Every finding on record at Lakeland Community Care Center

Based on record review and interviews, the facility failed to ensure personal funds that were deposited with the facility were returned within (30) days of discharge for one (1) of six (6) sampled residents. Resident #1.Findings Included:Record review of the Transaction Report dated 6/16/26 for 11/01/25 through 7/16/26 revealed the resident had a credit balance of $580.07.Record review of the Trust Statement dated 2/28/26 for Resident #1 revealed that she had an Opening Balance of $178.00 with one debit on 2/10/26 for $21.00 for Shampoo, Cut & Style (in-facility beauty shop service) leaving a Closing Balance of $157.00.On 6/15/26 at 3:40 PM, during an interview the Administrator explained that Resident #1 was cared for by the facility 11/14/25 through 11/30/25 at no charge to the resident. She said that in January 2026 the resident paid $3,173.92 and should have paid $3,343.97. She said that the resident's account was charged $119.42 for the eight days she resided at the facility which left a credit balance of $573 due to the resident which had not been paid, along with the $157.00 that remained in her trust account.On 6/16/26 at 3:00 PM, during an interview the Business Office Manager (BOM) confirmed that she had not issued payment for the remaining balance of the resident's trust fund account and that $157.00 was due to the resident since her discharge on [DATE]. She confirmed that she had not been instructed to issue any refund to the resident.On 6/16/26 at 3:33 PM, during an interview the Complainant stated that he thought the facility owed Resident #1 the money from her resident trust fund account and a refund of the money left on her account. He said he had spoken with facility staff regarding the balance owed Resident #1 but could not remember whom he spoke. Record review of the admission Record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included hypertension, macular degeneration, depression and pain.Record review of the Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/09/26 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact.

Based on observation, interview, record review and facility policy review, the facility failed to ensure the residents' rights to access the use of a telephone privately for one (1) of six (6) sampled residents. Resident #1Findings Include:Record review of the facility policy Resident Rights revised December 2016 revealed . 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to.cc. access to a telephone, mail and email; dd. communicate in person and by mail, email and telephone with privacy.Record review of the admission Record for Resident #1 revealed the facility admitted the resident on 12/18/24 and the resident had diagnoses of Sjogren syndrome, rheumatoid arthritis, chronic kidney disease, and morbid obesity.On 4/21/26 at 11:00 AM, during an interview Resident #1 reported that she had dropped and broken her personal cellular telephone, which she had used for private communication. She reported that the facility did not have any telephone that was convenient for her to use for private communication. She reported that there were plans for having her cellular telephone repaired, but it had not been returned to her yet. She stated that no staff had offered her the use of a staff office or any other mechanism for private communication and she was upset because she was accustomed to having a telephone to keep in touch with her significant other who had cancer and was unable to visit her at the facility.On 4/21/26 at 11:50 AM, during an observation it was revealed there was no cordless telephone for use by residents on the 100 Hall of the facility.On 4/21/26 at 12:00 PM, during an interview the Director of Nurses (DON) confirmed that the facility did not have a method to provide residents with the ability to have private communication without first making arrangements or an appointment to use a staff office. She explained that the facility did have cordless telephones but that the range did not reach South Hall.On 4/21/26 at 12:20 PM, during an interview the Social Services Director (SSD) revealed there were no cordless telephones available at the South Hall nurses' station which could be taken to residents' rooms for private use by residents. She confirmed that Resident #1 broke her cellular telephone last week and she asked the SSD to take the phone to a nearby business that repairs cellular telephones. She stated her sister sent money to pay for the repair and Resident #1 was awaiting the return of the repaired telephone. She stated that she was aware that the resident was close to her significant other who could not visit the facility due to illness.On 4/21/26 at 3:45 PM, during an interview the Administrator confirmed that the facility did not have a method to provide residents on South Hall with the ability to have private communication without first making arrangements or an appointment to use a staff office, and confirmed that it was a guaranteed resident right to have access to a private communication method.

Based on observation, interview, record review, and facility policy review, the facility failed to provide assistance with activities of daily living (ADLs) to maintain personal hygiene for one (1) of six (6) sampled residents. Resident #2. Findings Included:Record review of the facility policy Activities of Daily Living (ADLs), Supporting revised March 2018 revealed .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene .Record review of the admission Record for Resident #2 revealed the facility admitted the resident on 12/09/25 with diagnoses that included heart failure, chronic kidney disease and hypertension.Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/11/26 revealed a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment, was always incontinent of bowel and bladder and the resident required substantial/maximal assistance for personal hygiene and was dependent for toilet hygiene.On 4/22/26 at 1:42 PM, during a telephone interview with the complainant, she revealed she had concerns related to a complaint reported to her by Resident #2 that he had difficulty getting staff to provide assistance with activities of daily living.On 4/22/26 at 3:30 PM, during an observation and an interview with Resident #2, accompanied by Licensed Practical Nurse (LPN) #2, revealed Resident #2 reported that he had difficulty getting assistance with ADLs. Observation revealed the resident had ten long, dirty fingernails that protruded 3.0 to 3.5 millimeters past the end of his fingers with black substance beneath all fingernails. Resident #2 stated, They need cleaning and cutting/ They are too long.On 4/22/26 at 3:35 PM, during an interview with LPN #2 revealed she characterized the resident's fingernails as too long and dirty and said that his fingernails need to be cleaned and trimmed. She confirmed that nursing staff were responsible for checking each resident's fingernails daily during care and weekly during body audits and were also responsible for provision of fingernail care as part of ADLs. She confirmed that long, dirty, unkempt fingernails had the potential of causing damage or scratches to the resident's skin.On 4/22/26 at 4:00 PM, during an interview the Director of Nurses (DON) revealed she was not aware that Resident #2 had any complaints regarding lack of care. She confirmed that she expected the ADLs for all residents' dependent on staff for personal hygiene to be maintained and provided as needed. She stated that only licensed nurses could trim fingernails for some residents, but any nursing staff could clean under resident fingernails. On 4/22/26 at 4:15 PM, during an interview the Administrator confirmed that personal hygiene and grooming were part of resident ADLs, and that she expected all ADLs for all residents who were dependent on staff to be provided by the staff.

Based on observation, interviews and facility policy review the facility failed to ensure a clean, orderly homelike environment for two (2) of four (4) sampled residents. Resident #1 and Resident #2. Findings included:Record review of the facility policy titled, Homelike Environment with Revision Date February 2021, revealed Policy Statement: Residents are provided with a safe, clean, comfortable and homelike environment .The facility staff and management maximize .the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a. clean, sanitary and orderly environment. On 1/26/26 at 1:40 PM, during an interview with Housekeeper #1 revealed that housekeeping conducted a deep cleaning of all rooms prior to admission of new residents.On 1/26/26 at 2:00 PM, observation and interview with Resident #1 in her room revealed a urine collection device on the floor of the resident's bathroom, and a one and a half (1 1/2) inch by one half (1/2) inch hole in the drywall above the light. There were six (6) cracked linoleum tiles ten feet from the door on the right side of the room upon entrance. Resident #1 stated that she was at the facility for therapy and was not impressed with housekeeping services. On 1/26/26 at 2:15 PM, an interview with the Housekeeping Supervisor in the room of Resident #1 revealed that the blackish brown discolored areas of floor needed to be cleaned with stripper and scraper. She further confirmed that the baseboards in the rooms of Residents #1 and #2 were dust covered. She confirmed that substances easily removed by water and tissue should have been cleaned by housekeepers. She stated that missing plaster and broken floor tiles would have to be repaired by maintenance.On 1/26/26 at 3:00 PM, observation and interview with Resident #2 in her room revealed there as a three-inch piece of the bathroom door frame and the threshold piece of the floor between the resident's room and her bathroom were missing. There was a wall mounted hand sanitizer dispenser in her room that was dust covered. On the wall to the right facing the door from inside the room there were twenty-four (24) pinpoint brown spots and a one (1) inch long by one-eight (1/8) inch brown streak and two (2) three (3) inch by one-eight-inch streaks below the hand sanitizer dispenser. The base boards around the entire room were discolored and dusty with substance that wiped off easily with water and tissue. The floor behind the room's door was discolored with brown to black substance in the corner. The exposed plumbing pipes under the sink in the resident's bathroom were partially covered by polyfoam cover with one (1) inch by one-half (1/2) inch area of dark brown substance. There was a six (6) inch by (1) inch area of drywall missing in the resident's bathroom. Resident #2 stated that the housekeepers came in each day but didn't do a very thorough job. She stated that she was able to do some putting away but was not able to do a lot and that staff were not conscientious about putting her belongings away. There were clothing and other items scattered on all surfaces of the room. Resident #2 stated that she was surprised by the overall lack of cleanliness and maintenance of the room and bathroom because the front entrance of the facility was neat, clean and attractive. On 1/27/26 at 3:40 PM, during an interview the Administrator revealed that she was aware of maintenance and housekeeping needs in resident rooms. She stated that the facility had undergone a change of management and there were plans in place for painting, and plaster and floor repair and replacement were needed. Resident #1Record review of the admission Record for Resident #1 revealed the facility admitted the resident on 1/12/26 with diagnoses that included type 2 diabetes, hypertension and acute kidney failure.Record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/19/26 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment.Resident #2Record review of the admission Record for Resident #2 revealed the facility admitted the resident on 12/30/25 with diagnoses of diabetes and hypertension. Record review of the 5-Day MDS with an ARD of1/06/26 revealed a BIMS score of 14 indicating the resident was cognitively intact.

Based on observation, interviews and facility policy review the facility failed to provide palatable food at an appetizing temperature for two (2) of four (4) sampled residents. Resident #1 and Resident #2. Findings included:Record review of the facility policy Assisting the Resident with In-Room Meals with a revised date of 2013 revealed .6. Check that hot foods are hot.On 1/26/26 at 2:00 PM, during an interview Resident #1 stated that she ate her meals in her room and they were usually cold, or too cool to be enjoyable. She said that staff told her that her meals were not hot because she was the last served due to the location of her room. On 1/26/26 at 3:00 PM, during an interview with Resident #2 in her room, she reported that she ate in her room and her meals were never served hot, she said she ate the meals without them being replaced or heated because I'm going home this week.On 1/27/26 at 11:20 AM, observation in the kitchen revealed that as the cook prepared the resident meals the dietary aid placed the plates on trays and placed insulated dome-covers on the plates without the insulated base, also known as the heat-keeper base or underliner. Nine (9) of (25) meals prepared and placed on trays and onto carts had insulated dome-covers that did not fully cover the plate and left the plate and its contents not completely covered to conserve heat, including the meal of Resident #1. Six (6) of the (25) plates were covered by heat-keeper bases instead of dome-covers, including that of Resident #1. On 1/27/26 at 12:44 PM, during an interview with the Dietary Aide and the Dietary Supervisor revealed they were unable to explain why they used heat-keeper bases instead of covers for (6) of the (25) meals prepared to be transported to and served to residents in their rooms. The Dietary Supervisor stated that the facility did not have enough of the heat-keeper bases for all residents who ate in their rooms.On 1/27/26 at 3:40 PM, during an interview the Administrator revealed she did not know why the dietary staff were not using insulated bases/heat-keeper bases for meals served to residents in their rooms. She stated that she had not been notified of a shortage of insulated heat keeper components, domes or bases. Resident #1Record review of the admission Record for Resident #1 revealed the facility admitted the resident on 1/12/26 and the resident had diagnoses of type 2 diabetes, hypertension and acute kidney failure.Record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/19/26 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Resident #2Record review of the admission Record for Resident #2 revealed the facility admitted the resident on 12/30/25 with diagnoses that included diabetes and hypertension. Record review of the 5-Day MDS with an ARD 1/06/26 revealed a BIMS score of 14, which indicated the resident was cognitively intact.

