Every finding on record at Life Care Center of Hilliard

Based on food service observations, staff interviews, and a review of the facility's policies and procedures, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, by failing to ensure food items were properly labeled and dated in the main kitchen. This deficient practice prevents staff from determining the appropriate use by date and increases the risk of pathogen exposure to all residents who consume foods from the facility's kitchen.The findings include:On 04/20/2026 at 10:33 AM, an observation of the dry storage room revealed one opened box of cabbage, one opened box of zucchini, one opened box of potatoes, one opened box of sweet potatoes, one opened box of bananas, one open crate of onions, and one opened bag of pasta with no label or date. Observations of the reach-in freezer in the cook area revealed one opened bag of French fries, one opened bag of cauliflower, and one opened bag of biscuits with no labels or dates. (photographic evidence obtained)On 04/22/2026 at 11:19 AM, another observation of the dry storage room revealed the same opened boxes of potatoes, sweet potatoes, bananas, crate of onions, and bag of pasta with no labels or dates. The same observations were made of the reach-in freezer in the cook area of one opened bag of French fries, one opened bag of cauliflower, and one opened bag of biscuits with no labels or dates. (photographic evidence obtained)On 04/23/2026 at 1:21 PM, an interview with Dietary Aide G revealed that food items taken out/opened but not completely used, were to be put back, dated and discarded after three days of the written date.On 04/23/2026 at 1:28 PM, an interview with Dietary Aide H revealed that the facility's procedure for date marking food entailed sealing used items, dating them for two days, and after two days the items were discarded.On 4/23/2026 at 1:33 PM, an interview with [NAME] I revealed that when a food item was used and placed back where it came from without a date, it had to be discarded because the staff did not know when the item was opened or how long it had been sitting there.On 04/23/2026 at 1:41 PM, during an interview with Certified Dietary Manager (CDM) J, he confirmed that all dietary staff were responsible for dating and labelling food items. He stated when items were received, they were marked with the date received. Once opened, used or unused products that were placed back in the dry storage, refrigerator or freezer should have an open date and a use-by date that was two days after the opened date. Perishable items should have the use-by date indicating two days after the opened date, and should be discarded on the third day. Reference: FDA Food Code 2022. https://www.fda.gov/media/184685/download?attachment; (Accessed on 4/21/2026) Annex 5 - C. Intervention Strategies for Achieving Long-term Compliance. 4. Establish First-In-First-Out (FIFO) Procedures. Page 555. Product rotation is important for both quality and safety reasons. First-In-First Out (FIFO) means that the first batch of product prepared and placed in storage should be the first one sold or used. Date marking foods as required by the Food Code facilitates the use of a FIFO procedure in refrigerated, ready-to-eat, TCS foods. The FIFO concept limits the potential for pathogen growth, encourages product rotation, and documents compliance with time/temperature requirements. A review of the facility's policy and procedure titled Food Safety and Sanitation (dated 2023), revealed:Food is stored and maintained in a clean, safe and sanitary manner following federal, state and local guidelines to minimize contamination and bacterial growth. Receiving: .5 The First In, First Out (FIFO) method is used in food storage or according to state regulation. 6 Food is labeled with the date received if not already indicated on the item. Dry Storage: .2 Opened packages of food are resealed tightly to prevent contamination of the food item and 'use by date' will be used when applicable. 8. Foods not safe for consumption or the safety of the food is in question will be removed from storage.

Based on observations, record reviews, interviews, and a review of the facility's policies and procedures, the facility failed to provide transfer/discharge notification to the Long-Term Care (LTC) Ombudsman's office for seven (Residents #129, #127, #48, #8, #91, #98 and #135) of 21 residents reviewed for transfer/discharge. Appropriate notification to the LTC Ombudsman's office provides added protection to residents from being inappropriately transferred or discharged . It provides residents with access to an advocate who can inform them of their options and rights, and it ensures that the LTC Ombudsman's office is aware of facility practices and activities related to transfers and discharges. The findings include:1.A review of Resident #129's medical record revealed an admission date of 02/26/2026 with diagnoses including fracture of the superior rim of the right pubis, subsequent encounter for fracture healing.A review of the resident's active care plans revealed a focus area indicating a short stay with a discharge plan to return home with her spouse once her rehabilitation was completed (03/06/2026).A review of the progress notes revealed that Resident #129 had a planned discharge home on [DATE].A review of the Minimum Data Set (MDS) dated [DATE] revealed a Discharge/Return Not Anticipated assessment was completed.Further review of the record revealed that the facility completed a discharge summary, recapitulation, and discharge disposition on 03/20/2026. Resident #129's electronic medical record (EMR) did not contain a Nursing Home Transfer/Discharge Notice (CMS (Centers for Medicare and Medicaid Services) Form 3120) or evidence of notification of the LTC Ombudsman's office.2.A review of Resident #127's medical record revealed an admission date of 01/28/2026 with diagnoses including unspecified Intracranial Injury without loss of consciousness. The resident was transferred on 03/13/2026 to an acute care hospital for evaluation. The EMR did not contain a Nursing Home Transfer/Discharge Notice (CMS Form 3120) or evidence of notification of the LTC Ombudsman's office.3.A review of Resident #48's medical record revealed an admission date of 12/04/2025 with diagnoses including metabolic encephalopathy. The resident was transferred to an acute care hospital for evaluation on 03/27/2026. The EMR did not contain a Nursing Home Transfer/Discharge Notice (CMS Form 3120) or evidence of notification of the LTC Ombudsman's office.4.A review of Resident #8's medical record revealed an admission date of 08/26/2025 with diagnoses including hemiplegia (total to near total paralysis) and hemiparesis (muscular weakness) following cerebral infarction (stroke) affecting the resident's left non-dominant side. Resident #8 was transferred to an acute care hospital for evaluation on 03/22/2026. The EMR did not contain a Nursing Home Transfer/Discharge Notice (CMS Form 3120) or evidence of notification of the LTC Ombudsman's office.5.A review of Resident #91's medical record revealed an admission date of 12/08/2025 with diagnoses including sepsis (systemic infection). Resident #91 was transferred to an acute care hospital for evaluation on 03/20/2026. The EMR did not contain the Nursing Home Transfer/Discharge Notice (CMS Form 3120) or evidence of notification of the LTC Ombudsman's office.6.A review of Resident #98's medical record revealed an admission date of 07/18/2025 with diagnoses including congestive heart failure (CHF). Resident #98 was transferred to an acute care hospital for evaluation on 03/03/2026. The EMR did not contain a Nursing Home Transfer/Discharge Notice (CMS Form 3120) or evidence of notification of the LTC Ombudsman's office.7.A review of Resident #135's medical record revealed an admission date of 02/13/2026 with diagnoses including nonrheumatic aortic valve stenosis. The resident was discharged home on [DATE]. The EMR did not contain the Nursing Home Transfer/Discharge Notice (CMS Form 3120) or evidence of notification of the LTC Ombudsman's office.On 04/22/2026 at 1:33 PM, an interview was conducted with the Administrator. She was asked who was responsible for sending the Nursing Home Transfer/Discharge Notice (CMS Form 3120) to the LTC Ombudsman's office when a resident was transferred or discharged . She stated the responsibility fell on the Social Services Director. She was asked how often the LTC Ombudsman's office was notified of facility transfers/discharges. She stated, I'm not sure about that; I'll need to get back to you.On 04/22/2026 at 1:43 PM, an interview was conducted with Social Services Director (SSD) D, who confirmed that the LTC Ombudsman's office was notified of transferred/discharged residents monthly by the end of the month via certified mail. She confirmed that she had not sent the transfer/discharge notices to the LTC Ombudsman's office for the month of March 2026. She explained that the facility's Case Manager usually mailed the notices to the LTC Ombudsman's office monthly, but that she had not been employed by the facility since February 2026, and furthermore, she was unaware of where the certified mail receipts were kept. She was asked if she had knowledge of the regulation concerning transfer/discharge notification to the LTC Ombudsman's office. She replied, Not off the top of my head. She was asked where the transfer/discharge notifications were stored after the residents were discharged . She confirmed that copies of the notices were kept in her office in a file. She was asked to provide the files for review.On 04/22/2026 at 3:05 PM, the Administrator provided the Nursing Home Transfer and Discharge Notices (CMS Form 3120) for 21 residents who were discharged /transferred in March 2026. Resident #129 was not included. The Administrator confirmed that she had emailed the nursing home transfer/discharge notices for March 2026 to the LTC Ombudsman's office on 04/22/2026 (the date of this interview).On 04/22/2026 at 4:48 PM, an email was received from the LTC Ombudsman confirming that their office had not received any transfer/discharge notices from this facility for March 2026 until today, 04/22/2026.A review of the facility's policy and procedure titled Notice of Transfers and Discharges (revised 02/17/2026), revealed:The facility will notify the resident and the resident's representative(s), and Office of the State Long-Term Care (LTC) Ombudsman of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. This written notification from the facility includes the following:4. The facility must maintain evidence that the notice was sent to the Ombudsman. While Ombudsman Programs vary from state to state, facilities should know the process for Ombudsman notification in their state. 6. For any other types of discharges, the facility must provide notice of discharge to the resident and resident representative along with a copy of the notice of the State LTC Ombudsman at least 30 days prior to discharge or as soon as possible. The copy of the notice must be sent at the same time notice is provided to the resident and or the resident representative.

Based on observations, record reviews, interviews and a review of facility policies and procedures, the facility failed to ensure that residents who needed respiratory care, were provided such care, consistent with professional standards of practice, by failing to ensure that oxygen was administered at the ordered flow rate for four (Residents #95, #115, #119 and #6) of 10 residents reviewed for oxygen therapy. The findings include: 1.On 04/20/2026 at 1:10 PM, an observation of Resident #95's oxygen concentrator revealed an oxygen flow rate of 3 liters per minute (LPM). (photographic evidence obtained) On 04/22/2026 at 10:09 AM, another observation was made of Resident #95 in her wheelchair receiving oxygen from a portable oxygen tank at a flow rate of 3 LPM. (photographic evidence obtained) A review of Resident #95's medical record revealed an admission date of 03/29/2026 with diagnoses including chronic obstructive pulmonary disease (COPD) and shortness of breath (SOB). A review of the resident's Comprehensive Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 possible points, indicating moderate cognitive impairment. On 04/22/2026 at 10:05 AM, an interview with Resident #95 revealed she was not aware of what her oxygen flow rate setting should be. A review of the resident's active care plans revealed a focus area for Shortness of Breath related to COPD. The care plan interventions included: Oxygen at 1 LPM via nasal cannula as needed for shortness of breath. A review of the physician's orders revealed an active order for oxygen at 1 LPM per nasal cannula, as needed, with a start date of 3/30/2026. On 04/23/2026 at 10:46 AM, in an interview with Licensed Practical Nurse (LPN) K, she stated Resident #95's oxygen flow rate was ordered for 2 LPM as of 04/23/2026 and stated it was the responsibility of the certified nursing assistant (CNA) to report oxygen flow rate settings to the nurse; only a nurse could adjust oxygen flow rate settings. LPN K stated if the physician's orders for PRN (as needed) oxygen settings did not contain parameters, oxygen was to be administered when a resident was experiencing shortness of breath, or when oxygen saturation levels were below 90%. 2.On 04/21/2026 at 10:18 AM, Resident #115 was observed lying in bed wearing her nasal cannula with oxygen infusing at 2.5 LPM. (photographic evidence obtained) A review of Resident #115's medical record revealed an active oxygen order for oxygen at 2 LPM continuously via nasal cannula. Further review of the record revealed the most recent admission date of 10/08/2025 with an initial admission date on 05/14/2021. Resident #115's diagnoses included emphysema and heart failure. A review of the resident's Annual MDS assessment, dated 02/12/2026, revealed that Resident #115 received oxygen therapy and had a BIMS score of 3 out of 15 possible points, indicating severe cognitive impairment. A review of Resident #115's active care plans revealed a focus area for Risk for Complications with Breathing/Wheezing related to heart failure, emphysema and seasonal allergic rhinitis. Another focus area for History of Pneumonia with continuous oxygen ordered at 2 LPM via nasal cannula related to emphysema was noted. 3.On 04/20/2026 at 12:41 PM, Resident #119 was observed sitting in bed wearing her nasal cannula with oxygen infusing at 3 LPM. (photographic evidence obtained) On 04/21/2026 at 10:41 AM, Resident #119 was observed lying in bed with her oxygen running at a flow rate of 1.5 LPM. She was not wearing her nasal cannula. At 12:38 PM, she was observed sitting up in bed. She was not wearing her nasal cannula and stated, I take it out sometimes. (photographic evidence obtained) On 04/22/2026 at 2:29 PM, Resident #119 was observed lying in bed removing her nasal cannula. Her oxygen was running at a flow rate of 1.5 LPM. (photographic evidence obtained) On 04/23/2026 at 8:54 AM, Resident #119 was observed in bed with her nasal cannula hanging from her right ear (not positioned in her nose). The oxygen concentrator was running. When she was asked if she removed her nasal cannula herself, she replied, yes. When she was asked if nursing was aware that she was removing her nasal cannula, she replied, yes. A review of the resident's active physician's orders revealed an order for oxygen at 2 LPM via nasal cannula as needed (1/20/2026). A review of the resident's medical record revealed the most recent admission date of 09/22/2025 with an initial admission date of 10/08/2022. The resident's diagnoses included chronic congestive heart failure (CHF). A review of the Quarterly MDS assessment, dated 03/13/2026, revealed the resident received oxygen therapy and had a BIMS score of 3 out of 15 possible points, indicating severe cognitive impairment. A review of the active care plans revealed focus areas for Risk for Shortness of Breath related to CHF and anemia. Interventions included administration of oxygen at 2 LPM as needed for shortness of breath. On 04/23/2026 at 9:55 AM, RN K observed Resident #119 with her nasal cannula hanging from her ear and asked the resident, May I put your oxygen back on? Resident #119 agreed and RN K placed the nasal cannula back in her nose and exited the room without verifying the oxygen flow rate. RN K was accompanied to her medication cart, and she confirmed that Resident #119's oxygen flow rate was ordered at 2 LPM via nasal cannula as needed. She stated nursing provided ongoing monitoring of residents' oxygen therapy and ensured residents received oxygen at the flow rates ordered by their physicians'. Correct oxygen flow rate settings were identified by reviewing the physicians' orders and were communicated from one nurse to the next during change-of-shift report. When RN K was asked if Resident #119 made changes to her own oxygen flow rate, RN K replied, No, she is not able to, but she is able to take off the nasal cannula at times. On 04/16/2026 at 2:37 PM, a Health Status note revealed that Resident #119 was reviewed in an Interdisciplinary Team meeting. Resident continues to use oxygen of 2 liters via nasal cannula as needed and nebulizer treatments as needed due to the diagnosis of shortness of breath/cough/congestion. The resident's Medication Administration Record for April 2026 identified oxygen was provided as ordered by the physician. 4.On 04/20/2026 at 10:50 AM, Resident #6 was observed in bed with oxygen infusing at 3 LPM via nasal cannula. (photographic evidence obtained) When he was asked if he knew what his flow rate should be, he replied, Two liters. A review of the resident's medical record revealed an active physician's order dated 10/10/2025 for oxygen at 2 LPM via nasal cannula as needed for shortness of breath related to Chronic Obstructive Pulmonary Disease (COPD). On 04/21/2026 at 10:16 AM, the resident was observed with oxygen infusing at 3 LPM via nasal cannula. (photographic evidence obtained) On 04/21/2026 at 10:21 AM, Licensed Practical Nurse (LPN) A was observed standing at the doorway of the resident's room with her medication cart, preparing medication. She was asked to verify the resident's oxygen flow rate, and she stated, 3 LPM. She was asked to check the resident's physician's order for oxygen. After reviewing the physician's order, she stated the resident was supposed to be receiving oxygen at 2 LPM via nasal cannula as needed for shortness of breath. A review of Resident #6's medical record revealed an admission date of 11/25/2023 with diagnosis including Chronic Obstructive Pulmonary Disease (COPD). A review of the Quarterly MDS assessment with an assessment reference date (ARD) of 04/02/2026, revealed a BIMS score of 15 out of 15 possible points, indicating intact cognition. The MDS revealed the resident exhibited shortness of breath (SOB) with exertion and received oxygen therapy. A review of the resident's care plans revealed a focus area for Risk for Shortness of Breath related to Congestive Heart Failure (CHF), Anemia and COPD as of 10/23/2025. Care plan Interventions included oxygen at 2LPM via nasal cannula as needed for shortness of breath (04/09/2025). On 04/22/2026 at 10:32 AM further review of the resident's medical record revealed that the Nurse Practitioner was notified on 04/21/2026 at 11:55 AM of the resident's current oxygen flow rate and no new orders were received. The resident was to continue on 2 LPM as needed (PRN). A review of the facility's policy and procedure titled Oxygen Administration (Infection Control, Safety, & Storage) (Revised 03/03/2026), revealed: Policy: To ensure oxygen is administered and stored safely within the facility or in an outside storage area.

