Unit revealed the resident had a diagnosis of [CONDITION(S)]. The eval included the resident had daily behavioral symptoms not directed toward others, that the resident was unaware of her own safety needs, and required the Special Care Unit. A provider progress note dated May 3, 2021 revealed the nurse reported that the resident had an altercation with another resident who walked into the resident's room. The police were notified and spoke with the resident as the other resident fell and hit their head. Resident #27 denied pushing the resident per nurse. Review of a Social Services Progress note dated May 3, 2021 at 9:00 a.m. revealed that social services was informed of a resident to resident altercation that morning at approximately 5:15 in the secured unit. It was reported that that this resident's neighbor wandered into her room while she was sleeping and began touching her table and her papers and the resident asked the other resident to leave. This resident speaks Korean and the other resident speaks Spanish. The other resident would not leave her room. Resident stated that she tried to get her out and when she finally turned to leave, she lost her balance and fell . Resident stated that she did not push her or try to hurt her, just that she wanted her out of her room. The other resident hit her head and was sent to the hospital for treatment and observation. Social services notified case management and non-emergent police. The resident called the CNA staff a liar for saying that she pushed the other resident. Review of a physical incident report dated May 3, 2021 revealed that resident #5 wandered into the resident #27 room. A verbal argument was heard. A CNA reported resident #27 pushed resident #5. Review of the Nurses Station Scheduling Reports for April 1 through April 30, 2021 and May 1, 2021 revealed one Certified Nursing Assistant (CNA) worked the night shift (10:00 p.m. to 6:00 a.m.) on the Secured Dementia Unit (SCU). No nurses were assigned to work the SCU on the night shift. An interview was conducted on May 3, 2021 at 12:55 p.m. with a Registered Nurse (RN/staff #70). She stated that there had been an altercation between resident #5 and resident #27. She stated that resident #27 does not let anyone into her room and that resident #5 wandered into resident #27's room that morning. She stated that resident #27 pushed resident #5 down and resident #5 hit her head. An interview was conducted on May 4, 2021 at 8:54 a.m. with a family member of resident #5. The family member stated the facility stated that resident #5 wandered into another resident's room and that the other resident pushed resident #5 down. The family member stated that resident #5 had a hematoma and had to be sent to the hospital for Magnetic Resonance Imaging (MRI). An interview was conducted on May 6, 2021 at 10:56 a.m. with a CNA (staff #34). She stated that resident #27 had really bad trust issues and no one was allowed in her room, she stated that when staff delivers the meal tray they have to stand by the door and the resident would come to the door to get it. Staff #34 stated that if someone went into her room she would probably hit them with a stick. She stated that the resident had a stick that she used to chase other residents out of her room. She stated that she shakes the stick in the air but had not hit anyone with it. The CNA stated that there were three residents on the secured unit that wander, which included resident #5, and that those residents wander into other residents' rooms. She stated that only resident #27 would react badly to residents wandering into her room. Staff #34 stated that resident #5 and another resident had wandered into resident #27's room before. She stated that she heard that resident #5 wandered into resident #27's room on Monday (May 3, 2021) and was pushed to the floor. The CNA stated that when she is not in the nursing station that she walks up and down the hall as a lot of the residents are in the hallway. The CNA stated that she can look at the mirrors mounted outside of the station and see if anyone is in the hall but that she cannot visualize resident #27's room from the mirror. Staff #34 stated that she works from 6 a.m. to 2 p.m. She stated that there was only one CNA on the hall and that it would be nice to have another CNA on the unit because sometimes the residents were wandering or fighting each other and the nurse was busy. She stated that when she arrives to the unit at 6:00 a.m., the door to the secured unit had been propped open a couple of times, but that it was usually closed. She stated that there was no nurse on the unit at night and only one CNA. She stated the CNA would prop open the door when she had to leave the secured unit to go to help in other areas of the facility. She stated that the door would be propped so that the nurse working the Medicare hall could supervise the secured unit. An interview was conducted on May 6, 2021 at 11:21 a.m. with a RN (staff #5). She stated that resident #27 had been there for a long time and that the staff all know her. She stated that resident #27 was very private, spoke Korean, and did not speak English. The RN stated that resident #27 was delusional and hallucinates, did not take any medication, and that she did not know if the resident had any psychiatric care. The RN stated that resident #27 is sometimes scary to the other residents and had been on 15-minute checks since she pushed resident #5 down. She stated that resident #27 was not a danger to other residents if the other residents stayed out of her room, or if the other residents left her room when she told them to/warned them, or staff pulled the other resident out. She stated that resident #27 would say hey hey hey or get out, and that staff would respond quickly if they heard that. She stated that, mostly, staff had to keep up with residents that wander. Staff #5 stated that this was the first time she can think of that resident #27 had become physical with anyone. The RN stated that in her opinion they did not have enough staff on the secured unit to give the supervision to meet the needs/care for the clientele there. The RN stated that if any resident needed two people to assist them with care there would be no supervision on the unit while the nurse and CNA were doing the task. She stated that it was a constant worry related to the population served on the secured unit and that many of the residents acted spontaneously. Staff #5 stated that she had asked the Director of Nursing (DON) for more staff related to the concerns that she had and was told that the facility did not staff according to acuity, that the facility staffed by numbers. A phone interview was conducted on May 6, 2021 at 12:30 p.m. with a RN (staff #54) He stated that he was the nurse working at the time of the altercation between resident #27 and resident #5 on May 3, 2021. He stated that resident #27 resided on the secured unit and that she would freak out if someone entered her room. He stated that resident #5 was up wandering/pacing the hall and the CNA (identified as staff #50) on the hall was in a room caring for a resident. Staff #54 stated that the CNA heard yelling and when she got to the room she saw resident #27 push resident #5 and that resident #5 fell . He stated that resident #27 called the CNA a liar and made a hand motion to show that she was trying to guide resident #5 out of the room, not push her. The RN stated that he could not say if resident #27 was a reliable reporter but that he felt that she had the right to defend herself. He stated that he could recall one prior instance when resident #5 was in the doorway of resident #27's room and resident #27 made noise so the CNA was able to redirect resident #5. The RN stated that resident #27 considers her room her personal space and that she would be a physical risk to other residents if they were to wander into her room. Staff #54 stated that when a resident is up wandering, the staff usually sit outside of the doorway near the dining room to supervise the hall and re-direct the residents. He stated that at night he is the nurse for the Medicare hallway and that there is a CNA on each hallway. The RN stated that there would be times at night when the CNA from the secured unit (SCU) is needed to