Every finding on record at Heritage Post Acute

Based on interview, record review, and facility policy review, the facility failed to provide a discharge summary and supplemental oxygen at the time of discharge for 1 (Resident (R)137) of 4 sampled closed records reviewed.Findings include:Review of a facility policy titled Discharge Summary and Plan, revised on 10/2022, revealed, When a resident's discharge is anticipated, a discharge summary and post-discharge plan is developed to assist the resident with discharge. The policy specified, . 12. A copy of the following is provided to the resident and receiving facility and a copy will be filed in the resident's medical records: a. An evaluation of the resident's discharge needs; b. The post-discharge plan; and c. The discharge summary.Review of R137's admission Record revealed the facility admitted R137 on 11/07/2025. According to the admission Record, the resident had a medical history that included but was not limited to a diagnoses of respiratory failure. Per the admission Record, the resident discharged home with home health services on 11/27/2025.During an interview on 02/06/2026 at 3:19 PM, R137's Responsible Party (RP) stated they informed the Admissions Coordinator (AC) on 11/26/2025 they would take R137 home on [DATE]. According to the RP, the AC informed them R137's discharge paperwork would be available when the resident was picked up from the facility. The RP stated when they arrived at the facility on 11/27/2025 to take the resident home, the facility did not have R137's discharge paperwork available. The RP stated a nurse tried to call someone to get the discharge paperwork, but they were not able to reach that person. The RP stated they left the facility with the resident on 11/27/2025 without discharge paperwork. The RP stated while R137 was in the facility, the resident received supplemental oxygen; however, when the resident discharged on 11/27/2025, the facility did not discharge the resident with supplemental oxygen.During an interview on 02/06/2026 at 10:56 AM, the Social Worker (SW) stated when a resident discharged from the facility, she would set up home health services, print the orders for durable medical equipment, and provide discharge paperwork to the resident or the resident's representative at the time of discharge. The SW stated when R137 discharged from the facility, it was a holiday weekend (Thanksgiving) and she was not working in the facility. The SW stated she believed the discharge paperwork for R137 was mailed to the RP. The SW stated on 12/01/2025, she reviewed R137's discharge paperwork with the RP over the phone, four days after R137 discharged from the facility. The SW stated if the resident received supplemental oxygen in the facility, the resident would have been discharged with an order for supplemental oxygen. The SW confirmed R137 received supplemental oxygen in the facility and there were no orders for supplemental oxygen to be sent home with the resident when they were discharged .Review of R137's Discharge Instruction Form signed by the SW and dated 12/01/2025, had a handwritten note that specified the Discharge Instruction Form was discussed with R137's RP verbally on 12/01/2025.During an interview on 02/07/2026 at 8:56 AM, the Director of Nursing stated the expectation when a resident discharged from the facility was that the resident would receive education, medications, and discharge instructions at the time of discharge.During an interview on 02/07/2026 at 9:08 AM, the Administrator stated the expectation was when a resident discharged from the facility, the resident would receive education, medications, post-discharge arrangements, and discharge paperwork at the time of discharge.

Based on observation, interview, record review, and facility policy review, the facility failed to develop a comprehensive person-centered care plan for the use of enablers for 1 (Resident (R)76) of 24 sampled residents.Findings include:Review of a facility policy titled Care Planning, Comprehensive Person-Centered, revised on 03/2022, revealed A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy specified . 7. The comprehensive, person-entered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.Review of a facility policy titled Enablers, revised on 05/05/2023, revealed Policy: 1. The nursing staff will use enablers whenever possible in lieu of restrains to assist the patient/resident to obtain, maintain and enhance the functional status, an improve his/her quality of life. The policy specified, . 6. Record intervention(s) on the plan of care and inform staff.Review of R76's admission Record indicated the facility admitted R76 on 02/14/2025. According to the admission Record, the resident had a medical history that included, but was not limited to a diagnosis of multiple sclerosis.Review of R76's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/12/2025, revealed R76 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had intact cognition. The MDS revealed the resident required substantial/maximal assistance to roll left to right while lying on their back.Review of R76's Care Plan Report with an admission date of 02/14/2025, did not reference the resident's use of enabler bars.During a concurrent observation and interview on 02/04/2026 at 10:26 AM, R76 was observed supine in the bed with bilateral enabler bars attached to the left and right side of their bed in the elevated position. R76 stated they used the enabler bars to assist with mobility and positioning in the bed.During an interview on 02/06/2026 at 9:45 AM, Licensed Practical Nurse (LPN)4 stated R76 had bilateral enablers in place to use for positioning. LPN4 stated all residents who had enablers installed on their bed would have a care plan for the enablers. LPN4 stated R76 did not have an enabler care plan and it would need to be added.During an interview on 02/06/2026 at 10:15 AM, the MDS Registered Nurse (RN) stated R76 had bed enabler bars installed on both sides of their bed. The MDS RN stated residents with enablers would require a care plan. The MDS RN stated R76 did not have a care plan for their enabler bars and that would need to be corrected.During an interview on 02/06/2026 at 10:31 AM, the Administrator stated her expectation was for all residents with enabler bars in place to have a care plan for the enabler bars. The Administrator stated R76 did not have a care plan for their enabler bars and it would need to be added.During an interview on 02/06/2026 at 11:38 AM, the Director of Nursing (DON) stated her expectation was for all residents with enabler bars on their bed to have a care plan for the enablers. The DON stated R76 did not have a care plan for enablers and it would need to be corrected to reflect their use.

Based on observation, interview, record review, and facility policy review, the facility failed to update the care plan to reflect the resident's use of fall matts for 1 (Resident (R)7) of 24 sampled residents.Findings include:Review of the facility policy titled Care Planning, Comprehensive Person-Centered, revised on 03/2022, revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy specified, . 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.Review of R7's admission Record indicated the facility admitted R7 on 11/15/2024. According to the admission Record, the resident had a medical history that included, but was not limited to diagnoses of muscle weakness and unsteadiness on feet.Review of R7's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/12/2025, revealed R7 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated the resident had severe cognitive impairment. The MDS indicated R7 had a fall with major injury since admission/entry or reentry or the prior assessment.Review of R7's Care Plan Report included a focus area initiated on 11/29/2024, that indicated the resident had a history of falls. There were no interventions that specified the resident's use of fall mats at their bedside.During an observation on 02/04/2026 at 10:52 AM, R7 had fall mats placed at the foot of their bed and one on each side of the bed.During an observation on 02/06/2026 at 9:23 AM, R7 was observed asleep in a bed and there were fall mats placed at the foot of the resident's bed and one on each side of the bed.During an interview on 02/06/2026 at 9:45 AM, Licensed Practical Nurse (LPN)4 stated R7 had three fall mats in place due to their fall risk. LPN4 stated fall mats would need to be care planned. LPN4 stated R7 was not care planned for the fall mats and she did not know why the care plan did not reflect fall mats being used.During an interview on 02/06/2026 at 10:15 AM, the MDS Registered Nurse (RN) stated the facility used fall mats as an intervention for residents that had fallen. The MDS RN stated a resident's care plan would reflect the use of fall mats. The MDS RN stated R7's fall mat intervention got missed and would need to be added to the resident's fall care plan.During an interview on 02/06/2026 at 11:38 AM, the Director of Nursing (DON) stated fall mats were used as an intervention for residents that had fallen. The DON stated when fall mats were used as a fall intervention, the resident's care plan would be updated to reflect the use of fall mats. The DON stated R7 had three fall mats in their room around the bed, but they were not care planned. The DON stated the expectation was for all residents' fall mats to be care planned. The DON stated R7's care plan needed to be updated to show the fall mats as a fall intervention.During an interview on 02/06/2026 at 2:38 PM, the Administrator stated her expectation for any resident with falls mats was to have documentation in the chart, including care plan interventions in place. The Administrator stated R7 did not have any documentation in the care plan that reflected the use of fall mats and it would need to be corrected.

