Every finding on record at Hobart Nursing & Rehabilitation

Based on observation, record review, and interview, the facility failed to ensure:a. a resident with known exit seeking/wandering behaviors had adequate supervision to prevent elopement for 1 (#1) of 5 sampled residents reviewed for adequate supervision to prevent elopement; andb. adequate supervision to prevent access to the kitchen for 2 (#2 and #3) of 5 sampled residents reviewed for adequate supervision to prevent accidents and hazards.The DON identified five residents at risk for elopement and wandering. 1. On 04/24/26, an Immediate Jeopardy (IJ) situation was determined to have existed related to the facility's failure to prevent a resident with known exit seeking behaviors from eloping from the facility. The deficient practice resulted in Resident #1 eloping from the facility and being found by local law enforcement in a residential neighborhood three blocks from the facility. The failure had the potential for serious injury, serious harm or death.On 04/24/26 at 5:18 p.m., the OSDH confirmed the existence of the immediate jeopardy situation.On 04/24/26 at 5:23 p.m., the DON, corporate administrator, social services, and the MDS coordinator were notified of the IJ situation and provided the IJ template.On 05/29/26 at 8:36 a.m., an acceptable plan of removal for elopement was received related to the facility's failure to prevent a resident with known exit seeking behaviors from eloping from the facility. The POR, read in part, 1. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address and prevent any additional residents from leaving the facility unsupervised. (Completion Date: 4-8-26) Resident directly involved in this incident had their care plan reviewed and updated by the DON or designee and updated to reflect current wandering and elopement risk. 4-8-26 Resident directly involved in this incident was immediately assessed by DON upon return to the facility with no injuries noted 4-8-26 Resident directly involved in this incident is on 1:1 supervision until alternate placement can be identified or is assessed and does not demonstrate active elopement behavior 4-8-26 and ongoing The DON or designee reviewed the elopement risk assessment on all residents 4-8-26 The DON, designee(s) and/or MDS Coordinator re-evaluated the plans of care for all residents at risk for elopement 4-8-26 All nursing staff on all shifts received education on elopement, and resident safety from the DON or designee(s). Any staff on leave will receive education on their next scheduled work day 4-8-26 and ongoing2. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent this incident from reoccurring. (Completion Date: 4-8-26) Elopement residents' policy was reviewed on 4-8-26. The DON or designee will audit new admissions for elopement risk and ensure appropriate interventions are in place - ongoing. The DON or designee did audit completed MDS's to ensure the care plan reflects needs/concerns identified in the CAAs (care areas assessment) on 4-8-26. New hires will receive education on elopement, and resident safety by the DON, Director of Social Services, or designee(s) - ongoing. Residents at risk for elopement are monitored q 2 hours for safety - ongoing. An Elopement Response Drill schedule was implemented, with drills occurring quarterly on all shifts. 4-8-26 and ongoing. All exit doors and alarms were tested for functionality 4-8-26. Additionally, all doors will continue to be monitored daily - ongoing. Windows in rooms occupied by residents at risk for elopement will be monitored q 2 hours for security. 5-27-26 and ongoing. Root cause analysis has been conducted. Risk factors include:Accurate assessment of resident elopement risk.Training and education of staff on resident elopement.Monitoring process of residents at risk for elopement.Exit doors (including those to the smoking area)Residents at risk for elopement have the potential to follow staff and visitors outside.Environmental assessment including monitoring doors (including doors that lead to the smoking area) and windows for security. 5-27-28 Signage has been posted at the entrance to remind staff and visitors not to allow residents to follow him/her outside the facility. 4-8-26 Staff will be educated on risk factors and take extra precautions to ensure residents are secure and prevent elopement. A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project was implemented to review and interpret all audit findings. All findings will be discussed at the monthly QAA meeting for a minimum of three months or until the pattern of compliance is maintained - ongoingDate Facility Asserts This Incident Has Been Addressed: 4-8-26Action Plan to Ensure Relevant Recommendations Are Followed:Action/Task Person(s) Assigned Date CompletedReview current policies to ensure appropriate procedures are in place to prevent elopement. [name of administrator]/ [name of DON] 4-8-26Checklists and monitoring tools used to verify compliance in PCC (point click care).[name of DON] 4-8-26 and ongoingEducate necessary staff on facility procedures with return demonstration, where applicable.[name of DON] and designee(s) 4-8-26 and ongoingDocument PIP implementation, PIP progress, and QAA Committee Meeting Minutes where PIP is discussed.[name of administrator] As scheduled IDT / MDS / Care Planning [name of DON] and IDT 4-8-26 and ongoingImplementation of window monitoring for security. [name of DON] 5-27-26 and ongoing.The IJ related to elopement was lifted, effective 05/29/26 at 5:00 p.m., when all components of the plans of removal had been verified as completed. A review of the resident audits was conducted. Resident #1 discharged to another facility on 05/05/26. Observations were made of the facility exits and signage in place. Staff were observed responding to exit alarms timely. In-service training regarding care plan updating by the IDT, elopement prevention strategies and policy which included facility access monitoring, window monitoring, identifying residents at risk for elopement and their care plans were reviewed. Staff from multiple departments and shifts were interviewed to ensure the in-service trainings had been completed. The deficient practice remained at an isolated level with the potential for more than minimal harm that is not immediate jeopardy. 2. On 05/26/26 at 9:35 a.m., an Immediate Jeopardy (IJ) situation was determined to have existed related to the facility's failure to prevent residents having unsupervised access to the kitchen to prevent potential accidents and hazards. This had the potential for serious injury, serious harm, or death due to access to toxic chemicals, hot liquids, sharp objects, and an unlocked exterior door.On 05/29/26 at 4:18 p.m., the OSDH confirmed the existence of the IJ situation.On 05/29/26 at 4:26 p.m., the administrator was notified of the IJ situation and was provided the IJ template. On 06/02/26 at 10:46 a.m., an acceptable plan of removal was received related to the facility's failure to prevent adequate supervision to prevent residents with a history of wandering from having access to the kitchen in order to prevent potential accidents and hazards. The POR, read in part, 1. Immediate action(s) taken for the resident(s) found to have been affected include:Residents Res #2 and Res #3 could have been affected by failure to prevent access to the kitchen. These residents did not enter the kitchen or sustain injury, but nursing conducted an assessment to ensure the residents were not harmed. 5-29-262. Identification of other residents having the potential to be affected was accomplished by:Residents with cognitive impairment have the potential to be affected by this alleged deficient practice.3. Actions taken/systems put into place to reduce the risk of future occurrence include:a. Facility Administrator read and understands the Accident and Supervision Policy. 5-29-26b. Kitchen staff have been educated on the Accident and Supervision Policy. This education included a discussion about the failure of kitchen staff to leave the environment unsecured / unattended as a case study. This education also included a tour of the kitchen to specifically identify risk factors, i.e. hot surfaces, food items cooking, sharp objects, freezer, chemicals, etc. This education specifically outlined securing the half door, kitchen door, back kitchen door and dish room door to prevent resident entrance. Education also included the importance of not leaving the kitchen unattended, which requires schedule and breaks to align with kitchen supervision. 5-29-26c. Facility conducted a Root Cause Analysis based on findings (the facility failed to provide adequate supervision to prevent resident access to the kitchen). Risk factors include: 5-29-26i. Doors entering the kitchen were not closed and not secured.ii. Staff were not present in the kitchen to monitor the environment.iii. Lack of staff understanding that residents entering the kitchen are at risk for serious injury, serious harm, serious impairment, or death.d. Facility posted signs on the kitchen door, dish room door and door leading outside as a visual reminder to close and lock doors to prevent residents entering the kitchen. 5-29-26e. Facility leadership conducted an emergency QAPI to discuss these interventions. The Medical Director was notified telephonically. 5-29-26f. Facility expanded the in-service education to all staff. This education includes a discussion about the failure of kitchen staff leaving the environment unsecured / unattended as a case study. This education also included a tour of the facility to specifically identify risk factors, i.e., closets and areas that contain hazardous items to residents and the importance of securing and locking these doors. Departments specifically reviewedincluded nursing, maintenance, housekeeping, laundry, and the kitchen. During the tour, examples of injuries that could occur in each department were discussed to illustrate the importance of accident and hazard prevention. 6-1-264. How the corrective action(s) will be monitored to ensure the practice will not reoccur:Dietary Manager or designee is responsible for monitoring access to the kitchen during regular 'open' hours of operation. Dietary Manager or designee is also responsible for ensuring half door, kitchen door, back kitchen door, dish room door are secured and locked before leaving the kitchen outside of regular 'open' hours of operations. 5-29-26Facility managers or designees are responsible for monitoring access to that department's area. These areas include housekeeping closets, laundry room, maintenance areas, and medication room / carts. These areas should be secured and locked while not actively in use or monitored by staff. 6-1-26Corrective action completion date: 6-1-26.The IJ related to providing adequate supervision to prevent accidents and hazards was lifted on 06/02/26 when all aspects of the POR was reviewed and validated as completed. A review of potential affected residents' health record was reviewed. In-service trainings reviewed showed staff from all departments received training on ensuring all areas with potential accidents and hazards were secured to prevent residents from having access to all potential accidents and hazards in the facility. Observations were made throughout the facility of all closets, maintenance rooms, medications rooms, storage areas, and the kitchen of being secured and not accessible to residents. Signage was observed to make staff and visitors aware of any risk and to keep all areas with accident and hazards concerns locked and not accessible to residents. All chemicals, sharp objects, hot liquids, medications, and environmental hazards were observed to not be accessible to residents. Staff from multiple shifts and departments were interviewed over the in-service trainings they received. All staff interviewed were able to articulate the in-service training they received over preventing residents from having access to potentially hazardous areas, items, and providing adequate supervision. The deficient practice remained at an isolated level with the potential for more than minimal harm that is not immediate jeopardy. Findings:A policy titled Accidents and Supervision, dated 04/16/24, read in part, The resident will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to decrease the risk of accidents. This includes:Identifying hazards and risk. Evaluating and analyzing hazards and risks.Implementing interventions to reduce hazards and risks.Monitoring for effectiveness and modifying interventions when necessary.4. Monitoring and Modification- Monitoring is the process of evaluating the effectiveness of care plan interventions. Modification is the process of adjusting interventions as need to make more effective in addressing