Every finding on record at Lexington Manor Senior Care, LLC

Based on observation, staff interview, record review, and facility policy review, the facility failed to promote an environment as free of accident hazards as possible, when the facility failed to provide a resident a smoking protection assistive device to prevent accidents for one (1) of three (3) residents reviewed for accidents and hazards.(Resident #44) Findings include: A review of the facility policy titled, Smoking/Tobacco Use Policy, last review 2024 revealed, Procedure: 5.) Smoking aprons will be provided for residents who are evaluated to need them by the smoking safety assessment. Wearing of the apron will be assisted by staff during smoking times for those residents who require them . An observation of Resident #44 on 10/15/24 at 12:52 PM, revealed small cigarette burn holes on the blanket covering his legs. A record review of a Smoking Safety Screen for Resident #44 dated 5/28/24, revealed the resident needed adaptive equipment during smoking with a smoking apron and supervision. Notes on safety from Interdisciplinary team: Staff noted that Resident #44 fell asleep while holding a lit cigarette. Due to the risk of injury, Resident #44 will be required to wear an apron while smoking. Review of the Smoking Safety Screen for Resident #44 dated 10/14/24 revealed resident need for adaptive equipment needed was a smoking apron and supervision. Notes on safety from the Interdisciplinary team: Resident #44 has a history of dropping ashes on clothing. Resident requires supervision and an apron. Record review of the Smoking and Tobacco/Snuff list of residents revealed Resident #44 was listed but did not have two (2) asterisks next to his name to indicate he required a smoking apron. On 10/16/24 at 10:00 AM, an observation revealed Resident #44 smoking with the supervision of Housekeeper #1 and it was observed that Resident #44 was not wearing a smoking apron while he was smoking a lit cigarette. It was observed that there were two small burn holes on the blanket covering Resident #44's legs. Interview with Housekeeper #1 on 10/16/24 at 10:04 AM, revealed the Social Service Director lets him know who requires a smoking vest, and confirmed he was unaware that Resident #44 needed a smoking vest. He then revealed he was unaware of a smoking list that reflected which residents required a smoking vest. In an interview with the Social Service Director on 10/16/24 at 10:10 AM, she confirmed Resident #44 was to wear a smoking vest and stated the housekeeper was unaware that the resident required a smoking vest. She confirmed that she updated the smoking list as changes occurred. In a review of the smoking list with the Social Service Director, she confirmed the smoking list did not reflect that Resident# 44 required a smoking vest. She then revealed that by not applying the smoking apron, the staff placed Resident #44 at risk for burning himself. An interview with the Minimum Data Set (MDS) Coordinator on 10/16/24 at 10:53 AM she revealed after review of the Smoking Assessment for Resident # 44 he should have been wearing a smoking apron and stated the smoking list should have been updated by the Social Service Director. Review of the Admission Record revealed the facility admitted Resident # 44 on 12/02/22 with a diagnosis of Nicotine Dependence. Record review of Resident # 44's Section C of the Annual MDS with an Assessment Reference Date of 10/14/24 revealed a Brief Interview for Mental Status (BIMS) score was 12, indicating the resident was moderately cognitively impaired.

Based on observation, staff interview, record review, and facility policy review, the facility failed to implement a smoking care plan for one (1) of 17 care plans reviewed. Resident #44 Findings include: A review of a facility policy titled, Comprehensive Care Plans, reviewed 10/23 revealed, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident An observation on 10/16/24 at 10:00 AM, revealed Resident #44 smoking with the supervision of Housekeeper #1. During the observation it was revealed that Resident #44 was observed to not be wearing a smoking vest while he was smoking a lit cigarette. A review of the care plan titled, Resident #44 is at risk for injuries related to smoking, revealed, Interventions: Resident #44 will require a smoking apron due to falling asleep while smoking initiated 5/28/24. In an interview with the Minimum Data Set (MDS) Coordinator on 10/16/24 at 10:53 AM, it was revealed after review of Resident #44's smoking care plan that staff were not following the care plan to wear a smoking apron. She then revealed the purpose of the care plan is to let staff know of the specific care a resident requires. Record review of the Admission Record revealed the facility admitted Resident # 44 on 12/02/22 with a diagnosis of Nicotine Dependence. Record review of Resident # 44's Section C of the Annual MDS with an Assessment Reference Date of 10/14/24 revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating the resident was moderately cognitively impaired.

Based on staff interview and record review, the facility failed to accurately complete an Annual Minimum Data Set (MDS) for a resident that had a serious mental illness for one (1) of 17 MDS reviews. Resident #2 Findings Include: The facility provided a statement on letterhead dated 10/16/24, It is the practice of this facility, Proper Name, to document data for the MDS 3.0 according to the instructions per the RAI (Resident Assessment Instrument) Manual. Record review of Resident #2's Preadmission Screening and Resident Review (PASRR) Summary of Findings Report dated 3/23/23 revealed under, Mental Health: . The individual meets criteria for having a diagnosis of mental illness as defined by PASRR with the primary diagnosis of Schizophrenia. Record review of the Transfer/Discharge Report revealed the facility admitted Resident #2 on 4/6/23 with a medical diagnosis of Schizophrenia. Record review of Resident #2's Annual MDS with an Assessment Reference Date (ARD) of 3/14/24 revealed under section A, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? No was documented. An interview with the MDS Nurse on 10/16/24 at 12:00 PM, confirmed she made an error when completing Resident #2's MDS and revealed she must have been rushing and missed it. She explained that the MDS should be accurate so that the residents get the care they need. An interview with the Director of Nursing (DON) on 10/16/24 at 12:11 PM, confirmed the MDS should be completed accurately so that the resident's individualized care needs were met.

Based on observation, staff interview, record review and facility policy review the facility failed to provide nail care for a resident dependent on staff for Activities of Daily Living (ADL's) as evidenced by brown substance under the resident's nails for one (1) of five (5) residents reviewed for ADL's. Resident # 48 Findings include: A review of the policy titled, Care of Fingernails for the Certified Nursing Assistant, dated 5/2019, revealed Policy: It is the purpose of this procedure to provide appropriate care according to current standards of practice. Care of fingernails will be provided by the Certified Nursing Assistant . An observation of Resident #48 on 8/08/23 at 1:00 PM, revealed the resident's fingernails to be approximately 1/4 inch long with an unknown dark brown substance under the nail beds. During an observation and interview of Resident #48's nails on 8/09/23 at 8:30 AM, with Licensed Practical Nurse (LPN) #1 and Certified Nursing Assistant (CNA)#1 revealed both CNA #1 and LPN #1 confirmed Resident #48's nails were approximately 1/4 inch long and had a brown substance under the fingernails. LPN #1 confirmed the nails were dirty and needed to cleaned and trimmed. LPN #1 then revealed a possible concern from not cleaning and trimming Resident #48's nails is the resident could scratch herself and would be at risk for infections. A review of the Progress Notes related to behavior monitoring, for the last 30 days for Resident #48, revealed no documentation of refusal of ADL care. A record review and interview with the Director of Nursing (DON) on 8/09/23 at 8:55 AM, revealed a possible concern from Resident #48's nails being long and having an unknown brown substance under them could place her at risk for an infection. A continued review of the last 30 days of Progress Notes and the daily CNA Behavior Monitoring for Resident #48 with the DON confirmed there was no documented refusals of care. An interview with the Infection Control Nurse on 8/09/23 at 2:51 PM, revealed failing to perform proper nail care could lead to accidents such as tears to the skin and and possible infections especially if the resident scratches or is a digger. A review of the Admission Record revealed that the facility admitted Resident #48 to the facility on [DATE] with diagnoses that included Bilateral Primary Osteoarthritis of Hip and Benign Neoplasm of the Pituitary Gland. Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) on 6/27/23, revealed that Resident #48 had a Brief Interview for Mental Status (BIMS) score of 4 which indicated that he was severely cognitively impaired. Section G revealed Resident #48 was extensive assistance of one staff for personal hygiene.

Based on observation, staff interview, record review, and facility policy review the facility failed to implement an Activities of Daily Living (ADL) care plan for one (1) of 20 care plans reviewed. Resident #48 Findings include: A review of the facility policy titled, Comprehensive Care Plans, revised 2/2017, revealed, 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 timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. #4 The Comprehensive Care Plan will describe at a minimum the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being . An observation of Resident #48 on 8/08/23 at 1:00 PM, revealed the resident's fingernails to be approximately 1/4 inch long with an unknown dark brown substance under nail beds. A review of the care plan for Resident #48, undated, revealed Focus: The resident has an ADL self-care performance deficit r/t (related to) fall . Intervention: .Personal Hygiene Routine: The resident requires total assist with personal hygiene . An interview with the Director of Nursing (DON) on 8/09/23 at 8:55 AM, confirmed staff were not following the ADL care plan and revealed the purpose of the comprehensive care plan is to direct the resident's care. A review of the Admission Record revealed that the facility admitted Resident #48 to the facility on [DATE] with diagnoses that included Bilateral Primary Osteoarthritis of hip and Benign Neoplasm of the Pituitary Gland. Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 6/27/23, revealed that Resident #48 had a Brief Interview for Mental Status (BIMS) score of 4 which indicated that he was severely cognitively impaired. Section G revealed Resident #48 was extensive assistance of one staff for personal hygiene.

