Every finding on record at Lafayette Pointe Nursing & Rehab CTR

Based on observation, record review, interview and facility policy review the facility failed to maintain enhanced barrier precautions (EBP) during wound care for a resident with a pressure injury. This deficient practice affected one resident (Resident #35) out of three residents reviewed for infection control. The facility census was 58.Findings Include:Review of Resident #35's medical record revealed an admission date of 04/21/23 with diagnoses including but not limited to type two diabetes, Peripheral Vascular Disease (PVD), edema, and depression.Review of Resident #35's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #35 had intact cognition, had an unhealed stage three pressure injury and surgical wounds were present.Review of Resident #35's physician orders revealed an order dated 10/26/25 to cleanse left outer heel with normal saline (NS) and apply a layer of hydrogel and cover with an abdominal dressing and gauze daily and as needed (PRN) for wound care, and an order dated 11/18/25 for Enhanced Barrier Precautions (EBP) for wounds.An observation was conducted on 11/19/25 from 1:32 P.M. to 1:45 P.M. of Licensed Practical Nurse (LPN) #220 completing wound care and dressing change to Resident #35's left outer heel pressure injury. Resident #35's door had a sign indicating Resident #35 was on EBP for wound care, and staff were to wear a gown and gloves while completing the task. LPN #220 entered the room, washed hands and put gloves on prior to removing the soiled dressing and disposing of the dressing in the trashcan. LPN #220 removed the soiled gloves, washed hands and placed clean gloves on to cleanse the left outer heel pressure injury with normal saline and gauze. LPN #220 placed the used gauze in the trashcan, washed hands and placed a clean pair of gloves on to place the medication and clean dressing in place. LPN #220 completed the dressing change, removed the towel barrier and placed the dressing packaging in the trashcan, washed hands and exited the room. LPN #220 did not place a gown on during wound care and dressing change for Resident #35.An interview on 11/19/25 at 1:45 P.M. with LPN #220 confirmed a gown was not worn during the wound care and dressing change for Resident #35 requiring EBP due to having wounds. LPN #220 also confirmed the EBP sign located on Resident #35's door indicated the use of a gown during high contact resident care activities, which included wound care.Review of the facility policy titled Standard and Transmission-Based Precautions dated 03/24/24 revealed Enhanced barrier precautions refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities.This deficiency represents non-compliance investigated under Complaint Number 2644903.

2. Review of the infection control logs dated 04/2025 to 06/2025 revealed that in April 2025 there were five urinary tracts infections (UTI), one left knee infection, one left hand infection, one sacral wound infection, and one other infection. There was no evidence of the type of infection or organism. In May 2025 there was one nose infection, 10 UTI's, one eye infection, one toe infection, and one other infection. There was no evidence of the type of infection or organism. In June 2025 there were six UTI's and one eye infection. There was no evidence of the type of infection or organism. Review of the trending dated 04/2025 to 06/2025 revealed the facility was using maps of the building to trend the infections. The maps only indicated the site of the infection. Interview on 06/18/25 at 10:28 A.M., with the Director of Nursing (DON) and Corporate Nurse #410 confirmed the infection control log (tracking) nor the maps (trending) were comprehensive to include all infections. The DON reported that moving forward she would complete the culture results on the log and ensure the map included the infection as well. The DON confirmed she was also the facility's Infection Preventionist and responsible for tracking and trending infections. Review of the infection control policy dated 08/18/10 revealed it was the facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection. Surveillance included a system of surveillance was utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable disease for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards. The Infection Preventionist (IP) serves as the leader in surveillance activities, maintains documentation of incidents, finding, and any corrective actions made by the facility and reports surveillance finding to the facility's quality Assessment and Assurance Committee. The Registered Nurses (RN's) and Licensed Practical Nurses (LPN's) participate in surveillance through assessment of residents and reporting changes in condition to the residents' physicians and management staff. Please note, the policy did not include a procedure for how the facility was tracking and trending infections as part of the infection control program. Based on observations, review of medial records, review of the infection control logs, review of the facility policy and interview the facility failed to ensure hand hygiene and infection control was maintained during medication administration and failed to ensure a comprehensive infection control program to include adequate tracking of infections. This affected two residents ( Resident #3 and #19) of three observed for medication administration, however had the potential to affect all residents in the facility related to the lack of a comprehensive infection control program. The facility census was 47. Findings included: 1. Observation on 06/17/25 at 10:45 A.M. revealed Licensed Practical Nurse (LPN) #321 started to prepare medication for Resident #3, dropped a tablet of tramadol on the top of the medication cart and picked up, placed it in the medicine cup and proceeded to administer the medication to Resident #3. LPN #321 then placed lip balm on the lips of Resident #3. LPN #321 went out into the hallway to the medication cart without washing or sanitizing her hands. She moved the medication cart down the hallway and started to pull the medications for Resident #19. She proceeded to take the medications into Resident #19 and administered the medications to Resident #19. LPN #321 went back out into the hallway and pushed the medication cart down the hallway to another resident's room and then sanitized her hands from the bottle of hand sanitizer located on the top of her medication cart. On 06/17/25 at 10:58 A.M. an interview with LPN #321 verified she picked up the tramadol for Resident #3 with her bare hands and administered the Tramadol to Resident #3 and she had not washed her hands between medication administration for Resident #3 and #19.

Based on medical record review, observation, interview, and policy review the facility failed to ensure pain medication was administered as ordered and non-pharmacological interventions were offered prior to the administration of as needed pain medication. This affected four (Resident #2, #12, #16, and #40) of seven residents reviewed for medication use. Findings included: 1. Medical record review revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including chronic pain, breast cancer, lymphedema, migraines, history of venous thrombosis and embolism, chest pain, intervertebral disc degeneration, and lumbosacral region with discogenic back pain. Review of Resident #40's at risk for alteration in comfort plan of care dated 10/24/24 revealed administer medication as ordered and to offer non-pharmacological intervention (quiet environment, repositioning, back rub, diversional actives). Review of Resident #40's orders dated 05/2025 and 06/2025 revealed to administer Roxicodone 15 milligrams (mg) one tablet every four hours as needed for mild to moderate pain rated one through four (on a 0-10 numerical pain rating scale with 0 representing no pain and 10 representing the most severe pain the resident has encountered) and two tablets every four hours as needed for severe pain rated six to ten (on a 0-10 numerical pain rating scale). There was no evidence of how many tablets to administer for a pain rating of five on a numerical pain rating scale. Review of Resident #40's May 2025 medication administration record (MAR) revealed to administer Roxicodone 15 milligrams (mg) one tablet every four hours as needed for mild to moderate pain one to four. On 05/09/25 and 05/17/25 staff only administered one tablet of Roxicodone 15 mg for a pain rating of seven, on 05/30/25 staff administered one tablet of Roxicodone 15 mg for a pain rating of six, on 05/18/25 staff administered one tablet of Roxicodone 15 mg for a pain rating of eight, and on 05/17/25 and twice on 05/30/25 staff administered one tablet of Roxicodone 15 mg for a pain rating of five. Further review revealed to administer two tablets of Roxicodone 15 mg every four hours for severe pain rated six to 10 on a numerical pain rating scale. On 05/02/25 two Roxicodone were administered for pain rating of five, on 05/04/25 two Roxicodone was administered for pain rating of four, on 05/05/25 two Roxicodone was administered for pain rating of four, on 05/06/25 staff administered two tablets for pain rating of five, on 05/07/25 twice staff administered two tablets for pain rating of four, on 05/09/25 two Roxicodone was administered for pain rating of five, on 05/10/25 two Roxicodone were administered for pain rating of four, on 05/11/25 two Roxicodone were administered twice for pain rating of five, on 05/16/25 two Roxicodone were administered for pain rating of five, on 05/17/25 two Roxicodone were administered for a pain rating of five and four, on 05/18/25 two Roxicodone were administered for pain rating of four, on 05/22/25 two Roxicodone were administered for pain rating of two, on 05/23/25 two Roxicodone were administered for pain rating of three and four, on 05/29/25 two Roxicodone were administered for pain rating of five, and on 05/30/25 two Roxicodone were administered for pain rating of five. Review of Resident #40's MAR dated 06/10/25 revealed staff administered two tablets for pain rating of five on 06/05/25 twice, 06/06/25, and 06/07/25. Review of Resident #40's medical record revealed no evidence non-pharmacological interventions were attempted prior to administering as needed pain medications. Observation on 06/17/25 at 1:24 P.M., the resident approached the nurse's station and requested pain medication. Licensed Practical Nurse (LPN) #226 asked the resident the location and rate of pain. The LPN did not offer non-pharmacological intervention or assess if the resident had tried any non-pharmacological intervention prior to requesting the pain medication. Interview on 06/17/25 at 1:24 P.M., with LPN #226 revealed the resident requests pain medication right on the dot when it's due. Interview on 06/18/25 at 9:35 A.M., with Assistant Director of Nursing (ADON) #204 reviewed the MAR's and confirmed in May and June 2025 Resident #40's Roxocodone was not administered per parameters on 05/02/25, 05/04/25, 05/05/25, 05/06/25, 05/07/25, 05/09/25, 05/10/25, 05/11/25, 05/16/25, 05/17/25, 05/18/25, 05/22/25, 05/23/35, 05/29/25, 05/30/25, 06/05/25, 06/06/25, and 06/07/25. The ADON also confirmed she didn't realize there were no parameters on how many tablets to administer for pain rating of five. The ADON confirmed there was no documented evidence that non-pharmalogicals were attempted prior to administering pain medication per the resident's plan of care. 2. Medical record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including intervertebral disc degeneration, lumbar region with discogenic back pain and lower extremity pain, acute and chronic respiratory failure with hypoxia, fracture of orbital floor, anterior displaced type II dens fracture, fracture of nasal bones, fracture of left femur, and heart failure. Review of Resident #12's at risk for alteration in comfort plan of care revealed to offer non-pharmacological interventions (quiet environment, repositioning, back rub, diversional activities). Review of Resident #12's current orders dated 06/2025 revealed Tramadol 50 mg one every six hours as needed for pain. Review of Resident #12's MAR dated 06/2025 revealed the resident received Tramadol as needed daily. Review of Resident #12's medical record revealed no documented evidence non-pharmacological interventions were implemented prior to administration of Tramadol. Interview on 06/17/25 at 11:42 A.M., with Regional Nurse #226 confirmed there was no documented evidence non-pharmacological interventions were implemented prior to the administration of each as needed pain medication. The Regional Nurse reported staff complete a weekly pain assessment that indicates distractions, communication, and repositioning were used, however there was no documented evidence to support those non-pharmacological were attempted. 3. Review of the medical record for Resident #16 revealed an admission date of 08/24/21 with diagnoses including but not limited to unspecified dementia, disease of the pancreas, congestive heart failure (CHF), and type two diabetes (DM 2). Review of Resident #16's quarterly minimum data set (MDS) dated [DATE] revealed Section C - Cognitive Patterns marked with a brief interview of mental status (BIMS) of seven out of a possible score of 15, which indicated cognitive impairment. Further review revealed Section J - Health Conditions revealed Resident #16 received as needed (PRN) pain medication and had non-pharmacological interventions for pain management. Review of Resident #16's physician orders revealed an order dated 06/02/25 for pain medication Tramadol oral tablet 50 milligrams (mg) give one tablet by mouth every six hours as needed (PRN) for pain. Further review revealed a physician order dated 06/11/25 for pain medication Hydrocodone-Acetaminophen oral tablet 5-325 mg give one tablet by mouth every four hours PRN for pain. There were no non-pharmacological interventions noted on the orders. Review of Resident #16's Medication Administration Record (MAR) dated 06/01/25 to 06/17/25 revealed Resident #16 was administered Hydrocodone - Acetaminophen oral tablet 5-325 mg one tablet PRN 13 times from 06/05/25 to 06/11/25 for pain scale ranging from five to eight on a numerical pain rating scale. There were no non-pharmacological interventions documented as being attempted prior to the administration of the narcotic pain medication. Review of Resident #16's alteration in comfort care plan dated 06/05/25 revealed Resident #16 experienced chronic abdominal pain. Resident #16's approaches to pain management included offering non-pharmacological interventions such as quiet environment, repositioning, back rub, diversional activities. An interview on 06/17/25 at 1:13 P.M. with the Assistant Director of Nursing (ADON) confirmed non-pharmacological interventions for pain management were not documented prior to the administration of narcotic pain medication. The ADON stated the nurses should attempt up to three different non-pharmacological interventions prior to administering pain medication to a resident. 4. Review of the medical record for Resident #2 revealed an admission date of 05/31/24 with the following diagnoses including but not limited to pancreatitis, respiratory failure, right ankle fracture, and high blood pressure. Review of Resident #2's physician orders revealed an order dated 04/22/25 for narcotic pain medication Percocet Oral Tablet 5-325 milligram (mg) (Oxycodone w/ Acetaminophen) to give 1 tablet by mouth every 6 hours as needed (PRN) for moderate to severe pain. There were no non-pharmacological interventions documented in the order. Review of Resident #2's significant change minimum data set (MDS) dated [DATE] revealed Section C - Cognitive Patterns a brief interview of mental status (BIMS) score of 15 out a possible score of 15 indicating the resident had intact cognition. In Section J - Health Conditions marked as receiving both scheduled and as needed (PRN) pain medications and had non-pharmacological interventions for pain management. Review of Resident #2's medication administration record (MAR) dated 05/01/25 to 05/31/25 revealed Resident #2 was administered narcotic pain medication Percocet Oral Tablet 5-325 milligram (mg) (Oxycodone w/ Acetaminophen) to give 1 tablet by mouth every 6 hours as needed (PRN) 75 times for pain scale ranging from five to ten. There were no non-pharmacological interventions documented as being attempted prior to the administration of the narcotic pain medication. An interview on 06/18/25 at 9:36 A.M. with the Assistant Director of Nursing (ADON) confirmed Resident #2 did not have documentation of any non-pharmacological interventions attempted prior to the administration of narcotic pain medication. Review on the facility's policy titled Pain Assessment and Management dated 03/31/16 revealed assessment and adequate treatment of pain is central to the management of the physical and psychological well-being of residents. Non-pharmacological methods to reduce pain in a resident may be implemented. Notify the physician as needed.

Based on observations, review of the medical record, and interviews the facility failed to ensure the call light was within reach of Resident #18. This affected one resident ( Resident #18) of 16 residents observed on the 200 hallway. Findings included: Review of the medical record revealed Resident #18 was admitted to the facility on [DATE]. Diagnoses included asthma, insomnia, tracheostomy, major depressive disorder, convulsions, cerebral infarction, right frontal parietal encephalomalacia, chronic pain, and polyneuropathy. Review of the Admissions Minimum Data Set assessment dated [DATE] revealed Resident #18 had intact cognition, had no upper or lower body impairment, and was frequently incontinent of bowel and bladder. Resident #18 had a tracheostomy. On 06/16/25 at 9:25 A.M. an interview with Resident #18 revealed her call light was attached to her recliner across the room and she stated it had been there all night. Observation of Resident #18 revealed she was lying in bed, unable to access her call light. On 06/16/25 at 9:30 A.M. an interview and observation with Certified Nursing Assistant #371 verified the call light for Resident #18 was attached to the recliner chair across the room and Resident #18 was unable to reach the call light from her bed.

