Every finding on record at Heritage Nursing and Rehabilitation Community

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 03/15/2026 at 8:55AM, observed in the residents' refrigerator, an open container of [NAME] Thickened Water (no flavor), without an open date, or a facility provided use by date. When asked who is responsible for dating the foods in the residents' refrigerator, Dietary [NAME] (DC) N said the [NAME] thickened water should have had a date on it, and that nursing staff is responsible for dating product used for med-pass, and resident's food. The container was discarded by DC N. On 03/15/2026 at 8:57AM, observed in the walk-in cooler, open container [NAME] Ready Care Cranberry Cocktail that did not have an open date or a use by date. On 03/15/2026 at 8:58AM, observed the following in the walk-in cooler: beef barely soup with a preparation date of 3/9 and use by date of 3/12, egg salad with a preparation date of 3/9 and use by date of 3/13. On 03/15/2026 at 9:00AM, when asked what the policy or procedure is for date marking of time, temperature controlled for safety (TCS) food to include how long the food was routinely held for; DC N responded each dietary staff member date marks food using their individual method and there is no specific written procedure on how to date food for holding. On 03/15/2026 at 10:15AM requested a copy of datemarking policy from the Certified Dietary Manager (CDM) O. On 03/15/2026 at 11:35AM CDM O provided copies of the following policies: Refrigerated Leftover Storage, Dry Storage Chart, Refrigerated Storage Chart and Freezer Storage Chart. On 03/15/2026 review of Refrigerated Leftover Storage policy, lists egg-based entrees, salads, side dishes or desserts as Do Not Save, broth-based gravies or soups have a 1 to 3 Day Storage. Review of the Refrigerated Storage Chart does not directly address hold times for the egg salad or beef barley soup as the policy in general covers unopened and opened containers of manufacturers packaged products. On 03/15/2026 at 1:40PM, interview with CDM O provided the following information, the egg salad and beef barley soup were dated incorrectly by dietary staff and should have been date marked with a seven-day use by date, and that CDM O is responsible for removing expired items from the refrigerator. According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROLFOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety .

Based on interview and record review, the facility failed to fully implement the employee illness surveillance practices when reviewed for infection control. Findings:During an interview on 3/17/26 at 10:05 AM the following information was reported by the Infection Control Preventionist/Director of Nursing (ICP/DON): (a) employee call-ins that were illness related were placed on the Employee Illness Tracking Log (EITL), (b) when shown the most recent EITL, the last employee call-in was dated 1/2/26, (c) when asked if there had been any call-ins that were illness related and required tracking in February and March of this year, ICP/DON stated that there had been none, (d) the ICP/DON stated that employee call-in forms were generated by the staff person that took the phone call and the form was given to employee H to be filed, (e) and the ICP/DON then stated that she receives a copy of the employee call in forms and decides which should be listed on the EITL based on symptoms reported at the time of the call-in. Review of employee call-in forms revealed the following: (a) on 3/16/26 Licensed Practical Nurse (LPN) J called in sick to work and reported vomiting, the employee call-in was not placed on the EITL (employee illness tracking log) for further monitoring and tracking, (b) on 2/09/26 Certified Nurse Aide (CNA) L called in sick to work and no explanation for the call-in nor a description of an illness was listed on the employee call in form, (c) CNA L called in sick on 2/03/26 and 2/04/26 with symptoms of vomiting and diarrhea and the employee call in was not placed on the EITL for further monitoring and tracking, and (d) LPN K called in sick to work on 1/06/26 and reported cramps, bloating, diarrhea, and GI (gastrointestinal) virus. The call-in was not placed on the EITL for further monitoring and tracking. Review of the facility policy Employee Illness Surveillance Practices, last reviewed 01/2025, reflected: The facility shall have a process in place for identifying, tracking signs and symptoms and controlling the spread of employee illness .(3) in the event an employee calls in due to illness it will be recorded on the Employee Call In Form. Illness symptoms will be recorded on the form and reported to the Infection Control Preventionist (ICP/DON). (4) In addition to the Employee Call In Form, the employee illness will also be tracked on the EITL. The purpose of this is to provide real time tracking of illness to be control the spread. (5) Employee illnesses will be reported to the ICP/DON to determine necessary actions needed to contain and control the spread of illness. (6) Some actions that may be necessary to control the spread of illness are additional cleaning of areas last worked by an ill employee, additional monitoring of resident(s) that could be affected by the illness and physician notification.

Based on observation, interview, and record review, the facility failed to safely transfer one resident (Resident #28) out of three residents reviewed for accidents and hazards.Findings:Resident #28 (R28)Review of a Face Sheet revealed R28 was an [AGE] year-old female with pertinent diagnoses of morbid obesity, cognitive communication deficit, weakness, unsteadiness on feet, need for assistance with personal care, and reduced mobility. Review of a Care Plan for R28 reflected the following safety interventions: (a) status of toileting/elimination needs-assist x2 staff persons and (b) status of transfers-assist x2 staff persons with sit-to-stand lift. During an observation on 3/15/26 at 12:00 PM, R28 sat on the toilet with a sit-to-stand lift in front of her, and with the call light on. Certified Nurse Aide (CNA) F entered the room alone, used the mechanical sit to stand lift to lift R28 off the toilet, did not secure the middle safety strap, and transferred the resident to the chair. During an observation and interview on 3/16/26 at 1:31 PM, R28 sat on the toilet with a sit to stand lift in front of her, and the call light on. CNA E and CNA D entered the room to assist the resident. During an interview at the same time, CNA E indicated that all residents who utilize a sit to stand lift must have 2 staff persons for the transfer to be done safely. During an interview on 3/16/25 at 1:55 PM, Certified Occupational Therapy Assistant (COTA) I stated that all transfers made with mechanical lifts require 2 staff persons for safety reasons. During an interview on 3/17/26 at 8:21 AM, R28 stated that sometimes only one staff person will transfer her off the toilet with the sit to stand lift.

Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food in the kitchen. Findings include: During an initial tour of the kitchen on 2/19/2025 beginning at 9:45 AM, it was observed that the handwashing sink next to the dish machine was obscured with a gallon size container of an unknown chemical. Further observation found a large, sealed, zippered plastic bag in the walk-in cooler containing scrambled eggs that had been served at breakfast. The bag was found warm to the touch. During an interview on 2/19/2025 at 10:00 AM, Dietary Manager (DM) L reported foods that are cooled for reuse are documented on a cooling log. There was no documentation pertaining to the leftover foods that had been discovered in the walk-in cooler. The leftover scrambled eggs were retrieved from the walk-in cooler and an analog temperature probe indicated the eggs were 100 degrees Fahrenheit. DM L reported cooling had started at 9:15 AM at 135 degrees Fahrenheit. It was noted at this time there was a plastic zippered bag containing sausage links. The sausage links temperature was 50 degrees Fahrenheit. DM L said the sausage links also began cooling at 9:15 AM at 135 degrees Fahrenheit. DM L then added the leftover eggs and sausage to a cooling log. According to the 2022 FDA Food Code section 3-501.15 Cooling Methods. (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under S 3-501.14 by using one or more of the following methods based on the type of FOOD being cooled: . (2) Loosely covered, or uncovered if protected from overhead contamination as specified under Subparagraph 3-305.11(A)(2), during the cooling period to facilitate heat transfer from the surface of the FOOD. During an observation and interview on 2/18/25 at 10:15 AM, DM L said the facility had a low temperature dish machine. A cycle was run, and chemical sanitizer concentration was measured with a test strip indicating the chemical concentration was 100 ppm (parts per million). DM L said the dish machine had to reach 120 degrees Fahrenheit. The temperature gauge outside of the machine did not indicate the cycle reached 120 degrees as required. The surveyor requested the water temperature be manually measured. The temperature was approximately 105 degrees. When asked, DM L reported the analog thermometer probes are calibrated monthly. DM L prepared ice water to calibrate two thermometers. Each thermometer required calibration from 40 degrees to 32 degrees and indicated a high likelihood food temperature measured before the breakfast meal were not accurate. The dish machine water was again temped. The wash cycle was 90 degrees, and the rinse cycle was 100 degrees. Review of a Dish Machine Temperature Log for February 2025 specified Check and record temperatures and test strip results before washing dishes. Plz (sic) notify yur (sic) Director/Manager with any identified issues. NOTE: For low temperature machines, if sanitize is less than 50 ppm or if the temperature is less than 120 degrees Fahrenheit or above 150 degrees Fahrenheit, Plz (sic) notify your director. The log reflected the rinse cycle did not meet the minimum required 120 degrees during the breakfast service every day except 2/2/25, 2/3/25 and 2/8/25. The rinse cycle did not reach 120 degrees during the lunch service on any day except 2/3/25. The rinse cycle did not meet the required 120-degree rinse during the dinner service on 2/15/25, 2/16/25 or 2/17/25. According to the 2022 FDA Food Code section 4-501.15 Warewashing Machines, Manufacturers' Operating Instructions. (A) A WAREWASHING machine and its auxiliary components shall be operated in accordance with the machine's data plate and other manufacturer's instructions. (B) A WAREWASHING machine's conveyor speed or automatic cycle times shall be maintained accurately timed in accordance with manufacturer's specifications. 38905 During a follow up tour of the kitchen, at 9:32 AM on 2/19/25, an interview with DM L found that staff cool down food frequently. Review of the facility log entitled Cooling Down Foods - Tracking Chart, contained items that cooled down between 2/2/25 and 2/10. The log states the foods need to cool from 135F to 70F within two hours and from 70F to 41F in four hours. A review of the log found Chicken Gravy cooled on 2/2/25 went from 135F at 1:00 PM to 76F at 3:00 PM, Chicken and Rice soup on 2/4 started cooling at 135F at 2:00 PM and was documented at 81F two hours later at 4:00 PM. When asked if these items were served to residents after improperly cooling, DM L was unsure. According to the 2017 FDA Food Code section 3-501.14 Cooling. (A) Cooked TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled: (1) Within 2 hours from 57 C (135 F) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less . During a follow up tour of the kitchen, at 9:40 AM on 2/19/2025, observation of the tabletop mixer found increased accumulation of brown dried debris on the underside arm of the unit and in and around nuts / bolts on the surface. Follow up observation of sheet pans and one saucepan, at 10:06 AM on 2/19/25, found that the surfaces of equipment had increased amount of encrusted black grease deposits. Accumulation was evident on the sides and corners of the pans. An interview with [NAME] J found that she tries hard to scrub the surfaces, but some don't come clean. According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. During a follow up tour of the dry storage room, at 10:20 AM on 2/19/25, it was observed that an open container of Teriyaki marinade was found on the dry storage shelf. A review of the manufacture label found that the item states Refrigerate After Opening. According to the 2022 FDA Food Code section 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57C (135F) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54C (130F) or above; or (2) At 5C (41F) or less.

Based on interview and record review, the facility failed to honor Advanced Directives for 1 resident (R2) out of 2 residents reviewed for Advanced Directives and ensure that the competent resident made their own Medical Treatment Decisions. Findings: Review of a Designation of Patient Advocate and Direction for Health Care (Durable Power of Attorney for Health Care) for (R2) dated 10/20/2020 reflected R2 appointed a Patient Advocate and Successor Patient Advocate(s). The document specified My Patient Advocate or Successor Patient Advocate may act only if I am unable to participate in making decisions regarding my medical, or as applicable, mental health treatment. Review of an admission Minimum Data Set (MDS) dated [DATE] indicated R2 admitted to the facility on [DATE] and was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13/15 and did not exhibit problematic behavior or reject care. Review of a Medical Treatment Decisions of Resident dated 12/20/2022 reflected I have been informed in writing, in language that I understand, of my rights and all rules and regulations to make decisions concerning medical care, including the right to accept or refuse treatment and the right to formulate and to issue Advanced Directives to be followed if I become incapacitated. In the absence of an advanced directive I understand that any and all life sustaining measures may be used. I may revoke any and all of my decisions at any time. The form was signed by the patient advocate R2 specified could only act on their behalf when they were unable to participate in making decisions regarding medical and mental health treatment decisions. Review of a Do-Not-Resuscitate Order dated 12/21/22, included sections pertaining to consent: Declarant Consent (a person or party who makes a formal declaration) that included a space for the Declarant's signature as well as a line for Signature of person who signed for Declarant if applicable. The section pertaining to Patient Advocate Consent was signed by the patient advocate R2 specified could only act on their behalf when they were unable to participate in making decisions regarding medical and mental health treatment decisions. Review of a Decision Making Capacity Determination reflected R2 was evaluated by 2 physicians and . Determined to lack capacity to make reasoned medical decisions . An individual, a de facto surrogate, resident advocate or durable power of attorney, will have the ability to make decisions on their behalf. The determination was effective as of the date the second physician signed the form on 2/27/2023, two months after R2 admitted to the facility. During an interview on 2/20/2025 at 9:57 AM, the Social Services (SS) staff F confirmed R2 had not been deemed incapacitated at the time the Medical Treatment Decisions of Resident form or Do-Not-Resuscitate Order were completed.

