Every finding on record at Mercy Harvard Hospital Care Center

Based on observation, interview, and record review, the facility failed to perform hand hygiene and glove changes while providing incontinence care and colostomy care to a resident (R1). This applies to 1 of 2 residents reviewed for incontinence care in the sample of 14.The findings include:R1's electronic face sheet printed on 2/18/26 showed R1 has diagnoses including but not limited to chronic hypoxic respiratory failure, chronic bronchitis, atrial fibrillation, hypotension, pleural effusion, ostomy, left hemicolectomy, and Alzheimer's dementia without behaviors. R1's care plan dated 6/4/25 showed, (R1) is occasionally incontinent of urine. Provide incontinence care after each incontinent episode . On 2/17/2026 at 12:55 PM, V5 (Certified Nursing Assistant) provided urinary incontinent care and colostomy care to R1. V5 applied clean gloves, emptied R1's colostomy bag and cleaned around R1's colostomy, removed R1's soiled incontinence brief and pants, applied clean pants and a clean incontinence brief to R1, removed R1's surgical mask from her face, applied a clean shirt, provided perineal care, and assisted R1 to her wheelchair without performing any glove changes or hand hygiene. V5 stated, I should be changing my gloves when going from a dirty to clean task. I guess I didn't realize I didn't change them I must have been nervous or something. On 2/18/2026 at 1:02PM, V6 (Registered Nurse) stated, When we are providing cares to a resident, we should be changing our gloves and performing hand hygiene when going from a dirty to clean task or whenever our gloves are visibly soiled. I would have done the perineal care first and then changed my gloves and then performed colostomy care so there is no cross contamination. The facility was unable to provide a policy regarding glove usage during incontinence care or colostomy care.

Based on observation, interview, and record review the facility failed to check expiration dates of insulin prior to administering expired insulin to a resident (R3). This applies to 1 of 1 resident reviewed for medications in the sample of 14. The findings include:R3's Physician Orders showed an order for fast-acting ranging from 0-12 units to be given at mealtimes. On [DATE] at 1:07 PM, V4 Registered Nurse (RN) began preparing R3's insulin pen. R3's insulin pen showed a handwritten date of [DATE] denoting the date it was placed into service. Below was a handwritten expiration date, Exp 1/29. V4 prepared this fast acting insulin pen and injected 4 units of insulin into R3's right lower abdomen. V4 stated the date of [DATE] was the date the pen was opened and first used. On [DATE] at 10:27 AM, V3 Director of Nursing (DON) stated when nursing staff open a new insulin pen they should write on the pen the date it was opened, and per manufacturers instructions, write the expiration date. V3 stated the expiration date for insulin pens is typically one month. V3 stated night nurses should be verifying the insulin pen dates and disposing of expired pens. V3 also stated nursing staff should be verifying insulin pen expiration dates prior to use. V3 stated V4 should have noted the insulin pen was over 2 weeks expired, disposed of the pen, and obtained a new pen. V3 stated the manufacturer of the insulin has a reason for the expiration date; however, he was not certain of the reason. On [DATE] at 11:40 AM, V3 stated the reason for the one month expiration date is due to the insulin losing efficacy over time. (Insulin is less effective as time progresses.) The facility's Vial and Irrigation Solution Expiration Dating policy showed, Once a multiple-dose vial is punctured, it should be assigned a beyond-use expiration date.The beyond-use date for a needle-punctured multiple-dose container is 28 days unless otherwise specified by the manufacturer. The manufacturer's instructions for the fast-acting insulin pen showed, Storing your pen.Throw away the [fast-acting insulin pen] you are using after 28 days, even if it still has insulin left in it.