Based on record review, facility policy review and interviews, the facility failed to ensure resident discharge rights by not providing all medications, specifically as needed pain medications, for one (1) of four (4) discharged residents. Resident #1. Findings include:Record review of the facility policy Discharge Medications with the most recent history of July 2024 revealed Procedure: 1. Medications are sent with the resident on discharge based on.the physician's order.On 9/03/25 at 3:40 PM, during an interview Licensed Practical Nurse (LPN) #1 confirmed she had been working on 6/27/25 when Resident #1 discharged home with home health care. She stated she didn't recall reviewing upcoming scheduled appointments with the resident prior to discharge. She confirmed she used the Current Medications list included in the Transfer/Discharge Reported dated 6/27/25 to review medications with the resident and that the list included a current prescription for Hydrocodone-Acetaminophen Oral Tablet 5-325 MG (milligrams) one (1) tablet by mouth every 6 hours as needed for pain. LPN #1 stated she did not send the resident's Hydrocodone-Acetaminophen tablets home with her because I was told if it was a certain number. She could not explain. She stated that she recalled discussing pain medications with other nurses but had not consulted the prescribing physician or the resident's primary healthcare provider for clarification.On 9/03/25 at 4:07 PM, during an interview the Minimum Data Set (MDS) Nurse stated that she had participated in discharge planning for Resident #1. She stated that discharge planning began upon admission. She stated that Resident #1 had been her own Representative and made her own healthcare decisions. She confirmed that Resident #1 had decided to discharge a few days early and had personally made her decision known to her primary healthcare provider (PHP) in person during an in person visit to the facility. She stated she had arranged home health care for Resident #1 prior to discharge from the facility. She stated that it was not unusual for residents to be instructed to follow-up with their PHP for refills, but that current medications should be sent home with the resident unless otherwise instructed by the physician.On 9/03/25 at 4:13 PM, during an interview with the Director of Nursing (DON) revealed residents were to be discharged with all current medications unless otherwise instructed by the resident's physician. She stated that Resident #1 had undergone hip replacement surgery approximately two weeks prior to discharge from the facility and had other pain related diagnoses and that she had been admitted with. Resident #1 had physician orders for Hydrocodone-Acetaminophen Oral Tablet 5-325 MG (1) tablet by mouth every 6 hours as needed for pain. She confirmed that the order was still current at the time of the resident's discharge from the facility and the PHP had not issued any explicit instructions or orders that the medication be discontinued. She confirmed that Resident #1 had telephoned the facility the week following discharge and complained that her Hydrocodone-Acetaminophen Oral Tablet 5-325 MG had not been sent home with her.On 9/03/25 at 4:25 PM, during an interview the Administrator stated that it was the policy of the facility that unless otherwise instructed/ordered by the PHP all medications were to be discharged with the resident following discharge conference with the resident and/or their representative during which all medications were to be discussed as well as notification of scheduled appointments.Record review of the admission Record for Resident #1 revealed the facility admitted the resident on 6/13/25 with diagnoses that included Aftercare following joint replacement surgery and End stage renal disease. Record review of the 5-Day MDS with an Assessment Reference Date (ARD) 6/20/25 revealed the resident had a Brief interview for Mental Status score of 10, which indicated moderate cognitive impairment. Section J indicated Resident #1 received PRN (as needed) pain medications and frequently had pain that interfered with sleep and limited day-to-day activities and had recent surgery, hip replacement, requiring active SNF (skilled nursing facility) care. Section N of the MDS documented that the facility assessed that the resident required administration of opioid pain management.Record review of the History and Physical (H&P) dated 6/25/25 for Resident #1, signed by her primary healthcare physician, Medical Doctor (MD) #1, revealed the resident was admitted after hospitalization for right total hip arthroplasty (THA) secondary to severe osteoarthritis/avascular necrosis unresponsive to conservative treatment who complained of postoperative right hip pain. The H&P included diagnoses of right hip pain and other acute postprocedural pain and treatment plans that included continuation of current medications and monitoring for pain control. Record review of the Order Summary Report revealed an order dated 6/13/25 for Hydrocodone-Acetaminophen Oral Tablet 5-325 MG Give (1) tablet by mouth every (6) hours as needed for pain.Record review of the Physician's Telephone Orders dated 6/27/25 revealed Discharge home with home health and medications. Record review of the Discharge Summary/Instructions dated 6/27/25 revealed the Education regarding medications/treatments, exercises, or other services: Continue as ordered all medications. Follow up with primary care MD for refills. Record review of the Transfer/Discharge Report which included Current Medications List dated 6/27/25 for Resident #1 revealed Resident #1 discharged home on 6/27/25. The medication list included Hydrocodone-Acetaminophen Oral Tablet 5-325 MG one (1) tablet by mouth every 6 hours as needed for pain. Record review of the Controlled Drug Record revealed the Hydrocodone-Acetaminophen Oral Tablet 5-325 MG (quantity of 29) was destroyed on 7/17/25. Disposition of remaining doses indicated doses mixed with cat litter/coffee grounds.

Based on observation, staff interviews, and record review, the facility failed to ensure sufficient nursing staff to meet the needs of residents for four (4) of 14 staffing days reviewed in January, 2025. (1/19/25, 1/20/25, 1/25/25, and 1/27/25). Findings Include: Record review of a typed document on facility letterhead dated January 30, 2025, and signed by the Executive Director (Administrator) revealed There is no Staffing policy A review of anonymous complaints, received 1/20/25 and 1/21/25, revealed 3-11 and 11-7 shifts are always short CNAs and there was one CNA working the floor Central Unit by herself on 3-11 Sunday 1/19/25. A record review of the PBJ (Payroll Based Journal) Data Report for the 4th Quarter (July 1-September 30) revealed the facility triggered for One Star Staffing Rating and Excessively Low Weekend Staffing. A record review of the Facility Assessment Tool dated 1/10/2025, revealed .There are 3 units: South, Central, and North .Staffing plan .Nurse aides .3-11 CNA (3 South/2 Central/4 North) 11-7 CNA (2-3 south/2 central/ 3 north unit) . The facility assessment indicated the resident acuity and population required 9 total CNAs for 3-11 shift and 7-8 CNAs for 11-7 shift. A record review of the staffing grid completed by the facility revealed on 1/27/24 there were three (3) CNAs on the 11-7 shift (85 census), on 1/25/24 there were three (3) CNAs on the 11-7 shift (87 census), on 1/20/25, there were three (3) CNAs on the 11-7 shift (85 census), and on 1/19/24 there were four (4) CNAs on the 3-11 shift and three (3) CNAs on the 11-7 shift (84 census). On 01/28/25 at 9:39 AM, during an interview with Licensed Practical Nurse (LPN) #1/Staffing Coordinator, she revealed the facility faces challenges keeping the building staffed on weekends due to frequent call-ins. She noted that while the required number of staff is scheduled appropriately, the high rate of call-ins creates difficulties in maintaining weekend staffing levels. She indicated that this month, January 2025, the facility has had to operate with only one (1) CNA on halls that should have had two (2). During an observation and interview on 1/28/25 at 5:00 PM, LPN #5 confirmed a resident's medication was left on the resident's table because the resident was slow taking her medication. The nurse stated there was no time to encourage the resident to take her medication because there was only one CNA assigned to the unit to assist with the residents' care, provide showers and meals. On 1/29/25 at 09:28 AM, during a follow-up interview with LPN #1/Staffing Coordinator, she confirmed the staffing grids accurately reflect all staff that were assigned to the halls, including any agency staff. She said she knows that having one CNA on the units is not appropriate because there should be two on each unit to cover the resident needs. In an interview with the Administrator on 1/29/25 at 2:31 PM, she indicated that it was because of illnesses due to COVID-19 and constant call ins as to why they had low staffing on the weekends.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure Enhanced Barrier Precautions (EBP) were followed while providing care to a resident requiring high-contact precautions for two (2) of three (3) care observations, Resident #27. Findings included: A review of the facility's Enhanced Barrier Precautions policy, dated 04/2024, revealed, Enhanced Barrier Precautions are indicated for residents with .indwelling medical devices, secretions/excretions that are unable to be covered/contained, and are not known to be infected/colonized with any MDRO (Multidrug-Resistant Organism) during high-contact resident care activities, as these residents are at an increased risk of being infected . On 01/29/2025 at 8:50 AM, during an observation, Licensed Practical Nurse (LPN) #2, the Nursing Supervisor, was observed administering medications to Resident #27 via percutaneous endoscopic gastrostomy (PEG) tube. LPN #2 did not wear a gown while accessing the resident's PEG tube. On 01/29/2025 at 10:20 AM, during an observation, LPN #7 was observed performing PEG tube care for Resident #27. The nurse entered the resident's room and explained that she was going to clean the PEG tube site. LPN #7 washed her hands and applied clean gloves but did not apply a gown prior to providing care. On 01/29/2025 at 10:27 AM, during an interview, LPN #7 stated that Enhanced Barrier Precautions are used to protect Resident #27 from staff. She acknowledged that she should have donned (put on) a gown before providing care. On 01/29/2025 at 10:35 AM, during an interview, LPN #2, the Nursing Supervisor, stated that she should have worn a gown when administering PEG tube medications to Resident #27. She acknowledged that her actions put the resident at risk for complications, including infection. On 01/30/2025 at 9:45 AM, during an interview, LPN #6/ Infection Preventionist (IP) stated that nurses should have donned a gown before providing care to Resident #27's PEG site . She explained that the gown protects the resident. She stated that the nurses' failure to follow proper precautions could result in the resident having complications. She explained that her expectation was for staff to don the appropriate Personal Protective Equipment (PPE) when providing care to residents that are at high risk for MDROs. A record review of the Admission Record revealed the facility admitted Resident #27 on 6/14/24 with diagnoses including Metabolic Encephalopathy. A record review of the Order Summary Report with active orders as of 1/29/2025, revealed Resident #27 had a Physician's Order, dated 6/14/24, to clean the PEG site with soap and water, pat dry, and cover with split gauze every night shift. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/17/2024 revealed Resident #27 had a Brief Interview for Mental Status (BIMS) score of nine (9), which indicated the resident's cognition was moderately impaired. A record review of the Enhanced Barrier Precautions signage on Resident #27's door revealed instructions indicating, Everyone must .wear gloves and a gown for the following High-Contact Resident Care Activities .Device care or use .feeding tube .

Based on observation and staff interview, the facility failed to ensure proper food handling and sanitation practices to prevent cross-contamination when Dietary [NAME] (DC) #2 failed to sanitize the thermometer when checking food temperatures on the tray line for one (1) of two (2) kitchen observations Findings included: On 01/27/2025 at 11:15 AM, during an observation of the tray line, DC 2 was observed checking food temperatures. DC #2 used a brown paper towel to clean the thermometer between food items. DC #2 wiped food residue off onto a brown paper towel and then tested each food item on the tray line without properly sanitizing the thermometer. On 01/27/2025 at 12:10 PM, during an interview, the Dietary Manager (DM) #1 stated that staff should always use an alcohol pad to clean the thermometer when checking tray line temperatures. DM #1 explained that using a paper towel instead of an alcohol pad constitutes cross-contamination. She confirmed that dietary staff had been trained to use alcohol swabs when performing tray line temperature checks. On 01/29/2025 at 1:56 PM, during a phone interview, DC #2 confirmed that she had used a brown paper towel instead of an alcohol pad when checking tray line temperatures on 01/27/2025 at 11:15 AM. DC #2 stated that she had been trained to use an alcohol pad but was nervous and forgot to follow the procedure. She acknowledged that her actions constituted cross-contamination and could cause residents to develop gastrointestinal issues.