Based on observation, interview, and record review, the facility failed to ensure medications were administered following nursing professional standards of practice, for 3 of 8 residents (R35, R11, and R30), resulting in medication errors and the withholding of medications without a physician order. Findings: Resident # 35 (R35) Review of an Admission Record revealed R35 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included type 2 diabetes mellitus. Review of R35's Order Summary dated 2/6/25 revealed, insulin aspart U-100 insulin pen; 100 unit/mL (3 mL); Amount to Administer: 3 units; subcutaneous; Before Meals. There were no parameters ordered to hold the insulin if the blood sugar was below a specific level. Review of R35's February Medication Administration Record revealed: *On 2/15/25 at 11:00 AM R35's aspart insulin was Not Administered: On Hold Comment: BS (blood sugar) 89. *On 2/17/25 at 11:00 AM R35's aspart insulin was Not Administered: Other Comment: glucose 75. Review of R35's Electronic Medical Record revealed no documentation that the licensed nurse received an order to hold the ordered insulin or that the provider was notified that the insulin was not administered. Resident # 11 (R11) Review of an Admission Record revealed R11 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included diabetes. Review of R11's Order Summary dated 8/28/24 revealed, Lantus Solostar U-100 Insulin (insulin glargine) insulin pen; 100 unit/mL (3 mL); Amount to Administer: 30 units; Subcutaneous; Once A Day. Review of R11's January Medication Administration Record revealed: *On 1/20/25 R11 was administered 15 Units of Lantus. *On 1/28/25 R11 was administered 15 Units of Lantus. Review of R11's Electronic Medical Record revealed no documentation that the provider had ordered a decreased dose of R11's Lantus on 1/20/25 or 1/28/25 or a rationale for the documentation/administration of 15 units of Lantus instead of the ordered 30 units of Lantus. 29073 Resident #30 (R30) Review of an Admission Record revealed R30 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included hypertension (high blood pressure). Review of R30's Order Summary dated 2/9/24 revealed, metoprolol succinate tablet extended release 24 hr; 25 mg; Amount to Administer: 1 tablet; oral; Once A Day. There were no parameters ordered to hold the metoprolol if the blood pressure was below a specific level. Review of R30's January Medication Administration Record revealed that on 1/11/25 R30's metoprolol was Not Administered: Other Comment: outside parameters. Review of R30's Electronic Medical Record revealed no documentation that the provider had ordered the metoprolol to be held or that the provider was notified that the metoprolol had not been administered. During an observation on 2/19/25 at 8:57 AM, Registered Nurse (RN) A prepared medications for R30, including metoprolol succinate extended release 24 hr; 25 mg (milligram); Amount to Administer: 1 tablet; oral; Once a Day. RN A measured R30's blood pressure which was 126/51. RN A withheld R30's metoprolol, destroying it in a drug buster. When asked, RN A said she thought there were parameters to hold R30's metoprolol. RN A reviewed R30's order for the metoprolol and confirmed there were no parameters to hold the drug. RN A said there used to be parameters. Review of Resident Progress Notes dated 2/19/25 did not reflect RN A contacted the physician to inform them R30's ordered metoprolol had been held and/or that the order was clarified to include parameters. During an interview on 2/20/25 at 8:15 AM, the Director of Nursing (DON) confirmed that R35's aspart insulin did not have parameters to hold if the blood sugar was below a specific level at the time the medication was held. The DON reported that a new order was received to include blood sugar parameters. The DON reported confirmed R11's Lantus was documented as 15 units administered and not the ordered 30 units. The DON reported that she spoke with the nurse that administered the insulin, and the nurse reported she mixed them up with a different resident and it was a documentation error. The DON was unable to provide documentation ensuring R11 received the correct dose of Lantus. The DON confirmed there were no ordered parameters for R30's metoprolol and reported licensed nurses were not to make medication decisions (such as holding a medication) without first discussing or notifying the provider.

Based on interview and record review, the facility failed to administer and accurately document administration of controlled substances for 3 of 6 residents (Resident #17, #16, and #239) reviewed for the administration of controlled medications, resulting in the potential for ineffective management of pain and the potential for diversion of controlled drugs. Resident #17 (R17) Review of an Admission Record revealed R17 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: anxiety, spinal stenosis, and severe osteopenia. Review of R17's Order Summary dated 7/20/24 revealed, hydrocodone-acetaminophen (Norco) tablet; 5-325 mg; Twice A Day to be administered between 06:00 AM-10:00 AM and 04:00 PM-07:00 PM Review of R17's Controlled Substances Proof of Use form revealed that on 2/15/25 R17's Norco was documented as being removed/administered 1 time at 8:00 AM. R17's evening dose of Norco was not documented as being administered. Review of R17's Medication Administration Record revealed R17's Norco was documented as administered 2 times on 2/15/25. Review of R17's Order Summary dated 9/28/24 revealed, lorazepam (Ativan) tablet; 0.5 mg; Amount to Administer: 1/2 tablet; oral Once A Day takes 1/2 tablet of 0.5mg =0.25mg. Review of R17's Controlled Substances Proof of Use form revealed that on 2/15/25 R17's dose of Ativan was not documented as being removed/administered. Review of R17's Medication Administration Record revealed R17's Ativan was documented as being administered on 2/15/25. Review of R17's Electronic Medical Record revealed no documentation and/or rationale for the withholding of R17's Norco or Ativan on 2/15/25. Resident #16 (R16) Review of an Admission Record revealed R16 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: a history of pelvic and rib fractures. Review of R16's Order Summary dated 1/21/25 revealed, oxycodone tablet; 5 mg; Amount to Administer: 1 tab; oral Every 6 Hours - PRN (as needed). Review of R16's Controlled Substances Proof of Use form revealed R16's oxycodone was documented as being pulled/administered on the following dates and time: *1/24/25 at 11:23 AM *1/25/25 at 9:00 PM *1/26/25 at 3:00 PM *1/26/25 at 9:00 PM *1/27/25 at 9:00 PM *1/30/25 at 7:45 PM *1/31/25 at 9:00 PM *2/14/25 at 8:00 PM Review of R16's Medication Administration Record revealed R16's oxycodone was not documented as being administered on the above listed dates. Resident #239 (R239) Review of an Admission Record revealed R239 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: Review of R239's Order Summary dated 2/3/25 revealed, oxycodone tablet; 5 mg; Amount to Administer: 1 tab; oral Every 6 Hours - PRN (as needed). Review of R239's Controlled Substances Proof of Use form revealed R239's oxycodone was documented as being pulled/administered on 2/7/25 at 6:00 PM and on 2/8/25 at 3:15 AM. Review of R239's Medication Administration Record revealed R239's oxycodone was not documented as being administered on 2/7/25 or 2/8/25. During an interview on 2/20/25 at 8:15 AM, Director of Nursing (DON) confirmed the medication/documentation errors for R17, R16, and R239's controlled drug medications and reported licensed nurses are to document in the Medication Administration Record when a controlled drug is administered at the time it is administered. DON reported a medication error report would be completed for the withholding of R17's Norco and Ativan on 2/15/25. Review of the facility policy Controlled Substances Standards of Practice updated 09/2022 revealed, .Once the nurse completes the administration, then the nurse is to document on the MAR (Medication Administration Record) paper record or E-Mar electronic record. If PRN (as needed) medication is administered, additional documentation regarding reason, result, time and initials are required .Director of Nursing or Licensed Designee will conduct reviews in addition to above to ensure compliance in monitoring and be alert to any potential errors in accuracy .

This citation pertains to intake # MI00146937 Based on interview and record review the facility failed to 1.) involve residents/resident representative in the medication management process and 2.) evaluate and track progress and/or decline towards the gradual dose reduction of a psychotropic medication for 2 of 5 residents (Resident #4 and #24) reviewed for psychotropic medication use. Findings: Resident #4 (R4) Review of an Admission Record revealed R4 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: Dementia with unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety and major depressive disorder. R4 had a DPOA (Durable Power of Attorney) in place and did not make her own decisions. During an interview on 02/19/25 at 11:41 AM, DPOA G reported that R4 had been on Paxil (antidepressant) for approximately [AGE] years and was the medication used to treat her wild mood swings throughout the years. DPOA G reported that the facility staff notified him that R4's Paxil was to be reduced as part of a Gradual Dose Reduction (GDR) required by the State. DPOA G reported he didn't want them to (reduce R4's Paxil) because that was what worked with her for [AGE] years. DPOA G reported that because of the GDR of Paxil R4 had been swatting at other patients and they (facility) lost control (of her aggression/behaviors). During an interview on 02/20/2025 at 10:00 AM, Social Services (SS) F reported that the Behavior Management Team consisted of herself, the pharmacist, the facility provider, and a psychiatric consultant. SS F stated that if a resident didn't have a qualifying diagnosis of schizophrenia or bipolar (disorder) or if the resident didn't have qualifying documentation, we have to at some time attempt a GDR.SS F reiterated that a GDR attempt was required to be made on any psychotropic medications. During an interview on 02/20/2025 at 10:22 AM, Medical Doctor (MD) H reported that a GDR was attempted on psychotropic medications if a resident's behaviors and mood had been stable. If a GDR was determined to not be in the best interest of a resident a rationale was documented in the residents Electronic Medical Record. MD H reported he would defer to the psychiatric consultant and/or the pharmacist for their recommendations as it was not his area of expertise. During an interview on 02/20/25 at 12:18 PM, SS F reported that the pharmacist recommended the GDR of Paxil and had said it's not a medication that's good for the elderly. SS F reported that R4 had been doing well with the GDR then started having behaviors again. SS F reported that R4 was not followed by the psychiatric consultant. During an interview on 02/20/25 at 1:44 PM, Director of Nursing (DON) stated they had to get her off (of Paxil) per the pharmacist due to the side effects of the medications. Review of R4's Pharmacy Consultation Report dated 7/18/24 revealed the pharmacist recommended a decrease in R4's Paxil from 20mg once daily down to 10mg once daily. This recommendation was approved by the provider and signed on 7/24/24. A handwritten note at the bottom of the form revealed medication changed and was signed off by the Director of Nursing (DON) on 7/24/24. Review of R4's Order Summary dated 7/22/24 revealed, Paxil (paroxetine hcl) tablet; 10 mg; one tab .GDR per pharmacy recommendation telephone order from PA (physicians assistant) Once A Morning. Review of R4's Electronic Medical Record revealed no documentation that DPOA G had been consulted on further decreasing R4's Paxil and had not been notified of the medication change on 7/22/24. Review of R4's Progress Note dated 7/24/24 revealed, Resident medication change with Paxil from 20mg down to 10mg once daily. No adverse effects noted. Resident exhibiting some behaviors this am. Resident observed raising fist and yelling out at another resident in the dining room. Resident moved to a different table and behavior stopped. Indicating a change in behaviors with aggression towards other vulnerable residents. Review of R4's Progress Note dated 7/25/24 revealed, Aide noted resident to be somewhat aggressive in am when getting up into w/c via sit to stand with 2 assist. Aide reported resident pinching and poking at her breasts. No injuries note from aide. Otherwise, resident sitting in dining room quietly for lunch. Indicating new physically aggressive behaviors. Review of R4's Progress Note dated 7/28/24 revealed, Resident medication change with Paxil from 20mg down to 10mg once daily. No adverse effects noted. Resident exhibiting some behaviors this am. Resident making faces at staff while providing care. Resident unable to sit next to certain resident when in dining room due to getting angry and waving fists when sitting near them. Will continue to note changes. Indicating ongoing aggression towards other residents. Review of R4's Progress Notes revealed the last behavior note was documented on 8/3/24. There was an Activities quarterly assessment completed on 8/9/24 and a Covid progress note completed on 8/23/24. Review of R4's Progress Note dated 8/27/24 revealed, refused to get up this am stated no wouldn't hold onto bars of sit to stand, refused to remain seated upright, spit out am meds at first attempt accepted on second noted glaring at staff, slept most of day resistive to care stiffening up and pushing staff away, noted sticking out tongue and growling at staff. Review of R4's Progress Note dated 9/1/24 revealed, during lunch in dinning (sic) room, kitchen staff overheard another resident yelling stop it stop it. to this resident. this resident became agitated and slapped at other residents right arm striking right forearm/wrist area, on top side with open palm. then this resident began screaming out nonsensically. residents immediately separated with investigation showing no injury to other resident, this resident placed at nurses station where began yelling at staff stating i need it i need it. once tray delivered from dining room resident calmed but continues to glare harshly and pint at staff who removed from dinning room whenever passed saying you you you. for next 10 minutes. This incident was reported to the State Agency due to R4 assaulting another resident. (All incidences of resident to resident abuse are to be reported to the State Agency for review/investigation as all residents have the right to be free from abuse). Review of R4's Progress Note dated 9/15/24 revealed, resident became agitated i dining room when another resident was tearful, and began spitting noises while making face at other resident from across the dinning room . Review of R4's Progress Note dated 9/16/24 revealed, making faces and pointing at other residents at times easily redirected with conversation, combative with AM care, pulling away and slapping with open palm at times. Review of R4's Psychotropic Monthly Review forms revealed no reviews were completed in August 2024 or September 2024. (Confirmed with Nursing Home Administrator via email on 2/20/25 at 3:20 PM.) . Indicating the Behavior Management Team did not evaluate and track progress and/or decline towards the GDR of R4's Paxil since previous GDR on 7/22/24. There was no documentation that the Behavior Management Team reviewed/discussed the increased behaviors/aggression towards staff and residents as documented in the Progress Notes or that the resident to resident abuse, where R4 had been the perpetrator on 9/1/24 was reviewed/discussed. Documentation that R4 failed the Paxil GDR despite the change in behaviors was not reviewed/discussed. Review of R4's Physician Progress Note dated 9/19/24 revealed, .Following up at the request of the nursing and social services to consider discontinuation of the patient's Paxil and start the patient on Zoloft. The nursing staff otherwise do not report any other acute concerns .I have DC'd (discontinued) the patient's Paxil and start the patient on Zoloft 25 mg . Indicating the provider had not been made aware of the increased behaviors/aggression towards staff and residents as documented in the Progress Notes from the previous GDR on 7/22/24. Review of R4's Electronic Medical Record revealed no documentation that DPOA G had been consulted on discontinuing R4's Paxil and had not been notified of the discontinuation on 9/19/24. During an interview on 02/20/25 at 11:31 AM, Consultant Pharmacist (CP) I reported that an attempt to GDR R4's Paxil was made due to the high risk of side effects noted in the geriatric population. CP I reported that medication reviews are completed monthly, and he completes them either remotely or in person. CP I reported that he reviews behavior logs as well as psychiatric consultant notes. If the psychiatric consultant identifies that a GDR of a medication is contraindicated, he follows their lead. If a patient has been stable for a long period of time it indicates that a GDR could be attempted. CP I reported that the recommendation would have been to have go back up on the Paxil if R4 was displaying increased behaviors during the GDR process and the benefits of the medication would have outweighed the risk. CP I reported they could revisit the GDR of Paxil at a later date if she was experiencing side effects from the medication. CP I reported that the GDR process for R4's Paxil revealed she required the medication, and it was restarted on 1/22/25. During an interview on 02/21/25 at 11:40 AM, CP I reported he could not recall if he was notified of R4's resident to resident abuse identified on 9/1/25. Resident #24 (R24) Review of an Admission Record revealed R24 was an [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: Vascular dementia, unspecified severity, with psychotic disturbance, Delirium due to known physiological condition, and Unspecified dementia, unspecified severity, with agitation. R24 had a DPOA in place and did not make his own decisions. Review of R24's Psychiatric Consultation Report dated 1/2/25 revealed, .Patient continues to experience hallucinations per his report approximately twice a week Continue .Depakote ER 500 mg daily . Review of R24's Pharmacy Consultation Report dated 1/2/25 revealed, (R24) has experienced a recent fall in [DATE], and is at moderate to high risk of falls due to medications which may contribute to fall risk .Recommendation: Please consider the following actions to reduce the future risk of falls .2. Trial decrease to depakote ER 250 mg po HS (by mouth at night) . Indicating the depakote GDR was initiated due to a fall and not due to long term stability with behaviors/moods. During an interview on 02/19/25 at 12:00 PM, DPOA E reported that she had not been notified of a GDR for R24's Depakote. DPOA E stated she was told the GDR process was dictated by the state. They have to try to lower it and see if it works. DPOA E stated unless he actually needs to be reduced, I don't prefer that further stating that R24 tends to be unstable and has a lot of hallucinations. DPOA E reported she was not aware that she had a say in the GDR process or that a GDR could be deemed contraindicated if the benefits of the medication outweighed the risks due to his history of aggression and the fact that R24's reductions in the past did not go well. A request was made to Nursing Home Administrator (NHA) for documentation that DPOA E was consulted/notified of an attempt to GDR R24's Depakote on 2/21/25 at 9:42 AM via email. NHA provided an email sent by SS F on 1/15/25 which revealed, Pharmacy gave a recommendation for a trail (sic) GDR (Gradual dose reduction) for (R24's) Depakote, which is his mood stabilizer medication. We have to attempt reductions with all medications, and we have not tried one yet for this medication. (Psychiatric consultant name omitted) that follow's (sic) (R24) is in agreement that we need to trail (sic) a GDR, if it does not go well, then we will put it back. I wanted to update you on this, so we can get this order in and signed by the doctor. This notification email did not include risk versus benefit documentation or the rationale for the initiation of the Depkote GDR. On 2/21/25 at 9:49 AM NHA was asked to provide documentation that DPOA E agreed to R24's Depakote GDR via email. At 2/21/25 at 10:00 AM NHA stated, Unfortunately, (SS F) is unable to find a response email. Confirming DPOA E did not consent to the GDR of R24's Depakote. Review of the facility policy Psychotropic Medication Use last reviewed 01/2024 revealed, .3. Residents and/or representatives will be educated on the risks and benefits of psychotropic medication use, as well as alternative treatments/non-pharmacological interventions. 4. Residents who use psychotropic medications will receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue the medication if possible . 9. The effects of psychotropic medications on residents will be evaluated. This may be through physician evaluation, pharmacist routine medication review, nurse assessments and medication monitoring, and the plan of care 10. The resident response to the medication will be documented in the resident's medical record . Review of the State Operations Manual revealed, When selecting medications and non-pharmacological approaches, members of the IDT, including the resident, his or her family, and/or representative(s), participate in the care process to identify, assess, address, advocate for, monitor, and communicate the resident's needs and changes in condition . o Involvement of the resident, his or her family, and/or the resident representative in the medication management process. o Selection of medications(s) based on assessing relative benefits and risks to the individual resident . o Selection and use of medications in doses and for the duration appropriate to each resident's clinical conditions, age, and underlying causes of symptoms and based on assessing relative benefit and risks to, and preferences and goals of, the individual resident . o Resident Choice -If a resident declines treatment, the facility staff and physician should inform the resident about the risks related to the lack of the medication, and discuss appropriate alternatives such as offering the medication at another time or in another dosage form, or offer an alternative medication or non-pharmacological approach . Track progress and/or decline towards the therapeutic goal .Determining the frequency of monitoring-- The frequency and duration of monitoring needed to identify therapeutic effectiveness, achievement of resident goals, and adverse consequences will depend on factors such as clinical standards of practice, facility policies and procedures, manufacturer's specifications, and the resident's clinical condition and choices .Periodic planned evaluation of progress toward the therapeutic goals.

