Every finding on record at Laredo South Nursing and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #1) reviewed for infection control practices. The facility failed to ensure Resident #1 had the appropriate isolation and precaution signage posted outside of her door or room. Resident only needed the EBP sign, but she had both an EBP and droplet precaution sign on her door. The facility failed to ensure Resident #1 had an infection control physician's order for Enhanced Barrier Precautions to be re-implemented after Contact Isolation had ended 06/24/2026.The facility failed to ensure Resident #1 had a previous infection control physician's order for contact isolation prior to Enhanced Barrier Precautions being re-implemented beginning 06/17/2026. These failures could place residents at risk for cross-contamination and infection.The findings included:Record review of Resident #1's face sheet, dated 07/15/2026, revealed an [AGE] year-old female with an original admission date of 03/04/2025, and a current admission date of 04/30/2026. Pertinent diagnoses included Obstructive and Reflux Uropathy (when urine cannot flow correctly through the urinary tract and caused reflux, or backward flow, into the kidneys). Record review of Resident #1's physician order summary, reviewed 07/15/2026, revealed a current order dated 05/21/2026 to change the suprapubic catheter (a device inserted into the bladder to drain urine if an individual could not urinate on their own) once every 4 weeks. The current active physician order summary did not reveal an order for any type of precautions or isolation. The previous, discontinued, physician orders did not reveal any recent precautions or isolation orders. The MDS nurse was able to print and show the surveyor an order which was both started and discontinued on the same date and time: 05/15/2026 at 12:16 PM to use gown and gloves for high contact resident care activities.Record review of Resident #1's Quarterly MDS assessment, dated 06/17/2026, revealed a BIMS score of 13, which revealed intact cognition. The Quarterly MDS assessment also revealed Resident #1 had an indwelling catheter. Resident #1's MDS also revealed an active diagnosis of Neurogenic Bladder (a condition which affects bladder function due to the nervous system) and Obstructive Uropathy. Record review of Resident #1's laboratory results, dated 06/17/2026, revealed Resident #1 had ESBL (groups of bacteria which could be resistant to common antibiotics) in her urine, and contact precautions should be initiated, per the laboratory results summary.Record review of Resident #1's progress note, dated 06/17/2026, signed by the NP, revealed Resident #1 had been placed on Meropenem (a broad-spectrum intravenous carbapenem antibiotic used to treat serious infections) 1 G IV every 8 hours for 7 days. Record review of Resident #1's care plan initiated 10/11/2025 and revised 05/22/2026, revealed the need for EBP due to an indwelling catheter. Interventions included ensuring EBP sign was placed on the door to notify staff and visitors of the precautionary measures. In an observation of Resident #1's room on 07/15/2026 at 12:03 PM revealed both an EBP sign and a droplet precaution sign located on the door of Resident #1's room, when the EBP sign was the only sign needed. In an interview on 07/15/2026 at 10:57 AM, the ADON, who was also the ICP, stated either herself or sometimes the MDS nurse would put in the infection control orders for precautions or isolation. She stated she was not sure why Resident #1's orders were missing other than maybe they were just overlooked. The ADON stated Resident #1 was previously on contact isolation, but she was switched back to EBP after she completed her antibiotic for her UTI. She also was not sure who placed the droplet precaution sign on Resident #1's door because it should have only been an EBP sign. In an interview on 07/15/2026 at 12:35 PM, LVN-A stated Resident #1 was on EBP, not droplet precautions, and he was not sure why there was a sign for droplet precautions on her door as well. LVN-A stated an order was not required to place residents on EBP because it was policy to place all patients with indwelling medical devices on EBP. He said an order was required though if the patient was being placed on contact precautions, which Resident #1 had recently been on prior to being switched back to EBP. After clarifying with the ADON, who was also the ICP, LVN-A stated he was wrong, and an order needed to be obtained when placing residents on EBP precautions, as well as the correct precautions or isolation signs and PPE implemented so staff knew the correct PPE to wear when assisting the resident to prevent cross-contamination. In an interview on 07/15/2026 at 1:06 PM, the MDS nurse stated floor nurses, the ADON, and/or the DON were the ones who placed the orders for EBP, or other precautions or isolations. The MDS nurse also stated anyone could add EBP to the care plan, but it was usually the MDS nurse. She stated she typically looked over and checked the orders prior to adding precautions or isolations to the care plan, but she guessed she overlooked the order for Resident #1's EBP. She stated she was still looking to try and find both the previous contact precautions order, as well as the current EBP order for Resident #1, which were needed to implement EBP, but so far she had only found the EBP order from May 2026 which had been written and discontinued on the same day at the same time. Record review of the facility's Enhanced Barrier Precautions Policy, implemented 11/24/2025, revealed Policy Explanation and Compliance Guidelines: 2. Initiation of Enhanced Barrier Precautions: B. An order for enhanced barrier precautions will be obtained for residents with any of the following: I.Indwelling medical devices.Record review of the CDC: Long-Term Care Facilities (LTCFs): Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 04/02/2024, revealed EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: A. Wounds or indwelling medical devices, regardless of MDRO colonization status; B. Infection or colonization with an MDRO. Contact Precautions: Contact Precautions are intended to prevent transmission of infectious agents, like MDROs, that are spread by direct or indirect contact with the resident or the resident's environment. Contact Precautions require the use of gown and gloves on every entry into a resident's room. Enhanced Barrier Precautions: Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices. Implementation: Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE. For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves. https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html?CDC_AAref_Val=https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html

Based on observation, interview, and record review the facility failed to provide reasonable accommodation of resident needs and preferences for one (Resident #1) of four residents reviewed for call light placement. The facility failed to ensure Resident #1's call light was within reach on 06/29/26. This failure could place residents at risk for needs and accommodations being unmet and a delay in care.Record review of a face sheet dated 6/29/2026 indicated Resident #1 was a [AGE] year-old male, initially admitted on [DATE] and last re-admitted on [DATE], diagnoses included Hypertensive Heart Disease without heart failure (heart damage or structural changes caused by long-term high blood pressure), Epileptic seizures related to external causes (sudden temporary bursts of abnormal electrical activity in the brain that disrupt normal communication between nerve cells), depression, Hemiplegia (the complete or partial paralysis of the entire side of the body) and hemiparesis (partial weakness or reduced control on one entire side of the body) following cerebral infarction (stroke), benign prostatic hyperplasia (non-cancerous enlargement of the prostate gland) without lower urinary tract symptoms, and cognitive communication deficit. Review of a quarterly MDS assessment dated [DATE] indicated Resident #1 had a BIMS (brief interview for mental status) score of 04 which indicated severe cognitive impairment. The MDS indicated Resident #1 was inattentive or had an altered level of consciousness. The MDS revealed Resident #1 needs substantial/maximum assistance with 6 out of 8 activities of daily living regarding self-care. Record review of Resident #1's care plan, undated revealed, Resident #1 is at risk for falls related to needing maximum assistance with activities of daily living, with an intervention to ensure his call light is within reach and to encourage the resident to use it for assistance as needed. During an observation of Resident #1 on 6/29/2026 at 12:36 pm, he was lying in bed with the door open. The call light was observed on the floor underneath the curtain that separated the room into side A and B. The call light was not within reach of Resident #1. During an interview with Resident #1, on 6/29/2026 at 12:36 pm, he stated he usually had his call light, but he did not remember when he had it last. Resident #1 stated he doesn't think he could use his call light and he did not need anything right now. Resident #1 stated if he needed anything he would just call out for help. During an interview with CNA B on 6/29/2026 at 12:45 pm, she stated Resident #1's call light should be within reach. CNA B stated it is not acceptable for residents not be able to reach the call light. CNA B stated, she was not assigned to this resident today, but staff usually made rounds every 2 hours. CNA B stated all residents call lights should be within reach. She stated that the call light is how staff would know if a resident needed something. During an interview with CNA A on 6/29/2026 at 12:45 pm, she stated she had given Resident #1 a shower about 11:30am. She stated she might not have put his call light within his reach. CNA A stated she had been trained that call lights were supposed to be within reach of the residents. CNA A stated the last call light training may have been about a month ago. CNA A stated there are all types of call lights and Resident #1 could use the call light he is assigned, but it must be on his strong side in order for him to press the button. During an interview with the DON on 6/29/26 at 1:00 pm, the DON stated it is her expectation that call lights are to always be within reach of every resident. The DON stated, Resident #1 does make his bed go up and down with his bed remote control and he had tremors which may cause the call light to fall. The DON stated there is a potential for Resident #1 to be harmed or to not have his needs met without his call light. The DON stated it is every staff member's job to ensure call lights are within reach of all residents. The DON stated all staff should make rounds every 2 hours to check on all residents. The DON stated the facility had in-serviced on call lights this month, but she will have one this month. Record review of facility policy titled Call lights: Accessibility and Timely Response and dated 10/13/2022 included verbiage 5. Staff will ensure the call light is within reach of residents and secure, as needed. 6. The call system will be accessible to residents while in their bed or other sleeping accommodation within the room.

Based on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food per professional standards for food service safety for 1 of 1 kitchen reviewed for storage, preparation, and sanitation.The facility failed to ensure dishes were cleaned after washing and not used for service.The facility failed to ensure the utensils were in good condition.The facility failed to ensure personal items were not in the prep areas.The facility failed to ensure a cabinet door was safe to open.The facility failed to ensure table scraps were disposed of properly.The facility failed to ensure personal items were separated from leftovers in refrigerator #D2.The facility failed to ensure food items in refrigerators #A1, and #D2, and freezers #B3, #C3, and #D2 were labeled, dated, and stored properly.The facility failed to ensure the dry storage area was free from fruit and dented cans.The facility failed to ensure food items in the dry storage area were properly sealed, labeled, and dated. The facility failed to properly maintain temperature logs in refrigerators #A1, and #D2, and freezers #B3, #C3, and #D2.The facility failed to maintain dishwasher temperature and sanitation logs. The facility failed to ensure all staff were properly trained in removing dishes from meal trays and serving residents seated at the same table at the same time. The facility failed to ensure all kitchen staff were using the designated handwashing sink and not the prep sink for handwashing.These failures could place residents who received meals and/or snacks from the kitchen and satellite kitchens at risk for food contamination and foodborne illness.Findings included:Observation and initial tour of the kitchen on 07/20/25 at 10:45 am revealed 13 of 26 coffee cups on the coffee cart were scratched and stained inside, and some had food stuck to the inside. The coffee maker on the coffee cart was leaking coffee. There were 20 of 78 juice glasses on the clean rack with a partially removable white substance in the bottoms and up the sides. There was a serving ladle stacked in another ladle in a clean drawer that had a sticky, red substance in it. When moved, the ladle beneath it had a sticky, red substance on its bottom, and inside the drawer. There was a large rubber spatula hanging from the pot rack with chips missing from the sides. There was a Styrofoam cup with foil over it and a personal cup next to the mixer on a prep table, both unlabeled and undated. There was a cabinet door above a prep area with an unscrewed hinge at the bottom that fell sharply when it opened. The DW was using an open trash bag on the floor to scrape food scraps into it. Refrigerator #D2 had a sign on the outside of the door that read, Kitchen Staff Only Refrigerator. One of the drawers inside refrigerator #D2 had a sign on it that read, This area is exclusive for employees and was full of what appeared to be jalapeno peppers. The peppers were loose in the drawer. Inside refrigerator #D2, there was an open Styrofoam cup without a lid that was 1/2 full of red liquid, unlabeled and undated. There were food items (later identified by the CK as leftovers for residents) stored in 5, 2-quart containers. Three of the containers were dated 07/16/25. There was a 1-gallon bag of what appeared to be 6 egg rolls unlabeled and undated; a partially empty 1-pint bottle of red liquid unlabeled and undated; 7 small sausages in a wrinkled, open piece of foil; a 1-gallon bag labeled turkey, but had no dates on it; a 1-gallon bag of a brown/red substance (later identified by the CK as left over beans) unlabeled and dated 07/16/25 inside refrigerator #D2. Refrigerator #A1 and freezer #s B3 and C3 had several unlabeled and undated trays of desserts inside. There was a 1/2-pint carton of milk open to air, unlabeled and undated in refrigerator #B3. There was a small juice glass filled with a white substance next to the open carton that was also not labeled or dated. There was a large bag of frozen ravioli in freezer #C3 dated 01/12/25. The ravioli was covered in frost and discolored. There were 3 resident pitchers open to air, 1/2 full of ice, undated and unlabeled in freezer #B3. There were 5, 6-pound dented cans on the use shelf in the dry storage room. The bin labeled Do Not Use Damaged Food Cans was empty. There was an uncut melon on the shelf in the dry storage room. There was a 1-gallon bag of bread and 8 slices of bread in a partially closed bag and a large, loosely closed bag of tortillas unlabeled and undated in the dry storage room. Refrigerator #A1 had an outer digital thermometer that read 36F even when the doors were opened for several minutes. The internal thermometers read 42F-45F with the doors open. The daily freezer and refrigerator temperature logs were missing data. The low-temp dishwasher temp and sanitation logs had the same numbers logged every day. There was one tray cart that had no covering on the sides or top. There were four regular push carts near the open tray cart.Observations and interview with the DW on 07/20/25 at 10:55 am, he said the low temp dishwasher temperature should be 120F, but it read 115F. He said he did not know how long the dishwasher water temperature had been low. He said he did not know what the sanitation level should be. [Chem strip container numbers and colors were scaled 0-light yellow, 100-light green, etc.] The DW demonstrated using a chem strip during the rinse cycle and he said the activated chem strip should be on the 100 of the chem strip container. The chem strip read 0. The DW said the chem strip was closer to zero than to 100. The DW said he was not sure what the level of sanitation was. He said the dishwasher temperature and sanitation log might not be accurate, as all the numbers were the exact same and did not reflect the temperatures or the sanitation level that had been documented. The DW said if the dishes were not getting sanitized in the dishwasher, it could cause cross-contamination and make residents sick. The DW said he did not know why he was not using a trash bin with a removable lid and the garbage bag inside to remove food from the dishes. Regarding the unhinged cabinet door, the DW said he had verbally told the maintenance man multiple times and wrote it in the log at the nurse's station but did not use the facility's electronic maintenance system. There was no log at the nurse's station. The DW said the kitchen staff never used the designated handwashing sink. He said kitchen staff used the prep sink for handwashing. He said he did not know why it mattered which sink they used for handwashing.Observation of dinner service in the dining room on 07/21/25 at 5:05 pm revealed CNA E was observed grabbing multiple resident cups and bowls by the top rim during meal service. Several tables with seated residents were not served at the same time. In an interview with the CK on 07/20/25 at 11:00 am, she said the coffee maker had been leaking badly for about 3 months and she told the FPM about it. She said they were not supposed to be using the leaking coffee maker. She said they liked it better than the thermoses they were supposed to be using. The CK said the food in refrigerator #D2 was leftovers for the residents. She said staff items should not be in there. She said all food should be labeled and dated. She said food should be thrown out after 3 days. She said she did not know who was responsible for making sure expired food in the refrigerators was removed. She said all kitchen staff were responsible for making sure food in the refrigerators and freezers was labeled and dated so everyone knew what it was and when to get rid of it. She said the kitchen staff were supposed to be using the designated handwashing sink for handwashing, and she never used the prep sink for handwashing. She said the dietary aides were responsible for logging the refrigerator and freezer temperatures. The FPM was unavailable for interview at this time.In an interview with the FPM (food protection manager) and the RD on 07/21/25 at 2:58 pm, the FPM said the DW did not know how to take the temperature of the dishwashing machine because he was nervous about it and the chem strips. She said he had been trained and should have known. She said the DW was responsible for making sure dishes were clean before placing them on the clean rack. She said the CNAs were responsible for the stains and stuck-on food in the coffee cups because it was easy for them to put oatmeal in the cups for the residents to eat from. The FPM and RD both said the residents used metal spoons to eat from the cups and to stir their coffee. She said the chemicals in the dishwasher were not strong enough to wash everything. She said the chem strip should be at 100ppm and thought they were using the correct test strips for the low temperature dishwasher. She said the water may not have been hot enough to clean the dishes. She said the dishwasher company did not come to check the (low temperature) dishwasher, even though the ADM called them. The RD said cross contamination from dirty dishes could make residents sick and affect their health. The RD said they could start using plastic spoons or wooden stirrers to prevent the plastic cups from becoming scratched and harboring bacteria. The FPM said leftover food was good for 3 days only and all food should be labeled and dated in the refrigerators, freezer, and dry storage area to prevent contamination. She said she had been trying to replace the coffee maker for 3 months and had let the ADM know. She said the ADM told her he was trying to see if another facility had a replacement. She said personal items were never allowed in the prep areas, but sometimes kitchen staff ate or drank inside the kitchen anyway. She said staff had been trained and should not have personal items in the kitchen. She said she was unaware of the broken cabinet door. She said she did not know why the DW was not using the trash bin for table scraps. She said refrigerator #1 was for residents only. She said she was unaware the staff was using refrigerator #1 for personal items. The FPM said the dry storage area had a bin for dented cans and did not know why the dented cans were on the shelf with the good cans. She said the dented cans were not to be used because the inside would go bad and could make residents very sick. She said a shipment came in last Thursday (07/17/25) and she was out that day for medical reasons. She said nothing when asked why the other kitchen staff did not place the dented cans in the dented can bin. She said temperatures for refrigerators should be 41F or less, or the food would go bad and must be thrown away. She said the temperatures of refrigerators and freezer were checked twice a day. She said no one was monitoring the logs for accuracy. The FPM said she did not know if kitchen staff were using the prep sink to wash their hands because the handwashing sink was easier to get to. She said the open tray cart and the four open push carts were how trays were delivered to residents who received their meals in their rooms.Refrigerator and Freezer Daily Temperature logs, Dishwasher Temperature and Sanitation Logs, Trainings/In-Services from May 2025 to present, and policies for Dishwasher Temperature and Sanitation, Food Storage, Refrigerator and Freezer Temperatures and Logs, and Personal Items in the kitchen were requested at this time. In an interview with CNA A on 07/21/25 at 5:29 pm, she said there was no reason why she was grabbing the resident cups from the lids. CNA A stated she just forgot to grab from the side. She said she had been trained on proper service but could not say when. CNA A stated it was important not to grab resident cups from the top due to cross contamination. She said she could be spreading germs and could make the residents sick. In an interview with the RD on 07/21/25 at 5:32 pm, she said she passes by the dining room when she was at the facility for her monthly visits. She said she had to help the FPM because she was new at her job and was coming in 2-3 times a month for the past month, then she said she had been coming in 2-3 times a month since May 2025. (The FPM hire date was 06/30/23). She said she was involved with training the kitchen staff monthly on various topics including serving from trays, but not nursing staff. She said cups and bowls should be handled by staff by the sides, not the top. She said tables should be served at the same time. The RD said she observed dining on the days she came to the facility and did not train nursing staff on how to pass out meal trays. The RD stated if she saw something wrong with the CNAs, she would let the DON know so further education could be provided. The RD said she did not know if residents who received meals in their rooms complained of the food being cold. She said she did tastings but could not elaborate timing or frequency. She said she was aware of the tray delivery system (open tray cart and open push carts). A test tray was requested at this time.Test tray received on 07/21/25 at 5:43 pm-temperatures were within range. The ADM and RD were present with the survey team. Ham, sweet potatoes, and green beans, along with a roll, matched the menu. The green beans were tasty and had a good texture. Everyone agreed the ham and sweet potatoes were not tasty. The ADM looked up the recipe and discovered it called for lemon juice and orange juice for both the ham and sweet potatoes. Everyone agreed with the ADM who said the texture was ok for the ham, but the sweet potato texture was not identifiable as potato and the flavor of the ham and sweet potatoes was not right and did not taste good. The ADM told the RD she should oversee the recipes.In an interview with the ADM on 07/22/25 at 1:00 pm, he said, the kitchen staff had a thermos to put coffee in. He said the coffee maker worked, but it leaked. He said he got a new coffee maker, but the temperature of the coffee was too hot, so they stopped using it and purchased the thermoses. He said the leaking coffee maker was supposed to have been thrown out. He said the leaking coffee maker was used on Sunday (07/20/25) out of convenience. He said he did not know why kitchen staff preferred wiping up the mess the leaking coffee maker made over the thermoses. He said he called the dishwasher maintenance guy on Sunday (07/20/25) but he did not come to the facility. He said the dishwasher maintenance guy did some trouble shooting over the phone with him instead. He said he checked the hot water heater, and the temperature of the water was 140F. He said he checked the sanitizer lines for blockages and kinks, and they were in good shape. He said the chem strips were correct for the machine. He said there was no excuse why the temperatures of the refrigerators and freezer were being documented by the external digital temp reading. He said the FPM did training on it. He said he did not know why the DW was scraping trash into a bag on the floor-that was not their process. He said their process was for trash to go into a bag inside the trash can with a lid. He said he told the entire team they had a process for getting repairs done through their electronic maintenance system. He said the cabinet door had been fixed several weeks ago, or so he thought. He said the cabinet was fixed yesterday and he uploaded a photo of the cabinet on 07/21/25. (Verified) He said the spatula looked melted and it should not be in use. He said there was more training to be done with kitchen staff to resolve these issues. He said more oversight was necessary, and the RD was coming out every other week, as well as her back-up. He said the RD performed dietary sanitation reviews monthly. He said the RD had her own system for food tasting but he did not know what it was nor if she watched service delivery. He said the RD could train staff on serving and seating arrangements, so the residents at the same table received their trays at the same time and not have to watch the others at the same table eat while they were waiting.Record review of the facility's Dish Machine Temperature and Sanitizing Logs revealed the following out-of-range findings for morning (a.m.), noon, and evening (p.m.) wash temps, final rinse temps, and sanitizer ppm: May 2025- a.m. wash temps 100F on five days, 110F on 3 days. Final Rinse temps were within range. Sanitizer ppm logged at 100ppm on 24 days and 50ppm seven days. Noon wash temps 100F on 12 days, 110F on 11 days. Final Rinse temps 110F on 2 days and 115F on 2 days. Sanitizer ppm logged at 200ppm on 4 days and 50ppm 1 day. p.m. wash at 100F on 8 days. Final Rinse 100F on 3 days, 110F on 4 days. Sanitizer logged at 100ppm each day.June 2025 (31 days logged)- had no outstanding numbers but had 4 days marked out for an unknown reason.July 1-22 2025 (the 19th was missing all data) a.m. Final rinse 110F for 6 days, 115F for 1 day. Sanitizer 110ppm. Noon wash temp 100F for 5 days. Final Rinse 100F for 12 days and 110F for 3 days. Sanitizer had no outstanding numbers. p.m. wash temps 100F for 4 days, Final rinse 100F for 13 days and 110F for 2 days. Sanitizer logged at 100ppm each day.Record review of the facility's Refrigerators and freezer temperature logs for May, June, and July 2025 revealed Refrigerator #A1 was 40F, and freezer #B3 was 0 degrees F for all a.m. and p.m. dates in May. Refrigerator #D2 was 40F for all days in June. Refrigerator #A1 was missing data for the mornings of July 15 and 22, and evenings of July 1 and 21. All July temperatures recorded were 36F. Freezer #B3 was missing data for the mornings of July 15 and 22, and evenings of July 1 and 21. Temperatures were out of range (above 0 degrees F) for 5 p.m. days. There was no documentation of reporting the out-of-range temperatures. Freezer #C3 was missing data for mornings of July 4, 15, and 22, and evenings of July 1, 12, 13, and 21. Temperatures were out of range (above 0 degrees F) for 7 a.m. days and 15 p.m. days. There was no documentation of reporting the out-of-range temperatures.Refrigerator #D2 was missing data for the mornings of July 12, 13, 14, 15, and 22, and evenings of July 1, 2, 5, and 21. All recorded temperatures were 40F. Freezer #D2 was missing data for the mornings of July 12, 13, 14, 15, and 22, and evenings of July 1, 22, and 21. All recorded temperatures were 0 degrees F except 4 a.m. days which were 36F, 38F, 40F, and 5F. One of the p.m. temperatures was recorded as 10F. There was no documentation of reporting the out-of-range temperatures.Record review of the facility's kitchen in-services: 04/17/25 For future dietary manager on how to access tray cards and diet orders. 07/21/25 Labeling and Dating, Food storage Guidelines, Temperature Logging, Cleaning, Sanitation, and Food Service Equipment Conditions. 07/22/25 Personal Items and Employee Sanitation.Record review of the facility policy titled, Employee Sanitation approved 10/01/18 reflected, Policy: The nutrition and foodservice employees of the facility will practice good sanitation practices in accordance with the state and US Food Codes in order to minimize the risk of infections and food borne illness. Procedure: 3e. Employees will not eat or drink in food storage and preparation areas, or in areas containing exposed food or unwrapped utensils, or where utensils are cleaned or stored. 4b. Cups, glasses, and bowls must be handled so that fingers or thumbs do not contact inside surfaces or lip-contact outer surfaces.Record review of the facility policy titled, Mechanical Cleaning and Sanitizing of Utensil and Portable Equipment approved 10/01/18 reflected, Policy: The facility will follow the cleaning and sanitizing requirements of the state and US Food Codes for mechanical cleaning in order to ensure all utensils and equipment are thoroughly cleaned and sanitized to minimize the risk of food hazards. Procedure: 7. If a machine that uses chemicals for sanitizing is in use, follow these guidelines: a. The temperature of the wash water must be at least 120F. e. The chemical sanitizing rinse water temperature must be at least or no less than the temperature specified by the machine's manufacturer. f. A test kit or other device that accurately measures the parts per million concentrations of the solution must be available and used. Record review of the facility policy titled, Food Storage approved 10/01/18 reflected, Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal, and US Food Codes and HACCP guidelines. Procedure: Procedure: 1. Dry storage rooms d. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. 2. Refrigerators a. Keep fresh meat, poultry, seafood, dairy products, and most fresh fruit and vegetables in the refrigerator at an internal temperature of 41F or less. c.Do not overstock the refrigerators and leave space between items to further improve air circulation. d. Date, label, and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. e. Use all leftovers within 72 hours. Discard items that are over 72 hours old. h. Place a thermometer inside refrigerators near the door where the temperature is warmest. Check the temperature of all refrigerators using the internal thermometer to make sure the temperature stays at 41F or below. Temperatures should be checked each morning and again on the PM shift. Record the temperatures on a log that is kept near the refrigerator. 3. Freezers h. Place a thermometer inside freezers near the door where the temperature is warmest. Check the temperature of all freezers using the internal thermometer to make sure the temperature stays at 0F or below. Temperatures should be checked each morning and again on the PM shift. Record the temperatures on a log that is kept near the freezer. Record review of the manufacturer specification for the dishwashing machine indicated for low-temperature models: Wash and rinse at temperatures between 120F and 140F, relying on chemical sanitizing agents with the wash water. Use test strip to ensure sanitizer levels is at least 50ppm and no more than 200ppm. Test strips are most accurate at 120F. Higher temperatures may distort reading. If this occurs, use a clean glass to dip water from inside the machine and let cool to 120F before testing. Contact your service representative if you still have trouble verifying sanitizer levels. References: https://www.autochlor.net

Based on observation, interview, and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 2 glucometers (device used to measure the amount of glucose in a resident's blood) reviewed for pharmacy services. The facility failed to ensure the glucometer in the nurse cart for halls 100, 200 and 400 were tested for accuracy and recorded in the glucometer logbook on 07/01/25, 07/02/25, 07/07/25, 07/08/25, and 07/21/25 in the month of July. These failures could place residents at risk of receiving either too much insulin or not enough. The findings included:Record review of the glucometer logbook on 07/22/25 at 10:37 AM revealed the test results for the glucometer in the nurse cart for halls 100, 200 and 400 were not recorded on 07/01/25, 07/02/25, 07/07/25, 07/08/25, and 07/21/25. In an interview with the DON on 07/22/25 at 1:11 PM, the DON stated the glucometers were supposed to be tested every day on the night shift by the nurses and the results recorded in the logbook. The DON stated night shift nurses were trained to test the glucometers every shift. The DON stated it was the DON and ADON's responsibility to check the logbooks and ensure the night shift nurses were recording the results of the tests. The DON stated he did not think there was an official policy on testing the glucometers every day, but that it was best practices for nursing. The DON stated it was important to test the glucometers to ensure they gave accurate readings. The DON stated if a glucometer gave inaccurate readings a resident may end up receiving insulin when they did not need it, or not receive insulin when they did need it. The DON stated this could impact any resident that received insulin. In an interview with LVN D on 07/22/25 at 2:06 PM, LVN D stated he did not work the night shift. LVN D stated it was the night shift nurse's responsibility to test the glucometers and record the results in the logbook every night. LVN D stated it was important to ensure the glucometers were working so there would not be any mistakes in administering insulin. LVN D stated an inaccurate glucose measurement may result in administering insulin to a resident that did not need it or vice versa. A phone interview was attempted with three different night shift nurses on 07/22/25 between 1:50 PM and 1:57 PM, but none answered the phone or called back. This stated surveyor requested a facility policy from the DON on 07/22/25 at 1:11 PM dictating how often to test the glucometers but none was provided prior to exit.

Based on observation, interview and record review, the facility failed to ensure the resident's right to privacy for 1 (Resident #5) of 17 residents reviewed for privacy. The facility failed to ensure the WCN provided privacy for Resident #5 while performing his wound care. This failure could cause residents to feel uncomfortable, disrespected, and possibly a loss of dignity due to a lack of privacy. The findings include:Record review of Resident # 5's face sheet dated 07/21/25 reflected an [AGE] year-old-male with an original admission date of 09/09/24. Diagnoses included congestive heart failure, high blood pressure, type two diabetes (insufficient production of insulin in the body), and pressure ulcer (a localized injury to the skin and underlying tissue caused by prolonged pressure) at an unspecified site and location. Record review of Resident #5's physician orders dated 07/20/25 reflected: Cleanse Sacrum (triangular bone at the base of the spine. Upper cack part of the pelvic cavity) with normal saline, pat dry, pack with hydrofera blue (bacteriostatic foam dressing infused with a combination that provides powerful antibacterial effect while maintaining a moist wound environment), cover with dry gauze and secure every other day one time a day. During an observation of wound care on 07/21/2025 at 9:48 AM, the WCN began to provide wound care for Resident #5. The WCN left the door open, closed the left side of the privacy curtain but not the front side of the privacy curtain, leaving Resident #5 exposed to people who passed by in the hallway. In an interview on 07/21/2025 at 10:13 AM, the WCN stated it was important to provide privacy to all residents because it was part of their patient rights, their dignity and respect. The WCN stated she should have closed the door or the rest of the curtain but did not because she was unsure of how I would be able to observe the wound care process. The WCN stated she should have at least closed the door but just forgot. In an interview on 07/22/2025 at 9:56 AM, the DON stated Resident #5's door or curtain should have been closed to maintain the resident's privacy and dignity. The DON stated by not providing privacy, anyone walking past the door would be able to see Resident #5 exposed. Record review of the facility's policy of Promoting/Maintaining Resident Dignity dated 01/13/23 reflected: Policy: It is the practice of this facility to protect and promote resident rights and teat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. 12. Maintain resident privacy.

Based on observations, interviews and record reviews, the facility failed to ensure all drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles reviewed for medications stored in 1 of 1 medication rooms reviewed for medication storage. The facility failed to ensure the medication room was locked at 11:21 AM on 07/20/25 This failure could place residents in the facility at risk of drug diversion or misuse of medications leading to harm. The findings included:During an observation at 11:21 AM on 07/20/25, the medication room door was left slightly ajar, allowing this state surveyor to open the door and gain entrance without any key. No employees were in the medication room at that time. This state surveyor stayed by the entrance to the medication room until the ADM walked by at 11:50 AM and was informed the door was slightly ajar. In an interview with the ADM at 11:50 AM on 07/20/25, the ADM stated the medication room door was supposed to be closed and locked when no one was inside the room. The ADM stated the medication room should be closed and locked to prevent any unauthorized personnel from gaining access to residents' medications. The ADM stated LVN A, CMA C, and RN B all had keys to the medication room and had been working today from 6:00 AM to 2:00 PM. The ADM stated if the door was left open, residents or unauthorized staff could gain access to medications and ingest them or steal them. In an interview with RN B on 07/20/25 at 1:05 PM, RN B stated she had a key to the medication room, and the last time she was in the room today was around 9:30 AM. RN B stated she closed and locked the door behind her when she left. RN B stated it was important to keep the door to the medication room closed and locked, so unauthorized people did not gain access to medications. In an interview with CMA C on 07/20/25 at 1:20 PM, CMA C stated she had a key to the medication room, and the last time she was in the room was around 10:00 AM. CMA C stated she closed and locked the door behind her when she left. CMA C stated it was important to keep the door locked so residents or staff could not go in and out of the room and possible eat or steal medications. In an interview with LVN A on 07/20/25 at 1:35 PM, LVN A stated she had a key to the medication room, and the last time she was in the room was around 10:30 AM. LVN A stated she closed and locked the door behind her after she left. LVN A stated it was important to keep the door closed and locked to keep any unauthorized people from going into the medication room and taking things that did not belong to them. In an interview with the DON on 07/22/25 at 1:11 PM, the DON stated the medication room door should be closed and locked whenever no authorized staff were present in the room. The DON stated the room should be locked to prevent any unauthorized people from getting int the room and ingesting or stealing medications. The DON stated he liked to pull on the door handle whenever he walked by the room just to be sure it was closed. Record review of the facility policy titled Medication Carts and Supplies for Administering Meds revealed the following: .The following equipment and supplies are acquired and maintained by the facility for the proper storage, preparation, and administration of medications: 1. Lockable medication carts, cabinets, drawers, and/or rooms with well-lit medication preparation areas.

Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for one resident (Resident #7) of 17 residents whose care plans were reviewed. The facility failed to ensure Resident #7's comprehensive care plan was updated was developed and implemented after starting anticoagulant (blood thinner) medication on 04/26/25. The deficient practice could place residents in the facility at risk of not being provided with the necessary care or services, and the implementation of personalized plan of care developed to address their specific needs. Findings include:Record review of Resident #7's face sheet dating 07/20/25 reflected a [AGE] year-old-male with an original admission date of 1/07/20. Diagnoses included pulmonary fibrosis (lung disease characterized by the scarring and damage of lung tissue), congestive heart failure, high blood pressure, chronic kidney disease, and type two diabetes (insufficient production of insulin in the body). Record review of Resident #7's Physician orders dated 04/26/25 reflected: Eliquis Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day related to chronic atrial fibrillation (type pf heart arrhythmia characterized by irregular and often rapid beating of the atria, upper chambers of the heart). Record review of Resident #7's care plan initiated on 01/07/2020 and revised on 06/02/2025 reflected no care plan for anticoagulants. In an interview on 07/22/2025 at 9:41 AM, the MDS Coordinator stated she was unable to find Resident #7's anticoagulant medication in the care plan. The MDS Coordinator stated it should be care planned to ensure the staff are aware of the signs and symptoms such as the risk of bleeding and bruising. The MDS stated it was an oversight, and there was no reason why Resident #7's care plan was not updated. In an interview on 07/22/2025 at 9:48 AM, the DON stated Resident #7's anticoagulants should have been care planned. The DON stated it was important to have any anticoagulants care planned so staff could be aware of what signs and symptoms to look for such as bleeding or bruising. The DON stated that whenever there is a change in condition or new medications for any resident, it would be discussed during morning meetings and the team would go over any revisions of care plans. The DON stated Resident #7's care plan was just overlooked. In an interview on 07/22/25 at 1:28 PM, the ADM stated Medical Records would do a lot of auditing and needed to get with her to see if she was responsible for conducting care plan audits. The ADM stated the facility had ensured Medical Records personnel were nurses so they would be able to assist with this kind of documentation. In an interview on 07/22/2025 at 1:47 PM, Medical Records stated she did not audit resident care plans and was not sure who did. Record review of the facility's Care Plan Revisions Upon Status Change dated 10/24/25 reflected: Policy: The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Policy Explanation and Compliance Guidelines: 2. Procedure for reviewing and revising the care plan when a resident experiences a status change: a. Upon identification of a change in status, the nurse will notify the MDS Coordinator, the physician, and the resident representative, if applicable. h. The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs.