Based on medical record review, observation, and interviews the facility failed to ensure a comprehensive and resident centered treatment plan was implemented related to Resident #40's edema to her left hand and bilateral lower legs. This affected one (Resident #40) of one reviewed for edema. Findings included: Medical record review revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including breast cancer, lymphedema, localized edema, acute kidney failure, acute embolism and thrombosis of left internal jugular vein, and history of venous thrombosis and embolism. a. Review of Resident #40's current plan of care for risk for alteration in skin integrity related to edema dated 10/24/24 and revised on 01/07/24 revealed on 04/16/25 a new intervention to measure girth of the left arm from the shoulder to wrist one time a day for edema. Notify the physician and family of changes as needed. Review of Resident #40's progress note dated 05/29/25 revealed the resident had swelling to the left arm and hand. The resident had plus four pitting edema (the most severe form of pitting edema, characterized by a deep indentation that takes more than 30 seconds to rebound after pressure is applied to the affected area) to the top of the hand. The nurse measured the circumference with the left hand at 7.5 inches, left forearm 11 inches and left upper arm 15 inches. The resident was educated on propping her arm up above her heart and monitoring for increased pain or development of redness. Review of Resident #40's progress note dated 05/30/25 revealed the nurse measured the left arm/hand and (there was) no change in circumference. Edema and plus three pitting edema to the top of the hand. No redness or warm to touch. The pulse to the right and left arm are equal. The resident denied increasing pain to area. Further review of Resident #40's medical record dated 05/31/25 to 06/18/25 revealed no evidence an assessment or measurements of the resident's left arm were obtained after 05/30/25. Observation and interview on 06/16/25 at 11:29 A.M., with Resident #40 revealed her left hand and arm had noted edema. The resident reported she had a history of blood clots in the right arm and left side of her neck, and she was concerned the facility was not adequately treating and monitoring her left arm and hand edema. The resident reported she had lymph nodes removed in the axillary area and the facility believed the edema was related to the removal of lymph nodes, however she didn't think it was related and was concerned. Interview on 06/17/25 at 1:21 P.M. with Resident #40 confirmed staff measured her arm/ hand once or twice and that was it. The resident confirmed that staff have not been monitoring or measuring the edema in her left arm/hand daily. The resident's arm/hand had noted edema during the interview. Interview of 06/17/25 at 1:24 P.M. with Licensed Practical Nurse (LPN) #226 confirmed the resident's current plan of care indicated to measure the resident's girth of her left arm from shoulder to wrist one time a day for edema. The LPN confirmed the resident's arm/hand had not been measured daily according to the plan of care. The LPN reported the resident had gone to the hospital recently and the order was not re-written when the resident returned. The LPN confirmed the resident had edema in the left arm and hand and she would reach out to the physician to clarify the orders. b. Review of Resident #40's current plan of care for risk for alteration in skin integrity related to edema dated 10/24/24 and revised on 01/07/24 revealed on 06/16/25 ace wraps to bilateral legs on in the morning and off at bedtime. Assess for pain and provide treatment per physician order(s). Review of Resident #40's current orders dated 06/2025 revealed ace wraps to bilateral legs on in the morning and off at bedtime. Review of Resident #40's treatment administration records (TAR) dated 06/2025 revealed staff had been signing off the ace wraps were applied to bilateral legs in the morning and removed at night. Observation on 06/16/25 at 11:29 A.M. and 06/17/25 at 1:21 P.M., of Resident #40 revealed no evidence the resident had ace wraps in-place. The resident had noted edema in the bilateral lower extremities. Interview on 06/17/25 at 1:21 P.M. with Resident #40 confirmed staff don't apply ace wraps to her bilateral legs. The resident reported that the ace wraps make the edema worse. Interview of 06/17/25 at 1:24 P.M. with Licensed Practical Nurse (LPN) #226 confirmed the resident's current plan of care, orders, and TAR indicated staff had been applying ace wraps to the resident's bilateral legs, however the ace wraps were not in-place. c. Review of Resident #40's current orders dated 06/2025 revealed to consult cardiology for weight gain and bilateral lower extremity edema. The orders did not indicate parameters when to notify the cardiologist. Review of Resident #40 weights dated 06/01/25 to 06/17/25 revealed: 06/17/2025 214.8 pounds (lbs) 60/16/2025 214.2 lbs 06/15/2025 213.0 lbs 06/14/2025 209.6 lbs 06/13/2025 206.8 lbs 06/12/2025 214.2 lbs 06/11/2025 213.2 lbs 06/10/2025 215.2 lbs 06/9/2025 215.4 lbs 06/8/2025 216.2 lbs 06/7/2025 216.8 lbs 06/6/2025 216.4 lbs 06/5/2025 218.0 lbs 06/4/2025 214.4 lbs 06/3/2025 213.2 lbs 06/2/2025 213.0 lbs 06/1/2025 211.8 lbs Review of Resident #40's medical record revealed no evidence the cardiologist was notified of weight gain or bilateral lower extremity edema. Interview on 06/17/25 at 1:24 P.M., with LPN #226 confirmed the orders did not include weight parameters when notifying the cardiologist. The LPN confirmed she would call the cardiologist for clarification on weight parameters but confirmed the cardiologist was not notified of weight gains/edema.

Based on medical record review, review of hospital records, review of quick note, interview, and policy review the facility failed to ensure medical records were complete and accurate. This affected three (Resident #12, #14, and #48) of 20 resident records reviewed. Findings included: 1. Medical record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including intervertebral disc degeneration, lumbar region with discogenic back pain and lower extremity pain, acute and chronic respiratory failure with hypoxia, fracture of orbital floor, anterior displaced type II dens fracture, fracture of nasal bones, fracture of left femur, heart failure, history of falling, age-related osteoporosis, osteoarthritis, and chronic pain. Review of Resident #12's progress note revealed the resident reported she couldn't breathe. Vital signs obtained: pulse oximeter on room air was 96%, temperature 98.0, blood pressure 155/102 (there was no evidence a pulse rate or respiration were obtained). The resident reported she usually slept with her mouth closed and was unable to completely close her mouth due to (wearing a) c-collar (type of neck brace to prevent certain movements). The resident admitted she may have some anxiety. The resident was asking for pain medication within one hour of administration of Tramadol (pain medications). On call physician contracted and new orders to continue Oxycodone 5 milligrams (mg) every six hours as needed for two more days and Hydroxyzine 25 mg every eight hours as needed. Review of Resident #12's progress note dated 05/05/25 revealed the nurse was in the room and helped aide walk resident to bathroom. The resident began straining on commode and nurse advised resident not to do that due to it possibly causing resident to have a vagal episode (stimulate the vagus nerve and pass out). Resident relaxed at this time, nurse asked resident how she was feeling and resident stated she felt lightheaded and then stated she felt like she was going to throw up. Resident had medium size emesis at this time. Nurse checked resident's pulse oximeter and obtained a reading of 78% on room air. Nurse placed resident on 3.5 liters of oxygen via nasal cannula. Nurse and aide transferred resident into wheelchair and then recliner. Resident lethargic and only answering a few times when asked questions. Pulse oximeter rechecked and obtained reading of 99% on oxygen, vitals also obtained at this time: 101/69, 88, 98.2, 99% on oxygen. Nurse called Certified Nurse Practitioner (CNP) regarding resident and advised CNP that resident stated she started feeling like this when she started taking the small pain pill. Nurse was advised by CNP after advising her of resident's symptoms to administer Narcan to resident to see if it reverses possible opiate reaction, obtain STAT completed metabolic panel (CMP) and basic metabolic panel (BMP) and chest x-ray of resident. CNP also advised to discontinue Oxycodone and Vistaril and restart Tramadol every six hours as needed for pain. Further review revealed the nurse administered one dose of Narcan in the resident's left nostril at 1:45 P.M., resident began to talk more and became more alert with staff. The Director of Nursing (DON) was monitoring pulse ox and removed oxygen after several minutes and continued monitoring and the resident remained at 99% on room air. Nurse administered second dose of Narcan in resident right nostril at 1:49 P.M. Resident became even more alert with staff after a couple minutes and was talking and stating she felt a little better but still felt lightheaded and in pain. Nurse and Administrator in room and resident stated she was going to throw up, resident had two large emesis at that time. Resident's pulse also showed that resident was in atrial fibrillation at this time. Nurse called squad and they arrived and transported resident via stretcher at this time to hospital for evaluation. Nurse called and gave report to emergency room. Review of Resident #12's hospital records revealed per notes the resident was having severe pain from resident fall with fractures and was receiving Tramadol, however pain was not controlled. The resident was switched to Oxycodone on 05/03/25 and subsequently developed increased confusion and hypoxia. The resident was given Narcan time two at the nursing facility and had nausea and vomiting after receiving the Narcan. Review of CNP quick note dated 05/05/25 revealed the nurse called and reported the resident was having increased confusion and hypoxia. Oxygen sats in the 80's with three liters of oxygen and increased to four liters and pulse ox in the mid 90's. Recently re-admitted and was given Tramadol for pain until Saturday when she was switched for Oxycodone. The last Oxycodone was administered at 8:00 A.M. today. The nurse was concerned that the Oxycodone was too much and increasing the symptoms. Ordered to give Narcan, stat Completed Blood Count (CBC), CMP, B-type Natriuretic Peptide (BNP), chest-x-ray, neuro checks ever hour time three, then every shift, if worsening neuro status or no improvement after Narcan, send to emergency room. Review of Resident #12's orders dated 05/01/25 to 06/17/25 revealed no written orders for the two Narcan doses administered. Interview on 06/17/25 at 1:43 P.M., with Regional Nurse #410 confirmed the nurse had administered two Narcan doses on 05/05/25 to Resident #12, however didn't write an order she had received verbally from the CNP. The resident did not have the stat testing completed because she was sent to the emergency room. Interview on 06/18/25 at 7:42 A.M., with the Director of Nursing (DON) confirmed she was present when the nurse had spoken to the CNP. The CNP had ordered to administer one Narcan and if the first Narcan didn't work, and a second dose could be administered even though the CNP quick note didn't indicate to administer a second dose. 2. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE]. Diagnoses included end stage renal disease, diabetes, reduced mobility, dysphagia, generalized anxiety disorder, dependent on renal dialysis, heart failure, dementia, edema, major depressive disorder, iron deficiency anemia, epilepsy, breast cancer, vertigo, hypertension, and osteoarthritis. Review of the weights in the medical record revealed on 04/01/25 Resident #14 weighed 188.4 pounds, on 05/01/25 weighed 178.4 with no reweigh, and on 05/22/25 weighed 201.8 with no reweigh. Review of the dialysis weights revealed on 04/28/25 Resident #14 weighed 200.64, on 04/30/25 weighed 197.78, and on 05/02/25 weighed 194.26. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #14 had intact cognition, weighed 188 pounds and did not trigger on the assessment for a significant weight loss or gain. Review of the progress note dated from 04/20/25 to 05/04/25 revealed no documentation of a reweigh obtained to clarify the 178.4 weight. On 06/17/25 at 11:50 A.M. an interview with Dietary Technician #360 revealed the 178.4 weight on 05/02/25 for Resident #14 was an error. She stated the dialysis center reweighed Resident #14 on 05/02/25 however she verified it was the facility's responsibility to reweigh for weight loss or gain. She verified the loss of 10 pounds was not addressed by her or the facility staff and if they had addressed it they would have figured out the weight of 178 pounds was an error. She stated they usually obtain a reweigh if there was a loss or gain of five or more pounds from the previous weight. Review of the facility policy titled,Weight Monitoring, dated 02/15/24 revealed the facility would ensure all residents maintained acceptable parameters of nutritional status. 3. Review of the medical record revealed Resident #48 was admitted to the facility on [DATE]. Diagnoses included pulmonary edema, protein-calorie malnutrition, diabetes, vascular dementia, hallucinations, major depressive disorder, atrial fibrillation, pacemaker, peripheral vascular disease, hypertension, heart failure, vertigo, chronic pain, cerebral aneurysm , and nonrheumatic aortic stenosis. She was discharged to the psychiatric hospital on [DATE]. Further review of the medical record revealed there was no written physician's order to send Resident #48 to the psychiatric hospital. On 06/18/25 at 7:30 A.M. an interview with the Director of Nursing verified there was no order written to transfer Resident #48 to the hospital.

Based on medical record review, review of hospital records, review of the infection control log, interview, and policy review the facility failed to ensure resident met criteria for antibiotic treatment. This affected two (Resident #6 and #42) of three residents reviewed for antibiotic stewardship. Findings included: 1. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including acute cholecystitis, diabetes, heart failure, overactive bladder, and chronic kidney disease. Review of Resident #6's hospital discharge note dated 04/18/25 revealed the resident's urine culture was growing mixed skin and fecal flora. The resident had dysuria (painful urination) and suprapubic tenderness on admission. Will complete a short course of Keflex 500 milligrams (mg) four times daily for 16 doses for bladder inflammation. The resident's cholecystitis (inflammation of the gallbladder) versus symptomatic cholelithiasis (gall stones) would be treated with a low-fat diet for which the resident could tolerate with minimal abdominal pain. Review of Resident #6's orders and medication administration records (MAR) dated 04/2025 revealed the resident received Keflex 500 mg from 04/18/25 to 04/22/25 for bladder inflammation. Review of the infection control log dated 04/2025 revealed the resident was treated with Keflex 500 milligrams four times a day for four days for cholecystitis. Review of Resident #6's Loeb's (minimum criteria for initiating antibiotic therapy) undated revealed the form was completed for UTI and the only indication marked was acute dysuria. The instruction indicated a urine culture should be sent prior to starting antibiotics. Interview on 06/18/25 at 12:06 P.M., with the Director of Nursing (DON) confirmed the infection control log was inaccurate due to the resident was ordered the Keflex for bladder inflammation not cholecystitis. The DON also confirmed the resident did not meet criteria for treatment due to a urine culture was never received to ensure the resident met criteria for treatment. 2. Review of closed record revealed Resident #50 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, heart failure, and muscle weakness. Review of Resident #50's orders dated 06/06/25 revealed the resident was ordered Cipro 500 mg twice daily for a UTI. Review of Resident #50's MAR dated 06/2025 revealed the resident received Cipro 500 mg from 06/06/25 till 06/11/25 for a UTI. Review of the infection control log dated 06/2025 revealed the resident was admitted with diagnoses with UTI and ordered Cipro 500 mg twice daily. There was no evidence that a urine or culture was obtained to ensure the resident met criteria for antibiotic treatment. Review of Resident #50's Loeb's (minimum criteria for initiating antibiotic therapy) undated revealed the form was blank except for a note on the bottom indicating awaiting culture from hospice. Interview on 06/18/25 at 12:06 P.M., with the DON confirmed there was no evidence the resident met criteria for antibiotic treatment. The DON confirmed the resident received Cipro 500 mg twice daily for five days without documented justification for use. Review of the facility's policy and procedure titled Antibiotic Stewardship Program dated 11/28/17 revealed the Loeb criteria was used to determine whether or not to treat an infection with antibiotics. Laboratory testing shall be in accordance with current standard of practices. The purpose of the program was to optimize the treatment of infections while reducing the adverse events associated with antibiotic use.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interview, and the facility submitted Payroll Based Journal (PBJ) tracking information, the facility failed to ensure a registered nurse (RN) for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 56 residents residing in the facility. Findings include: Review of the third quarter PBJ Staffing Data Report form submitted from 04/01/23 to 06/30/23 revealed the following dates the facility to not meet the RN staffing requirement: 04/01/23 Saturday (SA), 04/09/23 Sunday (SU); 04/15/23 (SA); 04/16/23 (SU); 04/29/23 (SA); 04/30/23 (SU) 05/06/23 (SA); 05/07/23 (SU); 05/20/23 (SA); 05/21/23 (SU); 05/27/23 (SA); 05/29/23 (MO); 06/10/23 (SA); 06/11/23 (SU); 06/18/23 (SU); 06/24/23 (SA); 06/25/23 (SU). Interview on 03/20/24 at 8:55 A.M. the Administrator revealed the facility had a hard time: getting registered nurses in 2023 but after the facility didn't meet the requirement with the PBJ report for the third quarter, the facility began to search for RNs to hire and RNs have been hired and should be fine now. Interview on 03/20/24 at 2:30 P.M. with the Assistant Director of Nursing (ADON) verified the following dates did not have the required eight hours per day of RN coverage: 04/01/23 Saturday (SA), 04/09/23 Sunday (SU); 04/15/23 (SA); 04/16/23 (SU); 04/29/23 (SA); 04/30/23 (SU) 05/06/23 (SA); 05/07/23 (SU); 05/20/23 (SA); 05/21/23 (SU); 05/27/23 (SA); 05/29/23 (MO); 06/10/23 (SA); 06/11/23 (SU); 06/18/23 (SU); 06/24/23 (SA); 06/25/23 (SU). The deficient practice was corrected on 01/01/24 when the facility implemented the following corrective actions: The facility hired RN #66 on 11/22/23, RN #67 on 12/18/23, RN # 71 on 11/28/23. Review of schedules and assignment sheets from 01/01/24 through 03/16/24 revealed eight consecutive hours of RN coverage seven days per week.