Based on interview and record review, the facility failed to ensure a complete and accurate medical record for one resident (R29) out of 9 residents reviewed when the physician did not document an assessment or date mark a signature on an assessment of capacity. Findings: Review of a Face Sheet reflected R29 admitted to the facility from a hospital on 1/09/2025 with pertinent diagnoses that included metabolic encephalopathy (a condition where the brain does not function properly due to an underlying metabolic imbalance). Review of an admission Minimum Data Set (MDS) assessment dated [DATE] reflected R29 was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 10/15. Review of a Hospitalist Progress Note dated 1/09/2025 reflected Assessment of capacity-Based on my evaluation of the patient (R29) on the morning of 1/9 patient lacks capacity to make informed decisions regarding complex medical decision making. Patient was interviewed at bedside and is unable to state where she was, current month or year, any underlying/chronic medical conditions or reason she was hospitalized . It is readily apparent that patient lacks capacity for advanced medical decision making and therefore would advise activation of MDPOA (medical durable power of attorney). The assessment was electronically signed by a hospital physician on 1/09/2025 at 1:32 PM EST (eastern standard time). Below the documented assessment, a handwritten X and signature line with the handwritten name of the facility Medical Director (MD) H. MD H signed the line. The signature is not dated and there is not a documented assessment or statement of agreement with the hospital physician's assessment. During an interview on 2/20/2025 at 9:48 AM, MD H was shown the Hospitalist Progress Note. MD H said he had no idea when he signed the document and intended to indicate agreement with the assessment of capacity.

Based on interview and record review, the facility failed explain terms of an Agreement to Resolve Legal Disputes Through Arbitration and ensure the validity of understanding/consent to enter into the agreement was witnessed for one resident's (R29's) Health Care Power of Attorney (HCPOA) out of 3 residents reviewed for Arbitration agreements. Findings: Review of a Face Sheet reflected R29 admitted to the facility from a hospital on 1/09/2025 with pertinent diagnoses that included metabolic encephalopathy (a condition where the brain does not function properly due to an underlying metabolic imbalance). Review of the facility Agreement to Resolve Legal Disputes Through Arbitration reflected This Agreement to Resolve Legal Disputes Through Arbitration (the Agreement) is made and entered into on 1/10/2025 by and between (name of facility) ('name of facility' or the facility), and ________ (Resident) and HCPOA N (Representative), collectively, the Parties. The space reserved for the resident's name was left blank. The Agreement was signed by HCPOA N and the Nursing Home Administrator (NHA) on 1/10/2025. The signature line for a Witness was blank. During an interview on 2/20/2025 at 10:31 AM, HCPOA N was asked if he recalled signing a binding arbitration agreement. According to HCPOA N, he recalled signing the agreement but did not like arbitration in general due to his understanding of arbitration being overall lacking in transparency, preferred arbitrators and the lack of appeal rights. HCPOA reported a family member was an attorney and used to talk about preferred arbitrators often favoring an entity rather than the complainant. HCPOA N was asked if he understood that the agreement meant that any dispute arising from care and/or services provided at the facility could not be heard in a court of law. HCPOA N was also asked if he understood that when he signed the agreement, he had 30 days to inform the facility in writing to cancel the agreement. HCPOA N said he did not understand what he was signing and was overwhelmed with the admission process and that upon review it sounds like a ridiculous arrangement. HCPOA N said he did not know that he could have cancelled the agreement within 30 days of signing the document if he submitted the cancellation request in writing. HCPOA said it was a [NAME] point now, because the 30 days have elapsed. During an interview on 2/21/2025 at 10:45 AM, the NHA reported she was surprised to hear that HCPOA N did not understand the binding arbitration agreement. According to the NHA, she had emailed with HCPOA N about the admission contract which included the binding arbitration agreement. The NHA was asked for the email communication at this time. Review of an e-mail sent by the NHA to the surveyor on 2/21/2025 at 12:08 PM reflected Here is the history of that contract. It states that it was sent to (HCPOA N) email and that he signed and sent it back. Attached to the email was a document labeled (R29's last name) Contract.pdf Review of (R29's last name) Contract.pdf reflected on 1/10/2025 at 11:02 AM, the NHA created an envelope and sent the envelope to herself at 11:04 AM. At 11:05, the NHA opened and viewed the envelope. At 11:10 AM the NHA signed the envelope and sent an invitation to HCPOA N. At 2:31 PM on 1/10/2025, HCPOA N opened and viewed the envelope which contained the following: -Adult Admission.pdf -Admit consent-(name of facility).pdf -Coronavirus (COVID-19) Statement.pdf -NOTICE OF AVAILABILITY OF HOSPICE CAR.pdf -Advanced Directive Information.pdf -Stop and Watch.pdf -Authorization for Professional Services.pdf -Professionals - Contact List - (name of facility).pdf -Resident Authorization & Release for Photographs.pdf -Understanding Regarding Services Provided.pdf -Bed Holds & Leaves of Absence.pdf -Medicare Secondary Payer Questionnaire.pdf -Resident Personal Funds.pdf -NEMB-SNF.pdf -Assignment of Benefits.pdf -Private Pay Methods - (name of facility).pdf -Designation of Medicaid Authorized Representative.pdf -AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION.pdf -PRIVACY ACT STATEMENT.pdf -Bed Rail Authorization.pdf -Sex Offender Verification Form.pdf -Non-Discrimination and Accessibility Notice-(name of facility).pdf -Consent Form for Vaccines in LTC-Residents.pdf -Admission Policy.pdf -Notice of Privacy Practices.pdf -Notice of Acknowledgements.pdf -Authorization Form and Supplier Standards.pdf -Resident Rights.pdf -Resident Handbook.pdf -(name of facility), new arbit.pdf HCPOA N signed the envelope containing 30 attachments, the last of which was the binding arbitration agreement, 13 minutes after he opened it on 1/10/24 at 2:44 PM. HCPOA N would have had 43 seconds to review each attachment, making it highly unlikely the documents were reviewed thrououghly. The signed documents were received by the NHA who immediately sent the documents to the facility Business Office Manager. No evidence additional signing was completed by the NHA, indicating the electronic signature of the NHA on the arbitration agreement was present before HCPOA N was assessed for understanding of the agreement. A follow-up email was sent by the surveyor to the NHA on 2/25/24 at 8:32 AM asking who reviewed any and all of the documents with HCPOA N. The NHA replied via email at 9:17 AM, I had contacted him via phone and asked if he would like to come in. He stated he had crazy hours and asked if it could be sent to him. I discussed with him that I could, but I wanted him to call if he had any questions. I sent it to him and he sent it back. He had my email and the SW (social worker) email. We had seen him after this and he never indicated that he had any questions. He stated he had a family member that was an attorney and so he was familiar with these contracts.

Based on observation, interview, and record review the facility failed to: 1. Ensure proper cooling of potentially hazardous foods; 2. Properly date mark and discard food product; and 3. Ensure cleaning of food and non-food contact surfaces. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 33 residents who consume food from the kitchen. Findings Include: 1. During the initial tour of the walk-in cooler, starting at 9:03 AM on 4/1/24, it was observed that a cooked pork roast was found on the bottom shelf of the walk-in cooler covered and in one solid piece. When asked when the pork roast was cooked, Certified Dietary Manager (CDM) B stated that he cooked and cooled it yesterday. The surveyor and CDM B both took a temperature of the pork roast and found it to be 47F. The surveyor then asked how the item was cooled, CDM B stated that the roast didn't get done cooking until around 7:00 PM and that he left at 7:30 PM. When asked what would need to be done to the pork roast, CDM B stated it needed to be discarded. According to the 2017 FDA Food Code section 3-501.14 Cooling. (A) Cooked TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled: (1) Within 2 hours from 57 C (135 F) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less . According to the 2017 FDA Food Code section 3-501.15 Cooling Methods. (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under S 3-501.14 by using one or more of the following methods based on the type of FOOD being cooled: (1) Placing the FOOD in shallow pans; (2) Separating the FOOD into smaller or thinner portions; (3)Using rapid cooling EQUIPMENT; (4) Stirring the FOOD in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods. (B) When placed in cooling or cold holding EQUIPMENT, FOOD containers in which FOOD is being cooled shall be: .(2) Loosely covered, or uncovered . 2. During the initial tour of the walk-in cooler, at 9:08 AM on 4/1/24, an interview with CDM B found that potentially hazardous foods are held for seven days. The following items were found stored in the walk in cooler: a container of shredded lettuce with a discard date of 3/30, a container of gravy with no date, a container of chicken and rice soup dated 3/19 to 3/25, a container of macaroni bake dated 3/25 to 3/31, a bag of beef steak dated 3/28 to 3/30, a bag with a chunk of beef dated 3/6 to 3/12, a container of red cabbage dated 3/18 to 3/24, and open bags of sliced turkey and sliced ham with no dates. During a tour of the single door cooler, at 9:30 AM on 4/1/24, it was observed that a container of broccoli and cheddar soup was found with no date, when asked when it was made, CDM B stated it was for dinner last night. During a tour of the dining room refrigerator, at 10:29 AM on 4/1/24, the following items were found: a resident container of soup with no date, a container of mashed potatoes from the kitchen with no date, a residents Chinese takeout with no date, two containers of thickened water with no date (manufacturer states good for seven days), a vanilla mighty shake with no date (manufacture states the item is good 14 days from thaw), a jar of peaches dated 2/24 to 3/24. According to the 2017 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety . According to the 2017 FDA Food Code section 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3501.17(A) . 3. During the initial tour of the kitchen, at 9:28 AM on 4/1/24, observation of the glenco single door cooler found an accumulation of black debris inside the top portion of the gasket. During the initial tour of the kitchen, at 9:30 AM on 4/1/24, observation of the tabletop mixer found white splash accumulation on the underside and back arm of the unit. An interview with CDM B found that the mixer had not been used today. According to the 2017 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.

Based on observation, interview, and record review, the facility failed to maintain call lights within sight and reach for 3 of 3 residents reviewed (Resident #27, Resident #138, and Resident #8). Findings: Resident #27 (R27) Review of a Face Sheet revealed R27 was a [AGE] year-old male, last admitted to the facility on [DATE], with pertinent diagnoses of cognition communication deficit, weakness, retention of urine, dementia, seizure disorder, hearing loss, and recent fall with a right femur fracture. During an observation on 04/02/24 at 7:52 AM, R27 sat up in the recliner and the call light laid on the floor on the opposite side of the bed as the resident, out of sight and out of reach. During an observation on 04/02/24 at 9:22 AM, R27 remained sitting in the recliner and the call light laid on the floor on the opposite side of the bed as the resident, out of sight and out of reach. During an observation on 04/02/24 at 3:22 PM, R27 sat awake in bed and the call light laid on the floor to the left of the resident, out of sight and out of reach. Review of a Resident Care Guide last updated 03/27/24 revealed a special alert for R27 clip on call light. Review of a Care Plan for R27 revealed the following staff intervention: call light to be within reach, ensure clip is on the call light and is secure near the resident before leaving the room. Resident #138 (R138) Review of a Face Sheet revealed R138 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses of multiple fractures of ribs on her right side, anxiety disorder, and high blood pressure. During an observation and interview on 04/01/24 at 9:41 AM, R138 sat in her wheelchair with her back to the door and the call light was stretched to the head of the bed out of reach of the resident. R138 indicated that she had returned from an appointment this am that was canceled and was waiting for staff to come help her. I sure would like to just sit in bed for a while. I will just have to wait until someone comes in I guess. Review of a Resident Care Guide revealed R138 was a 1 person staff assist to transfer from her wheelchair to the bed. Resident #8 (R8) Review of a Face Sheet reflected R8 was a [AGE] year-old female, last admitted to the facility on [DATE], with pertinent diagnose of recent (2/29/24) fracture to left upper arm, muscle weakness, anxiety disorder, mood disorder, stiffness in both knee, and chronic pain. During two observations on 04/01/24 at 11:49 AM and again at 12:22 PM, R8 laid in bed resting with eyes closed and the call light sat on the floor near the foot of the bed, out of sight and out of reach of the resident. During an observation on 04/01/24 at 3:19 PM, R8 laid in bed resting with eyes closed and the call light sat coiled up at the foot of the bed under the covers, out of sight and out of reach of the resident. Review of a Care Plan intervention for R8 revealed: call light to be within reach while in bed.