Based on observation, staff interview, record review and facility policy review the facility failed to maintain an environment that is free from accident hazards as is possible when an office door behind the nursing desk was left open and unsecured with a gallon bottle of Hibiclens (chlorhexidine gluconate), a small bottle of Hydrogen peroxide, syringes with needles intact, two (2) boxes of butterfly needles, vacutainer's, and a bottle of covid testing solution sitting on a shelf visible from the doorway for one (1) of three (3) days of survey. Findings include: A review of the facility policy titled, Storage of Medication, revealed, Policy: Medications and biological's are stored safely, securely, and properly, following manufactures recommendations or those of the supplier. The medication is accessible only to licensed personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.Procedures: B.) Medication rooms, carts and medication supplies are locked when not attended by persons with authorized access . Record review of a typed document on facility letter head, undated and signed by the Administrator revealed Lexington Manor Senior Care does not have a policy for the storage of new/unused needles. During an observation of the room behind the open floor plan nursing desk that was centrally located between all three resident occupied hallways on 8/09/23 at 8:35 AM, revealed the door was open to the room. There was no staff present in the room. The State Agency (SA) observed a large metal shelf with a 1 gallon bottle of Hibiclens, 1 small bottle of hydrogen peroxide, an open storage carry case filled with different size unopened syringes with needles intact, vacutainers, 2 boxes of butterfly needles, and a bottle of covid test solution. All the named items were in view from the doorway entrance by the SA. The SA stood at the doorway entrance of the room and waited for staff to return. The SA observed several staff walk past the nursing desk, a resident and visitor sitting in the lobby on the couch, and residents sitting in the dayroom while waiting. Interview and observation with the Charge Nurse on 8/09/23 at 8:40 AM, confirmed the open room was her office. The Charge Nurse revealed the office door should have been shut and locked before leaving. She said there are confused residents in the facility and a resident or unauthorized person could possibly enter the room, accidentally ingest the Hibiclens or hydrogen peroxide, become sick, and get 1 of the needles and stick themselves with it. During an interview with the Director of Nursing (DON) on 8/09/23 at 8:55 AM, confirmed the door to the charge nurse office should not be left open because a resident could have possibly ingested the Hibiclens and could have possibly stuck themselves with a needle. On 8/09/23 at 3:00 PM, during an interview with the Staffing Nurse , revealed any room that has sharps or medicine related items stored in it should always be locked when not occupied staff. During a phone interview with the Pharmacy Consultant on 8/09/23 at 3:46 PM, he revealed that a room with medication and related items should always be locked when not occupied by authorized staff and revealed accidental ingestion of Hibiclens and hydrogen peroxide cause nausea and vomiting and gastric distress and puts residents/unauthorized people at risk for possible needle sticks or cutaneous (skin) injury related to items not being secured in the room . 47158

Based on observations, staff interview, record review and facility policy review, the facility failed to store narcotics in the permanently affixed compartment in the refrigerator and left an office door behind the nursing desk open and unsecured with a gallon bottle of Hibiclens (chlorhexidine gluconate), a small bottle of Hydrogen peroxide and a bottle of covid testing solution sitting on a shelf one (1) of three (3) days of survey. Findings Include: A review of the facility policy titled, Storage of Medication, revealed, Policy: Medications and biologicals are stored safely, securely, and properly, following manufactures recommendations or those of the supplier. The medication is accessible only to licensed personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.Procedures: B.) Medication rooms, carts and medication supplies are locked when not attended by persons with authorized access. A review of the facility policy titled, Medication Storage in the Facility,revealed . The scheduled two-five medications and other medications subject to abuse or diversion are stored in a permanently affixed, (double locked) compartment separate from all other medications or per state regulation . Nursing Station Area: Observation on 08/09/23 at 8:35 AM, revealed a room with the door open that was centrally located behind the nursing desk. There were no staff present in the room. The State Agency (SA) observed a large metal shelf with 1 one gallon bottle of Hibilcens, 1 small bottle of hydrogen peroxide, and a bottle of covid test solution. All items were in view from the doorway entrance. An observation and interview with the Charge Nurse on 8/09/23 at 8:40 AM, confirmed the open room was her office. She stated the office should have been shut and locked before leaving because there are confused residents in the facility and a resident or unauthorized person could have possibly entered the room and accidentally ingested the Hibiclens or hydrogen peroxide and become sick. An interview with the Director of Nursing (DON) on 8/09/23 at 8:55 AM, confirmed the door to the charge nurse office should not be left open because a resident could have possibly ingested the Hibiclens. An interview with the Staffing Nurse on 8/09/23 at 3:00 PM, confirmed any room that medicine related items stored in it should always be locked when not occupied with staff. A phone interview with the Pharmacy Consultant on 8/09/23 at 3:46 PM, revealed that a room with medication and related items should always be locked when not occupied by authorized staff. He revealed accidental ingestion of Hibiclens and hydrogen peroxide could cause nausea, vomiting, and gastric distress. He revealed that by not having the items in a secured room could put residents and all unauthorized people at risk for injury. Medication Room East: An observation and interview on 08/09/23 at 03:35 PM, of the medication room East with Licensed Practical Nurse (LPN) #1 revealed a refrigerator with 1 vial of floor stock Lorazepam two (2) milligram (mg)/milliliter (ml) in a small plastic bag on the shelf inside the refrigerator and nine (9) vials of Lorazepam 2 mg/ml in a small plastic bag on the shelf inside the refrigerator. LPN #1 confirmed that there was a lock box in the refrigerator that was secured, attached to the inside of the refrigerator and locked, where the narcotics that require refrigeration are stored. LPN #1 confirmed the vials of Lorazepam were not in the locked and secure box. An observation and interview on 08/09/23 at 03:40 PM, with the Director of Nursing (DON) confirmed that the Lorazepam was in plastic bags inside the refrigerator, not inside the locked box that was for narcotics needing refrigeration. When the DON attempted she was unable to open the lock box with the key, she stated that the key wouldn't open the box and that something was wrong with the lock. The DON stated that the medication nurses should have notified her that the lock was not working on the locked box so that she could have it fixed, but that no one had made her aware of a problem with the lock. An interview on 08/09/23 at 03:54 PM the Pharmacy Consultant confirmed that the secured lock box inside the refrigerator was for narcotics in need of refrigeration and that the Lorazepam should have been inside the locked box and secured inside the refrigerator. The Pharmacy Consultant confirmed a visit to the facility on [DATE] but did not check the Lorazepam in the refrigerator. 47157

Based on observation, staff interviews, and facility policy review, the facility failed to prevent the potential of a food borne illness as evidenced by food open and used after the expiration date and food stored with an open lid and past the use by date on one (1) of three (3) kitchen tours. Findings include: The facility policy titled, Storage of Refrigerated Food with a revised date of ,d+[DATE] revealed POLICY: The facility ensures the quality and safety and sanitation of refrigerated foods through accepted storage practices. PROCEDURE: . 4. Food taken out of original containers is put in a clean sanitized container with a tight-fitting lid. No food is left uncovered. 5. All opened foods are labeled with common name of food, date stored and use-by date. An observation on [DATE] at 10:20 AM, of the kitchen revealed in the walk-in refrigerator a half gallon container of buttermilk that was ,d+[DATE] (three-fourths) empty. The container had an expiration date of [DATE] and an opened date of [DATE]. An interview on [DATE] at 10:20 AM, with Dietary Staff #3 confirmed that the buttermilk had an expiration date of [DATE] and an opened date of [DATE] and was ,d+[DATE] empty. Dietary Staff #3 confirmed that the buttermilk could have been used in cooked recipes or served as a drink for all the residents. Dietary Staff #3 confirmed that serving this out-of-date buttermilk could have caused the residents to be sick. An observation on [DATE] at 10:40 AM, of the 4-door refrigerator revealed a metal container with a plastic lid that had one corner opened. The metal container was ,d+[DATE] (one-fourth) full of fruit cocktail that had an opened and used by date of [DATE]. An interview on [DATE] at 10:42 AM, with Dietary Staff #1, Dietary Staff #2 and Dietary Staff #3 confirmed that the metal container had a plastic lid with one corner opened, it was ,d+[DATE] full of fruit cocktail and had an opened and used by date of [DATE]. They also revealed that the fruit cocktail could have been served to all residents, including those on a pureed diet. Dietary Staff #2 and Dietary Staff #3 revealed that the facility policy was to discard anything opened in the refrigerator after seven (7) days and if it had been served to the residents after the 7 days in the refrigerator it could have made the residents sick. An interview on [DATE] at 11:10 AM, with the Registered Dietician (RD) revealed that if buttermilk was used after the expiration date, then it could have made the residents sick. The RD revealed it is the facility policy to discard food when expired. The RD revealed that food stored in containers in the refrigerator must be covered with no loose lids and used within 7 days. Record review of an in-service dated [DATE], titled Food Handling and Storage revealed the in-service was attended by Dietary Staff #1, #2 and #3. The in-service content included, Went over food handling and storage, to date items when you open, then open date. Make sure all containers have a date on them always first in and last out .