Based on observation, interview, record review, and facility job description review, the facility failed to ensure the residents' right to a homelike environment for one (1) of eighteen (18) sampled residents, Resident #5. Findings included: A review of the facility's Job Description, dated 08/01/2012, for the Director of Maintenance revealed, .General Description .the Director of Maintenance . is accountable for the upkeep of the grounds, Facility, and equipment in a safe and efficient manner .Essential Duties 1. Provides a safe, clean environment for residents in accordance with Resident Care Policies and Procedures . On 01/27/2025 at 3:26 PM, during an observation, Resident #5 was seated in her wheelchair in her room. The resident was confused but able to make simple needs known. The linoleum flooring in the resident's room was torn and folded back under the resident's wheelchair. The flooring was also buckling up under the resident's bed. On 01/27/2025 at 4:00 PM, during an interview, Resident #5's sister stated that the resident's flooring had been torn for several months. She reported that she had complained to the nursing staff and the Administrator because she felt the flooring was a fall risk. On 01/28/2025 at 4:05 PM, during an interview, Certified Nursing Assistant (CNA) #3 stated that the flooring had been in ill repair for at least a month. CNA #3 explained that when housekeeping mopped the floor, they laid the torn flooring back down, but the edges lifted again within a day. CNA #3 also stated that she had reported the issue to the Maintenance Director. On 01/28/2025 at 4:15 PM, during an interview, Licensed Practical Nurse (LPN) #5 stated that the floor had been torn for as long as he could remember. He noted that the sharp edges at the base of the bed continued to rip the flooring each time the bed was moved. He stated that he had placed the information on the clipboard at the nurse's station for the Maintenance Director. On 01/28/2025 at 4:35 PM, during an interview, the Maintenance Director stated that he had known about the torn flooring for about a month. He reported that he had installed the linoleum flooring approximately a year ago. He stated that he was the only maintenance staff in the facility and had not had the opportunity to repair the floor. The Maintenance Director confirmed that the torn linoleum presented a potential fall hazard for the resident. On 01/28/2025 at 4:40 PM, during an observation and interview, the Administrator confirmed the linoleum in Resident #5's room was torn. The Administrator stated that she was aware of the linoleum coming up and planned to have new tile installed. She reported that she had not had time to complete the repair. The Administrator stated that she expected CNAs to elevate the bed onto its wheels to prevent it from dragging across the floor. She explained that the bed was a crank bed and required staff to manually adjust it. The Administrator confirmed that Resident #5 transferred herself from bed to wheelchair without assistance and was at high risk for falls. A record review of the Admission Record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses that included Spinal Stenosis. A record review of Resident #5's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/15/2024 revealed a Brief Interview for Mental Status (BIMS) score of eight (8), which indicated the resident's cognition was moderately impaired.

Based on staff interview and record review, the facility failed to accurately code a Minimum Data Set (MDS) assessment for a resident who was coded as discharged to the hospital but was discharged to home instead of the hospital for one (1) of 18 sampled residents. (Residents #83) Findings included: A record review of the Discharge MDS with an Assessment Reference Date (ARD) of 11/09/24 revealed the Resident #83 was discharged to a short-term general hospital. A record review of a Physician's Telephone Orders, dated 11/09/24, revealed Resident #83 had an order to be discharged home. On 01/29/25 at 08:07 AM, an interview with the Social Services Director (SSD), revealed Resident #83 was admitted for a brief time as she was there for skilled care and had planned to return home. The SSD stated she prepared the discharge summary based on the physician orders on the day Resident #83 left the facility. On 01/29/25 at 08:45 AM, in an interview with Registered Nurse (RN) #1/MDS, she acknowledged the MDS was coded incorrectly as being discharged to the hospital because he went back home after his stay at the facility. The RN stated the MDS nurse is responsible for assuring that the MDS is coded correctly prior to submission. The RN noted the purpose of the MDS is to have an accurate reflection of the patient. On 01/29/25 at 09:10 AM, in an interview with the Administrator, she acknowledged the discharge MDS for Resident #83 was incorrectly coded for the resident because he went home after his stay and did not go to the hospital. The Administrator stated the MDS Coordinator is responsible for making sure the MDS is coded correctly. The Administrator stated that the importance of accurate MDS coding is to have an overall outlook of care provided to the patient. A record review of the Admission Record revealed the facility admitted Resident #83 on 10/23/24 with diagnoses including Muscle Weakness.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure medications were secured and inaccessible to unauthorized residents and staff one (1) of four (4) days of survey observations. Findings included: A review of the facility's policy titled Medication Storage, dated 01/2015, revealed, .All drugs, treatments, and biologicals must be stored securely . Resident #5 A record review of the Admission Record revealed the facility admitted Resident #5 on 04/21/2017 with diagnoses including Spinal Stenosis. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/15/2024 revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of eight (8), which indicated the resident's cognition was moderately impaired. On 01/28/2025 at 4:40 PM, during an observation and interview with the Administrator, an unattended medicine cup was observed on Resident #5's bedside table alongside a glass of water. The resident was lying flat in bed, and no staff were present to monitor the resident taking the medication. On 01/28/2025 at 5:00 PM, during an interview, Licensed Practical Nurse (LPN) #5 confirmed he left the medication on the table because the resident was slow to take her medication. He stated he did not have time to encourage the resident to take her medication as she normally took one pill at a time. He acknowledged that he knew he should not have left the medication unattended because the resident could choke, or another resident could enter the room and take the medication. LPN #5 reported that the medication in the cup included Vitamin C, Multivitamin, Levothyroxine, Metoprolol and Pravastatin. On 01/28/2025 at 5:15 PM, during an interview, the Administrator confirmed that LPN #5 left the medication in a medicine cup unattended on the resident's bedside table. The Administrator stated she expected nurses to ensure residents swallowed their medications before leaving the room. Resident #56 A record review of Resident #56's Admission Record revealed the facility admitted the resident on 03/05/2024 and currently has diagnoses that include Pruritus. A record review of the Order Summary Report with active orders as of 1/30/2025, revealed Resident #56 had a Physician's Order, dated 10/25/24 for Nystatin External Cream. A record review of Resident #56's MDS with an ARD of 11/20/2024 revealed a BIMS score of 15, which indicated the resident was cognitively intact. On 01/28/2025 at 9:08 AM, during an observation and interview with Resident #56, the resident was observed sitting up in bed with two medication dispensing cups containing an unidentified cream on the bedside table. One cup was nearly empty, and the other contained a moderate amount of cream. Resident #56 stated that the weekend nurse gave her the cream to apply as needed for itching. On 01/28/2025 at 9:12 AM, during an observation and interview, LPN #3 acknowledged the medication cups containing some type of cream were left on Resident #56's bedside table. LPN #3 stated that nurses were not supposed to leave any medications at the bedside. After reviewing the physician orders, LPN #3 confirmed the unidentified cream was Nystatin External Cream. 41680

Based on interview, record review, and facility policy review, the facility failed to develop a person-centered care plan regarding a resident's impaired vision for one (1) of (18) care plans reviewed. Resident #68. Findings included: A review of the facility's policy titled Comprehensive Care Plan Policy, revised on 01//2025, revealed, Each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care. All disciplines work together to develop a plan of care that meets the resident's needs, preferences, and goals. A record review of the Comprehensive Care Plan revealed Resident #68 did not have a care plan regarding impaired vision. A record review of the Admission Record revealed the facility admitted Resident #68 on 6/23/23 and he had current diagnoses including Paralytic Ptosis of Left Eyelid. A record review of the Eye Examination, dated 09/19/2024, revealed Resident #68 was seen by a local optometrist and was diagnosed with Dry Eye Syndrome of bilateral lacrimal glands, Paralytic Ptosis of the left eyelid, and Contusion of the left eyelid and periocular area (active since 08/14/2024). The optometrist ordered glasses for Resident #68. On 01/28/2025 at 11:00 AM, during an interview, Licensed Practical Nurse (LPN) #3 stated the resident had poor vision in the left eye and that she must approach him from the right side. On 01/29/2025 at 10:00 AM, during an interview, LPN #2 stated she was responsible for adding new diagnoses to the care plan with interventions. LPN #2 stated she did not know the resident had seen the optometrist, had orders for glasses, or had a diagnosis of impaired vision. On 01/30/2025 at 1:00 PM, during a phone interview, the Optometrist Assistant confirmed that the resident ordered glasses in September 2024 due to impaired vision and stated the resident should always wear his glasses while awake. On 01/30/2025 at 3:15 PM, during an interview, LPN #4 confirmed that Resident #68 was not care planned for impaired vision. LPN #4 also explained that she did not know the resident had a diagnosis of Contusions/Ptosis to the left eye because it was not on the chart. LPN #4 stated that neither the resident nor staff informed her that his vision was impaired. She further stated that the current care plan reflected generic interventions because she was unaware of the diagnosis. LPN #4 explained that the Nursing Supervisor should have documented the care plan for the diagnosis as well as the resident's orders for glasses. She also stated that the eye examination and results were not on the chart and that she only included information on the care plan when nursing staff documented it or placed it in the chart. LPN #4 stated she was unaware that the resident had ordered glasses. On 01/30/2025 at 3:30 PM, during an interview, the Administrator stated she did not know the resident's left eye was impaired or that the resident had been seen by the optometrist. She stated she found the eye examination documentation in the medical records. The Administrator stated that the Nursing Supervisors were responsible for ensuring the orders were placed on the care plan and that the Care Plan Nurse served as a backup for the Nursing Supervisors. The Administrator stated she did not know how this had been missed and was unsure why the optometrist's report and admission diagnosis were not addressed.

Based on record review and staff interview, the facility failed to maintain complete and accurate medical records by failing to document that residents were informed of their rights regarding Advance Directives for three (3) of (18) resident records reviewed, Residents #22, #27, and #61. Findings included: A record review of the Admission Record revealed the facility admitted Resident #22 on 06/10/2024 with diagnoses including Unspecified Dementia, Resident #27 on 06/14/2024 with diagnoses including Atherosclerotic Heart Disease, and Resident #61 on 9/20/2024 with diagnoses including Vascular Dementia. A record review of the Resident Rights/Advance Directive revealed the Advance Directive was not initialed by the residents or Resident Representatives that confirmed they were informed of information regarding formulating an Advance Directive for Residents #22, #27, and #61. A record review of the Resident Rights/Advance Directive revealed the Advance Directive was not initialed by the residents to confirm being informed of information regarding formulating an Advance Directive for Residents #22, #27, and #61. On 01/28/2025 at 11:49 AM, during an interview, the Social Services Director (SSD) confirmed she was responsible for completing the Advance Directive. The SSD acknowledged the Advance Directive was incomplete and was not marked to indicate that the residents had been informed of rights regarding Advance Directives for Residents #22, #27, and #61. On 01/28/2025 at 4:08 PM, during an interview, the Administrator acknowledged that the Advance Directive forms were incomplete and failed to reflect the residents' receipt of information related to Advance Directives. The Administrator stated the Social Services Director was responsible for confirming that all information related to the residents' choices and that it should be documented.