This citation pertains to intake # MI00-143546 Based on interview and record review, the facility failed to provide coordinated quality care for 1 of 3 residents (Resident #35) reviewed, resulting in (a) incorrect transfer status used by staff, (b) inconsistent/conflicting skin assessments, (c) an incorrectly completed baseline care plan that provided little guidance to direct care staff on how to meet the resident's immediate needs, (d) incomplete nursing assessments and documentation, (e) a significant delay in downgrading the residents weight bearing status as ordered, and (f) low blood pressures not reported to the physician. Findings: Resident #35 (R35) Review of a Face Sheet revealed R35 was an [AGE] year-old female, admitted to the facility from the hospital on 03/11/24, with pertinent diagnoses of left femur fracture (due to a fall at home) that was surgically repaired, pain in right shoulder, atrial fibrillation, and diabetes mellitus type 2. Review of a Brief Interview for Mental Status (BIMS) dated 03/16/24, revealed a score of 6/15 which indicated R35 had severe cognitive impairment. Review of a Nurse to Nurse Admission Report (used to gather information prior to the admission when the discharging nurse-(at hospital) speaks to the admitting nurse-(at skilled nursing facility) for R35, indicated the following information: (a) 50% weight bearing, (b) stage 2 (wound) to bottom right cheek, (c) previously straight cathed despite having large (urine) output, still retaining (urine), (d) norco for pain, and (e) transfer status: sit/stand was handwritten in. Review of hospital physical therapy notes for R35 revealed: recommend to discharge to skilled rehab facility with two assist for all mobility and use of non-powered sit to stand device. (staff assist only) Review of hospital occupational therapy notes for R35 reflected: (R35) reported a right shoulder injury and needs active assistance with range of motion (ROM) to place right hand on the grab bar. Review of a Baseline Care Plan (a guide to direct staff in caring for a newly admitted resident for the first 48 hours or until a comprehensive care plan can be created) completed on 03/11/24 by nursing reflected: (a) Resident is being admitted to this facility because: PT/OT (physical therapy/occupational therapy), and fx L hip (fractured left hip) were listed, (b) Diet Orders: was left blank, (c) code status: was left blank, (d) Pressure Sore/Skin at Risk: was left blank, (e) Fall/Safety Risk: was left blank, (f) Fracture/Fractured Hip: was left blank, (g) Services and treatment: surgical cite care was checked but no specific instructions were listed, (h) Activities of Daily Living: all boxes were checked but only preference for bathing was filled in. No care needs, staff interventions, or the amount of assistance needed by staff were listed under ambulation, eating, bed mobility, transfers, going to the bathroom, locomotion, or personal hygiene & dressing. (g) Coordination of care needs: was left blank. The baseline care plan form showed the instructions . completed within the first 48 hours by a Registered Nurse (RN). The signature line showed RN Signature completing Baseline Care Plan was signed and dated by Licensed Practical Nurse (LPN) N. Review of an Admission Assessment for R35, dated 03/11/24 at 6:02 PM, reflected:(a) skin findings of dry, pale and area right butt cheek surgical incision (surgery had been to the left hip) and no specific documentation noted the size, color, or location of the stage 2 wound reported in the nurse to nurse admission report, (b) pain rated at 10/10 and listed gabapentin as the only current treatment for pain, and (c) the bowel/bladder assessment did not mention the urinary retention reported by the hospital nurse in the nurse to nurse admission report. Review of a nursing Progress Note for R35, dated and time stamped 03/11/24 at 10:37 PM, revealed red area noted coccyx between buttocks. No treatment orders for located in the electronic health record (EHR) Review of a Physical Therapy Evaluation dated 03/12/24, revealed the following recommendations made by Physical Therapy Assistant (PTA) K: (a) precautions-50% weight bearing on left lower extremity, (b) to transfer from sitting position to standing position required partial to moderate assistance from staff, and (c) to transfer between the bed and a chair required partial to moderate assistance from staff. The use of a mechanical sit to stand was not recommended by physical therapy. Review of a nursing Progress Note for R35, dated 03/12/24, revealed the following: (a) R35 had intermittent confusion, (b) complained of left hip pain but was unable to rate the pain, and (c) no observed signs of pain were documented by nursing (i.e. wincing, grimacing, tearful etc) nor were any non-pharmacological interventions discussed with the resident. Review of a nursing Progress Note for R35, dated 03/12/24, revealed the following regarding R35: (a) confusion noted in conversation, (b) extensive assist with sit to stand for transfers, (c) very confused this shift, banging TV remote on over-bed table and yelling, (c) unable to verbally express needs to staff, and (d) showed and reminded R35 to use call light. No documentation noted that staff attempted to identify R35's need, i.e. (increased pain, needed to go to the bathroom, needed to be changed etc). Review of a Skin Body Assessment for R35, dated 03/12/24, revealed skin impairment findings of red area coccyx not open, bruising of left outer thigh. No documentation identified the size of the coccyx red area. No documentation refuted, identified, or noted the size, color or location of the stage 2 wound reported in the nurse to nurse admission report. No treatment/monitoring orders put into place. Review of a Physical Therapy Daily Note for R35, dated 03/13/24, reflected the following: R35 demonstrated confusion and is easily distracted requiring maximum verbal cuing, encouragement, and redirection to complete activities. Transfer status listed as partial to moderate assistance from staff. Therapy did not recommend the use of a sit to stand machine. Review of a nursing Progress Note, for R35 dated 03/13/24, indicated: R35 is an extensive assist of 2 staff with sit to stand transfers. Review of a nursing Progress Note, for R35 dated 03/14/24, indicated: R35 is an extensive assist of 2 staff with sit to stand transfers. Review of a nursing Progress Note, for R35 dated 03/16/24, indicated: R35 is an extensive assist of 2 staff with sit to stand transfers. Review of a nursing Progress Note, for R35 dated 03/17/24, indicated: R35 is an extensive assist of 2 staff with sit to stand transfers. Review of a weekly Skin Body Assessment for R35, dated 03/18/24, indicated the only area of skin impairment was bruising to the left hip. The red area coccyx previously identified on 03/11/24 and 03/12/24 was not identified and addressed. Review of a nursing Progress Note, for R35 dated 03/18/24, time stamped at 10:33 AM and written by Licensed Practical Nurse (LPN) M indicated .A&O (alert and oriented) x 2 with some confusion. Admitting DX (diagnoses): surgical repair of L (left) hip fracture after fall. History of anemia, atrial flutter, type 2 diabetes, hyperlipidemia (high cholesterol), and neuropathy. She is an extensive assist of 2 with sit to stand for transfers. She is able to feed herself with set up. Surgical dressings are intact on her hip. She was sitting up in a chair today for a while. No complaints today from her so far. Review of further nursing Progress Notes and specifically a note dated 03/21/24, time stamped 10:20 AM and written by LPN M, revealed the exact same note, word for word, that was noted above and also written by LPN M on 03/18/24. Additionally another nursing progress note written by LPN M on 03/23/24 and time stamped 10:01 AM, contained the exact same word for word note as the above mentioned other two notes, except the last 2 sentences had been dropped. By the date of documentation on the second and third nursing note (03/21/24 and 03/23/24), R35's transfer status had been changed and this was not reflected in the nursing notes. This raised concerns that nursing had in fact not assessed R35 on 03/21/24 and 03/23/24, rather, had instead copy and pasted previous nursing notes. Review of an office note from the orthopedic follow up appointment on 03/18/24, reflected the following change to R35's treatment orders .toe touch weight bearing (ttwb) to left lower extremity. The change was made due to a new fracture, located just below the hardware placed to fix the femur fracture on 03/06/24, noted on an x-ray that was taken in the office at the follow up appointment. There were no nursing progress notes in the EHR that indicated nursing had evaluated R35 upon return from the appointment on 03/18/24 nor that nursing acknowledged the new orders for a change in weight bearing status. Review of an Interdisciplinary Team progress note, for R35 dated 03/19/24 and time stamped 9:47 AM, revealed .resident had an appointment yesterday with orthopedics. Weight bearing status changed to ttwb. Therapy updated. This was the first progress note that mentioned the weight bearing change made on 03/18/24. Review of a Physical Therapy Daily Note, dated 03/19/24, reflected that therapy had been notified of R35's left leg down-graded weight bearing status from 50% to toe touching only. During an interview on 04/03/24 at 8:50 AM, confidential informant L reported being contacted by telephone by the Director of Nursing (DON) on 03/19/24. The DON advised complainant L that R35's weight bearing status had been changed by the orthopedic surgeon on 03/18/24 from 50% weight bearing to toe touching only on the left leg. Complainant L asked the DON why the change had been made and was told I'm not sure. Complainant called the orthopedic surgeons office on 03/19/24 to ascertain why there had been a change to R35's weight bearing status and was advised of the new found fracture. Review of a Director of Nursing (DON) progress note for R35, dated 03/20/24 and time stamped 10:20 AM, reflected: called (orthopedic surgeon office) to clarify weight bearing status. R35 arrived with 50% weight bearing and returned from appointment as ttwb. Left message for return call. Review of a second DON progress note, dated 03/20/24 and time stamped 2:00 PM, revealed: received call back from orthopedic surgeon office. Repeat x-ray showed possible fracture and they want R35 ttwb until next orthopedic appointment. Message provided to therapy. During an interview on 04/03/24 at 8:50 AM, R35's confidential informant L reported the following regarding a visit to the facility the evening of 03/20/24: (a) while visiting R35 needed to go to the bathroom, (b) 1 staff person entered the room and began assisting R35 to get out of bed, (c) confidential informant L stopped the worker and told the staff person that R35 cannot get up and put weight on the left leg, (d) was told by the staff person that R35 could get up and walk to the bathroom, (e) after much insistence, the staff person and confidential informant L went to the desk to speak with the nurse, the nurse checked the book that provides care instructions to staff, and (f) nursing told confidential informant L that R35 was listed as 50% weight bearing on the left leg. Review of a Nursing-Direct Care Staff Services communication form for R35, dated 03/21/24, reflected the following special instructions: (R35) is hoyer lift for all transfers and is toe touch weight bearing (ttwb). Review of a Nursing Progress Note for R35, dated 03/21/24, revealed: R35 complaining of her bottom hurting, checked bottom, small opening between buttocks. TAO (topical antibiotic ointment) applied with dressing. The note did not include a description or size of the wound, nor did it indicate that the physician or DON were notified. Review of a Nursing Progress Note for R35, dated 03/22/24, indicated that an open area on the residents left buttock was found and assessed. Review of a Care Plan for R35, last reviewed/revised on 03/24/24, revealed the following staff interventions regarding R35's ADL (activity of daily living) Functional Status: (a) status of mobility-does not ambulate, start date 3/21/24, (b) status of going to the bathroom-extensive assist x 2 staff persons, start date 03/21/24, and (c) status of transfers: extensive assist x 2 staff persons with sit to stand, start date 03/21/24. R35's Care Plan had not been changed to reflect (a) the new orthopedic surgeon orders obtained on 03/18/24- toe touch weight bearing to left leg and (b) physical therapy instructions for R35 to be a hoyer left transfer, effective 03/21/24. Review of the same Care Plans for R35 revealed that the care plan for at risk for skin breakdown was not initiated until 03/21/24. Review of R35's Electronic Medication Administration Record (Emar) dated 03/01/24 to 03/31/24, reflected one order for wound care that was initiated on 03/22/24: Wound treatment-Left Buttock. An order for care of the coccyx wound identified on 03/11/24 and 03/12/24 could not be located in the Emar. Review of a weekly Skin Body Assessment for R35, dated 03/25/24, revealed .wound to coccyx, hyrocolloid dressing in place, changed every 3 days, fading bruise to left hip with steri strips to incision site. Review of an Emar for R35 dated 03/01/24 to 03/31/24, revealed orders for hydrochlorothiazide 12.5 mg (milligrams) one tab daily and for Diltiazem ER (extended release) 240 mg one tab twice daily. These medications were prescribed for a heart condition. Also ordered were blood pressure (BP) checks (along with other vitals) three times daily (every shift). The following dates revealed low blood pressures or blood pressures carried over from the previous shift and not re-checked. Documentation in the EHR could not be located that indicated that a physician or medical provider was notified of the following low blood pressure (BP) findings . (1) BP and other vitals from 2nd and 3rd shift on 03/12/24 were identical (2) BP from 3rd shift on 03/13/24 was 104/46 (3) BP and other vitals from 2nd and 3rd shift on 03/14/24 were identical (4) BP and other vitals from 1st and 2nd shift on 03/15/24 were identical, BP was 88/51 and vitals were not recorded on 3rd shift (5) BP from first shift on 03/16/24 was 94/64 and vitals from 2nd and 3rd shift were identical (6) BP and other vitals from 1st and 2nd shift on 3/18/24 were identical and the BP recorded on 3rd shift was 90/64 (7) BP and other vitals from 2nd and 3rd shift on 03/19/24 were identical and the BP was 67/55 (8) BP from 1st shift on 03/20/24 was 90/49 and all vitals were identical on 2nd and 3rd shift (9) All vitals from 2nd and 3rd shift on 03/21 were identical (10) Blood pressure from 3rd shift on 03/23 was 74/58 and pulse was 100 (11) All vitals from 2nd and 3rd shift on 03/24/24 were identical During an interview on 04/03/24 at 12:05 PM, Director of Therapy Services O reported the following regarding R35: (a) was initially a 2 person assist, (b) nursing can downgrade transfer status (decide to use a sit to stand machine or hoyer) but they must let therapy know so therapy can accurately assess, (c) therapy was not notified that staff were using a sit to stand machine to transfer R35, and (d) were notified by nursing of the change in weight bearing status to ttwb on 03/19/24 and initiated the order during therapy sessions. Review of a facility policy Pressure Injury Prevention and Care, last revised 02/2024, reflected .pressure injuries will be assessed and documented upon admission, upon discovery, and weekly thereafter. Assessment may include size, location, category/stage, odor (if any), wound edges, peri-wond condition, pain, and treatment order. Physicians and responsible parties will be notified of pressure injury upon identification and with change in status .Initiate treatment in accordance with facility protocols, standing orders, or physician orders .Notify the Director of Nursing. Update the care plan to address area of injury and approaches initiated.