help in other areas and the door to the secured unit would be propped open so that he can try to supervise both units. He stated he thought the point of the secured unit was for wandering residents, but that he felt that they had some geriatric psychiatric residents back there. He stated that the staff ratio for the secured unit is right but that those residents have more skilled needs than other residents, and are ambulatory and wander. The RN stated that he thought two permanent staff on each hall would be beneficial on the night shift. An interview was conducted on May 6, 2021 at 1:41 p.m. with a Licensed Practical Nurse (LPN/staff #66). She stated that resident #27 did not like people in her room. Staff #66 stated that resident #27 would only be considered a danger to other residents if they went into her room. The LPN stated that other residents sometimes wander into resident #27's room and that resident #27 chases them out of her room with a broomstick. She stated that she had never seen resident #27 do anything physical to anybody. She stated that they used to have another CNA on the secured unit before the COVID pandemic but they were shorthanded so they were unable to provide a second CNA. The LPN stated that there was no nurse scheduled on the secured unit for the 7:00 p.m. to 7:00 a.m. shift, but that there was always a CNA there who will get the nurse if something happens. The LPN stated that one of the other nurses voiced a concern to the DON regarding the staffing on the secured unit and that she agreed, but that they were told that the ratio did not allow for another CNA on the secured unit. A call was placed to the CNA (staff #50) on May 6, 2021 at 2:02 p.m. Message left. No call back received. An interview was conducted on May 6, 2021 at 2:47 p.m. with the DON (staff #47). She stated that she had not had any behavior concerns with resident #27 except for refusal of care. Staff #47 stated that resident #27 was on 15-minute checks since she had a resident to resident altercation with resident #5. She stated that when facility staff interviewed resident #27 about the resident to resident incident, resident #27 stated that she did not harm resident #5 and was trying to shoo her out her door. She stated that, by diagnoses, the resident was [CONDITION(S)] and not cognitively impaired. She stated that there was a language barrier present between the two residents. The DON stated that she had not been able to talk to the CNA witness to get her report. The DON stated that with resident #27's reaction to anyone entering her room, she could be a danger to other residents/wandering residents if they were to enter her room. She stated that when she was in talking to resident #27 today, the resident was tapping her stick but was not threatening with it. She stated that a CNA was on the secured unit at all times during the night. The DON stated that if the CNA were to leave for break or to help on other units, another staff member should go to the secured unit. The DON stated that the secured unit would not be able to be adequately supervised from Medicare nursing station, that the staff would need to be physically on the unit. She stated that staff were not permitted to prop open the secure unit door so that they would not need to go onto the secure unit. The DON stated that staff would not be able to adequately visualize the secure unit with the door propped because they would not be able to fully visualize the unit. The DON stated that patient safety was at risk if a staff member was not physically on the secured unit. On May 5, 2021 at 2:06 p.m., a phone interview was conducted with a member of the nursing staff (staff #71). Staff #71 stated that there was no night nurse on the SCU and that there was only one CNA scheduled to work the night shifts. Staff #71 stated that the night CNA would leave the door to the SCU open every night. Staff #71 stated that two nights prior, one of the residents got up and assaulted the CNA that was assigned to the unit. Staff #71 stated that it was a good thing the door had been left open otherwise no one would have heard the CNA when she yelled for help. A phone interview was conducted on May 6, 2021 at 10:15 a.m. with a member of the nursing staff (staff #31). Staff #31 stated that on the night shift the CAN would leave the door open because it is kind of creepy back there and also so that someone else could hear if one of the residents assaulted them. Staff #31 stated that the CNA from the SCU helps the CNA on the Medicare hall, because it is hard for one CNA to do the whole hall by themselves. Staff #31 stated that they leave the secured unit door open and a nurse from another unit will watch the hall through the open door. Staff #31 stated that the CNAs place a medication cart in the doorway and lock the wheels, so if a resident did get up in the middle of the night, the resident would not be able to move it. Staff #31 stated that they thought that if someone were really strong, they could move the cart. Staff #31 stated that the doors to the two units open in opposite directions, and that the cart does not block the doors from opening or closing. Staff #31 stated the cart just blocks the doorway so someone would have a difficult time getting out. A phone interview was conducted on May 6, 2021 at 12:16 p.m. with a member of the nursing staff (staff #80). Staff #80 stated that it has been the practice of the CNA to leave the door open with the cart in the doorway on the SCU because they do not feel safe with the aggressive resident that resides on the unit. Staff #80 stated that the SCU door stays open because the CNAs assist each other during rounds. Staff #80 stated that on the previous night, there had been only one CNA on the 200 and the 300 halls to care for about 40 residents. Staff #80 stated that was too many residents for one CNA. A phone interview was conducted on May 6, 2021 at 1:31 p.m. with a member of the nursing staff (staff #4). Staff #4 stated that the nurse covers two halls when the door to the SCU is left open. Staff #4 stated that if they have to leave the area, they try to time it when the CNAs have come back from their rounds and are back on the unit. Staff #4 stated that they personally had never left the area unsupervised. On May 6, 2021 at 2:26 p.m., an interview was conducted with the Assistant Director of Nursing (ADON/staff #57). The ADON stated she had seen the SCU door open herself when she had come in in the morning. She stated that she has told the nursing staff to close the door, and that she did not know that it was still going on. The ADON stated that leaving the secured unit door open was a safety risk and that the practice did not meet her expectations. An interview was conducted on May 6, 2021 at 3:23 p.m. with the Director of Nursing (DON/staff #47). She stated that it would not meet her expectation for the secure unit door to be left open for extended periods, including an entire shift. She stated that a nurse or another CNA needs to be on the unit for observation purposes. She stated that resident safety would be at risk. She said that she was not aware of the SCU door being left open. The facility policy titled Safety and Supervision of Residents stated that the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The policy included that safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes: QAPI (Quality Assurance and Performance Improvement) reviews of safety incident/accident data; and a facility-wide commitment to safety at all levels of the organization. Individualized, resident-centered approach to safety included addressing safety and accident hazards for individual residents, and the interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risk for individual residents. Resident supervision is a core component of the systems approach to safety. The types and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment.