Based on staff and Resident Representative (RR) interviews, record review, facility investigation, and policy review the facility failed to ensure nursing staff treated residents with respect and dignity during procedures and medication administration for two (2) of eight (8) residents sampled. Residents #5 and Resident #6. Findings Include: Record review of the facility's policy titled, Resident [NAME] of Rights, reviewed/revised on 1/23, revealed, Each resident has a right to a dignified existence . and communication with and access to persons and services inside and outside the facility in a manner and in an environment that promotes maintenance or enhancement of (his or her) quality of life .10. Reside and receive services in the facility with reasonable accommodation or resident needs and preferences . Resident #5 During an interview with Resident #5 on 5/19/24 at 1:22 PM, she stated Licensed Practical Nurse (LPN) #1 was disrespectful and demanding when she entered her room to collect a urine sample. She explained that this conduct was nothing new. This nurse had frequently treated her in this manner. She stated that, despite her desire to avoid interaction with the nurse because she becomes uneasy around her, she just followed all of the instructions given to her during the process. She pointed out the facility is only now transferring her meds to another nurse, despite her repeated complaints that the current nurse is disrespectful. She added that even though another nurse administered her medications, LPN#1 still worked on her hall, which made her nervous to see her. Resident #5 shared her wishes not to see the nurse at all. Record review of a handwritten statement written by LPN #1 dated 4/24/24 revealed .Asked resident how she cleaned herself and she stated after I get through, I wipe myself .Noted with a lot of nasty toilet paper between her legs, in her vaginal area . Informed resident this is probably why you're hurting because this tissue is nasty . Record review of the police department Voluntary Statement dated 4/24/24 revealed, .She spread me wide and started wiping hard and it was hurting .I was afraid she was going to do me bodily harm. Her body language and tone of voice said so. The hold time she was digging and stretching, I was yelling Stop You're hurting me. She would not stop . Record review of the Supervisor Investigation Summary Form dated 04/24/2024 at 8:45 AM, revealed facility's investigation revealed Resident #5 made an allegation of employee-to-resident abuse that occurred on 4/19/24. The facility's findings revealed that the allegations of abuse were not valid and that the resident was reassigned to another unit related to the resident not liking the Licensed Practical Nurse (LPN). In an interview with the RR on 5/20/24 at 9:48 AM, she disclosed that she had previously informed the Director of Nursing (DON) and Administrator on numerous occasions that her mother had reported LPN#1 was unkind and disrespectful to her. Nevertheless, she asserts that they would defend the nurse, suggesting that the situation is not as severe as her mother portrayed it. In the absence of any evidence, she was unable to take any action. However, in the present scenario involving the urine sample, she insisted that the nurse stop administering her mother's medications. Subsequently, they transferred her medications to another nurse. She noted that the Administrator offered her mother a relocation to a different area of the facility, but she declined. However, she believes the nurse should have relocated to a different hall. She also stated from what she gathers, her mother experiences anxiety upon encountering the nurse and tries to avoid her. During an interview with LPN #1 on 5/20/24 at 10:53 AM, she verified that she was the nurse responsible for entering Resident #5's room to collect a urine sample. She also disclosed that she typically works the night shift in the north corridor, which is where Resident #5 is located. Furthermore, she frequently picks up extra shifts in the central hall. She clarified that the medications for Resident #5 were transferred to another nurse due to her knowledge that the resident harbors animosity toward her and makes up stories about her. She also mentioned that there are other residents who lie and disapprove of her because she refuses to let them have their way. In an interview with the Unit Manager (LPN#2) for north hall on 5/21/24 at 10:13 AM, she confirmed that Resident #5 did express concerns about LPN#1 before this current complaint. However, she would have to check her notes to remember the actual concerns. On 5/21/24 at 10:25 AM, during the interview with the DON, she said there is just a personality conflict between LPN#1 and the resident because she is a by-the-book nurse. She says Resident #5 tends to want to take multiple medications at one time, and LPN #1 tells her she cannot give them all at one time. She points out that LPN #1 is very tall and has a deep voice, so her presence and tone can come across as harsh. She thinks Resident #5 is accusing the nurse of being rude because of the nurse's outward appearance, tone, and pitch. A record review of the Face Sheet of Resident #5 revealed the facility admitted the resident on 5/12/17. Her diagnoses included Urinary Tract Infection, Paranoid Schizophrenia, and Generalized Anxiety Disorder. A record review of Resident #5's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/24/24 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Resident #6 On 5/20/24 at 10:35 AM, during an interview with Resident #6, she stated she reported to the Administrator about LPN #1's rudeness a few months ago, and the nurse's behavior improved. Nevertheless, LPN#1 has recently resumed her previous behavior of being demanding and rude when administering medication or performing any medical procedures with her. The resident admits that she experiences anxiety when in the presence of LPN#1 and responds to her inquiries without hesitation, merely responding with yes or no as required. She continued by stating that she had asked the Unit Manager (LPN #2) to prevent LPN #1 from returning to her room. Still, LPN#1 continues to administer her medications. The resident asserted that she should not be required to experience feelings of anxiety or nervousness in the presence of any staff members. She stated this facility is my home and the employees should be mindful of the manner in which they interact with all the residents. On 5/20/24 at 11:05 AM, during the interview with the RR of Resident #6, she revealed that in recent visits with the resident, she was told LPN #1 had started being mean and demanding again, over the last couple of weeks or so. She indicated that she could tell the nurse makes her aunt anxious, and the facility should have fired the nurse or moved her off the hall when Resident #6 had made the first complaint regarding LPN #1, back in March. On 5/22/24 at 10:48 AM, the Administrator confirmed that she was aware Resident #6 had complained about LPN #1 and addressed the allegation immediately. She acknowledged she counseled LPN#1 but did not move Resident #6's medication to another nurse or move LPN#1 to another hall. The Administrator added that as of 5/22/24, LPN #1 was moved to another hall. A record review of the Face Sheet revealed the facility admitted Resident #6 on 1/11/24. Her diagnoses included Depression and Urinary Tract Infection. A record review of the Quarterly MDS, for Resident #6, with an ARD of 4/12/24, revealed a BIMS of 15, which indicated the resident was cognitively intact.

Based on observations, interviews and record reviews the facility failed to ensure call lights were within reach for three (3) of five (5) sampled residents. Resident #3, Resident #4 and Resident #5 Findings Include: Resident #3 On 1/25/24 at 11:15 AM, an observation revealed the call light for Resident #3 was draped over the back of a bedside chair at the end of the resident's bed. The resident was seated on the end of the bed with the call light out of reach. On 1/25/24 at 4:14 PM, an observation revealed the call light for Resident #3 was draped over the back of a bedside chair. The resident was seated in her wheelchair with her call light out of reach. Resident #3 was observed looking for her call light, attempted to reach it, however, the call light was out of reach. On 1/26/24 at 11:18 AM, observation revealed that Resident #3 was seated in her wheelchair in her room with her call light out of her reach, draped over the back of the bedside chair at the end of her bed. She was coughing and sneezing. The resident needed a tissue, but there were none in her room. The resident attempted to reach her call light, but again, her call light was out of reach. On 1/26/24 at 1:50 PM, an interview with Certified Nursing Assistant (CNA) #4 assigned to the care of Resident #3 revealed she stated she had not noticed during morning rounds that the resident's call light was not within her reach. She confirmed that call lights should always be left within reach of the resident. Record review of the Face Sheet for Resident #3 revealed the resident was admitted by the facility on 4/21/17, with diagnoses that included Spinal Stenosis, Polyosteoarthritis, and Mild Intermittent Asthma, with Status Asthmaticus. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 12/13/23, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated severe cognitive impairment. Further MDS review revealed Resident #3's used a wheelchair for mobility and was dependent on facility staff for toileting, and personal hygiene, and was always incontinent of bowel and bladder. Resident #4 On 1/25/24 at 12:15 PM, an observation revealed the call light for Resident #4 was wrapped around the grab bar, wedged between the bar and the mattress hanging down below the mattress on the resident's left side. The bed control was wrapped around the grab bar, wedged between the bar and the mattress hanging down below the mattress on the resident's right side. Resident #4 stated I can't find my bed control or call light. I need to be repositioned so I can eat. Record review of the Face Sheet for Resident #4 revealed the resident was admitted by the facility on 8/22/22, with diagnoses that included Hypertensive Heart Disease with Heart Failure, Morbid Obesity, and Chronic Respiratory Failure with Hypoxia. Record review of the Quarterly MDS of Resident #4, with ARD 1/23/24, revealed the resident had a BIMS score of 12, which indicated moderate cognitive impairment. Further review of the MDS revealed that the resident was totally dependent on staff for bed mobility and was always incontinent of bowel and bladder. Resident #5 On 1/25/24 at 12:20 PM, an observation revealed that the call light for Resident #5 was hanging down from the resident's bed dangling just above the floor and not within reach of the resident. Record review of the Face Sheet for Resident #5 revealed the resident was admitted by the facility on 8/18/23, with diagnoses that included Malignant Neoplasm of Unspecified Part of Unspecified Part of Bronchus or Lung, Secondary Neoplasm of the Brain, and Chronic Obstructive Pulmonary Disease. Record review of the MDS for Resident #5, with ARD 11/17/24, revealed the resident had a BIMS score of 14, which indicated Resident #5 was cognitively intact. On 1/26/24 at 3:40 PM, an interview with the Director of Nurses (DON) revealed that she expected all resident's call lights to be positioned within their reach and answered in a timely manner. She confirmed that it was important so that residents could summon assistance as needed.

Based on observations, interviews, and record reviews, and facility policy review the facility failed to implement interventions included in the individualized care plans for four (4) of five (5) sampled residents. Residents #1, #3, #4 and #5. Findings Include: Record review of the facility policy titled, COMPREHENSIVE PERSON-CENTERED CARE PLANS, with revision date 3/18, revealed, Policy: Each resident will have a person centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care . Procedure: .6. Staff approaches are to be developed for each problem/strength/need . Assigned disciplines will be identified to carry out the intervention Resident #1 Record review of the Care Plan for Resident #1 with a problem onset date of 1/5/2024 revealed Total urinary incontinence related to impaired mobility and diuretic med use .Approaches Toilet checks on me q2h (every 2 hours) and prn .Keep call light within easy reach of me . Record review of the Care Plan for Resident #1 with a problem onset date of 1/5/2024 revealed I require assist with my adl's (activities of daily living) related to incontinence .Approaches . Provide my incontinence care q2h and as needed . Record review of the Face Sheet for Resident #1 revealed that the resident was admitted by the facility on 1/05/24 and with diagnoses that included Essential Hypertension, Type 2 Diabetes Mellitus, Repeated Falls, and Generalized Muscle Weakness. Record review of the 5 Day Minimum Data Set (MDS) with Assessment Reference Date (ARD) 1/12/24 revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #1 was cognitively intact. Further MDS review revealed the resident's assessment of functional status revealed the resident was dependent on facility staff for toileting and was always incontinent of bowel and bladder. On 1/25/24 at 2:37 PM, an interview with Resident #1 revealed that she reported that she was assisted with toileting needs prior to 11:45 AM, she reported that at 1:25 PM upon return to her room from therapy she was tired, uncomfortable in her wheelchair. She stated her incontinent brief was wet and did she not receive toileting assistance until 2:40 PM. Resident #1 confirmed that no staff had assessed her for incontinence care/toileting needs and said she was disappointed at the length of time staff took to respond to her need for assistance with incontinent care/toileting. Resident #3 Record review of the Care Plan for Resident #3 with a problem onset date of 10/14/2017 revealed Problem/Need I am at risk for respiratory distress related to my diagnoses of Dyspnea and Asthma .Approaches: Place my call light within reach . Record review of the Face Sheet for Resident #3 revealed the resident was admitted by the facility on 4/21/17, with diagnoses that included Spinal Stenosis, Polyosteoarthritis, and Mild Intermittent Asthma, with Status Asthmaticus. Record review of the Quarterly MDS with an ARD of 12/13/23, revealed the Resident #3 BIMS score of 4, which indicated severe cognitive impairment. Further MDS review revealed Resident #3 used a wheelchair for mobility and was dependent on facility staff for toileting, and personal hygiene, and was always incontinent of bowel and bladder. On 1/25/24 at 11:15 AM, 1/25/24 at 4:14 PM, and on 1/26/24 at 11:18 AM, observations revealed that Resident #3 was searching for her call light. During each of these times the the call light for Resident #3 was out of her reach. Resident #4 Record review of the Care Plan with a problem onset date of 8/22/2022 revealed I am incontinent of bladder .Approaches .Keep call light within easy reach of me . Record review of the Care Plan with a problem onset date of 8/22/22 revealed Problem/Need: I am at risk for Falls due to impaired mobility and antidepressant med use .Approaches .Place my call light and frequently used items within reach . Record review of the Face Sheet for Resident #4 revealed the resident was admitted by the facility on 8/22/22, with diagnoses that included Hypertensive Heart Disease with Heart Failure, Morbid Obesity, and Chronic Respiratory Failure with Hypoxia. Record review of the Quarterly MDS of Resident #4, with ARD 1/23/24, revealed the resident had a BIMS score of 12, which indicated moderate cognitive impairment. Further review of the MDS revealed that the resident was totally dependent on staff for bed mobility and was always incontinent of bowel and bladder. On 1/25/24 at 12:15 PM, an observation revealed the call light for Resident #4 was out of reach. The resident stated that she could not see or reach her food to feed herself, she needed to be repositioned in bed, but she could not find her bed control or her call light. Resident #5 Record review of the Face Sheet for Resident #5 revealed the resident was admitted by the facility on 8/18/23 with diagnoses that included Malignant Neoplasm of Unspecified Part of Unspecified Part of Bronchus or Lung, Secondary Neoplasm of the Brain, and Chronic Obstructive Pulmonary Disease. Record review of the MDS for Resident #5, with an ARD of 11/17/24, revealed the resident had a BIMS score of 14, which indicated Resident #5 was cognitively intact. On 1/25/24 at 12:20 PM, an observation revealed that the call light for Resident #5 was not within reach of the resident. On 1/26/24 at 3:00 PM, an interview with the Executive Director, she said that she expected all resident's care plans be followed by to for each resident according to the facility Care Plan Policy. On 1/26/24 at 3:40 PM, an interview with the Director of Nurses (DON) confirmed that she expected all resident's care plans be followed for each resident according to the facility care plan policy to meet the identified needs of all residents. She confirmed that the Certified Nursing Assistants (CNAs) were provided with instructions for resident care on the computer software program available to all CNAs on the wall mounted kiosks on each hallway. Pocket Care Guides which provide care instructions for each resident based on resident assessment and individualized care plans are also available for the CNAs on how to care for each resident.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure that dependent residents received the necessary services to maintain good grooming and personal hygiene for one (1) of five (5) residents reviewed for activities of daily living (ADLs). Resident #1 Findings include: Record review of the facility policy titled, INCONTINENT CARE, with a review date of 7/12, revealed, Policy: To provide routine, preventive skin, perineal care to residents after an incontinent episode. Responsibility: All Nursing Personnel . Record review of a statement signed by the Executive Director and dated 1/26/24, revealed that the facility did not have a specific policy for ADL (Activities of Daily Living) care. On 1/25/24 at 2:37 PM, an interview with Resident #1 revealed that she received morning care, including incontinent care and a bed bath prior to breakfast on 1/25/24 and received incontinent care following breakfast. She stated that she went to the Therapy Department prior to lunch at approximately 11:45 AM, returned to her room for lunch and then went back to the Therapy Department and finished her therapy. She stated that after she returned to her room after finishing therapy for the day, she was tired, uncomfortable in her wheelchair and her incontinent brief was wet. The resident stated I turned on my call light and a staff member, I don't know her name, came in and turned off my light and told me that my aide was on break and that she would tell my aide that I needed help when she returned from break. Resident #1 stated that she also reported to the medication nurse that she wanted to get into bed and that she needed to be changed. She stated that she waited almost an hour before her aide came to assist her to transfer to her bed and provide care for her. The resident voiced disappointment that she had to sit in the wheelchair, uncomfortable and with a wet incontinent brief so long. On 1/25/24 at 2:42 PM, an observation revealed Certified Nursing Assistant (CNA) #1 and CNA #2 assisted Resident #1 to transfer from her wheelchair to her bed using a sit-to-stand lift, after which CNA #1 assisted the resident with incontinent care. On 1/26/24 at 3:00 PM, during an interview with the Executive Director revealed she had viewed hallway security camera footage and reported that Resident #1 was returned to her room by a therapist at 1:25 PM. CNA #1 entered the room at 1:30 PM and exited and the resident's call light was engaged at 2:00 PM. She reported that Licensed Practical Nurse (LPN) #1 entered the room at 2:05 PM with the resident's medication and the call light was turned off. She stated that CNA #1 was observed getting a sit-to-stand lift at 2:30 PM and the resident's call light was engaged again at 2:38 PM. She stated CNA #1 and CNA #2 entered the room at 2:40 PM. The Executive Director confirmed that the resident waited for at least thirty-five (35) minutes for assistance to transfer from her wheelchair to her bed and have assistance for toileting/incontinent care. When asked if Resident #1's wait was an acceptable length of time for the resident to wait, she responded, It's kind of in between because she requires two-person assistance for transfers and CNA #1 had to wait for CNA #2 to finish care in another room. She confirmed that the resident had not received assistance with toileting or incontinent care since just after breakfast. She denied that the delay was related to lack of staff and that there were other staff available that could have assisted with resident care. Record review of the Face Sheet for Resident #1 revealed that the resident was admitted by the facility on 1/05/24 and with diagnoses that included Essential Hypertension, Type 2 Diabetes Mellitus, Repeated Falls, and Generalized Muscle Weakness. Record review of the 5 Day Minimum Data Set (MDS) with Assessment Reference Date (ARD) 1/12/24 revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #1 was cognitively intact. Further MDS review revealed the resident was dependent on facility staff for toileting and was always incontinent of bowel and bladder.