Based on interview, record review, and facility policy review, the facility failed to ensure weekly body audits (skin checks) were conducted and documented for 1 (Resident (R)137) of 3 sampled residents reviewed for pressure ulcers. Findings include:Review of the facility policy titled Pressure Injury/Wound/Skin Management, dated 08/2016, indicated, . 4. A Licensed Nurse performs a weekly body audit, wound measurements, and documents findings in the medical record.Review of R137's admission Record revealed the facility admitted R137 on 11/07/2025. According to the admission Record, the resident had a medical history that included but was not limited to diagnosis of unstageable pressure ulcer of sacral region. Per the admission Record, the resident discharged home with home health services on 11/27/2025.Review of R137's Baseline Care Plan Summary included a problem statement initiated on 11/07/2025, that indicated the resident had impaired skin on the sacrum. Interventions directed staff to perform weekly skin checks.Review of R137's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/14/2025, revealed R137 had a Brief Interview for Mental Status (BIMS) score of 7 out of 15, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had one unstageable pressure ulcer that was present upon admission.Review of R137's medical record revealed evidence of a Skin & Wound Evaluation dated 11/07/2025, that indicated the resident's sacral wound measured 8.0 centimeters (cm) by 4.5 cm with 70 percent (%) granulation and 30 % eschar (dead tissue). There were no evidence of any other documented skin check or wound measurement for the resident.During an interview on 02/05/2026 at 11:04 AM, the Licensed Practical Nurse (LPN) Wound Care Nurse stated skin audits were done weekly.During an interview on 02/06/2026 at 2:46 PM, LPN2 stated the nurses conducted resident body audits weekly.During an interview on 02/07/2026 at 12:30 PM, LPN3 stated resident skin audits were completed weekly and documented in the resident's electronic health record (EHR). LPN3 stated the wound nurse was responsible for measuring a resident's wounds.During a follow-up interview on 02/07/2026 at 12:58 PM, the LPN Wound Care Nurse stated residents' initial body audits were done, then each room was assigned a time each week. The LPN Wound Care Nurse stated body audits were documented in the resident's EHR. The LPN Wound Care Nurse stated she did not know why R137's measurements were not documented.During an interview on 02/07/2026 at 1:05 PM, the Director of Nursing (DON) stated the LPN Wound Care Nurse would assess a resident's wound with the wound physician weekly, obtain the measurements, and document the skin and wound assessment with a picture. The DON stated her expectation was for a resident's wounds to be measured and documented weekly. The DON stated the facility was unable to locate wound documentation other than the initial evaluation dated 11/07/2025 for R137.

Based on interview and record review, the facility failed to document the administration of a nutritional supplement ordered for 1 resident (Resident (R)137) of 24 sampled residents.Findings include:Review of R137's admission Record revealed the facility admitted R137 on 11/07/2025. According to the admission Record, the resident had a medical history that included but was not limited to diagnosis of severe protein-calorie malnutrition.Review of R137's admission Minimum Date Set (MDS) with an Assessment Reference Date (ARD) of 11/14/2025, revealed R137 had a Brief Interview for Mental Status (BIMS) score of 7 out of 15, which indicated the resident had severe cognitive impairment. The MDS indicated the resident required supervision or touching assistance with eating.Review of R137's Care Plan Report included a focus area initiated on 11/26/2025, that indicated the resident had a nutritional problem or potential for a nutritional problem.Review of R137's Order Summary Report revealed an order dated 11/21/2025 for a nutritional supplement with meals.Review of R137's Medication Administration Record [MAR] for the timeframe 11/01/2025 - 11/30/2025, revealed no evidence to indicate staff administered the resident's nutritional supplement as ordered.During an interview on 02/06/2026 at 1:45 PM, the Director of Nursing (DON) stated if a resident received a nutritional supplement, the nurses had to document it on the resident's MAR. Whether the resident drank the nutritional supplement or not. The DON stated her expectations were for the staff to monitor the intake of any nutritional supplement that was ordered by the doctor and to have the documentation of the amount of the nutritional supplement the resident consumed.During an interview on 02/06/2026 at 2:38 PM, Licensed Practical Nurse (LPN)2 stated she knew R137 received the nutritional supplement because either she or the certified nurse assistant gave it to the resident. LPN2 stated she did not know why there was no documentation on the resident's MAR to indicate the nutritional supplement had been given.During an interview on 02/07/2026 at 7:50 AM, LPN3 stated she remembered that R137 received their nutritional supplement, but she did not know what happened with her initials not being on the resident's MAR to indicate she administered the nutritional supplement to the resident.During an interview on 02/07/2026 at 8:19 AM, the Administrator stated nutritional supplements should be signed out on a resident's MAR. The Administrator stated her expectation was that the nursing staff should sign the resident's MAR when nutritional supplements were given to a resident.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a catheter drainage bag was not on the floor for 1 (Resident (R)4) of 3 sampled residents reviewed for urinary catheter.Findings include:Review of the facility policy titled Catheter Care, Urinary, revised 08/2022, revealed The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. The policy specified, . 2. Be sure the catheter tubing and drainage bag are kept off the floor.Review of R4's admission Record revealed the facility admitted R4 on 01/06/2026. According to the admission Record, the resident had a medical history that included but was not limited to diagnosis of retention of urine.Review of R4's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/13/2026, revealed R4 had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was dependent on staff for toileting and had an indwelling catheter.Review of R4's Care Plan Report included a focus area initiated on 01/26/2026, that indicated the resident had an indwelling catheter related to urine retention.During an observation on 02/04/2026 at 12:17 PM, R4's urinary catheter drainage bag rested directly on the floor between the resident's bed and the wall.During an interview on 02/04/2026 at 3:53 PM, Registered Nurse (RN)1 stated the catheter bag was not supposed to be on the floor.During an interview on 02/06/2026 at 1:33 PM, the Director of Nursing stated a resident's catheter draining bag was not supposed to be on the floor.During an interview on 02/07/2026 at 7:45 AM, the Administrator stated her expectation was that the urinary catheter bags were not supposed to be on the floor.