Based on record review, interview, and policy review, the facility failed to ensure a comprehensive fall investigation was completed following a fall with major injury. This affected one resident (Resident #21) of three residents reviewed for accidents. Findings include: Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, weakness, difficulty walking, anxiety, and osteoarthritis. Review of the plan of care, dated 10/24/23, revealed Resident #21 was at risk for injury related to falls with interventions including bed and chair alarms to alert staff of unassisted transfers. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/02/24, revealed the resident's Brief Interview for Mental Status (BIMS) score could not be assessed due to the resident rarely/never being understood. The resident required physical assistance activities of daily living (ADLs). The resident's mobility devices were a walker and a wheelchair. The assessment indicated there was one fall without injury since admission or the prior assessment. Review of the fall risk assessment, dated 01/07/24, revealed Resident #21 was at risk for falls. Review of the Fall Investigation, dated 02/01/24, revealed the resident could not tell what happened due to her level of orientation. Current fall interventions were in place. The resident was wandering out of her wheelchair in the hallway, right outside of her room. The resident fell on her left side, mainly on hip, and the fall was witnessed by state-tested nursing assistant (STNA). The resident was sent to the emergency room (ER) for evaluation. Further review of the fall investigation section titled, Observations at the Time of Fall, did not indicate if any alarms were sounding or not sounding. Both choices were left blank. The resident sustained a fall on 02/01/24 which resulted in a left intertrochanteric femur fracture. During interview on 03/20/24 at 3:52 P.M. with Licensed Practical Nurse (LPN) #100 confirmed that although her nursing progress note failed to indicate if Resident #21's wheelchair alarm was sounding, the chair alarm was properly working and sounding at the time of the fall. During interview on 03/20/24 at 4:40 P.M. with Regional Clinical Consultant #400 and the DON both confirmed the fall investigation failed to indicate if Resident #21's wheelchair alarm was sounding at the time of the fall on 02/01/24. Regional Clinical Consultant #400 and the DON both confirmed the fall investigation should have included this information. Review of the facility's policy titled, Fall Management, revision date of 10/17/16, revealed residents who experience a fall will receive prompt medical attention. Immediate needs will be quickly assessed and responded to. A plan will be identified and implemented as necessary to protect the resident and/or others from recurrence. Management of falls includes the charge nurse gathers and records as much pertinent data as possible related to the fall.

Based on interview, record review, and review of the facility policy, the facility failed to complete a full investigation of verbal abuse for one (Resident #44) of 54 residents and/or family members interviewed. The facility census was 54. Findings include: Record review revealed Resident #44 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #44 was cognitively intact and required extensive assistance of one staff for dressing. Interview on 04/26/22 at 9:14 A.M. with Resident #44 revealed when he asked State tested Nursing Assistant (STNA) #523 to button his shirt, STNA #523 told him to go to [expletive]. Resident #44 revealed this occurred a while ago while at this facility, but he was unable to recall when. Resident #44 revealed he did speak with other staff regarding the concern. Interview on 04/26/22 at 4:04 P.M. with the Administrator confirmed Resident #44 expressed his concern that STNA #523 told him to go to [expletive] when he asked for assistance buttoning his shirt. The Administrator confirmed he could not recall when this occurred but stated a complete investigation to include suspension of STNA #523 during an investigation, interviews with additional residents and staff was not completed by the facility since the initial allegation was made. The Administrator stated Resident #44 frequently brought up the concern. Interview on 04/26/22 at 4:24 P.M. with STNA #523 revealed Resident #44 made this statement to several staff members multiple times. STNA #523 revealed the accusation first occurred around December 2020 during his shift while working at this facility. He was asked by the Administrator if it occurred, and the allegation was denied by STNA #523. STNA #523 confirmed he was not asked to leave at the time or at any time for an investigation to occur. Interview on 04/27/22 at 8:19 A.M. with the Facility Ombudsman revealed on 10/21/21 the Interim Facility Ombudsman spoke to Resident #44. Resident #44 mentioned STNA #523 told him to go to [expletive]. The Interim Facility Ombudsman notified the Director of Nursing (DON) on 10/21/21 of the concern. The Interim Facility Ombudsman again spoke with the DON on 11/02/21 to follow up on the concern. Review of the facility policy titled Abuse, Neglect, Exploitation, and Misappropriation of Residents Property, dated 11/21/16, revealed it is the facility's policy to investigate all alleged violations of abuse, neglect, exploitation or misappropriation of resident's property. If a staff member is accused or suspected of abuse, neglect, exploitation, or misappropriation of resident's property the facility should remove the staff member from the facility schedule pending the outcome of the investigation and have evidence that all violations are thoroughly investigated.

Based on record review and interview the facility failed to assist Resident #48 in repairing or replacing her prescription eyeglasses when the arm of the eyeglasses broke. This affected one (Resident #48) of 54 residents and/or their family members interviewed for ancillary services provided. The facility census was 54. Findings include: Record review for Resident #48 revealed an admitted [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #48 was cognitively intact. Resident #48's vision was adequate with corrective lenses. Interview on 04/26/22 at 9:36 A.M. with Resident #48 revealed her prescription eyeglasses broke several months ago. Resident #48 revealed she spoke with Social Service Designee (SSD) #528 at the time they broke, but they still haven't been repaired or replaced. Resident #48 revealed she was wearing a pair of old prescription glasses from several years ago, and she needed to frequently adjust them due to double vision. Resident #48 revealed she felt she had no choice but to wait another month for the repair of the glasses. Interview on 04/28/22 at 10:03 A.M. with SSD #528 confirmed she knew about Resident #48's prescription eyeglasses breaking. The arm of the eyeglasses broke. SSD #528 tried to take the screw out of the old pair and put it into the new pair to fix the arm, but the screw was too big. SSD #528 confirmed there was no documentation, and she could not recall when the glasses broke. SSD #528 confirmed the eye doctor was scheduled to visit the facility including Resident #48 on 03/14/22. On 03/14/22 Resident #48 was in isolation, so the eye doctor did not see her and would visit again in May 2022. SSD #528 confirmed she did not attempt further to repair or replace Resident #48's eyeglasses. Interview on 04/28/22 at 10:10 A.M. revealed SSD #528 called Resident #48's eye doctor. The office confirmed they would send Resident #48 a new pair that would arrive in five to seven days. Interview on 04/28/22 at 11:06 A.M. with SSD #528 confirmed she could have had the eye doctor fix the eyeglasses when he was there on 03/14/22 or ordered a new pair at the time they broke. SSD #528 revealed she just didn't even think about it and figured the eye doctor would see her next time he visited in May 2022.

Based on record review, staff interview, resident interview, observations, and policy review the facility failed to administer oxygen as ordered by the physician. This affected two residents (Resident's #60 and #18) of two residents reviewed for respiratory care. The facility census was 54. Findings include: 1. Review of the medical record for Resident #60 revealed an initial admitted [DATE] and a re-entry date of 05/28/17. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders for April 2022 identified an order dated 03/20/20 for observations to ensure Resident #60 avoided lying flat, related to shortness of breath or trouble breathing related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #60 had intact cognition with a Brief Interview of Mental Status (BIMS) score of 15 out of 15 (no impairment) and no noted behaviors. The resident required extensive assistance of one to two staff members for all activities of daily Living (ADL) except eating which he required set-up and supervision. Further review of the MDS revealed Resident #60 received oxygen therapy. Review of the plan of care dated 04/10/22 revealed Resident #60 was anemic. Interventions included alerting the nurse if the resident complains of/or exhibits signs/symptoms of fatigue, skin pallor, shortness of breath, lightheadedness, dizziness, or a fast heartbeat. Review of the plan of care dated 04/10/22 revealed Resident #60 had cardiac symptoms due to CHF, hypertensive heart disease, and [CONDITION(S)]. Interventions included oxygen per orders. Review of the plan of care dated 04/10/22 revealed Resident #60 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the plan of care dated 04/10/22 revealed Resident #60 was at risk for impaired respiratory function or respiratory infection related to a history of COVID-19 virus, [CONDITION(S)], and CHF. Interventions included oxygen as ordered. Review of the Electronic Treatment Administration Record (ETAR) revealed Resident #60's order for continuous oxygen, per nasal cannula, at two to four liters per minute to maintain oxygen saturation above 90 percent (%) was signed off every day in April 2022. Further review of the ETAR revealed Resident #60 was intermittently wearing zero to two liters of oxygen. Review of the plan of care dated 04/10/22 revealed Resident #60 had a self-care deficit, requiring assistance with ADL due to arthritis, pain, spinal stenosis, obesity, resident continued to sleep in her recliner chair due to shortness of breath lying flat. Interventions included monitoring as needed (prn) for changes in resident's abilities and adjust amount of assistance provided based on resident's needs. Review of the progress note dated 04/18/22 at 10:27 A.M. by Registered Nurse (RN) #536 revealed Resident #60 had [CONDITION(S)] and wore oxygen at night. Review of physician orders for April 2022 identified an order dated 04/21/21 for continuous oxygen, per nasal cannula, at two to four liters per minute to maintain saturation above 90 %. Observation and interview on 04/25/22 at 7:34 P.M. of Resident #60 revealed her oxygen concentrator was running, but Resident #60 was not utilizing the oxygen. The resident revealed she wore her oxygen at night. Observations on 04/26/22 at 8:02 A.M., 04/26/22 4:15 P.M., and 04/27/22 9:01 A.M. revealed Resident #60 was sitting in her room, with no oxygen in place. Interview on 04/26/22 at 4:15 P.M. with RN #533 confirmed Resident #60 only wore oxygen at night and did not need it throughout the day. Review of the facility policy titled Respiratory: Oxygen Administration via Nasal Cannula, revised 08/25/12, revealed the facility required a physician order to be obtained prior to the administration of oxygen via nasal cannula. The orders for oxygen via nasal cannula must state the liter flow and specific weaning criteria. 2. Review of the medical record for Resident #18 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders for April 2022 identified an order dated 03/07/22 for continuous oxygen per nasal cannula to maintain saturation above 90 % and to check Resident #18's oxygen saturation every shift while on oxygen. Review of the ETAR revealed the orders dated 03/07/22 for continuous oxygen per nasal cannula to maintain saturation above 90 % and to check Resident #18's oxygen saturation every shift while on oxygen, were checked off as completed every day of April 2022. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #18 had intact cognition with a BIMS score of 15 out of 15 (no impairment) and no documented behaviors. Resident #18 required limited to extensive assistance of one staff member for all ADL except eating which he required set-up and supervision and personal hygiene which he was independent. Further review of the MDS revealed the resident received oxygen therapy. Review of the plan of care dated 04/22/22 revealed Resident #18 did not have an oxygen therapy care plan. When the Director of Nursing (DON) was asked for an oxygen care plan, she provided the surveyor with the care plan for altered health maintenance related to progressive physical and mental status: right and left lung cancers undergoing treatment until recent illness, Fournier's gangrene with surgical debridement and s/p catheter placement, had hypertension ([CONDITION(S)]), [CONDITION(S)] (HLP), asthma, transcatheter aortic valve placement, [CONDITION(S)], [CONDITION(S)], and diabetes mellitus. Interventions included medications as ordered. Review of the progress note dated 04/26/22 at 8:45 A.M. by RN #553 revealed shortness of breath on exertion which was relieved by rest and/or oxygen. Resident #18 had been using supplemental oxygen less and remains above 95% on room air (RA). Review of Resident #18's oxygen saturations revealed no concerns. The oxygen saturations were intermittently RA and intermittently on oxygen. Interview on 04/26/22 at 4:15 P.M. with RN #533 confirmed Resident #18 only wore oxygen at night and did not need it throughout the day. Review of the facility policy titled, Respiratory: Oxygen Administration via Nasal Cannula, revised 08/25/12, revealed the facility required a physician order to be obtained prior to the administration of oxygen via nasal cannula. The orders for oxygen via nasal cannula must state the liter flow and specific weaning criteria.