Based on observations, interviews, record review ,and a review of the facility's policies and procedures, the facility failed to ensure that its medication error rate was not 5% or greater. There were 26 opportunities for error with two errors identified, resulting in an error rate of 7% and involving two (Residents #6 and #99) of five residents observed during medication administration.The findings include:On 04/21/2026 at 11:13 AM, Licensed Practical Nurse (LPN) A was observed preparing medications for Resident #6. She administered Refresh Tears Ophthalmic Solution, 1 drop in each eye. She was asked to compare the current physician's order with the dose she had just administered. She confirmed the current order was for Refresh Tears Ophthalmic Solution, instill 2 drops in each eye.On 04/22/2026 at 10:13 AM, Registered Nurse (RN) F was observed preparing medications for Resident #99. She prepared Sertraline Hydrochloride (HCL)100 milligram (mg), 1 tablet. She was asked to compare the dose she prepared with the current physician's order. She confirmed that the order was written for Sertraline HCL 100 mg, 2 tablets. A review of the facility's policy and procedure titled Administration of Medications (revised 02/13/2023, reviewed 09/09/2025), revealed:Policy:The facility will ensure medications are administered safely and appropriately per physician's order to address residents' diagnoses and signs and symptoms.Medication Error:This means the observed or identified preparation or administration of medications or biologicals which is not in accordance with:The prescriber's order.

Based on a record review, interviews, and facility policy review, the facility failed to thoroughly investigate allegations of abuse for two (Residents #1 and #5) of three residents reviewed for abuse, from a total sample of 5 residents. The findings include: 1. A record review for Resident #1 found she was admitted on [DATE] and readmitted on [DATE]. Her diagnoses included fracture of the upper end of the left humerus (the long bone between the shoulder and elbow). A review of Resident #1's Discharge Return Anticipated minimum data set (MDS) assessment with a reference date 12/24/24 noted Resident #1 had OK memory and was independent with daily decision making. She required substantial to maximum assistance with toileting and partial to moderate assistance to move from sitting to standing and transfers. On 1/13/25 at 2:00 pm, an interview was conducted with Resident #1. She explained she had fallen and broke her humerus in two places which resulted in a loss of dignity with her decline in activities of daily living (ADL). She complained that recently, she had asked for assistance wiping herself due to her broken shoulder. Her CNA told her staff was there to encourage her independence. Resident #1 felt that was abuse, given the way the CNA said it, so she reported it. She was fearful of retaliation, so she hesitated at first. Resident #1 had never had a problem with that CNA (she did not recall her name) but only had her once. When asked if she was satisfied with the facility response and resolution, Resident #1 shrugged and said she and her daughter were told in her care plan meeting the CNA had been suspended. She was not sure if she was fired or still worked in the facility. A review of nursing progress notes revealed on 12/6/24, Resident #1 was found on the floor in her bathroom. She was laying on her back, holding her left shoulder and complaining of pain. Staff called paramedics and she was transferred to the emergency room . She returned with a diagnosis of left humerus fracture with a sling on that shoulder. A progress note dated 12/10/24 revealed Resident #1 had a care plan meeting with her daughter present. Concerns with staffing were discussed, and the DON informed the resident/daughter she was having the situation investigated. There were no further details. A review of the facility's Nursing Home Federal Report authored by the Director of Nursing (DON) revealed on 12/8/24 at 3:06 pm, Resident #1 made an allegation of physical abuse by Certified Nursing Assistant (CNA) A. After being assisted to the bathroom and calling the CNA back, Resident #1 instructed the CNA to wipe her with a wet wipe then dry her with toilet paper. CNA A told Resident #1 they were there to encourage her to be independent. Resident #1 explained she had broken her arm and could not do it for herself. When Resident #1 attempted to raise herself from the toilet, CNA A roughly helped her up, roughly wiped her buttocks, then did not assist her to walk back to her chair. Resident #1 later informed Licensed Practical Nurse (LPN) A that she didn't want CNA A for the rest of the night. The investigation section of the report noted the Unit Manager spoke with Resident #1 and asked permission to write down her statement. The weekend supervisor spoke with Resident #1's daughter. CNA A was interviewed by the DON and was suspended pending investigation. Conclusion: a statement was collected from the resident and all associates and allegations were found to be unverified. A final warning was given to CNA A related to customer service. (Photographic evidence was obtained) A review of the facility's investigation file revealed written statements were obtained from the Unit Manager, LPN A and CNA A. There was no indication other staff, or residents on CNA A's assignment, were interviewed about their care or concerns. (Photographic evidence was obtained) On 1/13/25 at 3:23 pm, the DON was interviewed and confirmed she was the Abuse Coordinator. She stated that when she receives a resident grievance, she talks with the resident or family about their concern(s). If the concern rises to the level of neglect or abuse, that triggers her to investigate. This would involve obtaining written statements, reporting to Department of Children and Families and to the Agency. An in-house investigation is conducted and staff who were assigned to that resident around the time of the incident are interviewed. Other alert and oriented residents on the same hall are also interviewed about the CNA. Resident #1 had an incident over a weekend, and the DON was advised on that Monday. The Unit Manger took a written statement from Resident #1, who alleged she needed help with wiping wet to dry. The CNA did not help her back to the bed and had told the resident staff were there to encourage independence. Resident #1 told the nurse she didn't want that CNA any more. As a result of the allegations, CNA A was removed from the schedule and suspended. CNA was allowed to return and received a corrective action for poor customer service/ job performance. When the DON was asked if she had interviewed residents on the same hall about CNA A's care. She said no, but she should have. The DON said she was handling so many reportable incidents at that time; she had never seen so many and was learning as she goes. The DON acknowledged the missed opportunity to identify residents on same hall who may have similar concerns. She expressed an understanding that some may be fearful of reporting. The DON said Resident #1 and her daughter were notified the incident was reported, and CNA A was suspended pending investigation. She did not advise them of the final outcome of the investigation. She was not sure she could tell the resident(s) that. 2. A record review for Resident #5 found she was admitted [DATE]. Her diagnoses included orthopedic aftercare and fracture of the right femur. A review of the Quarterly MDS assessment dated [DATE] revealed Resident #5 had a brief interview for mental status (BIMS) score of 4 out of 15 points, indicating severe cognitive impairment. She required substantial to maximum assistance with ADLs. No anticoagulant medication (blood thinner) was used. A skin check assessment dated [DATE] reported no skin issues. The following assessment dated [DATE] noted bilateral dark bruising to both of Resident #5's hands. (Photographic evidence was obtained) A review of the facility's Nursing Home Federal Report authored by the DON found on 12/16/24, Resident #5's family notified the Administrator and DON of bruising on both of her hands. Assessment confirmed bruising on the top of each hand. Because of a diagnosis of dementia, Resident #5 was unable to explain what happened. An investigation was conducted, revealing the resident stated the bruises 'just come up' there sometimes. Her diagnoses included cognitive communication deficit and dementia, with a BIMS of 4. The weekly skin check 12/13/24 was noted to reveal bruising. The investigation summary concluded by reporting Resident #5 was complaining of hand pain. Conclusion: the allegation was not verified due to evidence obtained during the investigation. It was not determined how bilateral bruising occurred. Weekly skin checks were conducted by the nurse per policy. Staff was interviewed and ongoing education with staff about transfers and timely reporting were being conducted. Review of the investigation file contained only two written witness statements. One was the DON's, which reported she accompanied a DCF worker to speak with Resident #5. Resident #5 told the worker the bruises just come up there. Resident #5 denied being struck by anyone. The second statement in the file was from a CNA who remembered a large bruise on one of Resident #5's hand; the second bruise was newer to when she last had this resident. (Photographic evidence was obtained) There was no indication that any residents on the same hall were interviewed about their care or rough transfers or treatment by staff. On 1/13/25 at 3:55 pm, an interview was conducted with the DON. She stated as part of her investigation, she interviewed two employees on the schedule who had nothing to report. She admitted she did not interview other residents on the hall. A review of the facility's policy titled, Abuse-Conducting an Investigation issued 10/4/22, reviewed 6/17/24 instructs: Policy: It is the policy of this facility that allegations of abuse (abuse, neglect, mistreatment, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated . .3. When an incident or suspected incident of resident abuse and/or neglect, injury of unknown source, exploitation, or misappropriation of resident property is reported, the administrator/designee will investigate the occurrence. Protection will be provided to the alleged victim and other residents, such as room or staffing changes as needed to protect the resident(s) from the alleged perpetrator. a. If the investigation is being conducted by the designee, the administrator will be consulted daily concerning the progress of the investigation . .8. The written summary of the investigation should include, but is not limited to: .h. Interviews with staff members on all shifts having contact with the resident at the time of the incident. i. Interviews with the resident's roommate, family, and/or visitors who may have information regarding the incident. j. Interviews other residents who received care or services from the alleged perpetrator. k. A review all circumstances surrounding the incident . .14. The administrator or designee will inform the resident, physician, and/or resident representative of the results of the investigation and the corrective action taken. (Photographic evidence was obtained) A review of the facility's policy titled, Abuse - Identification and Types issued 10/4/22, reviewed 6/17/24 states on page 3 that injuries of unknown origin such as unexplained injury or bruises could indicate abuse. (Photographic evidence was obtained) A review of the facility's policy titled, Grievance Program effective 5/6/29, reviewed 9/26/24 and revised 1/7/25 noted on page 2 the facility will immediately report all alleged violations involving neglect, abuse and injuries of unknown source as required by state law. Under section 8. it states follow-up with the resident and family to communicate resolution or explanation and ensure the issue was handled to the resident/family's satisfaction will occur. (Photographic evidence was obtained)

Based on observations and interviews, the facility failed to ensure a sanitary and orderly interior, by failing to maintain the shower rooms on the 100, 200 and 600 hallways in an orderly and sanitary manner. The findings include: On 07/11/24, during a tour of the facility with the facility's Housekeeping and Laundry Director from 1:18 PM through 2:00 PM, the facility's shower rooms were observed. In the shower room on the 600-hallway, numerous used razors, deodorant sticks/canisters, and hairbrushes were present throughout the shower room, all of which were unlabeled. (Photographic evidence obtained) In the shower room on the 200-hallway, two shower basins were observed, in which were unlabeled, used bath products including used razors, a shower puff, deodorant sticks/canisters and hairbrushes. (Photographic evidence obtained) In the shower room on the 100-hallway, numerous used razors and deodorant sticks/canisters were observed, all of which were unlabeled. There was also a pile of soiled laundry and two bags of linens located on the floor near the toilet. (Photographic evidence obtained) An interview was conducted with Certified Nursing Assistant (CNA) V on 07/11/24 at 1:30 PM. She confirmed that part of her job duties was to assist in showering residents. When asked if she could identify who the bath products in the 600-hallway shower room belonged to, she stated she could not confirm which products belonged to which residents. She further stated she did not know if any of the products were being used by the staff on the residents. An interview was conducted with CNA T on 07/11/24 at 2:00 PM. She confirmed that part of her job duties was to assist in showering residents. When asked if she could identify who the bath products in the 100- or 200-hallway shower rooms belonged to, she stated she could not confirm which products belonged to which residents.