hazards and risk. Monitoring and modification process include:a. Ensuring that interventions are implemented correctly and consistentlyb. Evaluating the effectiveness of interventionsc. Modifying or replacing interventions as neededd. Evaluating the effectiveness of new interventions .5. Supervision- Supervision is an intervention and means mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision:a. Defined by type and frequencyb. Based on the individual resident's assessed need and identified hazards in the resident environment.1. An Elopement Risk Assessment for Resident #1, dated 09/11/25, showed the resident had made one attempt to elope and had to be redirected. The assessment was scored at a 10 which indicated a high risk for elopement. An Elopement Risk Assessment for Resident #1, dated 09/12/25, showed no history of elopements and was scored at a 10 which indicated a high risk for elopement. A nurses note for Resident #1, dated 09/22/25, read in part, Resident exited the door after the Hospice nurse, staff is notified immediately and resident is redirected back inside.An Elopement Risk Assessment for Resident #1, dated 12/12/25, showed no history of elopements and was scored at a 10 which indicated a high risk for elopement. A nurses note for Resident #1, dated 03/25/26, showed the resident had attempted to exit seek and had to be redirected back to their room. An annual assessment for Resident #1, dated 03/29/26 showed they had a BIMS score of 4 which indicated their cognition was severely impaired. The assessment showed they had diagnoses which included dementia and anxiety disorder. The assessment showed the resident was independent for ambulation and transfers. The assessment showed the resident did not wander during the seven day look back period.An Elopement Risk Assessment for Resident #1, dated 03/29/26, showed no history of elopements and was scored at a 10 which indicated a high risk for elopement. A facility incident report, dated 04/08/26, showed the BOM received a phone call from the police department. The report showed Resident #1 was found wandering and confused by the local police department in a residential neighborhood three blocks from the facility. The report showed the facility started their elopement drill by counting the residents. A Radio Log police report, dated 04/08/26, showed the following:a. on 04/08/26 at 7:48 a.m., the police located Resident #1 in the neighborhood three blocks from the facility,b. on 04/08/26 at 8:10 a.m., law enforcement notified the facility, that was not aware the resident was gone, they had located Resident #1. The log showed the resident was in the ambulance warming up, and the facility was on their way to get the resident, andc. on 04/08/26 at 8:31 a.m., the log showed Resident #1 was released to the facility.A care plan for Resident #1, revised on 04/08/26, showed a focus for being an elopement risk due to safety awareness. The care plan showed the following interventions:a. one on one supervision initiated on 04/08/26,b. medications reviewed by the physician initiated on 04/07/26,c. attempt to engage the resident in pleasant, meaningful, purposeful activities initiated on 12/29/23,e. distract the resident from wandering with pleasant diversions like food, activities, conversations, books, and television initiated on 12/29/23,f. document the resident's behavior and attempt interventions with meaningful activities, validation, and relationship-based redirection initiated on 12/29/23,g. psychiatric services to treat and evaluate as needed initiated on 03/13/25, andh. observe the resident's location in the community initiated on 12/29/23 and provide directional cues like pictures and names on the door to distract the resident initiated on 12/29/23.There was no revision of Resident #1's care shown after the following: a. a nurses note, dated 09/22/25, showed Resident #1 attempted to elope, andb. a nurses note, dated 03/25/26, showed exit seeking behavior.On 04/23/26 at 1:00 p.m., the front door was observed locked with a keypad and an audible alarm when opened. The door was observed posted with signage to alert visitors to be cautious there were residents in the facility who may try and exit.On 04/23/26 at 1:26 p.m., Resident #1 was observed in their room in bed. A housekeeper was seated outside of the resident's room providing one on one supervision with a clip board to document the residents one on one supervision.On 04/28/26 at 1:36 p.m., Resident #1 was observed in their room in bed. Driver #1 was observed outside the room in a chair to perform one on one supervision with a log on a clip board to document the resident's location hourly. On 04/23/26 at 1:26 p.m., Resident #1 stated they crossed the street and was trying to go home. On 04/23/26 at 1:55 p.m., CMA #1 stated on 04/08/26 at 6:30 a.m., Resident #1 stated they wanted to leave the facility to care for some children.On 04/23/26 at 2:00 p.m., the BOM stated Resident #1 talked about children down the street they needed to care for. The BOM stated Resident #1 hung around by the door. The BOM stated on 04/08/26 at 8:07 a.m., they were notified by local law enforcement Resident #1 was found three blocks from the facility in a residential neighborhood. On 04/23/26 at 4:10 p.m., the MDS coordinator stated on 04/08/26 at 7:30 a.m., Resident #1 had asked to leave the facility to care for children. They stated the resident was redirected to their room and they notified the administrator. The MDS coordinator stated local law enforcement notified the facility around 8:00 a.m., that Resident #1 had been found. They stated the facility started a code green (elopement drill) and started a head count of residents. The MDS coordinator stated they left the facility and went to where local law enforcement located the resident in a residential neighborhood. They stated Resident #1 was in an ambulance when they arrived at the location of the resident. The MDS coordinator stated Resident #1 had dementia, had tried to follow others out in the past, and was an elopement risk.On 04/24/26 at 9:27 a.m., the MDS coordinator was asked to review Resident #1's annual MDS assessment, dated 03/29/26. They stated the assessment was not correct because it did not reflect Resident #1's wandering which was documented in the nurses note on 03/25/26. They stated the care plan was not revised at the time of the assessment because it did not capture the wandering documented in Resident #1's nurses note 03/25/26.On 04/24/26 at 9:51 a.m., the DON stated Resident #1 eloped from the facility on 04/08/26. The DON stated the resident had spoken with the MDS coordinator earlier in the morning and expressed they wanted to leave the facility. They stated the facility was not aware the resident had eloped until law enforcement notified them on 04/08/26 at 8:07 a.m. The DON stated the resident was in an ambulance located in a residential neighborhood three blocks from the facility. The DON stated the resident was returned to the facility, assessed, and found to have no harm. The DON reviewed Resident #1's comprehensive assessment dated [DATE]. The DON stated the assessment was not correct due to the assessment did not document the wandering behaviors from the resident's nurses note dated 03/25/26. The DON stated the care plan should have been updated with new interventions which could have prevented the resident from eloping on 04/08/26. They stated residents with an elopement score of ten were considered a high risk.On 05/29/26 at 9:50 a.m., the CDM stated they could not identify any residents at risk for elopementOn 05/29/26 at 9:51 a.m., cook #1 stated residents at risk for elopement could be identified by a star.On 05/29/26 at 9:52 a.m., the administrator stated there was no star identifier for residents at risk for elopement.2. On 05/29/26 at 9:29 a.m., the lower door and split upper door going from the kitchen to the dining room was observed opened. There was no staff observed in the kitchen or dining area. Resident #2 was in a wheelchair 6 feet from the open door and Resident #3 was seated at a table 6 feet from the open door. A tour of the kitchen was conducted. The following observations were made:a. a stock pot was on the front burner of the gas stove, was being heated with no lid, and steam was coming from the pot, b. kitchen knives were on the wall on a magnetic rail holder,c. the storeroom was open and contained hazardous chemicals in one-gallon containers. The chemicals included: aa. one-gallon container of chlorine bleach, bb. one-gallon container of foaming hand sanitizer, cc. one-gallon containers of purple degreaser, dd. one can of aerosol [NAME] stainless steel cleaner, ee. one-gallon containers of Mach Dry Mate rinse additive, ff. one-gallon containers of Mach Endurance concentrated detergent, gg. one-gallon containers of concentrated quat sanitizer, andd. the exterior door in the back of the kitchen was unlocked and there was access to an unsecured area and extensive farm field.On 05/29/26 at 9:35 a.m., cook #1 was observed to exit the back door of the kitchen to outside the facility. The door was not locked or no alarm sounded.A MSDS titled Mach Endurance, dated 01/13/20, showed the product was harmful if swallowed and could cause burns to the skin and eyes. The sheet showed the product should have been stores locked up. A MSDS titled Mach Drymate, dated 01/01/20, showed the product was harmful if swallowed and if it came into contact with the skin and eyes could cause burns. A MSDS titled Solution QA, dated 01/01/20, showed the product was harmful if swallowed and could cause burns to the skin and eyes. The sheet showed the product should have been stores locked up. A MSDS titled D-Grease, dated 01/10/20, showed the product was harmful if swallowed and could cause burns to the skin and eyes. The sheet showed the product should have been stored locked up. A MSDS titled Stainless Steel Polish, dated 01/01/20, showed the product was harmful if swallowed and could cause burns to the skin and eyes. An undated facility document titled Elopement Risk List showed the following residents were elopement risk:a. Resident #2; andb. Resident #3.A nurses note for Resident #2 dated 04/17/26, showed Resident #2 was cursing at staff, went down a hallway they were not allowed on, grabbed the front door, and was attempting to exit the facility.An annual assessment for Resident #2, dated 04/18/26, showed they had a BIMS score of 00 which indicated their cognition was severely impaired. The assessment showed the resident wandered and their behaviors were worse since the last assessment. The assessment showed the resident ambulated with the assist of a manual wheelchair and required supervision or touching assistance intermittently to propel.An elopement assessment for Resident #2, dated 04/29/26, showed the resident propelled self with some assist, wandered near the doors, wandered aimlessly, and was at risk for elopement with a score of 10. A quarterly assessment for Resident #3, dated 04/16/26, showed the resident's BIMS score was 15 which indicated their cognition was intact. The assessment showed the resident ambulated without assistance. The assessment showed the resident had diagnoses which included schizophrenia and depression. A care plan for Resident #3, revised 04/24/26, showed the resident had a focus for being an elopement risk.On 05/29/26 at 9:31 a.m., the CDM stated the door from the kitchen to the dining room was left open and no staff were present in the kitchen or the dining area. The CDM stated the two residents near the open unattended door was Resident #2 and Resident #3. The CDM stated the residents could have accessed the kitchen, been burned, accessed sharp items, or eloped out the unsecured back door. On 05/29/26 at 9:44 a.m., the administrator stated staff should not be entering and exiting the facility by the rear kitchen door. They stated the door should have been locked at all times.On 05/29/26 at 10:40 a.m., the administrator stated the kitchen was not secured and locked which could have caused residents to be burned or harmed.On 05/29/26 at 1:35 p.m., CNA #2 stated Resident #3 ambulated without assistance, wandered inside the facility and in and out of other residents' rooms. CNA #2 stated Resident #2 self-propelled in a wheelchair and wandered in and out of other residents' rooms.On 05/29/26 1:40 p.m., CMA #1 stated Resident #3 ambulated without assistance, wandered inside the facility and went in and out of other residents' rooms. CMA #1 stated Resident #2 self-propelled in a wheelchair and tried to open all doors.On 05/29/26 at 2:01 p.m., the administrator stated that both staff persons in the kitchen went on break at the same time. They stated the other staff was on a smoke break, so the kitchen was left unattended and open.