Based on interviews and record review, the facility failed to ensure Resident #50's medical record accurately reflected the correct weights. This affected one (Resident #50) of three residents (Resident's #26, #39 and #50) reviewed for nutrition and weight loss. The facility census was 54. Findings include: Review of the medical record revealed Resident #50's was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #50's weights revealed on 12/22/21 he weighed 166.4 pounds (lbs.), 12/27/21 was 165 lbs., 01/03/22 was 165 lbs., 01/10/22 was 166 lbs., 01/17/22 was 166 lbs., 02/02/22 was 119.6 lbs., 02/07/22 was 119.8 lbs., 02/14/22 was 122 lbs., 02/24/22 was 122.4 lbs., 02/28/22 was 122 lbs., 03/07/22 was 121.8 lbs., 03/14/22 was 117 lbs., 03/21/22 117.5 lbs., 03/28/22 was 120.5 lbs., 04/02/22 was 122 lbs., 04/04/22 was 120 lbs., 04/11/22 was 123.7 lbs., 04/13/22 was 124 lbs., 04/18/22 was 121 lbs. and on 04/25/22 was 124.8 lbs. Review of Resident #50's hospital discharge summary dated 12/21/22 revealed he weighed 113 pounds. Interview on 04/27/22 at 9:00 A.M. with Dietician #567 revealed there was a discrepancy with the weights from 12/22/21 through 01/17/22. She verified the weights on 12/22/21, 12/27/21, 01/03/22, 01/10/22 and 01/17/22 were inaccurate. Dietician #567 stated Resident #50 was stable with nutrition, laboratory findings and had no change in appearance from 01/17/22 to 02/02/22 when there was a 46.8-pound weight loss. She verified findings from the hospital discharge paperwork stating Resident #50 weighed 113. Interview on 04/27/22 at 3:12 P.M. with the Director of Nursing (DON) verified Resident #50's weights from 12/22/21 through 01/17/22 were inaccurate.

Based on observation, record review, review of list of residents with rashes in the past 90 days and current rashes and interview the facility failed to adequately monitor, assess and treat skin alterations (rashes) for eight residents, Resident #14, #15, #37, #39, #40, #43, #51 and #53. This affected eight residents (#14, #15, #37, #39, #40, #43, #51 and #53) of nine residents reviewed for skin alterations (rashes). Findings include: Review of the list of residents with rashes in the past 90 days revealed the list contained eight current residents (#12, #14, #15, #37, #39, #41, #43, and #53) and one resident who had expired on [DATE]. Resident #15, #37, #43, and #53 were marked as currently being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] Interview on [DATE] at 1:00 P.M. and on [DATE] at 7:59 A.M., 9:45 A.M. and 12:21 P.M. with the Director of Nursing (DON) revealed as of yesterday she was responsible for monitoring skin alterations due to her assistant quitting. The DON reported Resident #15, #37, #43, and #53 were the only residents she was aware of who had rashes when she ran a report. She was not aware of the other four residents as noted above. The DON confirmed she had not been tracking the rashes to ensure there was not an outbreak, nor had she done a skin audit on all residents to ensure other residents did not have rashes. The DON reported the nurse practitioner (NP) visits the facility two to three times per week and monitored all rashes that were reported to nursing. The DON reported the Physician/NP notes were not available in the electronic medical record or paper chart for each resident and would have to printed from another source that was not available to the surveyor. Interview on [DATE] at 12:04 P.M. with Licensed Practical Nurse (LPN) #64 revealed there was only one resident, Resident #15 noted on the East Unit with a rash. Interview on [DATE] at 1:19 P.M. with Registered Nurse (RN) #61 revealed she had no residents with rashes on the North Unit, however there was a concern on the West Unit with residents with rashes. Interview on [DATE] at 1:29 P.M. with LPN #55 revealed there were three or four residents on her hall (West Unit) who currently had rashes. LPN #55 reported Resident #43's laundry had to separated and washed with different laundry detergent. Interview on [DATE] at 7:32 A.M. with State tested Nursing Assistant (STNA) #28 and STNA #31 revealed there were five or six residents on the West Unit with rashes and possibly a couple on the East Unit. Interview on [DATE] at 9:45 A.M. with the facility NP revealed she did not think the rashes were related due to the appearance of the rashes being different with some of the residents. She did not think the rashes were contagious nor did she biopsy any of the rashes to rule out scabies or any other type of contagious communicable diseases. The following residents were reviewed related to the presence of rashes: 1. Record review revealed Resident #14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #14's most recent Physician/Nurse Practitioner (NP) note, dated ,d+[DATE] revealed the resident had no skin alterations including rashes noted. The resident's skin was noted to be warm and dry. The Director of Nursing (DON) confirmed on [DATE] at 3:38 P.M. the last NP/Physician visit was ,d+[DATE]. Review of Resident #14's nursing progress notes and assessments dated [DATE] to [DATE] revealed on [DATE] a head to toe assessment was completed and no new skin areas was noted. There was no documentation or assessment of the rash or treatment orders noted on [DATE] for the [MEDICATION(S)] cream to thighs. On [DATE] the nurse's note indicated the resident had a head to toe assessment was completed. No new finding and resident continued to have a rash on his back. There was no evidence of an assessment or monitoring of the rash. Review of Resident #14's orders and medication and treatment administration records dated [DATE] to [DATE] revealed the resident had received [MEDICATION(S)] Cream 1% to thighs topically twice a day for 21 days started on [DATE] and ending on [DATE]. Further review revealed the resident was receiving [MEDICATION(S)] 10 milligrams (mg) at bedtime for sleep since [DATE]. Observation on [DATE] at 7:16 A.M. of Resident #14 with Licensed Practical Nurse (LPN) #65 revealed the resident had a fine red rash noted on his back, bilateral upper legs, and upper chest. The LPN reported the resident had recently been treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . She had reported the rash last week and the nurse practitioner (NP) was aware, however there were no new orders. Interview on [DATE] at 7:16 A.M. with Resident #14 revealed the rash was itchy and he was currently not receiving a treatment. He could not recall exactly how long he has had the rash. Interview on [DATE] at 12:21 P.M. with the Director of Nursing (DON) confirmed there was no physician/NP note regarding the rash or treatment ordered on [DATE]. There was no evidence of an assessment or monitoring of the rash noted in the assessments or nursing notes. The DON revealed she was not aware the resident currently had a rash. 2. Record review revealed Resident #15 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #15's physician/NP notes revealed on [DATE] nursing had reported the resident had a red raised rash on his knees, onset days prior. The assessment and plan included topical [MEDICATION(S)] cream to bilateral legs/knees for prickly heat (heat rash). On [DATE] the NP saw the resident and indicated the rash on the resident's knees had resolved. On [DATE] the NP was asked to see the resident for follow up rash and diagnostic test (labs, chest, and abdominal x-ray). The resident denied itch to rash, however staff reported they felt he was itching more the past few days. The resident had a noted increased white blood cell. New orders for the steroid medication, [MEDICATION(S)] (taper dose) for prickly heat (heat rash) to bilateral legs, knees and chest. The most current NP/Physician note dated [DATE] revealed the rash had improved on the torso, no complaints of pain itching. There was no evidence the resident was seen by the NP or Physician after [DATE]. The DON confirmed on [DATE] at 3:38 P.M. the resident's last physician/NP visit was [DATE]. Review of Resident #15's nursing progress notes and assessment dated [DATE] to [DATE] revealed [DATE] the NP had seen the resident for rash on bilateral lower extremities. New orders were received for [MEDICATION(S)] cream 1% to affected areas for seven days. Further review revealed no evidence of monitoring or assessment of the skin rash. Review of Resident #15's orders and medication and treatment administration records dated [DATE] to [DATE] revealed the resident was ordered and received [MEDICATION(S)] Cream twice daily from [DATE] till [DATE] and [DATE] till [DATE]. On [DATE] he was ordered a [MEDICATION(S)] titrating dose pack for a rash. On [DATE] he was ordered Lac-hydrin to be applied to lower legs daily for 30 days for itching and [MEDICATION(S)] ointment to be applied to bilateral knees and thighs daily for frequently itching for 30 days. Observation on [DATE] at 7:16 A.M. of Resident #15 with LPN #65 revealed the resident had a rash noted around the bilateral ankles and bilateral legs. The nurse confirmed the rash had been there a while. LPN #65 reported the resident had orders for [MEDICATION(S)] cream twice daily, [MEDICATION(S)] (over the counter (OTC) skin protectant) once daily, and Lac-hydrin (skin moisturizer to treat dry, scaly, itchy skin) once daily, however the resident was still scratching the areas. Interview on [DATE] at 7:16 A.M. of Resident #15 revealed the resident reported the rash was itchy. The resident could not recall how long he had had the rash. Interview on [DATE] at 12:21 P.M. with the DON confirmed there was no evidence in the medical record that staff had assessed or monitored the resident rash. 3. Record review revealed Resident #37 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #37's physician/NP notes, dated [DATE] to [DATE] revealed on [DATE] the nurses reported the resident had a rash on the left side that started days prior. The resident was ordered [MEDICATION(S)] (taper dose) for pruritic rash. On [DATE] the NP was asked to see the resident by the nurse due to rash on the left arm. The nurse reported rash on left arm and rash continued left back, which was improving with current treatment ([MEDICATION(S)]). New order for [MEDICATION(S)] cream to affected area on left arm. On [DATE] the physician had seen the resident. There was no evidence the rash was addressed or assessed. On [DATE] the NP saw the resident per nurses request due to a rash on the resident torso. There was a faint raised rash on left side, back, and torso. The resident was ordered [MEDICATION(S)] cream for 14 days and [MEDICATION(S)] taper. On [DATE] the NP saw the resident for rash. The resident has a rash on torso, left side, back, and bilateral arms. Resident noted to be restlessness, likely in context of itching, but unable to confirm due to mental status. Will treat the restlessness as caused by itch. Patient with unknown environmental exposure or sensitivity, the rash was primality on back. New orders for [MEDICATION(S)] daily for five days and apply topical [MEDICATION(S)] cream to affected areas twice a day for five days and consult dermatology. Review of Resident #37's orders and medication and treatment administration records revealed the resident received treatments and medication as ordered above from Physician/NP notes. Review of Resident #37's nursing progress notes and assessments dated [DATE] to [DATE] revealed no evidence of assessment or monitoring of the resident's rash. Observation on [DATE] at 8:40 A.M. of Resident #37 with the DON and State tested Nursing Assistant (STNA) #28 revealed the resident's entire back was covered with a raised red rash. The STNA reported the resident scratches the area and the rash had been on the resident's back for approximately a month. The DON reported she had bought the resident over the counter Aveno lotion and started washing his clothing in hyper [MEDICATION(S)] laundry detergent. The DON confirmed the facility had not changed their laundry detergent; however, the facility was just trialing the hyper [MEDICATION(S)] detergent. Interview on [DATE] at 12:21 P.M. with the DON verified there was no evidence of an assessment or monitoring on the rash in the resident progress notes or assessment. 4. Record review revealed Resident #39 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician note, dated [DATE] revealed no evidence of skin alteration/rash. Review of an NP note dated [DATE] revealed Resident #39 had a pruritic rash on the left side and left arm. The resident had complaints of mild itch to left arm and left side, which presented ,d+[DATE] days ago. The resident had a red, prickly scattered rash on left arm and left side. The rash was diffuse and no specific pattern, multiform shape. No rash or [CONDITION(S)] noted in between fingers or on other extremities. New orders for [MEDICATION(S)] daily for 14 days and [MEDICATION(S)] at bedtime for 10 days. Review of Resident #39's nursing progress notes and assessment dated [DATE] to [DATE] revealed on [DATE] the NP ordered [MEDICATION(S)] for three days and over the counter [MEDICATION(S)] cream daily to rash on left thigh for 10 days. On On [DATE] a notation was entered the NP was in earlier and seen resident and ordered [MEDICATION(S)] 20 milligrams (mg) daily for 14 days and [MEDICATION(S)] 25 mg at bedtime for 10 days for rash/itching. Review of Resident #39's orders and medication and treatment administration records dated ,d+[DATE] revealed the resident completed the [MEDICATION(S)] 25 mg on [DATE] and the [MEDICATION(S)] would be completed on [DATE]. Interview on [DATE] at 9:05 P.M. with STNA #28 revealed Resident #39 was currently at [CONDITION(S)], however he had a raised rash on his trunk of his body identical to the other residents. About two weeks ago she had found ,d+[DATE] residents with similar rashes and had reported them to the nurse. Interview on [DATE] at 12:21 P.M. with the DON confirmed there was no evidence nursing staffing were assessing and monitoring the skin alteration/rash. The DON reported she was not aware the resident currently had a rash. 5. Record review revealed Resident #40 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident resides in room [ROOM NUMBER]. Review of the NP note, dated [DATE] revealed Resident #40 had xeroderma (decreased ability to repair DNA damage such as that caused by ultraviolet light (sunburn, freckling, dry skin, etc.). Staff had reported the areas were present days prior. The lower back, buttocks, and thighs were noted to have patchy areas of gray/silver appearing skin with rough/flaky appearance. The resident denied pain and itching. New orders wrote for Lac-hydrin topically for 10 days. Review of Resident #40's nursing progress notes and assessments, dated [DATE] to [DATE] revealed no evidence of an assessment of the resident skin alterations or monitoring of treatment. Review of Resident #40's orders and medication administration records dated ,d+[DATE] revealed the resident received Lac-hydrin lotion 12% to be applied to back and posterior thighs topically two times a day for Xeroderma for 10 days from [DATE] to [DATE] then it was discontinued. Observation on [DATE] at 9:12 A.M. of Resident #40 with the DON and STNA #28 revealed the resident was a woman of color. The resident had raised areas that appeared to look live hives in appearance noted on her lower back, buttocks, and the back of the lower thighs. The STNA reported the resident had the areas for about two weeks. She was only using the standard basic lotion that was used on all residents on Resident #40's skin. The DON reported she did not feel the areas were abnormal for the resident, however the STNA reported it was a change in the resident's skin and she had reported the rash to the nurse last week when she had found other residents with rashes. Interview on [DATE] at 12:21 P.M. with the DON confirmed there was no evidence the skin alteration was assessed/monitored. 6. Record review revealed Resident #43 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #43's hospice notes dated [DATE] to [DATE] revealed only the LPN had assessed the resident for a rash. There was no actual assessment of the rash or location. On [DATE] the nurse was informed of a rash on the resident's waist area up to his neck area. Hospice nurse contacted and new orders for [MEDICATION(S)] 25 mg every six hours as needed. If it doesn't help let hospice know. There was no evidence of an assessment of the raised area. On [DATE] the resident's wife had called and asked if the [MEDICATION(S)] could be changed to something else due to it making the resident too tired. New orders were received for [MEDICATION(S)] 40 mg daily for five days, hold the [MEDICATION(S)] for five days, and start [MEDICATION(S)] cream 1% to affected rash areas twice daily for five days. Review of a NP note dated [DATE] revealed the resident had a rash on his torso and left arm that appeared to by cutaneous hypersensitivity (state of altered reactivity in which the body reacts with an exaggerate or inappropriate immune response to a chemical substance having the properties of an [MEDICATION(S)] or happen that was in contact with the skin, the resulting skin condition being allergic contact [CONDITION(S)]. Continue [MEDICATION(S)] area and start [MEDICATION(S)] and [MEDICATION(S)]. The nurse reported the rash on torso and left arm had been present the past days, improving with [MEDICATION(S)] and [MEDICATION(S)]. Daughter at bedside. The resident had no exposure to any contagious disease or person. The resident with no obvious signs of discomfort or itching. On [DATE] the resident's daughter called asking nurse to call hospice regarding new orders the facilities NP had wrote. Hospice wanted [MEDICATION(S)] held for 24 hours, [MEDICATION(S)] cream twice daily for seven days, discontinue [MEDICATION(S)], Start [MEDICATION(S)] 20 mg daily for 14 days, and start [MEDICATION(S)] 10 mg for seven days. The hospice nurse would be in tomorrow to evaluate the resident. On [DATE] the family was at the beside currently and voiced concerns regarding the new order. Wife stated she would like the [MEDICATION(S)] discontinued and wanted something more of the itching. The hospice NP gave new orders for [MEDICATION(S)] ([MEDICATION(S)]) 25 mg every six hours as needed and to educate the family to continue [MEDICATION(S)] for the full course. On [DATE] the hospice note indicated the rash appeared to be getting worse. There was no evidence of assessment including location of the rash. On [DATE] the NP note indicated the rash was less raised and less moist, no blisters noted on the torso or under left arm. Faint rash on torso with fine bumpy texture. Resident complains of itch to underarm. Will order [MEDICATION(S)] through [DATE]. On [DATE] the facilities NP saw the resident and ordered [MEDICATION(S)] 25 mg twice daily and twice daily as needed through [DATE]. On [DATE] the hospice note revealed the resident's rash appeared to be improving from last week. Last week it appeared very red and like hives. The rash was not raised and just a little red. There was no evidence of an assessment including location of the rash. On [DATE] the hospice NP wrote new orders for [MEDICATION(S)] 25 mg. Further review of the resident's progress and assessment revealed no evidence of assessment or monitoring of the appearance of the rash. Observation on [DATE] at 9:13 A.M. of Resident #43 with the DON and STNA #28 revealed the resident had a red raised rash covering his chest, abdomen, and back. The STNA reported the resident had the rash for about 1.5 to 2 months. The resident tried to scratch the areas; however, it was difficult for him due to his [CONDITION(S)] and TIA. Interview on [DATE] at 12:21 P.M. with the DON revealed there was no evidence the facility had completed an assessment or monitoring of the appearance of the rash. The DON reported she was not able to find an assessment in the hospice notes as well. 7. Record review revealed Resident #51 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #51's physician/NP notes dated [DATE] to [DATE] revealed no evidence the resident had a rash or treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #51's nursing progress notes and assessments dated [DATE] to [DATE] revealed no evidence the resident had a rash or received new orders on [DATE] for itching. Review of Resident #51's medication administration records dated ,d+[DATE] revealed the resident was ordered [MEDICATION(S)] Cream 1% to be applied to affected area every 12 hours as needed for itching until [DATE] and [MEDICATION(S)] 25 mg every 12 hours as needed for itching. There was no evidence the resident received either medication. Observation on [DATE] at 9:15 A.M. of Resident #51 with the DON and STNA #31 revealed the resident had red raised rash on her right abdomen. The resident reported the rash was itching and she was not receiving a treatment that she was aware of for the rash and itching. Interview on [DATE] at 9:21 A.M. with STNA #28 revealed the STNA had reported the resident had a rash on her abdomen for about a week. She was not aware of any treatment orders. Interview on [DATE] at 12:21 and 3:00 P.M. with the DON confirmed there was no documentation regarding the rash or new orders. 8. Record review revealed Resident #53 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #51's physician/NP notes dated [DATE] to [DATE] revealed on [DATE] the resident reported she had ,d+[DATE] red raised areas on the top of left thigh, noted the day prior with mild itching, no blistered areas noted, faint non-raided rash on left side of left thigh. The patient recently started a po antibiotic and that cannot exclude as contributing cause. Will add topical treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #51's nursing progress notes and assessments dated [DATE] to [DATE] revealed on [DATE] the NP ordered [MEDICATION(S)] cream to be applied to left thigh and left side twice daily for 10 days for a rash. Further review revealed nurse's continued to chart the resident continued antibiotics with no adverse reactions noted. There was no evidence of an assessment or monitoring of the rash for effectiveness of treatment. Review of Resident #51's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on [DATE] at 9:20 A.M. of Resident #51 with the DON and STNA #31 revealed the resident had a fine rash on her left thigh and both legs that (per interview with the resident) was driving her nuts. The resident reported she had the rash for a week or so and thought the nurse may have given her a [MEDICATION(S)] once. She could not recall if the nurse had put lotion on the rash. STNA #31 spoke up and reported the nurse had given her a cream in a cup to administer for the resident's rash. Interview on [DATE] at 12:21 with the DON confirmed there was no documented evidence the facility staff had documented on the rash or evidence the monitoring during treatment to ensure the treatment was effective. Interview on [DATE] at 12:21 P.M. with the DON revealed six of the above eight residents observed with rashes resided on the west unit and the other two residents shared a room on the East Unit. Six of the 18 total residents observed on the west unit had rashes. The DON reported a few weeks ago she had noticed the lack of documentation for skin alterations and had planned to have a staff meeting this week to educate staff on documentation. This deficiency substantiates Complaint Number OH 972.