Based on resident and staff interviews, facility documentation, and policy review, the facility failed to ensure there was sufficient nursing staff to meet the needs of residents, by failing to utilize all avenues available including exhausting registry agencies and/or transferring residents to another facility due to being unable to meet the cares of the residents. The deficient practice resulted in residents' needs not being met. The census was 63. Findings include: During the initial phase of the survey, 4 out of 24 residents identified concerns of not having enough staff. Residents reported that they have waited up to 2-3 hours for call lights to be answered, for assistance with a Hoyer lift and slide board, and being incontinent due to the wait and feeling frustrated and embarrassed. Residents stated staffing was worse on the evening shift, and on the night shift on the weekends. Review of the Resident Council Grievance Log revealed that on January 21, 2021 residents complained that call lights were not answered quickly. On March 18, 2021, residents complained showers were missed. On April 6, 2021, residents complained of not having showers for two weeks, waiting up to an hour for call lights to be answered, and being left incontinent in the bed for over an hour. A Resident Council interview was conducted on May 5, 2021 at 9:58 a.m. The residents stated there was a shortage of Certified Nursing Assistants (CNAs). They stated that on the evening shift which might have been on the weekend, there were only 2-3 CNAs working in the entire building. One resident stated they had waited so long for assistance that they tried to transfer themselves and fell . The residents stated that the residents that are unable to care for themselves are frustrated. They stated showers have been missed and they have waited more than 30 minutes for call lights to be answered. They also stated that call lights have been answered immediately today. Review of the facility assessment updated March 19, 2021 stated that to meet the needs of the resident population, the required number of direct staff included 7 licensed Nursing Assistants (NAs) or CNAs for the day shift and the evening shift, and 4 for the night shift. The assessment included an average daily census of 60-65. A review of the Nurses Station Scheduling Reports for April 2021 revealed there were less than 7 CNAs for all the evening shifts and less than 4 CNAs for 9 of the night shifts. In an interview conducted with a CNA on May 3, 2021 at 11:51 a.m., the CNA stated that there were more than 35 staff call-offs for April 2021. The CNA stated that they had worked most of the month as the only CNA on the hall, providing care to 22 or more residents. The CNA stated they complained to management several times but nothing has been done. On May 5, 2021 at 8:51 a.m., an interview was conducted with a CNA who stated that if there is only one CNA on a hall, most often the residents will not receive showers. The CNA stated that she tries to provide at least two incontinence changes per shift. The CNA also stated that at the beginning of the shift, residents were found soaking wet because they were not changed during the prior shift. On May 5, 2021 at 1:31 p.m., an interview was conducted with the Executive Director (ED/staff #88) and the Human Resources Director/Staffing Coordinator (staff #46). They stated that the Nurses Station Scheduling Reports dated April 1 through April 30, 2021 included administrative staff that had worked the floor as nursing and CNA staff. The ED stated that the facility was within the staffing guidelines, and within the guidelines of their facility assessment. Staff #88 stated that the information provided the complete picture of all staff, in total, that had worked the floor and that there was no further documentation. Another interview was conducted with a CNA on May 5, 2021 at 1:36 p.m., who stated that prior to this year, the Long-Term Care (LTC) Unit/300 hall was staffed with 3 CNAs for the day and evening shifts. The CNA stated that usually the LTC hall has approximately 40 residents, more or less. The CNA stated that there have been multiple instances of only one CNA providing care for all the residents on the hall. The CNA said that the Medicare Unit/100 hall was supposed to be staffed with 2 CNAs, and that the Secured Unit/200 hall should also have 2 CNAs. The CNA stated that since January, staffing has sometimes been half that. The CNA stated that the results of inadequate staffing included residents having to wait a long time, sometimes an hour or more, for their call lights to be answered, resident care is rushed, incontinence care may not always be provided, and that residents may not always have the assistance they need to get out of bed in the mornings. On May 5, 2021 at 2:06 p.m., an interview was conducted with another CNA. The CNA stated that there had been a shortage of direct care staff since the beginning of the year, and that the other day there had been one CNA providing care to the entire LTC/300 hall (approximately 30 residents). The CNA stated that on the night shift the CNAs have to work together to provide care, and that the CNA from the secured unit will leave that unit to assist the other CNAs. The CNA further stated that on the night shift, there is only one CNA on the secured unit and there is no nurse. The CNA also stated that now that State is in the facility, all of a sudden there is staff helping out on the floor. On May 6, 2021 at 3:28 p.m., an interview was conducted with the DON (staff #47). She stated that the administrative staff had approached the lack of staffing by taking on the Temporary Nursing Assistant (TNA) program, and that they have hired valets to do simple things such as answering call lights and getting the resident drinks, and did radio advertising for jobs. She stated that they had called the county, and that emails had been initiated/sent in January. She stated she was not sure if their Quality Assurance and Performance Improvement (QAPI) had addressed the staffing shortage. She stated the facility had tried calling other sister facilities, but that they did not call registry. She stated she was told that they had tried to call registry, but were told they did not have any staff available. She stated that additional interventions had included a group CNA text line, offering extra shifts, and bonuses - creative staffing strategies. An interview was conducted on May 6, 2021 at 4:03 p.m. with the ED (staff #88) and the ADON (staff #57). Staff #88 stated that staffing issues had been identified in their last QAPI meeting held on April 23, 2021. He stated that it had been an ongoing challenge. He said actions taken to correct the issues had included recruiting and retention activities. Staff #88 stated that he had reached out to the county on December 27, 2020, contacted a nurse staffing agency in December 2020. The ED stated he reached out to sister facilities on a monthly basis, and that he had reported staffing shortages to CMS (Centers for Medicare and Medicaid) in April 2021. The ED stated that the issue has not been corrected. He stated that they had one agency CNA that had just started working in the facility this week. When asked to provide documentation that the facility had implemented its Emergency Staffing policy and procedures, staff #88 stated he would do so. The facility's emergency staffing plan included utilizing registry staff and staff from other facilities. However, the facility had not demonstrated that this plan was implemented to address staffing shortages. The facility's policy titled Staffing stated that the facility would provide adequate staffing to meet needed care and services for the resident population. The facility maintains adequate staffing on each shift to ensure that the resident's needs and services are met. Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services. Certified Nursing Assistants/Nursing Assistants are available on each shift to provide the needed care and services of each resident as outlined on the resident's comprehensive care plan. The facility's policy titled Employee Staffing Procedures and Resources - Temporary Emergencies stated that in the event of a situation that results in a temporary emergency including events like a natural disaster, pandemic, public health crisis, or similar situations, the facility will take the following steps in order to review staffing needs in the event that the situation warrants immediate additional staff members. Based on the evaluation, the following efforts would then be taken including relying on previously contracted registry agencies to contract clinical staff members to fill any necessary shifts. The policy stated that after the facility leadership reviews the availability of additional staff and support members and, depending on the circumstances and resident needs, the facility may review the need to the transfer of residents to another location where current economies of scale and operational and clinical conditions would allow the receiving location to more effectively care for residents. The policy also included that resident transfers shall not be necessary unless the facility clinically and operationally cannot adequately provide care for residents under the circumstances.

