Every finding on record at Kensington Nursing and Rehabilitation Center

Based on observation, interview, and review of the facility's policy, the facility failed to store food in accordance with professional standards for food service safety, which had the potential to affect 74 of the facility's 74 residents who consumed food from the kitchen. Observation of the kitchen on [DATE], revealed unlabeled, undated, unsealed, and expired food items in the walk-in refrigerator and the dry pantry storage area. The findings include: Review of the facility policy titled, Policy and Procedure Manual, Food Storage, dated 2019, [NAME] and Associates, Inc. Chapter three: Food Production and Food Safety ,d+[DATE], revealed foods should be dated as it is placed on the shelves if required by state regulation. In addition, date marking will be visible on all high-risk food to indicate the date by which a ready-to-eat TCS (Time/Temperature Control for Safety) food should be consumed, sold, or discarded. Continued review revealed plastic containers with tight-fitting covers must be used for storing grain products, sugar, dried vegetables, and broken lots of bulk foods. All containers must be legible and accurately labeled and dated. Observation of the kitchen, on [DATE] starting at 11:10 AM, revealed the single walk-in refrigerator had one clear cup of white substance (of yogurt consistency) which was unlabeled, and undated; and eleven unfrozen Magic Cups (fortified ice cream) which was undated. Further observation revealed one case of Danimals Yogurt in individual containers which was expired with an expiration date of [DATE]; one Tupperware container labeled ham salad which was expired with a handwritten expiration date of [DATE]; and one Tupperware container labeled tomato soup which was expired with a date of [DATE]. Additionally, there was one block of bologna covered in plastic Ziplock, which was unlabeled with a handwritten date of [DATE]. Observation of the dry pantry storage area, revealed one cardboard box of uncooked rice in the original plastic bag which was opened without securement. Further observation revealed one package of [NAME] English Muffins with the handwritten opened date of [DATE] and package expiration date of [DATE]. During an interview with the Dietary Director, on [DATE] at 8:50 AM, he stated, It was everyone's responsibility, the cook, the dietician, even me, to check the refrigerator, freezer, and dry pantry storage for expired food items. He additionally stated, the refrigerator, freezer, and dry storage pantry should be checked for expired food items daily. During an interview with the Director of Nursing, on [DATE] at 2:50 PM, he stated it was his expectation expired food items in the kitchen would be discarded. He additionally stated expired food items could make residents sick and cause harm. During an interview with the Interim Administrator, on [DATE] at 3:34 PM, she stated there should be no expired food items in the kitchen and expired food items should be discarded if found. She additionally stated residents could become ill from expired food items.

Based on observation, interview, and review of the facility's policy, the facility failed to ensure proper storage of biologicals for 1 of 2 treatment carts. Observation of the 100 hall treatment cart on [DATE], revealed 28 packages of Hydrogel which expired in 2023 and 2024. The findings include: Review of the facility's policy titled, Medication Storage, effective [DATE], revealed medications were stored in carts and nursing staff was responsible for maintaining medication storage in a safe manner. Observation with Licensed Practical Nurse (LPN)9, on [DATE] at 1:25 PM, revealed the 100 hall treatment cart contained twenty-eight individually wrapped packages of Hydrogel, which expired 2023 and 2024. (Hydrogel is a wound dressing that helps keep wounds moist, which promotes healing by creating an environment conducive to cell growth). During interview on [DATE] at 1:25 PM, LPN9 stated she did not recall any residents receiving Hydrogel treatments at this time on the 100 hall. She stated hydrogel was used for wound treatment. The LPN stated the nurses tried to go through the treatments carts to ensure there were no expired treatments; however, there was no one designated person responsible to go through the carts. She further stated the expired hydrogel treatment may not be effective, as it may not heal wounds. During interview on [DATE] at 3:11 PM, the Director of Nursing (DON) stated all staff should be aware of expiration dates for treatments, and anyone who used the treatment should check the expiration date. He further stated he was not aware if staff documented when a treatment expired; however, the nurse should reorder the treatment upon discovering it expired. The DON further stated he audited the medication carts regularly and looked at expiration dates; however, he did not audit the treatment carts. In further interview, the DON stated he did not recall any residents receiving hydrogel treatment at this time. He stated he could not recall the purpose of hydrogel. However, he stated it was his expectation expired treatments would not be used, but would be discarded, and reordered. He further stated if an expired treatment was used the treatment could be ineffective or could cause harm to the resident. During an interview on [DATE] at 3:34 PM, the Interim Administrator stated she expected expired treatments to be discarded. She stated the DON was responsible to ensure the clinical team discarded expired treatments. The Administrator further stated she did not know if using the expired treatment of hydrogel could cause harm to a resident.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet the resident's safety needs for one (1) of five (5) sampled residents (Resident #1). On 06/26/2022, Certified Nursing Assistant (CNA) #1 found a box labeled [NAME]. CNA #1 notified Licensed Practical Nurse (LPN) #2, who discovered a handgun in the box. The Assistant Director of Nursing (DON) removed the weapon from Resident #1's room. On 07/08/2022, five (5) days later, the Comprehensive Care Plan (CCP) was developed to include a focus stating the resident expressed fear related to watching the news and current events. However, although the handgun was found in Resident #1's room on 06/26/2022, there was no documentation the CCP was developed to address safety interventions related to the discovery of the resident's possession of a handgun. The findings include: Review of the facility's, Person Centered Care Plan Policy, revised 07/01/2019, revealed the purpose was to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being; to eliminate or mitigate triggers that may cause re-traumatization to the resident, and to promote positive communication between the resident, resident representative, and team to obtain the resident's and resident's representative's input into the plan of care, and ensure effective communication and optimize clinical outcomes. Further, a resident's comprehensive care plan would be developed in place of a base line care plan if developed within forty-eight (48) hours and met the requirements of a comprehensive care plan. Review of Resident #1's medical record revealed the facility originally admitted the resident on 08/25/2017, with the most recent re-admission on 03/08/2019. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) which indicated intact cognition. Further review of the MDS Assessment revealed the facility assessed the resident as requiring two (2) or more persons for physical assistance with dressing, transfers, toilet use and personal hygiene, and one (1) person physical assist for bed mobility. Record review revealed while straightening Resident #1's belongings on 06/26/2022, Certified Nursing Assistant (CNA) #1 found a box labeled [NAME] and notified Licensed Practical Nurse (LPN) #2. LPN #2 discovered a handgun in the box and notified the Assistant Director of Nursing (ADON). The ADON removed the weapon from the resident #1's room. Record review revealed, although a handgun was found in Resident #1's room on 06/26/2022, Resident #1's Comprehensive Care Plan (CCP), print dated 06/27/2022, revealed no focus related to finding a handgun in the resident's room. Further review revealed no interventions related to the discovery of the resident's possession of a handgun. Review of Resident #1's CCP, print dated 07/08/2022, revealed a focus, dated 07/01/2022, five (5) days after the incident, which stated the resident expressed fear related to watching the news and current events. The goal was for Resident #1 to have no further decline in mood or increase in behaviors through next review. Interventions, dated 07/01/2022, included: if resident expressed fear related to current violent events, staff would offer to turn off the television; and reassure the resident he/she was safe and staff were trained regarding the measures to take to ensure the resident's safety. However, there was no documentation that the CCP was developed to address the handgun found in Resident #1's room. Further review revealed no safety interventions on the CCP related to the discovery of the resident's possession of a handgun. Interview with Licensed Practical Nurse (LPN) #8, on 07/08/2022 at 10:52 AM, revealed a resident's CCP was to be individualized and based on a resident's specific needs and preferences. She stated Resident #1's CCP should have been developed immediately related to the incident of staff discovering the handgun in his/her room in order to provide interventions for the safety of all residents. Interview with the Minimum Data Set (MDS) Nurse, on 07/08/2022 at 11:11 AM, revealed the resident's CCP was developed upon admission and revised with every MDS Assessment in order to ensure all necessary care areas were addressed. The MDS Nurse stated the CCP provided guidance on how care was to be provided for residents in order to ensure the resident's needs were met. Additionally, she stated staff developed/revised the CCP as needed. Further interview with the MDS Nurse revealed the clinical team reviewed Resident #1's care plan, but she did not believe that as of 06/30/2022, Resident #1's care plan had been updated related to a gun found in his/her room on 06/26/2022. Interview with the Assistant Director of Nursing (ADON), on 07/05/2022 at 11:29 AM, revealed the purpose of the CCP was to provide guidance to all who provided care to the resident. The ADON stated any nurse could develop care plans when needed; and the CCP should be developed related to unsafe incidents. The ADON stated the facility updated Resident #1's CCP related to his/her mood, as the facility determined this was the resident's need. However, the ADON stated the resident's CCP was not developed related to safety measures after the handgun was found in the resident's room. Interview with the Director of Nursing (DON), on 07/07/2022 at 12:17 PM, revealed the CCP provided guidance to staff on how to provide for the specific needs of residents. The DON stated the facility developed Resident #1's CCP related to reassuring the resident he/she was safe and turning off the television when the resident expressed anxiety while watching negative current events. Interview with the Center Executive Director (CED), on 07/08/2022 at 12:35 PM, revealed the CCP was a living document that guided the care for each resident. Additionally, any nurse could develop a resident's CCP and failure to do so could potentially omit necessary care. Further review revealed the CED expected the nurses to update the care plans after an incident was noted, such as finding a gun in a resident's room with interventions to prevent recurrence and promote safety for all residents.