Based on observation, interviews and record reviews, the facility failed to ensure the right to be free from abuse for one (Resident #1) of five residents reviewed for abuse. The facility failed to ensure Resident #1 was free from physical abuse on 01/13/25 when Resident #2 grabbed Resident #1 ' s head with both of his hands and hit Resident #1 ' s head against the wall several times then punched Resident #1 on the left side of his face with a closed fist. This failure could place residents at risk for physical, mental and psychosocial harm. Findings included: Record review of Resident #1's admission record on 05/14/25 reflected an [AGE] year-old male originally admitted to the facility on [DATE], with most recent admission on 08/26/21. Resident #1's diagnoses included hemiplegia and hemiparesis (paralysis and weakness on one side of the body) following cerebral infarction (stroke or brain injury) affecting left side, vascular dementia (problems with thought processes and memory caused by brain damage from impaired blood flow), cognitive communication deficit (difficulty with communication), generalized muscle weakness, Alzheimer ' s disease (progressive brain disorder that slowly destroys memory and thinking skills), reduced mobility, and need for assistance with personal care. Record review of Resident #1's quarterly MDS dated [DATE] reflected a BIMS score of 7, which indicated severe cognitive impairment, and Resident #1 used a wheelchair and required substantial assistance with transfers. Record review of Resident #1's care plan dated 03/30/16 reflected on 12/12/24, Resident #1 had the potential to be physically and verbally aggressive, picked fights and struck at others due to dementia related poor impulse control. Resident #1's goal was to verbalize understanding of need to control physical and verbal aggressive behavior through the review date with interventions which included monitor and document observed behavior and attempted interventions in behavior log, monitor/ document/ report any s/sx (signs/symptoms) of resident posing danger to self or others, and when Resident #1 became agitated, intervene before agitation escalated, guide away from source of distress, engage calmly in conversation and if he responded aggressively, staff would walk calmly away and approach later. This care plan also reflected on 01/13/25, Resident #1 had an altercation with another resident (Resident #2). Resident #1's goal was to remain free of any altercations with other residents with interventions which included resident would be redirected to the living, dining, or his room if he engaged in discussion with other residents and he would be encouraged to participate in activities. Record review of Resident #1's progress notes reflected the following entry: Type: NURSING - Nurse Note Effective Date: 01/13/2025 at 9:24 am by GVN Resident (#1) physically assaulted by another resident (Resident #2); resident (#1) was at living room sitting on his wheelchair when another resident (Resident #2) approached him and started to smack him against the wall. When staff intervened to stop him, resident (#2) stuck him on the left eye. SN asked to resident (#1) what happened, and resident responded: I was here on the wheelchair when the other resident came to me and attack me.SN performed head to toe assessment and noted redness discoloration to his outer side of left eye and left cheek. No other observations noted at this time. Resident #1 denies pain or discomfort. Vital signs as follows: BP-157/87, P-76, O2-97@RA, RR-20, T-97.7. RP made aware of incident and stated to call on any updates of Resident #1. [Physician] made aware and gave order as follows: Xray of skull and facial bones. Record review of Resident #1's order summary report dated 05/14/25 reflected the following physician orders: 1. [Psychiatric services provider] may provide psychological services (ordered 01/13/25), 2. SN to monitor skin q shift for- Resident has mild swelling and bruising to left side of face (ordered 01/13/25), and 3. Facial 2V/ Skull 2V (2 view x-rays of the face and skull) one time only (ordered 01/13/25). Record review of Resident #1's radiology results dated 01/13/25 reflected, Multiple views of the skull/face demonstrate no overt fracture or dislocation. The nasal septum is midline. The soft tissues are unremarkable. Record review of Resident #1's skin and wound evaluation dated 01/14/25 at 3:25 pm reflected intact skin with a bruise to his left eye area that measured 1.5cm long by 1.9cm wide. Resident #1 denied any pain or discomfort. Record review of Resident #2's admission record on 05/13/25 reflected a [AGE] year-old male admitted to the facility on [DATE] and discharged to another facility on 01/24/25. Resident #2's diagnoses included frontal lobe and executive function deficit following cerebral infarction (difficulties with higher level cognitive processes such as planning, organization, and impulse control after a stroke or brain injury), conversion disorder (a condition in which emotional or psychological stress causes physical symptoms) with seizures (abnormal brain activity which affects muscle control, behavior, and awareness), schizoaffective disorder, depressive type (mental health problem characterized by thinking and behavior problems and sadness), dementia, mild, with psychotic disturbance (dementia with delusions or hallucinations), anxiety disorder (mental disorder characterized by excessive and persistent worry, fear, or anxiousness which significantly interferes with daily life), and cognitive communication deficit. Record review of Resident #2's quarterly MDS dated [DATE] reflected a BIMS score of 11 which indicated moderate cognitive impairment and Resident #2 did not exhibit physical or verbal behavioral symptoms directed toward others nor other behavioral symptoms not directed toward others. Resident #2 required minimal to no assistance with walking and transfers. Record review of Resident #2's care plan dated 08/21/24 reflected on 01/13/25, Resident #2 had an episode of aggression toward another resident (Resident #1). Resident #2's goal was to be free of confrontations with other residents with interventions which included keeping him occupied or interested in activities he enjoyed such as watching football, providing him snacks and treats of choice twice a day. Resident #2 was also placed on one-to-one observation until he was discharged to another facility on 01/24/25. This care plan also reflected on 01/13/25, Resident #2 had potential to be physically aggressive r/t (related to) poor impulse control. Resident #2's goal was to not harm self or others through the review date and interventions included analyze times of day, places, circumstances, triggers, and what deescalated behavior and document, assess and address contributing sensory deficits, assess Resident #2's needs: food, thirst, toileting, comfort level, pain, etc., monitor/document/report any s/sx of resident posing danger to self or others, psychiatric/ psychogeriatric consult as indicated, one to one monitor for behavior, and when Resident #2 became agitated, intervene before agitation escalated, guide away from source of distress, engage calmly in conversation and if he responded aggressively, staff would walk calmly away and approach later. Record review of Resident #2's progress notes reflected the following entries: Type: NURSING - Nurse Note Effective: 01/13/25 at 8:17 am by LVN A Resident #1 was sitting on his wheelchair in the lobby and Resident #2 approached other resident and banged his head against the wall then punched him on the face with closed fist. Resident #2 was instructed to go to his room. Notified RP and physician made aware. Type: SOCIAL SERVICES - Social Service Note Effective: 01/13/2025 at 1:03 pm by SW This morning [Resident #2] was involved in a physical altercation with another resident (Resident #1), he was the aggressor, he lashed out at another male resident (Resident #1) that male resident is in a wheelchair, [Resident #2] grabbed the other male resident (Resident #1) and was banging the head of that male resident against the wall. Staff intervened and managed to get Resident #2 away from the male resident, but as per staff when [Resident #2] released his hold on the other male resident, [Resident #2] punched the male resident on his eye.The D.O.N. stated that the psychiatrist from [Psychiatric Services Provider] was contacted, she is recommending inpatient psychiatric care. Record review of Resident #2's order summary report dated 01/24/25 reflected the following physician orders: 1, Resident placed on one-to-one monitoring pending transfer to another facility (ordered 01/13/25), 2. Resident to be placed in an inpatient psychiatric hospital (ordered 01/13/25), 3. Hydroxyzine Pamoate Oral Capsule 50mg. Give 1 capsule by mouth every 4 hours as needed for restlessness related to anxiety disorder due to known physiological condition until 01/27/25 at 11:59 pm (ordered 01/13/25). 4. Lorazepam Oral Tablet 0.5mg. Give 1 tablet by mouth every 6 hours as needed for anxiety until 01/27/25 at 11:59 pm (ordered 01/13/25), 5. Quetiapine Fumarate Tablet 50mg. Give 1 tablet by mouth at bedtime related to schizoaffective disorder (ordered 01/13/25), 6. Lab work: CBC (complete blood count) with auto diff (automatic differential), Comp. (Complete) Metabolic Panel, and Urinalysis with reflex (urine test with urine culture if needed to determine type of infection) (ordered 01/13/25). and 7. Bactrim DS (Double Strength) Oral Tablet 800- 160mg (Sulfamethoxazole- Trimethoprim, an antibiotic used to treat multiple infections including urinary tract infections). Give 1 tablet by mouth two times a day related to Escherichia coli (bacteria that can cause urinary tract infections) for 14 days (ordered 01/19/25). Record review of the facility's provider investigation report dated 01/17/25 reflected the facility notified the physician and the responsible parties for both residents as well as the local police department and the investigation findings were confirmed. The facility held an in-person in-service on abuse, neglect, and exploitation on 01/13/25 by the (previous) ADON and an in-person in-service on behavior chaining (the sequence of behaviors, events, situations, and interactions that led up to a particular event) by the (previous) ADON on 01/14/25. Observation and interview of Resident #1 on 5/14/25 at 10:43 am reflected Resident #1 was sitting in the dining room watching television with other residents. Resident #1 stated that he was doing good. Resident #1 did not recall the incident in January with Resident #2. Resident #1 stated he did not have issues with any other residents, and he liked living in this facility. Resident #1 stated he was not scared of any other residents or staff. In an interview on 05/14/25 at 11:49 am, the SW stated Resident #2 came to the facility from an out-of-town facility because he had family in this city. The SW stated she did a social history on Resident #2 and neither the transferring facility nor the RP gave any history of Resident #2 having aggressive behavior. The SW stated Resident #1 had a tendency to make gestures or say things to others. Resident #1 had bruising under his left eye, but not above it after the altercation with Resident #2. The SW stated witnesses said that Resident #1 said something or gestured something, and Resident #2 went at him and hit him. The SW stated Resident #2 was transferred to another facility shortly afterwards. In an interview on 05/14/25 at 12:30 pm, the DON stated Resident #1 said something to Resident #2 and Resident #2 was hitting Resident #1 ' s head on the wall then when the nurse stepped in and told him to stop, Resident #2 punched Resident #1 with a closed fist to the left side of his face. The DON stated Resident #1 initially had a quarter-sized bruise to his left cheek area. The DON further stated Resident #1 had no recollection of the incident after the day it occurred, and he was not fearful or withdrawn afterwards. The DON stated Resident #1 was evaluated by psychiatric services to determine if he had any distress from the incident and he did not. Resident #2 was transferred shortly after to another facility. The DON stated it was important for the facility to be free from abuse and neglect so the residents would feel safe because this is their home. The DON stated abuse or neglect could lead to physical, mental, or psychosocial harm, hospitalization , or even death. The DON stated abuse/neglect/exploitation was in-serviced every quarter and as needed as well as in the facility ' s online training every 2-3 months and the last abuse/neglect/exploitation in-service was in April. In an interview on 05/14/25 at 4:06 pm, LVN B stated on 01/13/25, she was walking past the nurse ' s station and heard a thumping sound. She stopped and looked around and realized it was coming from the front lobby area. She stated she looked in and saw Resident #2 had Resident #1 by the head and was banging his head against the wall and she said out loud, [Resident #2], Stop! LVN B stated, I told him to let him go and back away and that he could not do that and that was when he punched him and then walked away. He said, He [Resident #1] called me something, and I told him to just ignore it. Resident #2 then said he walked over to Resident #1 and told him that he (Resident #2) was a nice guy, and he should not talk to him like that. Resident #2 said Resident #1 raised his hand up and Resident #2 thought Resident #1 was going to hit him and that was why Resident #2 hit him. I told Resident #2 to go back to his room, and he walked to his room. LVN B stated she checked on Resident #1 and told him he had a little bruise, and she wanted to check him out and he said, No, I ' m OK in Spanish. LVN B stated Resident #1 had a small bruise near his eye, but he was not fearful, tearful, or withdrawn. LVN B stated she told Resident #1 she was going to call the doctor, and he told her he was fine and did not need the doctor called. LVN B stated LVN A had walked up at some point, and she told her she told Resident #2 to go to his room, and he went. LVN B stated LVN A took over from there. LVN B stated she had never seen Resident #2 do anything like that and afterwards he went back to being the same as before. LVN B stated Resident #2 had a lot of repetitive behaviors, like asking for chips and sodas, but never anything aggressive. LVN B stated, He was pretty chill. He could be a little intimidating at times because when he would talk to you, he would get really close, but he had never been violent. LVN B stated Resident #2 was put on one-to-one observation until he left. LVN B stated it was important that residents felt safe in this facility. LVN B named the abuse coordinator, stated the last abuse in-service was at the beginning of the year, and it was done quarterly in the facility ' s online training. In a telephone interview on 05/14/25 at 4:30 pm, LVN A stated Resident #1 and Resident #2 were in the lobby. She heard screaming and ran to the lobby area where she saw Resident #2 punch Resident #1 in the face. LVN A stated she had never seen Resident #2 do anything like that before and to her knowledge Resident #2 did not have any issues with Resident #1 prior to that. LVN A stated Resident #2 was usually in his room watching tv and did not have any issues with any other residents. LVN A stated after Resident #2 hit Resident #1, he was taken back to his room and the RP and doctor were notified about the incident. Resident #2 was put on one-to-one observation. Resident #2 did not get into any other fights afterwards and he had never done that before. LVN A stated the last in-service on abuse was at the beginning of the year they were done quarterly and as needed. In an interview on 05/14/25 at 1:09 pm, the admin stated Resident #2 had behaviors, but it was nothing aggressive; he would ask for chips and sodas all the time then staff would go in his room and find opened but not consumed bags of chips and cans of soda. On 01/13/25, after Resident #2 hit Resident #1, he was placed on one-to-one monitoring. The admin stated, After speaking with psychiatric services, we began looking for an inpatient psychiatric facility to transfer him to. It took a couple of weeks to find a facility to transfer him to and he remained on one-to-one monitoring during that time. Resident #2 did not have any further aggressive behaviors prior to his transfer. The admin stated it was important for residents to be free from abuse because this was their home, and they had a right to feel safe in their home. The admin stated he felt the facility was not at fault for Resident #2 hitting Resident #1 because Resident #2 had not shown aggressive behavior prior to this incident and staff immediately intervened, removed Resident #2 from the situation, and put interventions in place to prevent it from happening again. The admin stated the facility had in-services on abuse every three months and as needed in person and it was also part of the facility ' s online training every quarter. Record review of the facility's Abuse, Neglect and Exploitation policy dated 08/15/22 reflected in part: Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of property. Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor, or others but has not yet been investigated and, if verified, could be an indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property.

Based on observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs, for 1 (Resident #1) of 3 residents reviewed for care plans. The facility failed to develop a comprehensive person-centered care plan for Resident #1 to address the risk for falls and the fall mat. This failure could place the residents at risk of not receiving appropriate interventions and care to meet their current needs. The findings included: Record review of Resident #1's face sheet dated 12/14/24 reflected a [AGE] year-old female with an original admitted [DATE]. Her diagnoses included: hydrocephalus (buildup of fluid in the brain ventricles), encephalopathy (brain dysfunction), muscle wasting and atrophy, dysphagia (difficulty swallowing), cognitive communication deficit, acquired absence of unspecified breast, and gastrostomy status (opening in the stomach for feeding). Record review of Resident #1's fall risk evaluation dated 11/15/24 reflected a score of 7 which indicated a low risk. Record review of Resident #1's initial baseline care plan dated 11/15/24 reflected Resident #1 was not at risk for falls. Record review of Resident #1's MDS assessment dated [DATE] reflected Resident #1 did not have a BIMS conducted as she was never/rarely understood. Resident #1 was total dependence for bed mobility. Falls were not addressed on the MDS assessment. Record review of Resident #1's care plan dated 12/14/24 reflected risk for falls and the fall mat were not care planned. Interview and observation of Resident #1 on 12/14/24 at 12:00 PM revealed Resident #1 was non-interviewable. Resident #1 had a fall mat in place on the left side of her bed. Interview with CNA D on 12/14/24 at 12:50 PM revealed CNA D said Resident #1 had the fall mat in place, but she was not aware if Resident #1 had any falls. CNA D said maybe the fall mat was placed just as a precaution. Interview with LVN B on 12/14/24 at 1:10 PM revealed LVN B said Resident #1 had not fallen during her stay but she had a fall mat in place as a precaution. Interview with ADON P on 12/14/24 at 2:15 PM revealed ADON P said Resident #1 had not experienced any falls during her stay. ADON P said she was not sure why Resident #1 had a fall mat in place. Observation of Resident #1 on 12/18/24 at 11:20 AM revealed Resident #1 had a fall mat in place on the left side of her bed. Interview with MDS N on 12/18/24 at 1:10 PM revealed MDS N said Resident #1 did not trigger for risk of falls during the initial admission assessments. MDS N said the fall risk evaluation on 11/15/24 indicated Resident #1 was at low risk for falls. MDS N said the initial baseline care plan indicated that Resident #1 was not at risk for falls which would then not trigger the comprehensive care plan to include risk for falls. MDS N said the assessing nurse should have indicated Resident #1 was at risk for falls on the initial baseline care plan based on the fall risk evaluation, which would have triggered the risk for falls on the comprehensive care plan. MDS N said if there was a fall mat placed by the nurses, then the staff should have communicated that with the team so the care plan could be updated. MDS N said the team was not notified that the fall mat was implemented. MDS N said the nurses implemented interventions at times based on their nursing judgement. MDS N said she was not sure who placed the fall mat. MDS N said a fall mat would be considered an intervention and the fall mat would need to be care planned. MDS N verified the fall mat was not care planned for Resident #1 and a risk of falls was not care planned for Resident #1. MDS N said it was important for the fall mat and the risk for falls to be care planned so that staff were aware of the resident's needs, knew how to care for the resident, ensured the intervention was implemented, and to avoid any incident. Interview with the DON on 12/18/24 at 2:45 PM revealed the DON said Resident #1 had not experienced any falls. The DON said Resident #1 had the fall mat placed as a precaution. The DON said it had been brought to his attention that the care plan was not updated for Resident #1. The DON said the fall mat was implemented as a nursing judgment and should have been communicated to the team. The DON said the fall mat should have been care planned. The DON said Resident #1's initial fall risk assessment indicated she was at low risk for falls so the care plan should have included the risk for falls and the interventions which included the fall mat. The DON said although the risk was noted as low, the risk was still there and should have been care planned. The DON said Resident #1 was not negatively impacted by not having the risk for falls or the fall mat care planned. The DON said Resident #1 was at risk of the staff not knowing how to care for her. The DON said it was important for the fall mat and the risk for falls to be care planned to ensure the interventions were implemented and for the staff to know what to do for Resident #1 specific to her needs. Record review of Comprehensive Care Plans Policy date implemented: 10/24/22, reflected: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 3.a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.

Based on observation, interview, and record review, the facility failed to ensure that drugs and biologicals were stored in locked compartments for 1 of 5 medication carts located at the nursing station observed for compliance. The facility failed to ensure one medication cart found at the nursing station for residents in the 500/600 hall was not left unlocked and unattended by RN A. This failure could place residents at risk of access and ingestion of non-narcotic medications. Findings were: During an observation on 9/24/2024, at 12:41 p.m., revealed one medication cart was unlocked at the nursing station without a supervised staff in view of the cart. The cart was left unlocked for less than 2 minutes until RN A returned to the cart, no one else was around the cart at the time, and all medications were non-narcotics. During an interview on 9/24/2024 at 12:41 p.m., RN A verbalized the unlocked cart was her cart. She verbalized she thought she locked it before walking to the kitchen. RN A stated it was proper process to lock the carts when the cart is not in view or when not being utilized. She also stated a resident could have accessed the medications in the drawers that were accessible. During an interview on 9/25/2024 at 1:08 p.m., the Director of Nursing (DON) stated it was the expectation of the facility for all staff passing medications to lock the medication carts. All carts are to be within the line of sight of the staff member utilizing the cart or locked. (He/she) stated locked carts prevent residents from obtaining access to improper medication. During an interview on 9/26/2024 at 12:305 p.m., the Administrator stated it was the policy of the facility to keep all medication carts locked. He stated following the policy keeps residents safe from receiving incorrect medication. A review of the Medication Carts and Supplies for Administering Meds policy dated 10/01/2019 revealed Do not leave the medication cart unlocked or unattended in the resident care areas. The cart must remain in your line of sight when it is not locked.

46038 Based on observation, interview, and record review, the facility failed to ensure that the comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, for three residents (Resident #14, Resident #30, and Resident #49) of 24 residents whose care plans were reviewed, in that: 1) Resident #14's comprehensive care plan was not revised after being prescribed Albuterol Sulfate Inhalation Nebulization Solution on 5/1/24 to reflect a respiratory plan of care. 2) Resident #30's comprehensive care plan was not revised after her quarterly safe smoking evaluations (assessments) changed. 3) Resident #49's comprehensive care plan failed to include he was a smoker. This failure could place residents at risk for inadequate care. The findings included: 1) Resident #14 Record review of Resident #14s face sheet dated 6/24/24 reflected a [AGE] year-old-female with an original admitted [DATE]. Diagnoses included cerebral infarction (stroke that occurs when a blood vessel that supplies the blood to the brain is blocked), pneumonia (inflammatory condition of the lung(s) primarily affecting the small air sacs), and respiratory failure. Record review of Resident #14's MDS dated [DATE] reflected Resident #14 had an active diagnosis of respiratory failure and pneumonia with the use of oxygen therapy. Record review of Resident #14's care plan dated 4/30/24 and revised on 5/13/24 did not reflect any respiratory condition or the use of Albuterol Sulfate Nebulization Solution. Record review of Resident #14's physician orders dated 5/1/24 stated: Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG/3ML) 0.083% (Albuterol Sulfate) 1 application inhale orally via (by way of) nebulizer every 6 hours for Anti-asthmatic and Bronchodilator agents. In an interview on 06/26/24 at 1:08 pm the DON stated an order for albuterol should have been care planned for Resident #14 since Resident #14 was on respiratory treatments. The DON stated the care plan is necessary, so staff can monitor the goals of Resident #14 and access if the interventions need to be updated or revised. The DON stated the MDS Coordinators are the ones to audit care plans after the initial care plans have been entered by either charge nurses or administration. The DON stated he and the ADON oversee that care plans are up to date and accurate. The DON stated Resident #14's care plan was overlooked and missed. In an interview on 06/26/24 at 1:20pm the ADON stated Resident #14's care plan should have been updated to reflect the order of albuterol since it is person centered. The ADON stated it she and the DON oversee that care plans are up to date and accurate but Resident #14's care plan was missed. The ADON stated by not have Resident #14's respiratory plan of care updated, staff would not be aware of the goals and interventions if there were complications. In an interview on 06/26/24 at 2:18pm MDS Coordinator D stated care plans are reviewed and updated quarterly by both MDS Coordinators and the DON and the ADON are the ones to update acute changes in a resident's plan of care. MDS Coordinator D stated an order list, reflecting new resident orders, are printed out every business day and checked to see if there were any updates that need to be made on a resident's care plan. MDS Coordinator D stated it was an oversight and could not give an explanation on why Resident #14's change in medication was missed in the care plan. 2) Resident #30 Record review of Resident #30s face sheet reflected a [AGE] year-old-female with an initial admitted [DATE] and a re-admitted d 12/30/20. Diagnoses included chronic obstructive pulmonary disease (COPD), Heart disease, Alzheimer's, dementia, diabetes, schizophrenia, psychosis, nicotine dependence, high blood pressure, and need for assistance with personal care. Record review of Resident #30's MDS dated [DATE] reflected Resident #30 had a BIMS of 1, indicating severe cognitive impairment. Resident #30 had unclear and slurred or mumbled speech and had a limited ability to make concrete requests. She responded to adequately to simple, direct communication only. She had impaired vision. She was ambulatory and required substantial assistance with oral care, moderate assistance with toileting and showering, supervision with dressing, and set-up assistance with eating. She was incontinent of bladder and occasionally bowel. She had an active diagnosis of cardiorespiratory conditions. Record review of Resident #30's care plan dated 05/06/24 and revised on 11/02/22 reflected she was a smoker. Interventions included wear an apron when out smoking initiated 09/25/23, and she required supervision while smoking initiated 12/04/20 and revised on 09/27/21. Next review date 08/04/24. Record review of Resident #30's quarterly safe smoking assessments dated 02/05/24 indicated she required supervision only and was no longer required an apron. This was not reflected in the most recent care plan dated 05/06/24. Observation of smokers in the designated smoking area on 06/26/24 at 1:30 pm revealed 4 of 7 smokers were smoking. Resident #30 was not wearing an apron. Resident #49 was smoking. Interview with the DON and ADON on 06/26/24 at 1:17 pm revealed the care plans were updated immediately after a change. The DON stated they go over changes in their daily morning meetings with all department heads. They stated safe smoking evaluations (assessments) should be done quarterly and reflected and updated in the care plans as soon as they found out. The DON stated safe smoking evaluations (assessments) were supposed to be done on admission and quarterly. They both stated smoking should be care planned, and Resident #30's care plan was not complete regarding whether she should wear an apron, but it was not documented anywhere. They both stated the safe smoking evaluations (assessments) were done to determine the level of supervision required, and that should be care planned. They stated Resident #30's care plan had not been updated as it should have been. They stated the social worker attended the daily morning meetings and they were responsible for the work they input. The DON stated everyone was doing something different and they were working on it. The DON stated staff should have been updating their own care plans-when there were changes or updates needed. The DON stated the MDS nurses had their own system. The DON stated he only updated the care plans when a situation presented itself. 3) Resident #49 Record review of Resident #49s face sheet reflected a [AGE] year-old-male with an initial admitted [DATE] and a re-admitted d 05/07/24. Diagnoses included heart disease, diabetes, high blood pressure, malnutrition, amputations of his right leg below the knee and his left leg above the knee and need for assistance with personal care. Record review of Resident #49's MDS dated [DATE] reflected Resident #49 had a BIMS of 8, indicating moderate cognitive impairment. He was moderately hard of hearing and had visual impairment. He was dependent on staff for toileting hygiene and required substantial assistance with bathing, moderate assistance with dressing, supervision with dressing, and set-up assistance with eating and oral hygiene. He was occasionally incontinent of bladder and frequently incontinent of bowel. He had an active diagnosis of cardiorespiratory conditions. Record review of Resident #49's care plan dated 05/21/24 had initiation dates of 01/31/24 and revisions on 05/23/24. Smoking was not reflected in his care plan on any date. Record review of Resident #49's quarterly safe smoking assessment dated [DATE] documented cognitive loss, visual deficits, and dexterity problems. He could light his own cigarette and required supervision when smoking. Interview with the DON and ADON 06/26/24 at 1:17 pm revealed the care plans got updated immediately after a change. They stated smoking should be care planned, and Resident #49's care plan was not complete. They said Resident #49 did not start smoking until recently, but it was not documented anywhere. Record review of Care Plan Upon Status Change policy dated 10/24/24 stated: Policy The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Policy Explanation and Compliance Guidelines: 1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. 2. Procedures for reviewing and revising the care plan when a resident experiences a status change: b. The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options. c. The team meeting discussion will be documented in the nursing progress notes. d. The care plan will be updated with the new or modified interventions. e. Staff involved in the care of the resident will report resident response to new or modified. f. Care plans will be mortified as needed by the MDS Coordinator or other designated staff member. h. The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation. 1. The facility failed to ensure juice dispenser nozzles were sanitary. 2. The facility failed to ensure equipment was clean and sanitized. 3. The facility failed to ensure the kitchen staff was following their policies. These failures could place residents at risk of foodborne illnesses. Findings included: Observation and initial tour of the kitchen on 06/24/24 beginning at 12:00 pm revealed 2 of 2 juice nozzle had a thick, sticky red substance that was congealed on and in the nozzles. Inside the nozzles, the same thick, sticky, congealed red substance was stuck to them. In an interview with the DA on 06/24/24 at 12:15 pm, she stated the juice nozzle were cleaned only at night. She stated the juice nozzle always looked like that, especially over the last four months. She stated there was a cleaning schedule the kitchen staff followed. In an interview with the DM on 06/24/24 at 12:20 pm, he stated he had the entire juice machine replaced, but the juice nozzle continued to become congealed over the last 4-6 months. He stated he called the man who serviced the juice machine, and he told him to call the company. He stated the procedure was that he would put work orders into the facility's electronic work order system, and the MS was supposed to call the company for the juice machine, but the company never came or responded. He stated he would change the cleaning schedule to daily cleaning for the juice nozzle. He stated bacteria could grow in the nozzles and make the residents sick. In an interview with the MS by way of an interpreter HR on 06/26/24 at 2:40 pm, he stated he did not know how to pull reports from the facility's electronic work order system. He stated sometimes the kitchen staff notified him regarding the juice machine/juice nozzle, but they did not enter the problem(s) into the facility's electronic work order system. When asked how many times the kitchen staff had notified him about the juice machine/juice nozzle in the last four to six months, he stated the company from the juice machine came regularly to check on it and he thought it was once a week, but he needed to check with the DM. He stated the machine was replaced on 10/01/23. He stated the company that checked the juice machine/juice nozzle once a week told him they were there to regulate the juice because sometimes they said it (the juice) was too condensed. He stated kitchen staff had been complaining about the juice machine/juice nozzle for two to three weeks and the company that checked the juice machine/juice nozzle would have to regulate the juice every time they were there. He stated he did not know why the juice machine/juice nozzle was not getting fixed, and he guessed the dietary aid was not notifying the company. He stated the company from the juice machine was not allowing him to touch the machine too much and when there was an issue, the company from the juice machine was to come in and fix it. He stated he had seen the dirty nozzles on the juice nozzle and shook his head side to side indicating no when asked if the nozzles looked like they had been cleaned daily. He stated the DM should be in charge of contacting the company from the juice machine. He stated he himself had never contacted the company for the juice machine. Then he stated the people from the juice machine company that came once a week did not look at the machine because they only delivered juice once a week, unless they let them know there was something wrong, they would look at it, but typically, they come in and delivered or change the juices. Record review of the cleaning schedules dated 01/01/24-06/24/24 revealed all spaces filled, indicating cleaning had been done regularly on kitchen equipment, but there was no space labeled juice nozzle or juice machine. Record review of the electronic work order system requests revealed Work order #6393 dated 03/14/24 Check Juice Machine the work order was created by the DM on 03/14/24 at 10:39 am and closed by the MS on 03/14/24 at 1:50 pm. This was the only work order in the facility's electronic work order system regarding the juice machine from 02/01/24-05/30/24. Record review of in-services for kitchen staff: 12/18/23-Use Oven Mitts, pay attention to Surroundings, 01/18/24-Tray line Temperatures, food receipts, eating in the kitchen, dish machine logs. 06/25/24-Level 4 spoon/fork test, 06/26/24-Juice machine cleaning; how to and signing cleaning log. Record review of the facility kitchen policy titled, Cleaning Schedules dated 10/01/18 revealed under Policy: The facility will maintain a cleaning schedule prepared by the nutrition and food service manager and followed by employees as assigned in order to ensure that the kitchen is clean and free of hazards. Record review of the facility kitchen policy titled, Coffee machines and Juice Machines revised 06/01/2019 revealed under Policy: The facility will maintain coffee machines and juice machines in a clean and sanitized condition to minimize the risk of food hazards. Coffee and juice machines will be cleaned once per day. Under Procedure: 2. Juice machines should be cleaned following the manufacturer's instructions. The nozzle will be cleaned daily. References: TAC 554.1111 (b) The facility must store, prepare, and serve food under sanitary conditions, as required by the Texas Department of State Health Service sanitation requirements.

Based on interview and record review, the facility nursing staff failed to demonstrate competencies and skills sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care, for one resident (Resident #14) of 24 residents reviewed, in that: -The facility failed to revise orders for Resident #14's code status from full code to DNR after receiving a DNR form from Resident #14's family member on [DATE]. Resident #14 had both CPR and DNR reflected in their orders. This deficient practice could affect residents who require care and monitoring and place them at risk of not receiving the care and services to meet their needs. The findings included: Record review of Resident #14s face sheet dated [DATE] reflected a [AGE] year-old-female with an original admitted [DATE]. Diagnoses included cerebral infarction (stroke that occurs when a blood vessel that supplies the blood to the brain is blocked), pneumonia (inflammatory condition of the lung(s) primarily affecting the small air sacs), and respiratory failure. Record review of Resident #14's care plan dated [DATE] and revised on [DATE] stated: As per responsible party I know Resident #14 was dealing with all sorts of health issues, she had a stroke in the past, at her age, her health will continue to decline so, the decision is no- CPR/ DNR. Interventions included: If resident has a cardiac arrest, do not call 911. Notify physician/responsible party and follow physician orders after notification. Record review of Resident #14's physician orders dated [DATE] stated: -Full Code as evaluated by social worker and instructed nurse to place as so until further notice. No directions specified for order. -DNR (Do Not Resuscitate) No directions specified for order. In an interview on [DATE] at 12:56pm the DON stated charge nurses were in charge of in putting initial orders for the resident and the DON and the ADON oversaw that orders were inputted correctly. The DON stated Resident #14's orders should not reflect both full code and DNR status. The DON stated resident changes were discussed daily during morning meetings. The DON stated at times he was out on the floor working and unable to attend all morning meetings and, in that case, either the SW, MDS, or anyone who attended the morning meeting were supposed to communicate and inform him of any changes that had occurred. The DON stated he was not informed of Resident #14's code status change and that it was overlooked. The DON stated Resident #14's code status would be corrected and updated immediately. The DON stated by having both code status for Resident #14 could make it hard to determine what actions to take in case of an emergency. MDS and medical records take part in looking for discrepancies and notifying DON and ADON. In an interview on [DATE] at 1:22pm the ADON stated every morning Monday through Friday resident orders were checked and audited for accuracy. The ADON stated whenever there was a change in code status, it was usually discussed in morning meetings and the ADON and DON made the changes needed. The ADON stated sometimes she and the DON could not attend morning meetings if they were needed out on the floor and believed that was how Resident #14's code status was not accurate. The ADON stated it was important Resident #14's code status was accurate as to avoid confusion on what procedures to take in case Resident #14 had an emergency. In an interview on [DATE] at 02:28pm MDS Coordinators E stated resident orders were reviewed in morning meetings to make sure care plans matched the orders. MDS Coordinators E stated if there was a discrepancy in the order, she or the other MDS Coordinator would alert the DON or ADON of the error so it could be corrected. MDS Coordinator E stated Resident #14's code status was overlooked. In an interview on [DATE] at 03:07 PM, the SW stated, once the initial advance directives were completed by her, then it was communicated to the charge nurses or to the DON/ADON to update in their computer system. The SW stated during the time Resident #14's code status was changed; she was out on leave and there was two other SW's covering for her during that time. The SW stated she did not know who the other SW's were as they were from different companies. The SW stated when a code status was changed, medical records was notified about a resident's code status either through morning meetings or through communication by administration and then updated in their computer system. The SW stated if a resident's code status was not entered, the SW would notify the DON/ADON or the charge nurses so it could be inputted in their system. The SW stated some residents were audited for code status when she returned to work but Resident #14 was missed and was an oversight. The SW stated there was no communication done once she returned from vacation and was unsure what was done or not done during her absence. The DON was asked by this surveyor for a policy on code status/ Following physician's orders multiple times and no policy was provided during the duration of the survey.

Based on observation, interview, and record review, the facility failed to post the results of the most recent survey of the facility in a place readily accessible to residents, family members, and legal representatives for ten (Resident # 3,28,37,42,48,50,55,57,64, and 169) of ten residents interviewed for resident rights. The facility failed to ensure the most recent survey results were readily accessible to residents, family members, and legal representatives. This failure could place residents, family members, and legal representatives at risk of not being able to fully exercise their right to be informed of the facility's survey results and citation history. Findings included: In an interview on 06/26/24 10:02 AM in a group meeting with ten residents (Resident # 3,28,37,42,48,50,55,57,64, and 169), all ten residents stated they were not aware of nor had they seen a previous survey binder. Observation on 06/26/24 at 11:00am revealed the survey results book was not located in the common areas of the facility nor was there a sign that indicated where the survey results book could be found. In an interview on 06/26/24 at 11:13 AM, the ADON stated the survey results were posted up front. The Admin and the ADON went up to the front lobby and searched for the survey binder. The ADON located the binder in a drawer of the unattended reception desk. Record review on 06/26/24 at 11:24 AM of the survey binder that was located in the unattended reception desk drawer revealed a 1/2 inch white binder with an 8 1/2 x 11 inch piece of paper slid in the front cover that had Full Book Survey April 2023 printed on it. Pages 1-3 were a letter a dated 04/24/23 from Texas Health and Human Services to the Administrator that stated in part the HHSC had conducted a health investigation on 04/06/23, and the survey found that the facility did not meet state licensure requirements and was not in substantial compliance with federal participation requirements. There was no information on what violations/deficiencies were cited. Pages 4-7 were a letter dated 03/04/22 from Texas HHSC that stated in part that the HHSC had conducted a Health and Life Safety Code Recertification Survey and a Health Complaint Investigation on 02/17/22 and the Life Safety Code survey found that the facility did not meet state licensure requirements and was not in substantial compliance with federal participation requirements and that the Health survey found that the facility was in substantial compliance with federal participation requirements. Page 8 was the CMS 2567 Form that had survey completion date 02/18/22 and stated in part that the facility was in compliance with federal requirements for long term care. Page 9 was the HHSC 3724 Form that had a survey completion date 02/18/22 and stated in part that the facility was in compliance with state licensure requirements. The following 12 pages listed the Life Safety Code violations. There was no policy provided by the facility regarding the availability of survey results to residents, family members, or legal representatives.

Based on observation, interview and record review, the facility failed to ensure the residents' right to privacy for 1 of 9 residents (Resident #32) reviewed for privacy. The facility failed to ensure RN A provided privacy by closing Resident #32's door or privacy curtain during administration of a subcutaneous insulin injection into Resident #32's abdomen on 06/25/2024 at 10:59 AM. This failure could place residents at risk of having their bodies exposed to the public, resulting in low self-esteem and a diminished quality of life. The findings included: Record review of Resident #32's face sheet dated 06/26/2024 reflected a [AGE] year-old male with an original admitted [DATE] and a readmitted [DATE]. Pertinent diagnoses include Type 2 Diabetes Mellitus (chronic condition that occurs when the body does not produce enough insulin or cells do not respond to insulin properly), Generalized Anxiety Disorder (feelings of extreme worry or nervousness even when there is little or no reason to have them), and Alzheimer's Disease (progressive brain disease that causes a mental decline affecting the quality of daily living). Record review of Resident #32's MDS dated [DATE] reflected a BIMS score of 11 (moderate impairment) Record review of Resident #32's care plan dated 06/26/2024 reflected Resident #32 had Diabetes Mellitus with daily insulin injections. Interventions listed include, but were not limited to, administering diabetes medication as ordered by doctor and observe/document for side effects and effectiveness, encourage resident to practice good general health practices, and compliance with treatment regimen. Record review of Resident #32's order summary report dated 06/26/2024 revealed an active order for Novolog FlexPen Solution (Insulin). During an observation of RN A performing medication administration on 06/25/2024 at 10:59 AM, RN A measured the blood glucose and gave a subcutaneous Novolog insulin injection to Resident #32 in his abdomen in his room while Resident #32 was sitting in his wheelchair. After RN A walked into the room, the door was left wide open, and throughout the medication administration, the privacy curtain was never utilized. No other residents or facility staff were present in the room at that time. RN A lifted Resident #32's shirt to expose Resident #32's skin and to have an exposed site to give the insulin injection. Resident #32 was in full view from the hallway by any individual walking by his room throughout the blood glucose test and insulin administration. In an interview with RN A on 06/25/2024 at 1:34 PM, RN A stated she has given insulin injections to residents in common areas before. RN A stated the DON and ADON have told her to not give injections in common areas. RN A stated some residents do not listen to her, and she struggles with balancing giving them the medication they need and protecting their privacy. RN A stated the door was open during the entire time she was in Resident #32's room for the blood glucose test and insulin injection. RN A stated she did not know she needed to shut the door or use the privacy curtain when administering insulin injections. RN A stated that residents may get agitated or it could make them feel more vulnerable and destroy rapport if their privacy was not protected. In an interview with the DON on 06/26/2024 at 12:56 PM, the DON stated that residents should be in their rooms when being administered any medication. The DON stated that in order to protect the privacy of the residents, their doors, curtains, and possibly blinds should be closed depending on what administration or procedure was taking place. The DON stated that it was not appropriate to give insulin injections to residents in their rooms without first closing the door or privacy curtain. The DON stated that not providing residents with privacy could impede on the resident's dignity and cause negative emotional effects. The DON stated that he has spoken to staff about administering medications with the appropriate protections for privacy, but does not remember a specific in-service. Record review of the facility's policy titled Medication Administration dated 10/24/2024 stated: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: 7. Provide privacy.