Based on clinical record reviews, staff interviews, and review of facility policies and procedures, the facility failed to ensure that four of five residents (#'s 5, 16, 18, and 19) did not develop pressure sores and failed to provide the necessary treatment and services to promote the healing of existing pressure sores. As a result, Substandard Quality of Care was identified. The sample size was five. Findings include: -Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]., and discharged to another facility on December 29, 2014. Review of the Care Plan for actual impaired skin/tissue integrity related to decline in functional mobility, incontinence, weakness, and debility, with the following interventions: apply skin treatments as ordered, assess skin weekly and prn, encourage and assist to turn and reposition, ensure resident is clean, dry and odor free, dated November 4, 2014, (a previous admission) and revised on December 29, 2014; the day the resident was discharged to another facility. Review of the Care Plan for activities of daily living (ADL) self care performance deficit related to decline in functional mobility, [MEDICAL CONDITION], weakness, debility, cervical spondylosis, [MEDICAL CONDITION], incontinence, and non-ambulatory dated November 4, 2014, and revised on December 29, 2014, the day the resident was discharged to another facility. An admission order dated November 15, 2014, for wound vac to decubitus ulcer, and wound care; with no documented evidence of what was to be provided and how often for the wound care and the wound vac. A Braden Scale for Predicting Pressure Sore Risk was completed on November 15, 2014, with a score of 13; moderate risk. Review of the closed clinical records revealed no documented evidence that wound care was provided from November 15 through 18, 2014. A physician's order was written on November 18, 2014, to cleanse coccyx with wound cleanser, pat dry, apply [MEDICATION NAME], cover with foam on Tuesday and Friday and as needed (PRN) for a stage II pressure ulcer. Cleanse right buttock with wound cleanser, pat dry, apply [MEDICATION NAME], cover with foam on Tuesday and Friday, and PRN. Review of the Care Plan for stage III pressure ulcer to right hip, stage II on coccyx and right buttock dated November 18, 2014, revealed the following interventions: Apply skin treatments as ordered, assess skin weekly and prn, encourage and assist with turning and repositioning, ensure resident is clean, dry and odor free. Review of the closed clinical records revealed that from November 15 through November 20, 2014, no documented evidence was able to be found for wound vac orders regarding how often to change the wound vac dressing, and pressure settings for the wound vac. Review of the Medical Nutrition Therapy Recommendation dated November 19, 2014, revealed a recommendation for 237 milliliters (ml) of the house supplement between meals two times per day, and record the per cent consumed on the Medication Administration Record [REDACTED]. This recommendation was authorized by the physician on November 21, 2014. A physician's order was written on November 20, 2014, for a wound vac to the right hip and change every seventy-two hours for a pressure ulcer. However, no documented evidence was able to be found regarding specific orders for the wound vac pressure settings. A physician's order dated November 20, 2014, was written for [MEDICATION NAME] 500 milligrams (mg) orally three times per day; continue until stools have been formed for ten days for ,[MEDICAL CONDITION]. difficule ([MEDICAL CONDITION]). Review of the Weekly Pressure Ulcer Report dated November 21, 2014, revealed that the right hip pressure ulcer (wound #1) measured 4 cm. by 3.6 cm. with no documented depth, stage III; with undermining of more than 2 cm. in any area, with scant amount of bloody exudate, and bright, beefy red. On November 24, 2014, wound #1 measured 4.6 cm. by 3.6 cm. with a depth of 0.8 cm., stage III No documented evidence that wound #1 was measured from November 24, 2014, to December 5, 2014; eleven days. On December 5, 2014, wound #1 measured 4.6 cm. by 4.0 cm. with a depth of 0.6 cm., stage III On December 9, 2014, wound #1 measured 4.6 cm. by 3.4 cm. with a depth of 0.6 cm., stage III On December 15, 2014, wound #1 measured 4.8 cm. by 3.6 cm. with a depth of 1.0 cm., stage III On December 22, 2014, wound #1 measured 4.6 cm. by 2.8 cm. with a depth of 0.8 cm., stage III A physician's order was written on December 11, 2014, to discontinue wound vac to the resident's right hip pressure ulcer, clean with wound cleanser, pat dry, apply wet to dry dressing two times per day. Review of the TAR for December, 2014, revealed no documented evidence that the physician ordered treatment for [REDACTED]. Review of the Weekly Pressure Ulcer Report dated November 21, 2014, revealed that the right buttock pressure ulcer (wound #2) measured 0.6 cm. by 0.6 cm. with no depth, stage II, full thickness skin loss involving epidermis and/or dermis, undermining 2 cm. in any area, and no exudate noted. On November 24, 2014, wound #2 measured 0.4 cm. by 0.4 cm. with no depth, stage II. No documented evidence that wound #2 was measured from November 24, 2014, to December 5, 2014; eleven days. On December 5, 2014, wound #2 measured 1.4 cm. by 0.4 cm. with no depth, stage II. On December 9, 2014, wound #2 measured 1.4 cm. by 0.4 cm., with no depth, stage II. On December 15, 2014, wound #2 measured 2 cm. by 2 cm. with no depth, stage II. On December 23, 2014, wound #2 measured 2.4 cm. by 1.5 cm., unstageable. Review of the closed clinical records revealed no documented evidence that the wound orders were changed when the resident's right buttock pressure ulcer (wound #2) went from a stage II to unstageable. Review of the Nursing Progress Note dated December 23, 2014, revealed that the right buttock pressure ulcer measured 2.4 cm. by 1.5 cm., unstageable with wound bed covered in yellow slough. Review of the Weekly Pressure Ulcer Report dated November 17, 2014, revealed that the coccyx pressure ulcer (wound #3) measured 1 cm. by 0.2 cm., with no depth, stage II, partial thickness skin loss involving epidermis and/or dermis, undermining 2 cm. in any area, no exudate, and 75 to 100 per cent [MEDICATION NAME]. On November 24, 2014, wound #3 measured 0.8 cm. by 0.2 cm., with no depth, stage II. On December 5, 2014, wound #3 measured 1.4 cm. by 1.0 cm., with no depth, stage II. On December 9, 2014, wound #3 measured 1.4 cm. by 1.0 cm., with no depth, stage II. On December 15, 2014, wound #3 measured 2.5 cm. by 1.4 cm., with no depth, stage II. On December 23, 2014, wound #3 measured 3 cm. by 3 cm., with no depth, unstageable. Review of the Nursing Progress Note dated December 23, 2014, revealed that the coccyx pressure ulcer (wound #3) was unstageable, with the wound bed covered in yellow slough 85 per cent, and no signs or symptoms of infection noted. A physician's order was written on December 10, 2014, to turn and reposition at least every two hours while in the bed and chair, and document every shift. Review of the December, 2014, TAR revealed no documented evidence that the resident was turned and repositioned at least every two hours for all 10 a.m. to 6 p.m. shifts, and for most of the 6 p.m. to 2 a.m. shifts. The resident was documented as turned per physician's orders on most 2 a.m. to 10 a.m. shifts only. Review of the Medical Nutrition Therapy Recommendation dated December 11, 2014, revealed a recommendation for one scoop of protein powder mixed with 120 ml. of fluid two times per day for wound healing. No documented evidence