Based on observations and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment, and to help prevent the transmission of communicable diseases and infections, by failing to ensure proper infection control practices during insulin administration, resident dining, gloving, and linen handling. This impacted two (Residents #54 and #4) of 44 residents in the total survey sample, as well as numerous residents in the dining room on 7/10/24 during the breakfast meal, and potentially more receiving assistance with meals and other care from Certified Nursing Assistants (CNAs) Y and C. The findings include: 1. On 7/11/24 at 11:26 AM, an observation was made of Licensed Practical Nurse (LPN) J administering Novolog Insulin (a medication used to control elevated blood sugars) to Resident #54. LPN J did not clean the hub of the Novolog Flex Pen with alcohol prior to inserting the needle. On 7/11/24 at 11:30 AM, an interview was conducted with LPN J, who acknowledged that she did not clean the hub of the Novolog Flex Pen prior to inserting the needle to the insulin syringe. She confirmed that this would be considered an infection control issue, and further stated she should have cleaned the syringe hub with an alcohol prep prior to inserting the needle. On 7/11/24 at 11:58 AM, an interview was conducted with the Director of Nursing (DON), who stated it was her expectation that nursing staff clean the hub of the Flex pen prior to inserting the needle. The DON confirmed that failure to do so would be considered an infection control issue. A review of the facility's policy titled Insulin Pen Administration (Issued: 08/10/22; Revised: 8/30/23), revealed under Policy: The facility will ensure residents with orders for insulin administration through the use of a pen delivery device is performed in accordance with current standards of practice and manufacturer's guidance. A review of the Manufacturer's Guidance revealed: Under Prepare to inject: 5. Wipe the pen tip with an alcohol pad. 6. Remove the seal on the needle cap 7. Twist or push (based on the needle type) the needle straight onto the pen tip. 2. During a tour of the facility on 7/8/24 at 5:30 PM, Resident #4 was observed being assisted with her dinner tray by Certified Nursing Assistant (CNA) P, who was sitting on Resident #4's bed while assisting her with her meal. A review of the medical record revealed that Resident #4 was last readmitted to the facility on [DATE] with a medical history significant for dementia, malnutrition, failure to thrive, anxiety, and depression. A review of the resident's Significant Change minimum data set (MDS) assessment, dated 6/27/24, revealed a brief interview for mental status (BIMS) score of 2 out of 15 possible points, indicating severe cognitive impairment. Resident #4 was documented as dependent on staff for assistance with her meals. On 7/9/24 at 5:15 PM, Resident #4 was observed being assisted with her dinner tray by Certified Nursing Assistant (CNA) Q, who was sitting on Resident #4's bed while assisting her with her meal. On 7/10/24 at 11:48 AM, Resident #4 was observed being assisted with her lunch tray by CNA R, who was sitting on Resident #4's bed while assisting her with her meal. On 7/10/24 at 1:16 PM, an interview was conducted with the Director of Nursing (DON), Administrator, and Regional Director of Clinical Services (RDCS). The abovementioned concern regarding staff sitting on Resident #4's bed while assisting with her meals was shared. The DON and Administrator agreed that this was a concern. Concerns regarding staff handling resident dinnerware/trays incorrectly, improper handling of linens, wearing gloves in the hallway, and improper procedures for insulin administration were also shared. 3. On 7/10/24, beginning at 8:20 AM, an observation of the dining room during the breakfast meal revealed the following: A dietary staff member was observed bringing a tray of coffee mugs from the kitchen into the dining room. The dietary staff member touched each cup at the top rim/lip with bare hands while placing them on the rack for use in the dining room and before re-entering the kitchen area. CNA Y was observed preparing drinks/coffee and serving beverages while picking up the cups and touching the top rim/lip of the cups, then placing the cups in front of the residents. She did not wash her hands or use hand sanitizer prior to making the beverages, or between serving the cups to different residents. On 7/10/24 at 10:00 AM, CNA C was observed walking in the hallway from a resident's room in front of the nurses' station with gloves on. She entered the oxygen utility room, removed an oxygen tank, and walked back to the nurses' station and down the hallway to a resident's room. She was observed touching doorknobs and key pads with gloves on, and she did not remove the gloves until she completed care for the resident. On 7/10/24 at 10:20 AM, CNA C was observed walking into the clean linen room on the nursing unit, then walking through the hallway with clean linens in both arms cradled against her chest area and against her clothing. She then entered two different residents' rooms to place the linens in them. On 7/10/24 at 11:00 AM, an interview was conducted with CNA C, who stated she had been employed with the facility since April 2024. She received orientation training upon hire. Orientation training consisted of videos and a skills lab check off. She received infection control training via video with an understanding of appropriate hand hygiene, personal protective equipment (PPE), and when and how to use PPE. She stated she had not received any other training to date. She acknowledged that she should not wear gloves in the hallway or place clean linens against her clothing due to possible contamination and risk of spreading germs and infection. On 7/10/24 at 11:20 AM, an interview was conducted with Unit Manager/Registered Nurse (RN) B, who stated the appropriate process for removing clean linens from the linen room on the nursing unit was that staff should go to the clean linen closet, place needed linen in a clean plastic bag, and transport it to the resident's room. She further stated staff were not to wear gloves in the hallway after providing care to a resident due to infection control prevention policies. On 7/11/24 at 10:45 AM, a telephone interview was conducted with the Assistant Director of Nursing (ADON). She confirmed that she was the Infection Preventionist. When asked to describe education she provided to the staff most recently, she stated she provided education to the CNAs in June following dining audits. She had observed CNAs improperly handling residents' food trays, so she provided education about properly handling of residents' cups and silverware. She further stated the facility had a COVID-19 outbreak in June, so she provided education to the staff regarding hand hygiene. Education was also provided to the housekeeping staff regarding proper linen handling. She further clarified that this education (linen handling) was not provided to the rest of the staff. The infection control concerns regarding staff sitting on residents' beds during dining, improper handling of food trays, improper handling of linens, staff wearing gloves in the hallway, and improper insulin administration were shared with her. She stated she was out of the facility for the week, but she would begin audits and education when she returned.

Based on observations, interviews, and record reviews, the facility failed to maintain residents' dignity while dining related to staff standing while assisting with meals and tablemates not being served trays together for six (Residents #106, #4, #8, #75, #21, and #6) of eight residents reviewed for dignity, from a total of 44 residents in the survey sample. The findings include: 1. On 7/8/24 at 5:33 PM, Resident #106 was observed being assisted with his dinner tray by Certified Nursing Assistant (CNA) G, who was observed standing while assisting the resident with his meal. Resident #106 was admitted to the facility on [DATE] with a medical history significant for paraplegia, right hand contracture, and macular degeneration. A review of Resident #106's Quarterly Minimum Data Set (MDS) assessment, dated 5/24/24, revealed he had a Brief Interview for Mental Status (BIMS) Score of 12 out of 15 possible points, indicating moderate cognitive impairment. He was also documented as requiring set up assistance for his meals. Additional observations of Resident #106 were made during the survey week as follows: On 7/9/24 at 11:53 AM, Resident #106 was observed being assisted with his lunch tray by CNA H, who was observed standing while assisting the resident with his meal. On 7/9/24 at 5:13 PM, Resident #106 was observed being assisted with his dinner tray CNA I, who was observed standing while assisting the resident with his meal. On 7/10/24 at 11:50 AM, Resident #106 was observed being assisted with his lunch tray CNA G, who was observed standing while assisting the resident with his meal. An interview was conducted with Resident #106 on 7/10/24 at 9:50 AM. He stated he would like it if the staff sat with him while assisting him with his meals. 2. On 7/8/24 at 5:30 PM, Resident #4 was observed being assisted with her dinner tray by CNA P, who was observed sitting on Resident #4's bed while assisting the resident with her meal. Resident #4 was last readmitted to the facility on [DATE] with a medical history significant for dementia, malnutrition, failure to thrive, anxiety, and depression. A review of Resident #4's Significant Change MDS assessment, dated 6/27/24, revealed that Resident #4 had a BIMS score of 2 out of 15 points, indicating severe cognitive impairment. She was also documented as dependent on staff for assistance with her meals. Additional observations were made of Resident #4 during the survey week as follows: On 7/9/24 at 5:15 PM, Resident #4 was observed being assisted with her dinner tray by CNA Q, who was observed sitting on Resident #4's bed while assisting the resident with her meal. On 7/10/24 at 11:48 AM, Resident #4 was observed being assisted with her lunch tray by CNA R, who was observed sitting on Resident #4's bed while assisting the resident with her meal. 3. On 7/8/24 at 5:50 PM, Resident #8 was observed being assisted with her dinner tray by CNA L, who was observed standing while assisting the resident with her meal. Resident #8 was admitted to the facility on [DATE] with a medical history significant for encephalopathy, difficulty swallowing, mini-stroke, hemiparesis, and dementia. A review of Resident #8's Admission MDS assessment, dated 5/24/24, revealed Resident #8 had a BIMS score of 0 out of 15 points, indicating severe cognitive impairment. She was also documented as requiring moderate assistance from staff for her meals. Additional observations were made of Resident #8 during the survey week as follows: On 7/9/24 at 5:38 PM, Resident #8 was observed being assisted with her dinner tray CNA M, who was observed standing while assisting the resident with her meal. On 7/10/24 at 12:04 PM, Resident #8's roommate received her lunch tray but Resident #8 did not. Resident #8 received her lunch tray at 12:17 PM, but no staff were present in the room to assist her with dining. By 12:32 PM, no staff had arrived to assist Resident #8 with her meal. Registered Nurse (RN) N was interviewed at this time. The concern that Resident #8 was left with food in her room and no way to eat it for almost 30 minutes was shared with the nurse. RN N reviewed the CNA assignment log and stated the CNA who was assigned to assist Resident #8 with her meal was also assigned to the dining room, and was therefore unavailable to assist Resident #8 with her meal. RN N was asked if Resident #8 would be left without assistance until the CNA returned from the dining room, and she replied that she would go to Resident #8's room and assist her with her meal. 4. On 7/8/24 at 5:18 PM, Resident #75's roommate received their dinner tray, but Resident #75 did not. At 6:40 PM, Resident #75's dinner meal had still not arrived. Licensed Practical Nurse (LPN) J was interviewed at this time. She stated Resident #6 typically went to the dining room and therefore would have to wait until the last cart of meals was delivered to receive her meal. LPN J stated this was how it always worked and that it often took a long time for the residents to receive their meals if they did not go to the dining room. Resident #75 was admitted to the facility on [DATE] with a medical history significant for encephalopathy, dementia, malnutrition, mini-stroke, and communication deficit. A review of Resident #75's End of Part A Stay MDS assessment, dated 6/7/24, revealed a BIMS score of 0 out of 15 points, indicating severe cognitive impairment. The resident was also documented as independent with meals. On 7/9/24 at 5:10 PM, Resident #75's roommate received their dinner tray, but Resident #75 did not. At 6:45 PM, Resident #75's dinner meal had still not arrived. LPN J was interviewed at this time and was asked if Resident #75 would be served dinner this evening. LPN J asked for clarification. She was made aware that all other residents had received their dinner trays at 5:10 PM and the other residents had been taken to the dining room at 6:30 PM by the CNAs, but that Resident #75 had been left asleep in her bed. LPN J was again asked if the resident would be served dinner this night. LPN J picked up the phone and said, Oh, she's going to get dinner. and called the kitchen to bring a tray. 5. On 7/10/24 at 11:33 PM, Resident #21 was observed in bed with her eyes closed. The lunch trays were served to the residents on the hallway, but Resident #21 did not receive a lunch tray. Her roommate was taken to the dining room at 12:17 PM along with other residents from the units, but Resident #21 was left asleep in her bed. At 12:30 PM, Resident #21 had still not been taken to the dining room for her meal. RN N was interviewed at this time. She stated Resident #21 typically went to the dining room for lunch, and that she would call to see if a tray was going to be sent since the resident was asleep. RN N spoke to the kitchen and was told they would send a tray to her room. Resident #21 was last readmitted to the facility on [DATE] with a medical history significant for dementia, diabetes, difficulty swallowing, and esophageal obstruction. A review of Resident #21's Quarterly MDS, dated [DATE], revealed a BIMS score of 3 out of 15 points, indicating severe cognitive impairment. She was also documented as able to eat her meals independently. 6. On 7/8/24 at 5:18 PM, Resident #6's roommate received their dinner tray, but Resident #6 did not. At 6:40 PM, Resident #6's dinner meal had still not arrived. LPN J was interviewed at this time. She stated Resident #6 typically went to the dining room, and therefore would have to wait until the last cart of meals was delivered to receive her meal. LPN J stated this was how it always worked, and that it often took a long time for the residents to receive their meals if they did not go to the dining room. Resident #6 was last readmitted to the facility on [DATE] with a medical history significant for stroke, difficulty swallowing, malnutrition, dementia, and Parkinson's syndrome. A review of Resident #6's Annual MDS assessment, dated 5/24/24, revealed a BIMS score of 3 out of 15 points, indicating severe cognitive impairment. She was also documented as able to eat her meals independently. On 7/10/24 at 1:02 PM, an interview was conducted with the facility's Certified Dietary Manager (CDM). He stated the facility had started serving the meal trays in a new way on 4/24/24 based on nursing suggestions. He further stated they used to serve residents in the dining room mid-meal service but that the nursing staff had recommended they serve the trays to the resident rooms first and serve the dining room last. It was explained that the concern was that the facility was assuming which residents were going to go to the dining room for each meal, the other residents on the floor were served first, and if a resident did not go to the dining room for some reason, they then had to wait a very long time for their meal tray to be served to them. He stated the kitchen had a list of which residents were supposed to be served in the dining room and which residents were receiving restorative dining services. He said the kitchen staff removed the meal tickets from the hall service piles and placed them aside for the dining room service. They would then serve the resident halls, then the dining room, and then review which tickets were left over and serve those residents in their rooms last. He agreed that it could take up to two hours for a resident to receive a meal tray if they decided to not go to the dining room, but that it was ultimately not up to him or his staff in what order the trays were served because they make 110 trays regardless of how they are served to the residents. He further stated he had not been made aware that roommates were not being served their meals together, but he agreed that it was a concern. When asked if he felt the current process for serving meals to the residents was efficient, he stated he did not. When asked if he had expressed any concerns about the current meal service process to the administration staff, he stated he had not. On 7/10/24 at 1:16 PM, an interview was conducted with the facility's Director of Nursing (DON), Administrator, and Regional Director of Clinical Services (RDCS). The abovementioned concerns regarding staff standing while assisting residents with their meals and roommates not being served meals at the same time were shared with them. The DON stated she rounded the floor daily to watch how residents were being cared for and she had not observed the shared concerns, but she and the Administrator agreed that these were concerning for residents' dignity. The Administrator confirmed that the tray line order was changed in April based on nursing suggestions. The Administrator and the DON both verbalized that they had not followed up with staff or residents since the change to see whether the new process was effective. They said they would attempt to change the order of service making the dining room first to be served, so that all residents who chose to stay in their rooms would be served trays together and in a timely manner. On 7/11/24 at 9:40 AM, an interview was conducted with LPN J, who stated the nurses typically did not assist with dining, but she was aware that staff were expected to sit in a chair while assisting a resident with dining and not stand or sit on the resident's bed. On 7/11/24 at 9:45 AM, an interview was conducted with CNA R, who stated she was aware that staff were expected to sit in a chair while assisting a resident with dining and not stand or sit on the resident's bed. On 7/11/24 at 9:55 AM, an interview was conducted with CNA C, who stated she was aware that staff were expected to sit in a chair while assisting a resident with dining and not stand or sit on the resident's bed. On 7/11/24 at 10:05 AM, an interview was conducted with RN N, who stated she was aware that staff were expected to sit in a chair while assisting a resident with dining and not stand or sit on the resident's bed. A review of the facility's policy titled Dignity (Issued: 5/6/19, Reviewed: 9/25/23) revealed: Each resident has the right to be treated with dignity and respect. Interactions and activities with residents by staff must focus on maintaining and enhancing the residents' self-esteem including promoting resident independence and dignity while dining, such as avoiding staff standing over residents while assisting them to eat.