Based on observation, record review and interview the facility failed to ensure timely and comprehensive dental services were provided to all residents. This affected three residents (#54, #57 and #59) of four residents reviewed for dental services. Findings include: 1. Record review revealed Resident #54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed no evidence the resident had seen the dentist since admission. Review of Resident #54's ancillary consents dated 06/17/19 revealed the resident requested dental services. Review of Resident #54's oral assessment completed on 08/15/19 revealed the resident was edentulous. Review of Resident #54's care plan for impaired dentition and risk for oral problems related to missing some natural teeth or edentulous revealed the resident was ok to see the dentist, would be free of signs or symptoms or reports of poor self-image related to dental status, refer to dentist as needed, dental consults/follow up as ordered and as needed. Review of Resident #54's current orders dated 09/2019 revealed an order for [REDACTED].>Observation and interview on 09/23/19 at 3:48 P.M., with Resident #54 revealed he would like to see the dentist to get dentures. The resident was observed to be edentulous. Interview on 09/24/19 at 3:40 P.M., with Social Service Designee (SSD) #21 verified Resident #54 had signed consent to see the dentist, however had not been seen as of this time. The resident was scheduled to see the dentist on 07/26/19, however the dentist did not see him due to time constraints. The dentist was scheduled to see 15 residents but only saw three. The dentist had documented he was not able to see them due time constraints. The SSD reported she tried to add the new admissions on the next scheduled dental visit. 2. Record review revealed Resident #57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed no evidence the resident had been seen by the dentist. Review of Resident #57's ancillary consents revealed the resident's power of attorney signed consent on 06/25/18 for dental services. The SSD note dated 01/07/19 and 05/17/19 reveled the resident was not seen by the dentist on 01/07/19 and 05/17/19 due to time constraints of the doctor. Would be rescheduled. Review of the dental list dated 07/26/19 revealed no evidence Resident #57's was on the list to be seen. Review of Resident #57's oral assessment completed on 08/30/19 revealed the resident was edentulous. Review of Resident #57's current orders dated 09/2019 revealed the resident had orders to be treated by the dentist. Review of Resident #57's plan of care for impaired dentition and risk for oral problems revealed the resident would wear dentures as tolerated, no adverse effects from dentures or partials, if ill-fitting dentures contact SSD to make arrangements to get dentures examined for repairs if necessary, dental consult/follow up as ordered, dentures to be cleaned daily, dentures in-place of all meals, Observation and interview on 09/23/19 at 11:12 [NAME]M., with Resident #57 revealed he did not have dentures and would like dentures. The resident was observed to be edentulous. Interview on 09/24/19 at 3:40 P.M., with SSD #21 verified the resident had not been seen by the dentist. She confirmed the resident was not seen on 01/07/19 and 05/17/19 due to time constraints of the dentist. The resident was not seen on 07/26/19 when the dentist visited. Interview on 09/24/19 at 4:42 P.M., with the Director of Nursing (DON) confirmed the resident doesn't have dentures and the dental plan of care was inaccurate. Review of dental services policy dated 11/14/17 revealed the facility would assist the resident in obtaining routine and emergency dental care. 3. Review of medical record revealed Resident #59 was admitted on [DATE] with [DIAGNOSES REDACTED]. The current plan of care (initiated 04/23/19 revealed Resident #59 had impaired dentition and was at risk for oral problems related to the use of dentures/partials. The resident stated she lost her upper denture at a previous facility. Interventions included dental consults and follow up as ordered and as needed, dentures to be cleansed daily, and dentures to be worn for meals. Review of an admission oral examination dated 04/04/19 at 1:33 P.M. revealed Resident #59 stated she had lost her upper denture a couple weeks ago. The oral examination dated 04/22/19 at 1:14 P.M. revealed the resident's upper denture was missing and the resident had four or more decayed or broken natural teeth. The resident stated she had discomfort to lower teeth. The oral examination dated 05/04/19 at 3:55 P.M. revealed the resident's upper denture was missing. The resident stated she had discomfort to lower teeth. The oral examination dated 07/16/19 at 11:34 [NAME]M. revealed Resident #59 had her own teeth to the lower gum and was awaiting upper dentures. The resident reported oral pain/discomfort. The oral examination dated 07/23/19 at 5:29 P.M. revealed Resident #59 was awaiting upper dentures. The resident reported oral/pain discomfort. Review of dental summary report dated 07/26/19 revealed Resident #59 had an emergency, limited exam of upper and lower (gums/teeth). The summary revealed the area had been a problem for less than 24 hours. The doctor's note revealed Resident #59 had misplaced her upper denture and did not have any complaints. An oral examination dated 08/26/19 at 11:62 P.M. revealed Resident #59 had oral discomfort. Interview on 09/24/19 at 3:42 P.M. Administrator revealed Resident #59 did not have have a top denture when admitted on [DATE]. Interview on 09/25/19 at 10:50 [NAME]M. with Licensed Practical Nurse #52 verified Resident #59 had seen the facility dentist on 07/26/19 but there was not a explanation of what care had been provided or if an upper denture had been ordered. Interview on 09/25/19 at 2:06 P.M. Director of Nursing verified there was no documentation of the dental care Resident #59's had received.

Based on record review and interview the facility failed to implement a comprehensive antibiotic stewardship program to monitor and prevent unnecessary/inappropriate use of antibiotics. This had the potential to affect one resident (#47) of two residents reviewed for infections. Findings include: Record review revealed Resident #47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #47's urinalysis, orders, medication administration records (MAR), and progress notes dated 08/01/19 to 09/26/19 revealed: a. On 08/14/19 a urine was obtained due to the resident had an elevated white blood count 11.1 (4.5-10.8) on 08/13/19. There was no documented evidence the resident had urinary symptoms. On 08/16/19 the urine culture returned indicating the organism was [MEDICATION NAME] Faecalis greater than 100,000. The organism was sensitive to [MEDICATION NAME] and [MEDICATION NAME]. The physician ordered [MEDICATION NAME] 250 milligrams (mg) every six hours for two weeks on 08/16/19. The MAR indicated [REDACTED]. There was no documented evidence indicating why the antibiotic was not started until 08/20/19 or why it was switched. Review of the infection control/antibiotic stewardship log dated 08/2019 revealed Resident #47's did not meet the criteria for infection or antibiotic use. Further review revealed the resident had a UTI, the onset of date of the symptoms was 08/17/19 and date of the culture was 08/17/19. The resident was ordered [MEDICATION NAME] 250 mg four times a day for 14 days. The order was discontinued on 08/20/19 and new order was received for [MEDICATION NAME] 500 mg three times a day for five days. Interview on 09/26/19 at 9:51 [NAME]M., with the Director of Nursing (DON) verified the resident did not meet the McGeer criteria for infection or the Loeb criteria for antibiotic treatment. The DON revealed the facility used both McGeer and Loeb. The McGeer was used to ensure resident had a qualifying infection and the Loeb was used to determine if they met criteria for antibiotic use. The DON reported the facility received the urine culture back on 08/16/19, however the physician wanted the resident's urologist to address the urine results. The nurse called the urology office and the urologist was not available until Monday. On Monday the urologist wanted the resident started on a [MEDICATION NAME] for one day then start the [MEDICATION NAME] on Tuesday. The DON reported staff did not document the above information. She had interviewed the staff member yesterday after concerns were brought to her attention during the survey. She had no explanation why the [MEDICATION NAME] had to be started one day before the [MEDICATION NAME]. The DON reported the [MEDICATION NAME] was switched after two doses due to the pharmacist had reviewed the medical record and reported oral [MEDICATION NAME] was not absorbent and requested the antibiotic be changed to [MEDICATION NAME] 500 mg. The DON confirmed there was no documented evidence the physician was aware the resident did not meet criteria for treatment. b. On 09/09/19 a urine was collected, and the culture report was received on 09/11/19 which indicated the resident had the same organism as 08/09/19 ([MEDICATION NAME] Faecalis). There was no documented evidence the physician was made aware of the urine results or the resident had urinary symptoms. Review of the infection control/antibiotic stewardship log dated 09/2019 revealed no evidence the resident was listed on the log for infections. Interview on 09/26/19 at 9:51 [NAME]M., with the DON verified there was no documented evidence in the medical record that indicated the physician was notified of urinalysis results, however the shift report (not part of the medical record) revealed no new orders due to resident was not having any symptoms. She confirmed the resident was not listed on the infection control log. c. Review of the resident's Medication Administration Record [REDACTED]. There was no evidence of a urinalysis or culture results in the medical record. The resident was sent to the emergency room [DATE] for a low blood pressure and complaints of not feeling well. The emergency room reported the resident had UTI and sent the resident back the same day on antibiotics. Review of the infection control/antibiotic stewardship log dated 09/2019 revealed on the resident was started on [MEDICATION NAME] 500 mg on 09/22/19 and did not meet criteria. Interview on 09/26/19 at 9:51 [NAME]M., with the DON verified there was no documented evidence in the medical record of the urinalysis or culture that was obtained in the emergency roiagnom on [DATE]. The DON reported she called the laboratory today and they reported the urine culture showed greater than 100,000-gram negative rods and they did not have the culture results at this time. The DON verified there was no culture to confirm the [MEDICATION NAME] was sensitive to the organism. Review of the Loeb minimum criteria for imitation of antibiotics undated revealed suspected UTI's with indwelling catheter would have at least one of the following: -fever -new costovertebral tenderness -rigors -new onset of [MEDICAL CONDITION]. Review of the McGeer criteria for infection dated 2012 revealed the resident had to meet both criteria: 1. One of the following: -fever, rigor, [MEDICAL CONDITION] -change in mental status or acute functional decline -purulent drainage from around the catheter 2. Urinary catheter specimen culture with at least 100,000 of any organisms. Review of the antibiotic stewardship program policy dated 11/28/17 revealed the attending physician would prescribe appropriate antibiotics in accordance with standards of practice and facilities protocols. McGeer criteria would be used to define infections and the Loeb criteria would be used to determine whether to treat an infection with antibiotics. Antibiotics orders obtained upon admission or readmission to the facility shall be reviewed for appropriateness, as well as those obtained from consulting, specialty, or emergency providers.