Based on observation, interviews, record review, and facility policy review, the facility failed to provide Activities of Daily Living (ADL) care regarding fingernail care for residents who are dependent upon staff for two (2) of four (4) sampled residents. Resident #1 and Resident #2 Findings Include: Record review of the facility's policy, Fingernails/Toenails Care, reviewed 10/09, POLICY:The purpose of this procedure is to clean the nail bed, to keep nails trimmed, and to prevent infections. Responsibility: Nursing Assistant or Licensed Nurse .1. Nails can be partially cleaned during bath care .3. Nail care includes daily cleaning and regular trimming . Resident #1 On 12/04/23 at 4:00 PM, an observation and interview with Resident #1 revealed she had contractures of both hands, and all of her fingernails were long. There was a black substance caked under her right thumbnail. Resident #1 stated that she did not prefer to have long fingernails and wanted her fingernails trimmed. The resident said she could not recall the last time her fingernails were trimmed. On 12/05/23 at 10:30 AM, during a telephone interview with the Resident Representative (RR) for Resident #1 revealed that she did not feel that Resident #1 received adequate grooming/fingernail care. Record review of the Face Sheet revealed the facility admitted Resident #1 on 1/09/18 and she had diagnoses including Parkinson's disease and Dementia. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 12/04/23 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated her cognition was moderately impaired. Resident #2 On 12/04/23 at 4:20 PM, an observation of Resident #2, revealed the resident had ten (10) long fingernails with a brown/black substance under all ten fingernails. Record review of the Face Sheet revealed the facility admitted Resident #2 on 5/14/2014 with diagnoses that included Dementia and Polyosteoarthritis, unspecified. Record review of the Quarterly MDS with an ARD of 9/26/23 revealed Resident #2 required a staff assessment for mental status and her cognition was severely impaired. Section GG revealed she was dependent upon staff for showering/bathing. On 12/04/23 at 4:35 PM, an interview with Certified Nurse Aide (CNA) #1 confirmed that the facility provided in-service training to all nursing staff regarding the care of residents that required assistance with ADLs. She confirmed that fingernail care to keep fingernails clean, trimmed, and smooth was included in ADL care. CNA #1 stated that CNAs were supposed to observe residents' fingernails daily and residents were supposed to receive fingernail care to clean, trim and smooth fingernails, according to resident preference as needed based on observation. The CNA confirmed that Resident #1 and Resident #2 had long fingernails that needed to be trimmed and there was dirt under the nails. On 12/05/23 at 1:00 PM, during an interview with the Wound Care Nurse, she revealed that resident fingernails were to be observed daily by nursing staff, CNAs, and nurses, and care was to be provided as needed, including cleaning, trimming, and filing. The Wound Care Nurse stated that Resident #1 had long fingernails that need to be trimmed and that the resident's right thumb nail needs cleaning, it's dirty under there. The Wound Care Nurse stated that long, dirty fingernails increased the risk of infection. The Wound Care Nurse said that Resident #2 also needed fingernail care. On 12/05/23 at 3:15 PM, an interview with CNA #4 revealed that the facility policy was that CNAs were to provide residents with fingernail care as needed for cleaning and that if there were reasons the CNA could not trim the fingernails and they needed to be trimmed the CNA was to report the observation to the Wound Care Nurse or the resident's assigned nurse.

Based on observations, policy review, record review, and interviews, the facility failed to ensure secure storage of medication included limited of access, for one (1) of four (4) sampled residents reviewed for pressure sores as evidenced by skin protectant ointment left unattended at resident's bedside. Resident #1. Findings Include: Record review of the facility policy titled Medication Storage ,reviewed 11/10 revealed POLICY: Medication supply must be accessible only to licensed nursing personnel, or staff members lawfully authorized to administer medications. All drugs, treatments, and biologicals must be stored securely and following the manufacturer's labeled recommendations, or per facility policy . Record review of a handwritten statement dated 11/14/23 and signed by Certified Nursing Assistant (CNA) #2 revealed that she fed some of a white substance she noticed next to the resident's supper tray to the resident. Record review of the Resident Incident Report dated 11/14/23 at 6:00 PM revealed that CNA #1 reported that Resident #1 had ingested approximately five (5) cubic centimeters (cc) of Zinc Oxide. The report stated that Poison Control was contacted with recommendations to increase water intake. The resident was assessed by the Director of Nursing Services (DNS), including vital sign measurement and neuro assessment. Resident #1's primary physician and responsible party were notified. Record review of a Physician's Telephone Orders for Resident #1, dated 9/19/2023, revealed . CLEAN EXCORIATED SKIN TO LEFT GLUTEAL FOLD .APPLY ZINC OXIDE OINTMENT TOPICAL DAILY UNTIL HEALED. Record review of a handwritten statement dated 11/14/23 and signed by Licensed Practical Nurse (LPN #3) stated that CNA #1 reported to her that CNA #2 had fed Resident #1 some white cream that was not food. On 12/04/23 at 4:00 PM, an interview with Resident #1, revealed she had no recollection of being fed zinc oxide and denied feeling nausea or abdominal pain. On 12/05/23 at 10:30 AM, a telephone interview with the Resident Representative (RR) for Resident #1 revealed she had been concerned that a CNA had fed zinc oxide skin protectant to Resident #1. She stated that she had been notified at approximately 6:30 PM on the evening of 11/14/23 that Resident #1 had ingested zinc oxide intended for topical use on her buttocks areas, after being fed the substance by a CNA during the evening meal. Resident #1's RR stated that she had not noted any adverse reaction or change in the condition of Resident #1 since the 11/14/23 incident. On 12/05/23 at 11:07 AM, a telephone interview with CNA #2 revealed the CNA confirmed that there was a plastic medication cup that contained a white cream on the over the bed tray of Resident #1 at approximately 6:00 PM on 11/14/23 when she had gone to assist Resident #1 to eat her supper. CNA #2 stated that she fed about a half of a teaspoon of it to Resident #1. CNA #2 stated that CNA #1 had entered the resident's room at that time and informed her that the white substance was not food. CNA #2 said the resident's nurse was notified immediately. CNA #2 stated that she worked for a staffing agency and that 11/14/23 was the second day she had worked at the facility. She stated that following the incident she provided a written statement and left the facility and had not returned. She stated that she was not allowed to work at the facility anymore. CNA #2 stated that no one had instructed her to feed the substance to the resident. On 12/05/23 at 1:30 PM an interview with the Director of Nursing Services (DNS) revealed that she confirmed that she had been made aware of the incident in which Resident #1 ingested zinc oxide on 11/14/23 at approximately 6:00 PM. She stated that she had immediately removed CNA #2 from all assignments, requested a written statement from CNA #2 and went to the resident's room and assessed the resident, including measurement of vital signs and neurochecks, which were all within normal limits. She stated that she contacted the Poison Control Center emergency hotline and reported the ingestion and received information to monitor the resident for nausea and increase water intake by mouth. The DNS stated that she notified the Emergency Department and prepared an In-Service Training for all nursing staff, which included proper storage and securement of medications. She said she also prepared a report for the Quality Assurance and Performance Improvement (QAPI) committee. She confirmed that she participated in audits of resident rooms for unsecured or unadministered medications and had observed none. The DNS reported that a QAP) Committee had met on 11/15/23 in response to the incident, during which it reviewed the policy and procedures for medication storage and administration with no changes noted. The DNS stated, Medication should not have been left in the room, period. The DNS stated that Resident #1 had no signs or symptoms of adverse reactions following the incident. On 12/05/23 at 1:00 PM during an interview with the Wound Care Nurse, she revealed that she did not recall leaving a medicine cup of unused zinc oxide at the bedside of Resident #1 on 11/14/23. She stated that the nurses who performed wound care and medication nurses for each unit each had a key to the treatment cart on each hall, which was where the skin protectant ointments were stored. She confirmed that she had received facility provided in-service training regarding the storage and security of medications and not leaving medications in resident rooms on 11/14/23. She confirmed that skin protectant ointments, such as zinc oxide were to be administered by a licensed nurse and any remaining ointment was to be discarded in the appropriate, secure receptacle outside the resident's room. Record review of the Face Sheet revealed the facility admitted Resident #1 on 1/09/18 with diagnoses that included Dementia. Record review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/04/23 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated Resident #1 had moderate cognitive impairment. Based on the facility's implementation of corrective actions on 11/15/23, the State Agency (SA) determined the deficiency to be Past Non-Compliance (PNC) and the deficiency was corrected as of 11/15/23, prior to the SA's first entrance on 12/4/23. Validation: On 12/04/23 through 12/05/23, the SA validated through staff interviews, record review, and facility policy review the facility began an immediate investigation when the incident occurred. The SA validated through record review of the Resident Incident Report dated 11/14/23 that CNA #1 reported that Resident #1 had ingested approximately five (5) cubic centimeters (cc) of Zinc Oxide. The report stated that Poison Control was contacted with recommendations to increase water intake. The report documented that the resident was assessed by the DNS, including vital sign measurement and neuro assessment and that Resident #1's primary physician and responsible party were notified on 11/14/23. The SA validated through a telephone interview with CNA #2 that the resident's nurse was notified immediately. CNA #2 stated that she worked for a staffing agency and that 11/14/23 was the second day she had worked at the facility and that following the incident she was removed from duty and instructed to provide a written statement and left the facility and had not returned. She stated that she was not allowed to work at the facility anymore. The SA validated through record review of the 'Educational In-Service Record' with attached sign-in sheets dated 11/14/23 and 11/15/23 that the facility provided in-service training regarding mediations/ointments left at bedside which included Nurses are to remove all medication cups when leaving room and Nursing staff must ensure no medications to include Lantiseptic, zinc oxide or other cream barriers are left in resident rooms to all nursing staff. The SA validated through an interview with CNA #1 that the facility provided in-service training to all nursing staff regarding medication storage, specifically nurses not leaving medications in resident rooms, and instructing CNAs to immediately notify their supervisor if they observed any medications unattended by nurses in resident rooms. The SA validated through an interview with LPN #4 that on or around 11/14/23 she had received facility provided in-service training regarding proper storage and securement of medications and treatment ointments which included instructions that no medications or treatment ointments should be left at in any resident's room. The SA validated through record review of the facility QAPI Project record dated 11/15/23 that the QAPI committee identified, Problem Identified Treatment medication left in residents room Action 1. Nursing staff educated on not leaving barrier creams (Lantiseptic, Zinc Oxide) or any other medications in resident rooms 2. Resident rooms monitored three times per week for four weeks to ensure medication and barrier cream not left in rooms Assessment 1. ED (Executive Director) and DNS to conduct monitoring for compliance Conclusion Documentation of conclusion to be provided to ED weekly for one month. Findings reported to QA Committee for review. The SA validated during an interview with the Wound Care Nurse, that she had received facility provided in-service training regarding the storage and security of medications and not leaving medications in resident rooms on 11/14/23. She confirmed that in-service instructions included that skin protectant ointments, such as zinc oxide were to be administered by a licensed nurse and any remaining ointment was to be discarded in the appropriate, secure receptacle outside the resident's room. The SA validated through an interview with the DNS that she had been made aware of the incident in which Resident #1 ingested zinc oxide on 11/14/23 at approximately 6:00 PM. She stated that she had immediately removed CNA #2 from all assignment, requested a written statement from CNA #2 and went to the resident's room and assessed the resident, including but not limited to measurement of vital signs and neurocheck, all within normal limits. She stated that she contacted the Poison Control Center emergency hotline and reported the ingestion and received information to monitor the resident for nausea and increase water intake by mouth. The DNS stated that she notified the ED and prepared an In-Service Training for all nursing staff, which included proper storage and securement of medications. She said she also prepared a report for the QAPI committee. She confirmed that she participated in audits of resident rooms for unsecured or unadministered medications and had observed none. The DNS reported that the QAPI Committee had met on 11/15/23 in response to the incident, during which it reviewed the policy and procedures for medication storage and administration with no changes noted. The DNS confirmed that the staffing agency had been contacted and that a Do Not Return request was issued for CNA #1. The SA validated through record review of the Medication Room Monitoring Audit Tool (Three times a week for 4 weeks) dated 11/15/23 through 12/01/23 and signed by the ED and DNS that resident rooms were audited for medications/barrier creams left in resident rooms and that none were observed during audits.