Based on observation, interview, and record review, the facility failed to operationalize policies and procedures to store medications and secure narcotics, per standards of practice for 2 of 2 medication carts and for one resident (Resident #138). Findings include: During an observation and an interview on 4/1/24 at 12:05 PM, a medication cart outside room [ROOM NUMBER] was not locked. All the drawers were easily opened including the narcotic lock box. Upon opening the unlocked narcotic drawer, the lock box inside the drawer did not have the lid locked and the narcotics were readily accessible. The top drawer had 1 unmarked souffle cup with 8 pills and another unmarked souffle cup with 2 pills. Licensed Practical Nurse (LPN) C reported she thought the cart was locked and the narcotic lock box was securely locked. The pre-set meds were for 2 residents who were not ready for their medications. Seven different loose pills sat under the medication blister packs, loose at the bottom of a drawer. Review of a policy titled Storage and Expiration Dating of Medications, Biologicals last revised 8/7/23 revealed: 1. Facility should ensure that only authorized Facility staff, as defined by Facility, should have possession of the keys, access cards, electronic codes, or combinations which open medication storage areas. Authorized staff may include nursing supervisors, charge nurses, licensed nurses, and other personnel authorized to administer medications in compliance with Applicable Law. 2. Facility should ensure that medications and biologicals are stored in an orderly manner in cabinets, drawers, carts, refrigerators/freezers of sufficient size to prevent crowding. 3. General Storage Procedures: 3.1 Facility should store Schedule II - V Controlled Substances, in a separate compartment within the locked medication carts and should have a different key or access device, i.e. 3.1.1 Store all drugs and biologicals in locked compartments, including the storage of Schedule II-V medications in separately locked, permanently affixed compartments, permitting only authorized personnel to have access. 3.3 Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. 37577 During an observation on 04/01/24 at 12:02 PM the west hall medication cart was unlocked and unattended by nursing staff. Resident #138 (R138) Review of a Face Sheet revealed R138 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses of multiple fractures of ribs on the right side. During an observation on 04/01/24 at 9:41 AM, a bottle of Flonase (a prescription medication used to reduce inflammation in the nasal passages) sat on R138's bedside table. During an observation on 04/02/24 at 8:23 AM, a bottle of Flonase sat on R138's bedside table. During an observation on 04/03/24 at 3:58 PM, a bottle of Flonase sat on R138's bedside table. Review of R138's electronic medication administration record (Emar), dated for the month of April 2024, did not contain an order for Flonase. Further review of the electronic health record (EHR) did not show an order for self administration of medications. During an interview on 04/03/24 at 4:20 PM, the regional nurse consultant C stated that medications are not to be sitting out in a residents room regardless of whether or not they have an assessment to self-administer medications. All medications should be stored and secured in a medication cart.

Based on observation, interview and record review, the facility failed to notify the physician for 1 (Resident #9) of 1 resident reviewed for physician notifications when her insulin was not available and not given. Findings include: Resident #9 (R9) Review of a Face Sheet revealed R9 has a diagnosis of type II diabetes. During an observation and an interview on 4/1/24 at 12:05 PM, an empty insulin glargine pen was in the top drawer of the medication cart for R9. Licensed Practical Nurse (LPN) C reported the insulin pen was there to remind her to order a new one for R9 because there was none in the back up storage. LPN C reported the resident did not get her insulin that morning and was going to call the pharmacy to have them send it as soon as possible. Review of the Medication Administration Record (MAR) on 4/2/24 for R9 revealed on 4/1/24, she did not receive her 30 units of insulin glargine subcutaneous injection as ordered between 7:00 AM and 11:00 AM because the drug was not available. Review of the Nursing Progress Notes for R9 revealed no documentation that the physician was notified of her insulin not being available and not receiving the ordered dose. In an interview on 4/3/24 at 8:00 AM, Registered Nurse (RN) I reported that she assisted LPN C the other day (4/1/24) when R9 did not have any insulin available to give her. There was not any in the back up stock either. RN I reported she did not call the physician and only assisted LPN C with communicating with the pharmacy to get the insulin. LPN C was not at the facility this day.

Based on observation, interview and record review, the facility failed to monitor and assess equipment in the facility to ensure proper working condition, resulting in a shower chair breaking and one resident (Resident #19) hitting her head, out of 5 residents reviewed for accidents and hazards. Findings include: Resident #19 (R19) Review of the Minimum Data Set (MDS) dated [DATE] revealed R19 required partial/moderate assistance for showers. During an observation on 4/3/24 at 9:00 AM, R19 was in the dining room when EMS (Emergency Medical Services) arrived to take her to the hospital. Registered Nurse (RN) J reported R19 fell in the shower room when the shower chair broke, and R19 hit her head. R19 had a goose egg on her head and reported blurry vision this morning. Staff are sending the resident to the hospital to get checked out. In an interview on 4/3/24 at 9:20 AM, Certified Nursing Assistant (CNA) G reported she had R19 in an oversized shower chair in the shower room and when CNA G pushed the chair into the shower the chair collapsed, R19 slid to the floor and hit her head on the entry doorway to the shower. During an observation and an interview on 4/3/24 at 9:44 AM, the Maintenance Director (MD) F had the broken shower chair in his office and the left back leg of the chair had a crack where the wheel broke off from the plastic. Above the crack was a hose clamp securing a joint, with evidence of purple pvc glue at the joint. MD F reported he had only been at the facility for 6 weeks and thinks the shower chair just got brittle and broke. The hose clamp was put there from the previous Maintenance Director and felt the chair should have been replaced at that time. MD F did not have a routine maintenance log for shower chairs, mechanical lifts, wheelchairs, beds, or any other patient care equipment. MD F reported the shower chairs should have a tag on them to indicate weight limits from the manufacturer. The broken shower chair did not have such tag. In an interview on 4/3/24 at 11:14 AM, the Nursing Home Administrator (NHA) reported the previous maintenance guy did have a maintenance log and a person from another facility was putting it together. She is not sure where it is now. Review of an Equipment Policy with no date revealed: It is the policy of this facility to maintain all essential mechanical, electrical, and patient care equipment in safe operation condition. 5. All facility equipment will be inspected at a minimum, on monthly basis or more frequently if indicated by manufacture guidelines and documented on the Equipment Inventory Log Form by Department (Form 3.3.1)

Based on observation, interview, and record review the facility failed to: 1. Upkeep general cleaning in the walk-in coolers; 2. Thoroughly clean food contact surfaces; 3. Ensure proper concentration of in use sanitizer; and 4. Maintain plumbing in good repair. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 34 residents who consume food from the kitchen. Findings Include: 1. During a tour of the kitchen, at 9:14 AM on 5/24/22, it was observed that an accumulation of dirt and debris, box and paper trash, as well as staining from spills, were found underneath racks in the walk-in cooler and freezer. When asked how often these areas should get swept out, Regional Dietician (RD) C, stated daily. According to the 2013 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions. (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. 2. During a tour of the kitchen, at 9:23 AM on 5/24/22, it was observed that the expediting rack in the single door Glenco cooler, was found to have an accumulation of spotted debris on portions of the rack where sheet pans were to be placed and stored. During a tour of the kitchen, at 9:25 AM on 5/24/22, an interview with Regional Dietary Manager (RDM) B, found that the facilities meat slicer has not been in use for awhile, as they have been purchasing pre-sliced deli meats. When asked if the slicer was clean, RDM B stated that she asked a staff member to clean the piece of equipment the day before. Observation of the slicer found a large amount of accumulation of dried food debris behind the blade of the unit that continued around the circumference of the back portion of the blade. During a tour of the kitchen, at 9:34 AM on 5/24/22, it was found that an increased amount of food crumbs was observed in the back of the clean utensil drawers on the cook line. During a tour of the kitchen. at 9:38 AM on 5/24/22, it was found that an accumulation of sticky staining debris was evident on the underside of the juice dispenser. When asked if she could see the accumulation, RDM B stated, Yes. During a tour of the dining room, at 10:11 AM on 5/24/22, it was observed that the spout of the ice machine was coated in white scale accumulation. During a revisit to the kitchen, at 12:05 PM on 5/24/22, it was observed that thermometers were being stored in a plastic tub on a shelf across from the cook line. The plastic tub was observed dirty with smears on the outside of the tub and an accumulation of debris inside the tub. According to the 2013 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 3. During a tour of the kitchen, at 9:42 AM on 5/24/22, it was observed that two spray bottles of quaternary ammonium were found in the chemical closet of the kitchen. When asked what concentration the facility looks for in quaternary ammonium sanitizer, RDM stated 200 parts per million (ppm). It was noted that the color of the solution was similar to the color of quaternary ammonium concentrate, which should be mixed heavily with water to achieve a proper concentration of 150 -400 ppm. At this time, the surveyor used the facilities QT-40 Hydrion test strips to find the concentration of the two spray bottles. After following manufactures instructions for testing, it was observed that the sanitizer bottles were well over the 500 ppm maximum reading on the test strips. According to the 2013 FDA Food Code section 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization Temperature, pH, Concentration, and Hardness. A chemical SANITIZER used in a SANITIZING solution for a manual or mechanical operation at contact times specified under 4-703.11(C) shall meet the criteria specified under §7-204.11 Sanitizers, Criteria, shall be used in accordance with the EPA-registered label use instructions, and shall be used as follows: .(C) A quaternary ammonium compound solution shall: (1) Have a minimum temperature of 24C (75F), (2) Have a concentration as specified under § 7-204.11 and as indicated by the manufacturer's use directions included in the labeling . According to the 2013 FDA Food Code section 7-204.11 Sanitizers, Criteria. Chemical SANITIZERS, including chemical sanitizing solutions generated on-site, and other chemical antimicrobials applied to FOOD-CONTACT SURFACEs shall: (A) Meet the requirements specified in 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (Food-contact surface sanitizing solutions), or (B) Meet the requirements as specified in 40 CFR 180.2020 Pesticide Chemicals Not Requiring a Tolerance or Exemption from Tolerance-Non-food determinations. 4. During a tour of the kitchen, at 9:25 AM on 5/24/22, it was observed that a strong sewer gas smell was emanating from the corner of the preparation areas of the kitchen. Observation under the preparation area found that a garbage grinder was once installed under the sink but has since been taken out and removed. The drain for the garbage grinder, however, was sitting open and exposed coming out of the wall of the kitchen. When asked if she could feel air coming out of the drain, RDM B stated that she could feel air when she placed her hand near the pipe. According to the 2013 FDA Food Code section 5-205.15 System Maintained in Good Repair. A PLUMBING SYSTEM shall be: (A) Repaired according to LAW; and (B) Maintained in good repair.

This citation pertains to intake MI 469 Based on observation, interview, and record review, the facility failed to honor food preferences for 2 residents (R#5 and R#7) and residents in a confidential group meeting, resulting in residents not receiving their food preferences and being dissatisfied with the dining experience. Findings include: Findings: During a confidential group meeting on 05/25/22 at 11:28 AM, 10 out of 10 residents in the meeting reported that there was not a lot of variety when it came to the menu. 2 residents reported that they often had to have meals with noodles and often had mashed potatoes for dinner. 1 resident reported that when eating in the dining room, her table was not served at the same time. The resident reported that she would receive her food, and by the time she finished her meal, her tablemate would just be receiving her plate of food. 1 resident reported that she would like to have an alternative offered to her prior to receiving her meal. The resident reported that they get what they get and are not offered anything else until after. 6 out of 10 residents reported that the food was cold by the time they received their meals. Resident #5 (R5) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R5 admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS) reflected a score of 14 out of 15 which represents R5 was cognitively intact. During an interview on 5/24/22 at approximately 9:44 AM, R5 stated that she does not know what will be served at each meal until it arrives on her tray. R5 states the menus are not posted as far as she knows. During an observation on 5/25/22 at approximately 10:05 AM, the Todays Menu board in the hall nearest the dining room had a holder to display what was being served for breakfast, lunch, and dinner. The holder was empty and did not reflect what the menu offered to eat each meal. Resident #7 (R7) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R7 admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS) reflected a score of 14 out of 15 which represents R7 was cognitively intact. During an interview on 5/24/22 at approximately 11:31 AM, R7 stated that she does not choose what is on her meal trays and does not know what will be served until it arrives to her. R7 stated that if you don't care for it you can ask for a substitute and wait for it to come. During an interview with Regional Dietician (RD) C, at 9:30 AM on 5/24/22, it was found that the plate warmer works on and off. In an interview with RD C, at 10:05 AM on 5/24/22, it was found that the facilities Certified Dietary Manager left awhile back, and the regional dietician that oversaw this facility, left last week. During an interview with RD C, at 10:08 AM on 5/24/22, it was found that likes and dislikes are not being tracked on resident meal tickets and she was unsure if the daily meal menus have been getting posted. An interview with Cook H, at 12:04 PM on 5/24/22, asked what the alternate meal choice was today besides the chicken. Cook H stated that there was only the main today because the kitchen was short staffed. During an interview with RD C, at 12:10 PM on 5/24/22, when asked how residents make meal choices, it was stated that no one is currently doing preferences or likes (and dislikes). It was found that the facility does supply some residents with a cold sandwich if they don't prefer the meal for that service. At this time, observation of the drink tray found four milks and the rest of the drinks were red juice. A temperature of the plates were taken at this time (with an infrared thermometer) and were found to be between 85F-88F. It was noted that the lunch meal was supposed to be Teriyaki chicken, and ended up being regular chicken with little to no seasoning found. An interview with the NHA, at 3:55 PM on 5/24/22, found that the kitchen is fully staffed, but has been hit this week with three dietary staff out due to injury, scheduled time off, and one staff that recently quit.

This citation pertains to intake number MI 8469 Based on observation and interview the facility failed to ensure residents were treated with dignity when staff did not protect and value residents' private space and knock on doors and request permission before entering resident rooms, resulting in feelings of frustration and diminished quality of life. Findings: During an observation and confidential interview with Resident #16 on 5/23/22 at 11:12 AM, the Director of Nursing (DON) walked into R16's room without knocking or asking for permission to enter in order to stock supplies into R16's cupboards. When asked, the DON said she did not need anything from R16 or the surveyor before leaving the room. During an observation on 5/23/22 at 1:09 PM, Housekeeper V entered room [ROOM NUMBER], room [ROOM NUMBER], then across the hall to room [ROOM NUMBER] without knocking or announcing herself or obtaining consent to enter the rooms. Housekeeper V exited room [ROOM NUMBER], returning a few minutes later with cleaning supplies and again entered the room without knocking or obtaining consent to enter the room. During a confidential group meeting on 05/25/22 at 11:28 AM, 10 out of 10 residents in the meeting reported that facility staff did not honor resident privacy by knocking on their room door prior to entering. The residents reported that if the facility staff did knock, they did not wait for a response from the resident prior to entering the resident room. The residents reported they would like to have a warning prior to staff walking in, would like staff to announce themselves and allow time for an answer.