Based on interviews, record reviews and policy and procedure review, the facility failed to ensure that all alleged violations involving neglect were reported immediately, but not later than 2 hours after the allegation was made. The facility failed to provide assistance with activities of daily living (ADL) for more than 8 hours for one (Resident #6) of three residents whose grievances were reviewed, from a total sample of eight residents. The findings include: A review of the facility's grievance log revealed a grievance dated 6/13/23 from Resident #5. Resident complained that her sister who was also her roommate (Resident #6) had not been checked and changed for over 8 hours from 6:30 am - 3:30 pm. On 6/14/23, the Assistant Director of Nursing (ADON) was assigned to investigate the concern. The investigation findings read, verified certified nursing Assistant (CNA) for that resident. The action taken included education for CNAs to check and change resident's every two hours. The grievance indicated that education was provided. (Photographic copy obtained) A review of the medical record for Resident #6 revealed an admitted [DATE] with re-entry date of 6/22/23. Her diagnoses included metabolic encephalopathy, muscle weakness, difficulty walking, dementia, and adult failure to thrive. A review of Resident #6's Modification of Medicare 5-day minimum data set (MDS) assessment dated [DATE] revealed she had a brief interview for mental status (BIMS) score of 1 out of 15 points, indicating severe cognitive impairment. The resident required extensive assistance with one staff for bed mobility, eating and toileting and extensive assistance with two people for transfer. The assessment also indicated that the resident was at risk for skin breakdown. A review of Resident #6's care plan with a review date of 5/26/23, indicated that the resident had an ADL self-care performance deficit related to muscle weakness and difficulty walking, back pain due to L1 compression fracture, frequent falls, and failure to thrive. Interventions included total transfer assistance of two persons using a Hoyer lift, and extensive to total assistance with toilet use, restorative dining for all meals. (Copy obtained) On 8/15/23 at 12:47 pm, an interview was conducted with the Administrator. He was asked about the grievance related to Resident #6. He stated the grievance was closed on 6/22/23. When asked about the findings, he said, staff were educated on check and change every 2 hours. He provided the in-service sign in sheet dated 6/16/23. When asked if the allegations were founded, he said that he was not sure, and confirmed that the resident and staff were not interviewed. When asked if there were any injuries to the resident, he again said that he was not sure and added that he would ask the ADON. When asked about the facility's abuse and neglect investigation and reporting policy, he stated that any allegation of abuse should be reported immediately within 2 hours. When asked if the allegation met the reporting requirements. He said that he would have to investigate. On 8/15/23 at 12:50 pm, the Administrator returned and stated he had interviewed the staff that was assigned to the resident, and she confirmed that she did not change Resident #6 per facility protocol. The administrator confirmed that a thorough investigation was not conducted and mentioned that he had not filed an immediate report. On 8/15/23 at 1:00 pm, Residents #5 and #6 were observed in room [ROOM NUMBER]. They were both seated in a wheelchair. An interview was attempted with Resident #6, however; she could not answer any questions. A green Hoyer lift pad was observed behind her back. Her roommate (Resident #5) said, that is my sister and I watch out for her. She is [AGE] years older than me. When asked about the care, she stated that 90% of the time the care was good. She added that sometimes the call light response was not the best and she has to wait 45 min - 1 hour. She added that about a month or so ago she turned the light on about 3:00 pm and it was not answered until 3:30 pm. She mentioned that on that day, she had not seen her sister from 6:30 am to 3:30 pm. She stated that her sister goes to the dining area for all her meals, and she required assistance and therefore the night shift staff normally dress her and get her up by 7:00 am. She said that when the restorative CNA brought her sister back to the room she was soaking wet. She added that she made a grievance to the social services. She was informed that staff had been educated to check and change the resident's every 2 hours. On 8/15/23 at 1:12 pm, an interview was conducted with CNA A. She stated that she has been in the facility for about a year and works as a restorative aide, but assists the staff as needed. When asked if she provided care to Resident #6, she said, yes, then continued to state that the resident was on restorative program for range of motion and assistance with meal. She added that resident attended dining for all meals. When asked who provided care to residents on restorative program, she said that the CNAs are assigned to the residents and are responsible for the care but could assist as needed. Normally those that attend dining for all meals are supposed to be dressed and ready to go to the dining room by 7:30 am for breakfast, therefore the night shift staff normally get them up. When asked if Resident #6 had any concerns with getting up early, she said the resident normally does not talk much, she will only answer yes or no questions. She added that her roommate/sister is her advocate. She confirmed that she had answered a call light for Resident 5 (Resident's #6 roommate/ sister). She was very upset because the call light had been on for a while and was concerned because Resident #6 had not been changed from 6:30 am - 3:30 pm. She explained that she went and got Resident #6 from the nurses station. She then assisted the resident to bed with the assigned 3-11 CNA and the resident was soaking wet, urine had penetrated through her brief to her pant and the Hoyer lift pad that was under her had made an imprint to her buttocks. After cleaning the resident, she notified the social worker. She stated that the CNA who was assigned to the resident during the day (7:00 am -3:00 pm) had already left for day. On 8/15/23 at 1:35 pm, an interview was conducted with CNA B. When asked how she was made aware of the residents functional status, she said, at the beginning of each shift the off going staff give a report about the residents, and if something is not shared then I would check the resident's chart or ask the nurse. When asked if she was familiar with Resident #6's functional needs she said, yes, she is total dependent, requires a Hoyer lift with two staff assist for transfer and was incontinent for bowel and bladder. When asked about the incident reported on 6/13/23 related to Resident #6, she stated that the resident was already up for the day when she got to the facility on that day. She added that the resident was also assigned to receive a shower and therefore she assumed that the shower team would change her. She confirmed that she did not check and change the resident during her shift. She said, I did not follow the facility protocol to check and change every 2 hours and I take accountability for not changing the resident and it will not happen again. A review of the facility's policy and procedures tilted, Abuse & Neglect, reviewed on 11/21/22 revealed: Reporting Allegations: In response to allegations of abuse, neglect exploitation, or mistreatment the facility must: Ensure that all alleged violations involving abuse or neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately, but not later than 2 hours after the allegation is made. Report the result of the investigation to the administrator or his or her designated representative and to other officials in accordance with State Law, including to the State Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. (Copy obtained)

Based on interviews, record reviews and policy and procedure review, the facility failed to ensure that all alleged violations of neglect were thoroughly investigated. The facility failed to investigate staff failure to provide assistance with activities of daily living (ADL) for more than 8 hours for one (Resident #6) of three residents whose grievances were reviewed, from a resident sample of eight. The findings include: A review of the facility's grievance log revealed a grievance dated 6/13/23 from Resident #5. Resident complained that her sister who was also her roommate (Resident #6) had not been checked and changed for over 8 hours from 6:30 am - 3:30 pm. On 6/14/23, the Assistant Director of Nursing (ADON) was assigned to investigate the concern. The investigation findings read, verified certified nursing Assistant (CNA) for that resident. The action taken included education for CNAs to check and change resident's every two hours. The grievance indicated that education was provided. (Photographic copy obtained) A review of the medical record for Resident #6 revealed an admitted [DATE] with re-entry date of 6/22/23. Her diagnoses included metabolic encephalopathy, muscle weakness, difficulty walking, dementia, and adult failure to thrive. A review of Resident #6's Modification of Medicare 5-day minimum data set (MDS) assessment dated [DATE] revealed she had a brief interview for mental status (BIMS) score of 1 out of 15 points, indicating severe cognitive impairment. The resident required extensive assistance with one staff for bed mobility, eating and toileting and extensive assistance with two people for transfer. The assessment also indicated that the resident was at risk for skin breakdown. A review of Resident #6's care plan with a review date of 5/26/23, indicated that the resident had an ADL self-care performance deficit related to muscle weakness and difficulty walking, back pain due to L1 compression fracture, frequent falls, and failure to thrive. Interventions included total transfer assistance of two persons using a Hoyer lift, and extensive to total assistance with toilet use, restorative dining for all meals. (Copy obtained) On 8/15/23 at 10:45 am, an interview was conducted with the Social Services Assistant. She was asked about the facility's grievance investigation procedure. She said, anyone can complete a grievance for the resident. There are blue cards at all nursing stations. Once I receive the grievance, they are assigned to the department heads for investigation. The department heads are required to return the grievance form with the resolution within 72 hour (most of the times it less than that) to social services. Once the grievance has been resolved, she then verifies with the residents if they are contented with the resolution, then I take the card to the administrator to sign. When asked about the grievance for Resident #5, she said she was notified by the restorative aide that the resident was very upset because her roommate who was also her sister had not been changed and had been up in her wheelchair from 6:30 am to 3:30 pm. She explained that the ADON was assigned to investigate the allegation, it was verified, and staff education was conducted. When asked if an abuse/neglect report was conducted, she stated that the administrator was responsible for reporting. When asked about the condition of Resident #6 and other resident that were taken care of by the staff involved. She said, I'm not sure, will ask the ADON. On 8/15/23 at 12:47 pm, an interview was conducted with the Administrator. He was asked about the grievance related to Resident #6. He stated the grievance was closed on 6/22/23. When asked about the findings, he said, staff were educated on check and change every 2 hours. He provided the in-service sign in sheet dated 6/16/23. When asked if the allegations were founded, he said that he was not sure, and confirmed that the resident and staff were not interviewed. When asked if there were any injuries to the resident, he again said that he was not sure and added that he would ask the ADON. When asked about the facility's abuse and neglect investigation and reporting policy, he stated that any allegation of abuse should be reported immediately within 2 hours. When asked if the allegation met the reporting requirements. He said that he would have to investigate. On 8/15/23 at 12:50 pm, the Administrator returned and stated he had interviewed the staff that was assigned to the resident, and she confirmed that she did not change Resident #6 per facility protocol. The administrator confirmed that a thorough investigation was not conducted and mentioned that he had not filed an immediate report. On 8/15/23 at 2:30 pm, a joint interview was conducted with the ADON and the administrator. The ADON confirmed that she was normally assigned to investigate grievances related to nursing services. When asked about the grievance on 6/13/23 related to Resident #6, she said that she conducted an in-service with staff on 6/16/23. When asked if she educated all the staff she said, no, only the staff that were on duty at that time. When asked if the resident had any injuries pertaining to the incident, she said that she did not conduct any skin assessment. She was then asked if there were any other residents that were affected, she said that she did not check or interview other residents assigned to the staff. The Administrator stated that the facility had initiated a PIP and all the grievances from June-August would be reviewed again to ensure that they were appropriately investigated/reported. A review of the facility's policy and procedures titled, Abuse - Conducting an Investigation, reviewed on 7/18/23 revealed: It is the policy of this facility that allegations of abuse (abuse, neglect, mistreatment, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated. The facility will prevent further abuse, neglect, exploitation and mistreatment from occurring while the investigation is in process; and take appropriate corrective action as a result of the investigation findings. Complaints and grievances will be investigated as outlined in the Concern & Comment (Grievance) program policy and will be reported immediately if the investigation reveals any alleged violation involving neglect, abuse (including injuries of unknown source) and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider, and as required by State Law. (Copy obtained)

Based on interviews and record reviews, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one (Resident #2) of 29 residents sampled, by failing to apply physician-ordered topical medication. The findings include: On 7/26/22 at 11:00 AM, an attempt was made to interview Resident #2. When asked if she had any concerns, she nodded yes. She had communication difficulty and was difficult to understand. She touched her knees, then said her daughter's name. When asked if her daughter should be contacted, she nodded yes. In a telephone interview on 7/26/22 at 2:41 PM, Resident #2's daughter stated she visited her mother regularly and attended her care plan meeting. She stated her only concern was that her mother's speech had gotten worse and she thought her mother had had mini strokes. She stated she had requested that her mother be evaluated by the speech therapist but she had not heard anything back about that. She also mentioned that her mother had been receiving medication very late. She had spoken to the nurse about the late medication administration because her mother required pain medication timely due to her arthritis. A medical record review revealed that Resident #2 was admitted to the facility on [DATE] with a re-entry on 4/23/22 and a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's July 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the annual minimum date set (MDS) assessment, dated 7/22/22, revealed that a Brief Interview for Mental Status score could not be obtained. The resident required limited assistance with bed mobility and toilet use, and supervision assistance with transfers. Her active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's care plan, with a review date of 7/13/22, revealed the resident had a communication problem related to unspecified voice and resonance disorder, and was at risk for complications related to pain due to [CONDITION(S)]. Interventions included: Staff to anticipate and meet resident needs and administer pain medication. (Copy obtained) A review of the July 2022 medication administration record (MAR) revealed that topical medications [MEDICATION(S)] Sodium 1% cream (100 grams) apply to knees topically four times a day for Arthritis, and [MEDICATION(S)] Cream 5 % ([MEDICATION(S)]), apply to forearms, hands, and fingers topically every shift for skin growth, were not initialed by nursing staff as having been administered. A review of the care management note dated 7/7/22, revealed, Annual care plan meeting via phone with interdisciplinary team (IDT) and resident's daughter. Discussed current code status, diet and weight. Current medications discussed and daughter questions whether dementia medicine needs to be increased. Another concern brought up is that medications are being administered too late. In an interview with the Social Services Director (SSD) on 7/27/22 at 2:34 PM, she stated, Anyone who receives resident's concerns is supposed to complete a grievance card. She added that concerns were discussed in the morning meetings and assigned to the appropriate department head for follow up. She added that concerns received/discussed during the care plan meetings should be coordinated by the nurse facilitating the care plan meeting. If not resolved at the time of the care plan meeting by the IDT, then a grievance card was completed. When asked if the were grievances from Resident #2, the SSD stated no. She added that she would follow up to see whether the concern was investigated. In an interview with Licensed Practical Nurse (LPN) D on 7/28/22 at 9:45 AM, she stated she was the assigned nurse for the day. When asked if she administered the [MEDICATION(S)] Sodium 1% cream (100 grams) and the [MEDICATION(S)] Cream 5 % ([MEDICATION(S)]), she scrolled through the MAR and stated the medication was on hold. She was asked why the medication was in hold and she replied that she was not sure and would find out. In an interview with Registered Nurse (RN) C/Interim Director of Nursing, on 7/28/22 at 11:00 AM, she confirmed that the medication was not administered for the entire month. She stated nurses and unit managers were responsible for auditing the charts, and if medication was not administered for 10 days, it was to be discontinued. She mentioned that she had contacted the pharmacy and was informed that the order was written inaccurately. She stated, The order said cream instead of gel and therefore the pharmacy could not dispense it. She added that she had contacted the physician for order clarification and a new order had been sent to the pharmacy. .