Based on observation, staff interview, record review, and facility policy review, the facility failed to notify the physician of adequate pain relief during wound care for one (1) of four (4) wound care observations, Resident #2. Findings include: Record review of the Facility's Pain Evaluation Management policy, with a revision date of 4/14, revealed all residents will be evaluated for pain upon admission, re-admission, and as needed. If the resident finds pain above acceptable levels, notify the physician. After the resident's pain is evaluated, and pain is identified, nursing will establish the problem on the care plan. The resident's physician will be notified of the pain results of pain evaluated and reviewed in order to develop further interventions for relief of pain. Observation of Resident #2's wound care on 8/03/16, from 3:15 PM until 3:24 PM, revealed LPN #1 performed wound care on the resident's sacral wound. Resident #2 moaned, groaned and grimaced throughout the procedure. LPN #1 continued wound care with the resident in pain. LPN #1 stated Resident #2 had been given [MEDICATION NAME] 50 milligrams (mg)earlier. LPN #1 did not ask Resident #2 if she was in pain or to rate her pain. Record review of Resident #2's cumulative August 2016 physician's orders [REDACTED]. There was also an order [REDACTED]. Review of Resident #2's Medication Administration Record, [REDACTED]. This was over an hour prior to Resident #2's wound treatment. There was no documented evidence of Resident #2 receiving PRN medications during the wound care treatment. Staff interview with LPN #1, on 8/04/16, at 12:10 PM, confirmed the resident was able to rate her pain, but she didn't ask her about her pain level during wound care, and did not stop the care while Resident #2 was moaning, grimacing, and groaning. She said the resident was uncomfortable and moaning and she should have stopped wound care and given her additional pain medication. LPN #1 stated Resident #2 usually moaned during the packing of her wound. When asked how a resident experiencing pain during wound care should be handled, LPN #1 stated she should call the physician and let him know the resident's pain medication is not holding her and get orders for additional pain medication. Staff interview with Resident #2's physician on 8/04/16 at 2:30 PM, confirmed if the resident moaned, groaned, and grimaced during wound care, he would expect the nurse to notify the nurse practitioner during the day, or him in the evenings. He stated he would not expect the nurse to continue with wound care if the resident experienced pain. He said he was unaware of the resident having unresolved pain with these symptoms until today. Staff interview with the Director of Nursing on 8/03/16 at 11:20 AM, confirmed if the resident is moaning when her wound is wiped during wound care, she would give the resident Tylenol, and call the physician, because the pain medication was not controlling the resident's pain. Based on the facility's face sheet, the facility readmitted Resident #2 on 6/21/16, with [DIAGNOSES REDACTED]. Review of the 5 Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/28/2016, revealed Resident #2 had a Basic Interview for Mental Status score of 6 indicating the resident had severe cognitive impairment. Section M- Skin Conditions of the MDS revealed, Section M0210 - resident with a stage 1 or higher pressure ulcer, Section M0300D1- reveals one (1) Stage 4 pressure ulcers at that time, and, Section 1M0300D2, reveals the resident had one (1) Stage 4 pressure ulcer on admission.

Based on observation, staff interview, and facility policy review, the facility failed to revise the comprehensive care plan as evidenced by no revisions to the care plan to reflect unresolved pain and changes in wound for one (1) of 18 care plans reviewed, Resident #2. Findings include: Record review of the facility's Care Plans policy, with a revision date of 4/14, revealed the care plan policy is for each resident to have a plan of care to identify the needs, problems, needs and strengths for the interdisciplinary team to provide care. For each problem, need, or strength, a resident centered goal will be developed. Care plan goals should be measurable. Staff approaches should be developed for each problem/strength/need. Assigned disciplines will carry out the approaches. The care plan will be reviewed, and revised at after completion of quarterly assessment, or significant changes and annual assessments. Record review of Resident #2's care plan, with an onset date of 4/05/16, revealed the resident had altered skin integrity related to pressure ulcer to the sacrum. Interventions included weekly skin audits, treatments as ordered by the physician, pressure reduction cushion to the wheelchair, and turn and reposition the resident as needed as nursing approaches. There was no mention of the resident's change in status secondary to her hospitalization on [DATE], for an infectious, Stage IV Wound to the resident's sacrum with debridement, or any interventions related to the infection. Record review of Resident #2's care plan, with an onset date of 01/16/16, revealed the resident was at risk for pain related to pressure ulcer to the sacrum and generalized pain. The care plan approaches included to observe resident's location, duration, frequency, and intensity of pain. Administer pain medications as ordered and as requested. Call light within reach, and, attempt non-pharmacological pain interventions as needed, with a target date of 10/03/16. The facility failed to include revisions to the pain care plan to address the unrelieved pain Resident #2 experienced during wound care. Record review of Resident #2's History and Physical, dated 6/13/16 at 10:47 PM, revealed under the section history of present illness: resident with decubitus ulcer with foul smell, progressively getting worse, therefore, she was admitted to the hospital with [REDACTED]. Record review of Resident #2's cumulative August 2016 physician's orders [REDACTED]. There was an order for [REDACTED]. Interview and record review of Resident #2's care plan, with the Licensed Practical Nurse/Minimum Data Set Coordinator #2, on 8/4/16 at 12:38 PM, confirmed staff failed to include revisions to the pain care plan to address pain medication prior to treatment and the unrelieved pain Resident #2 experienced during wound care. She also confirmed the changes in the resident's wound had not been addressed, and said she had been taught not to add stages of the wound or other information related to the resident's wound, on the care plan. Review of the facility's face sheet revealed the facility readmitted Resident #2 on 6/21/16, with the [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/28/16, noted Section M- Skin Conditions of the MDS revealed section M0300D1: one (1) Stage 4 pressure ulcers at that time, and, Section 1M0300D2, revealed the resident had one (1) Stage 4 pressure ulcer on admission/readmission. Resident #2 had a Basic Interview for Mental Status (BIMS) score of 6, indicating the resident had severe cognitive impairment.

Based on observation, staff interview, record review, and facility policy review, the facility failed to provide adequate pain relief during wound care for one (1) of four (4) wound care observations, Resident #2. Findings include: Record review of the facility's Pain Evaluation Management policy, revised 4/14, revealed all residents will be evaluated for pain upon admission, re-admission, and as needed. Obtain a pain rating each shift and record the results on the MAR (Medication Administration Record). If the resident finds pain above acceptable levels, notify the physician. After the resident's pain is evaluated, and pain is identified, nursing will establish the problem on the care plan. The resident's physician will be notified of the pain results of pain evaluated and reviewed in order to develop further interventions for relief of pain. Observation of Resident #2's wound care on 8/03/16, from 3:15 until 3:24 PM, revealed License Practical Nurse (LPN) #1 performed wound care on the resident's sacral wound, with the resident moaning, groaning, and grimacing throughout the procedure. LPN #1 continued to perform wound care with the resident in pain. LPN #1 stated Resident #2 had been given [MEDICATION NAME] 50 milligrams earlier. Record review of Resident #2's cumulative August 2016 physician's orders [REDACTED]. There was an order for [REDACTED]. Review of Resident #2's Medication Administration Record [REDACTED]. This was over an hour prior to Resident #2's wound treatment. There was no documented evidence of Resident #2 receiving PRN medications during the wound care treatment. Staff interview with LPN #1, on 8/04/16, at 12:10 PM, confirmed the resident was able to rate her pain, but she didn't ask her about her pain level during wound care, and did not stop the care while Resident #2 was moaning, grimacing, and groaning. She said the resident was uncomfortable and moaning and I should have stopped wound care and gave her additional pain medication, and given her 30 minutes and rechecked her pain level. LPN #1 stated sometimes the resident moans during wound care and usually moaned when packing the dressing in her wound. When asked how a resident experiencing pain during wound care should be handled, LPN #1 stated she should call the physician and let him know the resident's pain medication is not holding her and get orders for additional pain medication. Staff interview with Resident #2's physician on 8/04/16 at 2:30 PM, confirmed with the resident moaning, groaning, and grimacing during wound care, he would expect the nurse to notify the nurse practitioner during the day, or him in the evenings. He said he would not expect the nurse to continue with wound care if the resident is experiencing pain. He said he was unaware of the resident having unresolved pain with these symptoms until today. He said he ordered additional medication and the problem should be resolved. Staff interview with the Director of Nursing (DON) on 8/03/16 at 11:20 AM, confirmed LPN #1 should have stopped performing wound care on Resident #2 due to her unrelieved pain symptoms. The DON said, if the resident is moaning when her wound is wiped during wound care, she would give the resident Tylenol, and call the physician, because the pain medication was not controlling the resident's pain. Based on the facility's face sheet, the facility readmitted Resident #2 on 6/21/16, with [DIAGNOSES REDACTED]. Review of the five (5) Day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 6/28/2016, revealed Resident #2 had a Basic Interview for Mental Status (BIMS) score of 6, indicating the resident had severe cognitive impairment. Section M- Skin Conditions of the MDS revealed, Section M0210 - resident with a stage 1 or higher pressure ulcer, Section M0300D1- reveals one (1) Stage 4 pressure ulcers at that time, and, Section 1M0300D2, reveals the resident had one (1) Stage 4 pressure ulcer on admission.