Based on observations, facility policy, and interviews, the facility failed to remove expired medications and biologicals from 1 of 4 medication carts and from 1 of 1 medication storage rooms. Additionally, the facility failed to ensure the medication room was properly secure. Findings include: Review of the facility policy titled, Medication Storage in the Healthcare Centers with revised date 04/09/24 revealed, Policy Statement: .The medication supply is accessible only to licensed nursing personnel and pharmacy personnel .Procedure: 2. Only licensed nurses and the pharmacy personnel are allowed access to medications Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. 3. Nurses are required to check all medications for deterioration and expiration before administration. Nurses are also required to inspect medication storage facilities, including medication carts, routinely .12. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction, and reordered from the pharmacy, if a current order exists. During an observation and interview on 10/08/24 at 8:28 AM of the Chestnut Medication Storage Room revealed, Rugby Hemorrhoidal Suppositories with 12 suppositories in each box. Box One was observed with lot number 2JT0434 and expiration date 08/24. Box Two was observed with lot number 2KT0513 and expiration date 09/24. There was a total of 24 expired suppositories. Licensed Practical Nurse (LPN)1 verified the medication supplies were expired and removed them from the medication storage room on Chestnut. During an observation and interview on 10/08/24 at 11:48 AM of the Chestnut Medication Storage Room revealed, BD Vacutainer Safety-Lok Blood Collection Set: Four (4) packages with lot number 1F2281 and expiration date 06/30/24. In addition, there was [NAME] Povidone-Iodine, USP Swab Stick packets with 16 single swab packets containing the lot number CJB08-01 and expiration date 08/05/24. LPN2 verified the medication supplies were expired and removed them from the medication storage room on Chestnut. During an observation and interview on 10/08/24 at 11:53 AM of the Chestnut Front Hall Cart revealed. Hydrocodone-Acetaminophen 5-325 mg with dispensed date of 08/04/23. There were 21 tablets in the bottle. LPN2 verified the medication was expired with the pharmacy as of 08/04/24 and removed the bottle from the medication narcotic drawer on the Chestnut Front Hall Cart. The medication will be given to the Director of Nursing for disposal. During an interview on 10/10/24 at 9:40 AM, the DON stated that the pharmacy consultant and account managers from [NAME] Health check for expired medications on the medication carts and medication rooms. Unit supervisors and nurses on the floor are responsible for checking for expired supplies however there is no check off to ensure compliance. If items are found to be expired, they should be discarded. Additionally, unauthorized access to medication storage room by unlicensed personnel was observed. During an interview on 10/08/24 at 8:10 AM, Certified Nursing Assistant (CNA)3 entered the medication storage room on the Chestnut unit while the surveyor was present. Upon entry, the surveyor was notified that the CNA3 needed to warm a resident tray in the microwave on the counter. When asked if this was the designated room to use the microwave for the unit, CNA3 confirmed and stated that there was another microwave on the other unit but the only room to warm food on Chestnut. When asked how was the room accessed, it was confirmed that a code was used. When asked what the code was, the CNA provided the code. During an interview on 10/08/24 at 8:20 AM, LPN1 and unit manager confirmed that the lock was on the door was related to medication storage. When asked who should have access to the room where medications were stored, it was stated that only the nurses. LPN1 was asked if any unlicensed personnel come into the medication room such as nursing assistants. The nurse reported that nursing assistants are allowed in to heat food in the microwave. When asked how do nursing assistants get access to the locked room it was reported that everyone knows the code. It was asked if any other staff access the room and it was reported that the housekeepers come in to clean the microwave. LPN1 stated that this has been going on the [AGE] years she has been employed. During an interview on 10/08/24 at 8:39 AM, Housekeeper (HSK)1 reported that there was another person assigned to clean the Chestnut medication room microwave. During an interview on 10/08/24 at 8:41 AM, HSK2 confirmed that the assigned housekeeper had access to enter the medication room on Chestnut to clean the microwave. When asked what the code was, it was confirmed. When asked if it was known what is stored in the cabinets and refrigerator, it was reported as unknown. It was confirmed that the practice of entering the medication room to clean the microwave had been occurring for a while. During an interview on 10/08/24 at 8:44 AM, the DON confirmed that only nursing staff, specifically licensed nurses should have access to the medication room. It was confirmed that stock medication were stored in the medication room in unlocked cabinets and it was confirmed that other staff are able to access the room. However, the DON agreed that other staff should not have access although there is a lock on the door and both licensed and unlicensed staff have the code. The DON stated, Honestly I had not thought about this .about stock being accessible. The only thoughts the DON had was about the need for the narcotics to be double locked. When asked about how long this practice had been in process, it was reported that they had switched pharmacy around 2020 and stock meds were not in the room prior to this switch. Stock medications were maintained only on the medication carts and there was no excess.

Based on facility policy, record review, observation and interview, the facility failed to ensure ordered supplements were provided for 1 of 2 residents, (R)50 reviewed for nutritional supplements. Findings include: Record review of the facility policy dated 07/03/2019 titled, Telephone/Verbal Orders From Physician revealed under the policy, Llicensed staff may obtain orders from their extenders via verbal order or telephone orders. The nursing staff may repeat the order back to the physician or extender for verification if necessary. The physician signs the order on his/her next visit. Record review of R50's medical record revealed she was admitted to the facility on [DATE] with diagnosis that include but are not limited to anemia, hyperlipidemia, cerebral infarction, anxiety, gastroesophogeal reflux and osteoporosis. Record review of R50's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 13, indicating she is cognitively intact. Record review of the Registered Dietician's (RD) quarterly assessment of R50 dated 09/07/24 revealed unintentional weight loss of 10.40% x 180 days. R50 receiving nutritional supplements of IN-HOUSE supplements twice a day (BID) (LUNCH AND DINNER) (providing 400 calories, 12 gram protein) and Ice Cream BID (LUNCH and DINNER) (providing 280 calories, 4 grams protein) for nutrition and weight gain.Resident receiving nutritional supplements of IN-HOUSE BID (LUNCH AND DINNER) (providing 400 cal, 12 gm protein) and Ice Cream BID (LUNCH and DINNER) (providing 280 cal, 4 gm protein) for nutrition and weight gain. Review of R50's orders revealed an order for House Shake dated 03/15/24 to recieve at lunch and dinner. On 10/09/24 at 12:25 PM, an observation of R50's lunch tray revealed an ice cream was with her meal, but no House Shake was delivered. R50 stated, My ice cream is melted. I don't get the milkshakes, they give them to my roommate occasionally. Review of her meal ticket recorded her meal as regular, thin liquid and ice cream was written in on the ticket. Milkshake was not recorded on her lunch menu ticket. On 10/09/24 at 2:40 PM, an observation revealed snacks received from the kitchen. R50 did not have any supplement/snack on the tray. On 10/09/24 at 5:25 PM, R50's dinner tray was delivered. Observation of the meal tray revealed ice cream on her tray, but she did not receive the ordered supplement. On 10/10/24 at 9:25 AM, an interview with the Dietary Manager (DM) revealed, When the resident has an order for the Health Shakes, the RD will put that on the meal ticket. She said R50 gets it for lunch and dinner and she also gets ice cream. The DM reviewed R50's meal ticket dated 10/10/24 for lunch, and said, it isn't here. The ice cream is here. The DM said the dietary staff would not know to give the House Shake if it was not on the meal ticket. On 10/10/24 at 8:59 AM, an interview with the Director of Nursing (DON) revealed House Shakes are delivered by the kitchen. Sometimes it's ordered with meals and sometimes it comes up as a snack. She reviewed R50's medication administration record (MAR) and stated, it is not on the MAR for the nurses to sign it as given. On 10/10/24 at 11:35 AM, an interview with the Unit Manager revealed, I put the order in for the House Shake for lunch and dinner on 03/05/24. She said, I don't know why she has not received her House Shakes when I gave them the communication sheet that the order was written.