Based on observations, interviews, and record reviews, the facility failed to ensure that residents requiring respiratory care, received such care, consistent with professional standards of practice and the comprehensive care plan for three (Residents #53, #87 and #58) of five residents reviewed for oxygen use, from a total of 29 residents in the sample. The findings include: 1. Observations of Resident #53 were made on the following dates and times: On 7/26/22 at 3:05 PM, her oxygen concentrator flow rate was set at 4 LPM. (Photographic evidence obtained) The resident was asked if she knew what the flow rate should be, and she stated it should be set at 3 LPM. On 7/27/22 at 4:12 PM, the resident's oxygen concentrator flow rate was set at 4 LPM. (Photographic evidence obtained) On 7/28/22 at 11:04 AM, the resident's oxygen concentrator flow rate was set at 4 LPM. (Photographic evidence obtained) An interview was conducted with Licensed Practical Nurse (LPN) A on 7/28/22 at 11:15 AM. She stated if a resident was on oxygen, she would assess the resident to see if they had shortness of breath, and if their oxygen saturation was below 90, she would notify the resident's physician. She stated oxygen tubing and nebulizers were changed weekly. Every shift, the resident's oxygen saturation was checked unless the physician ordered it to be done more often. The nursing staff also checked the oxygen flow rates, the concentrators, and added water if it was empty, every shift. LPN A was asked to check Resident #53's oxygen flow rate order. She did and stated it was 3 LPM continuously. LPN A entered Resident #53's room on 7/28/22 at 11:20 AM and verified that the oxygen flow rate was set at 4 LPM. LPN A was observed adjusting the flow rate from 4 LPM to 3 LPM. A record review was conducted for Resident #53, who was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #53's annual minimum data set (MDS) assessment, dated 5/29/22, reported a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points, indicating intact cognition. She was also noted as receiving oxygen. Her Activities of Daily Living (ADLs) needs included extensive assistance of two persons for bed mobility and transfers. Walking did not occur and for locomotionm the resident was totally dependent and used a wheelchair. A review of the resident's active care plan revealed a focus area for a Risk for Decline in ADL function, and has a need for assistance with ADLs related to weakness, difficulty walking, and chronic disease processes secondary to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #53 was documented with a Risk for Episodes of Pain and Discomfort related to weakness and chronic disease processes secondary to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was also noted to be at Risk for Decreased Oxygen Saturation and Uncontrolled Shortness of Breath (SOB) related to chronic heart failure, [CONDITION(S)] and sleep apnea. A review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order start date was 5/2/22. A review of the July 2022 Treatment Administration Record (TAR) revealed that documentation was missing on 7/3, 7/10, and 7/17/22, to verify that the tubing was changed as ordered. Orders for oxygen saturation rates every shift with a start date of 1/19/22, and oxygen at a flow rate of 3 liters per minute (LPM), continuously per nasal cannula every shift, and dated 1/19/22, were also noted. 2. Observations of Resident #87's oxygen concentrator were made on the following dates and times: On 7/25/22 at 11:00 AM, the oxygen flow rate was set at 3 LPM. On 7/26/22 at 11:15 AM, the oxygen flow rate was set at 3 LPM. On 7/27/22 at 4:15 PM, the oxygen flow rate was set at 3 LPM. (Photographic evidence obtained) On 7/28/22 at 10:38 AM, the oxygen flow rate was set at 3 LPM. At the time of this observation, the resident stated the flow rate should have been set at 2 LPM and did not know why it was set at 3 LPM. An interview was conducted with LPN A on 7/28/22 at 11:15 PM. She stated Resident #87 had an oxygen order for a flow rate of 2 LPM continuously. An observation of Resident #87's oxygen concentrator was made on 7/28/22 at 11:21 AM with LPN A. She verified that the resident's oxygen was set at 3 LPM. LPN A was then observed adjusting the flow rate from 3 LPM to 2 LPM. A record review was conducted for Resident #87, revealing an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's quarterly MDS assessment, dated 6/24/22, revealed a BIMS score of 12 out of a possible 15 points, indicating minimal to moderate cognitive impairment. Her bed and transfer needs were documented as extensive with one-person assistance, and she was noted to become SOB while lying flat. Falls were documented since admission and she was receiving oxygen therapy. A review of the resident's July 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility's Oxygen Administration/Safety/Storage/Maintenance policy (revised on 8/2/2021) read: Purpose: To assure that oxygen is administered and stored safely within the healthcare centers or in an outside storage area. Infection Control: Change oxygen supplies weekly and when visibly soiled. 3. On 7/25/22 at 12:25 PM, Resident #58 was observed in bed wearing a nasal cannula. His oxygen concentrator was observed at his bedside and the flow rate was set at 4.5 LPM. (Photographic evidence obtained). On 7/28/22 at 9:58 AM, Resident #58's oxygen concentrator was again observed with a flow rate set at 4.5 LPM. (Photographic evidence obtained) A review of Resident#58's medical record revealed he was admitted into the facility on [DATE] with a re-entry on 6/9/2022. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Document every shift for [CONDITION(S)] ([CONDITION(S)]), dated 5/31/2022; Oxygen saturation rates every shift for [CONDITION(S)], dated 5/31/2022; Change oxygen tubing every night shift every Sunday for [CONDITION(S)], dated 5/31/2022; Clean oxygen concentrator filter with soap and water weekly every Sunday, dated 5/31/2022; and Oxygen at 4 LPM via nasal cannula as needed for oxygen saturation if less than 91 percent, dated 6/28/2022. A review of a progress note dated 6/28/2022 at 6:44 PM, read, Oxygen saturation at 90.0 percent, oxygen via nasal cannula. Further review revealed an administration note on the same date at 6:47 PM, which read, Oxygen at 4 liters per minute per nasal cannula as needed for oxygen saturation if less than 91 percent. A subsequent nurse's note at 9:02 PM read, Oxygen in place as ordered. On 7/28/22 at 12:25 PM, Registered Nurse (RN) F was asked to observe Resident #58's oxygen concentrator. The resident's room was entered and after observation of the unit, RN F confirmed that the oxygen flow rate was set at 4.5 LPM. (Photographic copy obtained). When she was asked what the resident's flow rate should be set at, she stated the resident had one oxygen order for oxygen at 3 LPM continuously, and another order for oxygen at 4 LPM, as needed, if his oxygen saturation was less than 91 percent. If the resident's oxygen saturation rose above 91 percent, the resident was to be placed back on 3 LPM. The resident's active care plan included a focus area for congestive heart failure. Interventions included oxygen via nasal cannula at 2 LPM every night. Another focus area was for coronary artery disease. Interventions included oxygen via nasal cannula at 2 LPM every night. A third focus area was for oxygen therapy. Interventions included oxygen settings via nasal cannula at 4 L/min every night. On 7/28/22 at 1:37 PM, the Director of Nursing (DON) confirmed that the Unit Manager should complete order changes in the electronic medical record as orders were received from the physician. She stated there was a report that was checked daily which showed orders that were in queue and care plans were updated and communicated with family members. She stated, We meet every morning and review care plans. At 3:00 PM, we discuss what happened throughout the day, changes families like to see made, updates, and concerns with care plans. .

Based on interview and record review, the facility failed to report the results of an investigation to the State Survey Agency within five working days of the incident for one allegation of misappropriation of resident property involving Resident #48, out of three incident investigations reviewed for compliance. The findings include: A review of Resident #48's clinical record revealed he was admitted to the facility on [DATE] with a primary medical [DIAGNOSES REDACTED]. The resident's cognition was impaired and he required extensive assistance with activities of daily living. A review of the facility's incident reports revealed that on 1/12/2021, the facility submitted an Immediate Federal Report related to an allegation of misappropriation of resident property for Resident #48. On 1/21/2021, the facility submitted a Five-Day Federal Report containing the findings of the investigation for the allegation of misappropriation of resident property for Resident #48. On 2/5/2021 at 3:50 p.m., an interview was conducted with the Director of Nursing (DON). She was asked to confirm the date the results of the investigation involving Resident #48 were submitted. She confirmed that the investigation findings were submitted to the State Survey Agency on 1/21/2021. A review of the facility's policy, titled Protection of Residents: Reducing the Threat of Abuse & Neglect, was conducted. The policy indicated that the facility must satisfy the federal requirement to report the results of an investigation within 5 working days from the date of the incident and that any report after that time would be considered out of compliance with the regulation. (Photographic Evidence Obtained)

Based on record review and interview, the facility failed to ensure the accuracy of the Preadmission Screening for individuals with a mental disorder and/or an intellectual disability for four (Residents #14, #37, #94 and #41) of 38 sampled residents. Failure to ensure the accuracy of the Preadmission Screening and Resident Review (PASRR) could result in a resident's not receiving necessary health care services, which could contribute to a cognitive or physical decline in health status. The findings include: 1. A record review for Resident #14 revealed he was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. His last readmission was on 10/13/2020, at which time he returned to the facility with a [DIAGNOSES REDACTED]. Further review of Resident #14's record revealed a PASRR screening dated 2/23/2017. The PASRR failed to identify the [DIAGNOSES REDACTED].#14. There was no record of a referral for/or a Level II assessment after the screening. 2. A record review for Resident #37 revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her last readmission was on 11/10/2019. Additional [DIAGNOSES REDACTED].#37 included schizophreniform disorder and anxiety disorder. Further review of Resident #37's record revealed a PASRR dated 8/27/2018. The PASRR identified the SMI [DIAGNOSES REDACTED]. There was no record of a referral for/or a Level II assessment after the screening. 3. A record review for Resident #94 revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Additional [DIAGNOSES REDACTED].#94 included major [MEDICAL CONDITION]. Further review of Resident #94's record revealed a PASRR dated 10/30/2020. The PASRR identified SMI [DIAGNOSES REDACTED]. There was no record of a referral for/or a Level II assessment after the screening. 4. A record review revealed that Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Additional [DIAGNOSES REDACTED].#41 included major [MEDICAL CONDITION] and anxiety disorder. Further review of Resident #41's record revealed a PASRR dated 3/13/2017. The PASRR identified SMI [DIAGNOSES REDACTED]. There was no record of a referral for/of a Level II assessment after the screening. During an interview conducted on 2/2/2021 with Employee A, Licensed Practical Nurse (LPN), she stated PASRRs were reviewed for accuracy by the facility nurses upon a resident's admission. She acknowledged that the PASRRs were incorrect and stated, The screener should have caught the error. During an interview on 2/2/2021 at 4:00 pm with the Director of Nursing (DON), she stated it was the responsibility of facility staff to ensure the accuracy of the PASRRs. She confirmed that the PASRR's identified were inaccurate. She stated she would consult the regulations and she and the Executive Director would review the PASRRs to identify residents who required Level II services. During a follow-up interview on 2/4/2021 at 10:40 am with the DON, she confirmed that the PASRR Level I screenings for Residents #14, #37, #94 and #41 were inaccurate and/or incomplete and that there had been no referrals for Level II services for these residents.