Based on observation, interview, record review and policy review, the facility failed to ensure that standards of practice were followed for one (1) of four (4) residents reviewed (Resident #4. There was no evidence that a dietary evaluation and interventions were documented to promote wound healing for Resident #4. Resident #4 developed an unstageable pressure ulcer to the heel that got became infected and required antibiotics for treatment. Findings Include: Cross refer to F-314 for the facility's failure to provide adequate evaluation and documentation from the Registered Dietician and interventions to further promote wound healing for Resident #4 after the development of an unstageable pressure ulcer.

Based on observation, interview, record review and policy review, the facility failed to ensure that a resident who entered the facility without pressure ulcers did not develop pressure sores or have worsening of pressure ulcers for one (1) of four (4) residents reviewed (Resident #4). Resident #4 developed a pressure ulcer on her left heel that was not identified until it was unstageable. There was insufficient dietary consultation for Resident #4's pressure ulcer. The pressure ulcer became infected while at the facility. At the time of and discharge the family was not given any discharge instructions for care of the pressure ulcer. Findings Include: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the initial Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 12/8/10 revealed that Resident #4 had moderate cognitive impairment; was totally dependent for transfers with two (2) persons assist; did not ambulate and had no pressure ulcers or skin concerns. Review of an MDS with ARD of 2/26/11 revealed that Resident #4 was cognitively intact with some confusion to date and time. There were no documented behaviors on the MDS and she had improved in the ability to transfer with extensive assistance of one (1) person. Resident #4 was ambulatory with limited assistance of one (1) person. Resident #4 was not coded for pressure ulcers until a corrected MDS was completed with an attestation date of 4/28/11 that revealed Resident #4 had an unstageable pressure ulcer that measured 2.0 centimeters (cm) x 6.0 cm. Review of a "Weekly Skin Audit" dated 2/2/11 revealed that Resident #4 had an unstageable pressure ulcer to the bottom of the left heel. The weekly skin audits prior to 2/2/11 revealed that there were no wounds for Resident #4 documented. Review of the Nurse's notes dated 1/31/11 at 10:40 p.m. revealed that Resident #4 had complaints of pain in her feet and heel area. There was no documented assessment of the feet and heel areas for Resident #4 in the nurse's note. There was no documented nurse's note about Resident #4's pressure ulcer until 2/10/11 at 3:43 p.m. when it was documented that Resident #4 had an ulcer to the heel with a treatment in progress. Review of a nurse's note dated 3/29/11 at 11:14 p.m. revealed that Resident #4's scab on her heel was coming loose and there was odor noted. A C&S (culture and sensitivity) was done. Review of a nurse's note dated 4/6/11 revealed that Resident #4 was started on antibiotics [MEDICAL CONDITION] (Methacillin Resistant Staph Aureus) to her ulcer. The nurse's notes for Resident #4 on 4/2/11 at 12:48 a.m.; 4/5/11 at 10:53 p.m.; 4/7/11 at 11:34 p.m.; and 4/16/11 at 10:03 p.m. documented a complaint of foot pain with medication being administered. Review of a "Wound Evaluation Form" dated 2/1/11, revealed that Resident #4 had a fluid filled blister pressure sore with a small amount of drainage that measured 3 x 7 centimeters on her left heel. On 2/2/11, the Wound Evaluation Form documented that the blister was open and the skin was dark purple and hard with no drainage and no odor and was classified as an unstageable pressure sore. Weekly documentation was noted on the Wound Evaluation Form that the pressure sore remained with a hard dark scab and had decreased in size to 1.5 x 5.0 cm on 3/30/11, when the edges of the scab was noted to be loosened with odor and serosanguinous drainage. The pressure ulcer was documented at 1.5 x 5.0 cm through 4/20/11 with a dark black scab that was unstageable. Review of a "Pressure Ulcer Scale for Healing" (PUSH) Push tool 3.0" dated 2/1/11 revealed that Resident #4 had a decline of the pressure ulcer from 3/23/11-3/30/11 due to having exudate. The score went from "11" to "13" during this time and was "12" at discharge on 4/20/11. The tool is used as an in-house pressure ulcer tool. Review of an "Assessment of Pressure Ulcer Risk" dated 12/1/10, 12/4/11 and 3/4/11 revealed that Resident #4 was at risk for developing pressure ulcers. Review of physician's orders [REDACTED]. Review of a physician's orders [REDACTED].#4's left heel wound with the next lab draw and cover the heel with a dry dressing daily. Review of the C&S for Resident #4's left wound with a report date of 4/6/11 revealed the following organisms: Proteus mirabilis, Citrobacter freundii, Methacillin Resistant Staphylococcus aures (MRSA), and [MEDICATION NAME]. Review of a physician's orders [REDACTED]. Review of Resident #4's care plan was updated on 3/29/11 to obtain a culture of the left heel wound. There was no updated care plan that included the intervention of antibiotics of [MEDICATION NAME] and Bactrim DS that was ordered for Resident #4's wound infection on 4/6/11. Review of Resident #4's "Treatment Record" from 2/1/11 - 4/21/11 revealed documentation that the left lower foot was swabbed with [MEDICATION NAME] daily and beginning on 3/29/11 it was covered with a dry dressing. There was documentation that a foam boot was on Resident #4's left lower leg while in bed from 2/18/11-4/21/11. Review of an incident report for Resident #4 revealed that on 2/1/11 the resident was in therapy and stated that she was not wearing any shoes because she had blisters on her feet. Resident #4 was returned to her room and the Charge Nurse, LPN #4, was notified of a dark area on the resident's heel. Resident #4 was examined and found to have bilateral lower ankles/feet [MEDICAL CONDITION] that was 3-4+. A blister was noted that measured 7.0 x 3.0 cm with a mixture of dark and cloudy fluid that wrapped completely around the left heel. The type of injury was noted to be a pressure ulcer. Review of a "Supervisor Investigation Summary Form" revealed that the area surrounding Resident #4's blister on the left heel was painful to touch as evidenced by the resident stating, "Ouch that hurts." The facility concluded that Resident #4 had bilateral lower extremity [MEDICAL CONDITION] since admission and at times was non-compliant with elevating the extremities. A bilateral lower extremity Doppler on 2/3/11 suggested greater than 50% stenosis involving the right popliteal and left superficial femoral arteries. Resident #4 stated that her daughter had brought shoes that were too big for her one (1) to two (2) weeks prior, that kept slipping down on her heels. The facility determined that the fluid filled blister that was noted to the resident's left heel was caused by the [MEDICAL CONDITION] to the lower extremity coupled with the friction from the shoes rubbing up and down on the resident's heel. Resident #4's current shoes were removed from the room and non-skid sole socks were applied. The Family replaced the old shoes with properly fitting shoes. Resident #4's leg rest was exchanged for leg rests that allowed elevation of bilateral lower extremities while in the wheelchair and the resident was to have lower extremities elevated when in the bed and as needed while up in the wheelchair. Review of a care plan dated 12/1/10,revealed that Resident #4 was at risk for altered skin integrity related to limited mobility, diabetes, [MEDICAL CONDITION] to lower extremities, impaired cognition and occasionally refusing to elevate [MEDICAL CONDITION] ankles/feet. The care plan was updated on 2/1/11 to include an unstageable pressure ulcer to Resident #4's left heel with interventions which included a foam boot to the left heel, weekly skin audits, and Iodine to the left foot daily. There was no documentation of an intervention related to Resident #4's shoes in the care plan. There was no documented evidence in the medical record that Resident #4 had concerns with her shoes fitting properly or that properly fitting shoes were provided. There was no documented evidence that the facility had monitored Resident #4's feet/heels for concerns related to the [MEDICAL CONDITION]. Resident #4's pressure ulcer to her left heel was not assessed until it had reached an unstageable level on 2/1/11. Interview with Family Member #1 on 7/7/11 at 10:15 a.m. revealed that Resident #4 had a bed sore on her foot within a couple of months after admission. She stated that the family had been informed of the sore, but, that they had not been aware of how bad the sore was until the resident was discharged . Family Member #1 stated that she visited Resident #4 approximately five (5) days out of the week. She stated that a foam type bootie was ordered for Resident #4 but that they were not always on her while she was in the bed. She stated that there was nothing provided for the resident to wear on her foot when she went to therapy. The family member stated that Resident #4's foot was painted with [MEDICATION NAME] and covered with a little bootie sock. She stated that Resident #4 was referred to wound care by the Internal Medicine Physician but an appointment could not be gotten until after Resident #4 had been discharged from the facility. The family member stated that the facility gave no discharge instructions for taking care of the wound on Resident #4's heel. Interview with Family Member #2 on 7/7/11 at 2:30 p.m. revealed that she was made aware of the ulcer on Resident #4's heel but did not believe that it was caused by a shoe. She stated that Resident #4 was going to wound care and that it was going to take a long time for the wound to heal. Family Member #2 had concerns about how the sore had gotten that bad. Interview with LPN #2 on 7/7/11 at 12:02 p.m. revealed that Resident #4's wound had started out as a dark fluid filled blister on her mid heel and [MEDICATION NAME] and foam boots were ordered. LPN #2 stated that the family was informed that it was from her shoe and they brought her some soft house shoes. She stated that Resident #4 had a lot of [MEDICAL CONDITION] in her legs and that she was not always compliant with keeping them elevated. LPN #2 stated that Resident #4 wore foam boots while in the bed and house shoes during the day. Interview with the Director of Nursing (DON) on 7/7/11 at 12:15 p.m. revealed that LPN #2 had gotten her to look at Resident #4's heel. The DON stated that there was some leakage on the resident's sock and there was a fluid filled blister on the resident's heel that started at the mid heel and beneath the heel. She stated that the skin was still intact. The DON stated that Resident #4 said that her daughter brought her some shoes that had rubbed against her heel. The DON stated that treatment was started that day with [MEDICATION NAME] to try to dry up the blister. Interview with a Licensed Physical Therapy Assistant (LPTA) on 7/7/11 at 12:06 p.m. revealed that Resident #4 used a rolling walker and that she toe-touched on the left foot. He stated that he did not recall looking at the wound and that the resident didn't complain of a lot of pain during therapy. Interview with a Certified Occupational Therapy Assistant (COTA) on 7/8/11 at 10:35 a.m. revealed that Resident #4 came in with swelling in the ankle. She stated that she took off the fuzzy little sock that the Resident mainly wore to therapy and saw an area on her heel that was dark. She stated that she notified the nurse on the unit. The COTA stated that Resident #4 would stand up on her toe and not put weight on her heel while in therapy. The COTA stated that Resident #4 and didn't complain during the sessions. Interview with LPN #4 on 7/7/11 at 3:55 p.m. revealed that after Resident #4 began therapy that she would roll herself in the wheelchair using her feet and hands. She stated that Resident #4 had not complained of pain prior to the day that the therapist brought her back to the room and said that there was something on her foot. LPN #4 stated that she examined Resident #4's foot and there was an area that wrapped around the entire heel that did have some give to it. She stated that it was a dark fluid filled area. She stated that she had the Unit Manager (LPN #2) and the DON to look at the area. LPN #4 stated that she did not recall if heel protectors were used on Resident #4 but that pillows were used beneath the calf to float her heels. Interview with the Nurse Consultant with the Administrator present on 7/7/11 at 4:10 p.m. revealed that the wound for Resident #4 was identified as unstageable to start with and went from a dark blistered area to eschar. Both the Consultant and Administrator agreed that no matter how the wound happened, whether shoes or direct pressure, that no one had discovered or assessed the wound until it was unstageable. They agreed that a nurse or CNA should have found it before it had gotten to that stage. They both agreed that there should have been documentation in the nurse's notes about the wound when it was discovered. Interview with RN #1 on 7/7/11 at 7:40 a.m. revealed that the floor nurses do daily wound care and the RNs do assessments and measurements weekly on Wednesdays. She stated that prevention of pressure ulcers included turning/repositioning every two (2) hours as needed and barrier creams. She stated that if there was a pressure ulcer that the treatment was changed every two (2) weeks if no improvement, air mattress, heel boots, float heels, vitamin regiment and dietary involvement. She stated that