Based on record review and interview the facility failed to ensure immunizations were administered as ordered. This affected one resident (#62) of five residents reviewed for immunizations. Findings include: Medical record review revealed Resident #62 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the consent titled, Pneumococcal Conjugate Vaccine (PCV13 or Prevnar 13) dated 05/01/19 revealed Resident #62 gave consent to receive the pneumococcal and Prevnar 13 vaccine. Review of the physician orders [REDACTED]. The vaccine was not administered on 05/02/19 as ordered as the facility was waiting for pharmacy to deliver. Review of the admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] and the quarterly MDS assessment dated [DATE] revealed Resident #62's pneumococcal vaccine was not up to date and was not offered to the resident. Review of the progress notes, dated 09/16/19 revealed Resident #62 was admitted to the hospital with [REDACTED]. Review of the record dated 05/02/19 to 09/25/19 revealed no documented evidence the pneumococcal vaccination had been administered. On 09/25/19 12:36 P.M., interview with Licensed Practical Nurse #52 unit manager verified Resident #62 consented to receive the Prevnar 13 vaccine on 05/01/19 and there was no documented evidence it was administered. Review of the policy titled Immunization of Residents, revised (MONTH) (YEAR) revealed it was the facility policy to deliver appropriate vaccinations in a timely manner in accordance with current CDC (Centers for Disease Control and Prevention) guidelines and recommendations. Procedures included upon admission residents were to be offered a pneumococcal vaccine unless contraindicated or already immunized. A physician order [REDACTED].

Based on observation, staff interviews, and policy and procedure review revealed the facility failed to properly store, date, and dispose of expired medication. This had the potential to affect all 66 residents. Facility census was 66. Findings include: 1. Observation on [DATE] at 8:30 A.M. revealed an undated opened vial of [MEDICATION NAME] skin test liquid in the medication room refrigerator on the 300 hall ([MEDICATION NAME] should be discarded 30 days after being opened). Registered Nurse (RN) #46 verified there was not a date on the [MEDICATION NAME] vial. 2. Observation on [DATE] at 8:32 A.M. of the medication cart on the 300 hall revealed an opened Fluticason (nasal spray for allergies [REDACTED].#63 dated [DATE] ([MEDICATION NAME] is good for 28 days after it is opened). Interview with Registered Nurse (RN) #46 , at the time of the observation, verified the vial of [MEDICATION NAME] was expired. Review of the Medication Storage policy and procedure dated [DATE] revealed outdated medications were to be immediately removed from stock and disposed of. 3. Observation on [DATE] at 8:45 A.M. revealed an open vial of [MEDICATION NAME] skin test liquid dated [DATE] ([MEDICATION NAME] should be discarded 30 days after being opened). Interview with Licensed Practical Nurse #71, at the time of the observation, verified the [MEDICATION NAME] vial had expired. Review of the Medication Storage policy and procedure dated [DATE] revealed outdated medications were to be immediately removed from stock and disposed of. 4. Observation on [DATE] at 8:52 A.M. revealed two clear plastic bags of medication on the top shelf in a closet on the secure unit. The closet was unlocked and State tested Nursing Assistants and a volunteer were observed getting into the closet to get movies and other items for the residents. Observations of the medications in the plastic bags with the Assistant Director of Nursing (ADON) revealed the medications included [MEDICATION NAME] (treats high blood pressure//heart failure), [MEDICATION NAME] (beta-blocker), Namzaric (treats moderate to severe [MEDICAL CONDITION]), Potassium (essential electrolyte), [MEDICATION NAME] (diuretic), Atorvastin (cholesterol medication), [MEDICATION NAME] (antipsychotic), Carbamzepine (anticonvulsant), [MEDICATION NAME] (antianxiety), Alendronate (slows bone loss), [MEDICATION NAME] (antidepressant), and [MEDICATION NAME] ([MEDICATION NAME][MEDICATION NAME]) inhaler. A follow up interview on [DATE] at 9:13 A.M. with the ADON revealed the medications belonged to former Resident #226, who had been discharged on [DATE]. The ADON confirmed the medications were not stored in a safe and secure manner. Review of the Medication Storage policy and procedure dated [DATE] revealed only licensed nurses, the consultant pharmacist, and those authorized to administer medications were allowed access to medications.

Based on review of self-reported incident and investigation, medical record review, personnel file review, staff interview, and policy review, the facility failed to prevent misappropriation of a resident's controlled medication. This affected one (Resident #173) of two residents reviewed for self-reported incidents. Findings include: Closed medical record review revealed Resident #173 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident was ordered [MEDICATION NAME] 0.5 milligrams (mg) one tablet every six hours as needed for anxiety/tremors. Review of self-report incident (SRI) dated 05/04/18 revealed on 05/03/18 at 6:00 P.M., Licensed Practical Nurse (LPN) #71 informed the director of nursing (DON) that there was a potential medication discrepancy with Resident #173's [MEDICATION NAME]. While completing their medication count she noticed that the count did not equal the number that was recorded upon the start of her shift. The DON counted the medications and verified possible discrepancy may have occurred. LPN #71 and LPN #77 were interviewed and denied any allegations of misappropriation. LPN #71 was sent for drug screen and the hospice nurse was notified. The DON typed a summary of the investigation dated 05/07/18 which revealed LPN #71 notified him that there was discrepancy in Resident #173's [MEDICATION NAME] count. The count was supposed to be 107.5 tablets and there was 98.5, which noted nine pills missing. Upon investigation LPN #71 reported she had given one that morning and forgot to mark it in the book, which would have made eight pills missing. All nurses who worked with the resident in question were contacted and questioned. One nurse reported that she had given the resident a pill the night before and forgot to mark it on the count sheet or document it. This would change the missing count to seven missing tablets. Several nurses admitted they had not counted the medication every shift since they believed they were sealed and not being used and/or there were so many in the bottle. No other nurses reported forgetting to document medication on the count sheet. LPN #71 was questioned why she did not count the pills at the beginning of the shift and she reported that there was so many that they did not think they needed to be counted every time. LPN #72 was in orientation with LPN #71 and denied any medications being removed that were not given to the residents. LPN #71 was directed to have a drug test performed that resulted in negative findings. All nurses working during that timeframe were disciplined for failing to correctly count and monitor narcotics, audits were completed on narcotics, and a new policy implemented to only accept bottled narcotics on a case by case basis and preferred to be in a blister pack. Review of Resident #173's controlled drug receipt/record/disposition form dated 04/19/18 revealed hospice Register Nurse (RN) #100 and LPN #77 signed the facility received 113.5 tablets of [MEDICATION NAME] 0.5 mg. Further review revealed the resident received a whole [MEDICATION NAME] on 04/28/18 at 9:25 P.M. with 112.5 tablets remaining, 04/29/18 at 8:30 P.M. with 111.5 tablets remaining, 04/30/18 at 8:00 A.M. with 110.5 tablets remaining, 04/30/18 at 7:58 P.M. with 109.5 tablets remaining, 05/01/18 at 10:20 P.M. with 108.5 remaining, 05/02/18 at 7:00 A.M. with 107.5 remaining, 05/03/18 at 8:10 A.M. with 106.5 remaining. The DON completed a reconciliation of the [MEDICATION NAME] 0.5 mg and the count was 98.5. The form was altered on an unknown date to reflect one [MEDICATION NAME] was administered on 05/02/18 at 10:00 P.M. Further review revealed the facility destroyed the 98.5 [MEDICATION NAME] and had hospice reorder 56 [MEDICATION NAME] on 05/05/18. Review of Resident #173's Medication Administration Record [REDACTED].M. Review of LPN #69, LPN #71, LPN #73, LPN #74, LPN #76, LPN #77, and LPN #101's disciplinary action forms dated 05/07/18 to 05/10/18 revealed the LPNs were disciplined for not accurately counting and monitoring bottled narcotics in the medication cart resulting in discrepancy in total count. LPN #101 was terminated due to previous disciplinary actions. Further review revealed LPN #69, #73, #74, #76, #77 had drug screens on 05/10/18 and 05/17/18 which were negative. LPN #74's drug screen dated 05/10/17 was rejected due to diluted and recommendation for recollection with observation. LPN #74's drug screen was recollected on 05/17/18, which was negative. LPN #101 was terminated before a urine drug screen was obtained. Review of typed staff statements dated 07/31/18 revealed LPN #71 indicated on 05/03/18, there was a discrepancy noted in Resident #173's [MEDICATION NAME] count. The bottle had been taped up and had not been counted accurately every shift due to the large quantity of pills. On 05/03/18 the medication was counted accurately while training a newly hired nurse. The count was noted to be off by nine pills. The total count was 98.5 tablets with the current recorded count of 107.5 tablets. Discrepancy was reported to the DON on 05/03/18. LPN #73 indicated on 05/04/18 the DON notified her of a discrepancy in the narcotic count sheet for Resident #173's [MEDICATION NAME]. LPN #73 informed the DON that she had given the resident one the night before due to increased anxiety related trouble breathing and would correct missed documentation as soon as able. The medication was not counted at shift change due to forgetting that it had been given and the medication was not being counted routinely due to large quantity. LPN #77 indicated the resident was admitted with a bottle of [MEDICATION NAME] that was sealed with tape. Medications were counted by the hospice nurse and LPN #77. The medication was taped back up with the hospice nurse present. The [MEDICATION NAME] count was 113.5 tablets. The [MEDICATION NAME] was not verified each shift due to being taped up and the large quantity. On 05/03/18, a count discrepancy was noted when doing narcotic count with LPN #71. The total count appeared to be off by nine pills. The actual count was 98.5 tablets. LPN #71 notified the DON of the discrepancy. RN #100 (hospice nurse) indicated she counted Resident #173's [MEDICATION NAME] upon admission with LPN #77 and the [MEDICATION NAME] count was 113.5 On 07/31/18 at 12:45 P.M. and 3:00 P.M., interview with LPN #71 revealed on 05/03/18 she did not count Resident #173's [MEDICATION NAME] prior to the start of her shift. At 8:00 A.M. she started orienting a new employee so at the end of the shift around 6:00 P.M., she thought she should show the new employee the correct way to reconcile narcotics. As they counted Resident #173's [MEDICATION NAME] the count was off by nine pills. She notified the DON. She was suspended, and drug screened on 05/04/18. LPN #71 worked the floor from 5:30 A.M. to 1:30 P.M. Review of LPN #71's time sheet confirmed she worked on 05/04/18 from 5:30 A.M. to 1:30 P.M., after the discrepancy was found on her shift the day prior (05/03/18 at 6:00 P.M.). On 07/31/18 at 2:00 P.M., interview with hospice RN #100 confirmed she counted Resident #173's [MEDICATION NAME] with LPN #77 on 04/19/18 and the [MEDICATION NAME] count was 113.5. On 08/01/18 at 8:10 A.M., interview with the DON and Administrator revealed they were not able to locate the written statements or interview statements from the staff that were completed during the original investigation on 05/03/18 to 05/07/18. The DON and Administrator confirmed there was seven [MEDICATION NAME] that were unaccounted for during 04/19/18 and 05/03/18 after the investigation was completed. The DON reported he did not know until 07/31/18 after re-obtaining staff statements that LPN #77 had counted Residents #173 [MEDICATION NAME] on admission (04/19/18) with hospice RN #100. He indicated in his SRI investigation he had reported the facility staff did not count the [MEDICATION NAME] and took the hospice nurse's word that there were 113.5 pills in the bottle. The DON reported staff had confirmed they had not been counting the [MEDICATION NAME] at shift change due to the large quantity of pills and/or they thought the bottle had not been opened since the tape was still intact on the lid. One nurse reported she had not signed out or documented she administered one [MEDICATION NAME] on 05/22/18 at 10:00 P.M. The DON destroyed the remaining 98.5 [MEDICATION NAME] and had hospice re-order 56 additional [MEDICATION NAME]. The Administrator confirmed the facility did not reimburse the resident or Hospice for the seven [MEDICATION NAME] that were unaccounted for or the 98.5 the DON destroyed. The Administrator confirmed the facility had only drug screened LPN #71 on 05/04/18 due to the discrepancy was noted on her shift; however, after the investigation was completed the corporate nurse suggested to drug screen all the nurses involved on 05/10/18 and 05/17/18. LPN #101 was not drug screened due to she was terminated after the incident for other reasons. LPN #74's drug screen was rejected on 05/10/18 due to it was diluted and had to recollected on 05/17/18 with observation, which returned negative. Review of Controlled Substances policy dated 06/21/17 revealed administration of scheduled controlled substances would be consistent with the policies for general medication administration with the additional requirement for logging all doses on the individual resident's Controlled Drug Receipt/Record/Disposition form. All controlled medications removed from storage for administering doses to the resident would be entered onto the individual resident's form. The authorized individual would then count or measure the remaining drug quantity in stock and enter the amount remaining onto the individual resident's control form. Any discrepancies in the individual resident's form were to be immediately reported to the DON. Each new supply of scheduled control substance should be accompanied by a new individual resident form with a beginning amount on the form that matched the amount of drug delivered. The facility would maintain a record and signed scheduled medication count at each change of shift, by on-coming nurse or authorized individual with off-going nurse or authorized individual, using form or a facility approved form. Staff were to enter date, time, if yes or no drug count was correct, staff member coming on duty and off going duty to verify balance. Review of Abuse policy/procedure dated 11/21/16 revealed misappropriation of resident's property was the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. All incidents and allegations of abuse, neglect, exploitation, mistreatment of [REDACTED]. The policy indicated to have evidence that all alleged violation were thoroughly investigated.