Based on observation, interviews and record review, the facility failed to provide services which met professional standards of quality, by failing to ensure qualified staff assessed residents with pressure ulcers for 1 (Resident #80) of 2 sampled residents, and by failing to adhere to professional standards of infection control practices related to wound care and dressing changes for 1 (Resident #80) of 2 residents sampled for pressure ulcers from a total sample of 29 residents. Professional Standard of Care is defined in Chapter 766.102 as, the prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment which in light of all relevant surrounding circumstances is recognized as acceptable and appropriate by reasonably prudent similar health care providers. The Florida Nurse Practice Act, Chapter 464.003 defines the practice of professional nursing as the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not limited to: the administration of medications and treatments as prescribed or authorized by a duly licensed practitioner ' practice of practical nursing as the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured or infirmed and the promotion of wellness, maintenance or health, and the prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician or a licensed dentist. The findings include: 1. A record review for Resident #80 revealed a [AGE] year-old female admitted on [DATE] with [DIAGNOSES REDACTED]. She was alert and oriented, and required extensive assistance with activities of daily living, except eating, related to fracture of right femur. A review of the initial nursing assessment dated [DATE], revealed there was no skin breakdown. A review of the Minimum Data Set (MDS) assessment, Section M, dated 1/13/19, revealed there were no pressure ulcers. On 1/14/19, Resident # 80 was found with a pressure ulcer to the right heel. The initial wound assessment, dated 1/14/19, included: wound was assessed as pressure ulcer, unstageable suspected deep tissue injury, and measured 2 cm x 2 cm (centimeters), 100% closed blister. The assessment was conducted by the Wound Nurse (WN), who was a Licensed Practical Nurse (LPN). On 1/17/19 the wound measured 3 cm x 2.5 cm and the wound base was documented as 100% deep tissue injury. On 1/25/19, the wound measured 3 cm x 2.5 cm. On 2/1/19, the WN documented that the skin was intact, the wound was a stage 2, and 100% [MEDICATION NAME] tissue was present. On 2/7/19, the wound was documented as unstageable suspected deep tissue injury, with 50% [MEDICATION NAME] and 50 % deep tissue and improving. On 2/14/19, the wound was documented as unstageable with slough/eschar, and measured 3 cm x 2.5 cm with no change. A review of the 1/14/19 physician's orders [REDACTED]. An interview was conducted with Resident #80 on 2/19/19 at 11:30 am. During the interview she was observed with a protective boot on her right foot. She was asked about the reason for the heel boot, and she stated she had a sore on her right heel that she did not have when she came into the facility. An interview was conducted with the Wound Nurse on 2/20/19 at 10:00 am. She was asked who measured and staged the wounds. She stated she did. She was asked if there was a wound physician that came to the facility, and she stated no. She stated if residents needed a wound physician, they were sent out to the wound clinic. An interview was conducted with the Staff Development Nurse on 2/20/19 at 2:45 pm. When asked if the LPN wound care nurse had any type of wound care certification, she stated yes. She was asked if the LPN wound nurse assessed and staged wounds, and she replied that the LPN did not assess, she documented her observations. When asked if a Registered Nurse assessed and staged the residents' wounds, she stated that the DON supervised the LPN. She further stated that the wounds were discussed weekly at the Interdisciplinary Team (IDT) meeting. When asked whether the DON was present when weekly wound assessments and measurements were performed, she stated the DON reviewed the findings. 2. An observation of a dressing change to Resident #80's right heel was made on 2/20/19 at 10:50 am. The dressing change was performed by the Wound Nurse (WN). She prepared the supplies and wrapped them in aluminum foil, then placed the wrapped supplies on the bedside table. The table contained the resident's personal items, and was not sanitized. Nor was a barrier placed on the table prior to placing the wound supplies on the table. Upon entering the room, Resident #80 was observed sitting in the wheelchair beside her bed. A male Certified Nursing Assistant (CNA) was present to assist. Resident #80 was not transferred onto the bed for the dressing change. The WN placed a towel on the floor under the resident's feet. The WN cleansed her hands with hand sanitizer from her pocket, then donned gloves. She retrieved a pair of bandage scissors from her pocket and removed the soiled dressing from the right heel. The WN removed her gloves and used hand sanitizer, then donned new gloves. The CNA was instructed to hold up the right leg, so the wound could be cleansed. The nurse had to stoop down to the floor to attempt to clean the wound with normal saline (NS). The NS was in a small individual packet and had to be held upside down to try to irrigate the wound. The saline ran down onto the gauze pad. Due to the positioning of the right foot, only partial observation could be made of the wound. The observation revealed dark eschar (dead tissue) covering the right heel. There was no drainage noted. The treatment included application of Santyl ointment. The nurse applied Santyl with an applicator to the wound, however the wound was not well visualized to ensure the Santyl was placed only on the wound and not on surrounding tissue. When the dressing change was completed, the soiled dressing was placed in red bag for disposal. The WN was observed going into the bathroom to wash her hands. When she came out, she had her scissors wrapped in paper towel. When asked how she cleaned the scissors, she stated she used soap, water and an alcohol wipe. She was asked if they were her personal scissors and she stated yes. She was asked if she kept them in her pocket to use with other residents, and she stated yes.

Based on record review and interviews, the facility failed to ensure that services provided or arranged by the facility were provided by qualified persons in accordance with the resident's written plan of care, by failing to ensure pressure ulcer assessments were performed by a Professional Registered Nurse for 1 (Resident #80) of 2 residents sampled for pressure ulcers from a total sample of 29 residents. The findings include: A record review for Resident #80 revealed a [AGE] year-old female admitted on [DATE] with [DIAGNOSES REDACTED]. She was alert and oriented, and required extensive assistance with activities of daily living, except eating, related to fracture of right femur. A review of the initial nursing assessment dated [DATE], revealed there was no skin breakdown. A review of the Minimum Data Set (MDS) assessment, Section M, dated 1/13/19, revealed there were no pressure ulcers. On 1/14/19, Resident # 80 was found with a pressure ulcer to the right heel. The initial wound assessment, dated 1/14/19, included: wound was assessed as pressure ulcer, unstageable suspected deep tissue injury, and measured 2 cm x 2 cm (centimeters), 100% closed blister. The assessment was conducted by the Wound Nurse (WN), who was a Licensed Practical Nurse (LPN). On 1/17/19 the wound measured 3 cm x 2.5 cm and the wound base was documented as 100% deep tissue injury. On 1/25/19, the wound measured 3 cm x 2.5 cm. On 2/1/19, the WN documented that the skin was intact, the wound was a stage 2, and 100% [MEDICATION NAME] tissue was present. On 2/7/19, the wound was documented as unstageable suspected deep tissue injury, with 50% [MEDICATION NAME] and 50 % deep tissue and improving. On 2/14/19, the wound was documented as unstageable with slough/eschar, and measured 3 cm x 2.5 cm with no change. A review of the 1/14/19 physician's orders [REDACTED]. An interview was conducted with Resident #80 on 2/19/19 at 11:30 am. During the interview she was observed with a protective boot on her right foot. She was asked about the reason for the heel boot, and she stated she had a sore on her right heel that she did not have when she came into the facility. An interview was conducted with the Wound Nurse on 2/20/19 at 10:00 am. She was asked who measured and staged the wounds. She stated she did. She was asked if there was a wound physician that came to the facility, and she stated no. She stated if residents needed a wound physician, they were sent out to the wound clinic. An interview was conducted with the Staff Development Nurse on 2/20/19 at 2:45 pm. When asked if the LPN wound care nurse had any type of wound care certification, she stated yes. She was asked if the LPN wound nurse assessed and staged wounds, and she replied that the LPN did not assess, she documented her observations. When asked if a Registered Nurse assessed and staged the residents' wounds, she stated that the DON supervised the LPN. She further stated that the wounds were discussed weekly at the Interdisciplinary Team (IDT) meeting. When asked whether the DON was present when weekly wound assessments and measurements were performed, she stated the DON reviewed the findings.

Based on observation, interview and record review, the facility failed to provide necessary services to maintain good nutrition by failing to ensure that 1 (Resident #64) of 1 residents reviewed for activities of daily living (ADL) care, in a total sample of 29 residents, received the assistance he needed with dining. The findings include: On 2/18/2019 at 12:17 PM, Resident #64 was observed sitting in bed with an over-the-bed table in front of him. His lunch tray with a plate containing pureed food and a spoon sitting in the middle of the food was observed on the table. Resident #64 was holding a bowl up to his mouth and was trying to get the pureed food to slide into his mouth. He was using his tongue to try to get the food out of the bowl. The food was dripping on to his bed clothes and blanket. He was asked if he needed help and he did not respond. After a few minutes and an inability to get any food from the bowl, he put it down on top of the food and spoon that was on his plate. Resident #64's call light was used to call for assistance when he put the bowl down. After approximately 2-3 minutes, a certified nursing assistant (CNA), Employee G, approached Resident #64's room. Employee G was asked if Resident #64 needed assistance with eating. She stated he ate on his own and she went in to assist him when needed. A record review for Resident #64 found he was admitted to the facility on [DATE] with the most recent admission on 9/24/2017. He was diagnosed with [REDACTED]. A review of the 1/11/2019 Quarterly Minimum Data Set (MDS) assessment found he was not able to be assessed for his mental status. He had long- and short-term memory problems, and his cognitive skills for decision making were severely impaired. A review of Section G found he needed extensive/one plus person physical assistance for eating. A review of Resident #64's care plan for activities of daily living, found it did not address eating/meals. A review of the nutritional risk care plan for Resident #64 found the approach to provide dining room/meal accommodations. The care plans had a hand written date of 1/14/2019 with a hand written note to continue the plan of care. A review of the (MONTH) 2019 physician's orders [REDACTED].#64 found an order dated 10/20/2017 with the following information written, Clarification for safe swallow protocol: 1. Fully upright in chair per oral 2. Supervised dining 3. Offer and encourage dining in the dining room. On 2/20/2019 at 8:08 AM, Resident #64's CNA (Employee H) was observed leaving Resident #64's room with his meal tray. In an interview with Employee H on 2/20/19 at 8:08 AM, she stated Resident #64 required a lot of assistance. He can hold a spoon, but he needs some help in moving the spoon to his mouth because he forgets the movement. She stated she and the other CNA (Employee G) were going to inform the Unit Manager. In an interview with the Unit Manager (Employee I) on 2/20/2019 at 9:00 AM, he stated he was not aware of any changes with Resident #64's eating ability until now. He stated Resident #64 usually ate in his room. He further stated that the resident would still eat in his room, but now that he had a decline, he was going to make him a total feed. During a second interview with Resident #64's CNA (Employee H) on 2/20/2019 at 11:37 AM, she was asked how the CNAs knew where Resident #64 should eat, or if he could be left alone in his room to eat. She stated there was nothing specific that they were told or that was in the CNA care system, but that they had tried to get him to eat in the dining room. During an interview on 2/20/2019 at 11:42 AM, with the MDS nurse (Employee K), she stated the CNAs should know each resident's dining needs based on what was documented in their computer system. She was asked to review the physician's orders [REDACTED].#64 and she confirmed what was written. During a second interview with MDS Nurse K, which included MDS Nurse J on 2/20/2019 at 12:07 PM, Employee J stated Resident #64 was going to be evaluated by speech therapy, and they were going to have the resident's physician fix his order, because he was now on thin liquids and was not at risk of aspirating. Further record review for Resident #64 found a new order was written on 2/20/2019 for Resident #64 to have all meals in restorative dining.

Based on observation, record review and staff and resident interview, the facility failed to ensure residents received care, consistent with professional standards of practice, to prevent new pressure ulcers and to promote healing of existing pressure ulcers, in part, by preventing infection to the extent possible. The facility failed to implement pressure relief measures to prevent the development of a pressure ulcer and failed to observe infection prevention measures during a dressing change for 1 (Resident #80) of 2 residents sampled for pressure ulcers out of a total sample of 29 residents. The findings include: 1.A record review for Resident #80 revealed a [AGE] year-old female admitted on [DATE] with [DIAGNOSES REDACTED]. She was alert and oriented, and required extensive assistance with activities of daily living, except eating, related to fracture of right femur. A review of the initial nursing assessment dated [DATE], revealed there was no skin breakdown. A review of the Minimum Data Set (MDS) assessment, Section M, dated 1/13/19, revealed there were no pressure ulcers. On 1/14/19, Resident # 80 was found with a pressure ulcer to the right heel. The initial wound assessment, dated 1/14/19, included: wound was assessed as pressure ulcer, unstageable suspected deep tissue injury, and measured 2 cm x 2 cm (centimeters), 100% closed blister. The assessment was conducted by the Wound Nurse (WN), who was a Licensed Practical Nurse (LPN). On 1/17/19 the wound measured 3 cm x 2.5 cm and the wound base was documented as 100% deep tissue injury. On 1/25/19, the wound measured 3 cm x 2.5 cm. On 2/1/19, the WN documented that the skin was intact, the wound was a stage 2, and 100% [MEDICATION NAME] tissue was present. On 2/7/19, the wound was documented as unstageable suspected deep tissue injury, with 50% [MEDICATION NAME] and 50 % deep tissue and improving. On 2/14/19, the wound was documented as unstageable with slough/eschar, and measured 3 cm x 2.5 cm with no change. A review of the 1/14/19 physician's orders [REDACTED]. An interview was conducted with Resident #80 on 2/19/19 at 11:30 am. During the interview she was observed with a protective boot on her right foot. She was asked about the reason for the heel boot, and she stated she had a sore on her right heel that she did not have when she came into the facility. An interview was conducted with the Wound Nurse on 2/20/19 at 10:00 am. She was asked who measured and staged the wounds. She stated she did. She was asked if there was a wound physician that came to the facility, and she stated no. She stated if residents needed a wound physician, they were sent out to the wound clinic. An interview was conducted with the Staff Development Nurse on 2/20/19 at 2:45 pm. When asked if the LPN wound care nurse had any type of wound care certification, she stated yes. She was asked if the LPN wound nurse assessed and staged wounds, and she replied that the LPN did not assess, she documented her observations. When asked if a Registered Nurse assessed and staged the residents' wounds, she stated that the DON supervised the LPN. She further stated that the wounds were discussed weekly at the Interdisciplinary Team (IDT) meeting. When asked whether the DON was present when weekly wound assessments and measurements were performed, she stated the DON reviewed the findings. 2. An observation of a dressing change to Resident #80's right heel was made on 2/20/19 at 10:50 am. The dressing change was performed by the Wound Nurse (WN). She prepared the supplies and wrapped them in aluminum foil, then placed the wrapped supplies on the bedside table. The table contained the resident's personal items, and was not sanitized. Nor was a barrier placed on the table prior to placing the wound supplies on the table. Upon entering the room, Resident #80 was observed sitting in the wheelchair beside her bed. A male Certified Nursing Assistant (CNA) was present to assist. Resident #80 was not transferred onto the bed for the dressing change. The WN placed a towel on the floor under the resident's feet. The WN cleansed her hands with hand sanitizer from her pocket, then donned gloves. She retrieved a pair of bandage scissors from her pocket and removed the soiled dressing from the right heel. The WN removed her gloves and used hand sanitizer, then donned new gloves. The CNA was instructed to hold up the right leg, so the wound could be cleansed. The nurse had to stoop down to the floor to attempt to clean the wound with normal saline (NS). The NS was in a small individual packet and had to be held upside down to try to irrigate the wound. The saline ran down onto the gauze pad. Due to the positioning of the right foot, only partial observation could be made of the wound. The observation revealed dark eschar (dead tissue) covering the right heel. There was no drainage noted. The treatment included application of Santyl ointment. The nurse applied Santyl with an applicator to the wound, however the wound was not well visualized to ensure the Santyl was placed only on the wound and not on surrounding tissue. When the dressing change was completed, the soiled dressing was placed in red bag for disposal. The WN was observed going into the bathroom to wash her hands. When she came out, she had her scissors wrapped in paper towel. When asked how she cleaned the scissors, she stated she used soap, water and an alcohol wipe. She was asked if they were her personal scissors and she stated yes. She was asked if she kept them in her pocket to use with other residents, and she stated yes.