was able to be found that this recommendation was signed by the physician. Review of the Minimum Data Set (MDS) admission assessment dated [DATE], section M. revealed that the resident had two stage II pressure ulcers, and one stage III pressure ulcer, with the largest pressure ulcer measuring 4.0 cm. by 3.6 cm. Section G. of this MDS assessment noted that the resident was totally dependent on staff for personal hygiene, toilet use, bed mobility, and bathing. Review of the Braden Scale for Predicting Pressure Sore Risk dated November 24, 2014, with a score of 12; high risk. An interview was conducted on March 17, 2015, with the wound nurse. The wound nurse stated that she does most of the wound care on pressure ulcers for the residents. She also stated that when a resident is admitted with a pressure ulcer, she tries to assess and recommend wound care within a day or two of admission. She further stated that this resident's wound vac was discontinued due to dehydration and does not know why the wound care was not provided as ordered when the physician's order was changed to twice per day. An interview was conducted with the director of nursing (DON) on March 17, 2015. The DON stated that this resident's wound care was provided by the wound nurse during the day shift, but does not know why the evening shift did not provide the physician ordered care for the resident's pressure ulcer. -Resident #19 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Braden Scale for Predicting Pressure Sore Risk dated October 22, 2014, with a score of 15; at risk. Review of the Weekly Skin Check dated October 27, 2014, revealed that there were no skin conditions, ulcers, or injuries present. Review of the Weekly Skin Check dated November 14, 2014, revealed that there was a right heel, stage II, clear blister, and left heel unstageable pressure ulcer. Review of the clinical records revealed no documented evidence that a skin check was done for this resident from October 27 to November 14, 2014; seventeen days. A physician's order was written on November 14, 2014, to cleanse left heel with wound cleanser, pat dry, apply [MEDICATION NAME], and cover with foam dressing on Tuesday and Friday and PRN for unstageable pressure ulcer. Cleanse right heel with wound cleanser, pat dry, cover with foam dressing on Tuesday and Friday and PRN for stage II pressure ulcer, and wrap bilateral heels with Kerlix. Review of the Care Plan for potential for skin/tissue integrity related to decline in functional mobility/ADL's, Alzheimer's dementia, history of [MEDICAL CONDITION] accident [MEDICAL CONDITION], incontinence, weakness, and debility dated November 14, 2014, with interventions to encourage and assist resident to turn and reposition when in bed, use positioning and pressure relieving divide, pressure reducing (air) mattress and chair pad, and when resident is out of bed, change position by toileting, uploading, shifting weight, ambulating or return to bed for rest. Review of the Weekly Pressure Ulcer Report dated November 17, 2014, revealed that the resident had a new onset left heel pressure ulcer (wound #1) that measured 1.4 cm. by 2.0 cm. with no depth, unstageable pressure ulcer first observed on November 14, 2014. On November 24, 2014, wound #1 measured 2.0 cm. by 2.4 cm., with no depth, unstageable. On December 3, 2014, wound #1 measured 2.0 cm. by 2.0 cm., with no depth, unstageable. On December 9, 2014, wound #1 measured 1 cm. by 2 cm., with no depth, unstageable. On December 16, 2014, wound #1 measured 2.2 cm. by 2.6 cm., with no depth, unstageable. On December 23, 2014, wound #1 measured 1.2 cm. by 2.0 cm., with no depth, unstageable. On December 30, 2014, wound #1 measured 1.6 cm. by 2.0 cm., with no depth, unstageable. On January 9, 2015, wound #1 measured 1.6 cm. by 2.0 cm., with no depth, unstageable. On January 15, 2015, wound #1 measured 1.8 cm. by 2.0 cm., with no depth, unstageable. On January 17, 2015, wound #1 measured 2.0 cm. by 1.6 cm., with no depth, stage II. On January 26, 2015, wound #1 measured 2.0 cm. by 1.4 cm., with no depth, stage III. On February 3, 2015, wound #1 measured 1.6 cm. by 2.0 cm., with no depth, stage III. On February 8, 2015, wound #1 measured 1 cm. by 1.4 cm., with no depth, stage III. On February 15, 2015, wound #1 measured 1.0 cm. by 1.0 cm., with no depth, stage III. On February 26, 2015, wound #1 measured 0.6 cm. by 0.8 cm., with no depth, stage III. On March 2, 2015, wound #1 measured 0.6 cm. by 0.7 cm., with no depth, stage III. On March 10, 2015, wound #1 measured 0.8 cm. by 0.8 cm., with no depth, stage III. On March 16, 2015, wound #1 measured 0.8 cm. by 0.8 cm., with no depth, stage III. Review of the Weekly Pressure Ulcer Report dated November 14, 2014, revealed that the resident had a new onset right heel pressure ulcer (wound #2), stage II, that measured 3.5 cm. by 2.0 cm., with no depth, stage II, with partial thickness skin loss involving epidermis and/or dermis, undermining 2 cm. in any area, and no exudate noted. On November 25, 2014, wound #2 measured 2.0 cm. by 2.0 cm., with no depth, stage II. On December 3, 2014, wound #2 measured 2.0 cm. by 2.0 cm., with no depth, stage II. On December 9, 2014, wound #2 measured 1.8 cm. by 2.0 cm., with no depth, stage II. On December 16, 2014, wound #2 measured 1.0 cm. by 1.6 cm., with no depth, stage II. On December 23, 2014, wound #2 measured 2.0 cm. by 1.4 cm., with no depth, stage II. On December 30, 2014, wound #2 measured 1.6 cm. by 1.2 cm., with no depth, stage II. On January 9, 2015, wound #2 measured 1.0 cm. by 1.2 cm., with no depth, stage II. On January 15, 2015, wound #2 measured 1.3 cm. by .3 cm., with no depth, stage II. On January 17, 2015, wound #2 measured 1.3 cm. by 1.0 cm., with no depth, stage II. On January 26, 2015, wound #2 measured 1.3 cm. by 1.0 cm., with no depth, stage II. On February 3, 2015, wound #2 measured 1.0 cm. by 0.6 cm., with no depth, stage II. On February 8, 2015, wound #2 measured 0.5 cm. by 0.6 cm., with no depth, stage II. On February 15, 2015, wound #2 measured 0.8 cm. by 0.6 cm., with no depth, stage II. On February 26, 2015, wound #2 measured 0.3 cm. by 0.5 cm., with no depth, stage II. On March 2, 2015, wound #2 measured 0.3 cm. by 0.5 cm., with no depth, stage II. On March 10, 2015, wound #2 measured 0.4 cm. by 0.6 cm., with no depth, stage II. On March 16, 2015, wound #2 measured 0.4 cm. by 0.4 cm., with no depth, stage II. Review of the Care Plan History revealed that on November 20, 2014, an intervention to float heels while in bed was added to the original care plan for pressure ulcers. Review of the Care Plan for Actual Impaired skin integrity related to decline in functional mobility/ADL's, Alzheimer's dementia, [MEDICAL CONDITIONS], incontinence, weakness, and debility dated December 19, 2014. The resident had a stage III pressure ulcer to the left heel, and stage II pressure ulcer to the right heel, with interventions to administer skin treatments as ordered, assess skin weekly and PRN, encourage and assist resident to turn and reposition when in bed, and encourage to wear heel protectors while in bed, and document every shift. A physician's order was written on January 3, 2015, to discontinue current treatment to bilateral heels. Clean left heel with wound cleanser, pat dry, apply [MEDICATION NAME], cover with foam dressing, and change every four days. Clean right heel with wound cleanser, pat dry, apply [MEDICATION NAME], cover with foam dressing and change every four days. Review of the MDS quarterly assessment dated [DATE], section M. revealed that the resident had two stage II pressure ulcers. Section G. of the MDS assessment noted that the resident required extensive assistance with bed mobility, transfers, dressing and toilet use. Review of the Health Status Note dated January 26, 2015, revealed that the resident was being treated for [REDACTED]. Current weight is 103 pounds and is stable; nutritional interventions in place for healing. Review of the Nursing Progress Note dated February 3, 2015, revealed that the left heel pressure ulcer measured 1.6 cm. by 2.0 cm., stage III, periwound pink, improvement noted as evidenced by small amount of yellow slough present. Right heel pressure ulcer, stage III, that measured 1.0 cm. by 0.6 cm., with a