Based on observation, staff and resident interview, record review and facility policy review the facility failed to provide nail care for a resident who was dependent for her Activities of Daily Living (ADLs) as evidenced by a brown substance on top of and underneath all fingernails for one (1) of eight (8) residents observed for ADL care. Resident #26 Findings include: Review of the facilities policy titled, Shower-Tub Bath Policy dated 04/2017 revealed Policy It is the policy of this facility to promote cleanliness and comfort, to relax the resident, to stimulate circulation, and to observe the condition of the resident's skin . Procedure . 8. Wash hands properly. Review of the facilities policy titled, Care of Fingernails for the Certified Nursing Assistant dated 5/2019 revealed Policy: It is the purpose of this procedure to provide appropriate care according to current standards of practice. Care of fingernails will be provided by the Certified Nursing Assistant for all no-Diabetic residents .Procedure: . 4. Place the basin of warm water on the over -bed table. 5. Ask the resident to soak their hands in the basin 3-5 minutes. 6. Leaving one hand in the water, wash and rinse the resident's other hand. Dry the hand and place it on a dry towel. 7. Clean under the nails with the orange wood stick. 8 . Repeat with the other hand and 10. Trim the resident's nails using the nail clipper. Clip nails straight across. Shape and remove any rough edges using an emery board or nail file. An observation on 11/29/21 at 11:45 AM, revealed Resident # 26's fingernails were covered in a brown substance both on top of the nails and underneath the nails. An interview on 12/1/21 at 8:27 AM, with Licensed Practical Nurse (LPN) # 3 revealed that residents get a bath or whirlpool bath every day. LPN # 3 revealed that the residents get foot and nail care along with their baths unless they are diabetic and then the nurse does the nail and foot care. An interview on 12/1/21 at 8:30 AM, with Certified Nurse Assistant (CNA) # 1 revealed that residents get a bath every day with nail care. CNA # 1 revealed that the residents get a whirlpool bath three (3) days per week and on the other days they get a bed bath. CNA # 1 revealed that nail care is also done as needed. An observation and interview on 12/1/21 at 8:32 AM, revealed Resident #26 had a thick brown substance under her fingernails. Her fingernails were long and two of the fingernails had jagged edges. Resident # 26 stated, I want them cut but not to the bone. I scratch so I need some nails. An observation and interview on 12/1/21 at 8:37 AM, with Registered Nurse (RN) # 1, the Infection Control Nurse confirmed that Resident # 26's fingernails had dirt under them and they were jagged. An interview on 12/1/21 at 8:40 AM, with the Director of Nurses (DON) revealed that nail care should be done on whirlpool days and as needed, but if they are a diabetic then the nurse must do the trimming. The DON revealed that every shift there should be cleaning up and providing nail care as needed. The DON revealed that according to documentation the resident had not refused any care since 11/18/21. The DON revealed that it is the facility policy to provide nail care as needed and on whirlpool days. An interview on 12/1/21 at 8:53 AM, with CNA # 2 revealed that Resident # 26 received a whirlpool bath on 11/18/21, 11/22/21, and 11/29/21. CNA # 2 revealed that Resident # 26 gets a whirlpool bath on Mondays and Thursday and gets a bed bath on the other days and she has no documentation of refusals of bath or nail care by Resident # 26. She reported that the CNA that completes the whirlpool bath initials beside the resident's name indicating they completed the bath and if the resident refuses, then the CNA will write refused beside the resident's name. Review of the facility bath schedule documentation titled Monday/Thursday Baths **DO BEFORE LUNCH** Nail care must be done with each bath revealed that Resident # 26 received a whirlpool bath on Mondays and Thursdays. Resident # 26's name was listed on the Monday/Thursday Bath schedule documentation with a CNA's initials beside her name. CNA # 2 had signed and dated the document that Resident # 26 had received a whirlpool bath on 11/18/21, 11/22/21 and 11/29/21. Review of the facilities in-service conducted by the DON on 9/21/21 revealed TITLED AND DETAILED CONTENT OF INSERVICE: Nail care: See policy, Care of fingernails will be provided by the CNA for all non-diabetic residents. Report to the nurse any redness, irritation, broken skin, or loose skin or swelling. Nurse will perform cut and trim nails of diabetics. Record review of the CNA care guide for Resident # 26 revealed that the resident was to receive total assistance with ADL's. Record review of Resident # 26's Admission Record revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Minimum Data Set (MDS) for Resident #26, with an Assessment Reference Date (ARD) of 10/7/21, Section C had a Brief Interview for Mental Status (BIMS) score of 03, which indicated that the resident had severe cognitive impairment.

Based on observation, staff and resident interview, record review and facility policy review, the facility failed to ensure the proper labeling of oxygen tubing and humidifier bottles and failed to place signage on resident doors indicating oxygen was in use for 4 (four) of 6 (six) residents receiving oxygen therapy. Residents #2, #26, #28 and #36. Findings include: Review of the facility policy Oxygen Concentrator reviewed 2021 revealed, . Policy Explanation and Compliance Guidelines: .h. Place an oxygen warning sign on the resident's door. Review of the facility's policy titled, Nebulizer and Oxygen Tubing Storage Policy with a review date of 2021 revealed, POLICY It is the policy of this facility to decrease the risk of potential and/or direct exposure to infection diseases, air contaminants, and bacterial exposure. We will provide our residents with the proper storage and cleaning of respiratory equipment. PROCEDURE The facility will replace all respiratory tubing's weekly. These tubing's will be dated and stored in a dated plastic bag when not in use. The plastic bags will also be changed out weekly. The equipment will be cleaned at the time of tubing change out and PRN (as needed). Documentation will be placed on the resident's record weekly. Resident #2 An observation on 11/29/21 at 12:07 PM, revealed Resident #2 had no oxygen (O2) in use sign posted on the door. Record review revealed Resident #2 had a Physician's Order, dated 11/5/21, for O2 at 2 Liters (L), via Nasal Cannulas (NC), while awake. Resident #26: An observation on 11/29/21 at 12:24 PM, revealed Resident # 26 receiving O2 via NC at 2 liters with no O2 in use sign outside the resident's door. Record review of Resident # 26's Physician's Orders dated 7/29/21 revealed Change oxygen order to O2 at 2L per NC PRN (as needed) SOB (shortness of breath). Record review of Resident # 26's Admission Record revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/7/21, revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 03 which indicated Resident #26 had severe cognitive impairment. Resident # 28 An observation on 11/29/21 at 11:19 AM, revealed Resident # 28 receiving O2 via nasal cannula at 3 liters with no date or label on the O2 tubing and no O2 in use sign outside the resident's door. An interview on 11/29/21 at 11:20 AM, with Resident # 28 revealed, I don't know if they put a date on the tubing or not. Record review of Resident # 28's Physicians Orders revealed .Continue admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . O2 @ (at) 3L (liters) per NC (nasal cannula) continuous. Dx: (diagnosis) [CONDITION(S)] ([CONDITION(S)]). Record review of Resident # 28's Admission Record revealed Resident #28 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/9/21, revealed Resident #28 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #28 was cognitively intact. Resident #36: An observation on 11/29/21 at 11:58 AM, of Resident #36's oxygen concentrator revealed there was no date on the O2 humidifier bottle or the O2 tubing to indicate when it was last changed. There was no O2 in use sign posted on Resident #36's door. Record review, of the Electronic Health Record (EHR) revealed Resident #36 had a Physician's Order, dated 11/25/21, for O2 at 2L via NC as needed for shortness of breath. On 11/30/21 at 3:30 PM, an interview with Licensed Practical Nurse (LPN) # 2 revealed that it is the responsibility of the nurse starting the O2 on the resident for the first time to put the O2 in use sign outside the resident's door. On 12/1/21 at 8:27 AM, an interview with LPN # 3 revealed that it is the responsibility of the nurse admitting the resident on O2 or starting O2 to put the O2 in use sign on the resident's door. On 12/2/21 at 9:12 AM, an interview with the Director of Nurses (DON) revealed it is the responsibility of the nurse starting the residents O2 for the first time to put the O2 in use sign on the resident's room door. The DON revealed the O2 tubing should be dated and labeled weekly. The DON revealed that the need to change the O2 tubing is on the Treatment Administration Records (TARS) and usually triggers for night shift to complete. Review of the facility In-service Training completed on 8/25/21 by the DON revealed TITLE AND DETAILED CONTENT OF INSERVICE: .changing and date of tubing.

Based on observations, staff interviews, facility policy review, the facility failed to prevent the possible spread of infection by failure to clean and disinfect multi-use equipment between resident use for one (1) of four (4) days of survey. Findings include: Review of facility policy titled, Policy for Cleaning and Disinfection of Resident-Care Equipment, dated 3/31/21, revealed, Resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC (Centers for Disease Control) recommendations in order to break the chain of infection .Policy Explanation and Guidelines, 3b. Each user is responsible for routine cleaning and disinfection of multi-resident items after each use, particularly before use of another resident. An observation, on 11/29/21 at 12:15 PM, revealed CNA #5, entered and exited the rooms of Resident #31, Resident #14, and Resident #48 using a [NAME] V 3 Automated Vital Sign System to check the residents' blood pressure, without cleaning and disinfecting it between resident use. An interview on 11/29/21 at 12:20 PM, with CNA #5 confirmed that she did not clean the blood pressure machine between use on the residents. She stated that this could cause the residents to catch a cold or virus. She stated that she had in-service education on cleaning equipment and that she should have cleaned it between each resident. An interview, on 12/01/21 at 12:55 PM, with the Director of Nursing, (DON), revealed that not cleaning and sanitizing the blood pressure cuff between residents, could cause a major transfer of several infections from one resident to another. Record Review revealed CNA #5 attended an in-service titled, Cleaning of Patient Equipment - Including vital sign machine, dated 9/23/21.