Based on observation, interview, and record review, the facility failed to maintain a comprehensive infection prevention and control program that included employing proper signage on the doors of resident's rooms to prevent the transmission of communicable diseases and infections for 2 of 28 residents (Resident #51 and Resident #19) reviewed for infection control. 1. The facility failed to place a readily visible EBP sign on the door of Resident #51 who was actively on EBP which requires an individual to don gown and gloves when performing patient care on 06/24/2024 at 11:35 AM. 2. The facility failed to place a sign on Resident #19's room door who was being tested for C. Diff(clostridioides difficile- a type of bacteria that is contagious and causes diarrhea and inflammation of the colon and can be life threatening) on 06/24/24. PPE such as gown and gloves was required to prevent cross contamination when providing care for residents with C-Diff. This failure could place residents at risk of cross contamination, infection, and illness. The findings included: 1) Record review of Resident #51's face sheet dated 6/24/2024 reflected a [AGE] year-old male with an original admitted [DATE] and a readmitted [DATE]. Pertinent diagnoses include Functional Quadriplegia (condition that causes complete immobility due to a severe physical disability or frailty, not due to spinal cord damage or stroke), Heart Disease (general term for many conditions that affect the heart's structure and function), and Respiratory Failure (condition in which it is difficult to breathe on your own). Record review of Resident #51's MDS dated [DATE] reflected a BIMS score of 6 (severe impairment). Record review of Resident #51's care plan dated 06/24/2024 reflected Resident #51 required tube feeding. Interventions listed include, but were not limited to, the resident needs assistance with tube feeding and water flushes. During an observation outside Resident #51's room on 06/24/2024 at 11:35 AM, it was noted that assorted PPE was placed in the pockets of an apron hanging on the door. Other PPE was noted in a drawer just outside the room. No sign was visible from the hallway advising visitors or staff to wear PPE before entering Resident #51's room or when performing care on Resident #51. Further observation found that there was a sign in the apron hanging on the door that read STOP SEE NURSE BEFORE ENTERING. The apron hanging on the door had folded over itself, obscuring this sign from view unless the apron was physically moved by an individual. In an interview with MA on 06/24/2024 at 11:41 AM, MA stated that Resident #51 was on EBP. MA stated that the proper PPE to wear before providing care for Resident #51 was a gown and gloves. MA stated that the STOP SEE NURSE BEFORE ENTERING sign was not visible from the hallway before entering the room. MA stated that because the sign was not readily visible, anyone could walk in the room and not put on PPE before interacting with Resident #51. In an interview with RN A on 06/24/2024 at 3:38 PM, RN A stated that Resident #51 was on EBP, and that gown and gloves were required when providing care for EBP residents. In an interview with the DON on 06/26/2024 at 12:56 PM, the DON stated that Resident #51 was currently on EBP. The DON stated that gown and gloves were required when providing care and when touch was necessary. The DON stated that an orange EBP sign should be posted on all doors of residents that are on EBP. The DON stated that if the signs are not on the door, individuals could walk in the room and potentially spread infection to or from the resident. The DON stated that, for example, all residents with a PEG tube (surgery to place a tube directly into stomach), wound, tracheostomy (surgical procedure that creates an airway by making and incision in the neck), and receiving intravenous fluids are placed on EBP. The DON stated they have had several in-services on proper EBP care but could not remember any specific dates. The DON stated that the facility does not have a specific policy on EBP, but that they go by the guidance provided from the CDC. In an interview with CNA D on 06/26/2024 at 4:19 PM, CNA D stated that any resident with certain conditions such as tracheostomies, catheters and PEG tubes are on EBP. CNA D stated that she knows which rooms require EBP because they have a sign on the door and PPE outside the room. CNA D stated that the ADON puts the EBP signs on the door. In an interview with LVN E on 06/26/24 at 4:19 PM, LVN E stated that any resident with certain conditions such as tracheostomies, catheters and PEG tubes are on EBP. LVN E stated that he knows which rooms require EBP because they have a sign on the door and PPE outside the room. LVN E stated that the ADON puts the EBP signs on the door. In an interview with the ADON on 06/26/2024 at 5:05 PM, ADON stated it was her responsibility to ensure all residents that require EBP have the appropriate sign on the door and it was plainly visible. 2) Record review of Resident #19's face sheet indicated a [AGE] year-old female that was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Diagnoses included diabetes, high blood pressure, Alzheimer's disease, muscle wasting and atrophy (decrease in muscle size), lack of coordination, and need for assistance with personal care. Record review of Resident #19's annual MDS indicated she had a BIMS score of 5 (severe cognitive impairment). Record review of Resident #19's care plan on 06/25/24 indicated that she required extensive staff assistance with all ADLs and that she was incontinent of bowel and bladder. Observation on 06/25/24 at 09:39 AM revealed there was no sign on Resident #19's door that indicated the resident was on isolation precautions for possible c. diff. Record review of Resident #19's order summary on 06/25/24 at 09:49 AM revealed that she had a stool sample sent to the laboratory on 06/24/24 at 08:21 AM to be tested for c. diff. That order summary did not include an order for c. diff precautions. In an interview on 06/25/24 at 10:32 AM, the ADON stated when someone has a c. diff test pending, the resident should be placed on isolation precautions. The ADON stated she did not know why Resident #19 was not placed on isolation precautions. Record review of Resident #19's order summary report on 06/25/24 at 10:49 AM revealed a telephone order dated 06/25/24 to place resident on isolation precautions for possible C. Diff. Observation on 06/25/24 at 1:36 PM revealed a PPE holder hanging on Resident #19's door. Along with gowns and gloves, the holder had a sign that read, STOP SEE NURSE BEFORE ENTERING and a canister of disinfecting wipes, however it was not bleach wipes and the label on the canister did not indicate the wipes were effective against c. diff. In an interview on 06/25/24 at 1:43 PM, the MA stated that c. diff precautions meant contact isolation: gown, gloves, mask, shoe covers, and wash hands with soap and water when someone went into and out of the resident's room. The MA stated there were no other precautions that she could think of and did not state that bleach wipes were required for disinfection of non-porous surfaces in the resident's room. The MA stated if they did not wash hands or use PPE, it could cause the c. diff to be spread to other residents. The MA stated that c. diff could cause dehydration and possible death. The MA stated they did in service modules on the computer every month, but could not remember the last time she did actual contact, c. diff, droplet, or airborne precaution training. The MA stated she had hand washing and EBP in service in the last month. In an interview on 06/25/24 at 1:51 PM, CNA F stated c. diff precautions included gown, gloves, mask, and hand washing. CNA F stated that the red or blue bleach wipes were supposed to be used but that the ADON had them and did not give them to her. CNA F stated she did yearly in services on the different types of isolation precautions. In an interview with LVN C and RN B on 06/25/24 at 2:07 PM, LVN C stated Resident #19 was on isolation precautions because she had possible c. diff. LVN C stated c. diff precautions included gown, gloves, shoe covers, and masks. RN B stated that hand washing was to be done after resident care. LVN C stated that any equipment used for or on Resident #19 was to stay in the room with her to be used only on her. LVN C stated the equipment was to be disposed of after Resident #19 was no longer on isolation precautions to prevent the spread of infection to other residents. RN B stated hand washing with soap and water was required to get rid of the c. diff microbes and that hand sanitizer alone was not effective. RN B stated to use Sani Wipes to wipe surfaces. RN B stated if proper precautions were not taken, c. diff could be spread to other residents and could lead to an outbreak. The MA stated it could cause diarrhea, dehydration, and malnutrition which could lead to kidney issues, electrolyte imbalance, and possible death. Both the MA and RN B stated they did not remember when they were last in serviced on hand washing and that the last in-service on isolation precautions was possibly before Christmas. Observation on 06/25/24 at 2:17 PM of Resident #19's door revealed the ADON placed bleach wipes in the PPE holder. In an interview on 06/25/24 at 2:27 PM, the TN stated the last in-service on hand washing and isolation precautions was recently. The TN stated she was not aware that Resident #19 had c. diff results pending. The TN stated the PPE for c. diff precautions was gown, gloves, and hand washing. The TN stated she would keep the supplies for a resident that was on c. diff precautions separate from supplies used for other residents. The TN stated she thought the alcohol/ ammonium wipes were effective against c. diff. After the TN read the label of the alcohol/ ammonium wipes she stated she did not think they would be effective against c. diff. The TN stated the Clorox wipes were effective against c. diff. The TN stated if hands or equipment were not cleaned properly, it could lead to the infection being spread to other residents which could cause them to become dehydrated, ill, or could possibly die. In an interview with the ADON and the DON on 06/25/24 at 2:47 PM, the ADON stated the last in service on hand washing and different types of isolation was in May, about a month ago. The ADON stated a resident should be put on c. diff precautions as soon as it was suspected and stay on them until after the c. diff test results are back. The ADON stated if the resident was positive for c. diff, then the precautions have to stay in place until a negative c. diff test was received. The ADON stated that Resident #19 possibly having c. diff was not discussed in the morning meeting and it did not come out on the 24-hour report because it was placed on there 19 minutes after the morning report was run. The ADON stated the nurse who entered the c. diff test should have asked the physician for an isolation order when she requested the test. Then ADON stated the difference between contact and c. diff isolation was that regular wipes could not be used for c. diff. The DON stated bleach wipes had to be used with c. diff precautions and that hand washing with soap and water was required to eliminate c. diff spores. Record review of CDC guidance 483.80(a)(1) on EBP: A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to S483.70(e) and following accepted national standards. Record review of the facility's Infection Prevention and Control Program Policy dated 05/13/23 stated in part: This facility has established and maintains an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Policy Explanation and Compliance Guidelines: 1. The designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases. 2. All staff are responsible for following all policies and procedures related to the program. 5. Isolation Protocol (Transmission-Based Precautions): a. A resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current CDC guidelines. 13. Resident/Family/Visitor Education and Screening: c. Isolation signs are used to alert staff, family members, and visitors of transmission-based precautions. 50039

Based on observations, interviews, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for one resident (Resident #1) reviewed for supervision. The facility failed to ensure Resident #1 received adequate supervision while Resident #1 eloped from the facility during lunch time. This failure could place residents requiring supervision at risk for injury and accidents with potential for more than minimal harm. The noncompliance was identified as Past Non-Compliance. The IJ began on 10/17/23 and ended on 10/18/23. The facility had corrected the noncompliance before the investigation began. Findings included: Record review of Resident #1's face sheet dated 5/09/24 reflected an [AGE] year-old-female with an original admitted [DATE]. Diagnosis included type two diabetes (insufficient insulin production in the body), acute (sudden) kidney failure, and dementia (mental decline that affects the quality of daily living). Record review of Resident # 1's physician orders for Wanderguard (device designed to prevent elderly individuals with dementia from wandering outside a perimeter) dated 1/28/2022 and a revision physician order for Wanderguard to right arm on 8/16/22. Record review of Resident #1's MDS dated [DATE] reflected a BIMS score of 1 (Severe Cognitive Impairment). Record review of Resident #1's quarterly Wandering assessment dated [DATE] reflected Resident #1 was a moderate wandering risk. Record review of Resident #1's nursing documentation dated 10/17/2023 at 12:35 PM documented: Late Entry: Received call from concerned family member that had witness someone outside the building that she thought might be one of our residents. Staff searched premises and found resident outside building wheeling self-up the street. SN approached resident asking her where she was going and mentioned home. Resident redirected and brought back to nursing home. No distress or discomfort noted. No visible trauma. Resident outside the building for approximately 5-10 minutes. No missed medications or meals. In an interview on 5/08/24 at 2:00 PM the DON stated on the day of the elopement, staff did not hear the Wanderguard alarm go off. The DON stated while staff were busy in the dining area, a concerned family member for another resident called the facility and stated Resident #1 was seen in the facility parking area in her wheelchair. The DON stated he and the ADON ran outside and found Resident #1 in the street by the stop sign on the opposite side of the facility parking area. The DON stated Resident #1 stated she was trying to go home. The DON stated Resident #1 was brought inside the facility and head to toe assessment was conducted with no injuries or distress noted. The DON stated a resident head count was conducted to make sure all residents were accounted for. The DON stated a facility walk around was conducted and during the walk around, that is when it was noticed the Wanderguard antenna was out of range since it had been moved to the ceiling. The DON stated at the time of the elopement, Resident #1 had the Wanderguard bracelet on her right ankle making the Wanderguard system unable to detect the bracelet at floor level. The DON stated Resident #1 was not in the intersection and did not consider the street Resident #1 was on to be a busy street. In an interview on 05/08/24 at 2:20 PM the Administrator stated the facility's front lobby area was going through a renovation and at that time the contracted construction company had put the Wanderguard antenna in the ceiling in an attempt to beautify the front lobby without his knowledge. The Administrator stated the antenna was still visible and the remodel was going on for about 6 months and Resident #1's elopement was the only elopement the facility had during that time and since then. The Administrator stated that all exit doors are checked daily by maintenance and on the day of Resident #1's elopement, the Wanderguard alarm system was working. Record review on 05/08/24 at 2:40pm of the Exit Door Logbook reflected on 10/16/23, and on 10/17/23, the day of Resident #1's elopement, the Wanderguard alarm system was working. In an interview on 5/8/24 at 3:04 PM the ADON stated she was in the office when the DON received a call from a concerned family member of another resident stating she saw a resident in a wheelchair out in the facility parking lot. The ADON stated she ran out the facility's font entrance while the DON ran out the facility's back entrance and at first, the ADON stated she couldn't see anything and kept going to the right of the facility and saw Resident #1 across the street up against the curb. The ADON stated the DON came around the back of the facility, ran to Resident #1 and took her inside the facility to get a head-to-toe assessment. The ADON stated the Wanderguard was on Resident #1's foot but was not sure which foot. The ADON stated she did not remember hearing the Wanderguard alarm go off as it can be heard throughout the building and her office. ADON stated Resident #1 could have gotten hit by a car and injured due to the elopement. The ADON stated nothing could have happened to Resident #1 as well. Interview beginning on 05/08/24 at 10:00am with 1 RN, 3 LVN's, 2 CNA's, 1 Business Office Manager, and 1 laundry aide from various shifts were all able to correctly identify the protocols for a resident elopement. Corrective action implemented by the facility beginning on 10/17/2023 included: Record review of the outside contractor invoice dated 10/18/23 revealed the alarm system was assessed and functional on door and was set at door alarm to maximum range. Observation of Resident #1 on 05/08/24 revealed she had her wanderguard bracelet moved to right arm as indicated in physician order. Interview with the Administrator and DON on 05/08/24 at 3:04 PM revealed they both verified that R #1's wanderguard bracelet was moved to R #1's right arm. Record review of all sampled residents revealed they had a current wandering evaluation. Record review of facility in-services dated 10/17/23 included: -Elopement and Wandering Residents -What to do when door alarm sounds, locate cause of alarm, locate person who went out or in the door. -Do not reset alarm without determining who entered or exited. -All new admissions will have wandering assessment completed. -All residents who are determined to be at risk of wandering will have care plan updated. -Daily exit door checks by maintenance, notify administrator and maintenance immediately if any of the doors appear to malfunction. -All residents have updated wandering assessments. -Daily Wanderguard bracelet checks by charge nurses and documented in computer system. -All residents who are determined to be at risk of wandering have an updated care plan. -All residents have an updated wandering assessment. -An electronic audit log for each exit door is kept and maintained by maintenance. -All staff have been educated on the definition of elopement, if an employee observes a resident leaving the premises, he/she should: -Attempt to prevent the resident from leaving in a courteous manner. -Get help from other staff members in the immediate vicinity if necessary. -Stay with the patient at all times. -Instruct another staff member to inform the charge nurse or Director of Nursing services that a resident is attempting to leave or has left the premises. Call local law enforcement if necessary. In-services included staff signatures as evidence of receiving and understanding the in-service. Interviews conducted on 05/08/24 revealed 1 RN, 3 LVN's, 2 CNA's, 1 Business Office Manager, and 1 laundry aide from various shifts were all able to correctly identify the protocols for a resident elopement. Record review of Elopements and Wandering Residents dated 11/21/22 stated: Policy: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Policy Explanation and Compliance Guidelines; 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. 3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Record review of Abuse, Neglect, and Exploitation dated 8/15/22 stated: Neglect means the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The noncompliance was identified as Past Non-Compliance. The IJ began on 10/17/23 and ended on 10/18/23. The facility had corrected the noncompliance before the investigation began.

Based on observation, interview and record review, the facility failed to provide treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for 1 resident (Resident #1) of 8 residents reviewed for quality of care. The facility failed to follow the physicians order on 08/16/2022 in accordance with the care plan for Resident #1's Wanderguard bracelet (device designed to prevent elderly individuals with dementia from wandering outside a perimeter) to be placed on her right arm. The Wanderguard bracelet was instead placed around her right ankle. This failure could place residents requiring supervision who had a Wanderguard at risk for injury and accidents. The findings included: Record review of Resident #1's face sheet dated 05/08/2024 reflected an [AGE] year-old female with an original admitted [DATE]. Pertinent diagnoses includes dementia (mental decline that affects the quality of daily living) with exit seeking behaviors. Record review of Resident #1's MDS dated [DATE] reflected a BIMS score of 1 (Severe Cognitive Impairment). Record review of Resident #1's quarterly Wandering assessment dated [DATE] reflected Resident #1 was a moderate wandering risk. Record review of Resident #1's comprehensive care plan dated 01/28/2022 indicated a problem stating she was an elopement risk, wanderer, and disoriented to place. An intervention included for this problem was to check placement and function of safety monitoring device as per policy/orders. Record review of Resident #1's physician orders for Wanderguard dated 1/28/2022 and a revision physician order for Wanderguard to right arm on 8/16/22. In an interview with the DON on 05/08/2024 2:00 PM, it was revealed that on 10/17/2023, the day of an elopement by Resident #1, she had the Wanderguard bracelet on her right ankle making the Wanderguard system unable to detect the bracelet at floor level. In an interview with the MD on 05/08/2024 2:15 PM, it was revealed that as a resident with a Wanderguard device approaches a closed door equipped with the Wanderguard system, the door locks for 15 seconds. He further revealed that if the Wanderguard device crosses the threshold of an open door equipped with the Wanderguard system, an alarm sounds throughout the building. Observation on 05/08/2024 at 2:50 PM revealed that Resident #1 was wearing her Wanderguard bracelet on her right arm on. Resident #1 could not be interviewed due to history of dementia. In an interview with the ADON on 05/08/2024 3:04 PM, it was revealed Resident #1 was wearing her Wanderguard device around one of her ankles during the head-to-toe assessment of Resident #1 immediately following the elopement incident on 10/17/2023. The ADON stated a potential outcome of the incident was Resident #1 getting hit by a car. In an interview with LVN D on 05/10/2024 10:25 AM, LVN D stated that not following physician orders could lead to medical errors or poor patient outcomes. LVN D also stated that if she saw a resident wearing their Wanderguard bracelet in a different location from where it stated on the physician's order then she would inform the DON of the discrepancy and then get assistance to move it to the correct location based on the physician's order. Record review of a work order from a contractor dated 10/18/2023 8:42 AM revealed the following: WanderGuard at front door not alerting when tag is present. Requested by the Administrator for the front door WanderGuard system not working. The system was checked by tech and was adjusted to maximum coverage the system would allow. It was noted that the system has an external signal interference, that causes the bracelet, to not be picked up by sensor when close to the door. All adjustments were made and a resident was used to test door response. The resident had a tag applied to ankle. The nurse admin was notified that the tag was to close to the ground and was part of the reason the tag was not picked up by receiver. This person stated that it had been done that way and she would speak to Admin on his return. Job complete.

Based on interview and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments, person-centered care plan to reflect the current condition for 1 of 11 residents (Residents #2) reviewed for care plan revisions. The facility failed to ensure Resident #2's care plan was comprehensive and updated to reflect Resident #2's fall preventions. This failure could place residents at risk of not receiving appropriate interventions meet their current needs. The findings include: Record review of Resident #2's admission records revealed an [AGE] year-old-female with an admitted [DATE] and re-admission on 02/09/24. Diagnoses included left femur (thigh)/hip fracture, heart failure, diabetes, osteoarthritis (severe bone degeneration), protein-calorie malnutrition, and muscle wasting. Record review of Resident #2's quarterly MDS dated [DATE] revealed a BIMS of 6 indicating severe cognitive impairment. Resident #2 was dependent for chair/bed to chair transfers and toileting transfer. Picking up objects, sit to stand or walking 10 feet was not attempted due to medical or safety reasons. Resident #2 required supervision with toileting, substantial assistance with footwear and dressing, rolling left and right, sitting to lying, lying to sitting on the side of the bed, wheeling her wheelchair 50 feet. Resident #2 was incontinent of bladder and bowel. She had a manual wheelchair she could self-propel. Record review of Resident #2's care plans only had partial Low risk interventions when Resident #2 was rated at a high risk for falls since her admission on 07/28/22. Record review of Resident #2's comprehensive care plan dated 7/28/2022 indicated she was at risk for falls r/t Hx of falls: 8/16/22-witnessed fall/with skin tear to left side of lip/attempted unassisted transfer from bed to w/c Date Initiated: 07/28/2022 Revision on: 08/17/2022. Interventions were: Anticipate and meet Resident #2's needs. Date Initiated: 07/28/2022 Revision on: 08/17/2022 o Be sure Resident #2's call light is within reach and encourage to use it for assistance as needed. Date Initiated: 07/28/2022 Revision on: 08/17/2022 o Rehab referral related to 8/16/22 fall. Date Initiated: 08/16/2022. 8/16/22-staff to continue to anticipate and meet needs. Revision on: 10/02/2022. 7/19/23-Resident sitting on bathroom doorway. Stated she slipped sitting down when she tried to self-transfer and forgot to lock her wheelchair and she was wearing socks. Date Initiated: 07/19/2023 o Resident #2 will have no major injuries from fall. Date Initiated: 07/19/2023 Target Date: 05/14/2024 o Call bell within reach to call for assistance. Date Initiated: 07/21/2023 o Perform frequent rounds to anticipate resident's needs. Date Initiated: 07/19/2023 o Therapy to evaluate and treat. Date Initiated: 07/19/2023 o 02/23/24-Resident found on floor in seated position: unwitnessed fall. 02/01/24-Resident voiced that she wanted to go to restroom. did not use call light. fell , c/o pain. Date Initiated: 02/23/2024 o Resident will have no major injuries from a fall. Date Initiated: 02/23/2024 Target Date: 05/14/2024 o Call bell within reach. Date Initiated: 02/23/2024 o Frequent rounds to anticipate resident's needs. Date Initiated: 02/23/2024 o Therapy to evaluate and treat. Date Initiated: 02/23/2024 o Resident #2 is High risk for falls r/t Hx of falls prior to admitted Initiated: 02/09/2024 Revision on: 02/14/2024 o The resident will be free of falls through the review date. Date Initiated: 02/09/2024 Target Date: 05/14/2024 o Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Date Initiated: 02/09/2024 o Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes. Date Initiated: 02/09/2024. Record review of Resident #2's Fall risk assessments dated 02/01/24 documented a score of 15 indicating a high risk for falls. Quarterly Fall risk assessments since 08/16/22 documented scores from 10-12, indicating a high risk for falls since her original admission on 07/28/22. Record reviews of Resident #2's initial baseline care plan dated 02/09/24, comprehensive care plans dated 02/09/24 and 02/14/24 revealed Resident #2's Care plan dated 02/14/24. Resident #2 has acute pain r/t recent ORIF (open reduction internal fixation=plates and screws). During an interview with the DON on 05/08/24 at 1:40 pm, he stated interventions for high risk fall scores should be care planned and in the physician orders. During an interview with the DON on 5/10/24 at 12:40 pm, he stated, Fall precautions should be in the care plan. Revisions were overlooked by the DON after Intra Disciplinary Team (IDT) daily morning meetings. The DON stated, Fall mats, call lights and low bed positioning should be in the interventions in the care plans. They (staff) need to keep the patients safe, so all staff should be very vigilant. If there was not something in the care plan that was suggested, it is rated by what the resident needs. The DON stated, Staff and the IDT review the fall prevention policy and go by that. The DON stated, The 02/09/24 care plan was after [Resident #2's] fall on 02/02/24 and again on 02/23/24. It had appropriate interventions, but there could have been more because she had broken her hip then fell again. The DON stated, The interventions in [Resident #2's] care plan were not adequate. The DON stated the fall interventions of call bell within reach and encourage to use it for assistance as needed, anticipate and meet Resident #2's needs were inadequate for Resident #2's current condition. The DON stated he did not see the interventions for a fall mat or low bed. The DON stated, There could be 15 of them (interventions), but if they weren't using them all, they tried to use the ones that were more useful. After reviewing the resident's Fall risk Evaluations, the DON stated, Some of the other interventions would have helped her and helpful in preventing a fall. The DON acknowledged Resident #2 was a high fall risk since 11/07/22 and more interventions would have been helpful. The DON stated he was not sure of what the facility's fall prevention program policy outlined. The DON was unable to show where fall interventions were located in Resident #2's electronic chart. Record review of facility policy titled, Fall Prevention Program dated 08/15/22 reflected-Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Policy explanation and compliance guidelines: 1. a. The risk assessment categorizes residents according to low or high risk. 3. The nurse will indicate the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk. 4. Low risk protocols: a. May implement universal environmental interventions, that decrease the risk of residents falling, including but not limited to: i. a clear pathway to the bathroom and bedroom doors. ii. Bed is locked and lowered to a level that allows the resident's feet to be flat on the floor when the resident is sitting on the edge of the bed. iii. Call light and frequently used items are within reach. iv. Adequate lighting. v. wheelchairs and assistive devices are in good repair. b. Implement routine rounding. c. Monitor for changes in resident's cognition, gait, ability to rise/sit and balance. d. encourage residents to wear shoes or slippers with non-slip soles when ambulating .g. Complete a fall risk assessment every 90 days and as indicated when the resident's condition changes. 5. High risk protocols: a. Provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in functional status. b. Provide additional interventions ass directed by the resident's assessment, including but not limited to ii. Increased frequency of rounds, v. Low bed, vii. Scheduled ambulation or toileting assistance. 8. When any resident experiences a fall, the facility will: e. Review the resident's care plan and update as indicated. f. Document all assessments and actions.

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 5 of 5 staff (Dietary staff A, B, C, D and E) and 1 of 1 kitchen, in that: 1) Dietary staff failed to store, serve or process foods in a manner to prevent contamination, 2) Dietary staff failed to handle food contact equipment in a manner to prevent contamination, 3) Dietary staff failed to ensure food contact surfaces were clean, 4) Dietary staff failed to perform sanitary handwashing between the handling of soiled and clean food equipment during dishwashing, 5) Dietary staff failed to use good hygienic practices, including incorrect handwashing techniques, 6) TCS/PHF foods were not maintained at 41 degrees F and below or 135 degrees F or above 7) The dial probe thermometers were not accurate 8) Wiping cloth quaternary sanitizer solutions were not at required levels and was not tested correctly 9) Food contact equipment storage areas were not maintained in a clean and sanitary manner 10) Dietary staff restroom did not have a functioning hand sink 11) Staff failed to effectively prevent the entry of pests/flies in the kitchen 12) Foods were spoiled and past their recommended expiration/use dates 13) Food preparation area nonfood contact surfaces were not clean, and 14) Foods were not thawed in a safe manner. These failures could place residents at risk for food contamination and foodborne illness. The findings include: - The following observations were made, and interviews conducted during a kitchen tour on 4/4/23 that began at 9:25 AM and concluded at 10:45 AM: Dietary staff B was observed washing her hands in the two-compartment sink. Dietary staff A was observed touching the trashcan lid and then handling clean trays. There was one of two sets of lights that were unshielded in the dishwasher area. The dishwashing area refrigerator had an opened zip top bag of three bean salad and an opened zip top bag of mixed vegetables. Both opened to air. The oven area walls were dirty with a heavy accumulation of dried spills and the kitchen return air vents had a buildup of grease. Observation and interview on 4/04/23 at 9:40 AM there were 2 wiping cloth buckets observed near the kitchen 2 compartment sink, one was green, and one was red. There were cloths in both. Dietary staff B took a chlorine test strip and tested the liquid in the red bucket. The results was 0 ppm. Regarding the contents of the red bucket, she stated at this time she did not know what solution was in it, and that other staff set up the buckets for them. Observation of the lower wooden kitchen cabinetry revealed that the shelving was scarred and had peeling paint. The doors and exterior of the cabinetry had a buildup of encrusted dried food and dirt. On 4/4/23 at 9:46 AM an interview was conducted with Dietary staff B. She stated she had worked at the facility three weeks and shadowed another cook for three or four days. Dietary staff B stated staff slowly allowed her to work alone. The hand sink in the kitchen employee's restroom was lying on the floor. On 4/4/23 at 9:49 AM an interview was conducted with Dietary staff A regarding the broken restroom hand sink. She stated, the hand sink fell off the wall on Sunday (4/02/23). She further stated they would have to wait until the Maintenance Supervisor came back to get it repaired. She added the Maintenance Supervisor would be off duty this week. Dietary staff A was observed handling soiled dishes, then washed her hands in the dishwasher area two compartment sink at the same time Dietary staff B was washing a colander in the same two compartment sink. Dietary staff B then washed her hands in the two-compartment sink in the dishwasher area which had dirty pans in it. After washing her hands, she disposed of the paper towel on top of a large trashcan. There was a large tube of frozen hamburger in a pan on a counter at the kitchen two compartment sink. There was a small amount of water in the pan, but the hamburger was not submerged in the standing water. The lower shelf of the stove area prep table was heavily soiled with grease buildup. The kitchen's three door refrigerator had a half a block of margarine that was uncovered exposed to air. There was also a zip top bag of small peppers that had six of the peppers that were molded and black. The zip top bag was labeled 1/11/23. There was also a 32-ounce container of Dannon yogurt that was labeled by the facility Use by 3/6/23. The manufacturer's label on the yogurt reflected, Best if used by December 26, 2022. Observation of the metal cabinetry drawers and bins revealed the scoop and ladle storage drawers were lined with heavily soiled paper. There were dried spills and scarring on the exterior of the drawers and bins of the cabinetry. In the pantry there was a large bag of brown sugar and a box of lentils that was open exposed to air. There was one 4-ounce container of Imperial Thickened Apple Juice from Concentrate that was stored on a shelf with current foods. The container's manufacture's label reflected Used by 2/02/23. The interior flashing of the icemaker had dried spills/smears. On 4/4/23 at 10:13 AM the large tube of frozen hamburger was now on a pan with no water in the pan at the kitchen two compartment sink. On 4/4/23 at 10:18 AM an interview was conducted with Dietary staff B regarding the frozen hamburger. She state, the hamburger would be used to make Carne Guisada for the noon meal. Dietary staff A was observed washing her hands in the two-compartment sink in the dishwasher area. She turned off the water with her bare hands She then dried her hands with a paper towel. Next, she handled clean dishes and put them away. On 4/4/23 at 10:22 AM Dietary staff B was about to prepare the pureed mixed vegetables. At that time the surveyor asked to see the interior of the processor and the blade before the food was added. The blade was dirty and had pureed beans on the lid. The lid stirrer was also dirty. Dietary staff B then took the processor back to the two-compartment sink and washed the lid with water only. She then placed it on the processor wet, placed the mixed vegetables in the processor pot and pureed them. Dietary staff A opened the kitchen exit door to the outside and left it open as a visitor was standing in the doorway. This action could allow flies/insects to enter the kitchen. Dietary staff B was washing her hands at the two-compartment sink and then she turned off the sink water with a paper towel. She then continued to dry her hands with the same paper towel. - The following observations were made, and interviews conducted during a kitchen tour on 4/04/23 that began at 11:50 AM and concluded at 12:58 PM: On 4/4/23 at 11:57 AM Dietary staff C and Dietary staff D were standing in the opened kitchen doorway to the outside entrance. They stood there from 11:57 AM to 11:59 AM. At that time a fly was observed, landing on uncovered bowls of peaches in the kitchen. Dietary staff D entered the kitchen and washed his hands in the two-compartment sink in the dishwasher area. He turned off the water then dried his hands with a paper towel. Next, he continued dietary duties. There were also soiled dishes in that two-compartment sink at the time. On 4/4/23 at 12:18 PM temperatures were taken on the service line by Dietary staff B. She used a dial probe thermometer. At this time, she stated, she was not sure how often the thermometer was calibrated for accuracy. The following were the temperatures taken: The mixed vegetables were 150 F. The potato tots were 142 F. The carne guisada was 140 F. The puree meat/Carne guisada was 135 F. The pureed potato tots were 124 F. The pureed mixed vegetables were 140 F. The pureed bread was 90 F and had been placed on the kitchen prep table at room temperature and not on any heat or cooling source since 11:50 AM when first observed by the surveyor. The breaded pork patty was 126 F and was not reheated to 165 F or maintained at 135 F. prior to meal service. On 4/04/23 at 12:25 PM, an interview was conducted with Dietary staff B regarding the preparation of the pureed bread. She stated she prepared the pureed bread using bread and milk. On 4/4/23 at 12:35 PM, the calibration on the facility's dial thermometer was checked with Dietary staff B. The surveyor's and the facility's thermometer were placed in ice water and the facility dial thermometer read 25 F and the surveyor's digital thermometer read 32.7 F. - The following observations were made, and interviews conducted during a kitchen tour on 4/04/23 that began at 3:43 PM and concluded at 5:33 PM: On 4/04/23 at 3:43 PM the pureed bread was in a container at room temperature on the counter near the steam table and not on any heating or cooling source. Dietary staff D was handling soiled dishes at the dishwasher and then washed his hands at the dishwasher area two compartment sink and then put away clean dishes. There were pots in the sink basin where he washed his hands. Dietary staff D handled soil dishes at the dishwasher and then handled clean dishes and insulated lids and did not wash his hands between the soiled and clean duties. Dietary staff C placed macaroni and cheese and ham in the processor pot. The surveyor intervened and pointed out that the lid to the processor and scraper/stirrer had a buildup of food. At this time the Visiting Dietary Manager took the lid and washed it, but it still had food debris on it. The Visiting Dietary Manager then washed it again and it was clean. On 4/4/23 at 4:00 PM an interview was conducted with Dietary staff C regarding the pureed bread. She stated she made the pureed bread with bread, milk, and cinnamon. On 4/4/23 at 4:09 PM an interview was conducted with the Visiting Dietary Manager regarding the green bucket and the red bucket that had wet wiping cloths in them. She stated the green bucket contained soap, and the red bucket contained sanitizer. At that time she tested the red bucket for quaternary sanitizer (Autochlor Solution QA) with quaternary test strips. The level of quaternary sanitizer was 0 ppm. The Visiting Dietary Manager changed out the sanitizer and it was 200 ppm. Observation and record review of the label of Auto Chlor System Solution Q A Sanitizer revealed the following documentation, . Sanitizing Food Contact Surfaces: . 200 ppm, active of this product for sanitizing and cleaning of equipment and utensils in restaurants, bars, and institutional kitchens. There was a live fly in the kitchen area. On 4/4/23 at 5:02 PM temperatures were taken on the service line as follows: The macaroni cheese and ham dish was 165 F at the time Dietary staff C wiped the probe of the thermometer with a wet paper towel between each food. The carrots were165F . The pureed macaroni cheese and ham dish was 110 F and reheated to 175 degrees F. The pureed carrots were 120 F and reheated to 167 F. The puree bread was at room temperature on the counter and was 80 F. The pureed macaroni and ham without cheese was 165 F. The regular ham and macaroni dish without cheese was 163 F. On 4/4/23 at 5:05 PM Dietary staff C was interviewed regarding her use of a wet paper towel to clean the thermometer probe between foods. She stated the paper towel only had water on it. Dietary staff C was observed grasping and touching the stove area preparation tabletop and edge with both hands. She then took one bare hand and flipped flour tortillas on a small skillet on the stove. - The following observations were made, and interviews conducted during a kitchen tour on 4/05/23 that began at 11:35 AM and concluded at 1:10 PM: Two of 2 drink guns had a buildup of syrup and debrison the spout. The walls in the oven area and two compartment sink area in the kitchen were dirty with splatter and dried spills and the return air vents were thick with dust and dirt. The dishwasher area had one of two sets of lights unshielded. The kitchen employee's restroom sink was off the wall and on the floor. Flies and gnats were observed in the kitchen area. There was a large bag of brown sugar that was open in the pantry and exposed to air. Observation of the kitchen area metal cabinetry revealed that there was peeling, and chipping paint and the interior of the drawers were lined with dirty paper. The icemaker interior flashing had dried spills. The lower wooden storage cabinets had doors and shelving that were scraped, had peeling paint, dirt buildup and dried spills. On 4/5/23 at 12:05 PM Dietary staff C was standing in an open exit door to the kitchen, and it was not closed until 12:06 PM. A fly was landing on an uncovered tray of marshmallow and chocolate pudding desserts. On 4/5/23 at 12:12 PM the service line temperatures were taken with a digital thermometer . The Pureed bread was on the counter at the service line at room temperature and not on any heating or cooling source. No temperature was taken. On 4/5/23 at 12:37 PM an interview was conducted with Dietary staff B, regarding how she made the pureed bread. She stated she used bread, milk, and cinnamon. On 4/5/23 at 2:24 PM an interview was conducted with Dietary staff B regarding observations in the kitchen. Regarding dietary sanitation she stated she had not been trained on testing sanitizer. She stated she had been told that the green bucket contained soap and the red contained sanitizer. She stated staff did not specify what type of sanitizer and said to change it every two hours. Regarding handwashing, she stated staff usually washed their hands at the kitchen hand sink. Regarding cleaning of the walls and cabinetry, she stated the cabinets doors and walls were cleaned after lunch. Regarding the thawing techniques, she stated staff tried to place the foods in the refrigerator to thaw. She stated she was not on duty the day before 4/04/23. She added to quick thaw food the foods were usually placed under running water in the (2 compartment) large sink, but the large sink was full of food equipment. Regarding the soiled processor blade, she stated she usually used the processor and then placed it in the dishwasher. She added that she was nervous due to the survey. Regarding potentially hazardous foods not at the proper temperature, she stated, the (pureed) bread should be at room temperature by lunchtime. Regarding calibrating thermometers, she stated she was not trained to calibrate thermometers. She added that the digital thermometer used today was a personal one that belonged to Dietary staff A. Regarding what could result from the dietary sanitation issues that occurred, she stated she did not want residents to be sick and foods off temperature (between 41 degrees F and 135 degrees F) could make residents sick. Regarding why these dietary sanitation issues occurred, she state, she was not prepared after having days off. On 4/5/23 at 4:49 PM, an interview was conducted with a Dietary staff C regarding issues in the kitchen. Regarding staff use of the two-compartment sink for handwashing purposes, she stated there's no reason why it was done. She stated that staff had not received any in-service training on correct handwashing procedures. Regarding the door left open to the outside she stated staff had been told to close the door and not leave it open for long periods of time. Regarding the pureed bread, she state, she was told to have pureed bread at room temperature. Regarding cleaning of the thermometer probe, she stated the facility had sanitizer wipes to clean them, but she could not find them. She stated staff were told to check the cleanliness of the processor and processor parts. Regarding bare hand contact while cooking/warming the flour tortillas, she stated staff were never told not to turn tortillas with their bare hands. She further stated that she started working as a cook approximately two weeks ago, and she worked as a dishwasher in the facility since November 2022. On 4/5/23 at 4:41 PM an interview was conducted with Dietary staff D. He stated he had been working in the facility approximately two weeks. Regarding handwashing in the two-compartment sink, he stated staff had not been instructed not to use the two-compartment sink to wash their hands. He stated he had been told just to wash his hands. He further stated he had not been taught the correct handwashing procedure. Regarding his training for the dietary department, he stated it lasted two or three days. He stated each day he was shown new things. He stated residents could get sick if staff washed their hands incorrectly. - The following observations were made, and interviews were conducted during a kitchen tour on 4/06/23 that began at 10:48 AM and concluded at 11:46 AM: On 4/06/23 at 10:48 AM the Dietary Manager stated the only employees using the kitchen restroom were kitchen staff. Dietary staff E was observed preparing to pureed beans. She placed the beans in the processor which was wet on the interior. On 4/6/23 at 10:52 AM Dietary staff A was interviewed regarding handwashing in the 2-compartment dishwasher area hand sink. She stated staff did not want to bring germs into the kitchen, so they washed at the dishwasher area 2 compartment sink. On 4/4/23 at 12:04 PM an interview was conducted with Dietary staff A. She stated she had been employed in the facility since 12/01/21. Observation of the three-door refrigerator revealed that the zip top bag of sliced ham was labeled by the facility Use by 3/23/23. Dietary staff E was observed washing the processor in the 2-compartment sink. Observation of the lid, after washing, revealed that it had food debris on the scraper/stirrer and the processor pot had food debris. The surveyor intervened, and Dietary staff E washed the lid again. Observation of the lid revealed that it was still dirty with food in places on the processor and lid. The surveyor intervened again, and the processor and lid were washed again. On 4/6/23 at 11:00 AM an interview was conducted with a Dietary Manager regarding issues found in the dietary department regarding the cleanliness of walls and cabinets. She stated she had been hired on 5/28/22 and the walls and cabinetry were in the same condition as now. She added that staff had tried to clean it, but the surface came off the wall. Regarding the timetable when walls and cabinetry were cleaned, she stated staff had not scrub them because they did not have the time. She stated staff applied some degreaser on the walls and cabinets and wiped it off. Regarding the soiled processor parts and processing foods when the processor was wet, she stated she had told staff to let it dry, but the dietary department did not have enough help. Regarding the soiled interior of the icemaker, she stated staff cleaned it every six months. Regarding the identification and incorrect level of quaternary sanitizer in the red bucket, she stated she had always told staff it contained the sanitizer in the red bucket. She stated the label had come off the red bucket and the sanitizer level should be 150 to 200 ppm. Regarding the exit door to the outside being left open, she stated the flies had entered the kitchen even with the zapper (electronic insect exterminator). Observation during this interview with the Dietary Manager revealed that Dietary staff E was washing her hands in the 2-compartment sink at the same time. When it was pointed out to the Dietary Manager, she stated staff should have wash their hands in the (kitchen) hand sink. She stated she knew staff used the two-compartment sink for handwashing. She further stated that she believed the staff had seen the soap and paper towel dispensers installed at the 2-compartment sink and were prompted to use it as a hand sink. Regarding handwashing in the two-compartment sink, she stated it had been easier for staff to wash their hands at the hand sink located in the kitchen, but staff will not do it since it is too far away. Regarding incorrect handwashing technique, she stated she had told staff to dry their hands, using the paper towel, and then turn off the water and dispose of the paper towel in the trashcan. Regarding staff not washing their hands between soiled and clean dishwashing duties, she stated she had told staff when they handle the soiled dishes, they need to wash their hands, then handle the clean. Regarding the broken hand sink in the restroom, she stated she had been aware of it and reported it through the facility's online maintenance reporting system. She stated she did not know how it happened or when the facility would have it repaired. Regarding bare hand contact with food, she stated she had told staff they should turn tortillas with tongs or a spatula. Regarding outdated foods, she stated the cook would be in charge when the Dietary Manager was absent, and they should check food dates and dented cans. She stated that was the responsibility of the Dietary Manager when present. Regarding thermometer accuracy, she stated, she had calibration instructions posted on the wall at the sink. She stated the dial thermometer was the one used by staff. Regarding cleaning thermometers, she stated staff should have cleaned the thermometer probe with sanitizer wipes. Regarding the improper thawing techniques, she stated she had told staff to thaw foods in the refrigerator in a pan on a lower shelf the day before use. She further stated she had not reviewed with staff any faster methods of thawing such as under running water. Regarding potentially hazardous food/TCS foods not maintained at 41 degrees F or below or 135 degrees F or above, she stated she preferred to make pureed bread with water and did not know why staff used milk. Regarding why all these dietary issues occurred, she stated it had been a lack of training and staff needed more monitoring due to her increased job duties. She stated she had conducted in-services within the past 3 months with one addressing dishwashing. She stated the Dietary Manager, and the cook were responsible to ensure that all functions in the kitchen were performed correctly. She further stated the dietary department did not have enough staff. Regarding what could result from the issues observed in the dietary department regarding dietary sanitation, she stated residents could get sick, especially with incorrect handwashing and temperatures. On 4/6/23 at 12:54 PM an interview was conducted with Administrator regarding issues in dietary. Regarding dietary sanitation, he stated the restroom hand sink broke recently, and he fixed it today. He stated he had no excuse for the delay in repairing the hand sink. He stated there could be a negative outcome as a result of the issues in the dietary department regarding dietary sanitation. On 4/6/23 at 2:13 PM an interview was conducted with the Dietary Manager regarding the repair of the kitchen restroom hand sink. She stated it was repaired at approximately 12:30 PM today. Observation, at this time of the hand sink in the kitchen restroom revealed that it had been repaired. Record review of the dietary in-services held from December 2022 thru April 2023 revealed there were only two. On 12/15/22 the Dietary Manager held an in-service on Handwashing. Dietary staff A and C attended. On 1/20/23 the Dietary Manager held an in-service on Use of Gloves. Dietary staff A, B, C and E attended. Record review of the facility policy titled Policy: Cabinets, Drawers, And Shelving, Policy Number: 04.008, Date Approved: October 1, 2018, revealed the following documentation, Policy: The facility will maintain cabinets, drawers and shelving free of food particles and dirt, to minimize the risk of food hazards. Cabinets, drawers, and shelving will be cleaned a minimum of every week or as needed. Procedure . 6. Do not use shelf liners in drawers, cabinets or shelving. Record review of the facility policy titled Policy: Employee Sanitation, Policy Number: 03.0 4.001, Date Approved: 12/01/11, revealed the following documentation, Policy: The consultant dietitian will monitor each facility to ensure that the facility uses good sanitation practices in accordance with the state and federal food codes. Guidelines . 6. Handwashing. a. Employees wash their hands and exposed portions of their arms at designated handwashing facilities at the following times: . 2. After using the toilet room. 4. Immediately before engaging in food preparation, including working with exposed food, clean equipment and utensils, and unwrapped, single service, and single used articles. 5. During food preparation, as often is necessary to remove soil, and contamination, and prevent cross-contamination when changing tasks. 7. After engaging in other activities that contaminate the hands. Record review of the facility policy titled Policy: Handwashing, Policy Number: 04.002, Date Approved: October 1, 2018, revealed the following documentation, Policy: The facility recognizes that foodborne illness has the potential to harm elderly and frail residents. All nutrition and food service employees will practice good handwashing practices in order to minimize the risk of infection and foodborne illness. Procedure: 1. Handwashing stations. b. Make sure there are handwashing stations in all areas that employee's hands may become contaminated, including food preparation areas, service areas, dishwashing areas, and restrooms. d. Sinks used for food preparation or washing utensils, or a service sink or curbed cleaning facility used to dispose of mop water or similar waste cannot be used as a handwashing station. 2. Hands should be washed after the following occurrences: a. Using the restroom. k. Touching unsanitized equipment, work surfaces are washcloth. 3. Hand washing steps. a. Wet hands and exposed arms with hot water at least 100 F. b. Apply soap. c. Scrub hands, expose arms and fingernails for a minimum of 20 seconds being sure to apply a vigorous friction. d. Rinse hands and expose arms thoroughly under hot running water. e. Dry hands and arms with a paper towel. f. Turn off the faucet with a paper towel to avoid contaminating hands and discard the towel. Record review of the facility policy titled Policy: Food Holding, And Service, Policy Number: 03.005, Date Revised: June 1, 2019, review in the following documentation, Policy: To ensure that all food served by the facility is a good quality and safe for consumption, all food will be held and served according to the state and US Food Codes and HACCP guidelines. Procedure: 1. Serve all hot foods at a temperature of 135 F or greater and all cold food at 41 F or less. 4. If hot food drops below 135 F, reheat to 165 F for a minimum of 15 seconds. 5. Take cold food items from the refrigerator only as needed. Ice down milk for use at meal services Record review of the facility policy titled Policy: Food Storage, Policy Number: 03.003, Date Revised: June 1, 2019, review of the following documentation, Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. Procedure: 1. Dry storage rooms. d. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. 2. Refrigerators . d. Date, label and tightly seal all refrigerated foods, using clean, nonabsorbent, covered containers, that are approved for food storage. Record review of the facility, policy, titled Policy: Food Preparation and Handling, Policy Number: 03.004, Date Revised: June 1, 2019, revealed the following documentation, Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be prepared and handle according to the state and US Food Codes and HACCP guidelines. Procedure: 1. General guidelines. a. Use clean, sanitize surfaces, equipment, and utensils. b. Wash hands properly before beginning food preparation. c. Prepare food with the least manual contact possible. Do not allow bare hands to touch raw food directly. 2. Thawing foods. a. Thaw meat, poultry, and fish in a refrigerator at 41 F or less. b. Foods may be thawed using the following procedures: i. Completely submerged under running water at a temperature of 70 F or below with sufficient water velocity to agitate and float off loosened food particles into the overflow. ii. In a microwave oven using the defrost mode and immediately transferred to a conventional cooking equipment with no interruption in the process. iii. As part of the cooking process.