Based on record review and interview, the facility failed to ensure a comprehensive assessment accurately reflected wandering/exit seeking behavior for 1 (#1) of 3 sampled residents reviewed for comprehensive assessments. The DON identified 37 residents resided in the facility.Findings:On 04/23/26 at 1:26 p.m., Resident #1 was observed in their room in bed. A housekeeper was observed seated outside of the resident's room providing one on one supervision with a clip board to document the resident's one on one supervision.On 04/28/26 at 1:36 a.m., Resident #1 was observed in their room in bed. Driver #1 was observed outside the room in a chair to perform one on one supervision with a log on a clip board to document the resident's location hourly. A nurses note for Resident #1, dated 03/25/26, showed the resident attempted to exit the facility and had to be redirected back to their room. A comprehensive assessment for Resident #1, dated 03/29/26 showed the resident had a BIMS score of 4 which indicated their cognition was severely impaired. The assessment showed Resident #1 had diagnoses which included dementia and anxiety disorder. The assessment showed the resident was independent for ambulation and transfers. The assessment showed the resident did not wander. An Elopement Risk Assessment for Resident #1, dated 03/29/26, showed no history of elopements and was scored at a 10 which indicated a high risk for elopement. On 04/23/26 at 4:10 p.m., the MDS coordinator stated Resident #1 had dementia, had tried to follow others out of the facility, and was an elopement risk.On 04/24/26 at 9:27 a.m., the MDS coordinator was asked to review Resident #1's annual comprehensive assessment, dated 03/29/26. They stated the assessment was not correct because it did not reflect Resident #1's wandering which was documented in the nurses note on 03/25/26. On 04/24/26 at 9:51 a.m., the DON stated the facility did not have a policy on accuracy of MDS assessments and they followed the RAI (resident assessment instrument) manual. The DON reviewed Resident #1's comprehensive assessment dated [DATE]. The DON stated the assessment was not correct due to the assessment did not document the wandering behaviors from Resident #1's nurses note dated 03/25/26.

Based on record review and interview, the facility failed to have an adequate hot water supply to ensure showers were conducted as scheduled for 3 (#2, 6, and #7) of 3 sampled residents reviewed for showers. The DON reported 35 residents resided in the facility. Findings: A Resident Showers policy, dated 04/15/24, read in part, Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. 1. Resident #2 had diagnoses which included paraplegia. The resident was admitted to the facility on [DATE]. The resident discharged from the facility on 02/23/25. A monthly shower record for December 2024 showed 13 scheduled showers. The shower record showed three showers were given (12/03, 12/10, and 12/12), eight showers were not given (12/05, 12/07, 12/14, 12/17, 12/24, 12/26, and 12/28) and two showers were refused (12/19 and 12/21). A quarterly assessment, dated 01/25/25, showed Resident #2's cognition was intact with a BIMS score of 15. The assessment showed they required substantial/maximal assist with showers. A monthly shower record for January 2025 showed 13 scheduled showers. The shower record showed one shower was given (01/02), 10 showers were not given (01/09, 01/11, 01/14, 01/16, 01/18, 01/21, 01/23, 01/25, 01/28, and 01/30), and two showers were refused (01/04 and 01/07). A monthly shower record for February 2025 showed 10 scheduled showers. The shower record showed two showers were given (02/15 and 02/20), six showers were not given (02/01, 02/04, 02/06, 02/08, 02/11, and 02/13), one shower was refused (02/22), and one shower was not applicable (02/18). A care plan, dated 02/07/25, read in part, Showers requires x two staff assist with transfers to shower chair. A grievance form, dated 02/13/25, showed Resident #2 reported not getting showers. The grievance form showed staff were educated related to showers. On 03/05/25 at 1:01 p.m., CNA #1 reported Resident #2 would request showers to be given at 1:00 a.m. or 2:00 a.m., so there would be hot water available. On 03/05/25 at 2:48 p.m., the DON reported Resident #2 was the only resident that had complained about not having hot enough water for showers. 2. Resident #6 had diagnoses which included spinal stenosis and chronic obstructive pulmonary disease. A care plan, dated 10/05/24, showed Resident #6 was able to bathe/shower areas on self within easy reach. A monthly shower record for December 2024 showed 13 scheduled showers. The shower record showed one shower was conducted (12/11), 11 showers were not conducted (12/02, 12/04, 12/09, 12/13, 12/16, 12/18, 12/20, 12/23, 12/25, 12/27, and 12/30), and one shower was not applicable (12/06). A quarterly assessment, dated 01/10/25, showed Resident #6's cognition was intact with a BIMS score of 15. The assessment showed the resident required set up help for showers. A monthly shower record for January 2025 showed 14 scheduled showers. The shower record showed two showers were conducted (01/06 and 01/13), and 12 showers were not conducted (01/01, 01/03, 0108, 01/10, 01/15, 01/17, 01/20, 01/22, 01/24, 01/27, 01/29, and 01/31). A shower schedule, dated 03/05/25, showed Resident #6 was scheduled for a shower on Monday, Wednesday, and Friday during the 6:00 p.m. to 6:00 a.m. shift. On 03/05/25 at 3:50 p.m., Resident #6 stated, I'm not going to take a shower until they get the hot water issue fixed. 3. Resident #7 had diagnoses which included morbid obesity and ataxic gait. A care plan, dated 01/11/24, showed Resident #2 required x two staff assistance with transfers. A quarterly assessment, dated 12/10/24, showed Resident #7's cognition was intact with a BIMS score of 15. The assessment showed the resident was dependent on staff for showers. A monthly shower record for December 2024 showed 13 scheduled showers. The shower record showed five showers were conducted (12/04, 12/09, 12/11, 12/18, and 12/20), six showers were not conducted (12/02, 12/13, 12/23, 12/25, 12/27, and 12/30), and two showers were refused (12/06 and 12/16). A monthly shower record for January 2025 showed 14 scheduled showers. The shower record showed five showers were conducted (01/01, 01/10, 01/13, 01/29, and 01/31), eight showers were not conducted (01/03, 01/08, 01/15, 01/17, 01/20, 01/22, 01/24, and 01/27), and one shower was refused (01/06). A shower schedule, dated 03/05/25, showed Resident #7 was scheduled for a shower on Monday, Wednesday, and Friday during the 6:00 a.m. to 6:00 p.m. shift. On 03/05/25 at 11:55 a.m., certified medication aide #1 reported the 300 hall shower tended to run out of hot water. On 03/05/25 at 12:04 p.m., LPN #1 reported the 100 hall was good for hot water. The LPN stated 200 and 300 halls had problems on and off with hot water in the shower rooms and maintenance had worked on the problem a lot. On 03/05/25 at 1:08 p.m., CNA #3 reported having trouble getting all showers done due to water not being hot enough throughout the shift and residents would refuse showers. On 03/05/25 at 2:30 p.m., the maintenance supervisor reported the hot water supply had been an issue for sometime. The maintenance supervisor reported a professional plumber looked at the hot water supply and instructed them on how to keep the hot water supply adequate until the plumbing was reworked. The maintenance supervisor reported the showers on 200 and 300 halls were on the same hot water system as the laundry and kitchen which effected the amount of hot water available for showers at certain times of the day. On 03/05/25 at 2:48 p.m., the DON reported not being aware residents were not getting showers. The DON reported if the water was not hot for a shower then a bed bath would be offered. On 03/05/25 at 4:00 p.m., Resident #7 reported not getting showers three times a week like they were scheduled. The resident reported staff told them there if no hot water or not enough staff to get the shower done when scheduled.

Based on record review and interview, the facility failed to provide adequate supervision and interventions to prevent elopement for 1 (#1) of 3 sampled residents reviewed for elopement. The DON reported 35 residents resided in the facility. The elopement book at the nurses station identified seven residents at risk for elopement. Findings: A policy titled Elopements, dated 08/01/21, read in part,Staff shall investigate and report all cases of missing residents. Resident #1 was admitted to the facility on [DATE] with diagnoses which included dementia and depression. An elopement risk assessment, dated 02/28/25, showed no risk for elopement. A progress note, dated 03/02/25 at 8:35 a.m., showed Resident #1 was found outside sitting in the grass across from the parking lot. The note showed the resident was assisted back into the facility. The note also showed the resident had scrapes on both knees and a red area to the right cheekbone. A incident report, dated 03/02/25, showed Resident #1 was observed outside across the street from the facility without staff present. The report showed staff reported the resident was unattended for approximately 10 minutes after being toileted after breakfast. The report showed the resident was alert and oriented to person only. The report showed staff were educated on the policy and procedure for elopement, educated to keep all alarms on and respond to alarms promptly, and the resident was to remain one on one with staff until no signs of exit seeking. The report showed the resident's elopement care plan was updated and the resident's face sheet with picture was added to the elopement book. An elopement risk assessment, dated 03/02/25, showed an elopement risk score of 10.0. The assessment showed interventions: staff aware of wander risk, exit alarms, and every one hour checks. An admission assessment, dated 03/05/25, showed the resident had moderate cognitive impairment with a BIMS score of 10. The assessment showed the resident had wandering behavior. The elopement book was reviewed and contained Resident #1's elopement care plan and elopement risk assessment. The elopement book did not contain the resident's face sheet with the resident's picture. On 03/05/25 at 11:46 a.m., the administrator reported the facility was having a software issue with getting the resident's photo added to the face sheet. The administrator reported all nurses had a picture of the resident on their phone and all staff were aware who the resident was. On 03/05/25 at 11:55 a.m., the DON reported the investigation of the elopement incident for Resident #1 concluded the resident exited the front door in the dining room. The DON reported the alarm on the door was not turned on for an unknown reason. The DON reported staff were educated that the door alarms were to be left on.