Based on observation, staff interview, record review, and the facility policy review, the facility failed to remove discontinued medications from Medication Cart #2, for one (1) of two (2) medication carts observed. Findings include: Review of the facility's Discontinued Medication Review policy, with a revision date of ,[DATE], revealed, It is the policy of this facility to monitor the med cart and med room for discontinued medication and ensure that discontinued medications are destroyed timely. Review of the Nurses Meeting, [DATE] in-service record, revealed: Make sure carts are clean, everything open has a date and remove any discontinued medication on cart. Observation with Licensed Practical Nurse (LPN) #4, of Medication Cart #2 on [DATE] at 9:20 AM, revealed one (1) bottle of Robafen Cough Syrup dated [DATE], with the label instructions to give three (3) times a day for seven (7) days, one (1) bottle of Ondansetron dated [DATE], with label instructions to give every six (6) hours for two (2) days, one (1) bottle of Nystatin dated [DATE], with label instructions to give four (4) times per day for five (5) days, one (1) bottle of Geri-Tussin Cough Syrup dated [DATE], with instructions to give every four (4) hours as needed for cough, and two (2) bottles of Megestrol dated [DATE], with label instructions to give twice per day for 30 days. LPN #4 stated the medications were no longer in use and should not have been on the Medication Cart. She further stated it was all the nurses' responsibility to remove discontinued medications. Interview on [DATE] at 2:40 PM, with Staff Development Nurse LPN #3, revealed she didn't have an explanation as to why the discontinued medications were still on the medication cart. Interview on [DATE] at 3:00 PM, with the Pharmacy Consultant, revealed she told the facility nursing staff to destroy the medications as soon as they were expired.

Based on record review, staff interview and the facility policy review, the facility failed to revise the comprehensive care plans as evidenced by omission of heel protectors, as ordered by the physician to prevent possible skin breakdown, for one (1) of nine (9) resident records reviewed (Resident #4). Findings include: Review of the facility's Comprehensive Care Plan policy, revised 2/2017, revealed: The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS (Minimum Data Set) assessment. Review of the facility's Pressure Injury Prevention policy, dated 04/2017, revealed, To prevent the formation of avoidable pressure injuries, interventions will be documented in the care plan and communicated to all relevant staff. Review of the comprehensive care plans, potential for skin breakdown and self care deficit, dated 5/9/17, did not include applying heel protectors to Resident #4 while in bed. Observation of Resident #4 on 6/26/17 at 1:50 PM, revealed the resident did not have heel protectors while in bed. Review of Resident #4's June 2014 physician's orders [REDACTED]. On 06/26/17 at 2:55 PM, an interview with Registered Nurse (RN) #1 revealed, I do the care plans. The heel protectors should have been on the care plans. Review of the facility's face sheet revealed, the facility admitted Resident #4 on 9/24/13. Resident #4's [DIAGNOSES REDACTED]. Review of Annual Minimum Data Set with an Assessment Reference Date of 05/09/17, revealed Resident #4 had a brief Interview of Mental status (BIMS) score of 6, indicating the resident had severely impaired cognition.

Based on observation, record review, staff interviews, and the facility policy review, the facility failed to follow the care plan for the problem of [MEDICAL CONDITION] related to unspecified [MEDICAL CONDITION], for one (1) of nine (9) records reviewed for care plans, Unsampled Resident #D, as evidenced by not administering medications as ordered, which included, per policy and recommended guidelines, waiting at least five (5) minutes between eye drops. Findings include: Review of the facility's Comprehensive Care Plans policy, with a revision date of 2/2017, revealed, 9. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. Review of the Nursing 2016 Drug Handbook, page 233, for [MEDICATION NAME] eye drops, revealed, If more than on ophthalmic product is being used, give them at least 5 minutes apart. Page 468 of the Nursing 2016 Drug Handbook, for Dorzolamide ([MEDICATION NAME]) eye drops, revealed if more than one ophthalmic drug was being used, give at least 10 minutes apart. Review of the care plan for Unsampled Resident D revealed a problem onset date of 11/29/2016. The care plan stated Unsampled Resident D was legally blind and could only see shadows and outlines of figures, did not wear glasses, and had a history of [REDACTED]. Review of a Specific Medication Administration Procedures policy, dated 5/1/09, revealed Wait at least five (5) minutes before applying additional medications in the eyes. Observation on 6/27/17 at 8:30 AM, during medication pass to Unsampled Resident #D, revealed Licensed Practical Nurse (LPN) #5 instilled [MEDICATION NAME] 0.15%, one (1) drop, in each eye, followed by [MEDICATION NAME] eye drops, one (1) drop in each eye, without waiting between each medication, per policy and care plan of medications as ordered, which includes the correct procedures. Interview with LPN #5 on 6/27/17 at 8:32 AM, revealed she had not waited three (3) to five (5) minutes, per manufacture guidelines (and care plan to give medications as ordered), between each eye drop for Unsampled Resident #D. Interview on 6/27/2017 at 11:10 AM, with Registered Nurse (RN) #1 revealed she was the only care plan/assessment nurse and had missed some things on the care plan.

Based on observation, record review, staff interview and the facility policy review, the facility failed to prevent possible skin breakdown as evidenced by not applying heel protectors as ordered by the Physician for one (1) of nine (9) resident observations (Resident #4). Findings include: Review of the facility's Pressure injury Prevention policy, dated 04/2014, revealed: To prevent the formation of avoidable pressure injuries, interventions will be implemented in accordance with Physician orders. Review of the facility's Transcribing Physician order [REDACTED]. Review of the physician's orders [REDACTED]. On 06/26/17 at 1:50 PM, during an observation/interview of Resident #4, with Certified Nursing Assistant (CNA)#1 present, revealed Resident #4 laying supine in bed with bilateral heel protectors not in use. CNA #1 stated, They aren't in here, I should have gone to the laundry and got some. I put them on all the time, yes ma'am except today. On 06/26/17 at 3:20 PM, an interview with CNA #2 revealed, I did check his (Resident #4) heel protectors because they told me he didn't have them on, I don't know what time it was. He had them on then. On 06/26/17 at 2:10 PM, an interview with the Director of Nursing (DON) revealed, The orders should pull to the kiosk but the CNA's have a kardex (what the CNAs use as a care guide to care for the residents) they check everyday for changes. During an interview on 06/26/17 at 3:30 PM, the Administrator stated that the CNA's look at the kiosk, they only look at the kardex if there is a power failure. Everything for the care of the resident in on the kiosk and should be done. Review of the facility's face sheet revealed the facility admitted the resident on 9/24/13. Resident #4's [DIAGNOSES REDACTED]. Review of Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/09/17, revealed Resident #4 had a brief Interview of Mental status (BIMS) score of 6, indicating the resident had severely impaired cognition. The MDS revealed Resident #4 was totally dependent for bed mobility, and transfers to wheelchair. The resident was at risk for developing pressure ulcers and a Stage I present ulcer. The Care Area Assessment (CAA) for Resident #4 included a trigger for pressure ulcers.

Based on observation, record review, staff interviews, and the facility policy review, the facility failed to maintain a less than five (5) percent (%) medication error rate for two (2) of 34 medications administered, which caused an error rate of 5.8%, as evidenced by failure to wait at least five (5) minutes between eye drops for Unsampled Resident D. Findings include: Review of the facility's Specific Medication Administration Procedures policy, with an effective date of 05/01/2009, revealed K. Wait at least five (5) minutes before applying additional medication to the eye. Review of the Nursing 2016 Drug Handbook, page 233, for [MEDICATION NAME] eye drops, revealed, If more than on ophthalmic product is being used, give them at least five (5) minutes apart. Page 468 of the Nursing 2016 Drug Handbook, for Dorzolamide eye drops, revealed if more than one ophthalmic drug was being used, give at least 10 minutes apart. During medication pass observation on 6/27/2017 at 8:30 AM, Licensed Practical Nurse (LPN) #5 administered eye drops for Unsampled Resident D. LPN #5 placed one (1) drop of Dorzolamide ([MEDICATION NAME]) into each eye. LPN #5 then placed an addition drop of [MEDICATION NAME] at 8:32 AM, into each eye. The time sequence between eye medications was two (2) minutes. Review of the June 2017 Physician Orders, for Unsampled Resident D, revealed an order dated 2/10/2015, for [MEDICATION NAME] for one (1) drop into both eyes twice a day and an order dated 4/10/2015, for Dorzolamide ([MEDICATION NAME]) one (1) drop in each eye twice a day. Interview on 6/27/2017 at 8:35 AM, with LPN #5, revealed she had not waited five (5) minutes between the eye medications but stated she should have. Registered Nurse (RN) #2, was also present during the administration of the eye medications, and when asked if giving both eye medications close together was a problem, she stated, I don't even know what they were. Interview on 6/28/2017 at 2:40 PM, with LPN #3, revealed there had been no in-service specific for eye drop administration. Interview on 6/28/2017 at 3:00 PM, with the Registered Pharmacist Consultant, revealed the statement, I tell them to wait five (5) minutes between eye drops.