decreased amount of yellow slough. A physician's order was written on February 14, 2015, to provide an air mattress to prevent skin breakdown. Review of the TAR for February, 2015, revealed no documented evidence that the air mattress was provided as ordered by the physician. A physician's order was written on February 15, 2015, for heel protectors on while in bed, and document every shift. Review of the TAR for February, 2015, revealed no documented evidence that the air mattress and heel protectors while in bed were done, and that wound care was provided as ordered by the physician. A physician's telephone order dated March 16, 2015, was written to increase house supplement to eight ounces four times per day and record per cent on the MAR for weight loss and wounds. Review of the clinical records revealed no documented evidence that a supplement was previously ordered for this resident despite being underweight. A pressure ulcer dressing change observation was done on March 18, 2015, with the wound nurse. The soiled dressings were removed and the following wound measurements were noted: left heel- 0.4 cm. by 0.8cm. with a large periwound area macerated; right heel-0.3 cm. by 0.6 cm., with a large periwound area macerated. The wound care was provided as ordered by the physician. (An observation was made prior to the dressing change of the resident sitting in her wheelchair wearing non-skid socks, with both heels resting on the foot supports of the wheelchair.) An interview was conducted with the wound nurse on March 18, 2015. The wound nurse stated that this resident's pressure ulcers were acquired in the facility, and the resident had a wedge cushion for her legs to float her heels while in bed was added to the care plan after the resident's pressure ulcers were found. She also stated that the resident now has heel protector boots as she is no longer ambulatory. The wound nurse further stated that the resident had a pressure relieving mattress in place prior to her pressure ulcers on her bilateral heels, but no other interventions were in place at the time. The wound nurse also stated that the resident does not have any foot protection when in her wheelchair, other than her non-skid socks. An interview was conducted with the DON on March 18, 2015. The DON stated that this resident was not given an air mattress due to being a fall risk and had fallen multiple times. The DON also stated that the resident was able to turn herself at the time the pressure ulcers were found, but she is not able to turn herself now. The DON further stated that all residents are placed on a pressure relieving mattress at the time of admission. Review of the facility's policy on Pressure Ulcer Prevention and Care revealed .A resident who enters the center without pressure ulcers and/or other non-pressure ulcers do not develop pressure ulcers.The center provides care and services to promote the prevention of pressure ulcer development. Promote the healing of pressure ulcers that are present.Prevent development of additional pressure ulcers.Implement individualized interventions to attempt to stabilize, reduce or remove underlying risk factors.Monitor pressure ulcer and document observations of the pressure ulcer's condition on a daily basis including pain and discomfort.Assess pressure ulcer at least weekly for effectiveness of treatment and other pressure ulcer reduction/prevention interventions until pressure ulcer is documented as healed.If a resident's pressure ulcer doesn't show signs of healing within two weeks, consult with the physician for alternative treatment and document in resident medical record. -Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's clinical record revealed a care plan dated October 8, 2014 with a focus which was Potential for impaired skin integrity related to decline in functional ADL's (activities of daily living), incontinence, dementia, and debility. An intervention documented was Assess (resident's name) skin weekly and as needed. A review of the resident's clinical record revealed a Braden Scale for Predicting Pressure Sore Risk dated October 8, 2014 which revealed that the resident's score was a 19 and that the resident was not at risk for developing pressure sores. The resident's clinical record revealed a Braden Scale for Predicting Pressure Sore Risk dated October 15, 2014 which revealed that the resident's score was a 22 and that the resident was not at risk for developing pressure sores. The resident's clinical record revealed a Braden Scale for Predicting Pressure Sore Risk dated October 22, 2014 which revealed that the resident's score was a 15 and that the resident was now at risk for developing pressure sores. A review of a Significant Change MDS (Minimum Data Set) assessment dated [DATE] revealed that the resident had a stage 2 pressure ulcer (coccyx) which was present on admission. Review of a Weekly Skin Check dated December 22, 2014 revealed that the resident's buttocks was red and blanchable and that the resident had a left heel callous. A Weekly Skin Check dated January 5, 2015 documented Redness to buttocks, but area is blanchable. Callous to left heel. A review of the resident's clinical record revealed no evidence that a Weekly Skin Check was completed on January 12 and 19, 2015 A review of a Weekly Pressure Ulcer BWAT (Bates-Jensen Wound Status Tool) dated January 22, 2015 revealed that the resident had a new unstageable pressure ulcer on her right outer ankle which measured 0.8 centimeter by 1 centimeter. Review of the resident's clinical record revealed an Evaluation Summary dated January 22, 2014 which documented Weekly Pressure Ulcer BWAT completed. Site information: Right ankle (outer) - Pressure: Length = 0.8 centimeter, Width = 1 centimeter. Stage: Unstageable. Date of initial observation: 1/22/2015. BWAT score = 34.0. Denies pain. Wound with black eschar, peri wound red and blanchable. No exudate, odor, or signs and symptoms of infection present. BWAT is a wound assessment tool with the higher the score, the more severe the wound status. A score of 1 is tissue health and a score of 60 is wound degeneration. A Weekly Skin Check dated January 23, 2015 revealed that the resident had a new pressure sore to her right outer ankle. An interview was conducted with an RN (registered nurse), wound nurse on March 17, 2015. The RN stated that the resident's pressure sore to her right outer ankle was acquired at the facility and that it was unstageable when first observed. The RN stated that the pressure sore came up out of no where. The RN stated that she was on vacation in January 2014. The RN further stated that Weekly Skin Checks should have been completed on January 12 and 19, 2015 but they were not done. An interview was conducted with the DON (director of nursing) on March 17, 2015. The DON stated that skin assessments should be done weekly but they were not completed on January 12 and 19, 2015. A review of the facility's policy Prevention and treatment of [REDACTED]. - Resident #18 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's Weekly Skin Check dated February 8, 2015, indicated a reddened area to groin and buttocks only. Review of the Admission Minimum Data Set (MDS) dated [DATE] for Functional Status notes that the assessment for bed mobility for the resident was extensive assistance with some resident involvement in the activity but two plus person assistance was needed. For transfers again the resident was assessed as an extensive assist with one person physical assistance. Review of the resident's clinical record revealed a Braden Scale for predicting pressure sore risk dated February 9, 2015, was scored a 20 or not at risk. Review of the Weekly Skin Check dated February 14, 2015, commented that the left buttock was excoriated. A new Braden Scale was done on February 15, 2015 and the resident scored a 19 which is still not at risk. Comprehensive care plan was completed on February 16, 2015 for actual impaired skin which just stated apply skin care treatments as ordered and assess resident's skin weekly and as needed (PRN). Good pericare with each episode of incontinence. Pressure reducing air mattress to bed. Review of the Shower Sheet dated February 20, 2015 described that the resident's buttocks was red only. The Weekly