Based on observation, interview, and record review, the facility failed to transfer a resident (R1) with a gait belt. This applies to 1 of 3 residents reviewed for safety and supervision in the sample of 14. The findings include:R1's electronic face sheet printed on 2/18/26 showed R1 has diagnoses including but not limited to chronic hypoxic respiratory failure, chronic bronchitis, atrial fibrillation, hypotension, pleural effusion, ostomy, left hemicolectomy, and Alzheimer's dementia without behaviors R1's fall risk assessment dated [DATE] showed R1 is a high fall risk. R1's care plan dated 6/7/25 showed, (R1) is at risk for falling due to unsteady gait, impaired balance, poor activity tolerance with continuous oxygen, previous CVA (cerebrovascular accident), and weakness. On 2/17/2026 at 12:55PM, V5 (Certified Nursing Assistant) assisted R1 with transferring to the toilet. R1 stated, Please help me get up, I'm very weak today and can't breathe well. V5 then assisted R1 to stand up by lifting underneath R1's arms and assisted R1 to pivot to sit down on the toilet with no gait belt applied. V5 stated R1 is a 1 assist for transfers and R1 can't breathe very well so she's weak sometimes & we have to help hold her steady. V5 stated R1 isn't really a fall risk and doesn't need a gait belt when transferring because she can stand on her own. She just needed a little help today. I guess I can see where one would help if she started to fall so we could catch her and hold her steady. On 2/18/2026 at 1:02PM, V6 (Registered Nurse) stated, (R1) is a fall risk, She will try to transfer herself to the toilet and has been more incontinent. The aides should transfer all residents with a gait belt whenever they require assistance so they ca keep them steady and hopefully prevent any falls. The facility's policy titled, Gait Belts dated 03/25 showed, Nursing staff will use a gait belt to assist residents to transfer and ambulate. A gait belt allows a secure hold on the resident .

Based on observation, interview and record review the facility failed to ensure the water system was flushed to prevent Legionnaire disease in the water. This applies to all 16 resident residing in the facility. The findings include: The facility's Long-Term Care Facility Application For Medicare and Medicaid (CMS-671) dated 4/8/24 shows a facility census of 16. On 04/09/24 at 10:15 AM, V5 Facility Manager said the facility had a recent low level positive for bacteria on the Legionella testing. V5 said the positive water sample came from an unoccupied resident room and was found during quarterly testing of dead leg areas (water not used frequently). V5 said the water supply comes from the city and is chlorinated. V5 said the dead leg areas are to be flushed daily to prevent legionnaires in the water. V5 said the testing was done as part of preventative maintenance. V5 said since the positive result, they have increased vigilance of flushing the positive room as recommended by the water testing company and are logging the flushing done. The facility's Microbiological Analyses for water testing done by an outside water company on 3/13/24 shows a positive result of 0.4 CFU/ml of Legionella non-pneumophila in resident room [ROOM NUMBER]. On 04/09/24 at 11:53 AM, V8 Outside Water Company Representative (who did the water testing on 3/13/24) said that you should not get a positive result if flushing the water daily in these rooms. V8 said the water supply comes from the city and is chlorinated. V8 said the amount of chlorine he measured in the water is sufficient to kill any legionella bacteria in the water system if the areas were being flushed. V8 said the purpose of flushing is to bring chlorinated water to the faucet and daily flushing around 15-10 minutes a day is recommended. V8 said medical facilities usually have this as part of their plan where someone goes in and turns the water on for the time period and then documents that the room has been flushed. V8 said it should be done for all rooms because even if the room is occupied, it's difficult to verify if the water in the room has been turned on that day or not. V8 said he was doing the re-testing of the facility on 4/10/24 and if there is a positive again it would mean the facility was not following the flushing recommendations and more aggressive measures would need to be taken. On 4/9/24 at 10:20 AM, V6 Environmental Service Supervisor said housekeeping is supposed to run the water for 20 minutes while cleaning the room each day, but this is not documented. V6 said there is route sheets filled out by the housekeepers for each room. On 4/9/24 at 10:25 AM, the door to resident room [ROOM NUMBER] was closed with a sign on the door to not use the room. On 04/09/24 at 11:15 AM, V6 presented the route sheets done by the housekeepers. V6 confirmed with this surveyor that flushing was not documented on the route sheets presented. V6 said flushing was not listed in the job descriptions for the housekeepers and no other logs were kept for flushing. V6 said she verbally educated the housekeepers but did not have an in-service sheet or any documentation for the education. The facility's Mercy-Care Center route sheets shows boxes for the resident room numbers which were marked done across all boxes. There was no documentation of the forms regarding flushing. On 04/09/24 at 01:39 PM, V7 Environment Service said she runs the water when cleaning the rooms and if the room is empty she tries to runs the water periodically. V7 said there is no log and flushing is not documented anywhere. V7 did not recall having any in-services or education regarding flushing. The facility's Maintenance and Monitoring of Water Systems Policy dated 3/2024 shows Mercyhealth plans for the prevention and control of Legionellosis and other waterborne pathogens and controls risky by assuring proper systems design, function, and routine systems's inspection. Water system conditions and risk factors are assessed mitigated ongoing via control measures. Listed for each control measure are a monitoring procedure. Control measure should be documented.