Based on observation, staff interview and facility policy review, the facility failed to prevent the possible spread of infection as evidenced by failure to wash hands when removing gloves, completing incontinent care without performing hand hygiene upon leaving resident's room, and when disposing of soiled care items in between residents for two (2) of six (6) care observations (Residents #1 and #2) Findings include: Review of the facility's Hand Hygiene Policy, with a revision date of 02/17, revealed staff involved in direct contact with the resident will perform proper hand hygiene procedures to prevent the spread of infection to residents. Hand hygiene refers to either hand washing or the use of an antiseptic hand rub, also known as alcohol based hand rub. The use of gloves does not replace hand hygiene. Wash hands after removing gloves. Antiseptic solution may be applied to hands after proper hand washing. Review of the facility's Hand Hygiene Table, not dated, revealed use either antimicrobial soap and water or alcohol based hand rub between residents, before applying and after removing protective equipment (PPE), including gloves, before and after handling clean or soiled linens, after assistance with personal body functions (elimination), and when in doubt. Observation during incontinent care on Resident #2, on 06/27/17 at 10:25 AM, with Certified Nursing Assistants (CNAs) #3 and #4, revealed CNA #3 removed her gloves after providing incontinent care, left the resident's room and went to the hallway where she obtained clean care supplies and a trash bag from the clean linen cart. CNA #3 took the clean items into Resident #1's room and left them on the night stand. She then went to another resident's room and retrieved a bedside table, then re-entered Resident #1's room to perform incontinent care, all without performing hand hygiene. Observation during incontinent care on Resident #1, on 06/27/17 at 10:40 AM, with CNAs #3 and #4, revealed them completing incontinent care on the resident. Each CNA bagged the soiled items in trash bags and carried them to the trash bins in the hallway. Each CNA lifted the trash can tops, disposed of the soiled bags and re-entered Resident #1's room without performing hand hygiene between residents or after disposing of soiled care items. Staff interview with CNA #3 and #4, on 06/27/17 at 2:30 PM, confirmed they failed to perform hand hygiene after disposing of used care items in the garbage cans in the hallway and prior to re-entering Resident #1's room. CNA #3 confirmed she did not perform hand hygiene after assisting with incontinent care on Resident #2 or before obtaining clean care supplies prior to entering Resident #1's room to perform incontinent care. Staff interview with License Practical Nurse (LPN), Staff Development Nurse/Infection Control Nurse #3, on 06/28/17 at 10:00 AM, confirmed the break in infection control when CNA #3 and #4 failed to perform hand hygiene after they disposed of soiled care items used during incontinent care on Resident #1, and when CNA #3 failed to perform hand hygiene after she assisted CNA #4 with incontinent care on Resident #2, then left the room to obtain clean supplies from the clean linen cart, which she took into Resident #1's room to prepare for incontinent care. LPN #3 stated the most important thing for them to do is wash their hands, especially when in doubt and to always wash their hands when gloves are removed. Interview with the Director of Nursing on 6/26/17 at 11:25 AM, confirmed CNAs should wash their hands when gloves are removed and when entering and exiting the resident's rooms. Review of the facility's face sheet revealed, the facility admitted Resident #1 on 10/25/16. Resident #1's [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of the Admission Assessment, dated 04/17/17, revealed Resident #1 had a Brief Interview Mental Status (BIMS) score of 3, indicating the resident had severe cognitive impairment Review of the facility's face sheet revealed, the facility admitted Resident #2 on 04/08/08. Resident #2's [DIAGNOSES REDACTED].#2 had a BIMS score of 7, indicating the resident had severe cognitive impairment.

Based on record review, staff interview and the facility policy review, the facility failed to accurately post daily staffing as evidenced by posted staffing included scheduled, but not actual working staff for one (1) of three (3) days of survey. Findings include: Review of the facility's Posting Direct Care Daily Staffing Numbers policy, dated 04/2017, revealed: Within two (2) hours of the beginning of each shift the number of available staff will be posted. The posting will include the nursing staff working during that shift. On 6/28/17 at 10:40 AM, a review of the facility's Daily Nurses Staffing Form for 06/28/17, revealed the facility included the actual staff hours worked for 24 hours: Day shift 7:00 AM-7:00 PM and Evening Shift 7:00 PM-7:00 AM. On 6/28/17 at 10:50 AM, an interview with the Director of Nursing (DON) revealed that Licensed Practical Nurse (LPN) #3 documents the daily staffing sheet. On 6/28/17 at 10:55 AM, an interview with LPN #3 revealed she had been told the year before that it was okay to document the staffing sheet for the whole time period and if it wasn't right just to mark it out. On 6/28/17 at 11:00 AM, an interview with the Administrator revealed, We had two (2) complaint surveys about staffing and they were okay.

Based on record review, resident interview, staff interview and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) assessment related to Activities of Daily Living (ADL) for Residents #1, #9, #10, #12; Hospice Services for Resident #13, for five (5) of 13 MDS assessments reviewed. Findings include: Review of the facility's Minimum Data Set (MDS) 3.0 Assessment Completion, Transmission and Validation policy, dated 07/14, revealed the facility uses an interdisciplinary approach to complete a comprehensive assessment of each resident's functional capacity. Members of the Interdisciplinary Team (IDT) will complete their assigned MDS sections and corresponding Care Area Assessments (CAA) within the specifications and timelines established by the Resident Assessment Instrument (RAI) Manual. Each IDT member is expected to use the RAI Manual as a resource during the assessment coding process. A review of the Centers for Medicare and Medicaid (CMS) RAI 3.0 Manual, dated 10/15, revealed under the section 1.3 Completion of the RAI, an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Sources must include the resident, direct care staff on all shifts, the resident's medical record, physician and family. Information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy by the IDT completing the assessment. A review of the RAI 3.0 Manual under Section G0110 Activities of Daily Living (ADL) Assistance, revealed to code total dependence, the resident must be unwilling or unable to perform any part of the activity over the entire 7 day look-back period. Resident #1 A review for Resident #1 revealed a quarterly MDS assessment with an Assessment Reference Date (ARD) of 05/16/16. Section G 120 revealed Resident #1 was totally dependent with bathing and required two (2) or more persons for physical assistance. Review of the five (5) day admission MDS assessment with an ARD of 02/24/16 revealed Section G 120 was also coded totally dependent of two persons with bathing. Review of the ADL charting during the seven (7) day look-back period (05/10/16 - 05/16/16) for the quarterly 5/16/16 MDS assessment, revealed Resident #1 required only physical help in part of bathing with assist of one person on 05/13/16. A review of the ADL charting during the 7 day look-back period (02/19/16-02/24/16) for the 2/24/16 MDS, revealed Resident #1 required physical help in part of bathing with one person on 02/20/16. Interview on 08/17/16 at 2:00 PM, with Certified Nursing Assistants (CNA) #6 and #7 revealed that Resident #1 does not assist staff when he gets his bath. CNA #6 stated He is dependent on 2 staff for bathing. Interview on 08/17/16 at 6:00 PM, with egistered Nurse (RN) #1, revealed that she completed the quarterly MDS assessment for Resident #1 and had coded total dependence for bathing with two (2) persons assist. RN #1 confirmed that the RAI Manual is used as a reference guide when completing the MDS assessment. RN #1 further revealed that total dependence cannot be coded unless the resident has required total assist from staff every shift during the 7 day look-back period of the MDS assessment completed. Review of the Face Sheet revealed the facility admitted Resident #1 on 02/17/16, with [DIAGNOSES REDACTED]. A review of the most recent quarterly MDS assessment with an ARD of 05/16/16, revealed Resident #1 scored 8 on the Brief Interview for Mental Status (BIMS), which indicated moderately impaired cognitive skills. Resident #9 Record review for Resident #9 revealed a quarterly MDS assessment with an ARD of 07/05/16. Section G 120 revealed Resident #9 coded as being totally dependent with bathing and required two (2) or more persons for physical assistance. A review of the ADL charting during the seven (7) day look-back period (06/29/16 - 07/15/16) for the quarterly 7/5/16 MDS assessment revealed Resident #9 required physical help limited to transfer only with assist of one (1) person for bathing on 06/30/16; physical help in part of bathing with one (1) staff assist on 07/02/16 and 07/04/16. Interview on 08/16/16 at 8:35 AM, with Resident #9 revealed she is able to wash herself but the CNA washes her back because I can't reach back there. Interview on 08/16/16 at 3:15 PM, with CNA #1 revealed Resident #9 required limited assistance of one (1) person for bathing. CNA #1 further revealed that Resident #9 receives her bath on the night shift. Interview on 08/17/16 at 4:45 PM, with RN #2 confirmed Resident #9 was not dependent for bathing. RN #2 revealed Resident #9 can do a lot for herself. RN #2 stated staff sets up for bathing, stays with her while she bathes, and probably assists with washing areas that she can't reach. Interview on 08/17/16 at 6:05 PM, with RN #1, revealed that Resident #9 was not dependent with bathing and required two (2) staff for assistance. RN #1 confirmed that she completed the MDS assessment for Resident #9. RN #1 further revealed that she codes the MDS assessment for ADL care based on the information that the CNAs chart in the computer. A review of the Face Sheet revealed the facility readmitted Resident #9 on 07/11/13, with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment with an ARD of 07/05/15, revealed Resident #9 scored 15 on the Brief Interview for Mental Status (BIMS), which indicated no cognitive impairment. Resident #10 A review of the annual MDS assessment with an ARD of 07/11/16, for Resident #10, revealed Section G 120 was coded as total dependent of two (2) of more staff for bathing. A review of the ADL charting during the seven (7) day look-back period (07/05/16 - 07/11/16) for the annual MDS assessment revealed Resident #10 required supervision and setup help only with bathing on 07/11/16. Interview on 08/17/16 at 4:40 PM, with RN #2, revealed Resident #10 was not totally dependent with bathing. Interview on 08/17/16 at 6:08 PM, RN #1 confirmed by stating No regarding whether Resident #10 was totally dependent upon two staff for bathing. RN #1 stated the MDS was coded wrong for bathing. Review of the Face Sheet revealed the facility admitted Resident #10 on 03/17/08 with [DIAGNOSES REDACTED]. A review of the annual MDS assessment with an ARD of 07/11/16, revealed Resident #10 scored 15 on the BIMS, which indicated Resident #10 was cognitively intact. Resident #12: Review of Resident #12's MDS with an ARD of 5/31/16, Section G 120, coded the resident with total dependence with the assistance of two (2) or more persons for bathing. The MDS with an ARD of 3/4/16, coded Resident #12 for total assistance with two (2) or more persons required for bathing. Record review of the Certified Nursing Assistants (CNA) computer documentation during the seven (7) day look-back period for the 3/4/16 MDS, from 2/26/16 through 3/4/16, revealed only three (3) of the seven (7) days reflected total assistance required for Resident #12's bathing. Computer documentation for the Quarterly 5/31/16 MDS, dates of 5/25/16 through 5/31/16, revealed only four (4) days where Resident #12 required two (2) person physical assist with bathing. An observation and interview of Resident #12 on 8/17/16 at 11:30 AM, revealed Resident #12 lying in her bed. She stated she was not feeling well today. She said she is normally up, washes her face before every meal, ambulates about the facility using her walker and usually bathes at the sink herself. An interview on 8/17/16 at 12:00 PM, with Registered Nurse (RN) #2, who serves as Monday through Friday, day charge nurse, revealed Resident #12 likes to stand at the sink and wash her face, brush her teeth and bathe. RN #2 said Resident #12 is not totally dependent upon staff for ADLs most days. In an interview on 8/17/16 at 6:00 PM, RN #1 revealed Resident #12 is not totally dependent for ADLs, and could help with some assistance from staff. She said she had miscoded the MDS for bathing on the Annual MDS assessment dated [DATE] and again on the Quarterly assessment dated [DATE]. The facility admitted Resident #12 on 7/3/12. Resident #12's [DIAGNOSES REDACTED]. Review of the MDS with an ARD of 5/31/16, revealed Resident #12 had a BIMS score of 15, indicating the resident was cognitively intact. Resident #13: Record review revealed Resident #13's physician orders [REDACTED].>Review of the MDS assessments with ARDs of 9/30/15 and 12/21/15 did not reflect Hospice Care Services. An observation of Resident #13, with CNA #6 on 8/17/16 at 12:00 PM, revealed the resident sleeping soundly on and air mattress with the head of the bed slightly elevated and several positioning devices noted under her coverings. CNA #6 stated Resident #13 received Hospice services daily Monday through Friday. An interview with RN #1, the MDS Coordinator, revealed her acknowledgment of a coding error on both the 9/30/15 and 12/21/15 MDS submissions. She stated she failed to code Hospice services on both MDS assessments. Review of the facility's face sheet revealed, the facility admitted Resident #13 on 4/4/06. Resident #13's [DIAGNOSES REDACTED]. Review of the MDS with an ARD of 5/31/16, revealed Resident #13 had a BIMS score of 3, indicating the resident had severely impaired cognition.