Based on observation, interview, and record review the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest, practicable physical, mental, and psychosocial well-being of each resident for seven (R #65, R #3, R #18, R #227, R #29, R #70, and R #79) of eight residents reviewed for quality of care and assessments. The Administrator failed to: 1) Implement policies and procedures for Resident Rights and Quality of Care. The administrator did not ensure the nursing staff could accurately assess, document, and communicate changes in resident's wound status to residents Physician. 2) Supervise the DON by ensuring a monitoring process was in place for Licensed Nurse competency with wound assessments, documentation and reporting resident's wound status to Physician. The DON failed to: 1) Implement policies and procedures for Resident's Rights and Quality of care by ensuring Registered Nurse and Licensed Nurse Competency with wound assessments, accuracy of wound documentation, and communication with Physicians with wound changes and obtain treatment orders. 2) Put effective measures into place to ensure staff accurately provided Head to Toe and Weekly Pressure Ulcer assessments. 3.) Train the nursing staff on accurate wound assessment and documentation process and obtaining physician's orders [REDACTED]. The above failures resulted in an IJ situation on 03/08/18. While the IJ was removed on 03/11/18, the facility remained out of compliance at actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure continued implementation of their plan of removal. These failures could place nine residents with pressure ulcers and 19 residents receiving preventive skin care at risk for developing new pressure ulcers or a deterioration in existing pressure ulcers. The findings included: Simultaneous interview with the Administrator, DON, and RN Consultant on 03/08/17 beginning at 1:13 p.m. revealed the surveyor discussed with them in detail of all evidence gathered via observations, interviews, and record reviews gathered of R #65, R #3, R #18, R #227, R #29, R #70, and R #79. The DON and RN Consultant confirmed most of the residents were missing several Weekly Pressure Ulcer Reports, the DON said There should be a separate Weekly Pressure Ulcer Report for each separate ulcer. It is important to document each ulcer separately on the Weekly Pressure Ulcer Report so that we can track the progress or deterioration of the wound. If we see a decline in the wound, we contact the physician to inform him and discuss whether we need to change a treatment. The DON was asked if she was aware of R #65's left heel pressure ulcer had changed from a DTI to an Unstageable to a DTI and then back to an unstageable from 02/07/18-02/27/18; after the DON reviewed R #65's pressure ulcer documents, she stated I don't know, I assume they were not staging correctly, it's inconsistent. Documentation of the wounds needs to be as detailed and accurate as possible to ensure we are identifying it accurately to be able to treat it correctly. The DON said Staff were trained and should be performing hand hygiene prior to donning PPE equipment, in between changing gloves, and after donning PPE equipment. The DON said it was especially important to follow hand hygiene procedures when caring for R #65 because He has infected wounds [MEDICAL CONDITION]. If not performing hand hygiene, his other wounds can get infected and/or we can cross-contaminate and risk infecting others. After the DON was informed of LVN E providing treatment on R #65's newly discovered pressure ulcers the DON said She should have called the physician for orders before she provided treatment. She is not a physician and we don't know if that is the most appropriate treatment that the physician would have ordered. It is important to get orders for treatment from a physician because we want to provide the most accurate treatment and care of the problem. The DON said R #65 should be repositioned frequently, at least every two hours. The DON said since R #65 had Stage 4 pressure ulcers on each hip it could be difficult to position him on the wound but staff could use pillows to off-load the buttocks and back. The DON said the treatment nurse that was working Monday - Friday had stop showing up for duty as of this week. The DON said she currently had three different nursing staff conducting wound care. The DON said she had not seen all the wounds in the facility but had seen some of R #65's ulcers while he was receiving wound care. The DON said she reviewed the Skin Logs weekly, reviewed physician orders, and review care plans for inclusion of pressure ulcers. The DON and Administrator said they both review all pressure ulcers in the facility from the Skin Logs on a weekly basis during the interdisciplinary meeting conducted every Tuesday. The DON said she was not wound certified but was very familiar with wounds. The DON said staff could always come to her if they had concerns or a question about wounds or wound care. The Administrator said the facility had resources for Pressure Ulcers such as their policy and procedure, Lippincott, DON, and Nurse Consultants. The RN Consultant said staff could refer to the National Pressure Ulcer Advisory Panel online if they needed to. After discussion of the concerns identified with R #65's documentation and care, the DON agreed that staff needed training in consistency, accuracy, identification, staging, description of pressure ulcer and the documentation of pressure ulcers. The Administrator said We will improve to document correctly, improve to document the situation as it occurs, and ensure to have the documentation completed by the end of the nurses shift. The DON explained that each light on the air mattress Comfort Adjust setting was equal to 50 pounds of weight per light and it should be set according to the resident's weight. The ADON said R #65's LALM pump setting should be set between the second and third light. The DON said if the Low Air Loss Mattresses (LALM) mattress was too soft or too hard, it could cause pressure to the bony prominence's or directly on the ulcers causing risk for deterioration. The DON said all nursing staff caring for the resident was responsible for routinely checking the setting on the LALM for correct setting. The DON stated the LALM mattresses should have a minimum amount of linen on the mattress for more effective therapy. After the DON was informed of R #65 lying on a draw sheet, folded in half, a thick cloth pad, and using a brief the DON said It's too many layers, the layers do not allow proper air flow and causes increased moisture, which could cause skin breakdown and pressure ulcer development or deterioration. The DON did not mention checking the proper placement of a low air loss mattress by using the hand check. On 03/08/18 at 5:32 p.m., the facility Administrator, DON, and the RN Consultant were notified that an Immediate Jeopardy situation had been identified due to the above failures. On 03/09/18 at 2:37 p.m., the facility was notified of the acceptance of the final Plan of Removal (POR).The facility's final Plan of Removal documented: Plan to Remove Immediately Jeopardy . (MONTH) 09, (YEAR) Audit will be completed by Director of Nurses, for residents (#3, #70, #18 and #29) related to the inaccurate documentation of pressure ulcers measurements, staging, assessments and treatments to ensure accuracy of documentation is completed. Start 3/08/2018 at 2:15pm. Finish 3/08/2018 at 11:30 p.m. Director of Nurses, was re-educated by (RN Consultant)/District Director of Clinical Services on hand hygiene to include when to glove, assessing and accurate documentation of a head to toe assessment , measuring and staging of wounds , and documenting skin condition on the appropriate Skin Weekly Pressure or non-Pressure Record. Administrator and IDT will review head to toe assessments for accuracy in the daily morning meeting. Administrator and IDT will review the Skin Weekly Pressure and non-Pressure Records for accuracy in the daily morning meeting. Administrator and IDT will review skin documentation weekly during the At Risk Skin Management meeting and will also review the Physician's documentation for discrepancies with wound measurements, description and staging. Licensed Nurse will round with the Wound Physician and ensure the documentation is accurate to include measurement, staging and description of wound. 100% Head to Toe assessments to be completed by 3/08/2018 by Licensed Nurses. District Director of Clinical Services validated Director of Nursing, and LVN, ADON, on hand hygiene, accuracy of documentation regarding the skin pressure and non-pressure condition, measuring wounds and staging on 03/08/2018. For those residents found to have new skin condition, Director of Nursing, and Licensed Nurses will notify Physician for orders, Licensed Nurses will document condition of skin on Skin Weekly Pressure or Non-Pressure Record. Director of Nursing, will validate the accuracy of the documentation. On (MONTH) 08, (YEAR) and (MONTH) 09, (YEAR) Ad Hoc subcommittee of the Quality Assurance & Performance Improvement Committee met to discuss, approve and implement the plan. Staff will be re-educated by Director of Nurses, and District Director of Clinical Services. All nursing staff will be included in the re-education , which will include the following: o The policy and procedure for monitoring pressure ulcers to include identification of wounds for Pressure, Non Pressure and Medical Device Pressure Injury for Licensed Nurses. o Notifying physicians of any change of skin condition to include Pressure and non Pressure wounds, Medical Device Pressure Injury, Skin tears and any other skin condition identified for Licensed Nurses. Notification to the Physician by the Licensed Nurse will be made upon identification of skin condition. o Reviewing physician orders [REDACTED]. If clarification needed for treatment orders, the licensed nurse will contact the prescribing Wound Physician; Medical Doctor during daily'morning clinical meeting. If unable to obtain clarification:, licensed nurse to clarify with Medical Director immediately. o Reviewing weekly Head to Toe skin assessment, weekly wound documentation, care plan for skin care, treatment orders during the skin management at risk meeting for Licensed Nurses. o Proper identification and description of skin tears and pressure ulcer staging to include staging for Medical Device Pressure Injury for Licensed Nurses. o Proper and timely documentation of skin assessments and wound care for Licensed Nurses to include accuracy on all required records to include Head to Toe record, SBAR,Skin weekly Pressure and non-Pressure Record. o Charge nurse will be responsible for completing weekly head to toe skin check, wound documentation and treatment documentation. Director of Nurses will follow up weekly to verify compliance for one month, and then biweekly for another month, and then monthly for one month. o Proper setting of low air loss mattress for resident's weight to include no cloth pads, may have a turning sheet. o Hand hygiene to include to glove in between tasks, repositioning at least every 2 hours, anchoring foley catheter and ensure no kinks, no tubing underneath resident to prevent Medical Device Pressure Injury for all nursing staff. o In-service Resident Care Specialist (Certified Nurse Aides) on reporting any skin conditions to include wounds without a dressing to Charge Nurse immediately and complete a stop and watch for notification. Charge nurse to assess wound and apply treatment and dressing as ordered immediately. o AMT, American Medical Technologies, RN,WCC will in service Nursing Staff on wound prevention to include importance of turning and repositioning, securement of F/C tubing, keeping F/C bag below bladder level, of reporting wounds without dressing to Charge Nurse, Charge Nurse to assess, treat and dress wound immediately. For Licensed Nurses the training will include staging, measuring, documentation and importance of following up with Physician for any changes and treatment order. On Monday, (MONTH) 12, (YEAR) at 2:00 pm. Note: Any nursing staff that has not received the in-service on (MONTH) 08, (YEAR) will not work until the training is completed. Monitoring: Director Of Nurses, ADON will review and observe all wound treatment every week for 4 weeks to ensure compliance. QAPI committee will meet weekly for 4 weeks and then monthly until compliance is achieved. Committee will review negative findings and make recommendations as appropriate. Interview with the Administrator, LVN E, DON, and the RN Consultant on 03/10/18 at 3:45 p.m. revealed they were made aware of R #79's observations. LVN E was asked if she had documented R #79's treatment she conducted at 11:28 a.m., LVN E said she had not documented it or filled out an SBAR because she did not have the measurements she took and was waiting to retrieve them from the surveyor. When LVN E was asked to recall, describe, and stage R #79's ulcers, LVN E said He had two Stage 2's to his right buttock, one Stage 2 on the right thigh all with 100% granulation tissue and small drainage. The left thigh had approximately 25% yellow slough, 75% granulation tissue with small drainage. It is a Stage 2. At 4:13 p.m., LVN E was asked if yellow slough in the wound bed met the definition of a Stage 2, LVN E said No, it doesn't, it should be identified as a Stage 3. The DON was asked how and why R #79's treatment orders began on 03/08/19 despite he was identified with wounds on admission. The DON responded I don't know. It should not have happened, the nurses should have called the doctor and received treatment orders upon admission. I found it on 03/08/19 as I was conducting the 100% chart reviews then I called the doctor myself for the orders. The DON said if the resident did not receive orders upon admission or upon identification of the wound then the resident would not get treatments and the wounds could become infected and/or worsen. The DON and LVN E confirmed R #79's left ulcer worsened from a Stage 2 to a Stage 3 pressure ulcer. The Administrator, DON, and other consultants re-assessed residents with pressure ulcers providing accurate identification, staging, and documentation. On 03/10/18, the facility provided the surveyor with an updated Weekly Pressure Ulcer Log dated 03/09/18, after conducting their 100% skin checks, that revealed 13 residents with current pressure ulcers. There were 21 pressure ulcers identified upon admission and 18 pressure ulcer identified as facility acquired. Of those facility acquired pressure ulcers, eight pressure ulcers were identified (as DTI's, Stage 3, and/or Unstageable) after the Immediate Jeopardy was called on 03/08/18. The log identified three residents with Medical Device Acquired Pressure Injuries. The surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: -five CNA's were interviewed and confirmed they had been trained as to which residents required repositioning and protective device use, and could identify them. -one CMA's were interviewed and confirmed they had been trained as to which residents required repositioning and protective device use, and could identify them. -six nurses (LVN/RN) were interviewed and said they had been trained as to which residents were identified with pressure ulcers and protective devices, and could identify them. The nurses said they received instruction and reference to the NPUAP for assistance with pressure injury description, staging and documentation. -The updated resident Care Plans for all residents with pressure ulcers were reviewed and it was found they contained a positioning schedule and any assistive and/or protective devices the resident required/was ordered. Interview with the DON and Administrator on 03/11/18 at 5:30 p.m., they were asked how this IJ could have been prevented; the DON said Could have done more supervision of staff, wound care, documentation, having a consistent treatment nurse or designated person to do wound care, definitely more education and training to staff on identifying, staging, accurate description, accurate/complete/thorough documentation, calling the physician of changes and for new wounds discovered for orders, and air loss mattresses; we started in-servicing on medical device associated pressure injuries, and hand hygiene. The DON said she will now be called for any change in condition and then direct the staff to follow the Skin and Wound Care Guideline, if applicable. The Administrator said he had just received approval this morning for the facility to use a Skin Formulary/ Skin Care Guidelines as instructions to care for a pressure ulcer until the resident was seen by the physician or wound care specialist. On 03/11/18 at 5:42 p.m., the Administrator, DON, RN Consultant, and DDC were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure assessments and documentation for pressure ulcers were accurate for all residents. The facility's CMS Form 672 dated 03/05/18 identified nine residents with pressure ulcers and 19 residents receiving preventive skin care. Please refer to F686 for detailed evidence of federal deficiency.

Based on observation, interview, and record review the facility failed to ensure residents who entered the facility without pressure ulcers did not develop pressure ulcers and a resident having pressure ulcers received care and treatment consistent with professional standards of practice to promote healing and prevent further development of skin breakdown or pressure ulcers for seven (R #65, R #3, R #18, R #227, R #29, R #70, and R #79) of eight residents reviewed for pressure ulcers. 1.) Resident #65: -The facility failed to assess and document a detailed description of R #65's pressure ulcers upon admission. -The facility's documentation of R #65's pressure ulcers was conflicting and inconsistent on separate forms making it difficult to track the progress and accurate staging of the pressure ulcers. -The facility did not consistently identify all of R #65's pressure ulcers in their Skin-Weekly Pressure Ulcer Record or the Skin Head to Toe Check. -The facility did not reposition or attempt off-loading techniques of pressure points for R #65, whom was identified as at risk for pressure ulcer development, at least every two hours as determined by the facility. -LVN E failed to perform hand hygiene practices as per the facility's policy and procedure, prior to initiating and during R #65's wound care on his pressure ulcers. R #65 had some infected ulcers [MEDICAL CONDITION]. -LVN E failed to consult with R #65's physician when two new pressure ulcers were identified and before treating them. -The facility failed to ensure the licensed staff providing wound care were knowledgeable and competent in the identification, assessment, documentation, and treatment of [REDACTED]. -Documentation of R #65's Sacral ulcer revealed staff were inconsistent with staging and were back-staging, which was incorrect according to the facility's policy and procedure and the National Pressure Ulcer Advisory Panel. -The facility did not ensure or monitor R #65's Low Air Loss Mattress was set at the appropriate setting for optimal therapy, as per the User-Guide. -The facility did not ensure R #65 received necessary treatment and services thru proper use of low air loss mattresses, which was chosen as [MEDICATION NAME] to prevent the development of or worsening of pressure ulcers. R #65's Left Heel Pressure Ulcer was initially identified as a DTI however, deteriorated to an Unstageable Pressure Ulcer from admission to 03/07/18; Left Lateral Ankle and Left Lateral Leg Unstageable Pressure Ulcers slightly increased in size from admission to 03/07/18; Right Medial Heel Pressure Ulcer was initially identified as a Stage 2 however, deteriorated to an Unstageable Pressure Ulcer from admission to 03/07/18; Right Lateral Ankle Pressure Ulcer was initially identified as a Stage 2 however, deteriorated to an Unstageable pressure ulcer from admission to 03/07/18; Left Upper Back, Mid Upper Back, and Mid Lower Back Unstageable Pressure Ulcers developed depth to the ulcers that he did not have on admission; Sacral Pressure Ulcer deteriorated from a Stage 3 to a Stage 4 from admission to 03/07/18. 2) Resident #3: -The facility did not reposition or attempt off-loading techniques of pressure points for R #3, whom was identified as at risk for pressure ulcer development, at least every two hours as determined by the facility. -R #3's Stage 3 pressure ulcer was left uncovered for an undetermined amount of time, despite R #3's physician orders [REDACTED]. R #3 developed a facility acquired Stage 2 pressure ulcer to her sacrum which doubled in size and deteriorated to a Stage 3 pressure ulcer. 3) R #227: -LVN S did not initiate documentation of R #227's left upper posterior thigh medical device related pressure injury (MDRPI) that was discovered upon the surveyor's inquiry. -LVN S did not consult with R #227's physician regarding the newly discovered MDRPI until a day later, upon the surveyor's inquiry. -The facility incorrectly identified R #227's newly discovered wound to her left upper posterior thigh as a skin tear rather than a confirmed MDRPI. R #227 developed a Stage 2 MDRPI in the facility five days after her admission to the facility. 4.) R #18: -The facility's incorrectly identified R #18's right buttock pressure ulcer as a Stage 2, which did not meet the definition, according to the facility's description of the wound. -The facility's documentation of R #18's pressure ulcers was conflicting and inconsistent on separate forms making it difficult to track the progress and accurate staging of the pressure ulcers. -The facility did not consistently identify all of R #18's pressure ulcers in their Skin-Weekly Pressure Ulcer Record or the Skin Head to Toe Check. R #18 was admitted to the facility with a Right Buttock blister however two days later R #18's blister deteriorated to a Stage 3 pressure ulcer and then to an Unstageable pressure ulcer. 5.) R #29 was not repositioned at least every two hours as determined by staff, on two separate occassions. R #29 was positioned on his left hip, which had a Stage 2 pressure ulcer, for over two hours. R #29 developed two Stage 2 pressure ulcers since admission to the facility. 6.) R #70: -R #70 was admitted to the facility on [DATE] with no pressure ulcers. On 02/26/18 R #70 was identified to have a pressure ulcer to the Left Buttock Stage 2 and a pressure ulcer to the Right Buttock Stage 2 but the facilty failed to obtain a Physician order [REDACTED].>-R #70's pressure ulcer was left uncovered for an undetermined amount of time, despite R #70's physician orders [REDACTED]. -CNA X did not report to licensed staff that R #70's pressure ulcer was uncovered. R #70 developed a Stage 2 pressure ulcer since admission to the facility. 7.) R #79: -R #79 was admitted to the facility on [DATE] with three pressure ulcers, and the facility did not obtain physician orders [REDACTED]. The facility did not continue to monitor and document the status of all three pressure ulcers on an ongoing basis. -LVN E incorrectly staged R #79's left postereior thigh pressure ulcer as a Stage 2 despite it meeting the definition of a Stage 3. -R #79's Low Air Loss Mattress was set at the appropriate setting for optimal therapy, as per the User-Guide. R #79 was admitted to the facility with three Stage 2 pressure ulcers; R #79's left posterior thigh pressure ulcer deteriorated to a Stage 3 pressure ulcer since admitted to the facility. The above failures resulted in an IJ situation on 03/08/18. While the IJ was removed on 03/11/18, the facility remained out of compliance at actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure continued implementation of their plan of removal. These failures could place nine residents with pressure ulcers and 19 residents receiving preventive skin care at risk for developing new pressure ulcers or a deterioration in existing pressure ulcers. The findings included: Shortly after entrance into the facility on [DATE], the facility provided their Centers for Medicare and Medicaid Services (CMS) Form 672 dated 03/05/18 that identified nine residents with pressure ulcers (excluding Stage 1), with four residents admitted with pressure ulcers (excluding Stage 1), and 19 residents receiving preventive skin care. On 03/05/18 at approximately 2:30 p.m., the facility also provided a copy of their Weekly Pressure Ulcer Log that identified 10 residents with pressure ulcers and a total of 27 pressure ulcers. Of the 27 total pressure ulcers, six were identified as facility acquired and 21 as community acquired. 1.) Resident #65 R #65's Face Sheet dated 03/06/18 documented a [AGE] year-old male admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed), Left Ankle - Unstageable (Full thickness tissue loss in which the base of the ulcer is covered by slough-yellow, tan, gray, green or brown and/or eschar-tan, brown or black in the wound bed), Left Upper Back - Unstageable, Right Heel - Unstageable, Left Heel - Unstageable, Right Ankle - Unstageable, and Pressure Ulcer of other site - Unstageable, Major [MEDICAL CONDITIONS] (paralysis on one side of the body) and Muscle Wasting and Atrophy. R #65's Hospital Discharge Summary dated 02/07/18 documented Discharge Diagnoses: [REDACTED]. 2. Infected decubitus ulcer, Stage 3, in the sacral area, status [REDACTED]. 3. Multiple unstageable decubitis ulcers, midback, both shoulders, both heels, and left lateral ankle . R #65's Nursing Admission Data Collection dated 02/07/18 revealed R #65 had skin issues: -Sacrum: Pressure: 5.0 X 5.0 X 1.7 centimeters (cm), Stage 3 -Left (Lt) Hip: Pressure: 8.0 X 7.0 X 3.2 cm, Stage 4 -Right (Rt) Hip: Pressure: 8.2 X 6.4 X 2.8 cm, Stage 4 -Left Shoulder (rear): Pressure, 0.8 X 2.0 cm, Unstageable -Left Upper Back: Pressure, 1.7 X 2.0 cm, Unstageable -Mid Upper Back: Pressure, 2.4 X 0.8 cm, Unstageable -Lower Back: Pressure, 4.0 X 1.4 cm, Unstageable -Left Lateral Leg: Pressure, 9.4 X 1.6 cm, Unstageable -Left Lateral Ankle: Pressure, 3.0 X 2.5 cm, Unstageable -Left Heel: Pressure, 1.5 X 1.0 cm, DTI (Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) -Right Medial Heel: Pressure, 0.5 X 0.6 cm, Stage 2 -Right Medial Leg: Pressure, 1.8 X 0.5 cm, Unstageable -Right Upper Back: Pressure, 1.4 X 1.5 cm, Unstageable -Lower Sacral Area: Skin Tear, 0.9 X 1.5 cm, Unstageable Notes: Lt hip stage 4- (8.0cm x 7.0cm) undermining all around 3.2 cm. Rt hip stage 4 (8.2cmx6.4cm) undermining from 9-5 deepest 2.8cm from 7-8 deepest 0.9cm. Sacral (5.0cmx5.0cm) undermining 5-12 deepest 1.7cm. sacral wound stage 3. Has multiple bruises throughout upper exts. Throughout back has multiple unstageable wounds with dry eschar. To Rt medial leg has unstageable wound with eschar. The document provided the following definitions: Suspected Deep Tissue Injury (DTPI- Deep Tissue Pressure Injury) - Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Stage I - Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. Stage II - Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. (MONTH) also present as an intact or open/ruptured serum-filled blister. Stage III - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling. Stage IV - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Unstageable - Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Continued review of this assessment revealed there was no detailed description of each identified wound. R #65's Braden Scale for Predicting Pressure Sores dated 02/07/18 documented a score of 10 - High Risk. R #65's Admission Brief Interview for Mental Status assessment dated [DATE] documented a score of 0- Severe impairment. R #65's Head to Toe Skin Check dated 02/07/18 documented Existing Pressure Ulcers: 1. Left Heel: Pressure 1.5 X 1.0 centimeters (cm.) Suspected Deep Tissue Injury 2. Sacrum: Pressure 5.0 X 5.0 X 1.7 cm Stage 3 3. Left Shoulder (rear): Pressure 0.8 X 2.0 cm Unstageable 4. Right Heel Medial: Pressure 0.5 X 0.6 cm Stage 2 5. Right Upper Back: 1.4 X 1.5 cm Unstageable 6. Left Upper Back: Pressure 1.7 X 2.0 cm Unstageable 7. Right Medial Leg: 1.8 X 0.5 cm Unstageable 8. Mid Upper Back: Pressure 2.4 X 0.8 cm Unstageable 9. Left Lateral Ankle: Pressure 3.0 X 2.5 cm Unstageable 10. Lower Back: Pressure 4.0 X 1.4 cm Unstageable 11. Left Hip: 8.0 X 7.0 X 3.2 cm Stage 4 12. Right Hip: 8.2 X 6.4 X 2.8 cm Stage 4 13. Left Lateral Leg: Pressure 9.4 X 1.6 cm Unstageable 14. Lower Sacral Area: Skin tear 0.9 X 1.5 cm Further description of skin issues: Has pressure wound bilaterally to hips and sacral region which are open with undermining. Throughout his back he has multiple wounds with dry eschar tissue. To right leg has wound with eschar tissue. To left heel has DTI. Wound vac to be bridged to hip wounds. After review of this assessment and further record review of R #65's electronic charting revealed there were no other documents that included a detailed description of each individualized wound. R #65's Head to Toe Skin Check dated 02/12/18 documented Existing Pressure Ulcers: 1. Left Heel: Pressure 1.0 X 0.5 cm. Unstageable (This ulcer deteriorated from a DTI to an Unstageable) 2. Sacrum: Pressure 3.5 X 4.0 X 1.3 cm Stage 3 3. Left Shoulder: Pressure 2.0 X 1.0 cm Unstageable 4. Right Heel Medial: Pressure 1.0 X 0.5 cm Stage 2 5. Right Upper Back: 1.7 X 0.1 cm Unstageable 6. Left Upper Back: Pressure 1.5 X 3.5 cm Unstageable 7. Right Medial Leg: 2.0 X 1.0 cm Unstageable 8. Mid Upper Back: Pressure 2.3 X 1.5 cm Unstageable 9. Left Lateral Ankle: Pressure 2.8 X 2.0 cm Unstageable 10. Lower Back: Pressure 3.2 X 1.0 cm Unstageable 11. Left Hip: 8.0 X 7.0 X 1.2 cm Stage 4 12. Right Hip: 8.3 X 6.6 X 1.5 cm Stage 4 13. Left Lateral Leg: Pressure 8.5 X 1.0 cm Unstageable 14. Lower Sacral Area: Skin tear 0.7 X 1.5 cm 15. Right Lateral Ankle: Pressure 0.8 X 1.0 cm Stage 2 (In comparison to 02/07/18 assessment, this wound is a newly acquired wound). There was no other documentation that provided any description or identification that this ulcer was newly acquired. 16. Left Upper Back: 2.3 X 1.5 Unstageable (In comparison to 02/07/18 assessment, there was only one Left Upper Back wound identified on admission and now there are two separate wounds documented). There was no other documentation that provided any description or identification that this ulcer was newly acquired. Further description of skin issues: Has pressure wounds bilateral hips, sacral region which open with undermining. Has multiple wounds throughout his back with dry eschar and mid back with slough. Record Review of the facility's electronic charting system from dates 02/07/18 - 02/12/18 revealed R #65 did not have any Weekly Pressure Ulcer Reports for each individualized ulcer that could provide a detailed description of each pressure ulcer. Review of the facility's Nurses Notes and Progress Notes revealed there was no additional documentation regarding R #65's pressure ulcer status on 02/12/18. R #65's Admission Minimum (MDS) data set [DATE] documented R #65: -Had clear speech; -Sometimes made self understood and sometimes understood others; -Had short and long-term memory loss; -Had severely impaired cognitive skills for daily decision making; -Required extensive assistance with one or two person physical assist for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene; -Had upper and lower extremity impairment on one side; -Had an indwelling catheter and was always incontinent of bowel; -Was at risk of pressure ulcer development, had one Stage 3 upon admission, had two Stage 4's upon admission, and had seven unstageable's upon admission. The dimension of the largest Stage 3 or 4 surface was 8.0 X 7.0 X 3.2 centimeters. Skin and ulcer treatments were: pressure reducing device for bed, pressure ulcer care, and nutrition or hydration intervention . R #65's Comprehensive Care Plan dated 02/14/17 documented: -I have a DTI pressure ulcer to my right lateral ankle r/t (related to) immobility. I want my pressure ulcer to heal . I have a DTI pressure ulcer to my right medial leg r/t immobility .I have an unstageable ulcer to right upper back r/t immobility .I have a DTI pressure ulcer to my left posterior heel r/t immobility .I have a DTI pressure ulcer to left medial heel r/t immobility .have an unstageable pressure ulcer to my left lateral ankle r/t immobility .I have an unstageable pressure ulcer to my left lateral leg r/t immobility .I have an unstageable pressure ulcer to my left upper back r/t immobility .I have an unstageable ulcer to mid lower back r/t immobility I have an unstageable pressure ulcer to my left shoulder r/t immobility .I have a pressure sore that is on my sacrum and is stage 4 r/t immobility .I have an unstageable pressure ulcer to my mid upper back r/t immobility .I have a pressure sore that is on my RIGHT hip and is stage 4 r/t immobility Interventions: Administer treatments as ordered and observe for effectiveness .have a pressure sore that is on my left hip and is stage 4 r/t immobility Assist me to reposition and/or turn at frequent intervals to provide pressure relief. Apply air mattress as ordered Notify nurse if dressing is soiled, loose, or missing Offload heels and ankles Teach resident/family the importance of changing positions for prevention of pressure ulcers. Encourage small frequent position changes .Weekly head to toe assessments as per protocol. Notify MD (Medical Doctor) as needed . -I have an ADL self-care performance deficit r/t Disease Process/recent hospitalization with debrided ulcers with pain, Fatigue, [MEDICAL CONDITION] d/t hx (history)[MEDICAL CONDITION]([MEDICAL CONDITION]- stroke) .BED MOBILITY: I require extensive assistance by X 1-2 staff to turn and reposition in bed as necessary .BEDFAST: I am bedfast all or most of the time .DRESSING: I require extensive assistance by X 1 staff to dress .PERSONAL HYGIENE/ORAL CARE: I am totally dependent on X1 staff for personal hygiene and oral care SKIN INSPECTION: I require SKIN inspection Q (every) shift. Observe for redness, open areas, scratches, cuts, bruises and report changes to the Nurse .TOILET USE: I am totally dependent on X 1 staff for incontinent care .TRANSFER: I require Mechanical Lift (Hoyer) with X2 staff assistance for transfers . -I have impaired cognitive function/dementia or impaired thought processes r/t [MEDICAL CONDITION] . -I have a communication problem r/t unable to answer questions appropriately . -I have bowel incontinence r/t [MEDICAL CONDITIONS]; potential for constipation . -I [MEDICAL CONDITION] to multiple ulcers which some have been debrided .My infection will resolve with minimal complications as evidenced by negative culture, vital signs WNL and no s/sx of acute infection by review date .CONTACT ISOLATION: Wear gowns and masks when changing contaminated linens. Place soiled linens in bags marked biohazard. Bag linens and close bag tightly before taking to laundry Hand washing before and after delivery of care . -May have potential nutritional problem (weight loss) r/t Anorexia/malnutrition; requires to be spoon fed at all meals; my admission weight is 129.6# . -I have Indwelling Catheter: to help with wound healing and keep infection free .Anchor catheter to prevent excess tension .CATHETER: I have size 16F indwelling Catheter. Position catheter bag and tubing below the level of the bladder Hand washing before and after delivery of care .Perineal care as indicated. Notify nurse of any redness or irritation at insertion site . -I am at risk for falls r/t lt side weakness from [MEDICAL CONDITION], poor memory .My risks and injury potential will be minimized through the next review date .At risk for falls .Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance .Landing Mat .The resident needs a safe environment with: floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; Slide fails as ordered, handrails on walls, personal items within reach . R #65's Head to Toe Skin Check dated 02/19/18 documented Existing Pressure Ulcers: 1. Left Heel: Pressure 0.6 X 0.4 cm. Unstageable 2. Sacrum: Pressure 3.5 X 3.8 X 1.1 cm Stage 3 3. Left Shoulder: Pressure 2.0 X 1.0 cm Unstageable 4. Right Upper Back: 0.1 X 0.1 cm Unstageable 5. Left Upper Back: Pressure 1.4 X 3.5 cm Unstageable 6. Right Medial Leg: 1.7 X 1.8 cm Unstageable 7. Mid Proximal Upper Back: Pressure 1.9 X 0.8 cm Unstageable 8. Left Lateral Ankle: Pressure 2.4 X 2.5 cm Unstageable 9. Lower Back: Pressure 3.2 X 1.0 cm Unstageable 10. Left Hip: 8.0 X 6.5 X 0.8 cm Stage 4 11. Right Hip: 7.9 X 5.8 X 0.0 cm Stage 4 12. Left Lateral Leg: Pressure 9.1 X 2.4 cm Unstageable (This ulcer increased in size compared to 02/07/18 assessment) 13. Lower Sacral Area: Skin tear 0.7 X 1.5 cm 14. Right Lateral Ankle: Pressure .07 X 2.0 cm Suspected Deep Tissue Injury (In comparison to 02/12/18 assessment, this ulcer changed from a Stage 2 to a DTI). There was no other documentation that included a description of the change in wound status. 15. Mid Distal Lower Back: 3.3 X 0.6 Unstageable (In comparison to 02/07/18 and 02/12/18 assessment, there was no prior mention of a Mid Distal Lower Back. There was no other documentation that provided any description or identification that this ulcer was newly acquired or an incorrectly documented site. It could not be determined if this ulcer is the same as the Lower Back ulcer previously identified on 02/07/18.) 16. Left Medial Heel: Pressure 0.7 X 0.3 cm Suspected Deep Tissue Injury (In comparison to 02/07/18 and 02/12/18 assessments, this ulcer had not been previously identified. Record review of R #65's electronic charting from dates 02/07/18 - 03/08/18 revealed no description or identification of this specific ulcer being newly acquired.) Further description of skin issues: Left Lower Back Blister (Distal) 1.0 X 0.7, has pressure wounds bilateral hips, sacral region which open with undermining. Has multiple wounds throughout back with eschar (There was no measurement of the undermining mentioned. It is difficult to determine if this blister is the same ulcer identified in this assessment as the Mid Distal Lower Back or if it is a new additional ulcer. No other documentation in R #65's electronic records from dates 02/07/18 - 02/19/18 provided further documentation of the description or newly identification of this ulcer. The Right Medial Heel Ulcer previously identified on 02/07/18 was not included in this assessment. Record Review of the facility's electronic charting system revealed R #65 did not have any Weekly Pressure Ulcer Reports for each individualized ulcer that could provide a detailed description of each pressure ulcer. Simultaneous interview with the Administrator, DON, and RN Consultant on 03/08/17 at 1:13 p.m. revealed they were informed of as of 02/19/18, there were two left heel ulcers documented versus just one identified on 02/12/18. The DON and RN Consultant reviewed R #65's electronic records and provided verification of two left heel ulcers. Neither the DON or the RN Consultant could provide an answer as to when the second left heel ulcer was initially identified and verified the nursing staff should have documented an SBAR/Nurse's Note and a Pressure Ulcer Report when a new ulcer was identified. After reviewing R #65's electronic records, the DON confirmed there was no documentation of R #65's Left Medial Heel ulcer date of discovery. The DON and RN Consultant confirmed that R #65's Right Medial Heel ulcer was not included in the 02/19/18 Head to Toe assessment and said It should have been included, there is inconsistency and the doctor should have been made aware of the new ulcer at the time of discovery but there is no evidence of when that was done. R #65's Weekly Pressure Ulcer Record dated 02/26/18 documented Left Rear Shoulder: Date of Onset: 02/07/18 Existing Pressure Ulcer, admitted with. Location/Description: Left Rear Shoulder- Pressure 2.0 X 0.8 cm Unstageable; wound bed with dry eschar, no undermining or tunneling, black wound bed, no drainage or odor, black wound edges, surrounding skin: normal for skin. Response to Treatment: No change, Continue treatment. R #65's Weekly Pressure Ulcer Record dated 02/26/18 documented Left Heel: Date of Onset: 02/07/18 Existing Pressure Ulcer, admitted with. Location/Description: Left Heel- Pressure 1.5 X 1.0 cm Suspected Deep Tissue Injury; no undermining or tunneling, wound bed with discoloration (there was no description of the discoloration), no drainage or odor, black wound edges, surrounding skin: normal for skin. Response to Treatment: No change, Continue treatment. This ulcer was identified on 02/19/18 assessment as measuring 0.6 X 0.4 cm., Unstageable; there was no other documentation anywhere in R #65's electronic records from dates 02/07/18 - 02/26/18 that could further explain how this ulcer changed from an Unstageable to a DTI or that any consultation with R #65's physician was made of the change in wound status. R #65's Weekly Pressure Ulcer Record dated 02/26/18 documented Mid Distal Back: Date of Onset: 02/07/18 Existing Pressure Ulcer, admitted with. Location/Description: Mid Distal Back- Pressure 3.5 X 7.0 cm Unstageable; wound bed with slough tissue present, no undermining or tunneling, yellow wound bed, small serosanguineous drainage or no odor, normal wound edges, surrounding skin: normal for skin. Response to Treatment: No change, Continue treatment. This ulcer increased in size as it was previously assessed to be 3.3 X 0.6 cm on 02/19/18 R #65's Weekly Pressure Ulcer Record dated 02/26/18 documented Right Medial Leg: Date of Onset: 02/07/18 Existing Pressure Ulcer, admitted with. Location/Description: Right Medial Leg- Pressure 1.8 X 0.5 cm Unstageable; wound bed with eschar, no undermining or tunneling, black wound bed, no drainage or odor, normal wound edges, surrounding skin: normal for skin. Response to Treatment: No change, Continue treatment. This ulcer was not identified in the prior Head to Toe assessment dated [DATE] however, it was identified on 02/07/18 and 02/12/18 as a Stage 2 pressure ulcer. There was no other documentation that detailed the description of this deteriorating ulcer. R #65's Weekly Pressure Ulcer Record dated 02/26/18 documented Left Outer Ankle: Date of Onset: 02/07/18 Existing Pressure Ulcer, admitted with. Location/Description: Left Outer Ankle- Pressure 2.5 X 2.1 cm Unstageable; wound bed with dry eschar, no undermining or tunneling, black wound bed, no drainage or odor, normal wound edges, surrounding skin: normal for skin. Response to Treatment: No change, Continue treatment. R #65's Weekly Pressure Ulcer Record dated 02/26/18 documented Right Medial Heel: Date of Onset: 02/07/18 Existing Pressure Ulcer, admitted with. Location/Description: Right Medial Heel- Pressure 0.5 X 0.5 cm Stage 2; wound bed with dry eschar, no undermining or tunneling, normal wound bed, scant serosanguineous drainage or no odor, normal wound edges, surrounding skin: normal for skin. Response to Treatment: No change, Continue treatment. R #65's Weekly Pressure Ulcer Record dated 02/26/18 documented Left Lateral Leg: Date of Onset: 02/07/18 Existing Pressure Ulcer, admitted with. Location/Description: Left Lateral Leg- Pressure 9.0 X 1.7 cm Unstageable; wound bed with dry eschar, no undermining or tunneling, black wound bed, no drainage or odor, normal wound edges, surrounding skin: normal for skin. Response to Treatment: No change, Continue treatment. The above Weekly Pressure Ulcer Records were the only records documented of R #65's ulcers. There was no Weekly Pressure Ulcer Record on this date for R #65's Right Heel, Sacrum, Mid Proximal Upper Back, Left Hip, Right Hip, Right Medial Proximal Back, Right Upper back, Left Lower Back, Right Lateral Ankle, Left Medial Heel, and Left Lower Back Pressure Ulcers identified in assessments prior to 02/26/18. Simultaneous interview with the Administrator, DON, and RN Consultant on 03/08/17 beginning at 1:13 p.m. revealed they were informed of the missing Weekly Pressure Ulcer Reports for some of R #65's pressure ulcers. The DON and RN Consultant confirmed there were several missing Weekly Pressure Ulcer Reports, the DON said There should be a separate Weekly Pressure Ulcer Report for each separate ulcer. It is important to document each ulcer separately on the Weekly Pressure Ulcer Report so that we can track the progress or deterioration of the wound. If we see a decline in the wound, we contact the physician to inform him and discuss whether we need to change a treatment. The DON was asked if she was aware of R #65's left heel pressure ulcer had changed from a DTI to an Unstageable to a DTI and then back to an unstageable from 02/07/18-02/27/18; after the DON reviewed R #65's pressure ulcer documents, she stated I don't know, I assume they were not staging correctly, it's inconsistent. Documentation of the wounds needs to be as detailed and accurate as possible to ensure we are identifying it accurately to be able to treat it correctly. R #65's Head to Toe Skin Check dated 02/27/18 documented Existing Pressure Ulcers: 1. Left Heel: Pressure 1.5 X 1.0 cm. Unstageable 2. Right Heel: Pressure 0.5 X 0.5 cm Unstageable 3. Sacrum: Pressure 3.5 X 3.4 X 1.0 cm Stage 4 (All previous prior assessments identified the Sacral ulcer as a Stage 3. The facility had no other documentation of additional information/description of this ulcer deteriorating to a Stage 4. There was no evidence anywhere in R #65's electronic records from dates 02/07/18 - 02/27/18 that the physician was consulted of the change in pressure ulcer status.) 4. Left Shoulder: Pressure 2.0 X 0.8 cm Unstageable 5. Right Medial Leg: 1.8 X 0.5 cm Unstageable 6. Mid Proximal Upper Back: Pressure 2.0 X 1.0 cm Unstageable 7. Left Lateral Ankle: Pressure 2.5 X 2.1 cm Unstageable 8. Left Hip: 7.0 X 6.6 X 1.0 cm Stage 4 9. Right Hip: 8.0 X 6.0 X 0.0 cm Stage 4 10. Left Lateral Leg: Pressure 9.0 X 1.7 cm Unstageable (This ulcer increased in size compared to 02/07/18 assessment) 11. Mid Distal Lower Back: 3.5 X 7.0 Unstageable There was no measurement of the undermining mentioned on initial assessment of the bilateral hip and sacral ulcers in this assessment. This assessment did not include documentation or detail of R #65's Right Medial Proximal Back, Right Upper back, Left Lower Back, Right Lateral Ankle, Left Medial Heel, Right Medial Heel or Left Lower Back Blister ulcers identified in previous assessments. Record Review of the facility's electronic charting system revealed R #65 did not have any Weekly Pressure Ulcer