Based on review of the facility policy, record review, observation, and interview, the facility failed to ensure hand hygeine was followed for 1 of 4 residents, (R)58, reviewed for pressure ulcers. Findings include: Review of the facility policy, date unspecified, titled, Wound Care/Dressing Change Procedure states under the policy, Clean the wound according to the order. Remove gloves and place in the trash. Hand hygeine. Put on clean gloves. Apply clean dressing as ordered. Remove gloves and place in the trash can. Make resident comfortable. Hand hygiene. Record review revealed R58 was admitted on [DATE] with diagnoses that included but not limited to dementia, depression, Alzheimers' Disease, dysphagia, and hypertension. Review of R58's treatment orders revealed a treatment order dated 09/03/24 to cleanse sacral wound with normal saline, apply medihoney and calcium alginate to wound bed, and cover with a dry dressing until healed. Apply house barrier cream and antifungal powder to skin surrounding wound to prevent moisture one time a day. Record review of a progress note dated 10/08/24 recorded Wound physician rounded and assessed R58's stage 4 pressure ulcer wound to sacrum. Surgical excisional debridement done at bedside by wound doctor. An observation of wound care on 10/09/24 at 11:27 AM with Registered Nurse (RN)1 revealed, She gowned and washed her hands, then applied gloves. The treatment supplies were already setup on R58's overbed table, to include a small tube of Medi-honey, calcium alginate, extra protective cream (EPC) anti fungal powder, normal saline and gauze on a towel on the overbed table. Privacy was maintained and her curtains were closed. The blankets were pulled down, and R58 was turned onto her side. There was no dressing observed. There was a foul odor emanating from the open wound. A deep crater was observed with a small amount of slough on the inside of the wound bed. RN1 cleaned the wound with normal saline solution and gauze. She discarded the gauze and removed the gloves, washed her hands and donned new gloves. She then applied Medi-honey into wound, with q-tip. She removed her gloves, but did not wash or sanitize her hands and applied another pair of gloves. She applied EPC cream with her fingered glove around the peri wound. She discarded one glove and applied another without sanitizing her hands. She placed the calcium alginate into the wound. She removed both gloves, and again falied to sanitize her hands. She applied the outer dressing, Mepore island dressing and applied antifungal powder, sprinkled to outer wound dressing and the dressing. She removed gloves, failed to wash or sanitize her hands, and donned new gloves. She repositioned R58 and turned her onto her left side with a wedge. Afterward, she removed her gloves. RN1 bagged all discarded items then removed the gown. She washed her hands and exited the room with the bag of soiled items. On 10/09/24 at 11:45 AM, during an interview with RN1, when asked why she failed to sanitize her hands after multiple gloves changes?, she stated, I should have sanitized my hands or washed my hands between glove changes. When I removed the one glove, it was because I didn't touch anything with the other glove. On 10/09/24 at 11:50 AM, during an interview with the Unit Manager, she stated, The nurses are supposed to sanitize after they remove gloves during a dressing change and apply new gloves. During an interview with the Director of Nurses (DON) on 10/10/24 at 8:59 AM, she stated, It's required to perform hand hygiene, before a dressing change, after removing a dressing, after completing the treatment. Whenever gloves are removed, they should sanitize their hands. Typically they remove both gloves, not just one, and then sanitize. 49818 Based on review of the facility policy, record review, observation, and interview, the facility failed to ensure hand hygeine was followed for 1 of 4 residents, (R)58, reviewed for pressure ulcers. Findings include: Review of the facility policy, date unspecified, titled, Wound Care/Dressing Change Procedure states under the policy, Clean the wound according to the order. Remove gloves and place in the trash. Hand hygeine. Put on clean gloves. Apply clean dressing as ordered. Remove gloves and place in the trash can. Make resident comfortable. Hand hygiene. Record review revealed R58 was admitted on [DATE] with diagnoses that included but not limited to dementia, depression, Alzheimers' Disease, dysphagia, and hypertension. Review of R58's treatment orders revealed a treatment order dated 09/03/24 to cleanse sacral wound with normal saline, apply medihoney and calcium alginate to wound bed, and cover with a dry dressing until healed. Apply house barrier cream and antifungal powder to skin surrounding wound to prevent moisture one time a day. Record review of a progress note dated 10/08/24 recorded Wound physician rounded and assessed R58's stage 4 pressure ulcer wound to sacrum. Surgical excisional debridement done at bedside by wound doctor. An observation of wound care on 10/09/24 at 11:27 AM with Registered Nurse (RN)1 revealed, She gowned and washed her hands, then applied gloves. The treatment supplies were already setup on R58's overbed table, to include a small tube of Medi-honey, calcium alginate, extra protective cream (EPC) anti fungal powder, normal saline and gauze on a towel on the overbed table. Privacy was maintained and her curtains were closed. The blankets were pulled down, and R58 was turned onto her side. There was no dressing observed. There was a foul odor emanating from the open wound. A deep crater was observed with a small amount of slough on the inside of the wound bed. RN1 cleaned the wound with normal saline solution and gauze. She discarded the gauze and removed the gloves, washed her hands and donned new gloves. She then applied Medi-honey into wound, with q-tip. She removed her gloves, but did not wash or sanitize her hands and applied another pair of gloves. She applied EPC cream with her fingered glove around the peri wound. She discarded one glove and applied another without sanitizing her hands. She placed the calcium alginate into the wound. She removed both gloves, and again falied to sanitize her hands. She applied the outer dressing, Mepore island dressing and applied antifungal powder, sprinkled to outer wound dressing and the dressing. She removed gloves, failed to wash or sanitize her hands, and donned new gloves. She repositioned R58 and turned her onto her left side with a wedge. Afterward, she removed her gloves. RN1 bagged all discarded items then removed the gown. She washed her hands and exited the room with the bag of soiled items. On 10/09/24 at 11:45 AM, during an interview with RN1, when asked why she failed to sanitize her hands after multiple gloves changes?, she stated, I should have sanitized my hands or washed my hands between glove changes. When I removed the one glove, it was because I didn't touch anything with the other glove. On 10/09/24 at 11:50 AM, during an interview with the Unit Manager, she stated, The nurses are supposed to sanitize after they remove gloves during a dressing change and apply new gloves. During an interview with the Director of Nurses (DON) on 10/10/24 at 8:59 AM, she stated, It's required to perform hand hygiene, before a dressing change, after removing a dressing, after completing the treatment. Whenever gloves are removed, they should sanitize their hands. Typically they remove both gloves, not just one, and then sanitize.

Based on review of the facility policy, record review, interviews, and observation, the facility failed to ensure Resident (R)60, 1 of 1 reviewed with food allergies, did not receive food items to which s/he was allergic. Findings include: Review of the facility's undated policy and procedure titled, ALLERGIES states: Policy- To avoid administration of medications and foods that cause residents to experience adverse reactions. The facility admitted R60 with diagnoses including but not limited to type 2 diabetes, anemia, osteoarthritis, and hyperlipidemia. Review of the Minimum Data Set with an Assessment Reference Date (ARD) of 11/28/22 revealed R60 has a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating he is cognitively intact. Record review on 01/05/23 at approximately 09:05 AM revealed a dietary order dated 11/22/22 stating CCHO REGULAR CONSISTENCY DIET ***NO FISH, NO PORK, NO SEAFOOD, AND NO IODINE CONTAINING COMPOUNDS***. Record review on 01/05/23 revealed a progress note dated 01/04/23 at 02:22 PM stating Resident ate a piece of shrimp gumbo during lunch. Resident has a shrimp allergy. Resident c/o dizziness. MD made aware. Resident sent to MRMC ED for evaluation. Attempts were made to interview R60 during the survey with no success. During an interview on 01/05/23 at 09:10 AM the Wing Supervisor/Licensed Practical Nurse (LPN) stated she couldn't give an answer on why R60 received shrimp on 01/04/23 when shrimp was listed as an allergy on 11/22/22. She stated to ask the Director of Nursing (DON). During an interview on 01/05/23 at 10:35 AM the Kitchen Manager (KM) stated that the residents have a meal ticket that tells the kitchen staff the type of diet and intolerances that the residents have. The KM did confirm R60 had shrimp gumbo for lunch on 01/04/23. S/he revealed kitchen staff that was plating the food didn't catch it, and it wasn't caught when the trays went out. She stated R60 went out to the hospital and returned the same day. During an interview on 01/05/23 at 12:30 PM the Administrator stated the kitchen staff preps the food, plates it, and disburses to Certified Nursing Assistants (CNA)s to hand out the trays on each unit. Administrator stated the meal tickets stay on the tray until the resident gets the tray and R60 had symptoms of dizziness and anxiousness after eating the shrimp gumbo. She revealed R60 was sent out to the hospital following the incident and returned the same day. During an interview on 01/05/23 at 1:50 PM the DON stated when the menu has an item that the resident is allergic to, typically there is an alternative list that staff provides the resident. She stated that R60 should have gotten an alternative menu on 01/04/23.