Based on record review, staff interview and facility policy review, the facility failed to revise the comprehensive care plan to reflect the conditions of the resident related to Foley Catheter Care and Oxygen use for Resident #4, and bathing for Residents #2, #9 and #10, for four (4) of the 13 resident records reviewed. Findings include: A review of the facility's Care Plans-Comprehensive policy, dated June 2015, revealed the facility develops a plan of care through the interdisciplinary team to coordinate and communicate care approaches and goals for the resident related to clinical [DIAGNOSES REDACTED]. Outcome objectives are reflective and the facility staff uses the objectives to monitor the resident's progress. The purpose includes the development and modification based on the resident's status. Review of the facility's Comprehensive Care Plans policy, dated 07/14, revealed the facility develops a comprehensive plan of care for each resident that includes measurable objectives and timetables to a meet a resident's medical, nursing and mental/psychosocial needs that are identified in the comprehensive assessment. The care plan will be reviewed and revised quarterly, annually, with significant change of status and as needed to enhance the residents ability's to meet his/her objectives. The facility also provided a document signed by the Administrator stating, It is our facility's policy to use the guidance from the CMS RAI manual for care planning. The RAI Manual, dated April 2012, provided by the facility, revealed under section 4.4: Facilities use the findings from the comprehensive assessment to develop an individualized care plan to meet each resident's needs. Resident #4 Record review of Resident #4's physician's orders [REDACTED]. An order, dated 7/28/16, noted to irrigate Foley catheter with 30 to 60 milliliters (ml) of sterile water as needed for leakage or obstruction. Review of Resident #4's incontinent care plan with an onset date of 7/05/16, revealed, the elder (resident) is continent of bowel, and had a Foley catheter. A care plan for the Stage 4 sacral wound dated 7/5/16, documented Resident #4's Foley catheter. There was no care plan intervention for providing catheter care daily and as needed or for the irrigation of the Foley for either care plan. Record review of Resident #4's physician's orders [REDACTED]. Review of Resident #4's care plan for shortness of breath, dated 7/5/16, did not reveal an intervention/approach for the resident to have two (2) liters of oxygen by nasal cannula as needed. Interview with Registered Nurse/Minimum Data Set Nurse (RN/MDS) #1 on 8/16/16 at 3:58 PM, confirmed she should have revised the care plans to reflect the physician's orders [REDACTED].#4's condition. She said she is responsible for initiating and updating the residents care plans. Review of the facility's face sheet revealed the facility readmitted Resident #4 on 7/05/15, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference date (ARD) of 7/12/16, revealed Resident #4 had a Brief Interview of Mental Status (BIMS) score of 8, indicating Resident #4 had moderate cognitive impairment. Resident #2 Review of the quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 07/11/16 for Resident #2, Section G 120 revealed Resident #2 was totally dependent with bathing and required two (2) or more persons for physical assistance. A review of the comprehensive care plan for Resident #2 revealed a problem related to the resident's need for assistance with Activities of Daily Living (ADL) due to weakness secondary to [MEDICAL CONDITIONS] and [MEDICAL CONDITION],dated 11/5/15. Interventions for this problem did not address bathing. Interview on 08/17/16 at 6:08 PM, with Registered Nurse (RN) #1 revealed the MDS assessment should match the care plan. Review of the Face Sheet revealed the facility readmitted Resident #2 on 01/09/14, with [DIAGNOSES REDACTED]. A review of the most recent quarterly MDS assessment with an ARD of 07/11/16, revealed Resident #2 scored 15 on the BIMS, which indicated no cognitive impairment. Resident #9 Review of the quarterly MDS assessment with an ARD of 07/05/16 for Resident #9 revealed Section G 120 was coded totally dependent with bathing with two (2) or more persons for physical assistance. A review of the comprehensive care plan for Resident #9, dated 4/11/16, revealed a problem that addressed resident requiring limited assistance with ADL related to weakness. Interventions for that problem did not address bathing for Resident #9. Review of the Face Sheet revealed the facility readmitted Resident #9 on 07/11/13, with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment with an ARD of 07/05/15 revealed Resident #9 scored 15 on the BIMS, which indicated the resident was cognitively intact. Resident #10 Review of the annual MDS assessment with an ARD of 07/11/16, for Resident #10, revealed Section G 120 was coded as total dependent of two (2) of more staff for bathing. A review of the comprehensive care plan for Resident #10, dated 7/11/16, revealed a problem to address the resident requiring limited assistance with ADLs related to an old [MEDICAL CONDITION]. Interventions for this problem did not address bathing for Resident #10. A review of the Face Sheet revealed the facility admitted Resident #10 on 03/17/08, with [DIAGNOSES REDACTED]. Review of the annual MDS assessment with an ARD of 07/11/16, revealed Resident #10 scored 15 on the BIMS, which indicated the resident was cognitively intact.