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure the residents' environment remained as free of accident hazards as possible for one (1) of five (5) sampled residents (Resident #1). The census was seventy-six (76) residents. On 06/26/2022, Certified Nursing Assistant (CNA) #1 discovered a box labeled [NAME] and notified Licensed Practical Nurse (LPN) #2. The nurse found a handgun in the box and notified the Assistant Director of Nursing (ADON). Resident #1's room was immediately searched for other dangerous weapons/items. However, the facility failed to search other residents' rooms for dangerous items, until after the State Survey Agency (SSA) entered the building the next afternoon, on 06/27/2022. The findings include: Review of the facility's OPS155 Weapons Policy, effective 05/01/2016, revealed the facility prohibited possession of firearms, knives, or any other dangerous weapons on facility property. Continued review revealed upon reasonable suspicion, the facility reserved the right to search company vehicles, packages, containers, briefcases, purses, lockers, desks, enclosures, and persons entering the property. Per Policy, the facility educated staff during orientation and annually. Review of the facility's, Welcome Packet, undated, revealed a section titled, Center Rules for Living and Conduct, which stated, firearms, explosives, knives, and other weapons considered dangerous were prohibited on the premises. According to an anonymous report received by the SSA, while straightening Resident #1's belongings in his/her room, a facility staff member moved a bag on a chair, which fell to the floor and a boxed handgun fell out. Record review revealed on 06/26/2022, Certified Nursing Assistant (CNA) #1 found a box labeled [NAME] while straightening Resident #1's belongings. CNA #1 notified Licensed Practical Nurse (LPN) #2. The nurse discovered a handgun in the box and notified the Assistant Director of Nursing (ADON). The ADON removed the weapon from the facility. Resident #1's room was immediately searched for other dangerous weapons/items Review of Resident #1's medical record revealed the facility originally admitted the resident on 08/25/2017, with the most recent re-admission on 03/08/2019. Admission diagnoses included Anxiety Disorder and Major Depressive Disorder. Later during the resident's stay, the diagnosis of Post-traumatic stress disorder ([CONDITION(S)]) was added. Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) which indicated intact cognition. Further review revealed the facility assessed the resident as requiring two (2) plus persons physical assistance for dressing, toilet use and personal hygiene, and one (1) person physical assistance for bed mobility. Locomotion on and off the unit occurred, but only once or twice during the assessment period. The facility assessed the resident as having no behavioral symptoms. Review of Resident #1's Comprehensive Care Plan, print dated 06/27/2022, revealed the resident was at risk for distressed/fluctuating mood symptoms related to sadness/depression caused by overall decline in health. The goal stated the resident would have no further decline in mood or increase in behaviors through next review. Interventions included: observe the resident for signs of [CONDITION(S)], including delusions/hallucinations; notify Physician/Advanced Practice Registered Nurse (APRN) as needed and observe for signs/symptoms of worsening sadness/depression/anxiety/fear/anger/agitation. Further review of Resident #1's Comprehensive Care Plan, print dated 06/27/2022, revealed no interventions related to the discovery of the resident's possession of a handgun, which was found on 06/26/2022. Review of Resident #1's Comprehensive Care Plan, print dated 07/08/2022, revealed a focus, dated 07/01/2022, five (5) days after the incident, that stated the resident had expressed fear related to watching the news and current events. The goals stated the resident would feel safe through next review. Interventions, dated 07/01/2022, included: if resident expressed fear related to current violent events staff would offer to turn off the television; and reassure the resident he/she was safe and staff were trained regarding the measures to take to ensure the resident's safety. However, there was no documented evidence the Care Plan addressed the handgun found in the resident's room or what to do if weapons were found in the resident's room in order to keep all residents safe. Interview with Certified Nursing Assistant (CNA) #1, on 06/28/2022, at 6:06 PM, revealed while she cleaned Resident #1's room on 06/26/2022, a bag fell from a chair. As she retrieved the bag, she observed what appeared to be a gun holster. Continued interview revealed she notified Licensed Practical Nurse (LPN) #1 and LPN #4 of her findings. LPN #1 and LPN #4 removed the bag from the resident's room. The CNA further stated Resident #1 watched a lot of news about recent mass shootings and had commented to her that if someone came in shooting, he/she would get their 38. Further interview with CNA #1 revealed the facility had not provided any training on weapons, or active shooters that she could recall. Interview with LPN #1, on 06/28/2022 at 7:13 PM, revealed she was working the shift the handgun was discovered in Resident #1's belongings. LPN #1 stated the ADON came to the building and retrieved the gun. LPN #1 further stated she believed Resident #1 was not stable enough to possess a handgun. Per interview, staff referred to the resident as Jekyll and [NAME], and the resident tried to work mind games on staff when in his/her room. Interview with Licensed Practical Nurse (LPN) #2, on 06/28/2022 at 8:06 PM, revealed on the day the gun was found, Resident #1 had commented on using his/her 38, if someone came in shooting. Continued interview revealed CNA #1 informed her a bag fell in Resident #1's room and the CNA asked her to look in the bag. LPN #2 observed a box labeled [NAME] and she knew that was a type of handgun. Per interview, she opened the box and observed a gun. LPN #2 stated LPN #1 and LPN #4 removed the gun from the resident's room and took it to the nurses' station. The LPN stated LPN #1 and LPN #4 had already called the Assistant Director of Nursing (ADON) to notify him of the gun. Continued interview revealed the ADON removed the gun from the building. However, LPN #2 stated she could not recall any training regarding the facility's policy on weapons or the procedure to follow upon discovery of weapons in the facility. LPN #2 stated as far as she knew other nurses had told her they were not allowed to search rooms and management had said no searching of rooms. Interview with LPN #4, on 06/30/222 at 2:55 PM, revealed she worked the shift the gun was discovered. She stated she locked the weapon in her medication cart until the ADON arrived to remove the weapon from the facility. LPN #4 stated the facility was responsible to ensure residents were safe, but she was unaware of any weapon search occurring in the facility after the discovery of the gun. Review of the documents titled, Training Session: Weapons Policy and Training Session: Armed Intruder, both dated 06/27/2022 and 06/28/2022, revealed the facility educated staff on the facility's Armed Intruder and Weapons policies on 06/27/2022 and 06/28/2022. Interview with CNA #4, on 06/30/2022 at 1:51 PM, revealed she worked the shift the weapon was discovered, but she was not aware of the discovery. She stated she believed weapons were prohibited in order to keep residents safe. CNA #4 further stated she was unaware of any searches of residents' rooms or education since the discovery of the weapon. Interview with the Unit Manager, on 06/30/2022 at 4:15 PM, revealed the facility began resident interviews regarding safety concerns. She stated interviews were conducted on the day, after the handgun was found, and after the SSA entered the building. The Unit Manager stated when interviewing residents, she asked if the facility could search their belongings for items that may be harmful. Further interview revealed the ADON and UM searched the rooms, on 06/27/2022. Additionally, the facility then began education on 06/27/2022, related to armed intruders and their weapons' policy. Review of the document titled, Sample Questions asked to Rsds on 06/27/2022 by ADON and UM revealed all residents, who were able to answer, were interviewed, by the ADON and UM. The interview included asking the residents if they felt safe in his/her home at the facility. The residents were also asked for permission to look around his/her room to make sure there was nothing present that could harm him/her or someone else. Interview with the ADON, on 06/30/2022 at 4:44 PM, revealed staff notified him of the handgun being found in Resident #1's room on 06/26/2022 at approximately 10:24 AM, and he arrived at the facility approximately twenty (20) minutes later. The ADON stated he first removed the weapon from the facility and then approached Resident #1. Further interview revealed when he asked Resident #1 about the weapon, the resident confirmed it belonged to him/her and it was his/her personal property. Continued interview revealed he obtained permission from Resident #1 to search his/her belongings and after searching discovered no other weapons or ammunition. The ADN stated the facility did not search any other areas or resident rooms that day, (on 06/26/2022) as he had no reason to suspect any other weapons. Additionally, law enforcement was not contacted as he believed any danger to the residents was removed. Further interview with the ADON, on 06/30/2022 at 4:44 PM, revealed there was no ammunition in the bag, box, room, or gun clip. The ADON stated the police were not called as he thought he had removed the danger and did not see any point in calling the police. Further interview with the ADON revealed, on the morning of 06/27/2022, an ad hoc QAPI meeting was held with the facility's department heads. A facility-wide search for weapons was made and residents were interviewed or observed to determine if they felt safe in their home at the facility and permission to look around the residents' rooms to make sure there was not anything present that could harm the resident or someone else. Residents The Medical Director was not present but was updated. Interview with the Director of Nursing (DON), on 07/07/2022 at 12:17 PM, revealed Resident #1's room was searched upon discovery of the handgun on 06/26/2022. Further interview revealed the facility did not search other residents' rooms, as the facility did not want to violate the residents' right to privacy. However, the DON stated the facility was expected to provide for the safety of the residents. Interview with the Center Executive Director (CED), on 06/30/2022 at 5:18 PM, revealed she first became aware of the handgun when the SSA entered the facility, on the afternoon of Monday, 06/27/2022. The CED stated, upon learning of the weapon, she and the ADON reviewed the steps taken and the ADON had no reason to suspect any other weapons were in the facility. Therefore, the facility did not conduct further searches to ensure resident safety until the evening of 06/27/2022. The CED stated the facility's weapons policy was reviewed and re-education was started.