Based on observation, record reviews, interviews, and review of the facility's policy titled, Wander/elopement alarms, the facility neglected to provide adequate supervision for 1 of 1 resident reviewed for accidents related to wandering. Resident (R)1 had a successful elopement on 12/07/21 at 12:55 AM and was found by local police, one half mile away from the facility on [MEDICATION(S)] Street, in front of the South State Bank. R1 obtained no injuries. On 12/08/21 at 3:00 PM, the survey team provided an Immediate Jeopardy (IJ) template to the Administrator, notifying IJ existed at F600 due to the facility's neglect to adequately monitor R1, who has wandering behaviors, with an effective date of 12/07/21. On 12/09/21 at approximately 11:00 AM, the facility provided an acceptable IJ Removal Plan. The immediacy of the IJ was removed as of 12/08/21. The IJ was lowered to a scope and severity of D. Additionally, the failure constituted substandard quality of care, warranting the completion of an extended survey on 12/09/21. The facility's removal plan for F600 included: 1) all wanderers identified, and care plans reviewed and updated with preventions. 2) Inservice on wandering done each shift times three by DON or Administrator. 3) Preventions put into place- when resident is considered wandering or leaving area on their assigned wing, ensure that resident is attended by staff at all times-even during emergencies until resident is settled or in bed. Nurses will locate resident every 30 minutes when not wandering-added to MAR. Notify oncoming shift of issues and write in 24 hour report. Nursing Supervisor(s) assessed resident wandering and added to plan of care within 24 hours to prevent resident from eloping. All nursing staff on all shifts received education on wandering and possible elopement. Any staff on leave will be educated prior to next working shift. Residents will be provided individual activities or 1:1 attention when attempting to wander off of the wing/unit. Resident will be assisted in ambulating. Wanderguard checked for placement and operation daily. Staff will immediately answer any alarms. Implementation of the removal plan was verified through observation, staff interviews, and record reviews. Observation verified that all doors were functioning successfully with the wanderguards being used in the facility. Documentation review revealed that staff was educated with demonstration check offs on the use of wanderguards, immediacy on responding to door alarms, and following the elopement policy and procedures. These trainings were conducted on 12/08/21. Findings include: R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 10/26/2021 Minimum Date Set Assessment showed R1 has a Brief Interview of Mental Status (BIMS) of 4, indicating severe cognitive impairment. She also was coded in Section E:Behaviors as exhibiting wandering behaviors. The facility submitted a 24-hour report via facsimile to the State Agency on 12/07/21 indicating that around 1:00 AM on 12/07/21, staff heard a chirping sound coming from the front door on Chestnut hall. Staff saw that the door alarm was flashing and immediately started searching rooms. It was noticed that R1 was missing, so staff notified the Administrator and activated 911 to assist in the search. Staff began searching surrounding areas of the facility with police and R1 was found 1/2 mile down the road from the facility. R1 was returned back to the facility around 1:35 AM on 12/07/21. R1 was assessed and no injuries were noted. R1's family was contacted by the Director of Nursing (DON) about the incident. A record review of R1's progress note dated 12/07/21 at 2:09 AM revealed at approximately 1 AM, staff was unable to locate R1. All staff in the building alerted and all rooms were searched. Resident was not located in the facility. Administrator was made aware and 911 called. R1 was found by the police walking down [MEDICATION(S)] Street. Resident was returned to the facility by police. A 5 Day Report was submitted to the State Agency on 12/10/21, which states that once the staff knew the door alarm sounded, they started the search inside the facility before looking outside to see who had gotten out of the facility. Once staff realized that R1 was the resident that was missing, the Administrator was called and 911 was called as well. R1 was located by the police and a staff member met the police officer to pick her up and returned to facility. R1 was assessed and no injuries were found. Since the occurrence, the DON has re-educated the staff on the door alarm system and what it sounds like when alarm is activated. Staff was educated on wandering residents and the importance of documenting on wanderers every 30 minutes. On 12/8/21 at 11:00 AM, review of the facility's Policy titled Wander/Elopement Alarms: Elopement and Wandering Residents, states: the facility must ensure that residents that are exhibiting wandering behaviors and/or at risk for elopement must receive adequate supervision to prevent accidents. During the investigation on 12/08/21 at 11:17 AM, the Director of Maintenance (DOM) reported being aware of what door the resident R1 exited, and a tour was conducted of the facility with the DOM. Additionally, review of the video surveillance in the Administrator's office with the DOM revealed R1 was left at the nurses station alone and unsupervised by staff and exited the facility on 12/07/21 at 12:55 AM from the Chestnut unit near resident rooms [ROOM NUMBERS]. During the tour on 12/08/21 at approximately 11:45 AM, the DOM demonstrated the use of the door and held the bar down for 15 seconds and it alarmed. The DOM stated there was never a malfunction in the door alarm. The DOM placed a wanderguard up to the door and a click sound was heard and doors and wanderguard were observed to be working properly. During the investigation on 12/08/21 at 1:00 PM, a telephone interview with Certified Nursing Assistant (CNA)1 revealed, she was on duty during the elopement of R1. CNA1 reported R1 was sitting in front of the nurses' station for about an hour. CNA1 went into resident room [ROOM NUMBER] to assist with care and when she exited room [ROOM NUMBER], R1 was not sitting on the sofa and the back door had a chirp sound coming from it. A light went off at the end of the hall and the facility staff started looking for R1. CNA1 stated she got in her car to go look for R1, as did the nurse. CNA1 then saw blue lights on the corner of Quarts and [MEDICATION(S)] Street, with the police speaking to the R1 in front of South State Bank. CNA1 stated she did not hear the alarm go off. On 12/08/21 at 1:00 PM, an interview with Licensed Practical Nurse (LPN)2 revealed, R1 had been at the nurses' station for 1 hr and had reported she was waiting on her mother. LPN2 reported she left the nurses station to get lunch and to post the census and on her way back, she was met by an agency staff member who asked, if she knew where was resident R1? LPN2 responded, I do not know, look in the shower room. R1 was not in the bathroom and a frantic search was started. The Administrator was called, and the Administrator advised to call 911. On 12/08/21 at 1:20 PM, an interview with LPN3 revealed she was not working on that unit, but around 1:00 AM, she and another CNA heard a chirping noise and thought this was a C-Pap machine that was out of water. The CNA reported the chirping sound was not coming from the resident's room. LPN3 noticed the light was blinking at the far end of the hall and she went to the door and opened it, looked out of it, but did not see anything and closed the door back. Afterwards, LPN2 came and reported R1 was missing, and they began to search for R1. Observations of R1 on 12/8/21 and 12/9/21 showed R1 either in her room or in the day area with a wanderguard in place to ankle. Review of R1's undated care plan revealed wandering as a problem, without an onset date. The goals are for R1 to wander only within specified boundaries through the next care plan review date and to wander off floor no more than one time per week by next care plan review date. Interventions are to place resident in area where constant observation is possible, place monitoring device on resident that sounds alarms when resident leaves building, alert staff to resident's wandering behavior, provide diversional activities for resident when needed, approach resident in calm, accepting manner. The care plan indicated no successful elopements since admission.