Based on observation, record review, and interview, the facility failed to maintain a home like environment by ensuring: a. the tile was in good repair around a toilet to prevent odors; b. the wall was in good repair; and c. the lighting was sufficient in one bathroom of 16 bathrooms observed for a homelike environment. The DON identified 38 residents resided in the facility. Findings: A Homelike Environment policy, revised 05/17, read in part, .The facility staff and management shall maximize, to the extent possible, the characteristics of the facility and reflect a personalized, homelike setting, these characteristic include .Clean, sanitary, and orderly environment .Pleasant, neutral scents .Comfortable and adequate lighting is provided in all areas of the facility to promote a safe, comfortable, and home like environment. The lighting design emphasizes: a. Sufficient general lighting in resident-use areas . On 03/24/24 at 10:46 a.m., the following observations were made in a room on the 200 hall: a. the tile around toilet was cracked, raised, and soft to the touch with a strong urine smell coming from the bathroom, b. the wall paint was peeling and damaged above the toilet, and c. the light above the sink bulb was out and only one bulb was functioning causing the room to be dimly lit. On 03/27/24 at 8:23 a.m., the Housekeeping Supervisor was shown the above mentioned concerns. They stated the tile was broken for the last two months around the toilet and it created a bad smell of urine under the tile after the bathroom was freshly mopped. They stated the bathroom was not well lit and the wall was damaged above the toilet. On 03/27/24 at 8:36 a.m., the Administrator stated there were no pending or open work orders for tile replacement, broken lights, and/or wall repairs. On 03/27/24 at 9:10 a.m., the Maintenance Supervisor was shown the above concerns. They stated the tile was stained, cracked, and raised with a strong urine smell after being freshly mopped. They stated the light needed to be repaired or replaced and the globe covering the light was not installed correctly. They stated the wall above the toilet was in need of repair. The Maintenance Supervisor stated they did not have an open work order for any of the concerns. They stated it was not a home like environment and they would not allow their family to live in such an environment.

Based on observation, record review, and interview, the facility failed to ensure a qualified staff administered a resident's breathing treatment for one (#140) of one sampled resident observed for breathing treatments. The DON identified 38 residents resided in the facility. Three residents had orders for nebulizer breathing treatments in the facility. Findings: Resident #140 had diagnoses which included chronic obstructive pulmonary disease and chronic diastolic heart failure. A physician's order, dated 03/18/24, documented albuterol sulfate inhalation nebulization solution 2.5 mg per 3 ml give 1 vial via mask every four hours related to chronic obstructive pulmonary disease. On 03/24/24 at 10:18 a.m., Resident #140 had their call light on to start their breathing treatment. CNA #1 walked in and turned on the Resident's nebulizer machine. They left the room. A mist started flowing through the Resident's handheld mouthpiece. On 03/24/24 at 10:20 a.m., Resident #140 stated the nurse had put the medication in the handheld device earlier that morning. Resident #140 coughed multiple times during the breathing treatment. The nurse was not present during the administration of the breathing treatment. On 03/24/24 at 10:30 a.m., Resident #140 called after completing the breathing treatment. CNA #1 walked in, turned off the machine, and left the room. On 03/24/24 at 10:43 a.m., CNA #1 stated they were not allowed to put the medicine in the medication cup of the handheld device ,but they can turn the nebulizer machine on and off. On 03/24/24 at 10:54 a.m., LPN #1 stated the nurses were responsible for the administration of breathing treatments and assessment of the residents receiving breathing treatments. On 03/24/24 at 10:56 a.m., LPN #1 stated they were not present during Resident #140's breathing treatment and they did not follow up after the Resident's breathing treatment was completed. On 03/25/24 at 2:47 p.m., the DON stated CNAs were not allowed to turn a nebulizer machine on or off for the administration of breathing treatments.

Based on observation, record review, and interview, the facility failed to care plan and ensure a resident was assessed for the use of bed rails prior to installation for one (#29) of four sampled residents reviewed for physical restraints. The DON identified 38 residents resided in the facility and 19 residents used bed rails or assist bars. Findings: The Proper Use of side Rails policy, revised 12/16, read in part, .An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails .The use of side rails as an assistive device will be addressed in the resident care plan . Resident #29 had diagnoses which included dementia and cerebral infarction. On 03/25/24 at 9:16 a.m., Resident #29 was observed in bed with full upper bed rails up on each side of the bed. A Care Plan, dated 01/01/24, did not document the the use of bed rails. On 03/26/24 at 11:05 a.m., LPN #2 stated Resident #29's bed rails were up. They stated the bed rails were used for positioning. On 03/26/24 at 11:06 a.m., LPN #2 stated there should be a resident assessment and an order for the use of bed rails for positioning. On 03/26/24 at 11:08 a.m., LPN #2 stated there was no order or an assessment for Resident #29's use of the bed rails. On 03/27/24 at 9:59 a.m., the Administrator stated they failed to care plan the use of bed rails for Resident #29.

Based on observation and interview, the facility failed to ensure medications were locked when not attended for two (treatment carts) of four carts observed for medication storage. The DON identified two medication carts and two treatment carts. Findings: A Medication Storage In The Facility policy, revised 01/18, read in part, .Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations .The medication supply is accessible only to licensed nursing personnel .or staff members lawfully authorized to administer medications . On 03/24/24 at 9:21 a.m., two carts were observed unlocked on a hallway. One cart had insulin medications, insulin needles, insulin syringes and glucometers. The other cart had pain topical creams, breathing treatments, and wound care supplies. There were five residents in the vicinity of the two carts and no staff present. On 03/24/24 at 9:28 a.m., CNA #1 went by the two carts and locked them. CNA #1 stated the two carts were unlocked. On 03/24/24 at 9:30 a.m., LPN #1 stated the two carts were treatment carts. On 03/24/24 at 10:05 a.m., a treatment cart was observed unlocked outside of a room on the 200 hall. No staff were present. RN #1 stated the cart had nebulizers, inhalers, and wound care supplies. They stated the cart should be locked per facility policy. On 03/24/24 at 10:54 a.m., LPN #1 stated the carts should not be left unlocked.

Based on record review and interview, the facility failed to ensure residents were informed, with a signed acknowledgment from the resident, of items and services for which the resident might be charged for skilled services, for three (#2, #19 and #37) of three residents sampled for beneficiary notification review. The Administrator reported 18 residents who had discharged from skilled services in the last six months. Findings: The clinical record for Resident #2 documented the resident was admitted to skilled services on 08/02/22 and was discharged on [DATE]. The Advanced Beneficiary Notice (ABN), form CMS-10055, was not signed by the resident or their representative. The clinical record for Resident #19 documented the resident was admitted to skilled services on 01/06/23 and was discharged on [DATE]. The ABN, form CMS-10055, was not signed by the resident or their representative. The clinical record for Resident # 37 documented the resident was admitted to skilled services on 07/21/22 and was discharged on [DATE]. The ABN. form CMS-10055, was not signed by the resident or their representative. On 02/07/23 at 12:06 p.m. the ABN forms were requested. The corporate Administrator reported the forms had not been completed to have the resident or their representative sign the form to indicated they were given information related to possible charges. She reported in the future the forms would be included in the admission packet.

Based on record review and interview, the facility failed to complete a discharge summary for one (#42) of one resident reviewed for discharge. The Resident Census and Conditions of Residents, documented a census of 38 residents. Findings: Resident #42 was admitted to skilled services on 12/01/22. The record documented the resident was discharged to home on 12/28/22. A physician progress note, dated 12/06/22, documented the resident lived alone but would like to get strong enough to go home. The clinical record was reviewed and no documentation of a discharge summary was found in the record. On 02/09/23 at 4:13 p.m., the regional Registered Nurse reviewed the clinical record and reported a discharge summary was not completed as required.

Based on record review and interview, the facility failed to reduce a psychoactive medication, per physician orders, for one (#16) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form documented 38 residents resided in the facility. Findings: A facility policy, Medication Monitoring and Management, revised on January 2018, documented in parts, .During the first year in which a resident is admitted on a psychopharmacological medication (other than an antipsychotic or a sedative/hypnotic), or after the facility has initiated such medication, the facility attempts a GDR [gradual dose reduction] during at least two quarters (with at least one month between the attempts), unless clinically contraindicated . The clinical record for Resident #16 documented the resident was admitted with a diagnosis of insomnia. Resident #16's Physician Orders, dated 10/07/22, included Trazodone HCL (hydrochloride) tablet 50 mg (milligram), give one tablet at bedtime by mouth, related to insomnia. A Consultant Pharmacist/Physician Communication form for resident #16, dated 11/20/22, documented a dose reduction for Trazodone 50 mg QHS to be reduced to 25 mg QHS. A review of physician orders from November 2022 through February 2023 revealed the medication had not been reduced. On 02/09/23 at 3:06 p.m., the DON stated the charge nurse was supposed to change the orders when received by the physician. She reported resident #16's Trazodone 50 mg was not decrease for the trial reduction as ordered. On 02/09/23 at 3:46 p.m., the Administrator reported if the physician ordered the medication to be reduced, the medication should have been changed at the time of the order.

Based on record review and interview, the facility failed to appoint an Administrator, licensed by the State, to actively engage in the operations of the facility. The Director of Nurses reported 30 residents who resided at the facility. Findings: On 06/16/22 at 9:20 a.m., the DON reported the facility was looking for an Administrator. She stated they had a corporate employee in charge that day. The corporate employee was identified as the dietary consultant for the facility and reported she did not have an Administrator's license. On 06/16/22 at 9:20 a.m., the DON stated both she and the corporate dietary consultant filled in as Administrator. The DON reported the previous Administrator's last day in the facility was 05/16/22.

Based on observation and staff interviews, it was determined the facility failed to ensure hot water temperatures were maintained in the kitchen. The facility identified 29 residents received services from the kitchen. Findings: On 03/05/20 at 9:50 a.m., a tour of the kitchen was conducted. The low temperature dishwashing machine (chemical sanitization) was observed to be in use. The temperature observed on the machine's temperature gauge was 110 degrees F during multiple dishwashing cycles. The manufacturer's specification sticker on the the machine documented the wash and final rinse temperature should have been 120 degrees F. The dietary manager (DM) stated the temperature gauge on the dishwashing machine was 15 to 20 degrees too low and needed to be replaced. She stated they had been taking the temperatures of the water in the bottom of the dishwashing machine or water which they accumulated in a cup during the dishwashing cycle. The temperature of the water remaining in the machine immediately following multiple dishwashing cycles ranged from 113.6 degrees F to 116.6 degrees F with a handheld thermometer. The DM stated the temperature should have been 120 degrees F. She stated they had issues with the boiler and had been without hot water recently. She stated during that time they had to boil water and used paper products. At 12:10 p.m., the maintenance supervisor was asked what temperature hot water was to be maintained at in the kitchen. He stated 120 degrees F. He was asked how often he obtained water temperatures. He stated on a weekly basis, but he had not taken temperatures in a few weeks due to other job responsibilities. He stated they have had issues with the boiler which controlled the water temperature. He was made aware of the above observations. He acknowledged the findings.