Based on record review, staff interview and facility policy review, the facility failed to maintain accurate medical records for two (2) of 13 resident records (Residents #2 and #7). Findings include: Resident #2 Record review revealed that Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 01/23/2012 revealed a Brief Interview for Mental Status of 0, which indicated That Resident #2's cognitive status was severely impaired. Record review revealed an alert form notifying staff that Resident #2 had no known allergies [REDACTED]. Review of the physician's orders [REDACTED]. Review of Immunity records revealed that on 03/19/2013 Resident #2 the PPD was placed for Resident #2. On 03/22/2013 documentation of the result of the PPD was 00 milliliters. Record review revealed Resident #2's care plan did not address allergies [REDACTED]. Review of the physician's orders [REDACTED]. (calories) 45 cc(centimeters)/(per) HR (hour) per pump. Review of Resident #2's care plan dated 05/01/2013 revealed Nothing by mouth. Two Cal (calories) HN at 45 ml (milliliters)/hr per pump. Resident #2's care plan was not updated to reflect current orders for feeding. Interview on 07/11/2013 at 9:55 a.m. with Registered Nurse #1 revealed, "Those are just computer input errors. The care plans were updated just not printed for the chart."Review of Physician orders [REDACTED]. Review of the Physician order [REDACTED]. Resident #7 Record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Review Date (ARD) of 05/22/2013, revealed a Brief Interview for Mental Status score of 0, which indicated that Resident #7's cognitive status was severely impaired. Review of the functional status section of this MDS coded that Resident #7 required assistance with one (1) and two (2) persons with activities of daily living (ADL), and was always incontinent of bowel and bladder. Review of the Resident #7's Minimum Data Set, with an Assessment Reference Date of 05/22/2013, did not code a Stage I or higher pressure sore. Review of the Departmental Notes revealed the Stage IV Pressure Ulcer was on found on 06/11/2013 and noted, "New tx (treatment) order to clean Stage IV to right buttock." Review of Resident #7's July 2013 physician's orders [REDACTED]." Review of the written orders revealed an order, dated 07/01/2013 at 4:00 p.m., for "[MEDICATION NAME] 500 mg PO (by mouth) QD (every day) X (times) 10 days. [MEDICATION NAME] 750 mg IV (intravenous) QD X 7 days draw trough level on 07/5/13 R/T (related to) C&S (Culture and Sensitivity) results." Review of Resident #7's care plan for pressure ulcer dated 02/26/2013 did not include any new or updated/revised care plan approaches for the Stage IV Pressure Ulcer found on 06/11/2013 except for approach on 07/07/2013 which stated "May insert 16 fr (French)/5 cc Foley cath (catheter) X (times) 30 days R/T (related to) Stage 4." Review of Resident #7 care plan for incontinence, dated 02/26/2013 did not address how often the resident was to be checked for incontinence. Resident #7's care plan revealed, "Elder is incontinent of bowel and bladder R/T (related to) severely impaired cognitive status with no recognition of need to void. Intervention-peri-care after incontinent episodes." Review of Resident #7 care plan revealed no nursing care plan initiated for [MEDICAL CONDITION] of the right buttock. Review of Resident #7 weekly skin audits revealed inconsistencies with documentation; 06/13/2013 pressure ulcer (yes), 06/21/2013 pressure ulcer (no) and 06/27/2013 pressure area (yes). There was also no documentation of treatment daily to right buttock between 06/11/2013 through 06/23/2013. Review of July 2013 physician's orders [REDACTED]. If any changes, chart in nurse's notes and notify the MD/RP (doctor/responsible party)." Review of Resident #7 physician orders [REDACTED]." Review of Resident #7 weekly body audits revealed the following documentation: 06/6/2013 at 12:42:00 a.m. pressure area (no) 06/13/2013 at 7:13:00 a.m. pressure area (yes) pressure area location, size & (and) date of occurrence: (see MAR). June 2013 eMar (Medication Administration Record) revealed no documentation of pressure area. 06/21/2013 at 12:41:00 a.m. pressure area (no). 06/27/2013 at 2:53:00 a.m. pressure area (yes) pressure area location, size & date of occurrence: right buttock. Review of the weekly skin reports dated with 06/14/2013 (written over 06/13/2013) with documentation; size (cm) 4 X 3 X<.2. Review of Resident #7 picture dated 06/19/2013 revealed documentation of measurements; 4 X 5 right buttock, but there was no documentation of treatment. Interview with Licensed Practical Nurse (LPN) #2/Treatment Nurse on 07/11/2013 at 3:40 p.m. revealed, LPN #2 stated, "I don't know why there's no documentation on the week of 06/18/2013. I know I did it. I will check my records and bring you a copy of that." Interview with Licensed Practical Nurse (LPN) #2 on 07/11/2013 at 4:40 p.m. revealed, LPN #2 stated, "Here is your copy of the pictures. The black and white copies don't show as good; so, I brought the original so you could compare them and here is a copy of the treatment sheet. That date on there is within a week."

Based on record review, staff interview and facility policy review, the facility failed to revise residents care plans to reflect changes in care and include measurable interventions for three (3) of 13 residents (Resident #2, #3, and #7). Findings include: Resident #2 Record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 01/23/2012, revealed a Brief Interview for Mental Status score of 0, which indicated that Resident #2's cognitive status was severely impaired. Record review revealed that Resident #2 had NKA (no known allergies [REDACTED]. Review of the physician's orders [REDACTED]. Review of Immunity records revealed that on 03/19/2013 Resident #2 the PPD was placed for Resident #2. On 03/22/2013 documentation of the result of the PPD was 00 milliliters. Record review revealed Resident #2's care plan did not address allergies [REDACTED]. Review of the physician's orders [REDACTED]. (calories) 45 cc(centimeters)/(per) HR (hour) per pump. Review of Resident #2's care plan dated 05/01/2013 revealed Nothing by mouth. Two Cal (calories) HN at 45 ml (milliliters)/hr per pump. Resident #2's care plan was not updated to reflect current orders for feeding. Interview on 07/11/2013 at 9:55 a.m. with Registered Nurse #1 revealed, "Those are just computer input errors. The care plans were updated just not printed for the chart." Resident #3 Record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/26/2013 revealed a Brief Interview for Mental Status score of 99, which indicated that Resident #3 was not able to complete the interview. Observation on 07/10/2013 at 4:00 p.m. revealed Resident #3 was at the nurses desk hollering at peers and staff that came by saying, "Get away, get outta here" while reaching and waving others away. Interview on 07/10/2013 at 4:04 p.m. with Certified Nurse Aide (CNA) #1 regarding the behaviors exhibited by Resident #3 revealed, "She gets like that and will throw food. That's why they brought her from the kitchen and put her in the hallway." Observation on 07/10/2013 at 4:18 p.m. revealed Resident #3 was in the hallway with a grip on the Director of Nursing (DON) hand. Resident #3 was hollering and yelling at staff. Observation on 07/10/2013 at 5:45 p.m. revealed Resident #3 was in her room hollering at staff and throwing her food. Review of Resident #3's care plan revealed a care plan with problem onset date of 04/26/2013 for "(Ms. Name of Resident)) can be resistive to care, such as refusing medication, refusing rest periods when she is overtired, refusing baths and difficult to redirect especially late in the day..." The approaches did not address Resident #2's behavior before she become overly agitated. Interview with the Social Service Director (SSD) on 07/11/2013 at 1:20 p.m. revealed the SSD stated, "I'm new but the facility has an outside source that monitors psychoactive meds (medications) and the staff do sheets for monitoring of the behavior." The SSD acknowledged she understands the need to rule out other factors with the increased level of behavior exhibited by Resident #3. Resident #7 Record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Review Date (ARD) of 05/22/2013, revealed a Brief Interview for Mental Status score of 0, which indicated that Resident #7's cognitive status was severely impaired. Review of the functional status section of this MDS coded that Resident #7 required assistance with one (1) and two (2) persons with activities of daily living (ADL), and was always incontinent of bowel and bladder. Review of the Resident #7's Minimum Data Set, with an Assessment Reference Date of 05/22/2013, did not code a Stage I or higher pressure sore. Review of the Departmental Notes revealed the Stage IV Pressure Ulcer was on found on 06/11/2013 and noted, "New tx (treatment) order to clean Stage IV to right buttock." Review of Resident #7's July 2013 physician's orders [REDACTED]." Review of the written orders revealed an order, dated 07/01/2013 at 4:00 p.m., for "[MEDICATION NAME] 500 mg PO (by mouth) QD (every day) X (times) 10 days. [MEDICATION NAME] 750 mg IV (intravenous) QD X 7 days draw trough level on 07/5/13 R/T (related to) C&S (Culture and Sensitivity) results." Review of Resident #7's care plan for pressure ulcer dated 02/26/2013 did not include any new or updated/revised care plan approaches for the Stage IV Pressure Ulcer found on 06/11/2013 except for approach on 07/07/2013 which stated "May insert 16 fr (French)/5 cc Foley cath (catheter) X (times) 30 days R/T (related to) Stage 4." Review of Resident #7 care plan for incontinence, dated 02/26/2013 did not address how often the resident was to be checked for incontinence. Resident #7's care plan revealed, "Elder is incontinent of bowel and bladder R/T (related to) severely impaired cognitive status with no recognition of need to void. Intervention-peri-care after incontinent episodes." Review of Resident #7 care plan revealed no nursing care plan initiated for [MEDICAL CONDITION] of the right buttock. Review of Resident #7's culture report, dated 07/01/2013, revealed a routine culture of Resident #7's right (R) buttock collected on 06/27/2013 was called in to the facility with critical value for [MEDICAL CONDITION]. Review of facility's policy entitled "Care Plans-Comprehensive", not dated, noted, "A comprehensive care plan shall be developed for each resident that includes measurable objections and timetables to meet the residents medical, nursing and psychological needs. The comprehensive care plan has been designed to a. incorporate identified problem; b. incorporate risk factors associated with identified problems; c. build on residents strength; d. reflect treatment goals and objectives in measurable outcomes; e. identify the professional services that are responsible for each element of care; f. prevent declines in the resident's functional status and/or functional levels... Care plans are revised as changes in the resident's condition dictates."