Based on observation, interview, and record review the facility failed to ensure residents have the right to be free from neglect for seven (R #65, R#3, R#18, R#227, R#29, R#70, and R#79) of eight residents reviewed for neglect, in that: 1.) Resident #65: -The facility failed to assess and document a detailed description of R #65's pressure ulcers upon admission. -The facility's documentation of R #65's pressure ulcers was conflicting and inconsistent on separate forms making it difficult to track the progress and accurate staging of the pressure ulcers. -The facility did not consistently identify all of R #65's pressure ulcers in their Skin-Weekly Pressure Ulcer Record or the Skin Head to Toe Check. -The facility did not reposition or attempt off-loading techniques of pressure points for R #65, whom was identified as at risk for pressure ulcer development, at least every two hours as determined by the facility. -LVN E failed to perform hand hygiene practices as per the facility's policy and procedure, prior to initiating and during R #65's wound care on his pressure ulcers. R #65 had some infected ulcers [MEDICAL CONDITION]. -LVN E failed to consult with R #65's physician when two new pressure ulcers were identified and before treating them. -The facility failed to ensure the licensed staff providing wound care were knowledgeable and competent in the identification, assessment, documentation, and treatment of [REDACTED]. -Documentation of R #65's Sacral ulcer revealed staff were inconsistent with staging and were back-staging, which was incorrect according to the facility's policy and procedure and the National Pressure Ulcer Advisory Panel. -The facility did not ensure or monitor R #65's Low Air Loss Mattress was set at the appropriate setting for optimal therapy, as per the User-Guide. -The facility did not ensure R #65 received necessary treatment and services thru proper use of low air loss mattresses, which was chosen as [MEDICATION NAME] to prevent the development of or worsening of pressure ulcers. R #65's Left Heel Pressure Ulcer was initially identified as a DTI however, deteriorated to an Unstageable Pressure Ulcer from admission to 03/07/18; Left Lateral Ankle and Left Lateral Leg Unstageable Pressure Ulcers slightly increased in size from admission to 03/07/18; Right Medial Heel Pressure Ulcer was initially identified as a Stage 2 however, deteriorated to an Unstageable Pressure Ulcer from admission to 03/07/18; Right Lateral Ankle Pressure Ulcer was initially identified as a Stage 2 however, deteriorated to an Unstageable pressure ulcer from admission to 03/07/18; Left Upper Back, Mid Upper Back, and Mid Lower Back Unstageable Pressure Ulcers developed depth to the ulcers that he did not have on admission; Sacral Pressure Ulcer deteriorated from a Stage 3 to a Stage 4 from admission to 03/07/18. 2) Resident #3: -The facility did not reposition or attempt off-loading techniques of pressure points for R #3, whom was identified as at risk for pressure ulcer development, at least every two hours as determined by the facility. -R #3's Stage 3 pressure ulcer was left uncovered for an undetermined amount of time, despite R #3's physician orders [REDACTED]. R #3 developed a facility acquired Stage 2 pressure ulcer to her sacrum which doubled in size and deteriorated to a Stage 3 pressure ulcer. 3) R #227: -LVN S did not initiate documentation of R #227's left upper posterior thigh medical device related pressure injury (MDRPI) that was discovered upon the surveyor's inquiry. -LVN S did not consult with R #227's physician regarding the newly discovered MDRPI until a day later, upon the surveyor's inquiry. -The facility incorrectly identified R #227's newly discovered wound to her left upper posterior thigh as a skin tear rather than a confirmed MDRPI. R #227 developed a Stage 2 MDRPI in the facility five days after her admission to the facility. 4.) R #18: -The facility's incorrectly identified R #18's right buttock pressure ulcer as a Stage 2, which did not meet the definition, according to the facility's description of the wound. -The facility's documentation of R #18's pressure ulcers was conflicting and inconsistent on separate forms making it difficult to track the progress and accurate staging of the pressure ulcers. -The facility did not consistently identify all of R #18's pressure ulcers in their Skin-Weekly Pressure Ulcer Record or the Skin Head to Toe Check. R #18 was admitted to the facility with a Right Buttock blister however two days later R #18's blister deteriorated to a Stage 3 pressure ulcer and then to an Unstageable pressure ulcer. 5.) R #29 was not repositioned at least every two hours as determined by staff, on two separate occassions. R #29 was positioned on his left hip, which had a Stage 2 pressure ulcer, for over two hours. R #29 developed two Stage 2 pressure ulcers since admission to the facility. 6.) R #70: -R #70 was admitted to the facility on [DATE] with no pressure ulcers. On 02/26/18 R #70 was identified to have a pressure ulcer to the Left Buttock Stage 2 and a pressure ulcer to the Right Buttock Stage 2 but the facilty failed to obtain a Physician order [REDACTED].>-R #70's pressure ulcer was left uncovered for an undetermined amount of time, despite R #70's physician orders [REDACTED]. -CNA X did not report to licensed staff that R #70's pressure ulcer was uncovered. R #70 developed a Stage 2 pressure ulcer since admission to the facility. 7.) R #79: -R #79 was admitted to the facility on [DATE] with three pressure ulcers, and the facility did not obtain physician orders [REDACTED]. The facility did not continue to monitor and document the status of all three pressure ulcers on an ongoing basis. -LVN E incorrectly staged R #79's left postereior thigh pressure ulcer as a Stage 2 despite it meeting the definition of a Stage 3. -R #79's Low Air Loss Mattress was set at the appropriate setting for optimal therapy, as per the User-Guide. R #79 was admitted to the facility with three Stage 2 pressure ulcers; R #79's left posterior thigh pressure ulcer deteriorated to a Stage 3 pressure ulcer since admitted to the facility. The above failures resulted in an IJ situation on 03/08/18. While the IJ was removed on 03/11/18, the facility remained out of compliance at actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure continued implementation of their plan of removal. These failures could place nine residents with pressure ulcers and 19 residents receiving preventive skin care at risk for developing new pressure ulcers or a deterioration in existing pressure ulcers. The findings included: Shortly after entrance into the facility on [DATE], the facility provided their Centers for Medicare and Medicaid Services (CMS) Form 672 dated 03/05/18 that identified nine residents with pressure ulcers (excluding Stage 1), with four residents admitted with pressure ulcers (excluding Stage 1), and 19 residents receiving preventive skin care. On 03/05/18 at approximately 2:30 p.m., the facility also provided a copy of their Weekly Pressure Ulcer Log that identified 10 residents with pressure ulcers and a total of 27 pressure ulcers. Of the 27 total pressure ulcers, six were identified as facility acquired and 21 as community acquired. 1.) Resident #65 R #65's Face Sheet dated 03/06/18 documented a [AGE] year-old male admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed), Left Ankle - Unstageable (Full thickness tissue loss in which the base of the ulcer is covered by slough-yellow, tan, gray, green or brown and/or eschar-tan, brown or black in the wound bed), Left Upper Back - Unstageable, Right Heel - Unstageable, Left Heel - Unstageable, Right Ankle - Unstageable, and Pressure Ulcer of other site - Unstageable, Major [MEDICAL CONDITIONS] (paralysis on one side of the body) and Muscle Wasting and Atrophy. R #65's Hospital Discharge Summary dated 02/07/18 documented Discharge Diagnoses: [REDACTED]. 2. Infected decubitus ulcer, Stage 3, in the sacral area, status [REDACTED]. 3. Multiple unstageable decubitis ulcers, midback, both shoulders, both heels, and left lateral ankle . R #65's Nursing Admission Data Collection dated 02/07/18 revealed R #65 had skin issues: -Sacrum: Pressure: 5.0 X 5.0 X 1.7 centimeters (cm), Stage 3 -Left (Lt) Hip: Pressure: 8.0 X 7.0 X 3.2 cm, Stage 4 -Right (Rt) Hip: Pressure: 8.2 X 6.4 X 2.8 cm, Stage 4 -Left Shoulder (rear): Pressure, 0.8 X 2.0 cm, Unstageable -Left Upper Back: Pressure, 1.7 X 2.0 cm, Unstageable -Mid Upper Back: Pressure, 2.4 X 0.8 cm, Unstageable -Lower Back: Pressure, 4.0 X 1.4 cm, Unstageable -Left Lateral Leg: Pressure, 9.4 X 1.6 cm, Unstageable -Left Lateral Ankle: Pressure, 3.0 X 2.5 cm, Unstageable -Left Heel: Pressure, 1.5 X 1.0 cm, DTI (Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) -Right Medial Heel: Pressure, 0.5 X 0.6 cm, Stage 2 -Right Medial Leg: Pressure, 1.8 X 0.5 cm, Unstageable -Right Upper Back: Pressure, 1.4 X 1.5 cm, Unstageable -Lower Sacral Area: Skin Tear, 0.9 X 1.5 cm, Unstageable Notes: Lt hip stage 4- (8.0cm x 7.0cm) undermining all around 3.2 cm. Rt hip stage 4 (8.2cmx6.4cm) undermining from 9-5 deepest 2.8cm from 7-8 deepest 0.9cm. Sacral (5.0cmx5.0cm) undermining 5-12 deepest 1.7cm. sacral wound stage 3. Has multiple bruises throughout upper exts. Throughout back has multiple unstageable wounds with dry eschar. To Rt medial leg has unstageable wound with eschar. The document provided the following definitions: Suspected Deep Tissue Injury (DTPI- Deep Tissue Pressure Injury) - Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Stage I - Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. Stage II - Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. (MONTH) also present as an intact or open/ruptured serum-filled blister. Stage III - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling. Stage IV - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Unstageable - Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Continued review of this assessment revealed there was no detailed description of each identified wound. R #65's Braden Scale for Predicting Pressure Sores dated 02/07/18 documented a score of 10 - High Risk. R #65's Admission Brief Interview for Mental Status assessment dated [DATE] documented a score of 0- Severe impairment. R #65's Head to Toe Skin Check dated 02/07/18 documented Existing Pressure Ulcers: 1. Left Heel: Pressure 1.5 X 1.0 centimeters (cm.) Suspected Deep Tissue Injury 2. Sacrum: Pressure 5.0 X 5.0 X 1.7 cm Stage 3 3. Left Shoulder (rear): Pressure 0.8 X 2.0 cm Unstageable 4. Right Heel Medial: Pressure 0.5 X 0.6 cm Stage 2 5. Right Upper Back: 1.4 X 1.5 cm Unstageable 6. Left Upper Back: Pressure 1.7 X 2.0 cm Unstageable 7. Right Medial Leg: 1.8 X 0.5 cm Unstageable 8. Mid Upper Back: Pressure 2.4 X 0.8 cm Unstageable 9. Left Lateral Ankle: Pressure 3.0 X 2.5 cm Unstageable 10. Lower Back: Pressure 4.0 X 1.4 cm Unstageable 11. Left Hip: 8.0 X 7.0 X 3.2 cm Stage 4 12. Right Hip: 8.2 X 6.4 X 2.8 cm Stage 4 13. Left Lateral Leg: Pressure 9.4 X 1.6 cm Unstageable 14. Lower Sacral Area: Skin tear 0.9 X 1.5 cm Further description of skin issues: Has pressure wound bilaterally to hips and sacral region which are open with undermining. Throughout his back he has multiple wounds with dry eschar tissue. To right leg has wound with eschar tissue. To left heel has DTI. Wound vac to be bridged to hip wounds. After review of this assessment and further record review of R #65's electronic charting revealed there were no other documents that included a detailed description of each individualized wound. R #65's Head to Toe Skin Check dated 02/12/18 documented Existing Pressure Ulcers: 1. Left Heel: Pressure 1.0 X 0.5 cm. Unstageable (This ulcer deteriorated from a DTI to an Unstageable) 2. Sacrum: Pressure 3.5 X 4.0 X 1.3 cm Stage 3 3. Left Shoulder: Pressure 2.0 X 1.0 cm Unstageable 4. Right Heel Medial: Pressure 1.0 X 0.5 cm Stage 2 5. Right Upper Back: 1.7 X 0.1 cm Unstageable 6. Left Upper Back: Pressure 1.5 X 3.5 cm Unstageable 7. Right Medial Leg: 2.0 X 1.0 cm Unstageable 8. Mid Upper Back: Pressure 2.3 X 1.5 cm Unstageable 9. Left Lateral Ankle: Pressure 2.8 X 2.0 cm Unstageable 10. Lower Back: Pressure 3.2 X 1.0 cm Unstageable 11. Left Hip: 8.0 X 7.0 X 1.2 cm Stage 4 12. Right Hip: 8.3 X 6.6 X 1.5 cm Stage 4 13. Left Lateral Leg: Pressure 8.5 X 1.0 cm Unstageable 14. Lower Sacral Area: Skin tear 0.7 X 1.5 cm 15. Right Lateral Ankle: Pressure 0.8 X 1.0 cm Stage 2 (In comparison to 02/07/18 assessment, this wound is a newly acquired wound). There was no other documentation that provided any description or identification that this ulcer was newly acquired. 16. Left Upper Back: 2.3 X 1.5 Unstageable (In comparison to 02/07/18 assessment, there was only one Left Upper Back wound identified on admission and now there are two separate wounds documented). There was no other documentation that provided any description or identification that this ulcer was newly acquired. Further description of skin issues: Has pressure wounds bilateral hips, sacral region which open with undermining. Has multiple wounds throughout his back with dry eschar and mid back with slough. Record Review of the facility's electronic charting system from dates 02/07/18 - 02/12/18 revealed R #65 did not have any Weekly Pressure Ulcer Reports for each individualized ulcer that could provide a detailed description of each pressure ulcer. Review of the facility's Nurses Notes and Progress Notes revealed there was no additional documentation regarding R #65's pressure ulcer status on 02/12/18. R #65's Admission Minimum (MDS) data set [DATE] documented R #65: -Had clear speech; -Sometimes made self understood and sometimes understood others; -Had short and long-term memory loss; -Had severely impaired cognitive skills for daily decision making; -Required extensive assistance with one or two person physical assist for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene; -Had upper and lower extremity impairment on one side; -Had an indwelling catheter and was always incontinent of bowel; -Was at risk of pressure ulcer development, had one Stage 3 upon admission, had two Stage 4's upon admission, and had seven unstageable's upon admission. The dimension of the largest Stage 3 or 4 surface was 8.0 X 7.0 X 3.2 centimeters. Skin and ulcer treatments were: pressure reducing device for bed, pressure ulcer care, and nutrition or hydration intervention . R #65's Comprehensive Care Plan dated 02/14/17 documented: -I have a DTI pressure ulcer to my right lateral ankle r/t (related to) immobility. I want my pressure ulcer to heal . I have a DTI pressure ulcer to my right medial leg r/t immobility .I have an unstageable ulcer to right upper back r/t immobility .I have a DTI pressure ulcer to my left posterior heel r/t immobility .I have a DTI pressure ulcer to left medial heel r/t immobility .have an unstageable pressure ulcer to my left lateral ankle r/t immobility .I have an unstageable pressure ulcer to my left lateral leg r/t immobility .I have an unstageable pressure ulcer to my left upper back r/t immobility .I have an unstageable ulcer to mid lower back r/t immobility I have an unstageable pressure ulcer to my left shoulder r/t immobility .I have a pressure sore that is on my sacrum and is stage 4 r/t immobility .I have an unstageable pressure ulcer to my mid upper back r/t immobility .I have a pressure sore that is on my RIGHT hip and is stage 4 r/t immobility Interventions: Administer treatments as ordered and observe for effectiveness .have a pressure sore that is on my left hip and is stage 4 r/t immobility Assist me to reposition and/or turn at frequent intervals to provide pressure relief. Apply air mattress as ordered Notify nurse if dressing is soiled, loose, or missing Offload heels and ankles Teach resident/family the importance of changing positions for prevention of pressure ulcers. Encourage small frequent position changes .Weekly head to toe assessments as per protocol. Notify MD (Medical Doctor) as needed . -I have an ADL self-care performance deficit r/t Disease Process/recent hospitalization with debrided ulcers with pain, Fatigue, [MEDICAL CONDITION] d/t hx (history)[MEDICAL CONDITION]([MEDICAL CONDITION]- stroke) .BED MOBILITY: I require extensive assistance by X 1-2 staff to turn and reposition in bed as necessary .BEDFAST: I am bedfast all or most of the time .DRESSING: I require extensive assistance by X 1 staff to dress .PERSONAL HYGIENE/ORAL CARE: I am totally dependent on X1 staff for personal hygiene and oral care SKIN INSPECTION: I require SKIN inspection Q (every) shift. Observe for redness, open areas, scratches, cuts, bruises and report changes to the Nurse .TOILET USE: I am totally dependent on X 1 staff for incontinent care .TRANSFER: I require Mechanical Lift (Hoyer) with X2 staff assistance for transfers . -I have impaired cognitive function/dementia or impaired thought processes r/t [MEDICAL CONDITION] . -I have a communication problem r/t unable to answer questions appropriately . -I have bowel incontinence r/t [MEDICAL CONDITIONS]; potential for constipation . -I [MEDICAL CONDITION] to multiple ulcers which some have been debrided .My infection will resolve with minimal complications as evidenced by negative culture, vital signs WNL and no s/sx of acute infection by review date .CONTACT ISOLATION: Wear gowns and masks when changing contaminated linens. Place soiled linens in bags marked biohazard. Bag linens and close bag tightly before taking to laundry Hand washing before and after delivery of care . -May have potential nutritional problem (weight loss) r/t Anorexia/malnutrition; requires to be spoon fed at all meals; my admission weight is 129.6# . -I have Indwelling Catheter: to help with wound healing and keep infection free .Anchor catheter to prevent excess tension .CATHETER: I have size 16F indwelling Catheter. Position catheter bag and tubing below the level of the bladder Hand washing before and after delivery of care .Perineal care as indicated. Notify nurse of any redness or irritation at insertion site . -I am at risk for falls r/t lt side weakness from [MEDICAL CONDITION], poor memory .My risks and injury potential will be minimized through the next review date .At risk for falls .Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance .Landing Mat .The resident needs a safe environment with: floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; Slide fails as ordered, handrails on walls, personal items within reach . R #65's Head to Toe Skin Check dated 02/19/18 documented Existing Pressure Ulcers: 1. Left Heel: Pressure 0.6 X 0.4 cm. Unstageable 2. Sacrum: Pressure 3.5 X 3.8 X 1.1 cm Stage 3 3. Left Shoulder: Pressure 2.0 X 1.0 cm Unstageable 4. Right Upper Back: 0.1 X 0.1 cm Unstageable 5. Left Upper Back: Pressure 1.4 X 3.5 cm Unstageable 6. Right Medial Leg: 1.7 X 1.8 cm Unstageable 7. Mid Proximal Upper Back: Pressure 1.9 X 0.8 cm Unstageable 8. Left Lateral Ankle: Pressure 2.4 X 2.5 cm Unstageable 9. Lower Back: Pressure 3.2 X 1.0 cm Unstageable 10. Left Hip: 8.0 X 6.5 X 0.8 cm Stage 4 11. Right Hip: 7.9 X 5.8 X 0.0 cm Stage 4 12. Left Lateral Leg: Pressure 9.1 X 2.4 cm Unstageable (This ulcer increased in size compared to 02/07/18 assessment) 13. Lower Sacral Area: Skin tear 0.7 X 1.5 cm 14. Right Lateral Ankle: Pressure .07 X 2.0 cm Suspected Deep Tissue Injury (In comparison to 02/12/18 assessment, this ulcer changed from a Stage 2 to a DTI). There was no other documentation that included a description of the change in wound status. 15. Mid Distal Lower Back: 3.3 X 0.6 Unstageable (In comparison to 02/07/18 and 02/12/18 assessment, there was no prior mention of a Mid Distal Lower Back. There was no other documentation that provided any description or identification that this ulcer was newly acquired or an incorrectly documented site. It could not be determined if this ulcer is the same as the Lower Back ulcer previously identified on 02/07/18.) 16. Left Medial Heel: Pressure 0.7 X 0.3 cm Suspected Deep Tissue Injury (In comparison to 02/07/18 and 02/12/18 assessments, this ulcer had not been previously identified. Record review of R #65's electronic charting from dates 02/07/18 - 03/08/18 revealed no description or identification of this specific ulcer being newly acquired.) Further description of skin issues: Left Lower Back Blister (Distal) 1.0 X 0.7, has pressure wounds bilateral hips, sacral region which open with undermining. Has multiple wounds throughout back with eschar (There was no measurement of the undermining mentioned. It is difficult to determine if this blister is the same ulcer identified in this assessment as the Mid Distal Lower Back or if it is a new additional ulcer. No other documentation in R #65's electronic records from dates 02/07/18 - 02/19/18 provided further documentation of the description or newly identification of this ulcer. The Right Medial Heel Ulcer previously identified on 02/07/18 was not included in this assessment. Record Review of the facility's electronic charting system revealed R #65 did not have any Weekly Pressure Ulcer Reports for each individualized ulcer that could provide a detailed description of each pressure ulcer. Simultaneous interview with the Administrator, DON, and RN Consultant on 03/08/17 at 1:13 p.m. revealed they were informed of as of 02/19/18, there were two left heel ulcers documented versus just one identified on 02/12/18. The DON and RN Consultant reviewed R #65's electronic records and provided verification of two left heel ulcers. Neither the DON or the RN Consultant could provide an answer as to when the second left heel ulcer was initially identified and verified the nursing staff should have documented an SBAR/Nurse's Note and a Pressure Ulcer Report when a new ulcer was identified. After reviewing R #65's electronic records, the DON confirmed there was no documentation of R #65's Left Medial Heel ulcer date of discovery. The DON and RN Consultant confirmed that R #65's Right Medial Heel ulcer was not included in the 02/19/18 Head to Toe assessment and said It should have been included, there is inconsistency and the doctor should have been made aware of the new ulcer at the time of discovery but there is no evidence of when that was done. R #65's Weekly Pressure Ulcer Record dated 02/26/18 documented Left Rear Shoulder: Date of Onset: 02/07/18 Existing Pressure Ulcer, admitted with. Location/Description: Left Rear Shoulder- Pressure 2.0 X 0.8 cm Unstageable; wound bed with dry eschar, no undermining or tunneling, black wound bed, no drainage or odor, black wound edges, surrounding skin: normal for skin. Response to Treatment: No change, Continue treatment. R #65's Weekly Pressure Ulcer Record dated 02/26/18 documented Left Heel: Date of Onset: 02/07/18 Existing Pressure Ulcer, admitted with. Location/Description: Left Heel- Pressure 1.5 X 1.0 cm Suspected Deep Tissue Injury; no undermining or tunneling, wound bed with discoloration (there was no description of the discoloration), no drainage or odor, black wound edges, surrounding skin: normal for skin. Response to Treatment: No change, Continue treatment. This ulcer was identified on 02/19/18 assessment as measuring 0.6 X 0.4 cm., Unstageable; there was no other documentation anywhere in R #65's electronic records from dates 02/07/18 - 02/26/18 that could further explain how this ulcer changed from an Unstageable to a DTI or that any consultation with R #65's physician was made of the change in wound status. R #65's Weekly Pressure Ulcer Record dated 02/26/18 documented Mid Distal Back: Date of Onset: 02/07/18 Existing Pressure Ulcer, admitted with. Location/Description: Mid Distal Back- Pressure 3.5 X 7.0 cm Unstageable; wound bed with slough tissue present, no undermining or tunneling, yellow wound bed, small serosanguineous drainage or no odor, normal wound edges, surrounding skin: normal for skin. Response to Treatment: No change, Continue treatment. This ulcer increased in size as it was previously assessed to be 3.3 X 0.6 cm on 02/19/18 R #65's Weekly Pressure Ulcer Record dated 02/26/18 documented Right Medial Leg: Date of Onset: 02/07/18 Existing Pressure Ulcer, admitted with. Location/Description: Right Medial Leg- Pressure 1.8 X 0.5 cm Unstageable; wound bed with eschar, no undermining or tunneling, black wound bed, no drainage or odor, normal wound edges, surrounding skin: normal for skin. Response to Treatment: No change, Continue treatment. This ulcer was not identified in the prior Head to Toe assessment dated [DATE] however, it was identified on 02/07/18 and 02/12/18 as a Stage 2 pressure ulcer. There was no other documentation that detailed the description of this deteriorating ulcer. R #65's Weekly Pressure Ulcer Record dated 02/26/18 documented Left Outer Ankle: Date of Onset: 02/07/18 Existing Pressure Ulcer, admitted with. Location/Description: Left Outer Ankle- Pressure 2.5 X 2.1 cm Unstageable; wound bed with dry eschar, no undermining or tunneling, black wound bed, no drainage or odor, normal wound edges, surrounding skin: normal for skin. Response to Treatment: No change, Continue treatment. R #65's Weekly Pressure Ulcer Record dated 02/26/18 documented Right Medial Heel: Date of Onset: 02/07/18 Existing Pressure Ulcer, admitted with. Location/Description: Right Medial Heel- Pressure 0.5 X 0.5 cm Stage 2; wound bed with dry eschar, no undermining or tunneling, normal wound bed, scant serosanguineous drainage or no odor, normal wound edges, surrounding skin: normal for skin. Response to Treatment: No change, Continue treatment. R #65's Weekly Pressure Ulcer Record dated 02/26/18 documented Left Lateral Leg: Date of Onset: 02/07/18 Existing Pressure Ulcer, admitted with. Location/Description: Left Lateral Leg- Pressure 9.0 X 1.7 cm Unstageable; wound bed with dry eschar, no undermining or tunneling, black wound bed, no drainage or odor, normal wound edges, surrounding skin: normal for skin. Response to Treatment: No change, Continue treatment. The above Weekly Pressure Ulcer Records were the only records documented of R #65's ulcers. There was no Weekly Pressure Ulcer Record on this date for R #65's Right Heel, Sacrum, Mid Proximal Upper Back, Left Hip, Right Hip, Right Medial Proximal Back, Right Upper back, Left Lower Back, Right Lateral Ankle, Left Medial Heel, and Left Lower Back Pressure Ulcers identified in assessments prior to 02/26/18. Simultaneous interview with the Administrator, DON, and RN Consultant on 03/08/17 beginning at 1:13 p.m. revealed they were informed of the missing Weekly Pressure Ulcer Reports for some of R #65's pressure ulcers. The DON and RN Consultant confirmed there were several missing Weekly Pressure Ulcer Reports, the DON said There should be a separate Weekly Pressure Ulcer Report for each separate ulcer. It is important to document each ulcer separately on the Weekly Pressure Ulcer Report so that we can track the progress or deterioration of the wound. If we see a decline in the wound, we contact the physician to inform him and discuss whether we need to change a treatment. The DON was asked if she was aware of R #65's left heel pressure ulcer had changed from a DTI to an Unstageable to a DTI and then back to an unstageable from 02/07/18-02/27/18; after the DON reviewed R #65's pressure ulcer documents, she stated I don't know, I assume they were not staging correctly, it's inconsistent. Documentation of the wounds needs to be as detailed and accurate as possible to ensure we are identifying it accurately to be able to treat it correctly. R #65's Head to Toe Skin Check dated 02/27/18 documented Existing Pressure Ulcers: 1. Left Heel: Pressure 1.5 X 1.0 cm. Unstageable 2. Right Heel: Pressure 0.5 X 0.5 cm Unstageable 3. Sacrum: Pressure 3.5 X 3.4 X 1.0 cm Stage 4 (All previous prior assessments identified the Sacral ulcer as a Stage 3. The facility had no other documentation of additional information/description of this ulcer deteriorating to a Stage 4. There was no evidence anywhere in R #65's electronic records from dates 02/07/18 - 02/27/18 that the physician was consulted of the change in pressure ulcer status.) 4. Left Shoulder: Pressure 2.0 X 0.8 cm Unstageable 5. Right Medial Leg: 1.8 X 0.5 cm Unstageable 6. Mid Proximal Upper Back: Pressure 2.0 X 1.0 cm Unstageable 7. Left Lateral Ankle: Pressure 2.5 X 2.1 cm Unstageable 8. Left Hip: 7.0 X 6.6 X 1.0 cm Stage 4 9. Right Hip: 8.0 X 6.0 X 0.0 cm Stage 4 10. Left Lateral Leg: Pressure 9.0 X 1.7 cm Unstageable (This ulcer increased in size compared to 02/07/18 assessment) 11. Mid Distal Lower Back: 3.5 X 7.0 Unstageable There was no measurement of the undermining mentioned on initial assessment of the bilateral hip and sacral ulcers in this assessment. This assessment did not include documentation or detail of R #65's Right Medial Proximal Back, Right Upper back, Left Lower Back, Right Lateral Ankle, Left Medial Heel, Right Medial Heel or Left Lower Back Blister ulcers identified in previous assessments. Record Review of the facility's electronic charting system revealed R #65 did not have any Weekly Pressure Ulcer Reports for each individualized ulcer that could provide a detailed description of each pressure ulcer. Simultaneous interview with the Administrator, DON, and RN Consultant on 03/08/17 beginning at 1:13 p.m. revealed the DON and RN Consultant researched