Based on observation and resident and staff interviews, it was determined the facility failed to ensure comfortable hot water temperatures and the building was maintained in good repair. The facility identified 29 residents resided the facility and 34 resident rooms. Findings: On 03/04/20 at 8:56 p.m., a tour of the facility was conducted. The following observations were made: ~ there was brown discoloration, exposed sheetrock and unsealed plaster on the ceiling above the dryers in the laundry room, ~ there was brown discoloration and exposed sheetrock on the ceiling and the ceiling was bowed in the two compartment sink area of the laundry room, ~ there was brown discoloration on the ceiling in the physical therapy room, ~ there was brown discoloration on the ceiling on hall 200 near the shower room, ~ there was brown discoloration and exposed sheetrock on the ceiling and the ceiling was bowed and paint was peeling in the dining room, ~ there was no hot water at the handwashing lavatories in the public and resident restrooms near the dining room. The highest temperature reached was observed to be 62.2 degrees Fahrenheit (F) with a handheld thermometer, ~ the ceiling was bowed in the living area on hall 100 and ~ there was brown discoloration on the ceiling, paint was peeling off of the ceiling, a hole was in the ceiling and a cloth had been used in the opening in the dishwash area in the kitchen. On 03/05/20 at 8:50 a.m., resident #14 was asked if there was hot water in her room. She stated the hot water temperature was not comfortable at the handwashing lavatory in her restroom. She stated she would like the water to be hotter. The hot water temperature at the handwashing lavatory in her restroom was observed to be 77.5 degrees F with a handheld thermometer. At 9:28 a.m., resident #15 was asked if there was hot water in his room. He stated the water at the handwashing lavatory in his room was not hot enough. He stated he wanted it to be warmer. The hot water temperature at the handwashing lavatory in his restroom was observed to be 89.7 degrees F with a handheld thermometer. At 9:38 a.m., resident #13 was asked if there was hot water in his room. He stated the water was cold at the handwashing lavatory in his room. He stated he wanted the water to be warmer. The hot water temperature at the handwashing lavatory in his restroom was observed to be 81.8 degrees F with a handheld thermometer. At 12:10 p.m., the maintenance supervisor was asked temperature the hot water was maintained at handwashing lavatories. He stated he tried to maintain the hot water temperature around 98 degrees F. He was asked how often he obtained water temperatures. He stated on a weekly basis, but he had not taken temperatures in a few weeks due to other job responsibilities. He stated they have had issues with the boiler which controlled the water temperature. He was made aware of the above temperature issues. He acknowledged the findings. The maintenance supervisor was asked how staff ensured the building was maintained in good repair. He stated he conducted audits on a regular basis. He stated staff reported issues to maintenance for repairs. He stated issues identified were fixed or he called someone else out for repairs. He stated they had issues with the roof leaking and had to catch water leaking from the ceiling with buckets. He was made aware of the above observations related to the ceiling. He acknowledged the findings.

Based on record review and staff interview, it was determined the facility failed to ensure interventions were in place to prevent pressure ulcers (PUs) and pressure injuries (PIs) for one (#1) of three sampled residents reviewed for pressure ulcers. The resident developed an avoidable stage IV decutius ulcer to her right upper buttocks. The facility identified seven residents with pressure ulcers. Findings: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Braden scale (skin assessment tool), dated 03/12/19, documented the resident was at moderate risk for skin breakdown and incontinent of bowel and bladder. A quarterly resident assessment, dated 03/12/19, documented the resident's cognition was severely impaired. It documented the resident was dependent on staff for all activities of daily living. It documented the resident was at risk for pressure ulcers and always incontinent of bowel and bladder. A care plan, last updated on 03/12/19, documented the resident was at risk for skin breakdown. Interventions included, monitor skin for breakdown and notify hospice, reposition every two hours and as needed, check for incontinence every two hours and change as needed. Provide peri-care after each incontinent episode and as needed. A weekly pressure ulcer record, dated 03/26/19, documented, .site Rt. (right) buttocks .stage u (unstageable) .size in CM (centimeters) 2 x 3 (length by width) .depth (? mark symbol) .exudate type/amount yes .odor (none) .wound bed eschar .surrounding skin color red intact .TX (Treatment) c (with) [MEDICATION NAME] QD (every day) . This is the first documentation of a skin issue for this resident. There was no documentation of weekly skin assessments, or any documentation the resident's skin had been assessed prior to the discovery of the pressure ulcer. A weekly pressure ulcer record, dated 04/01/19, documented, .site Rt. buttocks .stage u .size in CM 2x3 .no depth .exudate yes .no odor .wound bed eschar .surrounding skin color red intact. Treatment changed to Santyl . A physician's orders [REDACTED].Cleanse open area to right buttocks with dermal wound cleaner and apply Santyl QD until healed. Cover with fluffed gauze . A weekly pressure injury record, dated 04/10/19, documented, .site Rt. buttocks .stage u .size in CM 4x3.5 .no depth .exudate yes .odor yes .wound bed eschar .surrounding skin red intact. Treatment with Santyl . A physician's orders [REDACTED].[MEDICATION NAME] tab (tablet) one PO (by mouth) BID (two times a day) to aid in wound healing . A weekly pressure injury record, dated 04/18/19, documented, .site Rt. buttocks .stage u .size in CM 10x8 .depth 2cm .exudate yes .odor yes .wound bed black eschar .surrounding skin red. Treatment with Santyl not responding .will try to notify doctor and PT (Physical Therapy) for evaluation. Start [MEDICATION NAME] tab . An Antibiotic Stewardship Initiation Form, dated 04/18/19, documented, .Skin and Soft Tissue Infections. 1. At least one of the following: Pus present at wound, skin or soft-tissue site, -OR- 2. At least four of the following new or increasing signs/symptoms, Heat, Redness, Swelling, Tenderness or Pain, Serous Drainage, At least one constitutional criterion: Fever, leukocytosis, acute change in mental status, acute function decline . All boxes were checked. Additional notes: Keflex 500mg (milligram) QID (four times a day) x 10 days for wound . A PT Evaluation form, dated 04/19/19, documented, .Reason for Referral: Stage IV (four) Pressure Decubitus over sacrum, requiring Wound Consult and Sharp Excisional Debridement . A weekly pressure injury record, dated 04/25/19, documented, .site Rt. buttocks .stage u .size in CM 7x8 .depth 4cm .exudate yes .odor yes .wound bed black eschar .surrounding skin pink intact. Treatment with Santyl. Doing better after PT eval (evaluation) and sharp debridement . A physician's telephone order, dated 04/26/19, documented, Wound care clarification: For 7 (seven) days DC (discontinue) Santyl and apply Silvadine during daily dressing changes/wound care. A weekly pressure injury record, dated 05/02/19, documented, .site Rt. buttocks .stage u .size in CM 6x8x4 (depth) .exudate yes .odor yes .wound bed black eschar .surrounding skin pink intact. Treatment with Silvadine x 7 days and then will change to Santyl. 05/03/19, PT here for sharp debridement changed order for treatment . A physician's telephone order, dated 05/03/19, documented, Wound Care Clarification: Daily cleanse wound and use Santyl to necrotic areas and Silvadine to rest. Pack with 4x4 gauze and cover with ABD (abdominal) pad. Wound Care PT will re-eval on 5/10/19 to debride. A weekly pressure injury record, dated 05/10/19, documented, .site Rt. buttocks .stage IV .size in CM 7x5x3 .exudate yes .odor yes .wound bed some eschar mostly pink .surrounding skin pink intact. Treatment with Santyl/Silvadine. PT here for sharp debridement. Changed order to use Silvadine only . A physician's telephone order, dated 05/10/19, documented, Wound Care Clarification: DC Santyl. Continue, daily, apply cleansing with shower or normal saline, apply Silvadine -nickle thick- to open wound, pack with 4x4's, cover with ABD pad . Wound care to re-assess 05/24/19. A physician's telephone order, dated 05/21/19, documented Bactrim Suspension four teaspoons PO BID x 10days. [DIAGNOSES REDACTED]. (indwelling urinary catheter) until sacral wound is healed. A weekly pressure injury record, dated 05/22/19, documented, .site Rt. buttocks .stage IV .size in CM 4x6x3.5 .exudate yes .odor none .wound bed pink slough .surrounding skin pink intact. Stage IV decub to right buttocks with moderate drainage. Some slough noted . On 05/22/19 at 1:30 p.m., the director of nurses (DON) was asked to provide weekly skin assessments which documented the condition of the resident's skin prior to 03/26/19. On 05/23/19 at 9:06 a.m., the DON was asked for documentation the resident had been turned and repositioned every two hours. There was no documentation provided which showed the resident had been turned or repositioned every two hours. At 11:32 a.m., the DON was asked how staff ensured residents did not acquire pressure ulcers. She stated staff were to turn residents every two hours and as needed. The DON was asked, if the right buttocks wound was not reported until 03/26/19 and it already had eschar, was the resident receiving weekly baths and incontinent care? She stated the resident was receiving incontinent care, and the resident received her baths from the hospice aide. She stated the wound was reported to her by a licensed practical nurse and it appeared to be a deep tissue injury. She stated that was when the [MEDICATION NAME] treatment was started. The DON was asked if staff should have reported the appearance of the wound sooner. She stated, Yes.