Skin Check dated February 21, 2015 commented that the excoriation of the buttocks has improved. A new Braden Scale dated February 22, 2015 was done with the result of 18 or the resident was at risk. The February 24, 2015 Shower Sheet indicates the resident had refused his shower on this date. The next shower day on the 27 th of February indicates no skin problems at all. However the Weekly Skin Check dated February 27, 2015 contradicts the shower sheet by documenting that the coccyx area is reddened and excoriated. A new Braden Scale was done on March 1, 2015 and scored a 17 or at risk. A review of a Weekly Pressure Ulcer BWAT (Bates-Jensen Wound Status Tool) dated March 1, 2015 noted a change in condition that a suspected deep tissue injury that measured 5.6 x 6 centimeters (cm) was found on the residents sacrum. It indicated that the first time it was observed was March 1, 2015. The wound was described as purple and irregularly shaped. Shearing noted to the center of the wound. Doctor was notified and orders received to treat wound with Hydrogel and cover with a foam dressing, which was later that same day changed to [MEDICATION NAME] and cover with foam dressing every day. A review of the resident's comprehensive care plan dated March 1, 2015 noted that it had been updated to include; assess for pain prior to and during treatments and administer pain medication as ordered. Also to encourage the resident to stay off back when in bed. This was the first time that positioning in bed was mentioned in the resident's care plan. Review of the Weekly Skin Check dated March 6, 2015 reported that the sacrum wound has now been staged as an unstageable pressure ulcer to sacrum and described as covered with soft black eschar. A new Weekly Pressure Ulcer BWAT dated March 8, 2015 noted the the unstageable sacrum pressure ulcer now measured 5.5 cm x 5.5 cm and that it was irregularly shaped and purple in color. The document also notes that there is no complaints of pain during treatment. Review of the Weekly Skin Check dated March 10, 2015 notes that sacral pressure ulcer remains but also excoriation of bilateral buttocks. Review of the Weekly Pressure Ulcer BWAT Report dated March 10, 2015 reports that the sacral pressure ulcer measurements remain at 5.2 x 5.5 cm but shape is now round or oval and the wound bed is 100% eschar. The review of the Weekly Pressure ulcer BWAT Report describes the sacral pressure ulcer size as 5.5 x 5.6 cm. The appearance is round or oval with the wound bed with soft yellow and black eschar. Treatment evaluation recommends that the treatment continue, however it says that resident can turn himself in bed but continues to prefer to lie on his back. At this date the resident is educated in the importance of turning and repositioning while in bed. This is first documentation that staff has attempted to educate positioning importance to the resident. An observation of wound dressing change was conducted on March 18, 2018 at 8:00 a.m. with the facility wound nurse. Resident on entry to the room was in bed lying in a supine position. The wound nurse requested he turn and he was able to slowly turn on his left side so she could provide the wound treatment. The old dressing was removed and wound cleaned with normal saline and patted dry, hands were washed and new gloves applied. Wound nurse then pointed out the yellow and black eschar in the oval shaped wound. She then applied [MEDICATION NAME] to the wound bed and covered the wound with foam dressing.The resident then rolled back to his starting position on his back as he was first observed. An observation was made again on March 18, 2015 at 10:15 a.m. and resident was seen in bed lying in the same position he was at 8:00 a.m. An Interview was conducted with the Unit 100 nurse and she said that the resident prefers to stay in bed and she said that on occasion the resident does reposition but he prefers to remain on his back. When asked if the resident is turned every two hours she said a certified nursing assistant (CNA) would have to be asked to answer that question. An interview with a CNA was conducted on March 18, 2015, who was working on the 100 Hall Unit. She said that she did not know if the resident was on a turning schedule every two hours but would check with someone. She returned with the Director of Nurses and she answered by saying the CNAs are trained to do two hour rounds with the residents and those that are in bed at this time are to be repositioned every two hours. Review of the facility policy and procedures for Prevention and treatment of [REDACTED]. reduce pressure, friction and shear 1) repositioning at intervals determined per patients risk level and condition. Initiate a therapeutic support surface as indicated.

Based on clinical record reviews, observations, staff interviews, and review of facility policies and procedures, the facility failed to provide care and services in order to prevent the development of pressure ulcers for two residents (#95 and 134). The sample size was 3. Findings include: -Resident #95 was admitted on [DATE], with [DIAGNOSES REDACTED]. A Braden Scale for Predicting Pressure Ulcer Risk dated February 8, assessed the resident to be at risk for the development of pressure ulcers. Per a nursing evaluation dated February 8, 2014, the resident did not have a pressure ulcer; however, a notation in the comment section included the resident had redness on the coccyx. No measurements were documented. A nursing note dated February 8, 2014, also documented the resident had redness on the coccyx. A nursing note dated February 9, 2014, documented that the resident was incontinent of bowel and bladder and required assistance of two staff for bed mobility. Review of the clinical record revealed there was no evidence that the reddened area on the coccyx was assessed on February 9. Despite that the resident was assessed to be at risk for pressure ulcer development and had redness to the coccyx, there was no evidence that a care plan had been developed, nor were preventative measures implemented to prevent further breakdown. Per a nursing note dated February 10, 2014, the resident had a Deep Tissue Injury (DTI) on the coccyx , which measured 3.5 centimeters (cm) x 4 cm. Physician's orders dated February 10, 2014, included there was a "strict need" for the resident to be repositioned/turned in bed every 1-2 hours, due to a DTI to the sacral area. The February 2014 TAR included the order for the strict need for the resident to be turned every 1-2 hours. This order was noted on the MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED]. Instead, there were three shifts for each day for staff to initial that the resident was turned. On February 11, 2014, a skin inspection form documented that there was bruising on the sacrum and the treatment was to turn the resident every 2 hours. According to a skin inspection form dated February 12, the resident had a dark purple area on the coccyx that was now documented as an unstageable pressure ulcer. On February 13, 2014, a nursing note documented there was a purple area on the coccyx, with skin peeling. The area was cleansed with normal saline and covered with a foam dressing. Further noted was that the wound nurse was to assess the area. A care plan was now developed on February 13, 2014, five days after admission. The care plan identified actual skin impairment related to a stage 2 pressure ulcer on the coccyx, despite documentation the day prior that the pressure ulcer was unstageable. Per the care plan, the resident was at risk for further breakdown, due to a decline in functional mobility, weakness, and incontinence of bowel and bladder. A goal included that the pressure ulcer would exhibit signs of healing, as evidenced by a decrease in size, improved appearance, and be free from signs and symptoms of infection. Interventions included to identify and document potential causative factors and eliminate and resolve where possible, and to turn the resident every 1-2 hours when in bed. On February 14, 2014, there was conflicting data in two different nursing note entries related to the size of the pressure ulcer. One entry noted the pressure ulcer on the coccyx measured 1.5 cm x 1.0 cm and the wound was decreasing in size and the skin was "sloughing" to a stage 2. The other nursing note dated February 14, documented a stage 2 pressure ulcer to the coccyx, which was from a previous DTI that was healing. The wound was described as having a shallow wound bed, with minimal drainage. The wound measured 2 cm x 1.5 cm. Physician's orders dated February 14, 2014, included to cleanse the coccyx with wound cleanser, apply [MEDICATION NAME], and a foam dressing daily. A Braden Scale dated February 15, now assessed the resident to be at high risk for pressure ulcer development. The section of the Braden Scale related to friction and shear reflected that the resident required moderate to maximum assistance in moving and frequently slides down in bed and chair, and required frequent repositioning. Review of the Weekly Pressure Ulcer Report dated February 21, 2014, revealed the coccyx pressure ulcer was unstageable. The measurements were 4.0 cm x 1.0 cm. The wound bed was described as shallow, with loosely adherent yellow slough obscuring the wound bed, and the edges were pink and granulating. There was no clinical record documentation that the physician was notified of the deterioration of the coccyx pressure ulcer at this time. A physician's order was obtained seven days later on February 28, 2014. The change in wound treatment included for Santyl ointment (debridement agent) and to increase the dressing changes from once daily to twice daily. A Weekly Pressure Ulcer Report dated March 1, 2014, documented the coccyx pressure ulcer was unstageable. The wound measured 3.5 cm x 1.0 cm. The wound bed was covered with loose gray slough. Per this note, Santyl was added and the treatments were increased to twice a day, due to incontinence. A nursing note entry dated March 7, 2014, documented the pressure ulcer was unstageable. The wound measured 3.5 cm x 1.3 cm x 1 cm. The wound bed was described as having loose yellow slough that covered an area of 2 cm x 0.5 cm. On March 9, 2014, physician orders documented a change in treatment as follows: wound cleanser, [MEDICATION NAME]/Santyl mix and pack with nugauze, cover with alginate and dry dressing. Change twice a day and as necessary. According to the Weekly Pressure Ulcer Report dated March 14, the wound measured 3 cm x 1.5 cm x 1 cm, wound bed was no longer obscured by slough and was beefy red, and that undermining less than 2 cm was present. Further review of the skin integrity care plan revealed a revision date of March 22, 2014. However, there was no evidence that the care plan was revised to reflect the deterioration of the pressure ulcer, nor any additional interventions that were implemented. According to the wound documentation, the pressure ulcer continued to be assessed weekly. Review of the Weekly Pressure Ulcer Report doted April 19, 2014, revealed the wound measured 1.5 cm x 0.4 cm x 0.3 cm, with undermining present that was less than 2 cm in any area, and the wound bed was beefy red. An observation of the pressure wound treatment was conducted on April 22, 2014 at 4:30 p.m., with a Registered Nurse (RN). The pressure ulcer measured 1.0 cm x 0.5 cm, with granulation present and minimal tunneling. The RN stated the pressure ulcer was a stage 3 and was improving. Multiple interviews were conducted with the Director of Nursing (DON) on April 23, 24, 30, and May 1, 2014. Regarding the physician's order for strict repositioning of the resident every 1-2 hours, she stated the licensed staff was to make sure that the repositioning was actually being done and then documenting it on the TAR. She stated that shortly after admission there appeared to be confusion with the proper identification of the pressure ulcer. The DON further stated that the admitting nurses were responsible for initiating care plans to identify problems and provide appropriate interventions. She stated there had been no care plan developed upon admission for the resident. She acknowledged that the care plan was not revised, as the pressure ulcer declined. -Resident #134 was admitted on [DATE], with [DIAGNOSES REDACTED]. Per a nursing evaluation form dated January 24, 2014, the resident was noted to have a surgical incision on the right knee, however, did not have any pressure ulcers. A Braden Scale for Predicting Pressure Ulcer Risk dated January 24, 2014, revealed a score of 19, which indicated the resident was not at risk for the development of pressure ulcers. According to the skin inspection diagram dated January 25, 2014, the resident's skin was normal, with no open areas. A physician's order dated January 27, 2014, included that the resident was to be turned every 2 hours, due to a large purple area on the sacrum. Review of the January 2014 TAR revealed the order for the resident to be turned every 2 hours, due to a purple area on the coccyx. However, there was no corresponding block of hours to reflect a timeframe of every 2 hours for staff to indicate that this was done. Instead, there were only three shifts for each day for staff to initial that the resident was turned. Per the TAR, there was no documentation this was done on January 31, on the evening shift. Despite the identification of a purple area to the coccyx and the physician's order for repositioning every 2 hours, a care plan was not developed, nor were additional interventions implemented to help prevent further breakdown. Review of the clinical record revealed there was no further documentation regarding any assessments of the purple area to the coccyx through February 15. Skin documentation dated February 16, included the resident now had a new onset of a stage 2 pressure ulcer on the coccyx. No measurements were documented. Physician's orders dated February 16, 2014, documented to cleanse the open area to the coccyx with wound cleanser, apply [MEDICATION NAME], and cover with a foam dressing daily and as needed. According to the Weekly Pressure Ulcer Report dated February 22, 2014, the stage 2 pressure ulcer measured 0.5 cm x 0.5 cm and was beefy red, with granulation tissue. Further review of the February 2014 TAR revealed the order to turn the resident every 2 hours due to the purple area on the coccyx. However, from February 6 through 21, there were multiple shifts with no documentation that this was done. In addition, there was no documentation the resident was turned from February 21 through 28, as there was a hand written note that read "new order 2/16." Clinical record documentation revealed there was no physician's order to discontinue turning the resident every 2 hours. Continued review of the February TAR revealed the orders to cleanse the open area to the coccyx with wound cleanser, apply [MEDICATION NAME], and cover with a foam dressing daily and as needed. The treatment was noted to be initiated on February 16. However, there was no evidence that the treatment was provided on February 17, 18, 19, 20, or 26. The Weekly Pressure Ulcer Report dated February 28, 2014, included the stage 2 pressure ulcer measured 0.3 x 0.2 cm and that the wound bed was nearly healed. According to the March 2014 TAR, the order to turn the resident every 2 hours was included. On the MAR, there were two hour increments to document that the resident was turned. However, the two hour time frames were crossed off and only three shifts were noted. From March 2 through 6, there were multiple shifts with no documentation that the resident was turned as ordered. Clinical record documentation showed that the resident was discharged home on March 6, 2014. An interview was conducted with the DON on May 1, 2014. She stated there was no care plan that had been developed upon admission to identify any problem areas and potential interventions to be implemented. She also stated that if there were no licensed staff initials on the TAR for the treatments, that would mean that the treatment was not administered. A facility policy regarding pressure ulcers included the following: Pressure ulcer prevention interventions are initiated based on the Braden scale and Norton risk factors identified initially and ongoing. Pressure ulcer and other wound and skin related interventions are created in collaboration with the interdisciplinary team and implemented in order to identify, prevent or reduce the risk of acquiring pressure related wounds. treatment of [REDACTED].