Based on record review and staff interview, the facility failed to provide an environment as free of accident hazards as possible for 1 (Resident #32) of 2 residents sampled for falls with injury from a total of 29 sampled residents. The findings include: A record review for Resident #32 revealed a [AGE] year-old female admitted on [DATE] with a [DIAGNOSES REDACTED]. On 10/28/18 she was found sitting on her buttocks in the doorway of her room. She was observed with a large protrusion of the inner left elbow. She stated her pain level was 10 on a scale of 1-10 with 10 being the worst possible pain. When the nurse asked what happened, she stated she tripped over her roommate's oxygen tubing. The physician was notified, and she was transferred to the hospital. She was found to have a dislocated left elbow. The elbow was reset, and was placed in a cast along with a sling. She returned to the facility with orders for pain medication and orthopedic follow up. A review of the care plan dated 9/7/18 included a potential for falls related to medications and decreased mobility due to [MEDICAL CONDITION]. The interventions included: ensure proper fitting shoes, maintain environment free of clutter and safety hazards, place frequently used items within reach, provide adequate lighting, place call light within reach and bed in low position. An interview was conducted with the Director of Nursing (DON) on 2/21/19 at 11:10 am. When asked who was responsible for investigating falls, she stated that she was, along with the interdisciplinary team. She was asked about the findings for Resident #32. She said Resident #32 told the staff that she tripped over her roommate's oxygen tubing. She stated the facility performed a root cause analysis on 10/29/18. It was determined that the resident tripped over the oxygen tubing. When asked if the roommate used continuous oxygen, the DON replied, Yes, she had an oxygen concentrator at her bedside. She was asked if the roommate's bed was by the bathroom or the window, and she stated the window. She was asked whether the resident required oxygen to ambulate to the bathroom, and she replied yes. When asked what measures were put into place to prevent further occurrences, she stated Resident #32 was moved to another room. An interview was conducted with the Registered Nurse (RN) (Employee A) on 2/21/19 at 1:15 pm. She was asked if she was the nurse assigned to Resident #32 on 10/28/18 when she fell and sustained a dislocated left elbow. She confirmed that she was. She was asked about the circumstances of the fall, and she stated that she did not witness the incident. The CNA notified her of the incident and she went to the room. The resident was sitting on the floor at the doorway holding her left arm. She complained of severe pain. She asked the resident what happened, and the resident told her that she tripped over the roommate's oxygen tubing. She also stated that the roommate very quickly moved the tubing away from where she fell . She was asked if the roommate was in the bed by the bathroom or the window, and she replied the window. When asked whether she required continuous oxygen including times when walking to the bathroom, and she said yes. She was asked if the tubing reached from the concentrator across the room into the bathroom, and she stated yes. When asked if the room had been assessed for safety hazards related to the very long length of oxygen tubing, she stated, No, but we should have.

Based on observation, record review and staff and resident interviews, the facility failed to ensure that residents who required [MEDICAL TREATMENT] services, received such services, consistent with professional standards of practice, by failing to follow fluid restriction orders related to [MEDICAL TREATMENT] care for 1 (Resident #80) of 1 residents sampled for [MEDICAL TREATMENT] out of a total sample of 29 residents. The findings include: A record review for Resident #80 revealed a [AGE] year-old female admitted on [DATE] with [DIAGNOSES REDACTED]. She went out to the [MEDICAL TREATMENT] center three times a week for treatment. On 2/6/19 upon return from [MEDICAL TREATMENT], she was sent with a new order for a 1500 ml (milliliter) fluid restriction. The fluid restriction was necessary as Resident #80 was retaining excess fluid. During an interview with Resident #80 on 2/19/19 at 11:30 am, she was asked if she was on a fluid restriction, and she stated yes. She was asked if she knew the amount of fluids she was to receive each day, and she replied that she wasn't sure. During the interview, an observation of the bedside table found a 16 ounce Styrofoam cup filled with water and an 8 ounce bottle of apple juice. When she was asked how much water was she allowed to have each day, she did not know. She was asked if the facility had provided the apple juice, and she stated, no, her family brought it. A review of the nutrition note dated 2/8/19 revealed the resident was ordered a 1500 ml fluid restriction due to fluid retention. The registered dietitian (RD) determined that Resident #80 would receive 1200 ml from dietary on the meal trays and 100 ml three times a day from nursing for administration of medications. Further review of the record found no documentation indicating how staff were monitoring and recording the resident's fluid intake. An interview was conducted with the Registered Nurse (Employee A) on 2/20/19 at 1:45 pm. She was asked if Resident #80 was ordered a fluid restriction, and she stated yes, 1500 ml per day. When asked where the nurses documented fluid intake, she replied that they had no place to document that information. When asked how she knew the amount of fluid consumed, she stated she did not know. She further stated that dietary and nursing were allotted the amount to be given. She was asked how the Certified Nursing Assistants (CNAs) were informed of the fluid restriction, and she stated the information was in the care directives. A review of the care directives for Resident #80 did not include a fluid restriction. An interview was conducted with the Director of Nursing (DON) on 2/20/19 at 2:15 pm. When asked where the nurses documented fluid restriction, she stated there was no place to document that information. The amounts allotted for dietary and nursing were determined by the dietitian. When asked who monitored for compliance, she said the nurses were responsible. When asked if the resident had been provided education regarding fluid restriction, she was unaware. The DON was asked if residents on fluid restriction could have water at the bedside, and she replied no. An observation of the resident's room on 2/20/19 at 2:35 pm, found a full cup of ice water and 2 bottles of juice on the bedside table. An interview was conducted with the Staff Development Nurse on 2/20/19 at 2:40 pm. When asked how the staff documented fluid restriction, she said they did not record the amounts. The amount was determined by the dietitian, and that was what the resident received. A review of the facility's policy [MEDICAL TREATMENT] revealed: Monitor intake and output on an eight-hour shift and 24-hour basis, observe fluid restriction as ordered by physician, document resident's compliance/non-compliance with food or fluid restrictions.

Based on observation, interview with resident and staff, record review and facility policy review, the facility failed to follow accepted standards of nursing practice regarding pressure ulcer prevention when it failed to remove a resident's leg brace and check the integrity of the skin as ordered for 1 of 3 residents (Resident #2). The facility also failed to anticipate and treat Resident #2's pain associated with the wound care for the pressure ulcer. This resulted in actual harm with the development of a pressure ulcer to the resident's left heel, which became infected, had increased drainage and associated pain, and required antibiotic treatment. Professional Standard of Care is defined in Chapter 766.102 as the prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment which in light of all relevant surrounding circumstances is recognized as acceptable and appropriate by reasonably prudent similar health care providers. The Florida Nurse Practice Act, Chapter 464.003 defines the practice of professional nursing as the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not limited to: 1. The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. 2. The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner. The practice of practical nursing is defined as the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured or infirmed and the promotion of wellness, maintenance or health, and the prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician or a licensed dentist. The findings include: 1. The history and physical for Resident #2, dated 3/26/2015 and signed by the resident's physician, revealed that she was admitted to the facility on that date after conservative treatment (nonsurgical) in the hospital for a [MEDICAL CONDITION] distal femur (lower thigh bone). The resident was placed in an immobilizer brace to the left lower leg. Skin was intact. The resident was alert and oriented to time, place and person. Record review of Resident #2's Initial Data Collection Tool dated 3/26/2015 revealed in the section for skin condition that she did not have any wounds on her left foot. Record review of the Minimum Data Set Assessment for Resident #2 dated 4/2/15 revealed she was at risk for developing pressure ulcers. She was admitted with a Stage 2 pressure ulcer to the coccyx. No [MEDICAL CONDITION] were present on the left foot. The resident ' s cognition was scored 9 out of a possible score of 15 (moderately impaired). The resident's Care Area Assessment revealed that the resident was alert and oriented to time, place and person, and stated do not proceed with cognition care plan. The next Minimum Data Set assessment dated [DATE] recorded the resident's cognition as 15, no cognitive impairment. Record review of the Braden Scale pressure ulcer risk for Resident #2 revealed a score of 14 out of a possible 18, moderate risk, on the following dates: 3/26/15, 4/23/15, and 5/5/15. Record review of a physician's order for Resident #2 dated 3/26/15 revealed remove left leg brace every other day and check skin on Monday, Wednesday, and Friday. Review of the March and April, 2015 treatment records for Resident #2 revealed that the order to remove left leg brace every other day for skin check was signed as completed on Saturday 3/28/15. The next date that the skin check was signed off was Monday 4/6/15 (8 days elapsed). Further review of the resident's April, 2015 treatment record revealed that 13 days in April were designated for removal of the leg brace (Saturday and Sunday of every week were skipped). Additional designated days in April, 2015 for removal of the leg brace for skin check were also undocumented (4/13/15, 4/15/15, 4/24/15, and 4/27/15). Record review of nursing progress notes for Resident #2 dated 4/18/15 revealed, Resident noted with red pressure mark on lateral side of left foot and on the bottom lateral side of the foot noted with an area of maroon dark tissue injury, and left heel has necrotic (dead) tissue area. Review of the Advanced Registered Nurse Practitioner's (ARNP) progress notes for Resident #2, dated 4/16/16, revealed that she was advised by nursing of a concern for the beginning of a pressure ulcer to the resident's left lateral foot and heel from the brace. Record review of the weekly pressure ulcer tracking report for Resident #2, dated 6/2/15, revealed a left heel wound that started on 4/18/2015, approximately 3 weeks after the resident was admitted to the facility. The wound was recorded as unstageable (unable to determine depth), and measured 2.7 centimeters (cm) x 1.5 cm x 4.05 cm (total surface) x 0.1 cm depth. The left lateral foot was described as a suspected deep tissue injury that started on 4/18/2015 and measured 0.2 cm x 0.3 cm x 0.6 cm total surface, and unable to record depth at this time. Record review of the skin integrity plan of care for Resident #2, dated 5/8/15, revealed two new suspected deep tissue injury areas to left foot, heel and lateral foot. The left heel was described an unstageable. The approach was to remove left leg brace for skin observation per physician orders, observe for pain and medicate as needed per physician orders, and minimize pressure over boney prominences. A physician's order for Resident #2 dated 4/16/15 stated off-load left heel: make sure brace is in proper position every 2 hours. Review of the resident's April, 2015 treatment record revealed that this order was not signed as completed on 6 of 30 AM or PM shifts from April 16 through April 30, 2015 (4/17/15, 4/20/15, 4/22/15, and 4/30/15 on the AM shift. Also 4/28/15 on both the AM and PM shifts). This order was not transcribed onto the resident's medication or treatment records in May or June, 2015. There was no documentation in the resident ' s record that this was done in May or June, 2015. Review of Resident #2's Orthopedic consult notes dated 4/15/15 revealed instructions to inspect the resident's heel daily for decubitus prevention. A physician's order was written for Resident #2 dated 4/15/15 to inspect heel daily-decubitus-prevention. This order was not transcribed onto the resident ' s medication or treatment records in May or June, 2015. There was no documentation in the resident ' s record that this was done in May or June, 2015. Orthopedic consult notes for Resident #2 dated 4/24/15 stated adjust brace for better fit, continue wound care and off-load foot. This order was not transcribed onto the resident's medication or treatment records in May or June, 2015. Review of progress notes for Resident #2 dated 5/12/15 revealed Left heal wound now unstageable. Areas of slough (dead tissue). Change dressing daily. Orthopedic visit notes for Resident #2 dated 5/13/15 revealed an order to call the brace company and remove shoe portion of brace. Still needs immobilizer. The resident's shoe brace was removed on 5/14/15. Record review revealed staff were trained on 5/19/15 on proper fit of the resident's brace, and heel off-loading. Review of the facility's Unavoidable Pressure Ulcer Assessment for Resident #2, dated 6/2/15 and completed by the wound care nurse, revealed that the question Was a preventive plan of care initiated on admission and consistently thereafter? was marked Yes . Were appropriate preventive measures provided? was also marked Yes . Review of a physician's order for Resident #2 dated 6/4/15 revealed the resident started antibiotic treatment for [REDACTED]. In an interview on 6/7/15 at 6:04 pm with the Assistant Director of Nursing (ADON), she stated that Resident #2 did not come to the facility with wounds on her feet. The ADON said the resident's left heel and the left lateral foot sores developed on 4/15/2015. She said the left heel wound was found under the immobilizer of the left foot. She said, When Ortho writes an order, we follow the recommendations. Upon review of the resident's treatment records for March through June, 2015, the ADON stated she does not know why there were blanks on the resident's treatment record for skin checks every other day, and off-load left heel. She said the nurses are supposed to sign off on the orders daily, and ensure the orders are done. She said, If it is not recorded, it didn't get done. Review of the facility policy for Pressure Ulcer Prevention, revised 10/7/10, revealed to avoid skin injury, and [MEDICAL CONDITION] that develop subsequently to admission are treated according to medical direction and are conscientiously followed. It further stated to follow residents ' care plans. According to Mosby's Clinical Nursing Skills and Techniques, 2014, areas of skin underneath a brace should be inspected for signs of pressure, including redness or breakdown to ensure early identification of irritation. According to the National Pressure Ulcer Advisory Panel at npuap.org, immobilizers should be removed daily to thoroughly assess skin. 2. Further record review for Resident #2 revealed an order dated 3/26/2015 for [MEDICATION NAME] (a narcotic) 5/325 milligrams every 4 hours as needed for moderate to severe pain. Review of Resident #2's Pain Flow Sheet revealed that on 4/2/15 she did not receive any pain medication. The physical therapy notes for 4/2/15 documented that the resident complained of pain to left knee with mobility at a pain level of 5 of 10. The therapy notes stated that the resident received scheduled pain medication. Record review revealed that on 4/30/15 at 5:00 am Resident #2's pain level was documented as 6 of 10, and [MEDICATION NAME] 5/325 milligram one tablet was given. The resident's physical therapy notes dated 4/30/15 at 2:59 pm recorded her pain as moderate to severe with palpation in back of heel, and the wound care nurse was notified. The resident's next dose of pain medication was documented as given at 9:00 pm on 4/30/15. On 6/7/15 at 5:40 pm in an interview with Resident #2 she stated that she had an infection in her left foot. She said she did not have wounds on her leg when she entered the facility. The resident said she felt like she was worse off now than she was before she came in. She said she kept telling staff that her foot was hurting under the brace. She said she was screaming during her dressing change to the foot earlier today. She said the male nurse asked her why she was screaming. She said she told him wouldn't you?. She said the nurse gave her pain medication before the dressing change today. She said, It didn't kick in until much later. She said, It hurt so badly, the worst pain yet. She said no-one ever told her that she should wait awhile after taking pain medicine to have the dressing changed. She pulled the sheet back and a brace was observed to her left leg. On 6/7/15 at 6:04 pm an observation with the Assistant Director of Nursing (ADON) revealed that Resident #2 became anxious after being asked by the ADON to observe her feet. Resident #2 stated, Just don't touch my feet. On 6/7/15 at 6:15 pm in an interview with Employee B, Licensed Practical Nurse (LPN), she said that Resident #3 had her pain pill at 1:00 pm today. Employee B said the wound care nurse completed the resident's dressing change before noon, between 11:00-12:00 pm. Employee B said she did not give the resident any other pain medication today. On 6/7/15 at 8:08 pm in an interview with Employee C, LPN, he stated that he was the wound care nurse today and he completed Resident #2's dressing about 11:00 am. He said the resident's foot brace was on so he had to remove it, and the resident verbalized she was in pain. He said towards the end of the dressing change, she was saying it hurt really bad . He said it was the first time he has changed the resident's dressings, and now that he knows her he would definitely offer her pain medication prior to completing her dressing change. He said he normally does ask the residents if they had pain medication before the dressing change. He said he did not ask Resident #2 or the nurse about her pain medication prior to today's dressing change. He stated that he should have asked before the dressing change. On 6/7/15 at 8:21 pm in an interview with Employee D, Registered Nurse (RN), she stated that she is the wound care nurse during the week. She said that over the last week Resident #2's wound had gotten worse, and Resident #2 dreads the dressing changes. She stated the resident does not like us to remove the brace because of the pain. She said the area surrounding the foot wound is reddened; it started with a blister, and developed into a deep tissue injury, unstageable. She said the measurements of the wound got better, but this week the drainage was worse. Employee D said the resident's wound is infected with Multi Resistant Staph Aureus (MRSA, a bacteria). She said the resident needs pain medication for the dressing changes, and she spoke to the Advanced Registered Nurse Practitioner (ARNP) about this last week. Employee D stated she thinks the resident needs more pain medication. She said she ensures the nurse medicates her before she completes the dressing change, and she waits an hour before conducting the dressing change. She stated the resident is anxious anticipating the removal of the Velcro from the brace. She said the heel wound is a daily dressing change and the lateral foot is every other day. She said this past week is the worst the resident ' s pain has been. She said the resident received around the clock Tylenol, which was sufficient for her pain previous to this past week. She said the ARNP was going to speak to the doctor to see about getting an order for [REDACTED]. She said this resident is very alert and oriented. On 6/7/15 at 7:25 pm in an interview with the Director of Nurses (DON), she stated that the resident should have another pain assessment completed due to the development of her foot wounds (last pain assessment was completed on admission). She said the nurses should anticipate Resident #2's pain prior to the wound care, and make sure she has pain medication before the treatment. Review of Resident #2's June, 2015 medication record revealed that she received 6 doses of [MEDICATION NAME] 5mg-325mg for pain on 6/1/15, 2 doses on 6/2/15, 3 doses on 6/3/15, 4 doses on 6/4/15, 2 doses on 6/5/15, 4 doses on 6/6/15, and 3 doses on 6/7/15. The pain medication was ordered every 4 hours for moderate to severe pain as needed. On 6/8/15 at 3:37 pm in an interview with Resident #2's ARNP, she stated that the resident's wounds developed after her admission to the facility. She stated the cause of the wounds was because of pressure from the brace. She said she feels 100% certain that the brace caused the pressure sore. She said the tissue injury was deep after the sore opened. She said a nurse brought the resident's pain to her attention last week. She said she reviewed the resident's medication record and saw that she was getting pain medication at least 3x per a day. She said it was ordered every 4 hours around the clock as needed. She said the facility was underutilizing the resident ' s prescribed pain medication. She said the wound care nurse called her this am, and she clarified the order to ensure staff medicate the resident for pain at least 30 minutes to 90 minutes before her wound care. She said she does not want the resident over-medicated, but she wants the nurses to pre-medicate her and use the medication appropriately. She said, We need to investigate why she isn't getting the pain medication. She said the resident is alert and oriented, but forgetful. On 6/8/2015 at 3:15 pm in an interview with the physical therapist that treated Resident #2, she said the resident started to complain of pain in the beginning. She did not have an open wound at the time. She said we would barely touch her foot and she would complain of pain, anywhere around the heel she was really tender. She said the foot part of the splint constantly needed to be adjusted. She said she did a lot of training with the Certified Nursing Assistants on proper positioning of the resident's brace (only documented training was on 5/19/15). She said the resident's fracture was above the knee, and she would twist her foot outward. She said there was a bar on the back of the brace, and when it was out of place it would press on the resident ' s heel. She said when she adjusted the bar, it felt better for the resident. She said the resident had moderate to severe pain at times. She said moderate pain was about 5 out of 10; severe pain was 7 or 8 of 10. She said when the pain was really bad it was a 9 out of 10. She said when the resident was resting, the pain was minimal, but with contact on her heel she really did hurt. She stated the nurses told her that the resident was on scheduled pain medication. She said she did not know the resident had not received pain medication on a few occasions when she treated her.