Based on observation, record reviews, interviews, and review of the facility's policy titled, Wander/elopement alarms, the facility failed to provide adequate supervision for 1 of 1 resident reviewed for accidents related to wandering. Resident (R)1 had a successful elopement on 12/7/21 at 12:55 AM and was found by local police, one half mile away from the facility on [MEDICATION(S)] Street, in front of the South State Bank. R1 obtained no injuries. On December 8, 2021 at 3:00 PM, the survey team provided an Immediate Jeopardy (IJ) template to the Administrator, notifying IJ existed at F689 due to the facility's failure to adequately monitor R1, who has wandering behaviors, with an effective date of 12/7/21. On December 9, 2021 at approximately 11:00 AM, the facility provided an acceptable IJ Removal Plan. The immediacy of the IJ was removed as of December 8, 2021. The IJ was lowered to a scope and severity of D. Additionally, the failure constituted substandard quality of care, warranting the completion of an extended survey on 12/9/21. The facility's removal plan for F689 included: 1) Immediate meeting and in-service held on each shift by Administrator and Director of Nursing times next three shifts, 2) Write up the following for all staff to read and sign off on understanding including any agency staff (Have trained staff to do demonstrations for every agency staff). a. Demonstrate how wanderguards work b. Demonstrate the sound the alarm makes when a resident wearing the ankle monitor pushes on or opens a door c. Direct staff to immediately respond to sound of door alarms d. Direct staff to immediately and thoroughly check surrounding area outside to locate resident or determine reason for door alarm e. If no other reason for door alarm can be determined, continue to search area until resident is located inside or out f. Assign other staff to count all residents in the building (x2) to determine if a resident is missing and which resident it is g. Call Administrator to notify alarm sounding. Implementation of the removal plan was verified through observation, staff interviews, and record reviews. Observation verified that all doors were functioning successfully with the wanderguards being used in the facility. Documentation review revealed that staff was educated with demonstration check offs on the use of wanderguards, immediacy on responding to door alarms, and following the elopement policy and procedures. These trainings were conducted on 12/8/21. Findings Include: R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to: Dementia without behavioral disturbances and Hypertension. R1 has a Brief Interview of Mental Status (BIMS) of 4, indicating severe cognitive impairment. The facility submitted a 24-hour report via facsimile to the State Agency on 12/7/21 indicating that around 1:00 AM on 12/7/21, staff heard a chirping sound coming from the front door on Chestnut hall. Staff saw that the door alarm was flashing and immediately started searching rooms. It was noticed that R1 was missing, so staff notified the Administrator and activated 911 to assist in the search. Staff began searching surrounding areas of the facility with police and R1 was found 1/2 mile down the road from the facility. R1 was returned to the facility around 1:35 AM on 12/7/21. R1 was assessed and no injuries were noted. R1's family was contacted by the Director of Nursing (DON) about the incident. A record review of R1's progress note dated 12/7/21 at 2:09 AM revealed at approximately 1 AM, staff was unable to locate R1. All staff in the building alerted and all rooms were searched. Resident was not located in the facility. Administrator was made aware and 911 called. R1 was found by the police walking down [MEDICATION(S)] Street. Resident was returned back to facility by police. A 5 Day Report was submitted to the State Agency on 12/10/21, which states that once the staff knew the door alarm sounded, they started the search inside the facility before looking outside to see who had gotten out of the facility. Once staff realized that R1 was the resident that was missing, the Administrator was called and 911 was called as well. R1 was located by the police and a staff member met the police officer to pick her up and returned to facility. R1 was assessed and no injuries were found. Since the occurrence, the DON has re-educated the staff on the door alarm system and what it sounds like when alarm is activated. Staff was educated on wandering residents and the importance of documenting on wanderers every 30 minutes. On 12/8/21 at 11:00 AM, review of the facility's Policy titled Wander/Elopement Alarms: Elopement and Wandering Residents, states: the facility must ensure that residents that are exhibiting wandering behaviors and/or at risk for elopement must receive adequate supervision to prevent accidents. During the investigation on 12/8/21 at 11:17 AM, the Director of Maintenance (DOM) reported being aware of what door the resident R1 exited, and a tour was conducted of the facility with the DOM. Additionally, review of the video surveillance in the Administrator's office with the DOM revealed R1 was left at the nurses station alone and unsupervised by staff and exited the facility on 12/7/21 at 12:55 AM from the Chestnut unit near resident rooms 200 and 201. During the tour on 12/8/21 at approximately 11:45 AM, the DOM demonstrated the use of the door and held the bar down for 15 seconds and it alarmed. The DOM stated there was never a malfunction in the door alarm. The DOM placed a wanderguard up to the door and a click sound was heard and doors and wanderguard were observed to be working properly. During the investigation on 12/8/21 at 1:00 PM, a telephone interview with Certified Nursing Assistant (CNA)1 revealed, she was on duty during the elopement of R1. CNA1 reported R1 was sitting in front of the nurses' station for about an hour. CNA1 went into resident room 217 to assist with care and when she exited room 217, R1 was not sitting on the sofa and the back door had a chirp sound coming from it. A light went off at the end of the hall and the facility staff started looking for R1. CNA1 stated she got in her car to go look for R1, as did the nurse. CNA1 then saw blue lights on the corner of Quarts and [MEDICATION(S)] Street, with the police speaking to the R1 in front of South State Bank. CNA1 stated she did not hear the alarm go off. On 12/8/21 at 1:00 PM, an interview with Licensed Practical Nurse (LPN)2 revealed, R1 had been at the nurses' station for 1 hr and had reported she was waiting on her mother. LPN2 reported she left the nurses station to get lunch and to post the census and on her way back, she was met by an agency staff member who asked, if she knew where was resident R1? LPN2 responded, I do not know, look in the shower room. R1 was not in the bathroom and a frantic search was started. The Administrator was called, and the Administrator advised to call 911. On 12/8/21 at 1:20 PM, an interview with LPN3 revealed she was not working on that unit, but around 1:00 AM, she and another CNA heard a chirping noise and thought this was a C-Pap machine that was out of water. The CNA reported the chirping sound was not coming from the resident's room. LPN3 noticed the light was blinking at the far end of the hall and she went to the door and opened it, looked out of it, but did not see anything and closed the door back. Afterwards, LPN2 came and reported R1 was missing, and they began to search for R1. Review of R1's undated care plan revealed wandering as a problem, without an onset date. The goals are for R1 to wander only within specified boundaries through the next care plan review date and to wander off floor no more than one time per week by next care plan review date. Interventions are to place resident in area where constant observation is possible, place monitoring device on resident that sounds alarms when resident leaves building, alert staff to resident's wandering behavior, provide diversional activities for resident when needed, approach resident in calm, accepting manner. The care plan indicated no successful elopements since admission. Nursing Progress notes revealed on 7/21/21 resident was wandering in other residents' rooms but was re-directed to her own room. A review of R1's medical records and incident reports revealed she did not have a history of wandering out of the facility but wandering within the facility from room to room. R1's medical record since admission showed no other successful elopement attempts.

Based on record review, review of undated policy titled Baseline Care Plan, and interview, the facility failed to ensure the baseline care plan was completed for 2 of 3 residents (Resident (R) 1,2). The facility failed to ensure the baseline care plan was completed within the first 48 hours of admission. This failure places the resident at risk for improper care. Findings Include: A review of R1's undated Face Sheet revealed R1 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the form BASELINE CAREPLAN, indicated R1 was admitted on [DATE] at 1:30 PM. The form was signed by five staff members however; the line labeled Date Baseline completed was empty. There is no indication anywhere on the form of a completion date of R1's baseline care plan. A review of the undated policy titled Baseline Care Plan indicated the baseline care plan will be completed within 48 hours of the resident's admission. Additionally, it reveals a supervising nurse will verify within 48 hours that a baseline care plan has been developed. A review of R2's undated Face Sheet revealed R2 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R2 Minimum Data Set (MDS) with an assessment review date (ARD) of 11/1/21 revealed this was an admission assessment. R2 had a Brief Interview of Mental Status (BIMS) score of 15, indicating the resident is cognitively intact. A review of the form, BASELINE CAREPLAN, indicated R2 was admitted on [DATE] at 11:30 AM. The form is signed by five staff members however; the line labeled Date Baseline completed is empty. There is no indication anywhere on the form of a completion date of R2's Baseline Care Plan. An interview with the Director of Nursing (DON) on 11/18/21 at 1:30 PM confirmed the Baseline Care plan is to be completed within 48 hours. The care plan must have all staff signatures and a date and time of completion. An interview with the Administrator at 4:00 PM on 11/18/21 confirmed the baseline care plans need to be completed (signed and dated) within 48 hours of the resident's admission.