Based on interview and record review, the facility failed to ensure Licensed Nurses were immediately available (24 hours a day) and certified to perform Cardiopulmonary Resuscitation (CPR) when needed, resulting in the potential for a delay in emergency basic life support, including CPR, to residents requiring emergency care prior to the arrival of emergency medical personnel, and subject to accepted professional guidelines, the resident's advanced directives, and physician orders. Findings: Review of a policy Cardiopulmonary Resuscitation last reviewed ,d+[DATE] reflected The purpose of this policy and procedure is to ensure the facility is able to and does provide emergency basic life support immediately when needed, including cardiopulmonary resuscitation (CPR), to any resident requiring such care prior to the arrival of emergency medical personnel in accordance with residents physician orders, such as DNR/Full Code, and the residents advanced directives. The policy specified Licensed nurses providing direct resident care including supervision and or delegation responsibilities will have a current and valid CPR certification from American Heart Association for healthcare providers upon hire. The facility will track and monitor licensed nurse CPR certification annually with nurse licensure tracking. There is no Grace period for expired CPR certification; nurses will be removed from the schedule until they obtain a current healthcare provider CPR certification. Review of an employee file for Licensed Practical Nurse (LPN) P reflected an invalid CPR certification. Review of the employee file for Registered Nurse (RN) A did not reflect evidence of CPR certification. On [DATE] at approximately 3:00 PM, proof of all licensed nurse CPR certification was requested from the Regional Director of Operations (RDO) O. During an interview and record review on [DATE] at 4:12 PM, RDO O provided documentation located in 7 licensed nurse employee files related to CPR certification. Of the 7 records provided, only three licensed nurses had current and valid CPR certification. RDO O was not able to locate a record for RN A and reported that she asked RN A for proof of CPR certification and RN A reported she was pretty sure her CPR certification had expired. During a follow-up interview on [DATE] at 9:08 AM, RDO O reported she did not have any additional proof of licensed nurse CPR certification than was provided on [DATE]. RDO O reported she completed an audit of 11 licensed nurses and only 4 of the 11 licensed nurses had current, valid CPR certification.

This citation pertains to intake M 1878 and M 3755 Based on observation, interview, and record review, the facility failed to implement best infection control practices in the facility for 4 residents (Resident #12, Resident #14, Resident #17 and Resident #19), 2 treatment carts, and the environment, resulting compromised wound care, maggots in a wound, wound cultures not addressed by a physician, opened wound dressings and supplies stored in soiled and unsanitary treatment carts, dirty commodes shared between residents and then stored in the soiled utility, dirty ceiling fans, and dirty bedside tables and resident rooms. Findings include: Resident #12 (R12) Review of a Face Sheet revealed R12 admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) dated [DATE] revealed R12 is moderately cognitively impaired and requires extensive assistance of one staff for transfers. In an interview on 11/5/21 at 11:00 a.m., Family Member (FM) L reported she has visited R12 and found the commode in her room had been used but not cleaned or sanitized after it had been used. FM L reported she had concerns that the commodes were being used between residents because the commode is not always in R12s room. The room had a strong ammonia smell that was just awful. The sheets are dirty and changed. One day FM L visited R12, and her mattress was soaked and had a strong urine smell. She reported the staff cleaned it and put another covering over it when she brought it to their attention. FM L reported staff will provide incontinence care for R12 and drop the dirty and soiled brief on the floor that is carpeted and cannot be easily cleaned. During an observation on 11/9/21 at 10:44 a.m., R12 was in room [ROOM NUMBER] and needed to be toileted. Certified Nursing Assistant (CNA) C entered R12's room to assist and a commode was sitting in the middle of the room between R12 and her roommate. The commode bucket had excrements sitting inside. CNA C emptied the contents of the commode into the bathroom toilet and proceeded to toilet R12 via commode. CNA C removed R12s soiled brief and dropped the brief on the carpeted floor while cleaning her up. CNA C reported R12 is the only resident in the room who uses the commode. When R12 was done toileting, the CNA picked up the brief and tossed it in the trash then emptied the commode bucket in the bathroom. CNA C took the commode down the hall to the soiled utility room. The CNA reported he took the commode to the soiled utility so the commode could be disinfected. The CNA was not sure why a dirty commode was left in R12s room and not cleaned. R12s room was messy and dirty in appearance, the bedside tables for her and her roommate were dirty and had a sticky debris substance on them. R12s roommate had a pillow on the floor laying across the heat register, a Hoyer sling on the floor, socks across the floor, a positioning device laying on the floor, her bedside mattress that was laying on the floor next to her bed had a large container of water laying on it and an opened bag of donuts laying on her bedside table. The bathroom ceiling fan had a thick layer of dust/debris on it. During an observation and an interview on 11/10/21 at 7:50 a.m., CNA F was observed taking a commode out of room [ROOM NUMBER] with bodily excrements in the bucket of it and a full trash bag sitting on the top of it. The CNA rolled the commode down the hall to the soiled utility room and reported that is where she empties and cleanses the commodes. Inside the soiled utility room is a hopper where she emptied the bucket of the commode and put the dirty bucket back on the commode. She said there are usually bleach wipes in the room to clean the commodes, but none were available in the soiled utility room at this time. She left the room and came back with some bleach wipes and wiped the seat of the commode first then the handrails with the same wipe. When she was finished, I asked about the bucket being cleaned and she said they just rinse that with water. CNA F then took the bucket back off the commode and rinsed it with water from the hopper and placed it back on the commode. CNA F reported the commode is now ready for the next person to use if needed. The soiled utility room had several dirty items stored in it including large trash bins with red bags indicating biohazards are disposed of there, along with other large trash bins. There was other equipment considered to be dirty or contaminated in this room. The hopper was in the back corner of this small room behind the trash bins. CNA F left the room and the commode stayed there. There was another commode sitting in the soiled utility room. During an observation and an interview on 11/10/21 at 1:50 p.m., CNA F and CNA G were in room [ROOM NUMBER] when R12s roommate was observed sitting on the commode. CNA G reported they just toiled R12 first using that commode and the cleaned it so her roommate could use it. When they were done toileting R12s roommate, the CNAs placed the commode in the bathroom and reported they cleaned it. During an observation on 11/10/21 at 2:09 p.m., the commode in room [ROOM NUMBER] was in the bathroom and the bucket was empty with remnants of wet excrements in it and the toilet had urine drops on the seat. The bathroom is conjoined with the room next door. During an observation and an interview on 11/12/21 at 8:25 a.m., in R12s room, the commode was dirty and placed between R12 and her roommate. CNA H reported only R12 uses the commode but when her roommate uses the commode, she uses a different one. During an observation on 11/12/21 at 8:27 a.m., another CNA was observed transporting a commode from another resident's room down the hall to the soiled utility room with a bag of trash and came out of the room empty handed within a couple minutes. During an observation and interview on 11/12/21 at 12:10 p.m., R12s bedside table was dirty, and the sink had opened bottles of toiletries and dried debris around the counter tops. LPN B reported the room should not look like that and started to pick up the room. Resident #14 (R14) Review of a Face Sheet revealed R14 admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Facility Reported Incident (FRI) for R14 revealed on 10/13/21 R14 went to the wound clinic that morning and never came back to the facility. He was admitted to the hospital following a report from the wound clinic indicating R14s wound were extensive, worsening and found maggots in his wounds. In an interview on 11/9/21 at 10:20 a.m., Regional Consultant (RC) A reported R14 had venous stasis ulcers and did not have dressing change done 2 days before going to the wound clinic. The facility had some call ins and the nurses passed off the dressing changes to the next shift, and it kept getting passed off and not changed before going to the wound clinic. When he went to the Wound Clinic, they found maggots in his wound. RC A reported he was not compliant, and it took 1 hour to do dressing changes for him. He was planning to go home on that Friday but instead was admitted to the hospital. Review of the Progress Notes for R14 revealed on 10/1/21 R14 had thick green drainage from both legs toes of left foot are swollen with multiple open weeping areas. new order for culture of bilateral legs . Review of a Progress Noted dated 10/9/21 for R14 revealed dressing change to bilateral legs done large amount of thick green drainage from both legs toes of left foot are swollen with multiple open weeping areas. Resident having increased anxiety today . Review of a Late Entry Progress Note entered on 10/10/21 for 10/5/21 for R14 revealed: Wound culture C&S (culture and sensitivity) faxed (to the wound clinic). No indication the physician was notified. Review of a Progress Note date 10/10/21 for R14 revealed they refaxed the wound culture results to the wound clinic. No indication the physician was notified. Review of the September 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . No documentation indicating the physician was notified of missed dressing changes. Review of the October 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Bilateral Legs and Toes dressings ordered once a day did not happen from 10/11/21 to 10/13/21. No documentation indicating physician notified. Review of a Progress Note from the Wound Care Clinic dated 10/13/21 for R14 revealed: He continues with dressing changes to his toes daily. However, the patient reports that the nursing staff (at the Nursing Facility) has been neglectful over the last 1 week. He states his last dressing change was Saturday or Sunday (3 or 4 days ago) and the wound has been heavily draining. There are now maggots in the left foot wound between his toes. He reports malodor is increasing. The dressings removed today were copiously saturated with serous exudate, very heavy and full. Maggots to the left foot present. Review of the Hospital Records for R14 revealed on 10/13/21 he admitted to hospital after his wound clinic visit. He reports the dressings were last changed on Sunday. The orders are for daily dressing changes. He states he had urged the staff at (Nursing Home) to change the dressings. He denies refusing any wound care. Patient has had increasing drainage, odor over the past few weeks. On 10/1/21 (Nursing Home) told us the drainage had increased and was now green. We called (Nursing Home) on 10/5 and then again on 10/8 with no response on the wound culture results. Discharge/Transfer Documentation: . patient's wounds were examined and found to have maggots that invaded them, debridement and redressing . [CONDITION(S)] continue to improve, wound cultures that were obtained showed growth of Serratia marcescens as well as Pseudomonas aeruginosa (both are bacteria) . R17 Review of a Face Sheet revealed R17 admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Change dressing daily and prn (as needed) for soiling, saturation, accidental removal Review of Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 11/9/21 at 11:20 a.m., Registered Nurse (RN) D did the dressing changes for R17s wounds on her foot. RN D cleansed the first open wound by wetting the gauze with normal saline, dabbed/wiped the wound with the wet gauze several times in an up and downward motion with the potential of introducing surrounding bacteria into the wound. All the wounds were cleaned the same way then dressed as ordered. During an observation on 11/9/21 at 11:47 a.m., RN D had an opened package of [MEDICATION(S)] Alginate Foam dressing package on top of the treatment cart with a small piece of the dressing left inside the package. The package was not labeled or dated with a resident name. RN D placed the opened dressing package back inside the treatment cart. Review of the October Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #19 (R19) Review of a Face Sheet revealed R19 admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation and an interview on 11/12/21 at approximately 9:30 a.m., Licensed Practical Nurse (LPN) B cleansed open wounds on the R19s bilateral lower extremities. LPN B cleansed the wounds by spraying DermaKlens on the open wounds and patted them dry in an up and down motion a few times with the same dry gauze, (a different gauze for each wound) potentially introducing bacteria from the surrounding skin into the wound. LPN B continued with the dressing changes as ordered. LPN B reported she cleansed the wounds as ordered and is to pat them dry before applying the foam dressing. LPN B did not think that infection control concern with this technique. Review of the November 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply Aquacell Ag (alginate) to open wounds, cover with ABD pad, wrap with kerlix, wrap with ace wrap. During an observation and an interview on 11/12/21 at approximately 9:45 a.m., the treatment carts for the East and West Hall were inspected and found several concerns for infection control. These concerns included a gross amount of wound dressing packages not sealed and opened to the elements, not labeled, or dated for designated residents and scattered throughout the carts. Some dressings included but not limited to an opened bottle of [MEDICATION(S)] sterile gauze strips with a piece hanging out of the bottle down the side with the lid on it, impregnated hydrogel gauze opened and used, a calcium alginate opened and used, iodosorb, small rolls of gauze opened to the elements laying in the drawer, xeroform gauze, Provail dressing, and Derma Rite dressings all opened, used, and not sealed or labeled. Several containers of various creams and ointments were used and not dated or labeled which included but not limited to [MEDICATION(S)] cream, [MEDICATION(S)] cream, and Medi honey ointment. One cart had a special irrigation syringe opened and laying in the cart with no identifiers and LPN B reported it was for an acetic acid cleanse for a resident who was no longer getting that treatment. Both carts had dirty sticky debris. LPN J reported the carts should not look like that and the opened dressings should be thrown away as she started to clean the carts at this time. In an interview on 11/12/21 at 1:25 p.m. LPN B, reported she did not see any concerns with how she did R19's dressing change. LPN B reported she cleaned the wounds with DermaKlens wound cleanser and patted the wounds dry per the orders because the foam dressing needed to be applied to a dry area. LPN B denied any concerns of infection control as she patted the wounds dry with gauze in an up and down motion several times with the same gauze (a different gauze per wound). In an interview on 11/16/21 at approximately 3:00 p.m., Regional Consultant (RC) A reported the orders for the wounds on R17 and R19 were to pat the wound dry after cleansing with normal saline. When queried about cleansing the wound with normal saline or DermaKlenz, RC A reported the wound should be cleansed in a circular motion from the inside out and some wounds are ordered to pat dry. When queried about the commodes, RC A reported they just started implementing liners for them and the proper cleaning process needs to be done after a resident uses them. Review of a policy titled Infection Control Program last reviewed 1/2021 revealed: Purposes of Infection Control Program: The major purposes of Infection Control Programs in the nursing facility are to minimize the effects of infections on residents and employees, and to educate the staff. a successful Infection Control Program requires an underlying commitment and facility-wide participation. It should not just be seen as a way to meet paperwork requirements but as a way to analyze and use information effectively to improve care and prevent problems.