Based on observation, interview, and record review, the facility failed to immediately consult with the resident's physician regarding a significant change in the resident's physical status, for four (R #65, R #227, R #70, and R #79) of eight residents reviewed for changes in condition, in that: 1.) LVN E failed to consult with R #65's physician before treating two new pressure ulcers recently identified. 2.) LVN S did not consult with R #227's physician regarding the newly discovered MDRPI until a day later, upon the surveyor's inquiry. 3.) R #70 was admitted to the facility on [DATE] with no pressure ulcers. On 02/26/18 R #70 was identified to have a pressure ulcer to the Left Buttock Stage 2 and a pressure ulcer to the Right Buttock Stage 2 but the facilty failed to obtain a Physician order [REDACTED].>4.) R #79 was admitted to the facility on [DATE] with three pressure ulcers, and the facility did not obtain physician orders [REDACTED]. The above failures resulted in an IJ situation on 03/08/18. While the IJ was removed on 03/11/18, the facility remained out of compliance at actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure continued implementation of their plan of removal. These failures could place nine residents with pressure ulcers and 19 residents receiving preventive skin care at risk for developing new pressure ulcers or a deterioration in existing pressure ulcers. The findings included: 1.) Resident #65 R #65's Face Sheet dated 03/06/18 documented a [AGE] year-old male admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed), Left Ankle - Unstageable (Full thickness tissue loss in which the base of the ulcer is covered by slough-yellow, tan, gray, green or brown and/or eschar-tan, brown or black in the wound bed), Left Upper Back - Unstageable, Right Heel - Unstageable, Left Heel - Unstageable, Right Ankle - Unstageable, and Pressure Ulcer of other site - Unstageable, Major [MEDICAL CONDITIONS] (paralysis on one side of the body) and Muscle Wasting and Atrophy. R #65's Hospital Discharge Summary dated 02/07/18 documented Discharge Diagnoses: [REDACTED]. 2. Infected decubitus ulcer, Stage 3, in the sacral area, status [REDACTED]. 3. Multiple unstageable decubitis ulcers, midback, both shoulders, both heels, and left lateral ankle . R #65's Nursing Admission Data Collection dated 02/07/18 revealed R #65 had skin issues: -Sacrum: Pressure: 5.0 X 5.0 X 1.7 centimeters (cm), Stage 3 -Left (Lt) Hip: Pressure: 8.0 X 7.0 X 3.2 cm, Stage 4 -Right (Rt) Hip: Pressure: 8.2 X 6.4 X 2.8 cm, Stage 4 -Left Shoulder (rear): Pressure, 0.8 X 2.0 cm, Unstageable -Left Upper Back: Pressure, 1.7 X 2.0 cm, Unstageable -Mid Upper Back: Pressure, 2.4 X 0.8 cm, Unstageable -Lower Back: Pressure, 4.0 X 1.4 cm, Unstageable -Left Lateral Leg: Pressure, 9.4 X 1.6 cm, Unstageable -Left Lateral Ankle: Pressure, 3.0 X 2.5 cm, Unstageable -Left Heel: Pressure, 1.5 X 1.0 cm, DTI (Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) -Right Medial Heel: Pressure, 0.5 X 0.6 cm, Stage 2 -Right Medial Leg: Pressure, 1.8 X 0.5 cm, Unstageable -Right Upper Back: Pressure, 1.4 X 1.5 cm, Unstageable -Lower Sacral Area: Skin Tear, 0.9 X 1.5 cm, Unstageable Notes: Lt hip stage 4- (8.0cm x 7.0cm) undermining all around 3.2 cm. Rt hip stage 4 (8.2cmx6.4cm) undermining from 9-5 deepest 2.8cm from 7-8 deepest 0.9cm. Sacral (5.0cmx5.0cm) undermining 5-12 deepest 1.7cm. sacral wound stage 3. Has multiple bruises throughout upper exts. Throughout back has multiple unstageable wounds with dry eschar. To Rt medial leg has unstageable wound with eschar. The document provided the following definitions: Suspected Deep Tissue Injury (DTPI- Deep Tissue Pressure Injury) - Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Stage I - Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. Stage II - Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. (MONTH) also present as an intact or open/ruptured serum-filled blister. Stage III - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling. Stage IV - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Unstageable - Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Continued review of this assessment revealed there was no detailed description of each identified wound. R #65's Braden Scale for Predicting Pressure Sores dated 02/07/18 documented a score of 10 - High Risk. R #65's Admission Brief Interview for Mental Status assessment dated [DATE] documented a score of 0- Severe impairment. R #65's Head to Toe Skin Check dated 02/07/18 documented Existing Pressure Ulcers: 1. Left Heel: Pressure 1.5 X 1.0 centimeters (cm.) Suspected Deep Tissue Injury 2. Sacrum: Pressure 5.0 X 5.0 X 1.7 cm Stage 3 3. Left Shoulder (rear): Pressure 0.8 X 2.0 cm Unstageable 4. Right Heel Medial: Pressure 0.5 X 0.6 cm Stage 2 5. Right Upper Back: 1.4 X 1.5 cm Unstageable 6. Left Upper Back: Pressure 1.7 X 2.0 cm Unstageable 7. Right Medial Leg: 1.8 X 0.5 cm Unstageable 8. Mid Upper Back: Pressure 2.4 X 0.8 cm Unstageable 9. Left Lateral Ankle: Pressure 3.0 X 2.5 cm Unstageable 10. Lower Back: Pressure 4.0 X 1.4 cm Unstageable 11. Left Hip: 8.0 X 7.0 X 3.2 cm Stage 4 12. Right Hip: 8.2 X 6.4 X 2.8 cm Stage 4 13. Left Lateral Leg: Pressure 9.4 X 1.6 cm Unstageable 14. Lower Sacral Area: Skin tear 0.9 X 1.5 cm Further description of skin issues: Has pressure wound bilaterally to hips and sacral region which are open with undermining. Throughout his back he has multiple wounds with dry eschar tissue. To right leg has wound with eschar tissue. To left heel has DTI. Wound vac to be bridged to hip wounds. After review of this assessment and further record review of R #65's electronic charting revealed there were no other documents that included a detailed description of each individualized wound. R #65's Head to Toe Skin Check dated 02/12/18 documented Existing Pressure Ulcers: 1. Left Heel: Pressure 1.0 X 0.5 cm. Unstageable (This ulcer deteriorated from a DTI to an Unstageable) 2. Sacrum: Pressure 3.5 X 4.0 X 1.3 cm Stage 3 3. Left Shoulder: Pressure 2.0 X 1.0 cm Unstageable 4. Right Heel Medial: Pressure 1.0 X 0.5 cm Stage 2 5. Right Upper Back: 1.7 X 0.1 cm Unstageable 6. Left Upper Back: Pressure 1.5 X 3.5 cm Unstageable 7. Right Medial Leg: 2.0 X 1.0 cm Unstageable 8. Mid Upper Back: Pressure 2.3 X 1.5 cm Unstageable 9. Left Lateral Ankle: Pressure 2.8 X 2.0 cm Unstageable 10. Lower Back: Pressure 3.2 X 1.0 cm Unstageable 11. Left Hip: 8.0 X 7.0 X 1.2 cm Stage 4 12. Right Hip: 8.3 X 6.6 X 1.5 cm Stage 4 13. Left Lateral Leg: Pressure 8.5 X 1.0 cm Unstageable 14. Lower Sacral Area: Skin tear 0.7 X 1.5 cm 15. Right Lateral Ankle: Pressure 0.8 X 1.0 cm Stage 2 (In comparison to 02/07/18 assessment, this wound is a newly acquired wound). There was no other documentation that provided any description or identification that this ulcer was newly acquired. 16. Left Upper Back: 2.3 X 1.5 Unstageable (In comparison to 02/07/18 assessment, there was only one Left Upper Back wound identified on admission and now there are two separate wounds documented). There was no other documentation that provided any description or identification that this ulcer was newly acquired. Further description of skin issues: Has pressure wounds bilateral hips, sacral region which open with undermining. Has multiple wounds throughout his back with dry eschar and mid back with slough. Record Review of the facility's electronic charting system revealed R #65 did not have any Weekly Pressure Ulcer Reports for each individualized ulcer that could provide a detailed description of each pressure ulcer. Review of the facility's Nurses Notes and Progress Notes revealed there was no additional documentation regarding R #65's pressure ulcer status on 02/12/18. R #65's Admission Minimum (MDS) data set [DATE] documented R #65: -Had clear speech; -Sometimes made self understood and sometimes understood others; -Had short and long-term memory loss; -Had severely impaired cognitive skills for daily decision making; -Required extensive assistance with one or two person physical assist for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene; -Had upper and lower extremity impairment on one side; -Had an indwelling catheter and was always incontinent of bowel; -Was at risk of pressure ulcer development, had one Stage 3 upon admission, had two Stage 4's upon admission, and had seven unstageable's upon admission. The dimension of the largest Stage 3 or 4 surface was 8.0 X 7.0 X 3.2 centimeters. Skin and ulcer treatments were: pressure reducing device for bed, pressure ulcer care, and nutrition or hydration intervention . R #65's Comprehensive Care Plan dated 02/14/17 documented: -I use my left side rail because I need help with bed mobility and repositioning. During the time I need to use side rails. I will not have any injuries. I will not injure myself while using side rails as an enabler while in bed. I will use side rails to help with my mobility while in bed. -I have a DTI pressure ulcer to my right lateral ankle r/t (related to) immobility. I want my pressure ulcer to heal . I have a DTI pressure ulcer to my right medial leg r/t immobility .I have an unstageable ulcer to right upper back r/t immobility .I have a DTI pressure ulcer to my left posterior heel r/t immobility .I have a DTI pressure ulcer to left medial heel r/t immobility .have an unstageable pressure ulcer to my left lateral ankle r/t immobility .I have an unstageable pressure ulcer to my left lateral leg r/t immobility .I have an unstageable pressure ulcer to my left upper back r/t immobility .I have an unstageable ulcer to mid lower back r/t immobility I have an unstageable pressure ulcer to my left shoulder r/t immobility .I have a pressure sore that is on my sacrum and is stage 4 r/t immobility .I have an unstageable pressure ulcer to my mid upper back r/t immobility .I have a pressure sore that is on my RIGHT hip and is stage 4 r/t immobility Interventions: Administer treatments as ordered and observe for effectiveness .have a pressure sore that is on my left hip and is stage 4 r/t immobility Assist me to reposition and/or turn at frequent intervals to provide pressure relief. Apply air mattress as ordered Notify nurse if dressing is soiled, loose, or missing Offload heels and ankles Teach resident/family the importance of changing positions for prevention of pressure ulcers. Encourage small frequent position changes .Weekly head to toe assessments as per protocol. Notify MD (Medical Doctor) as needed . -I have an ADL self-care performance deficit r/t Disease Process/recent hospitalization with debrided ulcers with pain, Fatigue, [MEDICAL CONDITION] d/t hx (history)[MEDICAL CONDITION]([MEDICAL CONDITION]- stroke) .BED MOBILITY: I require extensive assistance by X 1-2 staff to turn and reposition in bed as necessary .BEDFAST: I am bedfast all or most of the time .DRESSING: I require extensive assistance by X 1 staff to dress .PERSONAL HYGIENE/ORAL CARE: I am totally dependent on X1 staff for personal hygiene and oral care SKIN INSPECTION: I require SKIN inspection Q (every) shift. Observe for redness, open areas, scratches, cuts, bruises and report changes to the Nurse .TOILET USE: I am totally dependent on X 1 staff for incontinent care .TRANSFER: I require Mechanical Lift (Hoyer) with X2 staff assistance for transfers . -I have impaired cognitive function/dementia or impaired thought processes r/t [MEDICAL CONDITION] . -I have a communication problem r/t unable to answer questions appropriately . -I have bowel incontinence r/t [MEDICAL CONDITIONS]; potential for constipation . -I [MEDICAL CONDITION] to multiple ulcers which some have been debrided .My infection will resolve with minimal complications as evidenced by negative culture, vital signs WNL and no s/sx of acute infection by review date .CONTACT ISOLATION: Wear gowns and masks when changing contaminated linens. Place soiled linens in bags marked biohazard. Bag linens and close bag tightly before taking to laundry Hand washing before and after delivery of care . -May have potential nutritional problem (weight loss) r/t Anorexia/malnutrition; requires to be spoon fed at all meals; my admission weight is 129.6# . -I have Indwelling Catheter: to help with wound healing and keep infection free .Anchor catheter to prevent excess tension .CATHETER: I have size 16F indwelling Catheter. Position catheter bag and tubing below the level of the bladder Hand washing before and after delivery of care .Perineal care as indicated. Notify nurse of any redness or irritation at insertion site . -I am at risk for falls r/t lt side weakness from [MEDICAL CONDITION], poor memory .My risks and injury potential will be minimized through the next review date .At risk for falls .Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance .Landing Mat .The resident needs a safe environment with: floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; Slide fails as ordered, handrails on walls, personal items within reach . R #65's Nutritional Data Collection dated 02/14/18 documented: 1. Most Recent Height Date: 2/7/2018 18:36 Scale: Lying down Height: 67.0 (Inches Method: Lying down 2. Most Recent Weight Date: 2/13/2018 13:59 Scale: Mechanical Lift Scale Weight: 129.0 (Lbs (pounds)) Scale: Mechanical Lift Scale 3. Usual Body Weight (UBW)- 129.6 4. Body Mass Index (BMI)- 20.2 72 yo male Resident is alert to person has short term memory loss has difficulty understanding others and speaks Spanish has own teeth, teeth missing Active bowel Sounds in all 4 quadrants 1+slight [MEDICAL CONDITION] present bilat feet limited ROM bilaterally of his upper exts 67 inches, 129 lb, 20.2 BMI 87%, IBW -148 lb, normal weight -.6 lb(.5%)/1 week [MEDICATION NAME] 400mg QD Zinc [MEDICATION NAME] Vitamin/Minerals HSG CCD diet HSG Puree texture Regular consistency Glucerna 1.2-1 can w/ meals provides 853kcal & 42.7gm protein ProMod Liquid 60mL BID provides 400kcal & 40gm protein Dependent on assistance w/meals Consuming 25% of meals & supplement & 0% of snack Needs=2100-2600 kcal(36-44 kcal/kg)90-120 gm protein(1.5-2 gm/kg)1700-2200mL H2O(31-37 mL/kg)/day Recommendations: [MEDICATION NAME] 400mg BID, [MEDICATION NAME] 15mg QD. R #65's Head to Toe Skin Check dated 02/19/18 documented Existing Pressure Ulcers: 1. Left Heel: Pressure 0.6 X 0.4 cm. Unstageable 2. Sacrum: Pressure 3.5 X 3.8 X 1.1 cm Stage 3 3. Left Shoulder: Pressure 2.0 X 1.0 cm Unstageable 4. Right Upper Back: 0.1 X 0.1 cm Unstageable 5. Left Upper Back: Pressure 1.4 X 3.5 cm Unstageable 6. Right Medial Leg: 1.7 X 1.8 cm Unstageable 7. Mid Proximal Upper Back: Pressure 1.9 X 0.8 cm Unstageable 8. Left Lateral Ankle: Pressure 2.4 X 2.5 cm Unstageable 9. Lower Back: Pressure 3.2 X 1.0 cm Unstageable 10. Left Hip: 8.0 X 6.5 X 0.8 cm Stage 4 11. Right Hip: 7.9 X 5.8 X 0.0 cm Stage 4 12. Left Lateral Leg: Pressure 9.1 X 2.4 cm Unstageable (This ulcer increased in size compared to 02/07/18 assessment) 13. Lower Sacral Area: Skin tear 0.7 X 1.5 cm 14. Right Lateral Ankle: Pressure .07 X 2.0 cm Suspected Deep Tissue Injury (In comparison to 02/12/18 assessment, this ulcer changed from a Stage 2 to a DTI). There was no other documentation that included a description of the change in wound status. 15. Mid Distal Lower Back: 3.3 X 0.6 Unstageable (In comparison to 02/07/18 and 02/12/18 assessment, there was no prior mention of a Mid Distal Lower Back. There was no other documentation that provided any description or identification that this ulcer was newly acquired or an incorrectly documented site. It could not be determined if this ulcer is the same as the Lower Back ulcer previously identified on 02/07/18.) 16. Left Medial Heel: Pressure 0.7 X 0.3 cm Suspected Deep Tissue Injury (In comparison to 02/07/18 and 02/12/18 assessments, this ulcer had not been previously identified. Record review of R #65's electronic charting revealed no description or identification of this specific ulcer being newly acquired.) Further description of skin issues: Left Lower Back Blister (Distal) 1.0 X 0.7, has pressure wounds bilateral hips, sacral region which open with undermining. Has multiple wounds throughout back with eschar (There was no measurement of the undermining mentioned. It is difficult to determine if this blister is the same ulcer identified in this assessment as the Mid Distal Lower Back or if it is a new additional ulcer. No other documentation in R #65's electronic records provided further documentation of the description or newly identification of this ulcer. The Right Medial Heel Ulcer previously identified on 02/07/18 was not included in this assessment. Record Review of the facility's electronic charting system revealed R #65 did not have any Weekly Pressure Ulcer Reports for each individualized ulcer that could provide a detailed description of each pressure ulcer. Simultaneous interview with the Administrator, DON, and RN Consultant on 03/08/17 at 1:13 p.m. revealed they were informed of as of 02/19/18, there were two left heel ulcers documented versus just one identified on 02/12/18. The DON and RN Consultant reviewed R #65's electronic records and provided verification of two left heel ulcers. Neither the DON or the RN Consultant could provide an answer as to when the second left heel ulcer was initially identified and verified the nursing staff should have documented an SBAR/Nurse's Note and a Pressure Ulcer Report when a new ulcer was identified. After reviewing R #65's electronic records, the DON confirmed there was no documentation of R #65's Left Medial Heel ulcer date of discovery. The DON and RN Consultant confirmed that R #65's Right Medial Heel ulcer was not included in the 02/19/18 Head to Toe assessment and said It should have been included, there is inconsistency and the doctor should have been made aware of the new ulcer at the time of discovery but there is no evidence of when that was done. R #65's Weekly Pressure Ulcer Record dated 02/26/18 documented Left Rear Shoulder: Date of Onset: 02/07/18 Existing Pressure Ulcer, admitted with. Location/Description: Left Rear Shoulder- Pressure 2.0 X 0.8 cm Unstageable; wound bed with dry eschar, no undermining or tunneling, black wound bed, no drainage or odor, black wound edges, surrounding skin: normal for skin. Response to Treatment: No change, Continue treatment. R #65's Weekly Pressure Ulcer Record dated 02/26/18 documented Left Heel: Date of Onset: 02/07/18 Existing Pressure Ulcer, admitted with. Location/Description: Left Heel- Pressure 1.5 X 1.0 cm Suspected Deep Tissue Injury; no undermining or tunneling, wound bed with discoloration (there was no description of the discoloration), no drainage or odor, black wound edges, surrounding skin: normal for skin. Response to Treatment: No change, Continue treatment. This ulcer was identified on 02/19/18 assessment as measuring 0.6 X 0.4 cm., Unstageable; there was no other documentation anywhere in R #65's electronic records that could further explain how this ulcer changed from an Unstageable to a DTI or that any consultation with R #65's physician was made of the change in wound status. R #65's Weekly Pressure Ulcer Record dated 02/26/18 documented Mid Distal Back: Date of Onset: 02/07/18 Existing Pressure Ulcer, admitted with. Location/Description: Mid Distal Back- Pressure 3.5 X 7.0 cm Unstageable; wound bed with slough tissue present, no undermining or tunneling, yellow wound bed, small serosanguineous drainage or no odor, normal wound edges, surrounding skin: normal for skin. Response to Treatment: No change, Continue treatment. This ulcer increased in size as it was previously assessed to be 3.3 X 0.6 cm on 02/19/18 R #65's Weekly Pressure Ulcer Record dated 02/26/18 documented Right Medial Leg: Date of Onset: 02/07/18 Existing Pressure Ulcer, admitted with. Location/Description: Right Medial Leg- Pressure 1.8 X 0.5 cm Unstageable; wound bed with eschar, no undermining or tunneling, black wound bed, no drainage or odor, normal wound edges, surrounding skin: normal for skin. Response to Treatment: No change, Continue treatment. This ulcer was not identified in the prior Head to Toe assessment dated [DATE] however, it was identified on 02/07/18 and 02/12/18 as a Stage 2 pressure ulcer. There was no other documentation that detailed the description of this deteriorating ulcer. R #65's Weekly Pressure Ulcer Record dated 02/26/18 documented Left Outer Ankle: Date of Onset: 02/07/18 Existing Pressure Ulcer, admitted with. Location/Description: Left Outer Ankle- Pressure 2.5 X 2.1 cm Unstageable; wound bed with dry eschar, no undermining or tunneling, black wound bed, no drainage or odor, normal wound edges, surrounding skin: normal for skin. Response to Treatment: No change, Continue treatment. R #65's Weekly Pressure Ulcer Record dated 02/26/18 documented Right Medial Heel: Date of Onset: 02/07/18 Existing Pressure Ulcer, admitted with. Location/Description: Right Medial Heel- Pressure 0.5 X 0.5 cm Stage 2; wound bed with dry eschar, no undermining or tunneling, normal wound bed, scant serosanguineous drainage or no odor, normal wound edges, surrounding skin: normal for skin. Response to Treatment: No change, Continue treatment. R #65's Weekly Pressure Ulcer Record dated 02/26/18 documented Left Lateral Leg: Date of Onset: 02/07/18 Existing Pressure Ulcer, admitted with. Location/Description: Left Lateral Leg- Pressure 9.0 X 1.7 cm Unstageable; wound bed with dry eschar, no undermining or tunneling, black wound bed, no drainage or odor, normal wound edges, surrounding skin: normal for skin. Response to Treatment: No change, Continue treatment. The above Weekly Pressure Ulcer Records were the only records documented of R #65's ulcers. There was no Weekly Pressure Ulcer Record on this date for R #65's Right Heel, Sacrum, Mid Proximal Upper Back, Left Hip, Right Hip, Right Medial Proximal Back, Right Upper back, Left Lower Back, Right Lateral Ankle, Left Medial Heel, and Left Lower Back Pressure Ulcers identified in assessments prior to 02/26/18. Simultaneous interview with the Administrator, DON, and RN Consultant on 03/08/17 beginning at 1:13 p.m. revealed they were informed of the missing Weekly Pressure Ulcer Reports for some of R #65's pressure ulcers. The DON and RN Consultant confirmed there were several missing Weekly Pressure Ulcer Reports, the DON said There should be a separate Weekly Pressure Ulcer Report for each separate ulcer. It is important to document each ulcer separately on the Weekly Pressure Ulcer Report so that we can track the progress or deterioration of the wound. If we see a decline in the wound, we contact the physician to inform him and discuss whether we need to change a treatment. The DON was asked if she was aware of R #65's left heel pressure ulcer had changed from a DTI to an Unstageable to a DTI and then back to an unstageable from 02/07/18-02/27/18; after the DON reviewed R #65's pressure ulcer documents, she stated I don't know, I assume they were not staging correctly, it's inconsistent. Documentation of the wounds needs to be as detailed and accurate as possible to ensure we are identifying it accurately to be able to treat it correctly. R #65's Head to Toe Skin Check dated 02/27/18 documented Existing Pressure Ulcers: 1. Left Heel: Pressure 1.5 X 1.0 cm. Unstageable 2. Right Heel: Pressure 0.5 X 0.5 cm Unstageable 3. Sacrum: Pressure 3.5 X 3.4 X 1.0 cm Stage 4 (All previous prior assessments identified the Sacral ulcer as a Stage 3. The facility had no other documentation of additional information/description of this ulcer deteriorating to a Stage 4. There was no evidence anywhere in R #65's electronic records that the physician was consulted of the change in pressure ulcer status.) 4. Left Shoulder: Pressure 2.0 X 0.8 cm Unstageable 5. Right Medial Leg: 1.8 X 0.5 cm Unstageable 6. Mid Proximal Upper Back: Pressure 2.0 X 1.0 cm Unstageable 7. Left Lateral Ankle: Pressure 2.5 X 2.1 cm Unstageable 8. Left Hip: 7.0 X 6.6 X 1.0 cm Stage 4 9. Right Hip: 8.0 X 6.0 X 0.0 cm Stage 4 10. Left Lateral Leg: Pressure 9.0 X 1.7 cm Unstageable (This ulcer increased in size compared to 02/07/18 assessment) 11. Mid Distal Lower Back: 3.5 X 7.0 Unstageable There was no measurement of the undermining mentioned on initial assessment of the bilateral hip and sacral ulcers in this assessment. This assessment did not include documentation or detail of R #65's Right Medial Proximal Back, Right Upper back, Left Lower Back, Right Lateral Ankle, Left Medial Heel, Right Medial Heel or Left Lower Back Blister ulcers identified in previous assessments. Record Review of the facility's electronic charting system revealed R #65 did not have any Weekly Pressure Ulcer Reports for each individualized ulcer that could provide a detailed description of each pressure ulcer. Simultaneous interview with the Administrator, DON, and RN Consultant on 03/08/17 beginning at 1:13 p.m. revealed the DON and RN Consultant researched R #65's electronic records and confirmed R #65's Head to Toe assessment dated [DATE] did not include all his wounds. The DON said It's inconsistent and not accurate. It doesn't show the true picture of his current status. The DON said she could not find any further documentation of R #65's Sacral ulcer changing from a Stage 3 to a Stage 4. The DON said Well according to this assessment, it deteriorated. I don't see when the physician was called about the change. R #65's (MONTH) (YEAR) Medication Review Report documented: -Air mattress - Active 2/8/2018 -Foley Catheter output q shift every shift, Active 2/8/2018 -Using aseptic technique cleanse right medial leg unstageable ulcer with NS (normal saline), pat dry, apply [MEDICATION NAME], cover with dry dressing, wrap with kerlix, secure with tape daily and prn (as needed) one time a day for unstageable ulcer to Rt medial leg related to PRESSURE ULCER OF OTHER SITE, UNSTAGEABLE and as needed, Active 2/16/2018 -Using aseptic technique cleanse left medial heel DTPI with NS, pat dry, apply [MEDICATION NAME], cover with dry dressing, wrap with kerlix, secure with tape daily and PRN, one time a day related to PRESSURE ULCER OF LEFT HEEL, UNSTAGEABLE AND as needed related to PRESSURE ULCER OF LEFT HEEL, UNSTAGEABLE, Active 2/15/2018 -Using aseptic technique cleanse left lateral leg with NS, pat dry, apply [MEDICATION NAME], cover with dry dressing, wrap with kerlix, secure with tape daily and PRN, one time a day related to PRESSURE ULCER OF LEFT ANKLE, UNSTAGEABLE AND as needed related to PRESSURE ULCER OF LEFT ANKLE, UNSTAGEABLE, Active 2/15/2018 -Using aseptic technique cleanse left upper back with NS, pat dry, apply [MEDICATION NAME], cover with dry dressing secure with tape daily and PRN, one time a day related to PRESSURE ULCER OF LEFT UPPER BACK, UNSTAGEABLE (L89.120) AND as needed related to PRESSURE ULCER OF LEFT UPPER BACK, UNSTAGEABLE, Active 2/15/2018 -Santyl Ointment 250 UNIT/GM (gram) ([MEDICATION NAME]) Using aseptic technique, cleanse area mid upper back ulcer with normal saline, pat dry, apply santyl, cover with dry gauze,secure with tape. Once daily and PRN. Dispensed Supply: SANTYL 250UNIT/1GM OINT. APPLY TO AFFECTED AREA(S) AS PER PHYSICIAN DIRECTIONS one time a day AND as needed, Active 2/15/2018 -Santyl Ointment 250 UNIT/GM ([MEDICATION NAME]) Using aseptic technique, cleanse area mid lower back ulcer with normal saline, pat dry, apply santyl, cover with dry gauze,secure with tape. Once daily and PRN. Dispensed Supply: SANTYL 250UNIT/1GM OINT. APPLY TO AFFECTED AREA(S) AS PER PHYSICIAN DIRECTIONS one time a day for ulcer AND as needed, Active 2/15/2018 -Santyl Ointment 250 UNIT/GM ([MEDICATION NAME]) Apply to right upper back topically one time a day related to PRESSURE ULCER OF RIGHT UPPER BACK, UNSTAGEABLE (L89.110) Using aseptic technique cleanse right upper back unstageable ulcer with NS, pat dry, apply Santyl, cover with dry dressing secure with tape daily and PRN. AND Apply to Right upper back ulcer topically as needed for right upper back ulcer related to PRESSURE ULCER OF RIGHT UPPER BACK, UNSTAGEABLE (L89.110) Using aseptic technique cleanse right upper back unstageable ulcer with NS, pat dry, apply Santyl, cover with dry dressing secure with tape daily and PRN, Active 2/15/2018 -Using aseptic technique cleanse left hip ulcer with ns pat dry apply [DEVICE] at 150mm/hg continuous suction change 3 times a week and prn one time a day every Mon, Wed, Fri for wound healing related to PRESSURE ULCER OF LEFT HIP, STAGE 4, Active 2/19/2018 -MONITOR: Pressure ulcer to Rt lateral ankle and document (+) if there are no observed abnormalities or changes to the skin, or pain associated with the wound. Document (-) if abnormalities or drainage, skin, or pain associated with the wound are present or observed, every shift, Active 2/18/2018 -MONITOR: Pressure ulcer to right medial leg and document (+) if there are no observed abnormalities or changes to the dressing, skin, or pain associated with the wound. Document (-) if abnormalities or drainage to the dressing, skin, or pain associated with the wound are present or observed. every shift, Active 2/18/2018 -MONITOR: Pressure ulcer to right upper back and document (+) if there are no observed abnormalities or changes to the dressing, skin, or pain associated with the wound. Document (-) if abnormalities or drainage to the dressing, skin, or pain associated with the wound are present or observed. every shift Other Active 2/18/2018 -MONITOR: Pressure ulcer to left medial heel and document (+) if there are no observed abnormalit