Based on observation, interview, and facility policy review, it was determined the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service Review of the facility Census and Condition, dated 10/15/19, revealed seventy-three (73) of seventy-six (76) residents received meals from the kitchen. A food tray line observation on 10/15/19 at 11:15 AM, revealed the day shift cook did not know the correct food temperatures of cold food. The findings include: Review of the facility's policy titled Food: Quality and Palatability, dated 05/2014, revealed the Cook (s) would prepare food in a sanitary manner utilizing the principles of Hazard Analysis Critical Control Point ) HACCP and time and temperature guidelines as outlined in the Federal Food Code. Observation of a meal service on 10/15/19 at 11:15 AM, revealed the temperature of the tuna fish sandwiches was fifty-three. seven (53.7) degrees Fahrenheit (F); cucumber and tomato salad was at a temperature of fifty-two. nine (52.9) degrees F, and the pudding was at a temperature of sixty-four.seven (64.7) degrees F. Cold foods should have a holding temperature of forty-one (41) degrees F. or below. However, interview with Dietary Cook #1, on 10/15/19 at 11:45 AM revealed she was not aware of what the temperature of the cold food should be. She stated she was aware the food temperatures were on the back of her name badge, however, she did not refer to them until the dietary manager reminded her of this. She stated she had been educated on food temperatures on hire. Interview with the Dietary Manager, on 10/16/19 at 1:52 PM, revealed she had a lot of training that needed to be done and it was her expectation the cook and other dietary staff should know the accurate food temperatures before serving. Interview with the Dietitian, on 10/18/19 at 3:08 PM revealed she expected staff to serve food at proper temperatures.

Based on observation, interview and review of the facility policy, it was determined the facility failed to ensure it must have food prepared by methods that conserve nutritive value, flavor, and appearance and food and drink that is palatable, attractive, and at a safe and appetizing temperature. Review of the facility Census and Condition, dated 10/15/19, revealed seventy-three (73) of seventy-six residents received meals from the kitchen. The findings include: Review of the facility's policy, titled Food and Nutrition Services Policies and Procedures dated 06/15/18, revealed foods were to be served at temperatures appropriate for food safety and palatability and food were to be held at appropriate holding temperatures. Observation of a lunch meal tray line service on 10/15/19 at 11:45 PM, revealed food was not at appropriate temperatures for serving. The foods included were tuna fish croissant sandwiches, cucumber and tomato salads. and pudding. The temperature of the tuna fish sandwiches was fifty-three. seven (53.7) degrees Fahrenheit (F); cucumber and tomato salad temperature was fifty-two. nine (52.9) degrees F, and the pudding temperature was sixty-four. seven (64.7) degrees F. The holding temperatures of these food items should have been at a cold temperature of forty-one (41) degrees F. or below. Interview with Dietary Cook #1, on 10/15/19 at 11:45 AM revealed she was not aware of what the temperature of the cold food should be; however, the appropriate temperatures for cold food was on the back of her name badge. Interview with the Dietary Manager, on 10/16/19 at 1:52 PM, revealed she had a lot of training that needed to be done and she expected the cook and other dietary staff to know the accurate food temperatures before serving. Interview with the Dietitian, on 10/18/19 at 3:08 PM revealed she expected staff to serve food at proper temperatures.

Based on observation, interview and review of the facility's policy, it was determined the facility failed to ensure it must prepare, distribute, and serve food in accordance with professional standards for food service safety. Review of the facility Census and Condition, dated 10/15/19, revealed seventy-three (73) of seventy-six (76) residents received their meals from the kitchen. Observation of a lunch meal service on 10/15/19 revealed dietary staff was not washing their hands in between glove changes or before donning gloves. The findings include: Review of the facility's policy, titled Food and Nutrition Services Policies and Procedures, last revised 06/15/18 revealed hand washing should be performed before preparing or handling food; before putting on disposable gloves to begin a task that involved food; during preparation of food; after contacting any soiled equipment or utensils; and when moving from one task to another. Use of disposable gloves did not take the place of proper hand washing. Observation of a lunch meal service, on 10/15/19 at 12:05 PM, revealed the day shift cook touched trash can lids and did not wash her hands and change gloves. In addition, the night shift cook came into the kitchen to begin his shift, and did not wash his hands before donning gloves or between glove changes before beginning food preparation for the dinner meal. Further observation revealed the day shift cook had gloves on and rinsed them under water and wiped them dry on her pants and continued to prepare food. Interview with Dietary Cook #1, on 10/18/19 at 1:50 PM, revealed she had been educated on changing gloves and washing her hands. She stated she should have washed her hands and changed her gloves. Interview with the Dietary Manager, on 10/16/19 at 1:52 PM, revealed she needed to do a lot of training with the staff and she expected staff to wash their hands and change gloves as needed. Interview with the Dietitian, on 10/18/19 at 3:08 PM, revealed it was her expectation the staff wash their hands and change gloves.

Based on observation, interview, record review, and facility's policy review, it was determined the facility failed to implement a comprehensive person-centered care plan one (1) of twenty-five (25) sampled residents (Resident #22). Resident #22 sustained falls on 09/18/19, 09/26/19, 10/12/19, and 10/13/19 due to the facility not ensuring staff not leave the resident alone in his/her room or dining room without staff supervision per care plan. The findings include: Review of the facility policy titled, Person-Centered Care Plan, last revised 07/01/19, revealed the facility must develop and implement a Person-Centered Care Plan which is individualized after completing of the Comprehensive Assessment for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, nutrition, and mental and psychosocial needs that are identified in the comprehensive assessments. The care plan will be reviewed and revised by the interdisciplinary team after each assessment. A comprehensive person-centered care plan must be developed for each resident and must describe services that are to be furnished and any services that would otherwise be required but are not provided due to the resident's exercise of rights, including the right to refuse treatment. The Care plans will be customized to each individual resident's preferences and needs. The care plans must be communicated to appropriate staff, resident, health care decision maker and family. The care plans will be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, and as needed to reflect the response to care and changing needs and goals. Review of the medical record revealed the facility admitted Resident #22 on 05/24/17 with [DIAGNOSES REDACTED]. Review of Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #22's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of zero (0) which indicated the resident was rarely/never understood. Further review of the MDS, Section G: Functional Status, revealed the facility assessed Resident #22's ability to transfer as 2/2; which indicated one staff person was to provide guided maneuvering of limbs or other non-weight-bearing assistance. Review of Resident #22's Comprehensive Care Plan titled, Resident at Risk for Falls, initiated 05/26/17, revealed interventions to encourage resident to be up at nursing station while awake; when finished with meals, encourage to come out of dining room and lie down, do not leave resident in dining room alone; resident to be in the TV room across from the nurses station; and do not leave resident alone in restorative dining and/or in room while up in wheelchair. However, review of Risk Management System (RMS) Event Summary Reports, dated 09/18/19 at 9:20 AM, 09/26/19 at 5:35 PM, 10/12/19 at 5:35 PM, and 10/13/19 at 5:05 PM revealed Resident #22 sustained falls from his/her wheelchair when he/she was left in the dining room or his/her room instead of at nursing station, in TV room across the hall in the dining room, or where the resident had supervision per care plan. Interview with Certified Nurse Aide (CNA) #7, on 10/18/19 at 1:50 PM, revealed she was working when Resident #22 had three (3) of the falls. She stated the resident was not to be alone during mealtime, however, CNA #7 admitted she left Resident #22 unsupervised and in the dining room alone to answer another resident's call light on 09/18/19. CNA #7 revealed she was aware Resident #22 was alone in his/her bedroom, while up in the wheelchair while she was providing care to other residents during falls on 10/12/19 and 10/13/19, when the resident should have been in TV room across from nursing station while up in his/her wheelchair. Interview with Certified Nursing Assistant (CNA) #6, on 10/17/17 at 2:20 PM, revealed Resident #22 is care planned to not to be left alone in dining room or in bedroom alone while in wheelchair however, CNA #6 revealed she left the resident unsupervised in the dining room while providing care to other residents on 09/26/19. Interview with Licensed Practical Nurse LPN#1, Unit Manager, on 10/18/19 at 4:30 PM, revealed she would expect staff to follow Resident #22's care plan related to fall interventions due the resident's [DIAGNOSES REDACTED]. She stated the resident had decreased safety awareness and staff failed to ensure Resident #22's safety related to falls. Interview with the Director of Nursing (DON), on 10/18/19 at 4:50 PM, revealed she expected staff to ensure Resident #22's safety and all staff members to follow the resident's care plan interventions to decrease potential of falls.

Based on observation, interview, and record review, it was determined the facility failed to provide respiratory care, consistent with professional standards of practice, for one (1) of twenty-five (25) sampled residents (Resident #3). Resident #3 had orders for Oxygen (02) at two (2) liters per minute via nasal cannula continuously; however, observation revealed Resident #3 was not receiving oxygen. The findings include: Record review revealed the facility admitted Resident #3 on 07/03/19 with [DIAGNOSES REDACTED].#3's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of three (3) which indicated the resident was not interviewable. Review of Resident #3's (MONTH) 2019 physician's orders [REDACTED]. Observation on 10/15/19 at 11:48 AM revealed an 02 tank on Resident #3's wheelchair and an 02 concentrator in the resident's room running but not in use. Observation on 10/16/19 at 8:50 AM and 1:14 PM revealed Resident #3 was sitting in the lounge in a wheelchair without 02 in use. Interview with the Director of Nursing (DON) on 10/17/19 at 01:46 PM, after being made aware of the continuous 02 order revealed the resident had an illness in (MONTH) 2019 that required the resident to need 02, but the O2 was no longer needed. However, she stated she expected the staff to follow the physician's orders [REDACTED].