Based on observation, interview, and record review, the facility failed to follow CDC guidance and/or appropriate infection control practices resulting in an immediate jeopardy on 4/20/21 when 1)All kitchen staff failed to follow current CDC COVID 19 guidelines, when on 4/20/21 all kitchen staff were observed not wearing masks. All facility staff received infection control re-education on 4/21/21. On 4/22/21 all kitchen staff were observed not wearing masks and a kitchen staff worker (cook) tested positive for COVID 19. The cook reported having cold like symptoms i.e. runny nose, could not taste food, and did not report those symptoms to management nor document those symptoms on sign in screen sheets. (2) Staff observed collecting meal trays from resident rooms with no hand hygiene between rooms. (3) Staff observed on 2 occasions not removing contaminated gloves following peri care, and handing resident items including linens, meal trays, bed controls and doorknobs. (4) Lack of hand hygiene during wound care. (5) Nursing staff observed at the nursing station talking with no masks on. Residents seated near by. This deficient practice has the high likelihood to cause serious harm, serious injury and/or death for all 35 residents who reside at the facility. Findings include: During the start of the initial tour of the kitchen at 9:15 AM on 4/20/21, it was osberved that Certified Dietary Manager (CDM) B and Dietary Aide P were not wearing masks while working in the kitchen area. When asked why she was not wearing a mask, CDM B stated, she didnt need to wear a mask while working in the kitchen. No masks were seen worn by these two staff during the entire intial tour of the kitchen. During lunch observations of the kitchen area, at 11:50 AM on 4/20/21, it was observed that Dietary Aide P was wearing a surgical mask below her nose while placing food plates and drinks onto trays for residents. During an observation on 4/22/21 at 8:15 a.m., 2 residents observed sitting a table together for breakfast in the dining room. An Agency Nurse at the dining table assisted both residents with their meal and no hand hygiene performed before or during assistance with both residents. Dietary Aide (DA) N observed in the dining area without a mask on serving food to residents and reported she is to wear one in the dining room. DA N then went back into the kitchen and grabbed a surgical mask that appeared slightly dingy. When queried about the mask, DA N reported she wore that mask last night. At 8:28 a.m., Certified Nursing Assistant (CNA) I entered the dining room to relieve the nurse from assisting the residents at the table and no hand hygiene noted pre/post resident assistance. A couple more CNAs entered the dining room and staff switched off assisting residents with their breakfast meals and no hand hygiene performed by any staff. During an observation on 04/22/21 at 08:21 A.M., kitchen staff, while working in the kitchen and preparing breakfast, were not wearing masks. During an interview on 04/22/21 at 8:24 A.M., Dietary Manager (DM) B reported that kitchen staff did not need to wear a mask while working in the kitchen, but did need to wear a mask in resident areas of the facility. DM B indicated that sometime at the beginning of the year, a corporate memo was sent out that specified kitchen staff did not need to wear masks. The surveyor asked DM B for a copy of the memo and did not receive one. During an observation on 4/22/21 at 9:03 a.m., CNAs observed collecting breakfast meal trays from rooms and no hand hygiene noted after collecting a dirty tray and placing in the collection cart, then entering another residents' room. During an observation on 04/23/21 at 7:10 A.M., a sign hung on the entry door to the facility that announced that a facility staff person had tested positive for Covid 19 on 04-22-21. During an interview on 04/23/21 at 7:50 A.M., the Administrator reported that full time Dietary Aide (DA) P had tested positive for Covid 19 last evening (4-22-21) via routine bi-weekly employee testing. DA P, after getting back the positive test result, reported having symptoms this past week of a cold, i.e.: a runny nose and could not taste food very well, and did not report those symptoms on the Covid screening sign in sheets and did not report them to DM . Resident #1 (R1) Review of a Face Sheet revealed R1 was a [AGE] year old female, admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 04/21/21 at 7:39 A.M., R1 was assisted to the bathroom by Certified Nurse Aide (CNA) M. CNA with gloves on, wiped R1 after urination. CNA M threw the toilet tissue in the garbage, did not remove the used gloves, and then gathered up linens and dirty clothes, handled clean sheets and made the bed, situated the breakfast tray in front of R1, and exited the room by touching the door handle. Resident #30 (R30) Review of a Face Sheet revealed R30 was a [AGE] year old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R30 was receiving services from Hospice. During an observation on 04/20/21 at 9:20 A.M., Certified Nurse Aide (CNA) L was in R30's room to provide peri-care. CNA L cleaned R30 in the following manner: (a) with one wash cloth, wiped once, down the crease of each thigh, from the iliac crest ( hip bone) to the perineum, did not spread R30's legs for optimal access to the perineum, did not clean R30's labia or inner thighs, (b) turned R30 onto right side, replaced brief, threw soiled brief in the garbage, and put the used gloves in the right front pocket of the scrub top CNA L was wearing. When asked if gloves were re-used, CNA L responded no, and indicated that the soiled gloves were in the gabrage. Gloves were visible in CNA L's front right pocket. CNA L took the bag containing the soiled brief to the dirty utility room and threw the bag into a gray barrel that had a new bag in it. The surveyor, following infection control guidelines, examined the contents of the bag CNA L had thrown in the barrel and found no gloves. CNA L had gone into another resident room and could not be quickly located. Per SA guidance, the incident was reported to the Administrator right away. During an observation on 04/21/21 at 1:29 P.M., CNA L was in R30's room to provide care. CNA L did not don gloves, removed the soiled brief and put it on the floor, and placed a new brief on R30. No peri-care was performed on R30. Review of an In Service Education dated 2/5/21 with the topic of POC (Plan of correction) and General Education for staff revealed an education not pertinent to the facility and staff. One example is COVID Reminders: Education school age children of social distancing (6'), Hand washing and wearing masks when attending classes in school. Ensure items children may share with classmates are thoroughly cleaned after use. One pertinent education is Staff are to wear face shields and face masks while in pt (patient) care areas or providing any care in patient rooms. If you have questions about what type of tasks required the PPE please contact DON/Admin. In an interview on 4/22/21 at approximately 1:00 p.m., the Director of Nursing (DON) reported they did a monthly surveillance for infection control for kitchen and dietary staff, and it is the policy to wear a mask in the kitchen and the dining room. The DON and Regional Nurse Consultant (RC) S reported there was no email at the beginning of the year indicating that dietary staff did not need to wear a mask. Review of the audits revealed very few front line staff were audited for infection control practices and not on a monthly basis. The Immediate Jeopardy was identified on 4/23/21 during initial tour. The immediate jeopardy began on 4/20/21 during initial tour when the cook and kitchen staff were observed in the kitchen with no masks. The Nursing Home Administrator (NHA) was notified of the immediate jeopardy on 4/23/21 at 10:55 a.m. The immediate jeopardy was removed on 4/23/21 at 1:00 p.m. when: 1. 4/22/2021 - all residents were tested using rapid tests and all results were negative. 2. All staff tested (currently 90%) on 4/22 and 4/23/21 have tested negative except for the 1 positive on 4/22/21. 3. 4/22/2021 - Dietary Manager and 1 staff have been educated on mask use at all times while in the facility. These dietary staff have signed documentation to this education. 4. 4/23/2021 - Remaining dietary staff member educated on mask use at all times while in the facility and signed documentation to this education. 5. 4/21/2021 Education began to all facility staff on wearing masks at all times when in the building. 6. 4/22/2021 - Facility implemented Covid action plan following cdc and cms guidelines. 7. 4/22/2021 Verbal notification to staff began on wearing full ppe when going into resident rooms for cares and units supplied with equipment. 8. 4/22/2021 - Entire kitchen was cleaned using bleach solution 600ppm and Quat Sanitizer 200ppm. 9. 4/22/2021 - all staff and residents were notified of positive staff member as well as Health Department and State of Michigan. 10. 4/23/2021 - All responsible parties, guardians and family members are being notified of positive staff member. 11. 4/23/2021 - education began on evening of 4/22/201 and thus far 56% of the staff have been educated on the wearing of masks at all times in the facility. 12. 4/23/2021 - Hand Hygiene education began on 4/23/2021 and will continue until 100% of staff educated. 13. 4/23/2021 - education to begin on screening process for covid to staff until 100% is achieved. 14. 4/23/2021 - audits to begin on staff mask use. 15. 4/23/2021 - audits to begin on handwashing 16. 4/23/2021 - audits to begin on ppe donning and doffing. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 4/23/21 Although the Immediate Jeopardy was removed on 4/23/2021, the facility remained out of compliance with a scope of pattern and severity of No actual harm with the potential for more than minimal harm that is not immediate jeopardy due to sustained compliance not being verified by the state agency.

Based on observation, interview and record review, the facility failed to assess, follow orders, maintain infection control, and prevent pressure ulcers for 2 (Resident #6 and Resident #16), resulting in pressure ulcers. Findings include: Resident #6 Review of a Face Sheet revealed Resident #6 admitted to the facility on [DATE] with pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #6 had a Brief Interview for Mental Status (BIMS) indicating he is cognitively intact and required extensive assistance of 2 for transfers and had limited range in motion on one side for the upper and lower extremity. The resident was at risk for a pressure ulcer but did not have one. During an observation and an interview on 4/21/21 at 10:40 a.m., Licensed Practical Nurse (LPN) G reported Resident #6 had a sore on the side of his foot but did not have a dressing change ordered, then clarified a short time later that the resident did have a dressing change and wound care usually sees the resident on Mondays, but the practitioner is on maternity leave. LPN G reported the practitioner sent the facility information yesterday (4/20/21), upon first day of survey, on all the residents wounds. LPN G went into Resident #6's room with supplies for a dressing change. The supplies were Calcium Alginate (a wound dressing), Dermaklenz (a wound cleanser with zinc) and an unwrapped roll of Kerlix (a rolled woven gauze) taken out of the cart and placed on the uncleaned bedside table. Resident #6 has contractures on his left upper and lower extremities and moaned in pain when the nurse tried to move his legs. LPN G put on gloves with no hand hygiene and started the dressing change on the resident's left foot. The nurse removed the old dressing and wore the same gloves throughout the procedure. The wound was approximately dime sized and necrotic. The nurse cleansed the wound with Dermaklenz, then cut a piece of the put calcium alginate and placed it over the wound, and then wrapped the Kerlix around the dressing. The unused calcium alginate went back into the package. The nurse then removed her gloves and performed hand hygiene. LPN G took her scissors back to the medication cart and cleansed them with alcohol, placed the calcium alginate package and opened Kerlix back into the treatment cart. There were no labels on the supplies to indicate which resident they belonged to. Review of a Nursing Progress note dated 4/14/21 at 1:56 p.m. for Resident #6 revealed: Observed areas on resident's right heel and left outer foot that have scabbed areas with no drainage. Resident tends to lay on his left side related to his CVA and is reluctant to turn on his right side. constantly moves his lower extremities up and down the sheets. Nursing had implemented pillows for positioning long ago with off loading boots however the resident refuses to wear them. States they are too small. Off loading boots were examined and his feet has ample room . Review of orders dated 11/25/20 and discontinued 3/11/21 for Resident #6 revealed: left outer malleolus, clean left outer malleolus with NS (normal saline) and cover with [MEDICATION(S)] (a wound dressing) every other day for protection. Review of the orders for Resident #6 revealed on 4/4/21 a new order for the left lateral foot, to cleanse area with NS (normal saline), apply [MEDICATION(S)] dressing on 3 times weekly, secure with kerlix and apply off loading boots as he will tolerate. Review of the orders for Resident #6 revealed: Left lateral foot- Cleanse with N.S. (normal saline), apply Calcium Alginate and secure dressing with Kerlix and change daily. Ordered 4/13/21. Review of a Skin Assessment for Resident #6 dated 4/4/21 revealed: Right heel has a scabbed area of 2x1 with no drainage. Skin surrounding is very dry. Left outer foot area has a scabbed area with no drainage 1x1. Treatments initiated for both areas. Review of a Skin Integrity Event document for Resident #6 revealed the event date is 4/4/21 and the created date is 4/21/21 (the date of this survey). In house acquired, left lateral foot, stage III, measurements 1x1.5x.01 (cm). Review of a Weekly Pressure Ulcer Progress Report for Resident #6 with an observation date of 4/5/21 and completed date of 4/19/21 revealed: weekly measurement of right posterior heel, in house acquired, pain 2/10, size 1.2x1.5. Resident has hx (history) of CVA (cerebral vascular accident) with paralysis to left side with contractures of left arm and left leg. Unstageable was discovered during care. Review of a Wound Care Progress Note dated 4/5/21 for Resident #6 revealed: Wound Assessments: Wound #4 Right, Posterior Heel is an Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 1.2 cm (centimeters) length x 1.5 cm width with non-measurable depth, with an area of 1.8 sq (square) cm. The patient reports a wound pain of level 2/10. Wound #5, Lateral Foot is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 0.9 cm length x 1.4 cm width x 0.1 cm depth, with an area of 1.26 sq cm and a volume of 0.126 cubic cm. There is a small amount of sero-sanguineous drainage noted which has no odor. The patient reports a wound pain of level 1//10. (sic) Review of a Wound Care Progress Note dated 4/12/21 for Resident #6 revealed: Wound Assessments: Wound #4 Right, Posterior Heel is a Pressure Ulcer and has received an outcome of Resolved. Wound #5 Left, Lateral Foot is a Stage 4 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 1.6 cm length x 1.2 cm width x 0.3 cm depth, with an area of 1.92 sq cm and a volume of 0.576 cubic cm. The wound is deteriorating. Wound #5 orders: Cleanse wound with Normal Saline, Apply Calcium Alginate, secure dressing with Kerlix, change dressing daily. (sic) Review of the Care Plan for Resident #6 revealed on 10/26/20 he was at risk for skin breakdown and the last new Approach revision was 11/14/20. Review of a Care Plan on 4/5/21 for a new stage 4 pressure ulcer to the residents left later foot with potential for infection and discomfort to the area. No Care Plan for refusal of care, or contractures. A Care Plan for Psychosocial Well-Being approach revealed: If ordered by the physician, honor resident's wishes for medication and pain control. A Pain Care Plan revealed implemented 10/26/20 with no new interventions since implemented: (Resident #6) has potential for actual pain related to stroke with left sided weakness, feeding tube, history of rib fracture, GERD (gastroesophageal reflux disease), history of spasms, pressure injury. Goal: . will demonstrate ability to manage pain with medication with few complaints of pain by next evaluation period. Approach: Discuss with resident the need to request pain medication before pain becomes severe in terms they can follow. Observe for nonverbal signs of pain, grimacing, moaning . Review of a policy titled Pressure Ulcer Prevention/Risk Assessment last reviewed 1/2021 revealed: . has established a standardized policy with guidelines that assigns responsibility and provides procedures for identifying residents at risk for pressure ulcers; to provide guidelines for the prediction, prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #16 Review of a Face Sheet revealed Resident #16 admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS dated [DATE] for Resident #16 revealed he had a BIMS indicating he is cognitively intact and required extensive assistance of 2 staff for transfers and no pressure ulcers. Review of a Skin Body assessment dated [DATE] for Resident #16 revealed: .Has new open area on his sacrum with treatment in place. Review of a Weekly Pressure Ulcer Progress Report with an observation date of 4/5/21 and completion date of 4/20/21 for Resident #16 revealed an In house acquired on buttocks is unstageable and measured 2.5x2 cm. Resident has an unstageable on coccyx. Was discovered during care on 4/1/21 as a stage II with no depth. This is a healed PU from earlier this year. labs continue to indicate he is clinically unavoidable with his medical history. Wound has 100% slough covering it and Santyl (wound dressing) was ordered. Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient has decreased mobility, has position preferences, not eating great, is a set up for ulceration. (sic) Review of Physician orders/Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/5/21 for Resident #16 revealed: Santyl ointment 250 unit/gram, apply Santyl topically to wound bed on sacrum only. (keep off healthy skin). Apply 4x4 bordered dressing daily. Review of the Nursing Progress notes for Resident #16 revealed no concerns for refusal of care. No progress notes from 3/31/21 to 4/17/21. Review of the Pressure Ulcer Care Plan with a problem start date of 4/1/21 for Resident #16 revealed: (Resident #16) has an unstageable pressure injury to coccyx with potential for infection and discomfort to area. Associated factors: decreased mobility, incontinence. In an interview on 4/22/21 at approximately 1:00 p.m., the Director of Nursing (DON) reported the nurse should have changed her gloves and performed hand hygiene throughout her treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] In an interview on 4/23/21 at approximately 1:00 p.m., Regional Consultant (RC) G reported Resident #16 had a stage II pressure ulcer when it was discovered and then a couple days later there was slough which made it unstageable.