Based on review of a self-reported incident and investigation, medical record review, personnel file review, staff interview, and abuse policy review, the facility failed to ensure their policies and procedures were implemented in relation to misappropriation of a resident's controlled drug. This affected one (Resident #173) of two residents reviewed for self-reported incidents. Findings include: Closed medical record review revealed Resident #173 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident was ordered [MEDICATION NAME] 0.5 milligrams (mg) one tablet every six hours as needed for anxiety/tremors. Review of self-report incident (SRI) dated 05/04/18 revealed on 05/03/18 at 6:00 P.M., Licensed Practical Nurse (LPN) #71 informed the director of nursing (DON) that there was a potential medication discrepancy with Resident #173's [MEDICATION NAME]. While completing their medication count she noticed that the count did not equal the number that was recorded upon the start of her shift. The DON counted the medications and verified possible discrepancy may have occurred. LPN #71 and LPN #77 were interviewed and denied any allegations of misappropriation. LPN #71 was sent for drug screen and the hospice nurse was notified. The DON typed a summary of the investigation dated 05/07/18 which revealed LPN #71 notified him that there was discrepancy in Resident #173's [MEDICATION NAME] count. The count was supposed to be 107.5 tablets and there was 98.5, which noted nine pills missing. Upon investigation LPN #71 reported she had given one that morning and forgot to mark it in the book, which would have made eight pills missing. All nurses who worked with the resident in question were contacted and questioned. One nurse reported that she had given the resident a pill the night before and forgot to mark it on the count sheet or document it. This would change the missing count to seven missing tablets. Several nurses admitted they had not counted the medication every shift since they believed they were sealed and not being used and/or there were so many in the bottle. No other nurses reported forgetting to document medication on the count sheet. LPN #71 was questioned why she did not count the pills at the beginning of the shift and she reported that there was so many that they did not think they needed to be counted every time. LPN #72 was in orientation with LPN #71 and denied any medications being removed that were not given to the residents. LPN #71 was directed to have a drug test performed that resulted in negative findings. All nurses working during that timeframe were disciplined for failing to correctly count and monitor narcotics, audits were completed on narcotics, and a new policy implemented to only accept bottled narcotics on a case by case basis and preferred to be in a blister pack. Review of Resident #173's controlled drug receipt/record/disposition form dated 04/19/18 revealed hospice Register Nurse (RN) #100 and LPN #77 signed the facility received 113.5 tablets of [MEDICATION NAME] 0.5 mg. Further review revealed the resident received a whole [MEDICATION NAME] on 04/28/18 at 9:25 P.M. with 112.5 tablets remaining, 04/29/18 at 8:30 P.M. with 111.5 tablets remaining, 04/30/18 at 8:00 A.M. with 110.5 tablets remaining, 04/30/18 at 7:58 P.M. with 109.5 tablets remaining, 05/01/18 at 10:20 P.M. with 108.5 remaining, 05/02/18 at 7:00 A.M. with 107.5 remaining, 05/03/18 at 8:10 A.M. with 106.5 remaining. The DON completed a reconciliation of the [MEDICATION NAME] 0.5 mg and the count was 98.5. The form was altered on an unknown date to reflect one [MEDICATION NAME] was administered on 05/02/18 at 10:00 P.M. Further review revealed the facility destroyed the 98.5 [MEDICATION NAME] and had hospice reorder 56 [MEDICATION NAME] on 05/05/18. Review of Resident #173's Medication Administration Record [REDACTED].M. Review of LPN #69, LPN #71, LPN #73, LPN #74, LPN #76, LPN #77, and LPN #101's disciplinary action forms dated 05/07/18 to 05/10/18 revealed the LPNs were disciplined for not accurately counting and monitoring bottled narcotics in the medication cart resulting in discrepancy in total count. LPN #101 was terminated due to previous disciplinary actions. Further review revealed LPN #69, #73, #74, #76, #77 had drug screens on 05/10/18 and 05/17/18 which were negative. LPN #74's drug screen dated 05/10/17 was rejected due to diluted and recommendation for recollection with observation. LPN #74's drug screen was recollected on 05/17/18, which was negative. LPN #101 was terminated before a urine drug screen was obtained. Review of typed staff statements dated 07/31/18 revealed LPN #71 indicated on 05/03/18, there was a discrepancy noted in Resident #173's [MEDICATION NAME] count. The bottle had been taped up and had not been counted accurately every shift due to the large quantity of pills. On 05/03/18 the medication was counted accurately while training a newly hired nurse. The count was noted to be off by nine pills. The total count was 98.5 tablets with the current recorded count of 107.5 tablets. Discrepancy was reported to the DON on 05/03/18. LPN #73 indicated on 05/04/18 the DON notified her of a discrepancy in the narcotic count sheet for Resident #173's [MEDICATION NAME]. LPN #73 informed the DON that she had given the resident one the night before due to increased anxiety related trouble breathing and would correct missed documentation as soon as able. The medication was not counted at shift change due to forgetting that it had been given and the medication was not being counted routinely due to large quantity. LPN #77 indicated the resident was admitted with a bottle of [MEDICATION NAME] that was sealed with tape. Medications were counted by the hospice nurse and LPN #77. The medication was taped back up with the hospice nurse present. The [MEDICATION NAME] count was 113.5 tablets. The [MEDICATION NAME] was not verified each shift due to being taped up and the large quantity. On 05/03/18, a count discrepancy was noted when doing narcotic count with LPN #71. The total count appeared to be off by nine pills. The actual count was 98.5 tablets. LPN #71 notified the DON of the discrepancy. RN #100 (hospice nurse) indicated she counted Resident #173's [MEDICATION NAME] upon admission with LPN #77 and the [MEDICATION NAME] count was 113.5 On 07/31/18 at 12:45 P.M. and 3:00 P.M., interview with LPN #71 revealed on 05/03/18 she did not count Resident #173's [MEDICATION NAME] prior to the start of her shift. At 8:00 A.M. she started orienting a new employee so at the end of the shift around 6:00 P.M., she thought she should show the new employee the correct way to reconcile narcotics. As they counted Resident #173's [MEDICATION NAME] the count was off by nine pills. She notified the DON. She was suspended, and drug screened on 05/04/18. LPN #71 worked the floor from 5:30 A.M. to 1:30 P.M. Review of LPN #71's time sheet confirmed she worked on 05/04/18 from 5:30 A.M. to 1:30 P.M., after the discrepancy was found on her shift the day prior (05/03/18 at 6:00 P.M.). On 07/31/18 at 2:00 P.M., interview with hospice RN #100 confirmed she counted Resident #173's [MEDICATION NAME] with LPN #77 on 04/19/18 and the [MEDICATION NAME] count was 113.5. On 08/01/18 at 8:10 A.M., interview with the DON and Administrator revealed they were not able to locate the written statements or interview statements from the staff that were completed during the original investigation on 05/03/18 to 05/07/18. The DON and Administrator confirmed there was seven [MEDICATION NAME] that were unaccounted for during 04/19/18 and 05/03/18 after the investigation was completed. The DON reported he did not know until 07/31/18 after re-obtaining staff statements that LPN #77 had counted Residents #173 [MEDICATION NAME] on admission (04/19/18) with hospice RN #100. He indicated in his SRI investigation he had reported the facility staff did not count the [MEDICATION NAME] and took the hospice nurse's word that there were 113.5 pills in the bottle. The DON reported staff had confirmed they had not been counting the [MEDICATION NAME] at shift change due to the large quantity of pills and/or they thought the bottle had not been opened since the tape was still intact on the lid. One nurse reported she had not signed out or documented she administered one [MEDICATION NAME] on 05/22/18 at 10:00 P.M. The DON destroyed the remaining 98.5 [MEDICATION NAME] and had hospice re-order 56 additional [MEDICATION NAME]. The Administrator confirmed the facility did not reimburse the resident or Hospice for the seven [MEDICATION NAME] that were unaccounted for or the 98.5 the DON destroyed. The Administrator confirmed the facility had only drug screened LPN #71 on 05/04/18 due to the discrepancy was noted on her shift; however, after the investigation was completed the corporate nurse suggested to drug screen all the nurses involved on 05/10/18 and 05/17/18. LPN #101 was not drug screened due to she was terminated after the incident for other reasons. LPN #74's drug screen was rejected on 05/10/18 due to it was diluted and had to recollected on 05/17/18 with observation, which returned negative. Review of Controlled Substances policy dated 06/21/17 revealed administration of scheduled controlled substances would be consistent with the policies for general medication administration with the additional requirement for logging all doses on the individual resident's Controlled Drug Receipt/Record/Disposition form. All controlled medications removed from storage for administering doses to the resident would be entered onto the individual resident's form. The authorized individual would then count or measure the remaining drug quantity in stock and enter the amount remaining onto the individual resident's control form. Any discrepancies in the individual resident's form were to be immediately reported to the DON. Each new supply of scheduled control substance should be accompanied by a new individual resident form with a beginning amount on the form that matched the amount of drug delivered. The facility would maintain a record and signed scheduled medication count at each change of shift, by on-coming nurse or authorized individual with off-going nurse or authorized individual, using form or a facility approved form. Staff were to enter date, time, if yes or no drug count was correct, staff member coming on duty and off going duty to verify balance. Review of Abuse policy/procedure dated 11/21/16 revealed misappropriation of resident's property was the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. All incidents and allegations of abuse, neglect, exploitation, mistreatment of [REDACTED]. The policy indicated to have evidence that all alleged violation were thoroughly investigated.

The following deficiency represents an incident of past non-compliance that was subsequently corrected prior to this survey. Based on closed medical record review, staff interview, policy review, review of the Ohio Revised Code (ORC), review of the Ohio Administrative Code (OAC) and review of the nursing staff schedules, the facility failed to initiate Cardio-Pulmonary Resuscitation (CPR) or contact emergency medical services (EMS) timely for one resident (#51) who was a Full Code and was found unresponsive without vital signs. Life threatening harm and death occurred when Resident #51 did not receive CPR or emergency medical services and expired at the facility. This resulted in Immediate Jeopardy for one (#51) of three residents reviewed for an emergent change in condition. The facility identified twenty-three residents residing in the facility designated with Full Code Status. The facility census was 64. The Administrator, Director of Nursing (DON), Corporate Clinician (CC) #100 and Regional Director of Operations #101 were notified on [DATE] at 3:41 P.M. that Immediate Jeopardy began on [DATE] at 4:40 A.M. when Resident #51 was found without vital signs and Licensed Practical Nurse (LPN) #44 failed to initiate CPR or notify emergency medical services. Resident #51 subsequently expired at the facility. The Immediate Jeopardy was removed and corrected on [DATE] when the facility implemented the following corrective actions: On [DATE] at 7:45 A.M. the Medical Director was notified by the DON the resident did not receive CPR. On [DATE] at 7:45 A.M. the facility DON initiated an investigation related to the lack of CPR. On [DATE] at 8:00 A.M. the DON assessed all 64 residents in the building to ensure accurate code status was in the medical records. On [DATE] at 8:30 A.M. LPN #44 was provided education by the DON related to resident code status location in the medical record, CPR policy, crash carts and CPR best practice. On [DATE] the DON audited all 64 resident records and verified current code status was accurate. No concerns were identified On [DATE] the DON reviewed Mock CPR drills from [DATE] to February 2017 to ensure no concerns were previously identified. No issues were identified. On [DATE] the Social Service Designee (SSD) audited all 64 medical records for psychosocial assessment accuracy related to code status. No concerns were identified. On [DATE] the DON completed audits of the two facility crash carts. No concerns were identified. On [DATE] the facility identified the current full code status identification with green stickers attached to the door plates to be ineffective and the practice was discontinued. The DON removed all green stickers on the door plates of residents who were a full code status. A plan for the DON to complete audits to ensure green stickers were not in place weekly for four weeks then as needed was initiated with no concerns identified. On [DATE] by 4:00 P.M the DON provided education to 12 LPNs and six Registered Nurses (RNs) on the CPR policy, the removal of green stickers, crash carts and a CPR best practice questionnaire. On [DATE] the DON and Human Relations (HR) #4 revised the nurse orientation packet and added the facility CPR policy and CPR best practice questionnaire. On [DATE] the DON and HR #4 verified CPR certifications were in place for licensed nursing staff completed by the American Heart Association. Eleven LPNs and five RNs were had evidence of American Heart Association CPR training. RN #50 and LPN #42 were identified to lack current CPR certifications from the American Heart Association. These two nurses were scheduled to work only with nursing staff with American Heart Association CPR training and had until [DATE] to complete a CPR course from the American Heart Association. On [DATE] at 5:00 P.M. the facility held a Quality Assurance Meeting to discuss all findings and the plan of correction. The QA meeting members included Physician #200, the DON and Administrator, Social Services Director #51, RN #49 and RN #99 and CC #100. The QA team reviewed the CPR policy, the emergency cart policy, CPR best practice and checklist. On [DATE] an additional QA meeting was held to review the audits related to the incident from [DATE]. The attendees included Physician #200, the Administrator and DON, RNs #49 and #99 and CC#100. Beginning on [DATE] and continuing until otherwise directed by the facility QA process, the DON/Designee completed four chart audits every shift for one week then four chart audits daily for three weeks and then as needed to verify code status. No concerns were identified. Beginning on [DATE] and continuing until otherwise directed by the facility QA process, mock CPR drills were completed weekly on each shift. No concerns were identified. Beginning [DATE] and continuing until otherwise directed by the facility QA process, new admission charts were audited within one business day for code status. No concerns were identified. Beginning [DATE] and continuing until otherwise directed by the facility QA process, performance improvement monitoring for CPR Best Practices was conducted daily with licensed nurses. No concerns were identified. On [DATE] from 6:13 P.M. to 6:52 P.M. and on [DATE] from 7:50 A.M. to 9:35 A.M. interviews with STNAs #63, #53, and #72; Activity Director #14, LPNs #43 and #44, HR #4, RNs #1 and #32 revealed knowledge of the facility CPR policy. LPNs #43 and #44 and RNs #1 and #32 stated they received education related to the CPR policy, mock drills, the removal of the green stickers and the crash cart. Review of two additional closed records (Residents #31 and #107) for an emergent change in condition. No concerns were identified. Findings Include: Review of Resident #51's closed medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #51's medical record revealed advance directives and a physician's order for Full Code status (all life-saving measures) dated [DATE]. Further review of Resident #51's medical record revealed the resident was not receiving Hospice services and/or palliative care at any time during her stay at the facility. Review of Resident #51's comprehensive 14-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance of two staff members with bed mobility, transfers, toilet use and personal hygiene. The resident was frequently incontinent of urine and always continent of bowel. Review of the plan of care for advanced care planning, initiated [DATE] revealed the resident's code status and orders would be reviewed as needed. The plan of care indicated the resident was a Full Code. Review of the Statement of Advanced Directives form, dated [DATE] revealed the resident wished to be a full code. The form was signed by the resident's daughter. Review of Resident #51's progress note revealed an entry dated [DATE] at 10:18 A.M. which documented the resident's heart rate was regular, lungs were clear and the resident had one plus [MEDICAL CONDITION] (indentation of two millimeters or less when the area is pressed) noted to the bilateral lower extremities. The resident was on room air and had no cough or shortness of breath. Further review revealed at 9:30 P.M. the resident had no pressure or non-pressure skin areas and required one staff assistance with activities of daily living. The resident was alert to her name only and no difficulties were noted. There was no further documentation and/or change noted in Resident #51's condition until a progress note dated [DATE] at 4:40 A.M. written by LPN #44. The note indicated, LPN #44 approached the resident to give her morning medication and the resident was noted with no pulse at that time. The finding was also verified by another un-identified nurse. The note indicated an unidentified STNA had been in the resident's room for morning care at 4:00 A.M. and the resident was without symptoms at that time. The note indicated Certified Nurse Practitioner (CNP) #102 and the resident's daughter were notified. Post mortem care (care after death) was provided. An additional progress note dated [DATE] at 5:35 A.M. revealed the family informed RN #1 they were ready for the funeral home to be notified. At 6:35 A.M. RN #1 documented the funeral home arrived to the facility to remove the resident from the facility. Review of the progress notes revealed no evidence CPR was provided when the resident was found without a pulse. Review of Resident #51's Certificate of Death revealed the resident passed away on [DATE] at 4:40 A.M. with the immediate cause of death documented as acute [MEDICAL CONDITION] infarction ([MEDICAL CONDITION]). On [DATE] at 2:19 P.M. interview with the DON and CC #100 verified Resident #51 was a Full Code status during her entire stay at the facility. The DON and CC #100 revealed the resident was found without a pulse or respirations by LPN #44 and the nurse did not initiate CPR or call 911 per the facility policy. Further interview revealed LPN #43 was the un-identified nurse in the room. The DON shared she was notified of the incident via text after the funeral home had removed the resident from the facility by the day shift nurse, RN #1. The DON verified an RN was not present to assess the resident's absence of vital signs at the time of the incident. CC #100 and the DON shared the facility had a green sticker system in place, which was used as an un-written way to identify full code residents. A green sticker would be placed on the door of a resident who was a Full Code status to alert staff of the resident's advance directive wishes. The DON revealed there was no check system in place to ensure the stickers were accurate or in place for full code residents. The DON stated the facility did not have a policy related to the use of green stickers. During the interview, the DON revealed LPN #44 did not follow the facility CPR policy in regards to properly checking the resident's code status and initiating CPR if the resident was a full code. CC #100 revealed following this incident, the green sticker system was immediately removed as a facility practice. The CC stated as a result of the incident, the nurses were now required to verify the resident's code status with the resident's medical record. Lastly, the DON stated the facility completed an internal investigation and determined LPN #44 did not implement the facility CPR policy for Resident #51 when she was found without a pulse. The LPN checked the resident's door for a green sticker and when she did not see a green sticker, the nurse did not verify the resident's code status with the medical record and failed to initiate CPR. On [DATE] at 3:58 P.M. a telephone interview with LPN #44 revealed she was caring for Resident #51 the morning of [DATE]. The resident had been alert and oriented and did not experience a condition change until 4:40 A.M. when she was found unresponsive and without a pulse. The LPN stated she did not provide CPR or call 911 because the resident did not have green sticker on her door so she assumed the resident was not a Full Code. LPN #44 revealed she did not verify the resident's code status with the medical record. LPN #44 shared she had LPN #43 verify the resident did not have vital signs. LPN #44 also shared she provided the facility with a statement of the events that had occurred and was educated regarding not implementing CPR or calling 911. An additional interview at 6:58 P.M. revealed when she discovered the resident unresponsive, the resident was lying on her back with some mottling noted. The resident's skin was cool to touch. On [DATE] at 8:15 P.M. interview with CC #100 revealed the facility CPR Policy revealed nurses were required to maintain CPR certification. Further review revealed when a resident was unresponsive, staff were to check the resident's code status, call 911, palpate for a carotid pulse and begin CPR if the resident was a full code. On [DATE] at 7:50 A.M. interview with LPN #43 revealed she was the second nurse in the room the morning Resident #51 passed away. LPN #43 stated she assessed the resident for an apical pulse and determined the resident was without vital signs. LPN #43 verified no CPR was provided for the resident when she was found without a pulse. On [DATE] at 9:35 A.M. interview with RN #1 revealed she was the nurse working day shift on [DATE] and started her shift at 5:00 A.M. RN #1 stated LPN #44 called her and requested she come to work early because Resident #51 had unexpectedly passed away during the night and LPN #44 was behind in her work. RN #1 shared the staff were starting to provide post-mortem care when she arrived and she also verified the resident was without vital signs upon her arrival to work. Review of the facility policy titled Cardio-pulmonary Resuscitation (CPR) initiated ,[DATE] and revised ,[DATE] revealed the purpose was to restore and maintain respiration and circulation in a resident/patient whose heartbeat and breathing have stopped. When a resident becomes unresponsive, the facility was to check the resident's code status. If the resident was a full code, call 911, palpate for a carotid pulse and check for signs of life for 10 seconds. Establish the absence of a pulse and begin CPR. Review of the ORC Section 4723.36 titled Determination of death by certified nurse practitioner or clinical nurse specialist revealed a registered nurse (RN) may determine and pronounce an individual's death, but only if the individual's respiratory and circulatory function are not being artificially sustained and, at the time of the determination and pronouncement of death is made, the RN is providing or supervising the individual's care through a licensed Hospice care program or any other entity that provides palliative care. Review of the OAC [DATE] titled Pronouncement of Death revealed a physician holding a current certificate to practice medicine or surgery or osteopathic medicine may pronounce a person dead without personally examining the body of the deceased on ly if a competent observer has recited the facts of the deceased 's present medical condition to the physician and the physician is satisfied that death has occurred. Per the OAC [DATE] a LPN is not permitted to pronounce an individual's death. Review of the nursing staffing schedule dated for [DATE] from 6:00 P.M. to [DATE] at 5:30 A.M. revealed LPN #41, LPN #43 and LPN #44 were the only nurses on duty in the facility. There was no RN on duty at the time of Resident #51's death. On [DATE] from 6:13 P.M. to 6:52 P.M. and on [DATE] from 7:50 A.M. to 9:35 A.M. interviews with STNAs #63, #53 and #72; Activity Director #14, LPNs #43 and #44, HR #4, RNs #1 and #32 revealed knowledge of the facility CPR policy. LPNs #43 and #44 and RNs #1 and #32 stated they received education related to the CPR policy, mock drills, the removal of the green stickers and the crash cart. Review of two additional closed records (Residents #31 and #107) for an emergent change in condition was completed. No concerns were identified.