Based on record review, interview and review of the facility policy titled, Advance Directive, the facility failed to ensure Resident #21 and Resident #68 and/or his/her Responsible Party was afforded the right to formulate or refuse an Advance Directive and/or medical/surgical treatment for 2 of 5 residents reviewed for Advance Directives. The findings included: The facility admitted Resident #68 (R) on 5/13/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 6/21/2021 at approximately 3:41 PM of the medical record for R #68 revealed no documentation to ensure R #68 or his/her Responsible Party was afforded the right to formulate an advance directive. During further review on 6/22/2021 at approximately 2:21 PM of the medical record for R #68 for an Advance directive, the Director of Nursing, stated the Attending Physician would address the Advance Directive on his/her next visit to the facility. Review on 6/22/2021 at approximately 4:00 PM of the facility policy titled, Advance Directive, states under Policy, It is the policy of this facility to establish, maintain, and implement the resident's right to formulate or refuse an Advance Directive and/or medical/surgical treatment.' R #21 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Upon review of R #21's e-chart there was a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #21's paper chart indicated a FULL Code status as evidenced by, written documentation, no red dot on the outside of the chart by Resident #21's name as well as the absences of a red dot on Resident #21's wall name placard by her/his door. Licensed Practical Nurse (LPN) #3 stated s/he would refer to the sticker on the chart when needing to know the resident's code status. When asked what R #21's status was, upon review of the chart, LPN #3 answered with FULL CODE as R #21 does not have a red dot near the name on the chart. S/he also confirmed the e-chart status of DNR.

Based on record review and staff interview, the facility failed to notify the resident and the resident's representative of the discharge/transfer to the hospital emergency room (ER) in writing, and in a language and manner, they understand for one of one sampled residents reviewed for hospitalization . Findings: The facility admitted R #78 on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record reviewed on [DATE] at 10:32 AM revealed that on [DATE] the facility sent R #78 to the hospital emergency room (ER) for evaluation and treatment related to signs and symptoms of aspiration and respiratory distress. The resident expired at the hospital ,d+[DATE]/ 2021. The resident's medical record did not contain documentation to support that the facility notified the resident and the resident's representative in writing of the transfers and reasons for it. The Administrator provided documentation of the facility's Bed hold Notification form which included a brief summary of the reason the resident was transferred to the hospital, however this documentation was not signed by the resident or the resident's representative. During an interview with the Social Services on [DATE] at 10:15 AM, Social Worker (SW) #1 stated s/he calls the representative the day they are mailing out the bed hold notification letter and explains the facility's bed hold policy to the resident's representative. SW #2 confirmed the above statement and stated that the Ombudsman is notified monthly, but the facility has not sent the Ombudsman notification for the month of June. During an interview with the Director of Nurses (DON) on [DATE] at 10:18 AM, the DON stated the facility calls the family and informs them the reason for the transfer. A transfer form is filled out and provided to the hospital, and the nurses document in the nurses notes when the representative is contacted via phone and informed about the transfer.

Based on observation, record review and interview, the facility failed to ensure that the necessary care and services were provided for a resident to maintain grooming and personal hygiene. The facility also failed to keep the resident's environment clean and free from offensive odors for one of two sampled residents reviewed for activities of daily living (ADLs). Findings: The facility admitted R #70 on 11/25/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/21/2021 at 11:47 AM observed R #70 in [his/her] room with the door closed. After knocking and asking permission to enter the room, the surveyor observed resident in bed. There was a very strong and offensive urine odor in the R #70's room, and around [his/her] bed. R #70's clothes were disheveled, exposing [his/her] soiled brief. His/her white t-shirt had, what appears, urine stains on it. There was a urinal, with urine in it, hanging off the bed side rail. There was trash on the floor; including a juice carton, paper towels and clothes. In an interview with R #70 on 6/21/2021 at 11:48 AM [s/he] stated that [s/he] would like to have more freedom. S/he would like to see spouse whenever [s/he] wanted to. R #70 was not interested in getting out of the room to socialize with other residents. S/he was only interested in getting out of the room if [s/he] going to visit with [his/her] spouse. On 6/21/2021 at 02:17 PM R #70 was observation in [his/her] room. Door closed, room not cleaned or free from offensive urine odor, resident not bathed or changed. On 6/21/2021 at approximately 4:15 PM, the resident was still not changed and [his/her] room not cleaned, and the urinal was not empty or removed. Care plan reviewed on 6/23/2021 at 1:29 AM indicated that R #70 is unable to do [his/her] own ADL care. S/he requires set-up to extensive assistance with ADLs. Resident needs total assistance with bathing. R #70 can feed self and move about in wheelchair. Resident refuses showers, baths, and changing clothes at times. Nurses' notes reviewed on 6/21/2021 at approximately 4:35 PM did not have notes regarding resident refusing showers, change of clothes or to having [his/her] room clean on 6/21/2021. Review of the Minimum data set (MDS) with an assessment date of 2/24/2021 and reviewed on 6/23/21 at approximately 1:45 PM indicated that R #70 needed supervision with bed mobility, transfer, dressing, toilet use and personal hygiene. The MDS assessment dated [DATE] indicated that R #70 needed supervision with bed mobility, transfer, and dressing. S/he needed limited assistance with toilet use and personal hygiene. Review of R #70's activity of daily living (ADL) log for June, revealed that bathing was not documented at all on 6/1/21, 6/2/21, 6/5/21, 6/6/21, 6/9/21, 6/16/21, 6/19/21, 6/21/2. On 6/4/21, 6/10/21, 6/12/21, bathing was done by resident independently and 6/13/21 and 6/18/21 bathing did not occur. In an interview with Certified Nursing Assistant (CNA) #3 [s/he] stated that R #70 has episodes of bowel and bladder incontinence. The CNA stated that [s/he] has no issues with the resident when providing care. S/he added that the resident moves around [his/her] room in the wheelchair and prefers to be in [his/her] room. On 6/24/2021 at 11:15 AM, an interview was conducted with the MDS Coordinator regarding discrepancies among the R #70's care plan, MDS assessment, and the ability/willingness care for self. S/he acknowledged concerns brought forward regarding R #70 and [his/her] ADLs care performance. In an interview with the Director of Nursing on 6/23/2021, [s/he] acknowledged the resident's poor hygiene status and stated that R #70 is upset. His/her spouse used to be at the facility and [s/he] was able to visit whenever [s/he] wanted to but the spouse was discharged to the community.

Based on observation, interview, record review and review of facility activity calendar, the facility failed to ensure two (R #54 and #56) of two residents received ongoing program of activities to meet the individual needs and interest, which had the potential to negatively affect the well-being of the resident. The findings included: On 06/21/2021 at 12:43 pm, R #56 was observed with his/her eyes closed in bed. Interview with the resident representative stated they are unsure if any activities are held with the resident. At 1:35 pm, the resident was observed being fed by staff. At 3:28 pm, the resident was observed sitting up in bed awake with no activities noted during this period. Subsequent observation of R #56 at 02:01 pm on 06/22/2021 revealed he/she was awake in the bed with the TV on watching it with no other activities noted. At 3:20 pm, the resident was observed laying in bed awake looking at TV with no other activities observed. On 06/23/2021 at 10:43 am the resident was observed laying in bed awake with the television on. At 12:00 pm, the resident was observed lying in bed awake with the television on and no activities observed. At 02:01 pm, the resident was observed in bed awake looking at television with no activities observed. Review of R #56's 05/26/2021 care plan denoted Provide individual activities or materials for activities in room, provide nail care and one on one visits to resident, and provide in room activities of choice, as able. Review of the resident activity calendar sheet dated 05/09/2021-06/23/2021 revealed the following activities listed: 05/09 Mother's Day with carnations and stop visits, 05/10/21 Stop visits, 06/03/21 stop visits, 06/07/21 Calendar hanging and stop visits, 06/18/21 stop visits, and 06/21/21 stop visits and hanging calendars in rooms. On 06/23/2021 at 3:30 pm interview with Activities Director revealed the residents that can't come to the activity I stop and talk with them and provide support to them. Staff also provide one on one. The care plan addresses what activities the resident will be provided. Care plans are updated every quarter and if there's any significant changes and annually. On 06/23/2021 at 3:45 pm review of the activity calendar revealed on the days of the survey one activity for each day with stop visits, mail visits, and one to one activities scheduled for each day. The facility's 03/11/2021 policy addressing Activities, 2. Activities will be designed with the intent to: h. Reflect choices of the residents. Activities will be accomplished via activities on each hall with residents in their doorway, room visits, 1:1 (one to one) activities . Additional findings included: On 06/21/2021 at 11:04 am R #54 was interviewed and stated that he/she was not doing any activities at all. We used to play Bingo but we haven't been doing that either. At 3:01 pm, the resident was observed asleep in bed with no activities observed during the day. Subsequent observation of R #54 at 09:45 am on 06/22/2021 revealed he/she was sitting up in a wheelchair with no activities in the hallway. At 01:19 pm, the resident was observed asleep in the bed. At 1:59 PM, the resident was observed asleep in the bed. At 3:23 pm, the resident was observed asleep in the bed. At 3:59 pm, the resident was observed awake in the bed with a Certified Nursing Assistant in the room assisting with care needs. On 06/23/2021 at 10:09 am R #54 was observed asleep in bed but easily aroused with the television on with no other activities. Resident stated that she still had not been provided any activities to do. At 12:05 pm, the resident was observed sitting in his/her wheelchair in his/her room with the television on and no activities observed for the resident. At 2:07 pm, the resident was laying in bed asleep with no activities observed. Review of R #54's 05/26/2021 care plan denoted Resident requires individualized activity visits and interactions due to imposed Public Health emergency precautions r/t (related to) Covid 19 I will accept and participate in 1:1 (one to one) visits with activity staff Provide individual activities or materials for activities in room, provide nail care and one on one visits to residents . Review of the resident activity sheet dated 03/23/21-06/23/21 revealed the following activities listed from May to June: 05/01/21 Stop visits, 05/03/21 stop visits, 05/04/21 Mail delivery, 05/07/21 stop visits, 05/09/21 Mother's day with carnations and stop visits, 05/10/21 stop visits, 05/11/21 stop visits, 05/19/21 one to one visits, 05/27/21 stop visits, 06/07/21 calendar hanging, stop visits, mail delivery, 06/08/21 stop visits, 06/09/21 stop visits, 06/11/21 stop visits, and 06/21/21 stop visits and hanging calendars in rooms. On 06/23/2021 at 3:45 pm review of the activity calendar revealed on the days of the survey one activity for each day with stop visits, mail visits, and one to one activities scheduled for each day.