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure the care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for two (2) of twenty-five (25) sampled residents (Resident #35 and #66) The facility failed to revise the care plan per facility policy for Resident #35 related to skin breakdown and Resident #66 related to receiving showers three (3) time a week. The findings include: Review of the facility policy titled, Person-Centered Care Plan, last revised 07/01/19 revealed the facility must develop and implement a Person-Centered Care Plan which is individualized after completing of the Comprehensive Assessment for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, nutrition, and mental and psychosocial needs that are identified in the comprehensive assessments.The care plans will be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, and as needed to reflect the response to care and changing needs and goals. 1. Record review revealed the facility readmitted Resident #35 on 11/30/17 with [DIAGNOSES REDACTED]. Review of Quarterly Minimum Data Set (MDS) assessment, dated 08/30/19, revealed the facility assessed Resident #35's cognition as severely impaired as the Brief Interview for Mental Status (BIMS) was not attempted since the resident was rarely/never understood and not interviewable. Further review of the MDS assessment revealed the resident had a [MEDICAL CONDITION]. Review of a Wound assessment dated [DATE] revealed an onset of skin breakdown described the as unstagable eschar measuring 3.1 centimeters (cm) x 3.0 cm x less than 0.1 cm to right dorsum of foot. However, review of Resident #35's Comprehensive Care Plan for At risk for skin breakdown, last revised 08/27/19 revealed there was no revision to reflect the actual skin breakdown to the right dorsal foot or interventions to address the wound care/treatment. Interview with Licensed Practical Nurse (LPN) #1 on 10/17/19 at 3:02 PM revealed she was not aware Resident #35's Care Plan for potential for skin breakdown had not been revised. She stated it should have been revised to actual breakdown and interventions added to address the wound. She also revealed she would not have revised this resident's care plan as she was not in charge of this unit. Interview with the Director of Nursing (DON) on 10/18/19 at 3:13 PM revealed the Care Plan should have been revised and updated upon the skin becoming an actual breakdown and wound. She stated the unit managers and/or the nursing staff caring for resident were responsible for updating the Comprehensive Care Plans. She stated she expected the care plans to reflect the resident's ongoing problems and interventions for treatment. 2. Record review revealed the facility admitted Resident #66 on 08/25/17 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 09/25/19 revealed the facility assessed Resident #66's cognition as intact with a BIMS score of fifteen (15) which indicated the resident was interviewable. Further review revealed the resident was totally dependent on two (2) staff members for bathing. Review of the Comprehensive Care Plan for resident at risk for decreased ability to perform Activities of Daily Living (ADL's) in bathing, grooming, personal hygiene, dressing etc., dated 09/07/17 revealed intervention dated 03/27/19, to provide resident with extensive assist of one to two (1-2) as needed for bathing, hygiene and dressing. Review of a Physician Order dated 10/03/19 revealed an order for [REDACTED].>Review of the (MONTH) 2019 Weekly Bath and Skin Report revealed the resident refused care on 10/04/19 and received three (3) showers from 10/03/19 to 10/16/19 (two {2}weeks). Interview with Resident #66 on 10/18/19 at 9:39 AM revealed he/she had received a physician order from the dermatologist to have a shower three times weekly for the Seborrhea he/she had around the scalp and face. Resident #66 stated he/she refused bed baths because it was like bathing in dirt, and he/she only wanted showers. Interview with Unit Manager on 10/18/19 at 3:11 PM, revealed the order should have been noted upon return of the resident's return from the doctor. She stated the order should have been noted and the Care Plan and Bath schedule revised to include the new order. Interview on 10/18/19 at 3:38 PM with DON revealed when this surveyor asked for a copy of the order, she revealed she had not seen the order before. She stated the resident should be getting showers three times a week per the order. The DON further revealed when the resident came back with new orders, the order should have been put in by nurse when the resident returned; however, there was no documented evidence the nurse saw the order since the order was not noted on the care plan or a new Weekly Bath and Skin report as it should have shown. She stated the resident has been made a new shower schedule to reflect his/her shower schedule.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure the services provided or arranged by the facility, as outlined by the comprehensive care plan, met professional standards of quality for one (1) of twenty-five (25) sampled residents (Resident #65). Staff failed to provide sterile technique per facility policy when providing [MEDICAL CONDITION] Care for Resident #66. The findings include: Review of the facility policy titled, [MEDICAL CONDITION] Care, dated 01/01/04 revealed to perform [MEDICAL CONDITION] care at least two times daily and as needed. Cleanse hands. Put on personal protective equipment. Remove soiled dressing and inner cannula. [MEDICAL CONDITION] enough so that you are able to maneuver [MEDICAL CONDITION]. Remove gloves. Discard in waste bag and cleanse hands. Open [MEDICAL CONDITION] using aseptic technique. Remove sterile drape [MEDICAL CONDITION] kit and spread on bedside table. Do not touch inner sterile field. Empty sterile contents [MEDICAL CONDITION] kit onto sterile drape. Fill basin with sterile water and another with peroxide. Put on sterile gloves. Remove inner cannula from peroxide soak and clean inside with soft brush or pipe cleaner. Rinse with sterile water. Place the cleaned inner cannula [MEDICAL CONDITION] and lock in place. Place drain sponge [MEDICAL CONDITION] neck plate, pulling the ends up under [MEDICAL CONDITION]. Remove gloves and cleanse hands. Record review revealed the facility admitted Resident #65 on 09/11/19 with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment, dated 09/18/19, revealed the facility assessed Resident #65's cognition as intact with a BIMS score of thirteen (13), which indicated the resident was interviewable. Review of the Comprehensive Care Plan for Resident exhibits or is at risk for respiratory complications related to [MEDICAL CONDITION], dated 09/12/19 revealed an interventions [MEDICAL CONDITION] two (2) times daily and as needed for extra secretions. However, observation of [MEDICAL CONDITION] change and care by Licensed Practical Nurse (LPN) #1, Unit Manager Transitional Care Unit, on 10/18/19 at 1:10 PM revealed she failed to use sterile technique while providing [MEDICAL CONDITION] Care when she contaminated her sterile gloves when she picked up a bottle of sterile saline with her sterile gloves on and emptied it into the tray. In addition, she failed to remove the contaminated gloves, wash her hands, and don new sterile gloves prior to pulling the inner cannula out of the hydrogen peroxide and cleaning the tube. She rapidly replaced the contaminated inner cannula since she had not changed her contaminated gloves. Interview with the Licensed Practical Nurse (LPN) #1 on 10/18/19 at 1:10 PM revealed she would not have changed anything with her [MEDICAL CONDITION] care technique. She stated she was not aware she contaminated her gloves with the saline bottle; however when she thought about it she agreed her hands would have been contaminated. She revealed she was nervous since someone was watching her. Interview with the Director of Nursing (DON) on 10/18/19 at 3:14 PM revealed she expected the staff to follow to use sterile technique to accomplish [MEDICAL CONDITION] Care.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure two (2) of twenty-five (25) sampled residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming, and personal hygiene (Resident #32 and #66). Resident #66 had a physician order to receive bath/shower three (3) times a week for Seborrhea treatment, and Resident #32 was to receive two (2) showers a week; however, staff failed to ensure the residents received their baths and/or showers. The findings include: Review of the facility policy titled Activities of Daily Living (ADL's) dated 11/28/16, revealed .based on the comprehensive assessment of a patient and with the patient's needs and choices, the Center must provide the necessary care and services to ensure that a patient who is unable to carry out ADL's receives the necessary services to maintain good grooming, and personal hygiene. 1. Record review revealed the facility admitted Resident #32 on 06/28/16 with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment, dated 08/28/19, revealed the facility assessed Resident #32's cognition as intact with a Brief Interview for Mental Status (BIMS) score of ten (10) which indicated the resident was interviewable. The MDS further revealed the resident had no behaviors of rejecting care (coded:0) and bathing did not occur (coded:8/8). Under section H for Urinary and Bowel Incontinence it was coded 3, indicating resident was always incontinent. Review of Resident #32 Comprehensive Care Plan Focus, dated 12/13/19, and Certified Nursing Aide (CNA) Care Plan, not dated revealed it is important for the resident to choose between a tub bath, shower, bed bath, or sponge bath. Review of Resident #32's Weekly Bath and Skin Report revealed he/she received two (2) showers in (MONTH) 2019 (09/20/19 and 09/22/19); and three (3) showers from 10/02/19-10/12/19 (10/02/19, 10/09/19 and 10/12/19). Interview with Resident #32 on 10/18/19 at 4:29 PM revealed he/she prefers to stay in bed, but never refuses a shower. Resident #32 stated he/she will frequently refuse a bed bath because he/she does not like bed baths. The resident further stated he/she was suppose to get two (2) showers a week and wants a shower every time it is due. The resident revealed he did not like the lift but understood this was the only way for him/her to get a shower Interview with Certified Nurse Aide (CNA) #2 on 10/18/19 at 12:15 PM revealed Resident #32 required a mechanical lift to get up, which takes two (2) staff and frequently there was just not enough staff to get him/her up. Interview with Licensed Practical Nurse (LPN) #3 on 10/15/19 at 12:15 PM revealed she was unable to do her own work, much less follow the CNA's to see if they were doing their work. She stated it was the administration's fault, as they have been told there was a staffing problem, but will do nothing about it. Interview with the Director of Nursing (DON) on 10/18/19 at 3:45 PM regarding showers and baths revealed she was aware Resident #32 refused care at times, but was not aware he/she was not receiving his/her showers as desired. 