pressure ulcer assessments were done on admit/re-admit and quarterly. Interview with the DON and Administrator on 7/11/11 at 8:25 a.m. revealed that they had reviewed Resident #4's chart the evening before and had pulled everything together. The DON stated that there was conflicting statements of whether something was actually on Resident #4's heel before 2/1/11 from the CNAs and nurses. The DON stated that CNA #1 and CNA #2 had written a statement that they had reported the blister on 1/26/11 to LPN #5. The DON stated that upon further investigation, LPN #5 completed a body audit on Resident #5 but ,was called away and didn ' t get back to look at the resident's feet. The DON stated that when LPN #5 was questioned about the CNAs reporting the blister on Resident #4's heel that LPN #5 did say that she did think that she had remembered being told about the blister. The DON stated that LPN #5 was suspended on 2/2/11. The DON stated that LPN #3 stated that she looked at Resident #4's heels on 1/27/11 and there was nothing there, however, there was no documentation in the nurse's note and no further mention of the area on the heel until 2/1/11. The DON stated that the treatment to Resident #4's wound was not changed due to the decrease in size. She stated that treatments were not usually changed unless they were not working. The Administrator stated that she did not remember all of the events until they had looked at the record and agreed that someone should have caught the area on Resident #4's heal before it got to an unstageable sore. Interview with Certified Nursing Assistant (CNA) #1 on 7/8/11 at 9:25 a.m. revealed that each resident's entire body was observed daily either during the shower or bed bath. CNA #1 stated that she and CNA #2 gave Resident #4 a shower and when they put her back in bed, she noticed a pressure blister on the bottom of her heel. CNA #1 stated that the back part was reddish with the skin peeling up on it and there was not a lot of fluid noted. CNA #1 stated that Resident #4 complained that it did hurt. CNA #1 stated that she left CNA #2, with the resident, told LPN #5 about the blister. She stated that LPN #5 told her to go tell RN #2, which she did. CNA #1 stated that she failed to document in the communication book because she wanted to get back to the resident and forgot. CNA #1 reviewed a written statement that was provided by the facility and verified that it was a statement that she had written about seeing the blister on Resident #4 on 1/26/11. Interview with CNA #2 on 7/8/11 at 10:15 a.m. revealed that she had assisted CNA #1 to the shower on 1/26/11 and observed a blister on her heel. She stated that she didn't recall exactly what it looked like but thought that it was red and the resident had said that her heel was sore. CNA #2 stated that she did not report the blister to the nurse but that CNA #1 had left the room to go and report it. Interview with LPN #5 on 7/8/11 at 9:10 a.m. revealed that she had started a body audit on Resident #4 on 1/26/11 but did not complete the observation of her feet because another resident had come into the room and she attended to the other resident. She stated that she had made a mistake by not coming back and documenting the complete body audit on Resident #4 . LPN #5 stated that she did not recall anyone telling her that there was an issue with Resident #4's heels. LPN #5 stated that she was called into the office the next week and suspended because she had signed the body audit on Resident #4 without it being complete. Also, for the CNAs telling her of the blister on the resident. Interview with RN #2 on 7/8/11 at 10:20 a.m. revealed that she did not recall anyone telling her that Resident #4's heel had a blister on it prior to 2/1/11. RN #2 stated that Resident #4 had a lot of [MEDICAL CONDITION] and that her heel had been painted with [MEDICATION NAME] because it had a hard black area on the heel. The area remained intact until she was discharged . RN #2 stated that they tried to keep the foam boots on the resident while she was in the bed. CNA #1 entered the room at 10:30 a.m. with RN #2 present and stated that RN #2 was the nurse that she had reported the blister to. CNA #1 stated that RN #2 was at the computer at the desk and looked up when she had told her about the blister but did not respond, however, she thought that she had heard her. CNA #1 also stated that she returned to LPN # 5 and informed her of telling RN #2 about the blister. RN #2 denied being told about the blister after CNA #1 had left the room. Interview with CNA #3 on 7/8/11 at 11:20 a.m. revealed that she was not aware of any blister on Resident #4's heel until it was already being treated. She stated that sometimes Resident #4 would already be up and dressed when she arrived. She stated that Resident #4 did not always wear her foam boots because she didn't like them. Interview with Resident #4's physician on 7/8/11 at 9:40 a.m. revealed that he had been made aware of the wound to the resident's heel and had looked at it. He stated that he did not recall exactly what it had looked like but thought that it was a blood filled blister. He stated that it was treated with [MEDICATION NAME] and the resident's heels were floated because she didn't like the boots. The Physician stated that he did recall the issue of wound care coming up before the resident's discharge. The physician stated that he did recall being told and understood that the wound was discovered approximately five (5) days earlier than it was reported to him and that it should have been addressed and treated at the time it was found. He stated that due to Resident #4's condition and [DIAGNOSES REDACTED]. The Physician stated that he did recall the wound getting an infection and that it was treated prior to the resident's discharge. Review of a Registered Dietitian (RD) note dated 2/10/11 at 3:40 p.m. revealed that Resident #4 had an unstageable wound to the left heel (3.0 x 7.0 cm). Resident received a regular low concentrated sweets/no added salt diet with an estimated 86% intake over the past week. A recommendation was made to add Sugar Free Med Pass 4 ounces three (3) times daily. There were no further notes from the RD that addressed Resident #4's dietary needs for the pressure ulcer. Review of a dietary note from the Dietary Manager (DM) on 3/11/11 at 3:14 p.m. revealed that Resident #4 had no evidence of increased need at this time and that the skin was intact and she would continue to monitor for weight, labs or intake changes. Review of a " Pressure Ulcer Intervention Guide " with a review date of 10/09 revealed: "To consider caloric counts as indicated and to evaluate the need for further vitamins and minerals when there was an unstageable pressure sore." There was no documented evidence that the RD or DM addressed any further skin issues for Resident #4 after 2/10/11. There was no documented evidence that further evaluation for vitamins and minerals were considered for Resident #4 after the pressure sore was infected. The RD was unavailable for interview. Interview with the DM on 7/8/11 at 12:50 p.m. revealed that she reviewed the dietary note of 3/11/11 and stated that she must have missed the pressure ulcer. She stated that she would normally let the RD know of any resident wounds and that the RD reviewed all wounds every time that she was here. The DM stated that the RD usually came every Thursday and got a list of wounds from nursing and let her know of any recommendations. The DM stated that she usually did a quarterly assessment but that she could not find one in Resident #4's medical record. The DM stated that she didn't know why the RD did not document on Resident #4's pressure ulcer after 2/10/11 unless it was overlooked. Review of the "24 Hour Nursing Report" dated 1/26/11 - 2/1/11 revealed no documentation of any skin concerns or pressure ulcers for Resident #4, even after the initial observation and treatment orders on 2/1/11. Review of a "Discharge Summary/Instructions" dated 4/21/11 revealed that there were no instructions or orders for a wound treatment to Resident #4's left heel. Interview with the DON on 7/8/11 at 11:30 a.m., with Resident #4's medical record available, revealed that when Resident #4's wound began to have an odor, a C&S was obtained. The DON stated that she did not see where the family had been notified of the odor or the C&S. The family was notified when the antibiotic was ordered about the results of the culture. The DON stated that Dietary was usually involved when a resident had a wound and would make recommendations according to the need. She stated that any added vitamins and minerals were ordered per physician discretion. She stated that the RD came every Thursday. The DON stated that there was no documentation in the nurse's notes where the RD or dietary was notified of the pressure ulcer for Resident #4. The DON stated that there was an initial nutritional assessment by the RD on 12/1/10 for Resident #4 and the next note was on 2/10/11 that documented a weight loss of 11.57%; and an unstageable wound to the left heel that measured 3.0 x 7.0 cm. The recommendation was to add a sugar free supplement three (3) times daily. The next note was from the DM on 3/11/11 with documentation that Resident #4's skin was intact. There were no further dietary notes documented. The DON stated that the RD got skin reports weekly and that she was not sure why there was no further documentation. The DON stated that there should have possibly been more vitamins or supplements added when Resident #4's wound became infected. The DON stated that the "Review of Pressure Ulcer Intervention Guide" for caloric count as needed and evaluate for need of further vitamins and minerals was only a guide and that she could not find where an evaluation was done for further vitamins and minerals. The DON reviewed the nurse's note for 1/31/11 at 10:40 p.m. where Resident #4 had complaints of pain to the heel and stated that there should have been a documented assessment of the resident's heel at that time. She agreed that this lead more to the belief that there was something actually present on Resident #4's heel prior to 2/1/11. The DON stated that the PUSH tool was done with the weekly skin reports and tells if the wound is progressing. She stated that Resident #4's wound did decrease in size and did not have drainage until around 3/30/11, when a culture was done and there was an infection. She stated that the tissue type remained the same with eschar. The DON agreed that the wound for Resident #4 may not have progressed to an unstageable if it had been reported and treated earlier. Further interview with the DON on 7/8/11 at 1:10 p.m. revealed that there were no discharge instructions for wound care on Resident #4's discharge summary and there should have been. Interview with the Administrator on 7/8/11 at 1:35 p.m. revealed that the facility should have caught Resident #4's heel sore earlier because two (2) CNAs had reportedly saw the area prior to 2/1/11. The CNA's stated that they had reported to nurses. When shown the nurse ' s note of 1/31/11 where Resident #4 had complained of heel pain, the Administrator stated that there should have been documentation of the observation and assessment at that time. The Administrator stated that the ball had been dropped and that there should have been more documentation, care plans should have been updated, and more communication about Resident #4's wound. She stated that 100% body audits were performed on other residents without concerns after Resident #4 was found with the unstageable wound and in-services were provided for documentation of CNA/Nurse communication, body audits and turning/repositioning. The Administrator stated that LPN #5 had been suspended and retrained for documenting a body audit on Resident #4 that was not completed. Review of the facility's policy "Preventative Skin Care" dated 7/09 revealed " It is the practice of this facility to provide routine preventative skin care. This policy will serve as a guide to facility staff with regard to clinically acceptable techniques to be applied for skin care prevention." The "Procedure" section documents the following: "1. A Risk Assessment will be completed on all residents upon Admission and Re-Admission with each MDS assessment. 2. Assessment of resident diagnosis, conditions and medications is to be completed to identify risk factors that may present complications. 3. Based upon the risk factors identified, the nursing staff will evaluate interventions that may need implementation. 4. Provide preventative skin care to all residents .... 5. Complete a Weekly Skin Assessment on all residents. 6. Utilize the Pressure Ulcer Intervention Guide to evaluate interventions that may be implemented based upon the resident's Risk Assessment. 7. Develop an individualized care plan for preventative skin care based upon evaluation and assessment." Review of the facility's policy "Pressure Ulcer & Skin Conditions Guide for Wound Evaluation Documentation" dated 10/10 revealed "It is the practice of this facility to ensure residents with pressure ulcers receive necessary assessment and treatment to promote healing, prevent infection and prevent new ulcers from developing." The facility failed to identify and treat Resident #4's wound until it was at an unstageable level. The facility failed to ensure that necessary assessment and evaluation of risk factors was provided to prevent the formation of a wound ([MEDICAL CONDITION] and ill-fitting footwear). The facility failed to provide adequate dietary interventions to promote wound healing after Resident #4 developed a pressure ulcer. Resident #4 ' s pressure ulcer became infected and had to be treated with antibiotics and there was no evaluation for a change in wound care treatment.