Based on observation, interview, record review, review of facility policy and procedure, the facility failed to ensure that one (R #56) of one resident received treatment and care based on the comprehensive person-centered care plan and assessment. The findings include: R #56 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of hospice recertification dated 03/29/2021 for certification period 04/13/2021 to 07/11/2021 denoted a calendar frequency for skilled nursing visits effective 04/13/2021 1W13 (one time a week for thirteen weeks), 4 PRN (four as needed visits) symptom management and Master social worker visits effective 04/13/2021 1M1 (one time a month for one month), 2M2 (two times a month for two months), 2 PRN (two as needed visits) psychological needs. Subsequent record review on 06/22/2021 noted ten hospice aide visits for April, twenty visits for May, and fourteen visits in June with no hospice aide order. On 06/23/2021 at 2:35 pm interview with LPN #1 revealed that the hospice facility provided an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional findings included: Review of Resident #56's 06/18/2021 hospice recert summary report denoted medications effective for the 4/13/21 to 07/11/21 certification period with the following medications noted as active: Novolog [MEDICATION(S)] U (unit)-100 (one hundred) insulin 3 (three) ml (milliter) as directed per sliding scale, [MEDICATION(S)] 80 (eighty) mg (milligram) at bedtime, and [MEDICATION(S)] Kwikpen U (unit)-100 (one hundred) insulin 3 (three) ml (milliter) at bedtime. Subsequent review of the facility Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/23/2021 at 9:28 am interview with LPN #2 revealed that hospice orders all meds for the patient. Hospice is supposed to give us (the facility) updates for the medications. They provide the list and we follow it but all insulins for the resident were discontinued and I am unsure why it is still showing on their list. Additional findings included: On 06/21/2021 at 12:13 pm R #56 was observed laying on his/her back during the resident representative interview. At 1:35 pm, the resident was observed being fed by staff. At 3:28 pm, the resident was observed sitting up in bed on his/her back awake. Subsequent observations at 1:05 pm on 06/22/2021 revealed R #56 sitting up in bed being fed by a staff member for lunch. At 2:02 pm, the resident was observed laying on his/her back watching television. At 3:56 pm, the resident was observed still laying on his/her back. On 06/23/2021 at 10:43 am R #56 observed laying in bed on back awake. At 12:00 pm, the resident was observed lying in bed on his/her back awake. At 2:01 pm, the resident in bed awake looking at TV on back. At 4:00 pm, the resident was laying on his/her back asleep. Review of resident monthly summary dated 06/01/2021 revealed the resident is to be positioned every 2 (two) hours. Review of charge nurse turn logs dated 06/21/2021 revealed documented position changes from eight am to four pm only with no documentation from twelve am to six am and six pm to ten pm, 06/22/2021 position changes noted from eight am to ten pm only with no documentation from twelve am to six am, and 06/23/2021 with twelve am to eight am with no documentation from ten am to four pm. On 06/23/2021 at 2:25 pm interview with LPN #1 revealed the nurses document information on the turn log. If a resident refuses the nurses document that and if the resident is self care or has a certain preference that information is placed on their care plan. The blank sections on the turn log are supposed to be filled out in its entirety.

Based on record review and interview, the facility failed to provide the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. Findings: Review of the daily nurse staffing postings dated from March 21, 2021 through June 20, 2021 on 6/22/2021 at approximately 4:00 PM revealed the following: On May 23, 2021, the facility's census was 85 and the services of the RN were not provided on the first, second, or third shift. On June 6, 2021, the facility's census was 84 and the services of a RN were not provided on the first, second, or third shift. On June 20, 2021, the facility's census was 79 and the services of a RN was not provided on the first, second, or third shift. In an interview with the Director of Nursing on 6/23/2021 at 2:53 PM, s/he reviewed and confirmed that the services of a RN were not provided for at least 8 consecutive hours a day for seven days a week on May 23, June 6, and June 20.

Based on record review and interview, the facility failed to ensure all residents were free of significant medication errors affecting one (#21) of two residents. The findings include: R #21 was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R #21 orders and Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Novolog 100 unit/ml [MEDICATION(S)]- inject 12 units subcutaneously three times daily with meals, dated 10/27/2020. It was not documented as given on: 3/12/2021 (12:30pm). 4/10/2021 (7:30am), 4/11/2021 (7:30am), 4/12/2021 (5:30 pm), 4/19/2021 (5:30 pm), 4/26/2021 (5:30 pm), 4/28/2021 (5:30 pm). 5/03/2021 (5:30pm), 5/06/2021 (5:30pm), 5/08/2021 (5:30pm), 5/9/2021 (5:30pm), 5/11/2021 (7:30am, 12:30pm, 5:30pm), 5/14/2021 (7:30am, 5:30pm), 5/18/2021 (5:30pm), 5/28/2021 (5:30pm), 5/31/2021 (5:30pm). 6/3/2021 (5:30 pm), 6/6/2021 (5:30 pm), 6/7/2021 (5:30pm), 6/11/2021 (7:30 am), 6/14/2021 (5:30pm), 6/17/2021 (5:30pm), 6/18/2021 (7:30 am, 12:30 pm), 6/19/2021 (7:30 am), 6/20/2021 (7:30 am) , 6/21/2021 (5:30pm) [MEDICATION(S)] 125 mcg tablet 1 tab by mouth daily, dated 4/12/2019, start date 7/11/2019. It was not documented as given on: 4/8/2021, 4/16/2021, 5/14/2021, 5/24/2021, Toresmide 100 mg tablet 1 tab by mouth daily, order date 9/12/2019, start date 10/12/2019, discontinue date 5/14/2021. It was not documented as given on: 4/12/2021. [MEDICATION(S)] Flextouch 100 unit/ml inject 20 subcut twice daily, order date 11/9/2020. It was not documented as given on: 3/18/2021 (7:00 pm). Medication policy reviewed.