Based on medical record review, policy review, and staff interview, the facility failed to consistently implement interventions to prevent a decline in transfers. There was a potential for harm that affected one (Resident #59) of four residents reviewed for activities of daily living. The census was 70. Findings include: Medical record review revealed Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physical Therapy Evaluation and Plan of Treatment (dated 09/27/12) revealed Resident #59 required minimum assist with transfers, the resident was able to complete sit-to-stand transfer pulling at parallel bars or railing with minimum assist. Resident #59's prognosis to maintain current level of function was good with consistent staff follow-through. Review of the medical record revealed no documented evidence a restorative transfer program was initiated for Resident #59 after physical therapy services were discontinued. Review of the quarterly Transfer and Lift Data assessment (dated 01/15/13) revealed Resident #59 participated in transfers with assistance and transferred with the use of a sit-to-stand lift. Review of the quarterly Minimum Data Set (MDS) assessment (dated 01/28/13) revealed Resident #59 was severely impaired for daily decision-making and required extensive assist for bed mobility and transfers. Review of the annual Transfer and Lift Data assessment (dated 04/15/13) revealed Resident #59 transferred with a mechanical hoyer lift. Review of the quarterly MDS assessment (dated 04/30/13) revealed Resident #59 was dependent on staff for bed mobility and transfers. Review of the medical record revealed no documented evidence interventions were implemented to prevent Resident #59's decline in transfers. On 06/13/13 at 8:19 A.M., Resident #59 was observed being transferred from a geri-chair to bed with the use of a mechanical hoyer lift. Review of Resident #59's Self-Care Deficit care plan (revised 03/23/10) revealed a decline may be expected and interventions included restorative and therapy to evaluate and treat as needed. Review of the Skilled Therapy Services policy (undated) revealed residents were referred to restorative services by the rehabilitation department after reaching the maximal level of functional potential. Review of the Restorative Program policy (revised 01/03/13) revealed maintenance restorative programs were to assist and promote the resident's ability to attain his or her maximum functional potential. On 06/13/13 at 8:25 A.M., interview with State tested Nurse Aide (STNA) #91 revealed Resident #59 participated with transfers with assist of a sit-to-stand lift until February 2013 then became dependent on staff for transfers with the use of a mechanical hoyer lift. On 06/13/13 at 8:27 A.M., interview with STNA #92 revealed a noted decline in Resident #59's ability to transfer in the last six months. STNA #92 stated the resident was currently transferred with a mechanical hoyer lift. On 06/13/13 at 11:32 A.M., interview with Certified Occupational Therapy Assistant #94 and Rehab Tech #93 verified the therapy department was not notified of Resident #59's decline in transfers and bed mobility. Rehab Tech #93 stated therapy screens were completed quarterly and annually. Rehab Tech #93 verified there was no documented evidence Resident #59 had been evaluated by occupational or physical therapy since August 2012. On 06/14/13 at 10:07 A.M., interview with the Assistant Director of Nursing (ADON) and Registered Nurse (RN) #41 stated a decline in activities of daily living was noted for Resident #59 on 03/21/13. RN #41 stated Resident #59 was not recommended for therapy due to the resident's cognitive impairment and RN #41 did not feel the resident could improve, even with therapy or restorative. RN #41 verified there was no documented evidence the physician or therapy was notified of the resident's decline in transfers in March 2013 and Resident #59 further declined to total dependence in transfers in April 2013. On 06/14/13 at 10:15 A.M., interview with the ADON verified there was no documented evidence in the medical record of interventions to prevent Resident #59's decline in transfers and no documented evidence interventions were implemented after the resident's decline in transfers. On 06/14/13 at 10:18 A.M., interview with RN #41 stated physician notification of a change in condition was to be completed within 24 hours.

Based on observation, record review, policy review, and staff interview, the facility failed to identify skin impairment and implement interventions and treatment to prevent the deterioration of the skin impairment to an unstageable pressure ulcer (full thickness tissue skin loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed). This affected one (Resident #27) of four residents reviewed for pressure ulcer. The facility identified eight residents with pressure ulcers. Harm resulted to Resident #27 when the facility failed to identify skin breakdown and implement additional interventions to prevent deterioration of the skin impairment. On 05/14/13, the facility identified the resident developed a purple area with an open area in the center on the left buttock. Findings include: Review of Resident #27's medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment (dated 03/13/13) revealed Resident #27 was assessed to be severely impaired for decision making regarding tasks of daily life. Resident #27 was totally dependent on staff for bed mobility and transfer. Resident #27 was assessed to be at risk for developing a pressure ulcer. Review of the skin pressure grid assessment (dated 05/14/13) revealed Resident #27 acquired a suspected deep tissue injury (SDTI) of the left buttocks measuring 2.0 centimeters (cm) in length (l) by 4.0 cm width (w) by 0.1 cm depth (d). The area was noted to the left buttock which was purple in color with an open area in the middle measuring 0.5 cm (l) by 0.8 cm (w) by 0.1 cm (d). There was no drainage noted. There was no signs or symptoms of infection noted. An intervention noted on the assessment revealed Resident #27 was to be laid down between meals and turned side to side. Review of the skin pressure grid assessment (dated 05/22/13) revealed Resident #27's pressure ulcer of the left buttock had changed to an unstageable area measuring 2.6 cm (l) by 1.5 cm (w) by 0.1 cm (d). The area was described as a small serous-thin, watery, clear exudate with granulation of 25% of the wound. Necrotic tissue was white/gray, non-viable tissue and/or non-adherent yellow slough covering 75-100% of the wound. Wound edges were distinct. The area around the wound was pink or normal. Review of the skin grid pressure assessment (dated 06/05/13) for Resident #27 revealed a decline in an unstageable pressure ulcer to the left buttock measuring 4.0 cm (l) by 3.0 cm (w) by 0.5 cm (d). The area was described as a small serous-thin, watery, clear exudate with no granulation tissue present. The wound was firmly, adherent with hard black eschar covering 75-100%. Review of a physician's orders [REDACTED]. The order revealed the resident was to be up for meals only and turned side to side as tolerated. Review of a physician's orders [REDACTED]. A physician's orders [REDACTED]. Review of the treatment administration record (TAR) for Resident #27, dated May 2013 and June 2013, revealed documentation indicating the resident was turned every two hours during each shift. The TAR was initialed once per shift from 6:00 A.M. to 6:00 P.M. and once per shift 6:00 P.M. to 6:00 A.M. The facility had no documentation of an every two hour turn schedule or flow sheet. Review of Resident #27's lab work dated 06/07/13 revealed Resident #27's [MEDICATION NAME] level was 10 milligrams (MG)/deciliters (DL). Normal range for [MEDICATION NAME] was 17 -34 MG/DL. Review of the plan of care for at risk for impaired skin integrity related to impaired mobility, incontinence, and underlying disease of Alzheimer's (initiated 08/15/09 and revised 05/14/13) revealed the resident had a suspected deep tissue injury (SDTI). The care plan updated to reflect the skin impairment and physician orders. Review of the facility's nursing policy and procedure for Skin-Pressure Ulcer (revised November 2006) revealed an avoidable pressure ulcer was one in which the resident developed a pressure ulcer and the facility did not do one or more of the following: evaluate the resident's clinical condition and pressure ulcer risk factors; define and implement interventions that were consistent with resident needs, resident goals and recognized standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. Interview with Resident #27's family member on 06/11/13 at 1:38 P.M. revealed she visited the facility daily to assist the resident with meals. She stated Resident #27 had a pressure ulcer on her bottom that was not improving. Resident #27's family member stated the resident was supposed to be turned every two hours and she did not think it was being done. She stated she did not think there was enough staff and the resident was not being turned timely because of it. Resident #27's family member stated she stopped in to visit her mother and returned later in the day to check on her and feed her. She stated she could tell from the position of her body and the position of the pillows, the resident had not been turned all day. On 06/12/13 at 1:10 P.M., Resident #27 was observed lying on her back with a pillow behind her neck and eyes closed. On 06/12/13 at 2:33 P.M., Resident #27 was observed lying on her right side. The bed was in low position and a pillow was behind her head. Her eyes were closed and a sheet was pulled up to her chest. On 06/12/13 at 4:37 P.M., resident #27 was observed lying on her right side. The bed was in low position and a pillow was behind her head. A sheet was pulled up to her chest. On 06/12/13 at 4:49 P.M., Resident #27 was observed lying on her right side with the bed in low position. The sheet continued to pulled up to her chest. A family member was sitting in the room at the resident's bedside. On 06/12/13 at 4:30 P.M., the Assistant Director of Nursing (ADON) was interviewed and revealed a low air loss mattress was not put in place for Resident #27 when she developed a facility acquired SDTI. The ADON stated she did not feel it was needed at that time. She stated they did not have documentation of an every two hour turn schedule for Resident #27 but nursing documented once per shift the resident was turned. The ADON stated the staff just knew it needed done. The ADON stated she was very active on the floor to make sure residents were being turned. She stated she did not know what caused the skin impairment assessed as a SDTI and denied any known injury to the area. She stated Resident #27's pressure ulcer went from an unstageable area that looked as if it was improving to eschar over night. The ADON provided no documentation revealing the skin impairment was identified prior to the assessment of the wound as a SDTI. Interview with State tested Nursing Aide (STNA) #110, on 06/13/13 at 8:16 A.M., revealed residents on a turn from side to side or reposition schedule was to be turned and repositioned every two hours. She stated there were times when the staff were busy and the residents did not get turned every two hours. Interview with Licensed Practical Nurse (LPN) #102, on 06/13/13 at 8:20 A.M., revealed residents who were on a turn schedule were to be turned every two hours. She stated sometimes it was difficult to get the residents turned on time due to the unit being busy. Interview with the Director of Nursing (DON), on 06/13/13 at 8:26 A.M.,. revealed Resident #27 was turned every two hours and documentation was completed once every shift. The DON provided no documentation indicating staff had identified the skin impairment prior to the assessed SDTI nor did she provide an explanation of why the staff believed the area was due to a SDTI. The DON stated they did not put a low air mattress in place for Resident #27 after 05/22/13 when the pressure ulcer of the left buttock changed from a SDTI to an unstageable because she felt the area was healing and did not need a change in treatment, even though the resident had end stage Alzheimer's, decreased mobility, and developed a SDTI.