Based on observation, interview with resident and staff, record review and facility policy review, the facility failed to prevent an avoidable pressure ulcer when it failed to remove a resident ' s leg brace and check the integrity of the skin as ordered for 1 of 3 residents (Resident #2). This resulted in harm with the development of a pressure ulcer to the resident ' s left heel, which became infected, had increased drainage and associated pain, and required antibiotic treatment. The findings include: The history and physical for Resident #2, dated 3/26/2015 and signed by the resident's physician, revealed that she was admitted to the facility on that date after conservative treatment (nonsurgical) in the hospital for a [MEDICAL CONDITION] distal femur (lower thigh bone). The resident was placed in an immobilizer brace to the left lower leg. Skin was intact. The resident was alert and oriented to time, place and person. Record review of Resident #2's Initial Data Collection Tool dated 3/26/2015 revealed in the section for skin condition that she did not have any wounds on her left foot. Record review of the Minimum Data Set Assessment for Resident #2 dated 4/2/15 revealed she was at risk for developing pressure ulcers. She was admitted with a Stage 2 pressure ulcer to the coccyx. No [MEDICAL CONDITION] were present on the left foot. The resident's cognition was scored 9 out of a possible score of 15 (moderately impaired). The resident's Care Area Assessment revealed that the resident was alert and oriented to time, place and person, and stated do not proceed with cognition care plan. The next Minimum Data Set assessment dated [DATE] recorded the resident's cognition as 15, no cognitive impairment. Record review of the Braden Scale pressure ulcer risk for Resident #2 revealed a score of 14 out of a possible 18, moderate risk, on the following dates: 3/26/15, 4/23/15, and 5/5/15. Record review of a physician's order for Resident #2 dated 3/26/15 revealed remove left leg brace every other day and check skin on Monday, Wednesday, and Friday. Review of the March and April, 2015 treatment records for Resident #2 revealed that the order to remove left leg brace every other day for skin check was signed as completed on Saturday 3/28/15. The next date that the skin check was signed off was Monday 4/6/15 (8 days elapsed). Further review of the resident's April, 2015 treatment record revealed that 13 days in April were designated for removal of the leg brace (Saturday and Sunday of every week were skipped). Additional designated days in April, 2015 for removal of the leg brace for skin check were also undocumented (4/13/15, 4/15/15, 4/24/15, and 4/27/15). Record review of nursing progress notes for Resident #2 dated 4/18/15 revealed, Resident noted with red pressure mark on lateral side of left foot and on the bottom lateral side of the foot noted with an area of maroon dark tissue injury, and left heel has necrotic (dead) tissue area. Review of the Advanced Registered Nurse Practitioner's (ARNP) progress notes for Resident #2, dated 4/16/16, revealed that she was advised by nursing of a concern for the beginning of a pressure ulcer to the resident's left lateral foot and heel from the brace. Record review of the weekly pressure ulcer tracking report for Resident #2, dated 6/2/15, revealed a left heel wound that started on 4/18/2015, approximately 3 weeks after the resident was admitted to the facility. The wound was recorded as unstageable (unable to determine depth), and measured 2.7 centimeters (cm) x 1.5 cm x 4.05 cm (total surface) x 0.1 cm depth. The left lateral foot was described as a suspected deep tissue injury that started on 4/18/2015 and measured 0.2 cm x 0.3 cm x 0.6 cm total surface, and unable to record depth at this time. Record review of the skin integrity plan of care for Resident #2, dated 5/8/15, revealed two new suspected deep tissue injury areas to left foot, heel and lateral foot. The left heel was described an unstageable. The approach was to remove left leg brace for skin observation per physician orders, observe for pain and medicate as needed per physician orders, and minimize pressure over boney prominences. A physician's order for Resident #2 dated 4/16/15 stated off-load left heel: make sure brace is in proper position every 2 hours. Review of the resident's April, 2015 treatment record revealed that this order was not signed as completed on 6 of 30 AM or PM shifts from April 16 through April 30, 2015 (4/17/15, 4/20/15, 4/22/15, and 4/30/15 on the AM shift. Also 4/28/15 on both the AM and PM shifts). This order was not transcribed onto the resident's medication or treatment records in May or June, 2015. There was no documentation in the resident ' s record that this was done in May or June, 2015. Review of Resident #2's Orthopedic consult notes dated 4/15/15 revealed instructions to inspect the resident's heel daily for decubitus prevention. A physician's order was written for Resident #2 dated 4/15/15 to inspect heel daily-decubitus-prevention. This order was not transcribed onto the resident's medication or treatment records in May or June, 2015. There was no documentation in the resident's record that this was done in May or June, 2015. Orthopedic consult notes for Resident #2 dated 4/24/15 stated adjust brace for better fit, continue wound care and off-load foot. This order was not transcribed onto the resident's medication or treatment records in May or June, 2015. Review of progress notes for Resident #2 dated 5/12/15 revealed Left heal wound now unstageable. Areas of slough (dead tissue). Change dressing daily. Orthopedic visit notes for Resident #2 dated 5/13/15 revealed an order to call the brace company and remove shoe portion of brace. Still needs immobilizer. The resident's shoe brace was removed on 5/14/15. Record review revealed staff were trained on 5/19/15 on proper fit of the resident's brace, and heel off-loading. Review of the facility's Unavoidable Pressure Ulcer Assessment for Resident #2, dated 6/2/15 and completed by the wound care nurse, revealed that the question Was a preventive plan of care initiated on admission and consistently thereafter? was marked Yes . Were appropriate preventive measures provided? was also marked Yes . Review of a physician's order for Resident #2 dated 6/4/15 revealed the resident started antibiotic treatment for [REDACTED]. In an interview on 6/7/15 at 6:04 pm with the Assistant Director of Nursing (ADON), she stated that Resident #2 did not come to the facility with wounds on her feet. The ADON said the resident's left heel and the left lateral foot sores developed on 4/15/2015. She said the left heel wound was found under the immobilizer of the left foot. She said, When Ortho writes an order, we follow the recommendations. Upon review of the resident's treatment records for March through June, 2015, the ADON stated she does not know why there were blanks on the resident's treatment record for skin checks every other day, and off-load left heel. She said the nurses are supposed to sign off on the orders daily, and ensure the orders are done. She said, If it is not recorded, it didn't get done. Review of the facility policy for Pressure Ulcer Prevention, revised 10/7/10, revealed to avoid skin injury, and [MEDICAL CONDITION] that develop subsequently to admission are treated according to medical direction and are conscientiously followed. It further stated to follow residents' care plans. On 6/7/15 at 5:40 pm in an interview with Resident #2 she stated that she had an infection in her left foot. She said she did not have wounds on her leg when she entered the facility. The resident said she felt like she was worse off now than she was before she came in. She said she kept telling staff that her foot was hurting under the brace. She said she was screaming during her dressing change to the foot earlier today. She said, It hurt so badly, the worst pain yet. She pulled the sheet back and a brace was observed to her left leg. On 6/7/15 at 6:04 pm an observation with the Assistant Director of Nursing (ADON) revealed that Resident #2 became anxious after being asked by the ADON to observe her feet. Resident #2 stated, Just don't touch my feet. On 6/7/15 at 8:21 pm in an interview with Employee D, Registered Nurse (RN), she stated that she is the wound care nurse during the week. She said that over the last week Resident #2's wound had gotten worse, and Resident #2 dreads the dressing changes. She stated the resident does not like us to remove the brace because of the pain. She said the area surrounding the foot wound is reddened; it started with a blister, and developed into a deep tissue injury, unstageable. She said the measurements of the wound got better, but this week the drainage was worse. Employee D said the resident's wound is infected with Multi Resistant Staph Aureus (MRSA, a bacteria). She said an MRI was requested to rule out [DIAGNOSES REDACTED]. She stated the wounds were caused by the brace. She said this resident is very alert and oriented. On 6/8/15 at 3:37 pm in an interview with Resident #2's ARNP, she stated that the resident's wounds developed after her admission to the facility. She stated the cause of the wounds was because of pressure from the brace. She said she feels 100% certain that the brace caused the pressure sore. She said the tissue injury was deep after the sore opened. She said the resident is alert and oriented, but forgetful. On 6/8/2015 at 3:15 pm in an interview with the physical therapist that treated Resident #2, she said the resident started to complain of pain in the beginning. She did not have an open wound at the time. She said we would barely touch her foot and she would complain of pain, anywhere around the heel she was really tender. She said the foot part of the splint constantly needed to be adjusted. She said she did a lot of training with the Certified Nursing Assistants on proper positioning of the resident's brace (only documented training was on 5/19/15). She said the resident ' s fracture was above the knee, and she would twist her foot outward. She said there was a bar on the back of the brace, and when it was out of place it would press on the resident's heel. She said when she adjusted the bar, it felt better for the resident. She said the resident had moderate to severe pain at times. She said moderate pain was about 5 out of 10; severe pain was 7 or 8 of 10. She said when the pain was really bad it was a 9 out of 10. She said when the resident was resting, the pain was minimal, but with contact on her heel she really did hurt.