Based on observation, interview, and record review the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of disease and infection for 13 Residents (R #1, R #3, R #4, R #5, R #6, R #7, R #8, R #9, R #10, R #11, R #12, R #13 and R #14) of 14 Residents reviewed for Infection Control. The facility failed to provide services when it: 1.) failed to follow the physician's orders [REDACTED].#4 and R #7. R #4 had bleeding wounds to both arms. 2.) failed to implement and follow appropriate measures and the facility's policy and procedures to prevent the re-infection and isolation of scabies for R #1, R #3, R #5, R #6, R #7, R #8, R #9, R #12, R #13, and R #14. 3) failed to clarify R #10 and R #11's orders for [MEDICATION NAME] Cream 1% as an effective treatment for [REDACTED]. These failures resulted in an Immediate Jeopardy (IJ) situation identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure continued implementation of their plan of removal. These failures could affect 80 residents residing in the facility for serious infection control and risk of contracting scabies. According to the facility's list of residents treated for [REDACTED]. 4.) R #5's Indwelling Urinary Catheter drainage bag was on the floor. These failures could affect four residents with indwelling urinary catheters by compromising care and risk factors for infection. The findings included: Facility Infection Prevention Manual for Long Term Care (revised ,[DATE]) Titled Scabies Care revealed Purpose: To adequately treat cases of scabies and prevent transmission to others. Policy: Any resident with positive evidence of Scabies (Sarcoptes scabiei) must be treated upon physician's orders [REDACTED].TO AVOID REINFESTATION A. Clean ALL clothing, bedclothes, etc. that have been in recent contact with the resident. Transport these items in plastic bags. Wash clothes and bedding in HOT soapy water (allow time between loads for full recovery of hot water) and dry on HOT cycle of dryer. Place unwashable clothing and articles in a plastic bag and seal for 7 days (the mites do not survive for more than ,[DATE] days without contact with the body). B. Wipe down beds, pillows, mattresses, furniture, etc. with a germicidal solution. E. Contact precautions for associates consist of wearing gloves and gown if in close contact with an infested person or things .This is necessary before treatment and for ,[DATE] hours after treatment. Hand hygiene is the best technique for protection of oneself and others .PROCEDURE .G. While treatment is being done, have bed stripped (place bedding in a plastic bag before sending to laundry); all washable clothing, etc. that has been in recent contact with the resident should be placed in a plastic bag to be washed. Unwashable items should be placed in a plastic bag and sealed for 7 days (label bag with name, date, etc.) H. Be sure the resident has CLEAN clothing and CLEAN bedding; make sure infested items have been removed from the room. I All furniture, mattresses, pillows, etc. should be wiped down with a germicidal solution. J. Have the resident bathe thoroughly after the time indicated on the product. Make sure the resident has clean clothes and that bed linens are changed again . R #4 R #4's Admission Record dated [DATE] revealed R #4 was a [AGE] year old male admitted to the facility on [DATE] with the following diagnoses; Scabies, Allergic contact dermatitis, Vascular dementia with behavioral disturbance, Muscle Weakness, Atrioventricular Block (conduction between the atria and ventricles of the heart is impaired) and Cardiac Pacemaker. R #4's admission MDS dated [DATE] revealed R #4 had severe cognitive impairment, required extensive assistance of one person for bed mobility, transfers, dressing, personal hygiene, and locomotion on and off the unit. R #4 had a wheel chair for mobility. R #4 was not assessed as having a rash. R #4's Care Plan completed [DATE] did not address scabies or chronic dermatitis. R #4's Head to Toe Skin Checks dated [DATE] R #4 had an existing rash. R #4's physician's orders [REDACTED]. R #4's physician's orders [REDACTED]. R #4's In-House Communicator dated [DATE] (provided by) House Keeping Supervisor (HKS) revealed Place in contact isolation DX: (Scabies) R #4's physician's orders [REDACTED]. R #4's TAR dated ,[DATE] revealed [MEDICATION NAME] Cream 5% Apply to affected areas topically one time only for scabies until [DATE] apply from neck to toes and remove by bathing 12 hours later may repeat in one week if necessary. (TAR was left blank on [DATE]/ no initials as applied) [MEDICATION NAME] Cream 5% was initialed as applied on [DATE]. ([MEDICATION NAME] was not given as ordered [DATE]). Written correspondence from DON dated [DATE] revealed (R #4) was admitted on [DATE] with RX of Scabies. Order for [MEDICATION NAME] obtained on [DATE]. Treatment not given due to the fact that this med did not arrive from our Pharmacy. On [DATE] same order for [MEDICATION NAME] was resubmitted and med arrived and administered on [DATE]. On [DATE] [MEDICATION NAME] was reordered and reapplied due to a resurgent of Scabies again. Then as per MD order [MEDICATION NAME] was reapplied on [DATE]. As per MD Scabies subsided. On [DATE] (Dr. XX) ordered [MEDICATION NAME] 1% Cream and [MEDICATION NAME] Cream for Dermatitis and on [DATE] MD ordered [MEDICATION NAME] 10 mg. R #4's physician's orders [REDACTED]. R #4's physician progress notes [REDACTED]. R #4's physician's orders [REDACTED]. R #4's Care Plan completed [DATE] did not address scabies or chronic dermatitis. R # 4's hospital admission History and Physical dated [DATE] revealed Impression: Scabies. R #4's hospital Discharge Summary dated [DATE] revealed Final Diagnoses: [REDACTED]. R #4's TAR dated ,[DATE] revealed [MEDICATION NAME] Cream 5% ([MEDICATION NAME]) Apply to body as directed topically at bedtime every Thu for Scabies for 2 Administrations repeat in 1 week. (TAR was left blank on [DATE] and [DATE] no initials as applied) [MEDICATION NAME] Cream 5% was initialed as applied on [DATE]. R #4's physician's orders [REDACTED]. R #4's physician's orders [REDACTED]. R #4's physician's orders [REDACTED]. R #4's physician's orders [REDACTED]. XX. R #4's physician's orders [REDACTED]. R #4's physician's orders [REDACTED].) Apply to body topically two times a day for dermatitis apply to body after applying the [MEDICATION NAME] cream. R #4's Doctor's Progress Notes dated [DATE] revealed .Has been treated x2 at least for scabies last TX. ,[DATE] when patient was hospitalized , patient now on [MEDICATION NAME] cream with partial relief but rash persists, no clear documentation of proper decontamination after TX for scabies given .Skin Presence of indurated papules with excoriations and areas of Linchenification on both arms, shoulders, lower back, and lower abdomen, both thighs .Scabies by history scabies TX X 2 at least .Plan will proceed to provide treatment for [REDACTED]. Review of facility infection control tracking and trending log dated: -,[DATE] revealed one case of Scabies. -,[DATE] revealed two cases of Scabies. -,[DATE] revealed three cases of Scabies. -,[DATE] revealed five cases of Scabies. -,[DATE] revealed seven cases of Scabies. On [DATE] at 2:45 p.m., during initial rounds Surveyor observed a tracking raised red rash on R #4's arms and legs. There were areas on R #4's anterior lower forearms with scratch marks and bleeding and scattered bruise marks across both arms. R #4 lifted up his shirt and exposed his abdominal area which was also covered in a tracking raised red rash. R #4's legs were covered with a scabbed over rash from the knees down to his ankle areas. R #4 said he has had the rash off and on for months. R #4 said he wanted the rash treated because it itched him all the time. During interview with R #4 there was a female whom identified herself as a friend in R #4's room. The friend PP said she had been asking for treatment for [REDACTED].#4's insurance would not pay for a dermatologist visit. Surveyor observation and interview revealed R #4 shared closet space with a room-mate. (R #4's clothing was co-mingled with room-mates clothing) On [DATE] at 5:45 p.m., observation revealed R #4 sitting in the dining room at a table with two other residents. R #4 was scratching at his back and arms, R #4 placed his right arm on the table cloth several times during the meal service. On [DATE] at 6:30 p.m., interview with the DON revealed the Treatment Nurse was responsible for treating all the residents for scabies while she was in the building. On [DATE] at 9:00 a.m., interview with the DON revealed the first case of Scabies in the facility was identified (R#8) and treated in [DATE]. The DON said the Physician was notified and the room-mate was removed from the room and R #8 was placed in Contact Isolation. All nursing staff was notified of R #8's Infection Control status by shift report, Cardex and verbal instruction to staff that was currently working with resident. Surveyor asked the DON what the facility protocol was for scabies and the DON said, for scabies the isolation period was for five days. The DON said that the Scabies medication was applied for 24 hours then was rinsed off the resident. The DON said skin checks were conducted post treatment for [REDACTED]. The DON said while the resident was being treated with the Scabicide, House Keeping cleans the resident's room from top to bottom including the resident's clothing. The DON said if the resident had un-washable items such as stuffed animals or pillows, those items were thrown away. The DON said Rehab., Activity Director, and House Keeping Supervisor were notified, two isolation bins were placed in the resident room, one for linens and the other for trash. They placed an isolation cart outside the resident's room for PPE then posted a sign outside resident's door advising people to report to nurse's station prior to entering the room. The DON said for meal service, the staff double bag the meal tray before delivering the tray back to the kitchen. The resident was scheduled for the last shower of the day and Activities are provided in room. The DON said the Nurse that obtained R #4's orders for [MEDICATION NAME] on [DATE] and should have followed up with the Pharmacy to ensure the medication was delivered. On [DATE] at 9:20 a.m., interview with RN A revealed the facility's process for Scabies was starting with the assessment, then notifies the CNAs to back off for a while and take Contact Isolation precautions. RN A said he would then call the Physician and obtain an order for [REDACTED]. RN A said he would apply the [MEDICATION NAME] 1% from neck down at 8:00 p.m. or 9:00 p.m., and then in the morning after resident had breakfast, rinse the medicine off. RN A said prior to placing resident back into the room all the curtains and all linens were washed. RN A said HSK was responsible for washing the resident's clothing. RN A said that House Keeping would take down the privacy curtains and replace with new curtains. RN A said for all un-washable items such as personal pillows, are to be bagged and then ask resident's family permission to get rid of the items. RN A said HSK emptied out resident clothing from drawers and closets for washing. RN A said he thought R #4 had an active case of Scabies. RN A said he thought Scabies in the facility was spread from improper hand washing and on clothing. RN A said the facility has not had any in-services on Scabies. (RX dosage for treatment of [REDACTED]. On [DATE] at 10:05 a.m., interview with HSK revealed she was notified if a resident had Scabies either in the morning meeting or by In-House Communication Sheet. HSK said if she was in the building at the time a resident was placed in Isolation for Scabies she would set up the Cart for PPE and place it outside resident room, then place a sign on resident door, and notify her staff that the resident was on Contact Isolation. HSK said she wears PPE, wipes down resident's bed with disinfectant; nursing staff takes all the linens off the beds and places in a biohazard bag linen bin in the resident room. HSK said the nursing staff places resident clothing in biohazard linen bin. HSK said when the resident was off isolation; HSK conducts a deep clean of resident's room, takes down all curtains and wipes down blinds and chair with disinfectant. HSK said she did not remove clothing from resident's closet or drawers. HSK only washes clothing and linens that nursing staff place in biohazard bags. On [DATE] at 10:15 a.m., interview with LVN B (treatment nurse) revealed she worked from 10:00 a.m.-6:00 p.m. Monday through Friday. LVN B said when she was in the building that she treated residents with orders for Scabicide. LVN B said the first action she takes if she identifies a resident has Scabies would be to notify the Charge Nurse and the Charge Nurse would notify the Physician and obtain orders. LVN B said all direct care nursing staff were notified and the resident would be placed on Contact Isolation, and HSK would be contacted to clean the resident's room. The Scabicide would be applied to the resident from neck down and left on for 12 hours and washed off. While the Scabicide was applied to the resident, all linens on the bed would be removed and placed in Biohazard bag by nursing staff. LVN B said she would then call HSK to clean the room and wash residents clothing. LVN B said 24 hours after the Scabicide treatment she would reassess the resident's skin. LVN B said if the resident that was infected with Scabies had a roommate; the roommate along with the roommate's belongings would be moved to another room until the infected resident was clear from scabies (without decontaminating the belongings). LVN B said if a resident with Scabies had un-washable items, the staff would place those items in the resident's closet or ask the family to take the items home. LVN B said that in her opinion R #4 no longer had Scabies and the Physician has ordered [MEDICATION NAME] 0.1% Cream for R #4's rash. Surveyor asked LVN B if she knew what the indications for [MEDICATION NAME] Cream? LVN B said, No, Surveyor asked LVN B as a nurse was she supposed to know what the indications were for Prescription drugs prior to application. LVN B said, yes, but I don't know. (Nursing Staff said in interviews that HSK washed resident's clothing as part of scabies treatment, and HSK said Nursing staff was responsible for resident's clothing) On [DATE] at 10:35 a.m., skin assessment by LVN B with R #4, LVN B said during skin assessment that #4 had raised red tracking rash to his bilateral upper extremities, left upper chest wall, behind ears and neck. LVN B said R #4 had dry scabbed areas to his lower extremities. LVN B described areas on R # 4's arms as open and bloody from scratching. LVN B said R #4 scratches until he bleeds. On [DATE] at 12:25 p.m., interview with HSK revealed she was never notified of R #4 being in isolation the second time R #4 was treated in ,[DATE]. On [DATE] at 5:15 p.m., interview with Dr. XX revealed if the facility did not properly follow decontamination procedures during Scabicide treatment, there was a possibility that R #4 could have been re-infected with Scabies. Dr. XX said all the resident's clothing must be washed as well as the room decontaminated while resident was receiving Scabicide treatment. Surveyor showed Dr. XX R #4's clothing closet was shared with another resident and asked the Physician what would be the proper infection control procedure to isolate the Scabies. Dr. XX said the resident that shared the clothing closet with R #4 would also have to have the clothing washed because the Scabies bug lived on clothing and that the bug could be transmitted to another resident. Dr. XX said he ordered the [MEDICATION NAME] Cream for R #4 to reduce the inflammatory response and itching from the dermatitis. Dr. XX said he was going to re-treat R #4 with [MEDICATION NAME] because there was no clear documentation that treatment orders were followed or effective decontamination was done. Dr. XX said he was going to place R #4 on Contact Isolation for one week. Record review of the facility's Log of Residents with Scabies dated ,[DATE]-[DATE] identified 11 residents: R #1, R #3, R #4, R #6, R #7, R #8, R #9, R #10, R #11, R #12 and R #13. R #5 and R #14 were not on the facility's log. R #1: R #1's Face Sheet dated [DATE] documented an [AGE] year-old male admitted to the facility on the 100 Hall on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]., Osteoarthritis, Insomnia, Mood Disorder, and Unspecified Chest Pain. R #1's physician's orders [REDACTED]. Contact isolation for Scabies. R #1's physician's orders [REDACTED]. Contact isolation for Scabies. R #1's [DATE] Treatment Administration Record (TAR) indicated R #1 was administered [MEDICATION NAME] Cream 5% on [DATE]. R #1's [DATE] Order Summary Report documented [DATE] at 11:26 a.m.- Discontinue [MEDICATION NAME] Cream 5%, Reason: Resident expired. R #3: R #3's Face Sheet dated [DATE] documented an [AGE] year-old female admitted to the facility in the 600 Hall on [DATE] with the [DIAGNOSES REDACTED]. This damage is often caused by an abnormally high pressure in your eye), and Osteoporosis (condition in which the bones become brittle and fragile from loss of tissue). R #3's physician's orders [REDACTED]. R #3's [DATE] TAR indicated R #3 was administered [MEDICATION NAME] Cream 5% on [DATE]. R #3's physician's orders [REDACTED]. Bath to remove in 12 hours and remove per schedule. Contact isolation for one week due to Scabies. R #3's [DATE] TAR indicated R #3 was administered [MEDICATION NAME] Cream 5% on [DATE]. R #6: R #6's Face Sheet dated [DATE] documented an [AGE] year-old female admitted to the facility on the 500 Hall on [DATE] with the [DIAGNOSES REDACTED]. R #6's physician's orders [REDACTED]. Contact isolation for one week due to Scabies. R #6's physician's orders [REDACTED]. R #6's [DATE] TAR indicated R #6 was administered [MEDICATION NAME] Cream 5% on [DATE] and [DATE]. R #6's Order Summary dated [DATE] documented Remove from isolation- Scabies resolved. R #7: R #7's Face Sheet dated [DATE] documented an [AGE] year-old male admitted to the facility on the 600 Hall on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. to the brain, causing limited or no blood flow to the affected areas), [DIAGNOSES REDACTED] (paralysis of one side of the body), and Generalized Muscle Weakness. R #7's physician's orders [REDACTED]. Contact isolation for one week due to Scabies. R #7's [DATE] TAR indicated [MEDICATION NAME] Cream 5%- Apply to area topically one time a day every 14 days for Scabies, as directed for two administration- Order Date: [DATE]. The TAR did not contain an entry indicating the medication was administered on any day in [DATE]. NOTE: R #7 should have been administered [MEDICATION NAME] Cream 5% on [DATE] and then a second dose should have been administered on [DATE]. R #7's physician's orders [REDACTED]. R #7's [DATE] TAR indicated [MEDICATION NAME] Cream 5%- Apply to affected area topically one time a day starting on the 19th and ending the 19th for Scabies for 2 administrations, as directed. Order Date: [DATE] at 10:43 a.m. The only entry that indicated the medication was administered was on [DATE]. NOTE: There was not a second administration of [MEDICATION NAME] Cream as ordered by the physician. R #8: R #8's Face Sheet dated [DATE] documented an [AGE] year-old female admitted to the facility on the 400 Hall on [DATE] with the [DIAGNOSES REDACTED]. R #8's physician's orders [REDACTED]. Contact isolation for one week due to Scabies. R #8's [DATE] TAR revealed R #8 was administered [MEDICATION NAME] Cream 5% on [DATE] at 11:51 p.m. R #8's physician's orders [REDACTED]. R #8's physician's orders [REDACTED]. [MEDICATION NAME] Cream 5%- Apply to affected area topically one time a day every Tuesday for scabies for two administrations as directed from neck to toes. May repeat in one week if necessary. R #8's [DATE] TAR revealed R #8 was administered [MEDICATION NAME] Cream 5% on Monday, [DATE] at 11:59 p.m. R #8's physician's orders [REDACTED]. R #8's [DATE] TAR revealed R #8 was administered [MEDICATION NAME] Cream 5% on Monday, [DATE] at 11:59 p.m. R #8's Order Summary Report dated [DATE] at 11:17 a.m. documented Remove from isolation, scabies resolved. R #9: R #9's Face Sheet dated [DATE] documented a [AGE] year-old female admitted to the facility on the 400 Hall on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. R #9's physician's orders [REDACTED]. Contact isolation for 48 hours due to Scabies. R #9's [DATE] TAR revealed R #9 was administered [MEDICATION NAME] Cream 5% on [DATE]. R #9's physician's orders [REDACTED]. R #12: R #12's Face Sheet dated [DATE] documented a [AGE] year-old female admitted to the facility on the 600 Hall on [DATE] with the [DIAGNOSES REDACTED]. R #12's physician's orders [REDACTED]. Contact isolation Dx- Scabies. R #12's physician's orders [REDACTED]. Contact isolation Dx- Scabies. R #12's physician's orders [REDACTED]. R #12's [DATE] TAR revealed R #12 was administered [MEDICATION NAME] Cream 5% on [DATE] and [DATE]. R #13: R #13's Face Sheet dated [DATE] documented an [AGE] year-old female admitted to the facility on the 200 Hall on [DATE] with the [DIAGNOSES REDACTED]. R #13's physician's orders [REDACTED]. Contact isolation for 7 days Dx- Scabies. R #13's physician's orders [REDACTED]. Contact isolation Dx- Scabies. R #13's [DATE] TAR revealed R #14 no entry to indicate R #13 was administered the [MEDICATION NAME] Cream 5% as ordered on [DATE] and [DATE]. R #13's physician's orders [REDACTED]. R #14: R #14's Face Sheet dated [DATE] documented an [AGE] year-old male admitted to the facility on the 200 Hall on [DATE] with the [DIAGNOSES REDACTED]. R #14's physician's orders [REDACTED]. Repeat application as instructed within two weeks of initial application. Contact isolation until Scabies resolved. R #14's Physician order [REDACTED]. R #10: R #10's Face Sheet dated [DATE] documented an [AGE] year-old female admitted to the facility in the 400 Hall on [DATE] with the [DIAGNOSES REDACTED]. R #10's physician's orders [REDACTED]. Place on contact isolation due to scabies. R #10's [DATE] TAR revealed R #10 was administered [MEDICATION NAME] Cream 5% on [DATE]. R #10's physician's orders [REDACTED]. Bathe in 12 hours to remove cream. R #10's [DATE] TAR revealed there was no entry to indicate R #10 was administered [MEDICATION NAME] Cream 5% as ordered in [DATE]. R #10's physician's orders [REDACTED]. R #10's physician's orders [REDACTED]. Repeat in one week if needed and apply entire body topically as needed for scabies until [DATE] 11:59 p.m. Contact isolation X 1 week for Scabies. This order was Confirmed by (the DON). R #10's [DATE] TAR revealed R #10 was administered [MEDICATION NAME] Cream 1% on [DATE]. R #10's physician's orders [REDACTED]. R #11: R #11's Face Sheet dated [DATE] documented

Based on observation, interview and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest, practicable physical, mental, and psychosocial well-being of each resident for 13 Residents (R #1, R #3, R #4, R #5. R #6 R #7, R #8, R #9, R #10, R #11, R #12, R #13 and R #14) of 14 Residents reviewed Infection Control. The Administrator failed to: 1) Implement policies and procedures for Scabies Treatment and Control. 2) Supervise the DON by using the Infection Control tracking and trending and Quality Assurance process, making rounds, and following up with scabies containment. The DON was aware that R #4 was infected with Scabies but failed to ensure effective interventions were in place to protect R #4 from re-infestation, and containment of disease to protect other residents from infection. 3) Implement and follow appropriate measures and the facility's policy and procedures to prevent the re-infection and isolation of scabies for R #1, R #3, R #5, R #6, R #7, R #8, R #9, R #12, R #13, and R #14. The DON failed to: 1) Implement policies and procedures for Scabies Control and re-infestation. 2) Put effective measures into place to ensure staff followed up with Physician Orders. 3) Supervise the nursing staff to ensure that the nursing staff was consistently following up with Physician Orders, Pharmacy Orders and Scabies treatment for [REDACTED]. Findings were: These failures resulted in an Immediate Jeopardy (IJ) situation identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure continued implementation of their plan of removal. These failures could affect 80 residents residing in the facility for serious infection control and risk of contracting scabies. According to the facility's list of residents treated for [REDACTED]. R #4 R #4's Admission Record dated [DATE] revealed R #4 was a [AGE] year old male admitted to the facility on [DATE] with the following diagnoses; Scabies, Allergic contact [MEDICAL CONDITIONS] with behavioral disturbance, Muscle Weakness, Atrioventricular Block (conduction between the atria and ventricles of the heart is impaired) and Cardiac Pacemaker. R #4's admission MDS dated [DATE] revealed R #4 had severe cognitive impairment, required extensive assistance of one person for bed mobility, transfers, dressing, personal hygiene, and locomotion on and off the unit. R #4 had a wheel chair for mobility. R #4 was not assessed as having a rash. R #4's Care Plan completed [DATE] did not address scabies or chronic [MEDICAL CONDITION]. R #4's Head to Toe Skin Checks dated [DATE] R #4 had an existing rash. R #4's physician's orders [REDACTED]. R #4's physician's orders [REDACTED]. R #4's In-House Communicator dated [DATE] (provided by) House Keeping Supervisor (HKS) revealed Place in contact isolation DX: (Scabies) R #4's physician's orders [REDACTED]. R #4's TAR dated ,[DATE] revealed [MEDICATION NAME] Cream 5% Apply to affected areas topically one time only for scabies until [DATE] apply from neck to toes and remove by bathing 12 hours later may repeat in one week if necessary. (TAR was left blank on [DATE]/ no initials as applied) [MEDICATION NAME] Cream 5% was initialed as applied on [DATE]. ([MEDICATION NAME] was not given as ordered [DATE]). Written correspondence from DON dated [DATE] revealed (R #4) was admitted on [DATE] with RX of Scabies. Order for [MEDICATION NAME] obtained on [DATE]. Treatment not given due to the fact that this med did not arrive from our Pharmacy. On [DATE] same order for [MEDICATION NAME] was resubmitted and med arrived and administered on [DATE]. On [DATE] [MEDICATION NAME] was reordered and reapplied due to a resurgent of Scabies again. Then as per MD order [MEDICATION NAME] was reapplied on [DATE]. As per MD Scabies subsided. On [DATE] (Dr. XX) ordered [MEDICATION NAME] 1% Cream and [MEDICATION NAME] Cream for [MEDICAL CONDITION] and on [DATE] MD ordered [MEDICATION NAME] 10 mg. R #4's physician's orders [REDACTED]. R #4's physician progress notes [REDACTED]. R #4's physician's orders [REDACTED]. R #4's Care Plan completed [DATE] did not address scabies or chronic [MEDICAL CONDITION]. R # 4's hospital admission History and Physical dated [DATE] revealed Impression: Scabies. R #4's hospital Discharge Summary dated [DATE] revealed Final Diagnoses: [REDACTED]. R #4's TAR dated ,[DATE] revealed [MEDICATION NAME] Cream 5% ([MEDICATION NAME]) Apply to body as directed topically at bedtime every Thu for Scabies for 2 Administrations repeat in 1 week. (TAR was left blank on [DATE] and [DATE] no initials as applied) [MEDICATION NAME] Cream 5% was initialed as applied on [DATE]. R #4's physician's orders [REDACTED]. R #4's physician's orders [REDACTED]. R #4's physician's orders [REDACTED]. R #4's physician's orders [REDACTED]. XX. R #4's physician's orders [REDACTED]. R #4's physician's orders [REDACTED].) Apply to body topically two times a day for [MEDICAL CONDITION] apply to body after applying the [MEDICATION NAME] cream. R #4's Doctor's Progress Notes dated [DATE] revealed .Has been treated x2 at least for scabies last TX. ,[DATE] when patient was hospitalized , patient now on [MEDICATION NAME] cream with partial relief but rash persists, no clear documentation of proper decontamination after TX for scabies given .Skin Presence of indurated papules with excoriations and areas of Linchenification on both arms, shoulders, lower back, and lower abdomen, both thighs .Scabies by history scabies TX X 2 at least .Plan will proceed to provide treatment for [REDACTED]. Review of facility infection control tracking and trending log dated: -,[DATE] revealed one case of Scabies. -,[DATE] revealed two cases of Scabies. -,[DATE] revealed three cases of Scabies. -,[DATE] revealed five cases of Scabies. -,[DATE] revealed seven cases of Scabies. On [DATE] at 2:45 p.m., during initial rounds Surveyor observed a tracking raised red rash on R #4's arms and legs. There were areas on R #4's anterior lower forearms with scratch marks and bleeding and scattered bruise marks across both arms. R #4 lifted up his shirt and exposed his abdominal area which was also covered in a tracking raised red rash. R #4's legs were covered with a scabbed over rash from the knees down to his ankle areas. R #4 said he has had the rash off and on for months. R #4 said he wanted the rash treated because it itched him all the time. During interview with R #4 there was a female whom identified herself as a friend in R #4's room. The friend PP said she had been asking for treatment for [REDACTED].#4's insurance would not pay for a dermatologist visit. Surveyor observation and interview revealed R #4 shared closet space with a room-mate. (R #4's clothing was co-mingled with room-mates clothing) On [DATE] at 5:45 p.m., observation revealed R #4 sitting in the dining room at a table with two other residents. R #4 was scratching at his back and arms, R #4 placed his right arm on the table cloth several times during the meal service. On [DATE] at 6:30 p.m., interview with the DON revealed the Treatment Nurse was responsible for treating all the residents for scabies while she was in the building. On [DATE] at 9:00 a.m., interview with the DON revealed the first case of Scabies in the facility was identified (R#8) and treated in [DATE]. The DON said the Physician was notified and the room-mate was removed from the room and R #8 was placed in Contact Isolation. All nursing staff was notified of R #8's Infection Control status by shift report, Cardex and verbal instruction to staff that was currently working with resident. Surveyor asked the DON what the facility protocol was for scabies and the DON said, for scabies the isolation period was for five days. The DON said that the Scabies medication was applied for 24 hours then was rinsed off the resident. The DON said skin checks were conducted post treatment for [REDACTED]. The DON said while the resident was being treated with the Scabicide, House Keeping cleans the resident's room from top to bottom including the resident's clothing. The DON said if the resident had un-washable items such as stuffed animals or pillows, those items were thrown away. The DON said Rehab., Activity Director, and House Keeping Supervisor were notified, two isolation bins were placed in the resident room, one for linens and the other for trash. They placed an isolation cart outside the resident's room for PPE then posted a sign outside resident's door advising people to report to nurse's station prior to entering the room. The DON said for meal service, the staff double bag the meal tray before delivering the tray back to the kitchen. The resident was scheduled for the last shower of the day and Activities are provided in room. The DON said the Nurse that obtained R #4's orders for [MEDICATION NAME] on [DATE] and should have followed up with the Pharmacy to ensure the medication was delivered. On [DATE] at 9:20 a.m., interview with RN A revealed the facility's process for Scabies was starting with the assessment, then notifies the CNAs to back off for a while and take Contact Isolation precautions. RN A said he would then call the Physician and obtain an order for [REDACTED]. RN A said prior to placing resident back into the room all the curtains and all linens were washed. RN A said HSK was responsible for washing the resident's clothing. RN A said that House Keeping would take down the privacy curtains and replace with new curtains. RN A said for all un-washable items such as personal pillows, are to be bagged and then ask resident's family permission to get rid of the items. RN A said HSK emptied out resident clothing from drawers and closets for washing. RN A said he thought R #4 had an active case of Scabies. RN A said he thought Scabies in the facility was spread from improper hand washing and on clothing. RN A said the facility has not had any in-services on Scabies. (RX dosage for treatment of [REDACTED]. On [DATE] at 10:05 a.m., interview with HSK revealed she was notified if a resident had Scabies either in the morning meeting or by In-House Communication Sheet. HSK said if she was in the building at the time a resident was placed in Isolation for Scabies she would set up the Cart for PPE and place it outside resident room, then place a sign on resident door, and notify her staff that the resident was on Contact Isolation. HSK said she wears PPE, wipes down resident's bed with disinfectant; nursing staff takes all the linens off the beds and places in a biohazard bag linen bin in the resident room. HSK said the nursing staff places resident clothing in biohazard linen bin. HSK said when the resident was off isolation; HSK conducts a deep clean of resident's room, takes down all curtains and wipes down blinds and chair with disinfectant. HSK said she did not remove clothing from resident's closet or drawers. HSK only washes clothing and linens that nursing staff place in biohazard bags. On [DATE] at 10:15 a.m., interview with LVN B (treatment nurse) revealed she worked from 10:00 a.m.-6:00 p.m. Monday through Friday. LVN B said when she was in the building that she treated residents with orders for Scabicide. LVN B said the first action she takes if she identifies a resident has Scabies would be to notify the Charge Nurse and the Charge Nurse would notify the Physician and obtain orders. LVN B said all direct care nursing staff were notified and the resident would be placed on Contact Isolation, and HSK would be contacted to clean the resident's room. The Scabicide would be applied to the resident from neck down and left on for 12 hours and washed off. While the Scabicide was applied to the resident, all linens on the bed would be removed and placed in Biohazard bag by nursing staff. LVN B said she would then call HSK to clean the room and wash residents clothing. LVN B said 24 hours after the Scabicide treatment she would reassess the resident's skin. LVN B said if the resident that was infected with Scabies had a roommate; the roommate along with the roommate's belongings would be moved to another room until the infected resident was clear from scabies (without decontaminating the belongings). LVN B said if a resident with Scabies had un-washable items, the staff would place those items in the resident's closet or ask the family to take the items home. LVN B said that in her opinion R #4 no longer had Scabies and the Physician has ordered [MEDICATION NAME] 0.1% Cream for R #4's rash. Surveyor asked LVN B if she knew what the indications for [MEDICATION NAME] Cream? LVN B said, No, Surveyor asked LVN B as a nurse was she supposed to know what the indications were for Prescription drugs prior to application. LVN B said, yes, but I don't know. (Nursing Staff said in interviews that HSK washed resident's clothing as part of scabies treatment, and HSK said Nursing staff was responsible for resident's clothing) On [DATE] at 10:35 a.m., skin assessment by LVN B with R #4, LVN B said during skin assessment that #4 had raised red tracking rash to his bilateral upper extremities, left upper chest wall, behind ears and neck. LVN B said R #4 had dry scabbed areas to his lower extremities. LVN B described areas on R # 4's arms as open and bloody from scratching. LVN B said R #4 scratches until he bleeds. On [DATE] at 12:25 p.m., interview with HSK revealed she was never notified of R #4 being in isolation the second time R #4 was treated in ,[DATE]. On [DATE] at 5:15 p.m., interview with Dr. XX revealed if the facility did not properly follow decontamination procedures during Scabicide treatment, there was a possibility that R #4 could have been re-infected with Scabies. Dr. XX said all the resident's clothing must be washed as well as the room decontaminated while resident was receiving Scabicide treatment. Surveyor showed Dr. XX R #4's clothing closet was shared with another resident and asked the Physician what would be the proper infection control procedure to isolate the Scabies. Dr. XX said the resident that shared the clothing closet with R #4 would also have to have the clothing washed because the Scabies bug lived on clothing and that the bug could be transmitted to another resident. Dr. XX said he ordered the [MEDICATION NAME] Cream for R #4 to reduce the [MEDICAL CONDITION] response and itching from the [MEDICAL CONDITION]. Dr. XX said he was going to re-treat R #4 with [MEDICATION NAME] because there was no clear documentation that treatment orders were followed or effective decontamination was done. Dr. XX said he was going to place R #4 on Contact Isolation for one week. Record review of the facility's Log of Residents with Scabies dated ,[DATE]-[DATE] identified 11 residents: R #1, R #3, R #4, R #6, R #7, R #8, R #9, R #10, R #11, R #12 and R #13. R #5 and R #14 were not on the facility's log. R #1: R #1's Face Sheet dated [DATE] documented an [AGE] year-old male admitted to the facility on the 100 Hall on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]., [MEDICAL CONDITIONS], Mood Disorder, and Unspecified Chest Pain. R #1's physician's orders [REDACTED]. Contact isolation for Scabies. R #1's physician's orders [REDACTED]. Contact isolation for Scabies. R #1's [DATE] Treatment Administration Record (TAR) indicated R #1 was administered [MEDICATION NAME] Cream 5% on [DATE]. R #1's [DATE] Order Summary Report documented [DATE] at 11:26 a.m.- Discontinue [MEDICATION NAME] Cream 5%, Reason: Resident expired. R #3: R #3's Face Sheet dated [DATE] documented an [AGE] year-old female admitted to the facility in the 600 Hall on [DATE] with the [DIAGNOSES REDACTED]. This damage is often caused by an abnormally high pressure in your eye), and [MEDICAL CONDITION] (condition in which the bones become brittle and fragile from loss of tissue). R #3's physician's orders [REDACTED]. R #3's [DATE] TAR indicated R #3 was administered [MEDICATION NAME] Cream 5% on [DATE]. R #3's physician's orders [REDACTED]. Bath to remove in 12 hours and remove per schedule. Contact isolation for one week due to Scabies. R #3's [DATE] TAR indicated R #3 was administered [MEDICATION NAME] Cream 5% on [DATE]. R #6: R #6's Face Sheet dated [DATE] documented an [AGE] year-old female admitted to the facility on the 500 Hall on [DATE] with the [DIAGNOSES REDACTED]. R #6's physician's orders [REDACTED]. Contact isolation for one week due to Scabies. R #6's physician's orders [REDACTED]. R #6's [DATE] TAR indicated R #6 was administered [MEDICATION NAME] Cream 5% on [DATE] and [DATE]. R #6's Order Summary dated [DATE] documented Remove from isolation- Scabies resolved. R #7: R #7's Face Sheet dated [DATE] documented an [AGE] year-old male admitted to the facility on the 600 Hall on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. to the brain, causing limited or no blood flow to the affected areas), [MEDICAL CONDITION] (paralysis of one side of the body), and Generalized Muscle Weakness. R #7's physician's orders [REDACTED]. Contact isolation for one week due to Scabies. R #7's [DATE] TAR indicated [MEDICATION NAME] Cream 5%- Apply to area topically one time a day every 14 days for Scabies, as directed for two administration- Order Date: [DATE]. The TAR did not contain an entry indicating the medication was administered on any day in [DATE]. NOTE: R #7 should have been administered [MEDICATION NAME] Cream 5% on [DATE] and then a second dose should have been administered on [DATE]. R #7's physician's orders [REDACTED]. R #7's [DATE] TAR indicated [MEDICATION NAME] Cream 5%- Apply to affected area topically one time a day starting on the 19th and ending the 19th for Scabies for 2 administrations, as directed. Order Date: [DATE] at 10:43 a.m. The only entry that indicated the medication was administered was on [DATE]. NOTE: There was not a second administration of [MEDICATION NAME] Cream as ordered by the physician. R #8: R #8's Face Sheet dated [DATE] documented an [AGE] year-old female admitted to the facility on the 400 Hall on [DATE] with the [DIAGNOSES REDACTED]. R #8's physician's orders [REDACTED]. Contact isolation for one week due to Scabies. R #8's [DATE] TAR revealed R #8 was administered [MEDICATION NAME] Cream 5% on [DATE] at 11:51 p.m. R #8's physician's orders [REDACTED]. R #8's physician's orders [REDACTED]. [MEDICATION NAME] Cream 5%- Apply to affected area topically one time a day every Tuesday for scabies for two administrations as directed from neck to toes. May repeat in one week if necessary. R #8's [DATE] TAR revealed R #8 was administered [MEDICATION NAME] Cream 5% on Monday, [DATE] at 11:59 p.m. R #8's physician's orders [REDACTED]. R #8's [DATE] TAR revealed R #8 was administered [MEDICATION NAME] Cream 5% on Monday, [DATE] at 11:59 p.m. R #8's Order Summary Report dated [DATE] at 11:17 a.m. documented Remove from isolation, scabies resolved. R #9: R #9's Face Sheet dated [DATE] documented a [AGE] year-old female admitted to the facility on the 400 Hall on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. R #9's physician's orders [REDACTED]. Contact isolation for 48 hours due to Scabies. R #9's [DATE] TAR revealed R #9 was administered [MEDICATION NAME] Cream 5% on [DATE]. R #9's physician's orders [REDACTED]. R #12: R #12's Face Sheet dated [DATE] documented a [AGE] year-old female admitted to the facility on the 600 Hall on [DATE] with the [DIAGNOSES REDACTED]. R #12's physician's orders [REDACTED]. Contact isolation Dx- Scabies. R #12's physician's orders [REDACTED]. Contact isolation Dx- Scabies. R #12's physician's orders [REDACTED]. R #12's [DATE] TAR revealed R #12 was administered [MEDICATION NAME] Cream 5% on [DATE] and [DATE]. R #13: R #13's Face Sheet dated [DATE] documented an [AGE] year-old female admitted to the facility on the 200 Hall on [DATE] with the [DIAGNOSES REDACTED]. R #13's physician's orders [REDACTED]. Contact isolation for 7 days Dx- Scabies. R #13's physician's orders [REDACTED]. Contact isolation Dx- Scabies. R #13's [DATE] TAR revealed R #14 no entry to indicate R #13 was administered the [MEDICATION NAME] Cream 5% as ordered on [DATE] and [DATE]. R #13's physician's orders [REDACTED]. R #14: R #14's Face Sheet dated [DATE] documented an [AGE] year-old male admitted to the facility on the 200 Hall on [DATE] with the [DIAGNOSES REDACTED]. R #14's physician's orders [REDACTED]. Repeat application as instructed within two weeks of initial application. Contact isolation until Scabies resolved. R #14's Physician order [REDACTED]. R #10: R #10's Face Sheet dated [DATE] documented an [AGE] year-old female admitted to the facility in the 400 Hall on [DATE] with the [DIAGNOSES REDACTED]. R #10's physician's orders [REDACTED]. Place on contact isolation due to scabies. R #10's [DATE] TAR revealed R #10 was administered [MEDICATION NAME] Cream 5% on [DATE]. R #10's physician's orders [REDACTED]. Bathe in 12 hours to remove cream. R #10's [DATE] TAR revealed there was no entry to indicate R #10 was administered [MEDICATION NAME] Cream 5% as ordered in [DATE]. R #10's physician's orders [REDACTED]. R #10's physician's orders [REDACTED]. Repeat in one week if needed and apply entire body topically as needed for scabies until [DATE] 11:59 p.m. Contact isolation X 1 week for Scabies. This order was Confirmed by (the DON). R #10's [DATE] TAR revealed R #10 was administered [MEDICATION NAME] Cream 1% on [DATE]. R #10's physician's orders [REDACTED]. R #11: R #11's Face Sheet dated [DATE] documented an [AGE] year-old female admitted to the facility on the 400 Hall on [DATE] with the [DIAGNOSES REDACTED]. R #11's physician's orders [REDACTED]. Contact isolation Dx. (Diagnosis)- Scabies. R #11's [DATE] TAR revealed R #11 was administered [MEDICATION NAME] Cream 5% on [DATE]. R #11's physician's orders [REDACTED]. Contact isolation for Scabies. R #11's physician's orders [REDACTED]. Contact isolation for Scabies. R #11's [DATE] TAR revealed R #11 was administered [MEDICATION NAME] Cream 5% on [DATE] and [DATE]. R #11's physician's orders [REDACTED]. Contact isolation for Scabies. R #11's [DATE] TAR revealed R #11 was administered [MEDICATION NAME] Cream 5% on [DATE]. R #11's physician's orders [REDACTED]. Leave for 12 hours then bath to remove cream. X 1 dose only.