2. Record review revealed the facility admitted Resident #66 on 08/25/17 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 09/25/19 revealed the facility assessed Resident #66's cognition as intact with a BIMS score of fifteen (15) which indicated the resident was interviewable. Further review revealed the resident was totally dependent on two (2) staff members for bathing. Review of a Physician Order dated 10/03/19 revealed an order for [REDACTED]. Review of the (MONTH) 2019 Weekly Bath and Skin Report revealed no more than two (2) showers a week; however, when this surveyor requested a copy of the (MONTH) 2019 bath/skin reports on 10/18/19 at 3:16 PM, the Director of Nursing revealed she could not find the bath reports to give a copy. Review of the (MONTH) 2019 Weekly Bath and Skin Report revealed the resident received three (3) showers in two (2) weeks (10/01/19 to 10/16/19), on 10/08/19, 10/11/19, and 10/16/19 and a bed bath on 10/01/19. Interview with Resident #66 on 10/18/19 at 9:39 AM revealed he/she had received a physician order from the dermatologist to have a shower three (3) times weekly for the Seborrhea he/she had around the scalp and face. He/She stated he refused bed baths because it is like bathing in dirt; and he/she only wants showers. Review of the (MONTH) Bath report revealed a Bed Bath had been given on 10/01/19; however, the resident stated, That is falsification of my record because I refuse bed baths. Interview with CNA #1 on 10/18/19 at 12:37 PM revealed Resident #66 never refuses his shower but refuses a bed bath. Interview with DON on 10/18/19 at 3:38 PM revealed the DON was not aware Resident #66 had an order for [REDACTED]. She stated when the resident came back with new orders, the orders should have been put in as an update to the bath/shower schedule and the Comprehensive Care Plan and the CNA care sheet should have been updated by the nurse.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care for one (1) of twenty-five (25) sampled residents (Resident #2). Therapy wrote an order on 10/09/19 for Resident #2 to be up in a Broda Chair for two (2) hours a day, seven (7) days a week because the resident enjoyed getting out of bed; however, staff were not getting the resident out of bed daily. The findings include: Review of the facility Resident's Rights, not dated, revealed the resident has a right to a dignified existence, self-determination, communication, with access to persons and services. Record review revealed the facility admitted Resident #2 on 06/25/19 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) assessment, dated 10/02/19, revealed the facility assessed Resident #2's cognition was intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. Further review of the MDS assessment revealed the resident was totally dependent with the assistance of two (2) for transfers. Review of a Therapy/Communication to Nursing form, dated 10/09/19 revealed for nursing to get Resident #2 up in Broda chair two (2) hours a day, seven (7) days a week. Review of Resident #2 Comprehensive Care Plan dated 07/03/19 revealed, Resident/Patient requires assistance/is dependent for Activities of Daily Living (ADL) care-provide resident/patient with extensive, total assist of two (2) for transfers using a slide board and/or hoyer (mechanical) lift. Observations on 10/15/19 at 8:49 AM, 11:00 AM, and 2:45 PM and on 10/16/19 at 9:10 AM, 1:25 PM and 3:00 PM revealed the resident lying in bed and not up in his/her Broda chair. Observation on 10/17/19 at 2:00 PM revealed Resident #2 was up in the Broda chair. Interview with Resident #2 on 10/15/19 at 8:49 AM revealed he/she was supposed to be assisted up two (2) hours a day, seven days a week, and that was not happening. Resident #2 stated the Certified Nurse Aides (CNA's) complain they are unable to get him/her up because two (2) CNA's have to transfer him/her with a mechanical lift and there is not enough staff for two CNA's to be available to transfer him/her. The interview further revealed he/she had to wait up to forty-five (45) minutes for a CNA to respond to the call light. Interview with CNA #8 on 10/18/19 at 12:56 PM revealed Resident #2 had an order to get up two (2) hours every day and the resident wants to get up, but Resident #2 required the use of a mechanical lift by two staff for transfer. CNA #8 stated it was hard to find someone to help get the resident up and then staff had to worry about finding enough staff to transfer him/her to bed at the end of the two hours. Interview with Licensed Practical Nurse #3 on 10/15/19 at 12:15 PM revealed she was unable to do her own work, much less follow the CNA's to see if they were doing their work, due to staffing. She stated it was the administration's fault as they were told there was a staffing problem, but have done nothing about it. Interview with Physical Therapist (PT) #9 on 10/18/19 at 9:00 AM, revealed there is not enough staff to get the residents out of bed. PT #9 stated he wrote an order to get Resident #2 up two (2) hours a day, because he/she enjoys getting up, but a shortage of staff was almost a daily concern and it really made their job hard. He further revealed he could tell what kind of day it was going to be when he finds out the number of staff working. Interview with the Director of Nursing (DON), on 10/18/19 at 2:10 PM revealed she was not aware of the resident not getting up, but it was her expectation that all orders and resident's plan of care be followed.

Based on observation, interview, and record review, it was determined the facility failed to ensure one (1) of twenty-five (25) sampled residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, based on the comprehensive assessment (Resident #219) Resident #219 had an order to put on right elbow brace in the AM and take off in the PM, but multiple observations revealed the resident was not wearing it. The findings include: Record review revealed the facility admitted Resident #219 on 11/17/17 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/30/19, revealed the facility assessed Resident #219's cognition as intact with a Brief Interview for Mental Status score of thirteen (13)) which indicated the resident was interviewable. Further review of the MDS assessment revealed the resident had not received restorative services during the lookback period. Review of an order written [REDACTED]. Patient to wear right elbow brace from 7 AM-7PM. Review of Resident #219's Comprehensive Care Plan for requires supervision/assist with Activities of Daily Living (ADL's), dated 11/17/19, revealed an intervention dated 09/09/19 for Nursing to don/doff right elbow brace, patient to wear right elbow brace. However, review of Resident #219 Certified Nurse Aide (CNA) care plan, not dated, revealed there was nothing listed related to applying or removing a right elbow brace. Observation on 10/15/19 at 11:35 AM revealed the resident lying in bed. A sign was posted above the head of the bed that stated to put left wrist splint (referrring to elbow brace) on in the morning (AM) and remove in the afternoon (PM). Further observation revealed Resident #219 did not have on an elbow brace. Observations on 10/15/19 at 2:29 PM, on 10/16/19 at 8:59 AM, and on 10/17/19 at 10:00 AM and 2:00 PM, revealed the resident did not have an elbow brace in place. Attempted interviews with Resident #219 at these times revealed the resident would not respond to surveyors questions about the elbow brace. Interview with Restorative Aide/Certified Nurse Aide (CNA) #9 on 10/18/19 at 8:40 AM revealed Resident #219 was not on his restorative case load, that nursing should be applying the splint. Interview with CNA #2 on 10/18/19 at 12:26 PM revealed she was aware of the sign posted above the head of the bed of Resident #219 but thought it was for Restorative to do. Interview with CNA #8 on 10/18/19 at 12:45 PM revealed she was not aware Resident #219 wore an elbow splint. She stated she saw the sign on the wall but thought it was for restorative, and she had never been instructed on how to apply the splint. Interview with Physical Therapist (PT) #8 on 10/18/19 at 1:14 PM revealed when a resident is discontinued (D/C) from therapy to restorative or nursing, the aide is trained on the recommended task by the therapist, then a communication form is signed by that aide, a copy is given to the DON, and therapy will keep a copy. The interview further revealed the brace was used for elbow pain, and the therapist thought it was helping. Interview with Licensed Practical Nurse #3 on10/15/19 at 12:15 PM revealed she was unable to do her own work, much less follow the CNA's to see if they were doing their work, due to staffing. She stated it was the fault of the administration, that they had been told there was a staffing problem, but will do nothing about it. Interview with the Director of Nursing (DON), on 10/18/19 at 1:44 PM revealed she was unable to find a communication form from therapy to nursing/restorative related to Resident #219's brace, but one should have been placed in her mail box. She stated she expected nursing and restorative staff to follow the physician's orders [REDACTED].