Based on observation, record review and staff interview, it was determined the facility failed to: ~ implement their elopement policy when a departing resident returned to the facility and ~ monitor wander/elopement alarms for one (#5) of one sampled resident reviewed for elopement. The facility identified two residents who wandered. Findings: An elopement policy, revised 12/07, documented, .Staff shall promptly report any resident who tries to leave the premises .to the Charge Nurse or Director of Nursing .When a departing individual returns to the facility, the Director of Nursing Services or Charge Nurse shall .Examine the resident for injuries .Notify the Attending Physician .Notify the resident's legal representative .of the incident .Complete and file Report of Incident/Accident .Document the event in the resident's medical record . Resident #5 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED].WANDERGUARD BRACELET CHECK PLACEMENT Q (every) SHIFT AND CHECK FUNCTION AT NIGHT . A quarterly resident assessment, dated 02/26/19, documented the resident's cognition was moderately impaired and she used a wandering/elopement alarm daily. A care plan, dated 03/05/19, documented, .Problem Onset .BEHAVIORAL EXPRESSIONS R/T (related to) DEMENTIA AND ANXIETY .ATTEMPTING TO LEAVE FACILITY .Approaches .ATTEMPTING TO LEAVE FACILITY .WANDERGUARD IN PLACE AT ALL TIMES. CHECK PLACEMENT EVERY SHIFT AND FUNCTIONING AT NIGHT .REDIRECT HER FROM THE EXIT DOOR WHEN SHE TALKS ABOUT LEAVING THE FACILITY . A nurse's note, dated 04/10/19 at 8:40 p.m., documented, .Resident has been exit seeking since early afternoon. Has actually made it out the front door without her anklet alarming and took staff several minutes, 10-20 to get her back into building . There was no documentation the resident had been examined for injuries, her legal representative had been notified or an incident report was completed. A nurse's note, dated 04/11/19, documented, .2-10p (p.m.) Resident has made numerous attempts to get out front door. All staff in different rooms providing care and this nurse heard alarm. Resident was outside, down road towards physician buildings. Was able to get resident back into building due to cooler weather . There was no documentation the resident had been examined for injuries, the resident's physician and legal representative had been notified or an incident report had been completed. A nurse's note, dated 04/30/19, documented, .2-10p Resident had exited building early in shift and took 20-30 minutes and several attempts to get into building . There was no documentation the resident had been examined for injuries, the resident's physician and legal representative had been notified or an incident report had been completed. On 05/22/19 at 9:51 a.m., the resident was observed walking out the front door unattended with her walker. The door alarm did not sound. At 9:54 a.m., licensed practical nurse (LPN) #2 was observed going outside to retrieve the resident. At 10:00 a.m., the resident was observed being escorted back inside the building by LPN #2. Her Wanderguard was observed on her right leg. At 10:39 a.m., the director of nursing (DON) was asked how staff ensured a resident's Wanderguard was working. She stated they had a scanner to check Wanderguards. She stated if the scanner lit up the wanderguard was working. She stated Wanderguards were checked every night and maintenance staff checked the bars on the doors maybe once a week. The DON was asked how staff knew when a resident eloped. She stated there were pictures of residents who were an elopement risk posted at the nurses station. She stated there was an alarm that would sound and staff would go after the resident. The DON was made aware of the above observation. She stated staff should have been more aware since the resident was wearing a coat. She stated corporate had been looking at getting another alarm system. She stated sometimes the weather caused the existing one not to work. At 1:47 p.m., the DON was shown the resident's nurses' notes and the facility's elopement policy. She was asked if the elopement policy had been followed. She stated the policy had not been followed.

Based on record review and resident and staff interviews, it was determined the facility failed to credit interest earned to an interest bearing account for one (#28) of one sampled resident reviewed for personal funds. The facility identified 14 residents with interest bearing accounts. Findings: A resident trust policy, undated, documented, .The facility will deposit money into an interest bearing account and the interest will be dispersed to the residents . On 04/02/18 at 10:02 a.m., resident #28 was asked if the facility took care of his money. He stated, Yes. He was asked if he could access his money when he needed it, including on the weekends. He stated, The main staff is not here over the weekends. He stated they only worked Monday through Friday. He stated, I can't get my money til then. On 04/03/18 at 10:01 a.m., the business office manager (BOM) was asked who was responsible for the resident trust accounts. She stated she was responsible. She was asked if the resident was in the resident trust account. She stated, Yes. She was asked to provide the resident's ledger for the account. The ledger was reviewed for (MONTH) (YEAR) through (MONTH) (YEAR). It documented a beginning balance for 01/01/18 of $575.35. The last balance documented was on 03/01/18 in the amount of $707.35. There were no documented entries of interest deposits. The BOM was asked if she had figured any interest for the account since January. She stated, Some of it, not all. She stated, I have the calculations, but don't have it recorded. She was asked if there was an accurate accounting for the resident's trust accounts if there was no interest posted to the account. She stated, I believe there is, except for the interest.

Based on record review and resident and staff interviews, it was determined the facility failed to account for resident funds for a petty cash account. The facility identified 14 residents in the resident trust account. Findings: A resident trust policy, undated, documented, .The facility will have on hand a petty cash fund for residents accounts, thus making requests for small amounts of cash available for resident use upon request after normal banking hours. Money shall be locked in business office and/or the med (medication) cart after hours and on weekends . On 04/02/18 at 10:02 a.m., resident #28 was asked if the facility took care of his money. He stated, Yes. He was asked if he could access his money when he needed it, including on the weekends. He stated, The main staff is not here over the weekends. He stated they only worked Monday through Friday. He stated, I can't get my money til then. On 04/03/18 at 10:01 a.m., the business office manager (BOM) was asked who was responsible for the resident trust accounts. She stated she was responsible. She was asked if the resident was in the resident trust account. She stated, Yes. She was asked how residents accessed their accounts. She stated they would either ask her or the administrator for money. The BOM stated if a resident wanted cash, they had to sign a voucher and they would dispense the cash. She stated they kept a little bit of cash on hand. She was asked where that money was kept. She stated in the office. She was asked what the policy was if a resident who had a trust account wanted money on the weekends. She stated, We have some money at the nurse's station that they keep there. She was asked to see where the money was located. The BOM was observed asking the licensed practical nurse (LPN) #1 to see the trust money. LPN #1 was observed unlocking the medication room and unlocked a cabinet which contained narcotic medications and a locked box. She was observed unlocking the box which contained cash and coins. There was no ledger sheet observed to be inside the box. LPN #1 was asked how staff determined which resident could get money from the box. She stated they had a list. She was observed looking through binders located next to the locked box. She stated staff counted the money when they counted the narcotics in the locked cabinet. She stated, We had a list somewhere. LPN #1 provided a document labeled, Ledger Sheet for Recipient's Account. The last entry was dated 12/29/17. It documented a resident's name and $5.00 used. There was no balance documented. The BOM was asked if this was a current ledger for the resident's petty cash. She stated she had counted the money this year. She was asked for a ledger that documented how much money was in the box. She stated the box should contain $65.00. She was asked how she determined that. She stated that was the amount of money she kept in the box. The stated when the amount of money in the box got low, she would add money to it to add up to $65.00. She was asked how she knew which resident had received monies so she could deduct it from their account. She stated it was on the ledger. She was asked to provide the ledger for the petty cash account for the past six months. At 1:25 p.m., the BOM was asked if she had located ledgers for the resident's petty cash account. She stated, I wish I could say I did. She stated, I did not. She was asked what system the facility had in place to safeguard against misappropriation of residents' funds. She stated, Well, we did. She stated, I just don't have the form. She stated, The nurses signed a form and they dispersed it and recorded it on a ledger. She stated, That particular form is absent for some reason. The BOM was asked if there should be an accounting for the resident funds taken from petty cash and should it be documented on the resident's individual ledgers. She stated, Yes.

Based on record review and staff interviews, it was determined the facility failed to assess a resident's pain level and location prior to administering a PRN (as needed) pain medication and failed to assess the effectiveness of the medication after administration for one (#13) of five sampled residents reviewed for unnecessary medications. The director of nursing (DON) identified 38 residents with orders for PRN pain medication. Findings: A preparation and general guidelines policy, dated 07/15, documented, .When PRN medications are administered, the following documentation is provided .Date and time of administration, dose, route of administration .Complaints or systems for which the medication was given .Results achieved from giving the dose and the time results were noted .Signature or initials of person recording administration and signature or initials of person recording effects, if different from the person administering the medication . Resident #13 had [DIAGNOSES REDACTED]. An admission resident assessment, dated 02/06/18, documented the resident received scheduled and PRN pain medication, had pain present almost constantly and rated the pain level at a ten on a one to ten scale. A care plan, dated 02/13/18, documented, .RISK FOR FALLS R/T RELATED/TO) .PAIN .Approaches .MONITOR INTENSITY, DURATION, AND FREQUENCY OF PAIN AND TREAT AS ORDERED . A physician's orders [REDACTED].[MEDICATION NAME] 20MG (milligram) 1 (one) TAB (tablet) PO (by mouth) Q (every) 6 (six) HRS (hours) PRN FOR PAIN . A controlled medication administration record for the resident's [MEDICATION NAME] 20 mg documented: ~ one tablet was administered on 04/01/18 at 12:30 a.m., ~ one tablet was administered on 04/01/18 at 6:00 a.m., ~ one tablet was administered on 04/01/18 at 12:00 p.m., ~ one tablet was administered on 04/01/18 at 6:55 p.m., ~ one tablet was administered on 04/02/18 at 12:30 a.m., ~ one tablet was administered on 04/02/18 at 5:30 a.m., ~ one tablet was administered on 04/02/18 at 11:30 a.m., ~ one tablet was administered on 04/02/18 at 5:35 p.m., ~ one tablet was administered on 04/03/18 at 12:00 p.m., ~ one tablet was administered on 04/03/18 at 6:20 p.m. and ~ one tablet was administered on 04/04/18 at 7:00 a.m. It was unclear how many doses of the [MEDICATION NAME] 20 mg was initialed as administered on the resident's (MONTH) (YEAR) medication administration record (MAR). The MAR did not document the resident's location of pain, the severity of the pain or the effectiveness of the medication administration for the above dates and times. On 04/04/18 at 10:44 a.m., the DON was asked what staff were instructed to document when a PRN pain medication was administered. She stated staff were to document what medication they administered and the effectiveness of the medication one hour after administration. She was asked to review the resident's MAR and identify how many doses of the PRN [MEDICATION NAME] 20 mg was administered for the month of (MONTH) (YEAR). She reviewed the record and stated nine, maybe. She was asked how many of the doses of the medication were documented per the facility policy. She stated three. The DON returned with the controlled medication administration record for the resident's PRN [MEDICATION NAME]. She was asked if staff documented the reason the PRN pain medication was administered or the location of the resident's pain for the above dates and times. She stated, No. She was asked if the staff assessed the resident after each administration to determine if the medication was effective. She stated, No. She was asked to review the resident's controlled medication administration record and identify how many total doses of the [MEDICATION NAME] 20mg PRN the resident received in (MONTH) (YEAR). She stated, Thirteen.