Based on observation, interview and record review, the faciltiy failed to assess, control and implement measures for pain for 1 (Resident #6) with comorbities that have painful tendencies resulting in unresolved pain that can affect care and quality of life. Findings include: Resident #6 Review of a Face Sheet revealed Resident #6 admitted to the facility on [DATE] with pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #6 had a Brief Interview for Mental Status (BIMS) indicating he is cognitively intact and required extensive assistance of 2 for transfers and had limited range in motion on one side for the upper and lower extremity. During an observation and record review on 4/20/21 at 11:10 a.m., Certified Nursing Assistant (CNA) L was providing care for Resident #6 and complained he had pain in his knee. The resident kept calling out in pain and the nurse came in and said she was going to get him something for pain and left the room. At 11:18 the nurse had not yet returned to the room and was not visible in the hallway. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The Pain assessment documented this day revealed a 0 pain level for the resident. Review of the Nursing Progress Note dated 4/20/21at 11:33 a.m. revealed: Resident complains of headache and knee pain, one time order obtained to give Tylenol 325 mg-two tablets through FT (feeding tube). During an observation and an interview on 4/21/21 at 10:40 a.m., Licensed Practical Nurse (LPN) G reported Resident #6 had a sore on the side of his foot Resident #6 has contractures on his left upper and lower extremities and moaned in pain when the nurse tried to move his legs. LPN G started the dressing change on the resident's left foot. The wound was approximately dime sized and necrotic. The nurse cleansed the wound and redressed it. The resident did not receive any pain medication prior to treatment. During an observation on 4/22/21 at 8:58 a.m., Resident #6 was in bed and complained of pain and was moaning and calling out. Licensed Practical Nurse (LPN) J entered the residents' room and told the resident he already received pain medication with his morning medications. The resident continued to moan in pain. In an interview on 4/22/21 at 9:10 a.m., LPN J looked into the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #6 did not receive pain medication with his morning medications. LPN J then went to give the resident pain medication. Review of the March Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Acetaminophen 160 mg/5mls, administer 20 ml every 6 hours as needed for pain Ordered 12/18/20 and discontinued 3/11/20. The resident received 2 doses for pain and 2 doses for a fever. Acetaminophen 160 mg/5mls, 20 ml ordered every 6 hours as needed for pain ordered 3/13/21 and the resident received a total of 2 doses. Review of the April Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Acetaminophen 160 mg/5ml, administer 20 ml every 6 hours as needed for pain, ordered 3/13/21 and only one dose given. Tylenol 325 mg tablets oral, give 2 tablets X1 for complaints of pain ordered 4/20/21 and discontinued 4/20/21, one dose given. Pain Assessment ordered every shift and on 4/22/21, LPN J rated the residents' pain at a 0 and documented he gave acetaminophen at 8:30 a.m. and oxycodone at 9:15 a.m. Review of Occupational Therapy Progress Notes for Resident #6 revealed: 10/29/20: . Patient frequently requests that therapist back down stretch due to pain. Patient able to achieve full extension of wrist today with intermittent (complaints) of pain. Discussed possibility of using dynamic elbow splint to decrease risk of contracture. 10/20/20: . neck contracted to left side as well. Review of a Wound Care Progress Note dated 4/5/21 for Resident #6 revealed: Wound Assessments: Wound #4 Right, Posterior Heel is an Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 1.2 cm (centimeters) length x 1.5 cm width with non-measurable depth, with an area of 1.8 sq (square) cm. The patient reports a wound pain of level 2/10. Wound #5, Lateral Foot is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 0.9 cm length x 1.4 cm width x 0.1 cm depth, with an area of 1.26 sq cm and a volume of 0.126 cubic cm. There is a small amount of sero-sanguineous drainage noted which has no odor. The patient reports a wound pain of level 1//10. (sic) Review of a Wound Care Progress Note dated 4/12/21 for Resident #6 revealed: Wound Assessments: Wound #4 Right, Posterior Heel is a Pressure Ulcer and has received an outcome of Resolved. Wound #5 Left, Lateral Foot is a Stage 4 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 1.6 cm length x 1.2 cm width x 0.3 cm depth, with an area of 1.92 sq cm and a volume of 0.576 cubic cm. The wound is deteriorating. Wound #5 orders: Cleanse wound with Normal Saline, Apply Calcium Alginate, secure dressing with Kerlix, change dressing daily. (sic) Review of the Care Plan for Resident #6 revealed no implementation for contractures. A Care Plan for Psychosocial Well-Being approach revealed: If ordered by the physician, honor resident's wishes for medication and pain control. A Care Plan for Dental Care revealed: (Resident #6) is at risk for mouth or facial pain related to broken natural teeth . Approach: Pain assessment per facility policy. A Pain Care Plan revealed implemented 10/26/20 with no new interventions since implemented: (Resident #6) has potential for actual pain related to stroke with left sided weakness, feeding tube, history of rib fracture, GERD (gastroesophageal reflux disease), history of spasms, pressure injury. Goal: . will demonstrate ability to manage pain with medication with few complaints of pain by next evaluation period. Approach: Discuss with resident the need to request pain medication before pain becomes severe in terms they can follow. Observe for nonverbal signs of pain, grimacing, moaning . In an interview on 4/22/21 at approximately 1:00 p.m. the Director of Nursing (DON) reported Resident #6 does have pain at times and has medications on an as needed basis. When told of this surveyors' observations of the resident in pain during care and when alone in bed and not receiving pain medications even when asked, the DON reported she did not think he needed the [MEDICATION(S)] because it was too strong. The Regional Nurse Consultant (RC) S reported that the resident may benefit from a scheduled pain medication.

This citation pertains to intake MI 014. Based on interview and record review, the facility failed to promote the healing of pressure ulcers by routinely assessing, monitoring, updating treatment changes timely and reporting changes to the physician for 3 of 3 residents (Resident #1, #2 and #3) reviewed for pressure ulcers. This deficient practice resulted in Resident #1's physician not being informed of a decline in healing, and treatment orders were not implemented timely, Resident #2's wound deteriorated from a stage 2 to a stage 3 pressure ulcer and the physician was not notified and the wound went unmonitored and measured for changes in condition for 14 days, and Resident #3 receiving the incorrect treatment and dressing to the pressure ulcer causing worsening or developing pressure sores. Findings include: The facility provided a copy of the Care Standard (for Pressure Ulcers) dated 4/2018 for review. The policy reflected, Weekly assessments of skin conditions will be documented in the residents electronic medical record using the following observation: Weekly Pressure Ulcer Progress Report .If the wound/skin condition does not show signs of improvement in fourteen (14) days, the physician will be notified for further recommendations and/or treatment changes .Notification of Change in Skin Condition will be made to the physician/NP/PA utilizing the INTERAT SBAR communication tool (an assessment tool). Resident #1 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS), reflected a score of 8 out of 15 which represents Resident #1 had moderate cognitive impairment. Resident #1 had a Resident Representative who made medical decisions. Resident #1 did not reside at the facility during the onsite survey. The facility provided the Pressure Ulcer Care Plan dated 2/5/20 for review. The care plan intervention included (but not limited to), Notify Dr. if wound exhibits decline in status, s/s (signs and symptoms) of infection or if pain is uncontrolled or increased. According to the hospital discharge orders dated 1/15/20 reflected the order for Santyl to the pressure ulcer once daily with the dressing change. According to the facility Treatment Administration Record (TAR) for January and February reflected the following orders and treatments provided: 1/15/20 apply Santyl to wound and cover with a derafilm, change daily. 1/17/20 apply Santyl to wound and cover with derafilm, change every 3 days. 2/3/20 apply Santyl to wound and cover with gauze and change daily. 2/11/20 clean wound with normal saline, apply Santyl and cover with gauze and secure with mepalex, change daily. This order came from the Wound Clinic visit and recommendation on 2/11/20. 2/17/20 clean wound with normal saline, apply Santyl to eschar (thick scab cover) area and pack tunneling at 7 o'clock with calcium alginate, change daily. This order was not signed out as done or initiated until 2/24/20 (7 days later). The February Medication Administration Record [REDACTED]. During an interview on 7/29/20 at approximately 11:00 AM, the Corporate Nurse Consultant (CNC) A stated that Resident #1 was admitted with an unstageable (unable to see the wound bed) pressure ulcer to the coccyx (tailbone area). CNC A read the following weekly wound measurements of the pressure ulcer as follows: 1/15/20 2.5 x 2.0 (unable to measure depth due to slough covering the wound bed) 1/17/20 2.5 x 2.0 with slough 1/24/20 2.5 x 1.8 with slough 1/31/20 5.4 x 5.3 (increase in size noted) 2/7/20 5.2 x 5.4 x 0.4 depth at 7 o'clock, no tunneling noted 2/14/20 5.1 x5.3 x 0.7, no tunneling noted 2/21/20 5.1 x 5.3 x 0.5, no tunneling noted (but had a treatment order to pack tunneling dated 2/17/20) When asked why the order from the hospital that recommended the dressing be changed daily was changed on 1/17/20 to change it every 3 days, CNC A reviewed the records and stated that must have been done in error. The TAR reflected that the dressing continued to be changed every 3 days from 1/17/20 until 2/3/20. When asked if the physician was notified of the decline in healing (increase in size) on 1/31/20, the CNC A stated, I remember talking with him but was unable to find an SBAR or a progress note regarding the notification and any changes in intervention the physician requested. According to the TAR the dressing order on 2/3/20 (3 days after the noted decline in the wound) was changed back from once every 3 days to once daily. The MAR indicated [REDACTED]. According to the physicians orders a urinary foley catheter was placed to reduce the irritation of urine to the wound on 2/5/20 (5 days after the noted decline in healing). CNC A stated the resident was sent out to the wound clinic on 2/11/20 for further evaluation and treatment recommendations. As a result of the wound clinic visit on 2/11/20 the order was changed to clean the wound with normal saline, apply Santyl and cover with gauze, secure with mepalex, and change daily. The dressing order was changed again on 2/17/20 to clean wound with normal saline, apply Santyl to eschar area, pack tunneling at 7 o'clock with calcium alginate, and change dressing daily. When asked why the dressing order dated 2/17/20 was not signed out as done or initiated until 2/24/20 (7 days later), CNC A stated upon receiving a change in order the old order must be discontinued and the new one printed and placed in the treatment book for the nursing staff to initiate the new order. The CNC A stated that the order must have been missed. The physician noted dated 2/13/20 reflected, Coccyx decub ulcer - Wound has deepened despite aggressive wound care by facility & wound clinic notes from hospital questioned deep tissue injury, suspect this is correct as wound has worsened. Now stage IV, about ½ deep. Not sure if we have seen the full extent of Res. (resident's) wound yet. Resident #2 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS), reflected a score of 15 out of 15 which represents Resident #2 was cognitively intact. During an interview and record review on 7/30/20 at 2:30 PM, the DON stated that an unavoidable stage 2 (partial dermis loss) pressure ulcer had developed to the right lower buttock on 4/2/20 that measured 3.0 x 3.5 x 0.5. The wound was measured weekly and on 5/15/20 measured 2.4 x 0.5 x 03 which represented healing. On 5/22/20 the wound measured 3.0 x 2.0 x 1.0 with 4 cm of undermining at 10 o'clock. The DON stated that it evolved from a Stage 2 to a Stage 3 with dermis loss and undermining. When asked if the physician was notified of this change in condition and if there were any order or interventions changed as a result, the DON stated that she remembered speaking with the physician but could not provide an SBAR, progress note or intervention/order change to promote the healing of the wound. The April and May TAR reflected that the wound treatment from 4/13/20 until 5/27/20 was to cleanse with normal saline, pack with calcium alginate, and cover with dermafoam and change it daily. On 5/27/20 the order was changed (5 days after the wound declined) to cleanse with normal saline, pack with calcium alginate and cover with thin bordered [MEDICATION NAME] wound dressing and change every 3 days. When asked why the new order was not initiated after the noted decline on 5/22/20, the DON stated that she did not know that when a new order is obtained the old one must be discontinued, a new TAR must be printed and placed in the treatment book to be initiated. According to the Pressure Ulcer Policy all wounds will be assessed and measured weekly. The facility provided a copy of assessments dated 7/10/20 and 7/24/20. There was no assessment provided to review covering that 14-day period. When asked why the stage 3 pressure ulcer went unassessed and monitored for 14 days, the DON stated that she did not know why but it should be measured weekly. Resident #3 Review of the Face Sheet and the admission assessment dated [DATE] revealed Resident #3 admitted to the facility on [DATE]. The admission assessment reflected that Resident #3 was cognitively intact. During an interview and record review on 7/30/20 at approximately 11:00 AM, the DON stated that Resident #3 had acquired a pressure ulcer at home (from an incident) before she was hospitalized , and later transferred to the facility on [DATE] with a wound to the right inner gluteal (buttock). Upon admission the wound measured 9.5 x 1.5 and was noted as a deep tissue injury (dark purple/maroon colored covering with intact skin). On 7/24/20 the wound measured 9.5 x 1.0 with eschar (scab like covering the wound bed) was forming with intact wound edges. The DON stated the treatment order was changed at that time. The July TAR reflected 2 treatment orders for the same wound. The first order was to apply Venelex ointment to the wound bed three times daily. The second order started on 7/25/20 (and overlapped with the first) to apply Santyl to the eschar, cover with border dressing and change it twice daily. The TAR reflected the Venelex was to be applied 37 times from 7/17/20 - 7/30/20 and it was not signed out as done (left blank) 17 times. The DON stated the Venelex treatment order should have stopped on 7/25/20 when the new order was obtained. The DON stated that when she talked with the nurses they told her that they were indeed applying both treatments. The DON stated that practice was incorrect, and she would get the first order clarified and stopped. Record review of the baseline care plan for Resident #3 identified the problem of the pressure ulcer but had no interventions listed to promote the healing of the wound. The DON stated the staff should have identified some immediate interventions to put in place for the pressure ulcer.