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of twenty-five (25) sampled residents was offered sufficient fluid intake to maintain proper hydration and health (Resident #3). The findings include: Review of facility policy titled Nutrition/Hydration Management, dated 03/15/16, revealed .The implementation of an individual patient's nutrition/hydration management occurs within the care delivered process. Staff will consistently observe and monitor patients for changes and implement revisions to the plan of care as needed to provide safe and effective care to manage patient's nutrition and hydration needs. Record review revealed the facility admitted Resident #3 on 07/03/19 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) assessment, dated 10/10/19, revealed the facility assessed Resident #3's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of three (3) which indicated the resident was not interviewable. Review of Resident #3's Nutritional Assessment, dated 07/08/19, revealed Resident #3's estimated fluid needs to be 2789 milliliters per day (ml/day). Review of Resident #3 Basic Metabolic Panel (BMP) collected 10/11/19 revealed A Blood Urea Nitrogen (BUN)/Creatinine Ratio of 44 (normal range 6-25), indicating an increased ratio may be to a condition that causes a decrease in the flow of blood to the kidneys, such as [MEDICAL CONDITIONS] or dehydration. Review of Resident #3's Comprehensive Care Plan for patient has suspected/actual Urinary Tract Infection, dated 10/15/19 revealed an intervention to offer encourage fluids of choice. Observation on 10/15/19 at 8:05 AM revealed the resident was sitting in a wheel chair in his/her room with a urinary catheter under the resident's wheel chair with dark, amber colored urine in the tubing. The resident's water picture was sitting on the television stand, not the bed side tray, out of the resident's reach. Observation on 10/15/19 at 11:13 AM revealed Resident #3 was sitting up in lobby, his/her lips were dry and peeling, eyes sunken, and he/she was confused, answering questions inappropriately. Observation on 10/15/19 at 11:42 AM revealed the resident to look frail and fragile, and had dry lips. Licensed Practical Nurse (LPN) #1 assessed the resident's lips to be dry and the resident' skin skin to be dry, cracking and flaky during skin assessment. Observation on 10/16/19 at 12:35 AM revealed Resident #3 sitting in the dining room, waiting for lunch, with plate and drinks sitting in front of him/her. The resident was sitting out of reach of the table without anyone offering to push up his/her wheel chair or offer assist. Observation on 10/16/19 at 8:02 AM revealed Resident #3 was sitting in room eating breakfast, with a empty glass of orange juice noted, with no other fluids noted on the tray. Further observation on 10/16/19 at 8:55 AM revealed the water picture was still sitting on the television stand as the day before , out of the resident's reach. Observation of the water picture revealed dried red liquid on the lid. Interview with Resident #3's daughter/Power of Attorney, on 10/16/19 at 9:15 AM revealed Resident #3 has a history of UTI's and was dehydrated in (MONTH) and had to have an IV prior to admission. She stated when she visited on Saturday (10/12/19), she put a water pill in the resident's water picture that turned the water red. She stated when she came for a visit on the following Monday (10/14/19), the water in the water picture was still red so she knew the resident had not been given any fresh water. Interview with the Dietary Manager on 10/18/19 at 3:41 PM revealed Resident #3 should be getting liquid protein at 10:00 AM, 2:00 PM, and 8:00 PM; and at least two (2) times a week the snacks come back not being passed. Interview with the Director of Nursing (DON) on 10/18/19 at 3:54 PM revealed, there had been a problem with the snacks getting delivered, so now either a unit manager or Certified Medication Aide (CMA) is supposed to sign that she was aware the snacks were on the unit and passed. She stated fresh ice water should be passed every shift and she expected the water to get passed.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of twenty-five (25) sampled residents had a right to make choices about aspects of his or her life in the facility that were significant to the resident (Resident #30). Resident #30 wanted to get out of bed after breakfast daily; however, staff failed to assist the resident out of bed. The findings include: Review of the facility policy titled, Resident Rights, not dated, revealed the resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the center. The center must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. The center must ensure the resident can exercise rights without interference, coercion, discrimination, or reprisal from the center. Record review revealed the facility admitted Resident #30 on 09/10/18 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment, dated 08/16/19, revealed the facility assessed Resident #30's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. Further review of the Annual MDS revealed the resident's daily preferences were very important decisions for him/her to make and the resident required extensive assist of two (2) for bed mobility, extensive assist of one (1) for transfers and dressing, and the resident was only able to stabilize with assistance when transferring surface to surface. Observation and interview of Resident #30 on 10/15/19 at 12:34 PM revealed the resident was in bed and stated he/she could not get up out of bed by him/herself and depended on staff for help. The resident stated he/she had asked to get up in the past; however, he/she was told no one was available to help him/her. He/She stated the staff help when they can but there was not enough staff to help to get him/her up out of bed. Interview with Resident #30 on 10/17/19 at 11:30 AM, revealed he/she was in bed and had not been able to get up today since there was not enough help. He/she stated, They try to get me up right before lunch so that I can stay up to right before supper, then I am back to bed. The resident also revealed he/she would like to get up earlier but there was not enough staff to help him/her until right before lunch when a third Certified Nurses Aide (CNA) starts to work. The resident further stated he/she felt trapped in bed since he/she could not transfer by him/herself. Interview with CNA #2 on 10/18/19 at 1:10 PM revealed she worked with Resident #30 and she does not have time to get the resident up until the third CNA comes in at 10:00 AM. She stated she knew Resident #30 wanted to get out of bed but she could not get him/her up till later before lunch. She revealed she had asked multiple times for help and he/she was tired of asking. She revealed she knew no one would help. Interview with Licensed Practical Nurse (LPN) #3 on 10/18/19 at 1:48 PM revealed she was very busy in the mornings giving medications and was usually running behind. She stated if she stopped to help the aides, then she would get further behind on her medications, finger sticks and insulin injections. She also revealed she understood the CNA's could not get everyone up out of bed as the residents would like. Interview with Director of Nursing (DON) on 10/18/19 at 3:44 PM revealed she expected the residents to get out of bed when the resident wanted to. She stated she expected resident rights to be exercised. Interview with the Administrator on 10/18/19 at 4:58 PM revealed she knew the resident's rights were not being violated and felt that the resident could get up when he/she wanted to. She stated it was a communication problem and the staff would get it fixed.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for one (1) of twenty-five (25) sampled residents (Resident #3). Certified Nurse Aide (CNA) #2, while performing catheter care on 10/18/19 at 9:10 AM, failed to wash the catheter tubing per facility policy. The findings include: Review of the facility policy titled, Indwelling Urinary - Care of, last revised 02/01/1, revealed #10 Wash perineal area with no-rinse cleanser; pat dry. For female, use downward [MEDICAL CONDITION] from pubic to rectal area using alternate sites on the washcloth with each downward stroke. #11 Cleanse the proximal third of the catheter with soap and water, washing away from the insertion site and manipulating the catheter as little as possible. Rinse. Record review revealed the facility admitted Resident #3 on 07/03/19 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) assessment, dated 10/10/19 revealed the facility assessed Resident #3's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of three (3) which indicated the resident was not interviewable. Review of Resident #3's (MONTH) 2019 Physician Orders, revealed to perform Catheter Care every day and night shift, with a start date of 07/04/19. Review of Resident #3's Comprehensive Care Plan for resident requires indwelling Foley catheter due to retention, dated 08/13/19 revealed an intervention to provide catheter care twice a day and as needed (PRN). Observation of Resident #3's peri/catheter care provided by Certified Nurse Aide (CNA) #2, on 10/18/19 at 9:10 AM, revealed CNA #2 cleaned the peri area appropriately but noticed stool from the rectum, so she turned the resident to clean the buttocks area, then preceded to apply clothing, failing to clean the catheter tubing when assisted to turn back over. Interview with CNA #2 revealed she realized she messed up, as she was nervous and failed to clean the tubing after rolling the resident to his/her back. Interview with the Director of Nursing (DON) on 10/18/19 at 10:00 AM revealed she expected staff to clean the tubing when performing peri/catheter care, per facility policy.