Based on record review and staff interviews, it was determined the facility failed to ensure medications were administered as ordered for five (#3, 7, 13, 14 and #21) of six sampled residents whose medications were reviewed. The Resident Census and Conditions of Residents report, dated 04/03/18, documented 41 residents. Findings: A medication administration policy, revised 08/14, documented, .Policy .To administer medications in a safe and effective manner .Procedures .After administration .document administration in the MAR (medication administration record) or TAR (treatment administration record), and controlled substance sign out record, if indicated . A preparation and general guidelines policy, dated 07/15, documented, .If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time .the space provided on the front of the MAR for that dosage administration is .initialed and circled. An explanatory note is entered on the reverse side of the record. If 3 (three) consecutive doses of a vital medication are withheld, refused, or not available the physician is notified. Nursing documents the notification and physician response . 1. Resident #3 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED].[MEDICATION NAME] 10 MG (milligrams) ORAL TABLET ONE PO (by mouth) BID (twice daily) AT 8 A (a.m.) AND 4 P (p.m.) [MEDICAL CONDITION]. A physician's orders [REDACTED].[MEDICATION NAME] 1000 MG ORAL TABLET ONE PO BID FOR DM . A physician's orders [REDACTED].[MEDICATION NAME] 60 MG ONE PO BID allergies [REDACTED]. A physician's orders [REDACTED].[MEDICATION NAME] 10 MG ORAL TABLET ONE PO DAILY FOR allergies [REDACTED]. A physician's orders [REDACTED].DOXYCYCLIN 100 MG ONE BID CONTINUOUS FOR ROSACEA . A physician's orders [REDACTED].[MEDICATION NAME] 325 MG-5 MG ORAL TABLET ONE PO AT 8 A AND 8 P FOR PAIN . A physician's orders [REDACTED]. The MAR documented 250 mg, take two tablets 01/08/18, then one every day until all taken for URI. A physician's orders [REDACTED].[MEDICATION NAME] 137 MCG (micrograms)/INH (inhalation) NASAL SPRAY TWO SPRAYS NASAL BID FOR ALLERGIC RHINITIS . The (MONTH) (YEAR) MARs documented on 01/25/18 the 6:00 p.m. dose of [MEDICATION NAME] nasal spray was not documented as administered. The administration section for staff to initial the medication was administered was blank. On 01/26/18 and 01/31/18 the 8:00 a.m. dose of [MEDICATION NAME] nasal spray was not documented as administered. The administration section for staff to initial the medication was administered was blank. On 01/31/18 the 6:00 p.m. dose had circled staff initials under the administration section. There was no documentation for the reason the medication was not administered. On 01/27/18 through 01/30/18 the 8:00 a.m. and 6:00 p.m. doses of [MEDICATION NAME] nasal spray had circled staff initials under the administration section. There was no documentation for the reason the medication was not administered. A physician's orders [REDACTED].BECLOMETHASONE NASAL 0.042 MG/INH SPRAY 2 SPRAYS NASAL 8AM FOR ALLERGY SYMPTOMS . The (MONTH) (YEAR) MARs documented the following: ~ on 02/02/18, 02/08/18 and 02/14/18 the 8:00 a.m. and 6:00 p.m. doses of [MEDICATION NAME] had circled staff initials under the administration section. On 02/11/18 the 8:00 a.m. dose had circled staff initials under the administration section. On 02/03, 02/05, 02/06, 02/09, 02/10, 02/12 and 02/15/18 the 6:00 p.m. had circled staff initials under the administration section. The back of the MAR documented on 02/08, 02/09, 02/14 and 02/15/18 the 6:00 p.m. doses were not administered due to waiting on the pharmacy. There was no other documentation for the reason the medication was not administered, ~ on 02/11/18 the 8:00 a.m. dose of [MEDICATION NAME] was not documented as administered. The administration section for staff to initial the medication was administered was blank, ~ on 02/11 and 02/12/18 the 4:00 p.m. dose of Vastotec had circled staff initials under the administration section. There was no documentation for the reason the medication was not administered, ~ on 02/11/18 the 8:00 p.m. dose of [MEDICATION NAME] had circled staff initials under the administration section. There was no documentation for the reason the medication was not administered and ~ on 02/16 and 02/17/18 the 8:00 a.m. dose of Beclomethasone nasal spray was not documented as administered. The administration section for staff to initial the medication was administered was blank. On 02/18 and 02/19/18 the 8:00 a.m. doses of Beclomethasone nasal spray had circled staff initials under the administration section. There was no documentation for the reason the medication was not administered. The (MONTH) (YEAR) MARs documented the following: ~ on 03/02/18 the 6:00 p.m. dose of [MEDICATION NAME] had circled staff initials under the administration section. The back of the MAR documented the medication was not administered due to being on order at the pharmacy, ~ on 03/03 through 03/05/18 the 8:00 a.m. dose of Singular had circled initials under the administration section. There was no documentation for the reason the medication was not administered, ~ on 03/05/18 the 6:00 p.m. dose of [MEDICATION NAME] had circled initials under the administration section. There was no documentation for the reason the medication was not administered and ~ on 03/20/18 the 6:00 p.m. dose of [MEDICATION NAME] had circled staff initials under the administration section. The back of the MAR documented the medication was not administered due to being on order at the pharmacy. On 04/04/18 at 10:01 a.m., the director of nursing (DON) was asked what the policy was for administering medications. She stated the policy was to check to first ensure there was an order and use the punch, initial and give method. She was asked what circled staff initials indicated on the MAR. She stated if the medication was not given for some reason, staff were to circle their initials and explain the reason the medication wasn't given on the back of the MAR. She was asked what it meant if the section on the MAR where staff were to initial where the medication was administered was blank. She stated staff failed to document the medication was administered. The DON was asked to review the January, (MONTH) and (MONTH) (YEAR) MARs. She was shown the blanks where medications were to have been administered and circled staff initials under the administration section with no reason for the medications not administered. She stated she didn't know why the medications were not administered. She was shown the circled staff initials under the administration section with documentation the medications were not given due to waiting on the pharmacy. She was asked if the medications were administered as ordered. She stated, No. 2. Resident #14 had [DIAGNOSES REDACTED]. The (MONTH) (YEAR) MARs documented the following: ~ on 03/03, 03/06 and 03/26/18 the 8:00 a.m. dose of potassium chloride solution 10 % (percent) take 15 ml (milliliters) by mouth every day mixed with four ounces of juice had circled staff initials. There was no documentation for the reason the initials were circled, ~ on 03/03 and 03/26/18 the 8:00 a.m. dose of [MEDICATION NAME] 10 mg oral tablet one by mouth daily for hypertension had circled staff initials. There was no documentation for the reason the initials were circled, ~ on 03/03 and 03/26/18 the 6:30 a.m. dose of [MEDICATION NAME] 20 mg oral delayed release capsule one by mouth twice a day [MEDICAL CONDITION] circled staff initials. There was no documentation for the reason the initials were circled and ~ on 03/03 and 03/26/18 the 8:00 a.m. dose of [MEDICATION NAME] 0.5 mg one by mouth twice a day for anxiety had circled staff initials. There was no documentation for the reason the initials were circled. On 04/04/18 at 11:04 a.m., the DON was asked to review the (MONTH) (YEAR) MARs for the resident. She was asked what the circled initials indicated. She reviewed the MARs and stated staff were to initial the medication, circle their initial and explain on the back of the MAR the reason their initials were circled. She was asked if the medications were administered. She stated there was no way to tell with no explanation on the back of the form. 3. Resident #7 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED].POTASSIUM CHLORIDE 20 MEQ (milliequivalents) ONE PO DAILY . The (MONTH) (YEAR) MAR documented the following: ~ circled initials for potassium chloride on 02/01, 02/02, 02/04, 02/05 and 02/06/18. It was blank on 02/03/18. The back of the MAR documented 02/05 and 02/06 the medication was on pharmacy order and ~ circled initials for [MEDICATION NAME] on 02/01/18. There was no explanation for the circled initial. The (MONTH) (YEAR) MAR documented the following: ~ circled initials for potassium chloride on 04/04/18. The back of the MAR documented the medication was on pharmacy order and ~ circled initials for [MEDICATION NAME] on 04/01/18 at 8:00 a.m. and 6:00 p.m. and 04/02/18 at 8:00 a.m. The back of the MAR documented on 04/01 the [MEDICATION NAME] was on pharmacy order. On 04/04/18 at 2:54 p.m., the DON was shown the physician's orders [REDACTED]. She was shown the (MONTH) and (MONTH) (YEAR) MARs. She was asked if the medications were out of stock. She stated, I don't know. She was observed reviewing the MARs. She stated, Yes. She was asked if it was acceptable for medications to be unavailable. She stated, No. She was asked if the MARs documented an explanation for all of the circled initials. She stated, No. She was asked if there should have been an explanation. She stated there should be. She was asked if the medications had been administered as ordered. She stated, No. 4. Resident #21 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED].[MEDICATION NAME] TABLET ONE PO BID FOR [MEDICATION NAME] . The (MONTH) (YEAR) MARs were reviewed. The [MEDICATION NAME] had circled initials on the following dates: ~ 01/24 at 6:00 p.m. with no explanations for the circled initials, ~ 01/25 at 8:00 a.m. and 6:00 p.m. with no explanation for the circled initials, and ~ 01/26 at 8:00 a.m. with no explanation for the circled initials. On 04/04/18 at 8:50 a.m., the DON was asked what the policy was for medication administration. She stated staff must have a physician's orders [REDACTED]. She stated staff would stay with the resident to ensure they swallowed the medication. She stated if residents refused medications, staff would circle the initials and document an explanation on the back of the MAR and flush the medication. She was asked if there would be other reasons staff would document circled initials for a medication. She stated maybe if the medication was not available, on order from the pharmacy, or maybe on hold. She was asked if there would be an explanation documented for the circled initials. She stated there should be an explanation on the back of the MAR. She was shown the (MONTH) (YEAR) MARs and asked if she could explain the reason the [MEDICATION NAME] had not been administered. She stated, No. She was asked if it was ever acceptable for routine medications to not be available in the facility. She stated, No. She was asked if the [MEDICATION NAME] had been administered as ordered. She stated, No. 5. Resident #13 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. ~ [MEDICATION NAME] 600 mg one tab (tablet) PO QID (four times a day) for pain, ~ [MEDICATION NAME] nasal spray two sprays nasal daily both nostrils and ~ [MEDICATION NAME] 50 micrograms oral tablet one tab by mouth at 6:00 a.m. for [MEDICAL CONDITION]. The (MONTH) (YEAR) MAR documented circled initials for the 8:00 a.m. dose of [MEDICATION NAME] on the 1st, 2nd, 3rd, 5th, 6th, 7th and 8th. It documented blanks for the 8:00 a.m. dose of [MEDICATION NAME] on the 4th and 9th. There was no documentation as to the reason the medication was not administered. The MAR documented circled initials for [MEDICATION NAME] at 8:00 a.m. on the 18th and 19th, the 12:00 p.m. dose on the 17th, 18th and 19th, the 6:00 p.m. dose on the 17th, 18th and 19th and the 10:00 p.m. dose on the 17th, 18th and 19th. The back of the MAR documented on 03/17/18, .[MEDICATION NAME] 600 mg not given d/t (due/to) waiting on pharmacy . The (MONTH) (YEAR) MAR documented circled initials for the 8:00 a.m. dose of the resident's [MEDICATION NAME] on the 1st and the 2nd. It documented a circle with no initials for the 6:00 a.m. dose of [MEDICATION NAME] on the 1st. The MAR indicated the order for [MEDICATION NAME] had changed to three times a day. It documented blanks for the 12:00 p.m. dose of [MEDICATION NAME] and the 2:00 p.m. dose of [MEDICATION NAME] opthalmic solution on 04/03/18. There was no documentation of the reason the medications were not administered. On 04/04/18 at 10:44 a.m., the DON was asked what the policy was for administering medications. She stated staff had to check the physician's orders [REDACTED]. She stated staff would also verify the resident took the medication. She was asked to explain what circled initials indicated. She stated if the initials were circled, there should be an explanation on the back of the MAR. The DON was asked what staff were instructed to do when a medication was not administered. She stated staff should document the reason it was not administered. She was asked to review the resident's (MONTH) (YEAR) MAR and was asked if the resident's [MEDICATION NAME] was administered on the 1st and second. She stated no, it was circled with no explanation given on the MAR. She was asked to explain the circle for the 6:00 a.m. dose of [MEDICATION NAME] on the 1st. She stated she could not explain and did not know if it was given. She was asked to explain the blanks for the resident's [MEDICATION NAME] and [MEDICATION NAME] eye drops on the 3rd. She stated, I don't know. She stated, It's not documented. The DON was asked to review the resident's (MONTH) (YEAR) MAR and was asked to explain the circled initials for the [MEDICATION NAME] on the 1st, 2nd, 3rd, 5th, 6th, 7th, 8th, and the blanks on the 4th and 9th. She stated she could not explain. She stated she knew the resident was refusing the medication at times, but the staff did not document anything. She was asked to explain the circled initials for the [MEDICATION NAME] 600 mg on the 17th, 18th and 19th. She stated the 03/17/18 note documented the medication was not given due to waiting on pharmacy.