Based on observation, staff interview, record review and facility policy review, the facility failed to assess and prevent the development of a Stage IV pressure ulcer for one (1) of two (2) residents observed with a wound (Resident #7). Findings include: Resident #7 Record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Review Date (ARD) of 05/22/2013, revealed a Brief Interview for Mental Status score of 0, which indicated that Resident #7's cognitive status was severely impaired. Review of the functional status section of this MDS coded that Resident #7 required assistance with one (1) and two (2) persons with activities of daily living (ADL), and was always incontinent of bowel and bladder. Review of Resident #7 faxed copy from Registered Nurse #3 (outside source wound nurse) of the Wound Care "Skin Integrity" Evaluation dated 06/20/2013 documented, "Wound right buttock onset 6/11/2013, assessment date 06/20/2013, exudates min (minimum). Full thickness, pressure ulcer Stage IV size (L x W cm) 4.00 x 3.00 depth UTD (unable to determine), drainage consistency serous; facility acquired. Progression of the wound documentation on 07/10/2013 revealed wound; bed; 70% dark soft necrotic tissue, 30% adherent yellow slough. Wound size 9.00 x 7.00 depth UTD, no change in drainage or treatment intervention." Review of Resident #7's treatment notes, dated 06/11/2013 at 5:35 p.m., noted, "New TX (treatment) order to clean Stage IV to right buttock with NS (normal saline), pat dry, apply collagen Hydrogel ET (and) cover with dressing daily until healed. RP (name) aware, Has unstageable Stage IV to right buttock measuring 4 X 3 X<.2 (4 by 3 by less than .2) and is 90% yellow and 10% dark purple around wound edges, no odor or drainage noted. Elder will be turned and repositioned Q 2 hrs per staff, incontinent care provided per staff." There was no documentation on Resident #7's record of the Stage IV pressure area to Resident #7's right buttock before 06/11/2013. Review of July 2013 physician orders [REDACTED]. If any changes, chart in nurse's notes, and notify the MD/RP (doctor/responsible party)." Review of Resident #7 weekly body audits revealed the following documentation: 06/6/2013 at 12:42 a.m. pressure area (no) 06/13/ 13 at 7:13 a.m. pressure area (yes) pressure area location, size & (and) date of occurrence: (see MAR). June 2013 eMar (Medication Administration Record) revealed no documentation of pressure area. 06/21/2013 at 12:41:00 a.m. pressure area (no) 06/27/2013 at 2:53 a.m. pressure area (yes) pressure area location, size & date of occurrence: right buttock. Review of Resident #7's July 2013 physician's orders [REDACTED]." Review of Resident #7 care plan for pressure ulcer, dated 02/26/2013, revealed there were no approaches for a Stage IV pressure area except on 07/07/2013 - May insert 16 fr(French)/5 cc Foley cath (catheter) X 30 days R/T (related to) Stage 4." Observation and interview during wound care with Licensed Practical Nurse (LPN) #2, Registered Nurse (RN)/Wound Consultant (outside source) #3 present and assistance from Certified Nurse Aide (CNA) #4 on 7/10/13 at 2:35 p.m. revealed, dressing with small brownish stain, on right buttock (hip) area dated 07/09/2013. The dressing was removed and revealed a large wound with areas of slough, dark black patches areas. LPN #2 stated "This is a new area. She didn't come in with it." The area was cleaned with normal saline, pat dry and collagen and Hydrogel applied with a tongue blade to wound and dry dressing applied, secured with tape. LPN #2 stated,"We have the air mattress. She's on Vitamin C and she is getting turned every two (2) hours." LPN #2 stated, "No it wasn't this size when I started treating it. I can get the measurement for you." RN #3 stated "You know it usually get bigger before it get better." Observation and interview during wound care with measurements with Licensed Practical Nurse (LPN) #2 on 07/11/2013 at 2:20 p.m. revealed when the dressing on the right buttock was removed a strong foul odor was noted. The wound measurements were 9.5 cm(long) X (by) 8 cm (centimeters) (wide) X 1.5 cm (deep), no drainage. LPN #2 stated, "I smell it. There is an odor now, and her infection may be back." CNA #4 was at the bedside assisting with turning and positioning during wound care. The area was cleaned with normal saline, pat dry and collagen and Hydrogel applied with a tongue blade to wound bed and dry dressing applied, secured with tape. Review of Resident #7 nurse's notes, dated 06/11/2013 at 10:00 p.m., noted, "Elder receives TX (treatment) to area on right hip as ordered." Review of Resident #7's pictures and measurements of the right buttock wound revealed the following progression of the wound, "122 B (Resident #7 name) 06/11/2013 right (r inside of a circle) buttock 43. 122 B (Resident #7 name) 06/19/2013 (right) line drawn through the word hip, buttock 45. 122 B (Resident #7 name) 06/24/2013 (right) buttock 56. 122 B (Resident #7 name) 06/27/2013 (right) buttock 86.5. 122 B (Resident #7 name) 07/04/2013 (right) buttock 97. No changes were made in the treatment of [REDACTED]. There was no documentation of treatment between 06/11/2013 through 06/24/2013 in the treatment notes. Review of Resident #7's treatment notes, dated 06/24/2013 at 6:45 p.m., noted, "Elder has Stage IV to right buttock measuring 5 X 6 X<.2 and 9 (et) is 95% yellow et 5% pink with no odor or drainage. TX (treatment) with collagen et Hydrogel dressing. Elder turned et repositioned Q2hrs per staff. Incontinent of B/B (bowel and bladder) with prompt assistance given after each episode, uses air mattress, vitamin C 500 mg, iron 325 mg, multivitamins et Prostat AWC R/T wound healing." Review of Resident #7's treatment notes, dated 06/28/2013 at 3:34 p.m., noted, "Elder has Stage IV to right buttock measuring 8 X 6.5 X<.2 ET is 70% yellow, 20% dark eschar ET 10% pink skin area has mild odor ET moderate drainage surrounding skin intact. TX with Hydrogel ET Collagen dressing, culture obtained from wound ET awaiting results of C&S (culture and sensitivity)." Review of Resident #7's treatment notes, dated 07/05/2013 at 4:41 p.m., noted, "Elder has stage IV to right buttock measuring 9 X 7 X 2 ET is 70% dark eschar ET 30% yellow slough area has moderate odor ET moderate purulent drainage surrounding skin intact ET pink in color. TX with Hydrogel ET Collagen ET cover with dressing continues to receive [MEDICATION NAME] 500 mg PO (by mouth) daily for 10 days R/T infection to right buttock." Interview with Licensed Practical Nurse (LPN) #2/Treatment Nurse on 07/11/2013 at 3:40 p.m., revealed LPN #2 stated, "I am usually notified by computer, but this time it was by word of mouth. When I'm notified, I go and assess the area, take pictures, do measurement notify the doctor and the family. The doctor then let me know how to treat, no the doctor has not seen it, they haven't looked at a wound since I've been here; I've been doing this (wound care) a couple of years now." LPN #2 stated, "I did wounds before coming here at my other job. I have been to a couple of seminars since I been here, we have a wound nurse that comes by once a month and writes suggestions if the wound is not improving, you met her yesterday. I don't know why there's no documentation on 06/19/2013, I know I did it; I will check my records and bring you a copy of that and a copy of the pictures along with the wound nurse (consultant) recommendations." Interview on 07/11/2013 at 1:45 p.m. with Registered Nurse (RN) #1/Director of Nursing (DON) revealed, RN #1 stated, "She (Resident #7) came in with wounds. She has a history of wounds." RN #1 stated she came in with it (pressure ulcer), said let me check on that to see if the wound was acquired. Interview with Registered Nurse (RN) #1 on 07/11/2013 at 2:45 p.m., stated, "I've looked everywhere and I don't see anything about the wound, I didn't see anything in the nurse's notes or CNA documentation, because they have a place that they can check and say nurse notified. I don't want you to leave here with a bitter taste in your mouth, but I want you to know we take real good care of our patients here and we don't have a high wound rate, we really do try. Yes, I have seen the wound. You as a nurse know it gets bigger before it gets better. Here are some dietary notes. I'm trying to get the rest of the copies of the dietary notes as soon as I can get to a computer." Review of the facility's policy entitled "Skin Care Policy and Procedure", revised 7/2007 noted, "Admission procedures; the skin at risk documentation on admission, and updated every three (3) months, and at significant change. If the resident is determined to be at risk or prone to skin break down, the assessment nurse will notify Dietary Manager. Daily skin checks during routine care will be done and documented by the CNA on the ADL's. Any signs of redness will be reported to the nurse in charge. Weekly body audits will be done by the assigned nurse and documented on the weekly body audit form. The MAR indicated [REDACTED]." Review of the facility's policy entitled "Skin Care Policy and Procedure", revised 5/2005, noted, "It is the policy of this facility that skin problems will be minimized to the greatest extent possible through aggressive approach the following components. I. Prevention, Evaluation and Screening. II. Ongoing Surveillance. III. Treatment Orders. IV. Treatment Regimen. The Director of Nursing will be responsible for ensuring this policy is applied consistently. I. Prevention, Evaluation and Screening - Each resident will be audited for special skin needs at the time of admission. Every effort through early intervention for prevention of skin breaks will be made. The Nursing Department's procedures will be such that the staff is alerted immediately if the resident either has the problem of skin breakdown or is at risk for the development of skin breakdown."