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of twenty-five (25) sampled residents received adequate supervision and assistive devices to prevent accidents (Resident #22). Resident #22 was care planned to encourage resident to be up at nursing station while awake, for resident to be in TV room across from nurses station when not in restorative dining, and to encourage the resident to come out of dining room when finished with breakfast, to lay down after meals, and do not have resident in dining room alone. However, Resident #22 sustained falls on 09/18/19, 09/26/19, 10/12/19, and 10/13/19 due to being left alone in the dining room or his/her bedroom without supervision of staff. The findings include: Review of the facility's policy titled, Falls Management, last revised 03/15/16, revealed residents will be assessed for falls risk as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. Residents experiencing a fall will receive appropriate care and investigation of a fall to reduce risk for falls and minimize the actual occurrence of falls. Practice standards identify resident's fall risk by reviewing the Nursing Assessment and Fall Risk Evaluation. Document accident/incident as a new event in the Risk Management System (RMS), on Change of Condition note, on 24-Hour report, and in Investigation using the Fall Investigation/QA and other appropriate tools in RMS. Record review revealed the facility admitted Resident #22 on 05/24/17 with [DIAGNOSES REDACTED]. Review of the Nursing Admission Assessment, dated 05/24/17, revealed the facility assessed Resident #22 as a moderate fall risk with a score of eighteen (18). Review of Resident #22's Comprehensive Care Plan for Resident at Risk for Falls, initiated 05/26/17, revealed the facility assessed the resident as a falls risk related to impaired mobility, antidepressant medication, and resident removes/turns off/hides alarm. Further review revealed intervention was added on 04/05/19, to encourage resident to be up at nursing station while awake. Review of a Quarterly Minimum Data Set (MDS) assessment, dated 08/09/19, revealed the facility assessed Resident #22's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of zero (0) which indicated the resident was rarely/never understood. Further review of the MDS, Section G: Functional Status, revealed the facility assessed Resident #22's ability to transfer as 2/2; which indicated he/she required one (1) staff to provide guided maneuvering of limbs or other non-weight-bearing assistance. Review of the RMS Event Summary Report, dated 09/18/19 at 9:20 AM, revealed Resident #22 fell in the dining room when he/she leaned forward in the wheelchair to pick up a spoon off the floor. Further review revealed the resident landed on his/her right side and immediately began to complain of pain to his/her right hip and right shoulder. Resident #22 was sent to the emergency room (ER) for evaluation and returned to facility following evaluation with no injury noted. Further review of the RMS Event Summary Report identified the root cause of the fall as the resident was reaching for something and the facility implemented an intervention to encourage the resident to come out of dining room when finished with breakfast, resident to lay down after meals, and do not have resident in dining room alone. Further review of Resident #22's Resident at Risk for Falls care plan, initiated 05/26/17, revealed the care plan was revised on 09/18/19 to include interventions to encourage the resident to come out of dining room when finished with breakfast, resident to lay down after meals, and do not have resident in dining room alone. Review of RMS Event Summary Report, dated 09/26/19 at 5:35 PM, revealed Resident #22 fell out of wheelchair in dining room attempting to pick trash off the floor. Review of the event summary report revealed the fall was unwitnessed although the resident sustained [REDACTED]. The facility implemented an intervention for resident to be in TV room across from nurses station when not in restorative dining. Further review of Resident #22's Resident at Risk for Falls care plan, initiated 05/26/17, revealed the care plan was revised on 09/26/19 to include intervention for resident to be in TV room across from nurses station when not in restorative dining. Review of RMS Event Summary Report, dated 10/12/19 at 5:35 PM, revealed Resident #22 was noted sitting in the floor of his/her bedroom. Further review revealed the resident stated, wanted to get something out from under the bed. Review of the event summary report revealed the fall was unwitnessed and no injuries were sustained. The facility identified the root cause of fall as resident attempted to transfer unassisted; however, there was no documented evidence the facility identified the Resident was not in the TV room across from the nurses station when not in restorative dining per the facility care plan. Review of RMS Event Summary Report, dated 10/13/19 at 5:05 PM, revealed staff member observed Resident #22 walking in his/her bedroom and the resident turned quickly and fell down to the floor. Further review of the Event Summary Report revealed assessment of the resident revealed no injuries. The facility identified the root cause of the fall as attempted ambulation without assistance with an intervention for Alarmed Velcro Seatbelt to wheelchair. However, there was no documented evidence the facility identified the resident was not at nursing station while awake and not be left alone in room while in wheel chair per care plan. Interview with Certified Nursing Assistant (CNA) #6, on 10/17/17 at 2:20 PM, revealed Resident #22 is care planned not to be left alone in dining room or in bedroom alone while in wheelchair; however, staff have left the resident unsupervised when providing care to other residents at the time the resident had falls. Interview with CNA #7, on 10/18/19 at 1:50 PM, revealed she was working when Resident #22 had three (3) of the falls. She stated the resident is not to be alone during mealtime; however, CNA #7 admitted she left Resident #22 unsupervised to answer a call light to check on another resident on 09/18/19. Interview with Licensed Practical Nurse (LPN) #1, Unit Manager, on 10/18/19 at 4:30 PM, revealed she would expect staff to follow Resident #22's care plan related to fall interventions due the Resident's [DIAGNOSES REDACTED]. She stated the resident had decreased safety awareness and staff failed to ensure Resident #22's safety related to falls. Interview with the Director of Nursing (DON), on 10/18/19 at 4:50 PM, revealed she would expect the staff to ensure Resident #22's safety. She stated all staff members are expected to follow the resident's care plan interventions to decrease potential of falls.

Based on observation, interview and facility policy review, it was determined the facility failed to ensure suitable, nourishing alternative meals and snacks must be provided to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care for (1) of twenty-five (25) sampled residents (Resident #3). The findings include: Review of facility policy titled Nutrition/Hydration Management, dated 03/15/16, revealed .The implementation of an individual patient's nutrition/hydration management occurs within the care delivered process. Staff will consistently observe and monitor patients for changes and implement revisions to the plan of care as needed to provide safe and effective care to manage patient's nutrition and hydration needs. Record review revealed the facility admitted Resident #3 on 07/03/19 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) assessment, dated 10/10/19, revealed the facility assessed Resident #3's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of three (3) which indicated the resident was not interviewable. The MDS further revealed the resident required supervision with one person to assist for feeding. Review of Resident #3's (MONTH) 2019 Physician order [REDACTED]. Observation on 10/16/19 at 8:51 AM revealed resident snacks were brought from the kitchen and placed behind the nurse's desk that contained four (4) to five (5) supplemental shakes with resident's name on them, and also oatmeal cream pies. Observation on 10/16/19 at 9:40 AM and 10:03 AM revealed snacks continued to sit at the nurse station. Interview with Certified Nurse Aide (CNA) #3 on 10/18/19 at 3:45 PM revealed she cannot answer for other staff but she passes her snacks. Interview with Licensed Practical Nurse (LPN) #4 on 10/16/19 at 10:15 AM revealed it was the responsible of the CNA's to pass the snacks and she was not sure why they had not been passed. Interview with the Dietary Manager on 10/18/19 at 3:41 PM revealed at least two (2) times a week, snacks come back not passed. She stated Resident #3 should be getting liquid protein at 10:00 AM, 2:00 PM, and 8:00 PM which means the resident is not getting his/her snacks as ordered. Interview with the Director of Nursing (DON) on 10/18/19 at 3:54 PM revealed she was aware of the concerns of snacks not being passed. She stated they had been trying to correct the problem by having either a Certified Medication Aide (CMA) or the Unit Manager sign for the snacks when they were brought out, and then hold the CNA's accountable for passing them, but this had not been followed implemented. Interview with the Administrator on 10/18/19 at 04:10 PM revealed the snacks needed to be passed, and the facility needed to QA this problem because the current plan was not working, and more improvement was needed.

Based on observation, interview and review of the facility policy, it was determined the facility failed to ensure drugs and biological's used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. Observations of one (1) of four (4) medication carts revealed two (2) insulin pens and one (1) bottle of insulin were not dated when opened. The findings include: Review of the facility's policy, titled Storage and Expiration Dating of Medications, Biological's, Syringes and Needles, last revised 10/31/16, revealed once any medication or bilogical package was opened, the facility should follow manufacturer or supplier guidelines with respect to expiration dates for opened medications and the date opened should be recorded on the medication container when the medication has a shortened expiration date once opened. Observation of medication storage on 10/17/19 at 3:40 PM, revealed one (1) of four (2) medication carts (cart for 200 hall) revealed one (1) pen of Levimer, one (1) pen of Humalog, and one (1) bottle of [MEDICATION NAME] Mix insulin, was not dated when opened. Interview with Licensed Practical Nurse (LPN) #1, on 10/18/19 at 3:19 PM, revealed any multidose vials of medication should be dated when opened. Interview with Unit Manager (UM) #1, on 10/17/19 at 3:54 PM, revealed it was the facility policy to date multidose vials of medications when opened. Interview with the Director of Nursing (DON), on 10/18/19 at 4:18 PM, revealed it was her expectation multidose vials of medications would be dated when opened.