Based on observation, interview, and record review the facility failed to implement its written policies and procedures that prohibit neglect of residents for 13 Residents (R #1, R #3, R #4, R #5, R #6, R #7, R #8, R #9, R #10, R #11, R #12 and R #13, R #14) of 14 Residents reviewed for neglect related to Infection Control. The facility failed to provide services to prevent harm when it: 1.) failed to follow the physician's orders [REDACTED].#4 and R #7. R #4 had bleeding areas on both arms. 2.) failed to implement and follow appropriate measures and the facility's policy and procedures to prevent the re-infection and isolation of scabies for R #1, R #3, R #5, R #6, R #7, R #8, R #9, R #12, R #13, and R #14. 3) failed to clarify R #10 and R #11's orders for [MEDICATION NAME] Cream 1% as an effective treatment for [REDACTED]. These failures resulted in an Immediate Jeopardy (IJ) situation identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure continued implementation of their plan of removal. These failures could affect 80 residents residing in the facility for serious infection control and risk of contracting scabies. According to the facility's list of residents treated for [REDACTED]. Based on observation, interview, and record review the facility failed to implement its written policies and procedures that prohibit neglect for two Residents (R #2 and R #4) of 14 Residents reviewed for neglect. R#2 did not have a bed or chair tab alarm and a Landing Mat in place as per the Interdisciplinary Team (IDT) intervention recommendations. Fall Risk assessments were not completed after each fall as per the facility's policy and procedure to determine his current level of fall risk. R #4 did not have a low bed as per the Interdisciplinary intervention recommendations. R #4 did not have any Fall Risk Assessments throughout his residence in the facility. These failures could affect 18 residents with history of falls at risk for serious injury or death. The findings included: Review of Facility Policy and Procedure titled Abuse & Neglect Prohibition (revision date:[DATE]) revealed, Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, injuries of unknown origin, and misappropriation of property .Definitions .Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Injuries of unknown origin may occur as a result of neglect . The Texas Department of Aging and Disability Services Provider Letter dated [DATE] documented: Abuse, Neglect, Exploitation and Other Incidents that Must be Reported. Health and Safety Code §260A.002 and Texas Administrative Code, Title 40, Part 1, Chapter 19, §19.602(a) require any facility staff member who has cause to believe that the physical or mental health or welfare of a resident has been or may be adversely affected by abuse, neglect or exploitation caused by another person to report the abuse, neglect or exploitation. Facilities are required at 40 TAC §19.601(c)(2) to ensure that all alleged violations involving mistreatment, neglect or abuse, including suspicious injuries of unknown source and misappropriation of resident property, are reported immediately to DADS. Facilities are also required to report certain other incidents, which may or may not constitute abuse, neglect or exploitation. Certified facilities are required by 42 Code of Federal Regulations (CFR) §483.13(c)(2) and (4) (F226) to report alleged violations involving mistreatment, neglect or abuse, including suspicious injuries of unknown source and misappropriation of resident property, and the results of the investigation conducted by the facility to the state survey and certification agency 2. NEGLECT (as defined in 40 TAC §19.101(81)) The failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness. The facility must determine if an injury, harm to or death of a resident was due to a facility failure to provide services, treatment or care to a resident. For certified facilities, neglect is also defined at 42 CFR §488.301 and prohibited at §483.13(c) (F224) Facility staff must report abuse, neglect, exploitation and other incidents to: · DADS Consumer Rights and Services Section at (800) [PHONE NUMBER] immediately (within 24 hours) upon learning of the incident; and · send a written investigation report to the Consumer Rights and Services Section within 5 working days after the telephone report. PROCEDURES FOR The FACILITY INVESTIGATION The facility must conduct an investigation of the reported act(s) and must send a written report of the investigation to DADS no later than the fifth working day after the oral report according to 40 TAC §19.602(b)(1)(2) The facility must have evidence that all alleged violations are thoroughly investigated and must prevent further potential abuse/neglect while the investigation is in progress. If the alleged violation is substantiated, appropriate corrective action must be taken .Facility Investigation: Facility actions when conducting an investigation must be documented and include: · observations, interviews and record reviews of all residents involved; · interviews of all witnesses, including residents, staff and family members; · notification of the physicians and, where appropriate, the families or responsible parties of the involved residents; and · recording of all relevant physical findings. Facility Infection Prevention Manual for Long Term Care (revised ,[DATE]) Titled Scabies Care revealed Purpose: To adequately treat cases of scabies and prevent transmission to others. Policy: Any resident with positive evidence of Scabies (Sarcoptes scabiei) must be treated upon physician's order [REDACTED].TO AVOID REINFESTATION A. Clean ALL clothing, bedclothes, etc. that have been in recent contact with the resident. Transport these items in plastic bags. Wash clothes and bedding in HOT soapy water (allow time between loads for full recovery of hot water) and dry on HOT cycle of dryer. Place unwashable clothing and articles in a plastic bag and seal for 7 days (the mites do not survive for more than ,[DATE] days without contact with the body). B. Wipe down beds, pillows, mattresses, furniture, etc. with a germicidal solution. E. Contact precautions for associates consist of wearing gloves and gown if in close contact with an infested person or things .This is necessary before treatment and for ,[DATE] hours after treatment. Hand hygiene is the best technique for protection of oneself and others .PROCEDURE .G. While treatment is being done, have bed stripped (place bedding in a plastic bag before sending to laundry); all washable clothing, etc. that has been in recent contact with the resident should be placed in a plastic bag to be washed. Unwashable items should be placed in a plastic bag and sealed for 7 days (label bag with name, date, etc.) H. Be sure the resident has CLEAN clothing and CLEAN bedding; make sure infested items have been removed from the room. I All furniture, mattresses, pillows, etc. should be wiped down with a germicidal solution. J. Have the resident bathe thoroughly after the time indicated on the product. Make sure the resident has clean clothes and that bed linens are changed again . Review of Facility Policy and Procedure titled Abuse & Neglect Prohibition (revision date: [DATE]) revealed, Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, injuries of unknown origin, and misappropriation of property .Definitions .Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Injuries of unknown origin may occur as a result of neglect . R #4 R #4's Admission Record dated [DATE] revealed R #4 was a [AGE] year old male admitted to the facility on [DATE] with the following diagnoses; Scabies, Allergic contact [MEDICAL CONDITIONS] with behavioral disturbance, Muscle Weakness, Atrioventricular Block (conduction between the atria and ventricles of the heart is impaired) and Cardiac Pacemaker. R #4's admission MDS dated [DATE] revealed R #4 had severe cognitive impairment, required extensive assistance of one person for bed mobility, transfers, dressing, personal hygiene, and locomotion on and off the unit. R #4 had a wheel chair for mobility. R #4 was not assessed as having a rash. R #4's Care Plan completed [DATE] did not address scabies or chronic [MEDICAL CONDITION]. R #4's Head to Toe Skin Checks dated [DATE] R #4 had an existing rash. R #4's physician's orders [REDACTED]. R #4's physician's orders [REDACTED]. R #4's In-House Communicator dated [DATE] (provided by) House Keeping Supervisor (HKS) revealed Place in contact isolation DX: (Scabies) R #4's physician's orders [REDACTED]. R #4's TAR dated ,[DATE] revealed [MEDICATION NAME] Cream 5% Apply to affected areas topically one time only for scabies until [DATE] apply from neck to toes and remove by bathing 12 hours later may repeat in one week if necessary. (TAR was left blank on [DATE]/ no initials as applied) [MEDICATION NAME] Cream 5% was initialed as applied on [DATE]. ([MEDICATION NAME] was not given as ordered [DATE]). Written correspondence from DON dated [DATE] revealed (R #4) was admitted on [DATE] with RX of Scabies. Order for [MEDICATION NAME] obtained on [DATE]. Treatment not given due to the fact that this med did not arrive from our Pharmacy. On [DATE] same order for [MEDICATION NAME] was resubmitted and med arrived and administered on [DATE]. On [DATE] [MEDICATION NAME] was reordered and reapplied due to a resurgent of Scabies again. Then as per MD order [MEDICATION NAME] was reapplied on [DATE]. As per MD Scabies subsided. On [DATE] (Dr. XX) ordered [MEDICATION NAME] 1% Cream and [MEDICATION NAME] Cream for [MEDICAL CONDITION] and on [DATE] MD ordered [MEDICATION NAME] 10 mg. R #4's physician's orders [REDACTED]. R #4's physician progress notes [REDACTED]. R #4's physician's orders [REDACTED]. R #4's Care Plan completed [DATE] did not address scabies or chronic [MEDICAL CONDITION]. R # 4's hospital admission History and Physical dated [DATE] revealed Impression: Scabies. R #4's hospital Discharge Summary dated [DATE] revealed Final Diagnoses: [REDACTED]. R #4's TAR dated ,[DATE] revealed [MEDICATION NAME] Cream 5% ([MEDICATION NAME]) Apply to body as directed topically at bedtime every Thu for Scabies for 2 Administrations repeat in 1 week. (TAR was left blank on [DATE] and [DATE] no initials as applied) [MEDICATION NAME] Cream 5% was initialed as applied on [DATE]. R #4's physician's orders [REDACTED]. R #4's physician's orders [REDACTED]. R #4's physician's orders [REDACTED]. R #4's physician's orders [REDACTED]. XX. R #4's physician's orders [REDACTED]. R #4's physician's orders [REDACTED].) Apply to body topically two times a day for [MEDICAL CONDITION] apply to body after applying the [MEDICATION NAME] cream. R #4's Doctor's Progress Notes dated [DATE] revealed .Has been treated x2 at least for scabies last TX. ,[DATE] when patient was hospitalized , patient now on [MEDICATION NAME] cream with partial relief but rash persists, no clear documentation of proper decontamination after TX for scabies given .Skin Presence of indurated papules with excoriations and areas of Linchenification on both arms, shoulders, lower back, and lower abdomen, both thighs .Scabies by history scabies TX X 2 at least .Plan will proceed to provide treatment for [REDACTED]. Review of facility infection control tracking and trending log dated: -,[DATE] revealed one case of Scabies. -,[DATE] revealed two cases of Scabies. -,[DATE] revealed three cases of Scabies. -,[DATE] revealed five cases of Scabies. -,[DATE] revealed seven cases of Scabies. On [DATE] at 2:45 p.m., during initial rounds Surveyor observed a tracking raised red rash on R #4's arms and legs. There were areas on R #4's anterior lower forearms with scratch marks and bleeding and scattered bruise marks across both arms. R #4 lifted up his shirt and exposed his abdominal area which was also covered in a tracking raised red rash. R #4's legs were covered with a scabbed over rash from the knees down to his ankle areas. R #4 said he has had the rash off and on for months. R #4 said he wanted the rash treated because it itched him all the time. During interview with R #4 there was a female whom identified herself as a friend in R #4's room. The friend PP said she had been asking for treatment for [REDACTED].#4's insurance would not pay for a dermatologist visit. Surveyor observation and interview revealed R #4 shared closet space with a room-mate. (R #4's clothing was co-mingled with room-mates clothing) On [DATE] at 5:45 p.m., observation revealed R #4 sitting in the dining room at a table with two other residents. R #4 was scratching at his back and arms, R #4 placed his right arm on the table cloth several times during the meal service. On [DATE] at 6:30 p.m., interview with the DON revealed the Treatment Nurse was responsible for treating all the residents for scabies while she was in the building. On [DATE] at 9:00 a.m., interview with the DON revealed the first case of Scabies in the facility was identified (R#8) and treated in [DATE]. The DON said the Physician was notified and the room-mate was removed from the room and R #8 was placed in Contact Isolation. All nursing staff was notified of R #8's Infection Control status by shift report, Cardex and verbal instruction to staff that was currently working with resident. Surveyor asked the DON what the facility protocol was for scabies and the DON said, for scabies the isolation period was for five days. The DON said that the Scabies medication was applied for 24 hours then was rinsed off the resident. The DON said skin checks were conducted post treatment for [REDACTED]. The DON said while the resident was being treated with the Scabicide, House Keeping cleans the resident's room from top to bottom including the resident's clothing. The DON said if the resident had un-washable items such as stuffed animals or pillows, those items were thrown away. The DON said Rehab., Activity Director, and House Keeping Supervisor were notified, two isolation bins were placed in the resident room, one for linens and the other for trash. They placed an isolation cart outside the resident's room for PPE then posted a sign outside resident's door advising people to report to nurse's station prior to entering the room. The DON said for meal service, the staff double bag the meal tray before delivering the tray back to the kitchen. The resident was scheduled for the last shower of the day and Activities are provided in room. The DON said the Nurse that obtained R #4's orders for [MEDICATION NAME] on [DATE] and should have followed up with the Pharmacy to ensure the medication was delivered. On [DATE] at 9:20 a.m., interview with RN A revealed the facility's process for Scabies was starting with the assessment, then notifies the CNAs to back off for a while and take Contact Isolation precautions. RN A said he would then call the Physician and obtain an order for [REDACTED]. RN A said prior to placing resident back into the room all the curtains and all linens were washed. RN A said HSK was responsible for washing the resident's clothing. RN A said that House Keeping would take down the privacy curtains and replace with new curtains. RN A said for all un-washable items such as personal pillows, are to be bagged and then ask resident's family permission to get rid of the items. RN A said HSK emptied out resident clothing from drawers and closets for washing. RN A said he thought R #4 had an active case of Scabies. RN A said he thought Scabies in the facility was spread from improper hand washing and on clothing. RN A said the facility has not had any in-services on Scabies. (RX dosage for treatment of [REDACTED]. On [DATE] at 10:05 a.m., interview with HSK revealed she was notified if a resident had Scabies either in the morning meeting or by In-House Communication Sheet. HSK said if she was in the building at the time a resident was placed in Isolation for Scabies she would set up the Cart for PPE and place it outside resident room, then place a sign on resident door, and notify her staff that the resident was on Contact Isolation. HSK said she wears PPE, wipes down resident's bed with disinfectant; nursing staff takes all the linens off the beds and places in a biohazard bag linen bin in the resident room. HSK said the nursing staff places resident clothing in biohazard linen bin. HSK said when the resident was off isolation; HSK conducts a deep clean of resident's room, takes down all curtains and wipes down blinds and chair with disinfectant. HSK said she did not remove clothing from resident's closet or drawers. HSK only washes clothing and linens that nursing staff place in biohazard bags. On [DATE] at 10:15 a.m., interview with LVN B (treatment nurse) revealed she worked from 10:00 a.m.-6:00 p.m. Monday through Friday. LVN B said when she was in the building that she treated residents with orders for Scabicide. LVN B said the first action she takes if she identifies a resident has Scabies would be to notify the Charge Nurse and the Charge Nurse would notify the Physician and obtain orders. LVN B said all direct care nursing staff were notified and the resident would be placed on Contact Isolation, and HSK would be contacted to clean the resident's room. The Scabicide would be applied to the resident from neck down and left on for 12 hours and washed off. While the Scabicide was applied to the resident, all linens on the bed would be removed and placed in Biohazard bag by nursing staff. LVN B said she would then call HSK to clean the room and wash residents clothing. LVN B said 24 hours after the Scabicide treatment she would reassess the resident's skin. LVN B said if the resident that was infected with Scabies had a roommate; the roommate along with the roommate's belongings would be moved to another room until the infected resident was clear from scabies (without decontaminating the belongings). LVN B said if a resident with Scabies had un-washable items, the staff would place those items in the resident's closet or ask the family to take the items home. LVN B said that in her opinion R #4 no longer had Scabies and the Physician has ordered [MEDICATION NAME] 0.1% Cream for R #4's rash. Surveyor asked LVN B if she knew what the indications for [MEDICATION NAME] Cream? LVN B said, No, Surveyor asked LVN B as a nurse was she supposed to know what the indications were for Prescription drugs prior to application. LVN B said, yes, but I don't know. (Nursing Staff said in interviews that HSK washed resident's clothing as part of scabies treatment, and HSK said Nursing staff was responsible for resident's clothing) On [DATE] at 10:35 a.m., skin assessment by LVN B with R #4, LVN B said during skin assessment that #4 had raised red tracking rash to his bilateral upper extremities, left upper chest wall, behind ears and neck. LVN B said R #4 had dry scabbed areas to his lower extremities. LVN B described areas on R # 4's arms as open and bloody from scratching. LVN B said R #4 scratches until he bleeds. On [DATE] at 12:25 p.m., interview with HSK revealed she was never notified of R #4 being in isolation the second time R #4 was treated in ,[DATE]. On [DATE] at 5:15 p.m., interview with Dr. XX revealed if the facility did not properly follow decontamination procedures during Scabicide treatment, there was a possibility that R #4 could have been re-infected with Scabies. Dr. XX said all the resident's clothing must be washed as well as the room decontaminated while resident was receiving Scabicide treatment. Surveyor showed Dr. XX R #4's clothing closet was shared with another resident and asked the Physician what would be the proper infection control procedure to isolate the Scabies. Dr. XX said the resident that shared the clothing closet with R #4 would also have to have the clothing washed because the Scabies bug lived on clothing and that the bug could be transmitted to another resident. Dr. XX said he ordered the [MEDICATION NAME] Cream for R #4 to reduce the [MEDICAL CONDITION] response and itching from the [MEDICAL CONDITION]. Dr. XX said he was going to re-treat R #4 with [MEDICATION NAME] because there was no clear documentation that treatment orders were followed or effective decontamination was done. Dr. XX said he was going to place R #4 on Contact Isolation for one week. Record review of the facility's Log of Residents with Scabies dated ,[DATE]-[DATE] identified 11 residents: R #1, R #3, R #4, R #6, R #7, R #8, R #9, R #10, R #11, R #12 and R #13. R #5 and R #14 were not on the facility's log. R #1: R #1's Face Sheet dated [DATE] documented an [AGE] year-old male admitted to the facility on the 100 Hall on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]., [MEDICAL CONDITIONS], Mood Disorder, and Unspecified Chest Pain. R #1's physician's orders [REDACTED]. Contact isolation for Scabies. R #1's physician's orders [REDACTED]. Contact isolation for Scabies. R #1's [DATE] Treatment Administration Record (TAR) indicated R #1 was administered [MEDICATION NAME] Cream 5% on [DATE]. R #1's [DATE] Order Summary Report documented [DATE] at 11:26 a.m.- Discontinue [MEDICATION NAME] Cream 5%, Reason: Resident expired. R #3: R #3's Face Sheet dated [DATE] documented an [AGE] year-old female admitted to the facility in the 600 Hall on [DATE] with the [DIAGNOSES REDACTED]. This damage is often caused by an abnormally high pressure in your eye), and [MEDICAL CONDITION] (condition in which the bones become brittle and fragile from loss of tissue). R #3's physician's orders [REDACTED]. R #3's [DATE] TAR indicated R #3 was administered [MEDICATION NAME] Cream 5% on [DATE]. R #3's physician's orders [REDACTED]. Bath to remove in 12 hours and remove per schedule. Contact isolation for one week due to Scabies. R #3's [DATE] TAR indicated R #3 was administered [MEDICATION NAME] Cream 5% on [DATE]. R #6: R #6's Face Sheet dated [DATE] documented an [AGE] year-old female admitted to the facility on the 500 Hall on [DATE] with the [DIAGNOSES REDACTED]. R #6's physician's orders [REDACTED]. Contact isolation for one week due to Scabies. R #6's physician's orders [REDACTED]. R #6's [DATE] TAR indicated R #6 was administered [MEDICATION NAME] Cream 5% on [DATE] and [DATE]. R #6's Order Summary dated [DATE] documented Remove from isolation- Scabies resolved. R #7: R #7's Face Sheet dated [DATE] documented an [AGE] year-old male admitted to the facility on the 600 Hall on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. to the brain, causing limited or no blood flow to the affected areas), [MEDICAL CONDITION] (paralysis of one side of the body), and Generalized Muscle Weakness. R #7's physician's orders [REDACTED]. Contact isolation for one week due to Scabies. R #7's [DATE] TAR indicated [MEDICATION NAME] Cream 5%- Apply to area topically one time a day every 14 days for Scabies, as directed for two administration- Order Date: [DATE]. The TAR did not contain an entry indicating the medication was administered on any day in [DATE]. NOTE: R #7 should have been administered [MEDICATION NAME] Cream 5% on [DATE] and then a second dose should have been administered on [DATE]. R #7's physician's orders [REDACTED]. R #7's [DATE] TAR indicated [MEDICATION NAME] Cream 5%- Apply to affected area topically one time a day starting on the 19th and ending the 19th for Scabies for 2 administrations, as directed. Order Date: [DATE] at 10:43 a.m. The only entry that indicated the medication was administered was on [DATE]. NOTE: There was not a second administration of [MEDICATION NAME] Cream as ordered by the physician. R #8: R #8's Face Sheet dated [DATE] documented an [AGE] year-old female admitted to the facility on the 400 Hall on [DATE] with the [DIAGNOSES REDACTED]. R #8's physician's orders [REDACTED]. Contact isolation for one week due to Scabies. R #8's [DATE] TAR revealed R #8 was administered [MEDICATION NAME] Cream 5% on [DATE] at 11:51 p.m. R #8's physician's orders [REDACTED]. R #8's physician's orders [REDACTED]. [MEDICATION NAME] Cream 5%- Apply to affected area topically one time a day every Tuesday for scabies for two administrations as directed from neck to toes. May repeat in one week if necessary. R #8's [DATE] TAR revealed R #8 was administered [MEDICATION NAME] Cream 5% on Monday, [DATE] at 11:59 p.m. R #8's physician's orders [REDACTED]. R #8's [DATE] TAR revealed R #8 was administered [MEDICATION NAME] Cream 5% on Monday, [DATE] at 11:59 p.m. R #8's Order Summary Report dated [DATE] at 11:17 a.m. documented Remove from isolation, scabies resolved. R #9: R #9's Face Sheet dated [DATE] documented a [AGE] year-old female admitted to the facility on the 400 Hall on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. R #9's physician's orders [REDACTED]. Contact isolation for 48 hours due to Scabies. R #9's [DATE] TAR revealed R #9 was administered [MEDICATION NAME] Cream 5% on [DATE]. R #9's physician's orders [REDACTED]. R #12: R #12's Face Sheet dated [DATE] documented a [AGE] year-old female admitted to the facility on the 600 Hall on [DATE] with the [DIAGNOSES REDACTED]. R #12's physician's orders [REDACTED]. Contact isolation Dx- S

Based on observation, interview, and record review the facility failed to implement its policies and procedures that prohibit neglect of residents for 13 Residents (R #1, R #3, R #4, R #5, R #6, R #7, R #8, R #9, R #10, R #11, R #12 and R #13, R #14) of 14 Residents reviewed for neglect related to Infection Control. The facility failed to provide services to prevent harm when it: 1.) failed to follow the physician's orders [REDACTED].#4 and R #7. R #4 had bleeding areas to both arms. 2.) failed to implement and follow appropriate measures and the facility's policy and procedures to prevent the re-infection and isolation of scabies for R #1, R #3, R #5, R #6, R #7, R #8, R #9, R #12, R #13, and R #14. 3) failed to clarify R #10 and R #11's orders for [MEDICATION NAME] Cream 1% as an effective treatment for [REDACTED]. These failures resulted in an Immediate Jeopardy (IJ) situation identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure continued implementation of their plan of removal. These failures could affect 80 residents residing in the facility for serious infection control and risk of contracting scabies. According to the facility's list of residents treated for [REDACTED]. Based on observation, interview, and record review the facility failed to implement its policies and procedures that prohibit neglect for two Residents (R #2 and R #4) of 14 Residents reviewed for neglect. R#2 did not have a bed or chair tab alarm and a Landing Mat in place as per the Interdisciplinary Team (IDT) intervention recommendations. Fall Risk assessments were not completed after each fall as per the facility's policy and procedure to determine his current level of fall risk. R #4 did not have a low bed as per the Interdisciplinary intervention recommendations. R #4 did not have any Fall Risk Assessments throughout his residence in the facility. These failures could affect 18 residents with history of falls placing them at risk for serious injury or death. The findings included: R #4 R #4's Admission Record dated [DATE] revealed R #4 was a [AGE] year old male admitted to the facility on [DATE] with the following diagnoses; Scabies, Allergic contact [MEDICAL CONDITIONS] with behavioral disturbance, Muscle Weakness, Atrioventricular Block (conduction between the atria and ventricles of the heart is impaired) and Cardiac Pacemaker. R #4's admission MDS dated [DATE] revealed R #4 had severe cognitive impairment, required extensive assistance of one person for bed mobility, transfers, dressing, personal hygiene, and locomotion on and off the unit. R #4 had a wheel chair for mobility. R #4 was not assessed as having a rash. R #4's Care Plan completed [DATE] did not address scabies or chronic [MEDICAL CONDITION]. R #4's Head to Toe Skin Checks dated [DATE] R #4 had an existing rash. R #4's physician's orders [REDACTED]. R #4's physician's orders [REDACTED]. R #4's In-House Communicator dated [DATE] (provided by) House Keeping Supervisor (HKS) revealed Place in contact isolation DX: (Scabies) R #4's physician's orders [REDACTED]. R #4's TAR dated ,[DATE] revealed [MEDICATION NAME] Cream 5% Apply to affected areas topically one time only for scabies until [DATE] apply from neck to toes and remove by bathing 12 hours later may repeat in one week if necessary. (TAR was left blank on [DATE]/ no initials as applied) [MEDICATION NAME] Cream 5% was initialed as applied on [DATE]. ([MEDICATION NAME] was not given as ordered [DATE]). Written correspondence from DON dated [DATE] revealed (R #4) was admitted on [DATE] with RX of Scabies. Order for [MEDICATION NAME] obtained on [DATE]. Treatment not given due to the fact that this med did not arrive from our Pharmacy. On [DATE] same order for [MEDICATION NAME] was resubmitted and med arrived and administered on [DATE]. On [DATE] [MEDICATION NAME] was reordered and reapplied due to a resurgent of Scabies again. Then as per MD order [MEDICATION NAME] was reapplied on [DATE]. As per MD Scabies subsided. On [DATE] (Dr. XX) ordered [MEDICATION NAME] 1% Cream and [MEDICATION NAME] Cream for [MEDICAL CONDITION] and on [DATE] MD ordered [MEDICATION NAME] 10 mg. R #4's physician's orders [REDACTED]. R #4's physician progress notes [REDACTED]. R #4's physician's orders [REDACTED]. R #4's Care Plan completed [DATE] did not address scabies or chronic [MEDICAL CONDITION]. R # 4's hospital admission History and Physical dated [DATE] revealed Impression: Scabies. R #4's hospital Discharge Summary dated [DATE] revealed Final Diagnoses: [REDACTED]. R #4's TAR dated ,[DATE] revealed [MEDICATION NAME] Cream 5% ([MEDICATION NAME]) Apply to body as directed topically at bedtime every Thu for Scabies for 2 Administrations repeat in 1 week. (TAR was left blank on [DATE] and [DATE] no initials as applied) [MEDICATION NAME] Cream 5% was initialed as applied on [DATE]. R #4's physician's orders [REDACTED]. R #4's physician's orders [REDACTED]. R #4's physician's orders [REDACTED]. R #4's physician's orders [REDACTED]. XX. R #4's physician's orders [REDACTED]. R #4's physician's orders [REDACTED].) Apply to body topically two times a day for [MEDICAL CONDITION] apply to body after applying the [MEDICATION NAME] cream. R #4's Doctor's Progress Notes dated [DATE] revealed .Has been treated x2 at least for scabies last TX. ,[DATE] when patient was hospitalized , patient now on [MEDICATION NAME] cream with partial relief but rash persists, no clear documentation of proper decontamination after TX for scabies given .Skin Presence of indurated papules with excoriations and areas of Linchenification on both arms, shoulders, lower back, and lower abdomen, both thighs .Scabies by history scabies TX X 2 at least .Plan will proceed to provide treatment for [REDACTED]. Review of facility infection control tracking and trending log dated: -,[DATE] revealed one case of Scabies. -,[DATE] revealed two cases of Scabies. -,[DATE] revealed three cases of Scabies. -,[DATE] revealed five cases of Scabies. -,[DATE] revealed seven cases of Scabies. On [DATE] at 2:45 p.m., during initial rounds Surveyor observed a tracking raised red rash on R #4's arms and legs. There were areas on R #4's anterior lower forearms with scratch marks and bleeding and scattered bruise marks across both arms. R #4 lifted up his shirt and exposed his abdominal area which was also covered in a tracking raised red rash. R #4's legs were covered with a scabbed over rash from the knees down to his ankle areas. R #4 said he has had the rash off and on for months. R #4 said he wanted the rash treated because it itched him all the time. During interview with R #4 there was a female whom identified herself as a friend in R #4's room. The friend PP said she had been asking for treatment for [REDACTED].#4's insurance would not pay for a dermatologist visit. Surveyor observation and interview revealed R #4 shared closet space with a room-mate. (R #4's clothing was co-mingled with room-mates clothing) On [DATE] at 5:45 p.m., observation revealed R #4 sitting in the dining room at a table with two other residents. R #4 was scratching at his back and arms, R #4 placed his right arm on the table cloth several times during the meal service. On [DATE] at 6:30 p.m., interview with the DON revealed the Treatment Nurse was responsible for treating all the residents for scabies while she was in the building. On [DATE] at 9:00 a.m., interview with the DON revealed the first case of Scabies in the facility was identified (R#8) and treated in [DATE]. The DON said the Physician was notified and the room-mate was removed from the room and R #8 was placed in Contact Isolation. All nursing staff was notified of R #8's Infection Control status by shift report, Cardex and verbal instruction to staff that was currently working with resident. Surveyor asked the DON what the facility protocol was for scabies and the DON said, for scabies the isolation period was for five days. The DON said that the Scabies medication was applied for 24 hours then was rinsed off the resident. The DON said skin checks were conducted post treatment for [REDACTED]. The DON said while the resident was being treated with the Scabicide, House Keeping cleans the resident's room from top to bottom including the resident's clothing. The DON said if the resident had un-washable items such as stuffed animals or pillows, those items were thrown away. The DON said Rehab., Activity Director, and House Keeping Supervisor were notified, two isolation bins were placed in the resident room, one for linens and the other for trash. They placed an isolation cart outside the resident's room for PPE then posted a sign outside resident's door advising people to report to nurse's station prior to entering the room. The DON said for meal service, the staff double bag the meal tray before delivering the tray back to the kitchen. The resident was scheduled for the last shower of the day and Activities are provided in room. The DON said the Nurse that obtained R #4's orders for [MEDICATION NAME] on [DATE] and should have followed up with the Pharmacy to ensure the medication was delivered. On [DATE] at 9:20 a.m., interview with RN A revealed the facility's process for Scabies was starting with the assessment, then notifies the CNAs to back off for a while and take Contact Isolation precautions. RN A said he would then call the Physician and obtain an order for [REDACTED]. RN A said prior to placing resident back into the room all the curtains and all linens were washed. RN A said HSK was responsible for washing the resident's clothing. RN A said that House Keeping would take down the privacy curtains and replace with new curtains. RN A said for all un-washable items such as personal pillows, are to be bagged and then ask resident's family permission to get rid of the items. RN A said HSK emptied out resident clothing from drawers and closets for washing. RN A said he thought R #4 had an active case of Scabies. RN A said he thought Scabies in the facility was spread from improper hand washing and on clothing. RN A said the facility has not had any in-services on Scabies. (RX dosage for treatment of [REDACTED]. On [DATE] at 10:05 a.m., interview with HSK revealed she was notified if a resident had Scabies either in the morning meeting or by In-House Communication Sheet. HSK said if she was in the building at the time a resident was placed in Isolation for Scabies she would set up the Cart for PPE and place it outside resident room, then place a sign on resident door, and notify her staff that the resident was on Contact Isolation. HSK said she wears PPE, wipes down resident's bed with disinfectant; nursing staff takes all the linens off the beds and places in a biohazard bag linen bin in the resident room. HSK said the nursing staff places resident clothing in biohazard linen bin. HSK said when the resident was off isolation; HSK conducts a deep clean of resident's room, takes down all curtains and wipes down blinds and chair with disinfectant. HSK said she did not remove clothing from resident's closet or drawers. HSK only washes clothing and linens that nursing staff place in biohazard bags. On [DATE] at 10:15 a.m., interview with LVN B (treatment nurse) revealed she worked from 10:00 a.m.-6:00 p.m. Monday through Friday. LVN B said when she was in the building that she treated residents with orders for Scabicide. LVN B said the first action she takes if she identifies a resident has Scabies would be to notify the Charge Nurse and the Charge Nurse would notify the Physician and obtain orders. LVN B said all direct care nursing staff were notified and the resident would be placed on Contact Isolation, and HSK would be contacted to clean the resident's room. The Scabicide would be applied to the resident from neck down and left on for 12 hours and washed off. While the Scabicide was applied to the resident, all linens on the bed would be removed and placed in Biohazard bag by nursing staff. LVN B said she would then call HSK to clean the room and wash residents clothing. LVN B said 24 hours after the Scabicide treatment she would reassess the resident's skin. LVN B said if the resident that was infected with Scabies had a roommate; the roommate along with the roommate's belongings would be moved to another room until the infected resident was clear from scabies (without decontaminating the belongings). LVN B said if a resident with Scabies had un-washable items, the staff would place those items in the resident's closet or ask the family to take the items home. LVN B said that in her opinion R #4 no longer had Scabies and the Physician has ordered [MEDICATION NAME] 0.1% Cream for R #4's rash. Surveyor asked LVN B if she knew what the indications for [MEDICATION NAME] Cream? LVN B said, No, Surveyor asked LVN B as a nurse was she supposed to know what the indications were for Prescription drugs prior to application. LVN B said, yes, but I don't know. (Nursing Staff said in interviews that HSK washed resident's clothing as part of scabies treatment, and HSK said Nursing staff was responsible for resident's clothing) On [DATE] at 10:35 a.m., skin assessment by LVN B with R #4, LVN B said during skin assessment that #4 had raised red tracking rash to his bilateral upper extremities, left upper chest wall, behind ears and neck. LVN B said R #4 had dry scabbed areas to his lower extremities. LVN B described areas on R # 4's arms as open and bloody from scratching. LVN B said R #4 scratches until he bleeds. On [DATE] at 12:25 p.m., interview with HSK revealed she was never notified of R #4 being in isolation the second time R #4 was treated in ,[DATE]. On [DATE] at 5:15 p.m., interview with Dr. XX revealed if the facility did not properly follow decontamination procedures during Scabicide treatment, there was a possibility that R #4 could have been re-infected with Scabies. Dr. XX said all the resident's clothing must be washed as well as the room decontaminated while resident was receiving Scabicide treatment. Surveyor showed Dr. XX R #4's clothing closet was shared with another resident and asked the Physician what would be the proper infection control procedure to isolate the Scabies. Dr. XX said the resident that shared the clothing closet with R #4 would also have to have the clothing washed because the Scabies bug lived on clothing and that the bug could be transmitted to another resident. Dr. XX said he ordered the [MEDICATION NAME] Cream for R #4 to reduce the [MEDICAL CONDITION] response and itching from the [MEDICAL CONDITION]. Dr. XX said he was going to re-treat R #4 with [MEDICATION NAME] because there was no clear documentation that treatment orders were followed or effective decontamination was done. Dr. XX said he was going to place R #4 on Contact Isolation for one week. Record review of the facility's Log of Residents with Scabies dated ,[DATE]-[DATE] identified 11 residents: R #1, R #3, R #4, R #6, R #7, R #8, R #9, R #10, R #11, R #12 and R #13. R #5 and R #14 were not on the facility's log. R #1: R #1's Face Sheet dated [DATE] documented an [AGE] year-old male admitted to the facility on the 100 Hall on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]., [MEDICAL CONDITIONS], Mood Disorder, and Unspecified Chest Pain. R #1's physician's orders [REDACTED]. Contact isolation for Scabies. R #1's physician's orders [REDACTED]. Contact isolation for Scabies. R #1's [DATE] Treatment Administration Record (TAR) indicated R #1 was administered [MEDICATION NAME] Cream 5% on [DATE]. R #1's [DATE] Order Summary Report documented [DATE] at 11:26 a.m.- Discontinue [MEDICATION NAME] Cream 5%, Reason: Resident expired. R #3: R #3's Face Sheet dated [DATE] documented an [AGE] year-old female admitted to the facility in the 600 Hall on [DATE] with the [DIAGNOSES REDACTED]. This damage is often caused by an abnormally high pressure in your eye), and [MEDICAL CONDITION] (condition in which the bones become brittle and fragile from loss of tissue). R #3's physician's orders [REDACTED]. R #3's [DATE] TAR indicated R #3 was administered [MEDICATION NAME] Cream 5% on [DATE]. R #3's physician's orders [REDACTED]. Bath to remove in 12 hours and remove per schedule. Contact isolation for one week due to Scabies. R #3's [DATE] TAR indicated R #3 was administered [MEDICATION NAME] Cream 5% on [DATE]. R #6: R #6's Face Sheet dated [DATE] documented an [AGE] year-old female admitted to the facility on the 500 Hall on [DATE] with the [DIAGNOSES REDACTED]. R #6's physician's orders [REDACTED]. Contact isolation for one week due to Scabies. R #6's physician's orders [REDACTED]. R #6's [DATE] TAR indicated R #6 was administered [MEDICATION NAME] Cream 5% on [DATE] and [DATE]. R #6's Order Summary dated [DATE] documented Remove from isolation- Scabies resolved. R #7: R #7's Face Sheet dated [DATE] documented an [AGE] year-old male admitted to the facility on the 600 Hall on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. to the brain, causing limited or no blood flow to the affected areas), [MEDICAL CONDITION] (paralysis of one side of the body), and Generalized Muscle Weakness. R #7's physician's orders [REDACTED]. Contact isolation for one week due to Scabies. R #7's [DATE] TAR indicated [MEDICATION NAME] Cream 5%- Apply to area topically one time a day every 14 days for Scabies, as directed for two administration- Order Date: [DATE]. The TAR did not contain an entry indicating the medication was administered on any day in [DATE]. NOTE: R #7 should have been administered [MEDICATION NAME] Cream 5% on [DATE] and then a second dose should have been administered on [DATE]. R #7's physician's orders [REDACTED]. R #7's [DATE] TAR indicated [MEDICATION NAME] Cream 5%- Apply to affected area topically one time a day starting on the 19th and ending the 19th for Scabies for 2 administrations, as directed. Order Date: [DATE] at 10:43 a.m. The only entry that indicated the medication was administered was on [DATE]. NOTE: There was not a second administration of [MEDICATION NAME] Cream as ordered by the physician. R #8: R #8's Face Sheet dated [DATE] documented an [AGE] year-old female admitted to the facility on the 400 Hall on [DATE] with the [DIAGNOSES REDACTED]. R #8's physician's orders [REDACTED]. Contact isolation for one week due to Scabies. R #8's [DATE] TAR revealed R #8 was administered [MEDICATION NAME] Cream 5% on [DATE] at 11:51 p.m. R #8's physician's orders [REDACTED]. R #8's physician's orders [REDACTED]. [MEDICATION NAME] Cream 5%- Apply to affected area topically one time a day every Tuesday for scabies for two administrations as directed from neck to toes. May repeat in one week if necessary. R #8's [DATE] TAR revealed R #8 was administered [MEDICATION NAME] Cream 5% on Monday, [DATE] at 11:59 p.m. R #8's physician's orders [REDACTED]. R #8's [DATE] TAR revealed R #8 was administered [MEDICATION NAME] Cream 5% on Monday, [DATE] at 11:59 p.m. R #8's Order Summary Report dated [DATE] at 11:17 a.m. documented Remove from isolation, scabies resolved. R #9: R #9's Face Sheet dated [DATE] documented a [AGE] year-old female admitted to the facility on the 400 Hall on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. R #9's physician's orders [REDACTED]. Contact isolation for 48 hours due to Scabies. R #9's [DATE] TAR revealed R #9 was administered [MEDICATION NAME] Cream 5% on [DATE]. R #9's physician's orders [REDACTED]. R #12: R #12's Face Sheet dated [DATE] documented a [AGE] year-old female admitted to the facility on the 600 Hall on [DATE] with the [DIAGNOSES REDACTED]. R #12's physician's orders [REDACTED]. Contact isolation Dx- Scabies. R #12's physician's orders [REDACTED]. Contact isolation Dx- Scabies. R #12's physician's orders [REDACTED]. R #12's [DATE] TAR revealed R #12 was administered [MEDICATION NAME] Cream 5% on [DATE] and [DATE]. R #13: R #13's Face Sheet dated [DATE] documented an [AGE] year-old female admitted to the facility on the 200 Hall on [DATE] with the [DIAGNOSES REDACTED]. R #13's physician's orders [REDACTED]. Contact isolation for 7 days Dx- Scabies. R #13's physician's orders [REDACTED]. Contact isolation Dx- Scabies. R #13's [DATE] TAR revealed R #14 no entry to indicate R #13 was administered the [MEDICATION NAME] Cream 5% as ordered on [DATE] and [DATE]. R #13's physician's orders [REDACTED]. R #14: R #14's Face Sheet dated [DATE] documented an [AGE] year-old male admitted to the facility on the 200 Hall on [DATE] with the [DIAGNOSES REDACTED]. R #14's physician's orders [REDACTED]. Repeat application as instructed within two weeks of initial application. Contact isolation until Scabies resolved. R #14's Physician order [REDACTED]. R #10: R #10's Face Sheet dated [DATE] documented an [AGE] year-old female admitted to the facility in the 400 Hall on [DATE] with the [DIAGNOSES REDACTED]. R #10's physician's orders [REDACTED]. Place on contact isolation due to scabies. R #10's [DATE] TAR revealed R #10 was administered [MEDICATION NAME] Cream 5% on [DATE]. R #10's physician's orders [REDACTED]. Bathe in 12 hours to remove cream. R #10's [DATE] TAR revealed there was no entry to indicate R #10 was administered [MEDICATION NAME] Cream 5% as ordered in [DATE]. R #10's physician's orders [REDACTED]. R #10's physician's orders [REDACTED]. Repeat in one week if needed and apply entire body topically as needed for scabies until [DATE] 11:59 p.m. Contact isolation X 1 week for Scabies. This order was Confirmed by (the DON). R #10's [DATE] TAR revealed R #10 was administered [MEDICATION NAME] Cream 1% on [DATE]. R #10's physician's orders [REDACTED]. R #11: R #11's Face Sheet dated [DATE] documented an [AGE] year-old female admitted to the facility on the 400 Hall on [DATE] with the [DIAGNOSES REDACTED]. R #11's physician's orders [REDACTED]. Contact isolation Dx. (Diagnosis)- Scabies. R #11's [DATE] TAR revealed R #11 was administered [MEDICATION NAME] Cream 5% on [DATE]. R #11's physician's orders [REDACTED]. Contact isolation for Scabies. R #11's physician's orders [REDACTED]. Contact isolation for Scabies. R #11's [DATE] TAR revealed R #11 was administered [MEDICATION NAME] Cream 5% on [DATE] and [DATE]. R #11's physician's orders [REDACTED]. Contact isolation for Scabies. R #11's [DATE] TAR revealed R #11 was administered [MEDICATION NAME] Cream 5% on [DATE]. R #11