Based on record review and staff interview, it was determined the facility failed to notify the physcian of multiple bilateral lower extremity ulcerations for five days for one (#33) of three sampled residents whose records were reviewed for hospitalization . There were no physcian orders to treat the multiple bilateral lower extremity ulcerations and three of the resident's wounds increased in size. The Resident Census and Conditions of Residents report, dated 02/08/17, documented a census of 45. Findings: Resident #33 was admitted on [DATE] with [DIAGNOSES REDACTED]. An admission order sheet, dated 08/19/16, did not document orders for wound care. An interim plan of care, dated 08/19/16, documented, .Skin integrity .numerous open areas .pressure ulcer . An interdisciplinary progress note, dated 08/20/16 at 3:30 p.m., documented, full body exam of wounds .outer (left) calf 4cm (centimeters) x (by) .3cm unstageable slough, (left) knee to foot scattered (with) areas of various stages of healing from scarred to scabbed. (Left) heel noted to have dry skin but (no) open area. (Left) outer foot 7cm x 2.5cm unstageable, open area (with) eschar (and) slough noted .(Left) great toe 1cm x 1.2cm scab area. (Right) heel 4cm x 5cm .wound covered (with) eschar. 16cm x 4cm outer (right) foot eschar (and) slough noted unstageable .foul odor noted to (right) foot. (Right) pinky toe 1cm x 1cm eschar area extending towards joint. 4th (right) toe 3cm x 2cm dark area (with) outside diameter dark in color. (Right) second toe surgically removed (with) 1cm x .5cm scabbed area between 1st (and) 3rd toes. (Right) great toe 3cm x 4cm extending (up) towards ball of foot. eschar covered .coccyx wound pink, granulated tissue wound measures 7cm x 10cm x 2cm deep. Areas cleaned (with) clean dry drsg (dressing) put on . An interdisciplinary progress note, dated 08/21/16 at 1:00 p.m., documented, .drsgs to bilat (bilateral) feet replaced x 2 d/t (due to) resident removing drsg .Encouraged resident to leave drsg in place . An interdisciplinary progress note, dated 08/22/16 at 9:00 p.m., documented, .wound care completed on coccyx, soaked through ABD (abdominal) pads, noticed the scabs (and) discoloration on BLLE (bilateral lower extremities), need to fax PCP (primary care physician) for order for TMC ([MEDICATION NAME] cream) . An interdisciplinary progress note, dated 08/24/16 at 6:00 a.m., documented, .All dressings clean (and) intact . A physician's telephone order sheet, dated 08/24/16 at 12:00 p.m., documented, .(1) .cleanse (Right) Great toe (with) DWC (dermal wound cleanser). Apply santyl (with) fluffed gauze, apply 4x4 dressing (and) tape QD (every day) . (2) cleanse (Right) 5th digit (with) DWC. apply santyl (with) fluffed gauze, 4x4 dressing (and) tape. QD . (3) cleanse (Right) lateral (with) DWC. Apply santyl (with) fluffed gauze. 4x4 gauze (and) ABD pad for padding (and) wrap QD until healed . (4) cleanse (Right) heel (with) DWC. Apply santyl (with) fluffed gauze (and) 4x4 dressing (and) wrap qd until healed . (5) cleanse (Left) outer leg (with) DWC. Apply santyl (with) fluffed gauze, 4x4 for padding (and) tape qd until healed . (6) cleanse (Left) heel (with) DWC. Apply santyl (with) fluffed gauze, 4x4 gauze for padding (and) wrap qd until healed . (7) cleanse (Left) outer (with) DWC. apply santyl (with) fluffed gauze. 4x4 (and) tape qd until healed . (8) cleanse (Left) Great toe (with) DWC. apply santyl (with) fluffed gauze, 4x4 (and) tape qd . (9) cleanse coccyx (with) DWC qd. Apply wet to dry dressing (and) tape. until healed . An interdisciplinary progress note, dated 08/24/16 at 12:00 p.m., documented, N.O. (new order) received for wound care .Measurements are the following: (Right) Great toe 3.5cm/2.5cm, (Right) 5th digit 2.2cm, (right) lateral foot 16 cm/2cm, (Right) heel 4cm/4cm, (Left) outer leg 5cm/2cm, (Left) heel 4cm/3cm, (Left) outer foot 7cm/3cm, (Left) great toe 1cm/1cm, coccyx 10cm/10cm x 2cm. On 02/09/17 at 9:58 a.m., the director of nursing (DON) was asked to review the resident's initial admission orders [REDACTED]. She stated it looked like the first wound care orders were received on 08/24/16. She was asked what the policy was for physician notification. She stated, Call immediately. The DON was asked what the policy was for obtaining orders for wound care when wounds were identified. She stated staff were to obtain orders immediately. She was asked when the physician had been notified of the resident's wounds. She stated she was notified on 08/24/16. She was asked when she should have been notified. She stated she should have been notified the very next day when the nurse had written the note. The DON was asked when the physician had been notified of the odor to the right foot. She reviewed the nurses' notes and stated they must have notified her because there were new orders on 08/24/16. She was asked if the physician should have been notified the day the foul odor had been discovered. She stated, Yes. She was asked to verify the resident had been admitted with wounds to his coccyx and bilateral lower extremities. She stated, Correct. She was asked if they received wound care orders five days later. She stated, Yes.

Based on record review and staff interview, it was determined the facility failed to obtain physician orders [REDACTED].#33) of three sampled residents whose records were reviewed for pressure ulcers. This resulted in actual harm to the resident. The wound increased in size. The Resident Census and Conditions of Residents report, dated 02/08/17, documented three pressure ulcers. Findings: A pressure ulcer treatment policy, last revised 11/13, documented, .Purpose .The purpose of this procedure is to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers . General Guidelines .The pressure ulcer treatment program should focus on the following strategies .Pressure ulcer care .Managing bacterial colonization and infection . Stage IV Protocol .Stage IV Pressure Ulcer Interventions/Care Strategies .Evaluate and determine pain level with pain assessment .Protect .Fill dead space including tunnels and undermining .Manage drainage .Promote moist wound healing . Treatment .Irrigate wound with normal saline or other designated wound cleanser .Determine wound treatment per wound status, exudate, bio-burden, location, and resident's underlying support system . Documentation .The following information should be recorded in the resident's medical record, treatment sheet or designated wound form .The date and time the dressing was changed .Wound appearance, including wound bed, edges, presence of drainage .The name and title of the individual changing the dressing, or initials .The type of dressing used and wound care given .All assessment data (i.e.(for example), wound bed color, size, drainage, .obtained when inspecting the wound . Resident #33 was admitted on [DATE] with [DIAGNOSES REDACTED]. An admission order sheet, dated 08/19/16, did not document orders for wound care. An interim plan of care, dated 08/19/16, documented, .Skin integrity .numerous open areas .pressure ulcer . An interdisciplinary progress note, dated 08/20/16 at 3:30 p.m., documented, full body exam of wounds .coccyx wound pink, granulated tissue wound measures 7cm (centimenters) x (by) 10cm x 2 deep. areas cleaned (with) clean dry drsg (dressing) put on . An interdisciplinary progress note, dated 08/22/16 at 9:00 p.m., documented, .wound care completed on coccyx, soaked through ABD (abdominal) pads . An interdisciplinary progress note, dated 08/24/16 at 6:00 a.m., documented, .All dressings clean (and) intact . A physician's telephone order sheet, dated 08/24/16 at 12:00 p.m., documented, .(9) cleanse coccyx (with) DWC (dermal wound cleanser) qd (every day). Apply wet to dry dressing (and) tape. until healed . An interdisciplinary progress note, dated 08/24/16 at 12:00 p.m., documented, N.O. (new order) received for wound care .Measurements are the following: coccyx 10cm/10cm x2cm. A comprehensive resident assessment, dated 8/25/16, documented he was admitted with one stage 4 pressure ulcer and one venous and arterial ulcer which was a diabetic ulcer. On 02/09/17 at 9:58 a.m., the director of nursing (DON) was asked to review the resident's initial admission orders [REDACTED]. She stated it looked like the first wound care orders were received on 08/24/16. She was asked what the policy was for physician notification. She stated, Call immediately. She was asked what the policy was for obtaining orders for wound care. She stated the staff would call and obtain orders immediately. She was asked when the physician had been notified of the resident's wounds. She stated she was notified on 08/24/16. She was asked when she should have been notified. She stated she should have been notified the very next day when the nurse had written the note. She was asked to verify the resident had been admitted with wounds to his coccyx and bilateral lower extremities. She stated, Correct. She was asked if they received wound care orders five days later. She stated, Yes.