Based on staff interview, review of the closed clinical record and the Pressure Ulcer Management policy, it was determined the facility failed to ensure preventative measures were implemented for identified risk of pressure sore development for one (1) of five (5) sampled residents (Resident #4). The facility assessed Resident #4 at risk for pressure sore development upon admission; however, failed to implement preventive measures that were consistent with the resident's identified needs until after the development of a pressure ulcer to the resident's back. The facility failed to perform weekly skin assessments according to their policy and failed to provide wound care treatment as ordered by the physician. The resident's wound increased in size, became infected, and the resident required hospitalization for several weeks. The resident experienced increased pain and received multiple treatments (IV, blood transfusion, wound vac, and chemical debridement). The findings include: Review of the facility's skin care and pressure ulcer management program policy (revised January 2008) revealed guidelines were utilized by the facility to prevent pressure ulcer development, promote healing, and prevent infection when skin breakdown occurs. The facility skin program used the 'APIE' approach to care giving: Assess, Plan, Implement, and Evaluate. Section (1) Assessment stated: upon admission, the facility would assess each resident's risk for development of pressure ulcers utilizing the nursing assessment and the Norton plus Pressure Ulcer Scale. Section (2) stated: planning; implementation; evaluation; and care planning, were to be based on the resident's assessment. A care plan would be developed with individualized interventions to prevent skin breakdown. The interventions would be specific to the risk factors identified through the assessment process, such as mobility, activity, moisture, nutrition, sensation, and friction. Once the care plan was written, the facility staff was responsible to ensure that all planned interventions and treatments were "carried out as written in the care plan." The policy stated a licensed nurse would perform a weekly head-to-toe skin check of the resident and document the findings on the treatment administration record (TAR) by using the notations of "Y" = skin intact and "N" = not intact. The policy revealed any new skin issue was to be considered an "incident." Every incident required investigation to determine the root cause. Through the investigation, information was to be gathered, to determine why the resident may have developed a pressure ulcer. Review of the closed clinical record for Resident #4 revealed the nursing facility had admitted the resident on 05/05/11 with the following Diagnoses: [REDACTED]. The nursing assessment dated [DATE] revealed Resident #4 did not have any pressure ulcers upon admission. The skin was assessed as warm, dry, and intact. Interview with Resident #4's daughter, on 07/20/11 at 11:00 AM, revealed the resident had no skin breakdown upon admission to the facility. The facility completed the Norton plus pressure ulcer scale assessment, on 05/05/11 which revealed the resident was at high risk for skin breakdown. Continued review of the closed clinical record revealed Physical (PT) and Occupational (OT) therapy initiated treatment on 05/12/11. Review of the weekly PT progress note dated 05/12/11 revealed the therapist had discussed the need to use a positioning device to support the resident's upper and lower back related to Kyphosis (forward curvature of the spine). The progress note identified increased risk for skin breakdown. The OT weekly progress note dated 05/12/11 revealed the resident's wheelchair had been modified to recline by raising the front wheels. Bilateral bolsters and a pommel cushion were added to achieve functional upright position. The therapist assessed the resident to have severe Kyphotic posture with the resident's chin pressed "snugly against breast bone." There was no documented evidence any type of pressure relief device for the back was placed in the resident's wheelchair. The weekly skin assessment for May 2011 revealed the facility performed the first skin assessment for Resident #4 on 05/12/11 and found no skin issues. Review of the admission MDS (minimum data set) assessment completed on 05/17/11 revealed the facility assessed the resident as at risk for pressure sore development related to urinary incontinence, decreased mobility, Norton Plus assessment, and cognition impairment. The MDS assessment identified the resident had no skin breakdown at the time of the assessment. In addition, the facility assessed the resident to require extensive assistance from staff for bed mobility, transfers, ambulation, eating, dressing, toilet use, locomotion on the unit, and bathing. Review of the care plan dated 05/17/11 revealed Resident #4 had a potential risk for skin breakdown related to decreased mobility, urinary incontinence, friction, and cognition impairment. The goal was for the resident to have no skin breakdown daily with the following interventions: (1) assist the resident to turn and reposition every 2 hours and as needed, (2) provide pressure reducing/relieving devices as ordered, (3) toilet the resident frequently, and (4) perform weekly skin assessments. Review of the May 2011 Nursing Assistant Care card revealed under the section "skin", there were instructions to turn and reposition every two (2) hours and as needed. Pressure relief was only marked under the bed section, not the chair. Continued interview with Resident #4's daughter, on 07/20/11 at 11:00 AM, revealed the resident developed a red area to the middle of the back on 05/18/11 and she had informed the nursing staff of the redness. She had reported the red area to a staff nurse (could not recall name) on 05/19/11. However, review of the weekly skin assessment revealed no documented evidence the facility assessed the resident's skin on this date despite being informed by the daughter of the red area. Interview with the Director of Nursing (DON), on 07/20/11 at 7:50 PM, revealed she did speak with the daughter on 05/19/11 and did not recall her reporting a red area on the resident's spine. She reviewed the skin assessment log and stated she could not provide evidence the skin assessment was conducted on 05/19/11 as scheduled and revealed there was no monitoring of the skin assessment forms to ensure they had been completed as scheduled. Review of the interdisciplinary progress notes, dated 05/25/11 at 2:00pm, revealed the facility documented a new stage II pressure area on Resident #4's medial spine. " Resident has curvature of the spine." " Kyphotic area appears to rub" when the resident is sitting in the wheelchair or lying down. The physician was notified and ordered a wound treatment to cleanse with normal saline, cover with [MEDICATION NAME] dressing and change every third day. On 05/25/11 the nursing facility called the daughter and reported an open area to the spine. The next skin assessment was not performed until Thursday, May 26, 2011 where it was documented the resident now had a pressure ulcer. In addition, review of the May 2011 Treatment Administration Record (TAR) revealed no documented evidence the wound treatment was completed on 05/31/11. Review of the pressure ulcer documentation form initiated on 05/25/11 revealed the pressure ulcer continued to increase in size and became 50% covered with eschar (06/08/11), then 100% slough (06/15/11). The wound treatment was not changed until after the daughter spoke with the physician on 06/02/11. Continued interview with Resident #4's daughter, on 07/20/11 at 11:00 AM, revealed the daughter had surgery (05/23/11) and was unable to visit the resident for awhile. Upon her return visit to the facility on [DATE], the daughter found the wound on the resident's back was now "black". The daughter stated she took a picture of the resident's wound and emailed a friend who is a wound care specialist. The nurse told the daughter the wound was necrotic. On 06/02/11, the daughter spoke with the physician, nurse manager and the Director of Nursing and stated she could get no answers. Review of the physician's progress note dated 06/02/11 revealed the open area was now a Stage III [MEDICATION NAME] spine decubitus with necrotic tissue in the center of the wound and redness on the sides. The physician documented, "spoke with daughter who found the decubitus and she is upset." The physician documented the daughter had spoken with a wound care nurse and recommended the present wound care orders: Santyl, ([MEDICATION NAME]) ointment daily, cover with wet saline gauze packing and foam. The physician also ordered the resident not to be up for more than one (1) hour at a time. The physician documented the daughter told him the resident's skin was clear without any pressure ulcers when the resident was admitted to the nursing facility. Interview with the physician (who is the facility's Medical Director) on 07/20/11 at 5:15 PM, revealed the daughter came to him on the above date and was upset because the resident had a pressure ulcer. The daughter told the physician she was the one who found the pressure ulcer and was upset because she said it had started as a red area. Continued review of the pressure ulcer documentation form initiated on 05/25/11 revealed the wound treatment was not changed until after the daughter spoke with the physician on 06/02/11. Interview with the daughter on 07/20/11 at 11:00 AM revealed she spoke with the Administrator on 06/03/11 and reported her concerns regarding the resident's pressure ulcer development. The daughter stated she went through the proper chain of command by speaking with a nurse, then the Director of Nursing, and then the Administrator. However, the daughter stated upon her visits, she found the resident sitting in the wheelchair for extended periods of time without a pillow or cushion to the resident's back. She stated the resident's curved spine rubbed the back of the wheelchair causing friction. Interview with the Administrator of the Nursing Facility, on 07/20/11 at 7:50 PM, revealed she was not aware of the pressure sore development until 06/03/11 when the daughter came to her with concerns. She stated she went with the daughter the evening of 06/03/11 and assessed the wound herself (she is a nurse). The administrator stated the wound was dark red with no eschar. Continued review of the closed clinical record revealed, on 06/15/11, the facility faxed a notification of change to the physician that stated moderate amount of yellow/tan foul odor drainage was observed in Resident #4's wound. The physician ordered a wound culture and sensitivity. However, the facility did not collect the wound culture until 06/17/11 due to no culture swabs available. The wound culture results were received by the facility on 06/19/11 that revealed heavy growth of Proteus Mirabilis and [MEDICATION NAME] (bacteria). The results were reported to the physician; however, the physician did not order any treatment because the daughter had informed the nursing facility that she was taking the resident to an acute hospital for treatment the next day. Continued interview with the daughter, on 07/20/11 at 11:00 AM, revealed the resident's wound was not getting better. She stated she had a nurse wound specialist (who was a friend) assess the resident's wound on 06/19/11 and was told it was "bad". She made the decision to transfer the resident to an acute hospital for wound evaluation and treatment. Review of a nurses' note dated 06/20/11 revealed at 12:55 PM, Resident #4 was transported to an acute hospital. Review of the acute hospital documentation (history and physical dated 06/20/11) revealed the resident was admitted with a Stage IV pressure ulcer with infection [MEDICAL CONDITION], electrolyte abnormalities, and severe dehydration. The resident was admitted for IV (intravenous) fluids, antibiotics, and possible debridement. Review of the hospital's skin assessment conducted upon admission on 06/20/11 revealed the wound opening measured 2 by 2 centimeters (cm). The wound had [DIAGNOSES REDACTED] (redness) with significant amount of undermining around the wound which measured 7 by 7 cm with foul-smelling drainage. A plastic surgeon was consulted; however, due to the resident's age and medical condition, surgical intervention was not appropriate. The resident was treated at this acute hospital and then transferred to another hospital specializing in wound care on 06/24/11 for further wound evaluation and treatment. Continued interview with the daughter, on 07/2011, revealed the resident suffered pain and discomfort because of the pressure ulcer formation. She stated the resident had to be transfused with one unit of packed red blood cells and treated for [REDACTED]. The daughter indicated the nursing facility failed to provide measures to prevent the pressure ulcer formation and did not take appropriate actions once the pressure ulcer developed. She revealed the resident remained in the hospital for almost a month. The daughter stated the resident experienced a lot of pain due to the infected wound and had to endure multiple treatments. Interview with the Director of Nursing (DON), on 07/20/11 at 7:50 PM, revealed there was no monitoring of the skin assessment forms to ensure they are completed as scheduled. The DON reviewed the pressure ulcer care plan with the surveyor and stated friction, as listed under the problem list, could be referring to the resident's back. She stated she thought a cushion was provided in the wheelchair; however, review of the care plan revealed a foam back cushion was not provided until 05/25/11, after the resident had developed a pressure ulcer on the back. A derma saver was placed on the resident's wheelchair on 06/01/11, and an air mattress was ordered on [DATE]. Interview with the Administrator on 07/20/11 at 7:50 PM revealed no investigation of the resident's pressure ulcer development had been conducted. When the Administrator and the Director of Nursing was asked what their root cause analysis was for the pressure ulcer development, they did not give an answer. The Administrator did not indicate an "incident" report was completed according to the facility's policy and protocol for skin care management. In addition, the identified risk for the resident (the resident's back deformity and friction from the wheelchair) was not addressed on the care plan with individualized interventions developed to prevent skin breakdown until after the resident developed a pressure ulcer on the back. The Administrator stated she was sure the staff had utilized a pillow in the resident's wheelchair; however, she had no documented evidence to support that statement. She stated the weekly skin assessments are forward to the DON and she thought they were being monitored for compliance.