Based on observation, interview and record review the facility failed to ensure resident's received significant medications as ordered by the physician. This applies to 1 of 6 residents (R5) reviewed for medication administration in the sample of 8. The findings include: On April 8, 2024 at 9:08 AM, R5 was lying in bed. There was a small round yellow pill lying on top of her lap on the blanket. She stated, the nurse just gave her, her morning medications. On April 8, 2024 at 9:20 AM, V4 Registered Nurse (RN) stated, she just gave R5 her morning medications. This surveyor showed her the small round yellow pill on R5's blanket. V4 RN took the pill and confirmed the pill was her morning dose of eliquis (blood thinner). She must have dropped it. R5's medication administration report for April 8, 2024 shows, apixaban (eliquis) tablet 2.5 mg (miligrams), 2 times daily. The medication was signed out as given on April 8, 2024 at 9:04 AM. R5's medical record did not show she could self administer her medications. The facility's acute medication administration dated March 27, 2023 shows, Policy: Only a physician, a registered nurse or licensed practical nurse (or a respiratory therapist for inhalation meds) may administer medications to SNF (skilled nursing facility)/Sub-acute residents. Medication administration times are individualized to resident needs and personal preferences, but are generally scheduled as follows: 0830-1230-1630-2100 (8:00AM, 12:30PM, 4:30PM, 9:00PM) and/or 0800-1200-1730-2200 (8:00AM, 12:00PM, 4:00PM, 10:00PM). The medications will be passed according to the 5 R's of medications administration: 1. Right Patient, 2. Right Route, 3. Right Dose, 4. Right Time, 5. Right Medication .

Based on observation, interview and record review the facility failed to ensure a resident with a history of dysphagia was supervised and failed to ensure the recommended swallowing strategies were implemented. This applies to 1 of 8 residents (R11) reviewed for safety. The findings include: R11's face sheet shows she is a [AGE] year old female with diagnoses including aphasia, oropharyngeal dysphasia, type 2 diabetes, progressive supranuclear palsy. R11's Minimum Data Set assessment dated [DATE] shows she requires supervision with eating. R11's Swallowing/Feeding Guideline dated July 12, 2022 documents swallowing supervision-periodic, strategies: eat/feed slowly, small bites/sips, one at a time, check mouth for pocketing of food on the right, check mouth for pocketing on left, chew thoroughly, moisten solids. R11's Speech Language Pathology Quarterly Screen dated 3/13/23 documents swallowing ability: dysphagia, liquids are thickened to nectar consistency, decrease in function, per nursing interview .(R11) with decline in swallowing, cognition, or speech at this time, under hospice care. On 4/8/24 at 12:18 PM, R11 was observed in her room sitting in her recliner chair during the noon meal. She was served a bowl of minced chicken with sauce, puree sweet potato and puree cauliflower. R11 took a bite of the minced chicken and was coughing after the bite, she took another bite of the chicken, and continued to cough. She spit out pieces of the chicken into a tissue and continued to cough several times. This surveyor asked R11 to open her mouth, a quarter size of food was on the top of her tongue. R11 continued to feed herself, and spit food out on the tissue. At 12:24 PM, R11 remained in her room feeding herself. There was no staff observed going into R11's room. R11's coughing was heard from the hallway. Two CNAs (Certified Nursing Assistants) were observed in the dining room at this time and V4 Registered Nurse (RN) was in another resident's room. On 4/8/24 at 1:18 PM, V4 (RN) said R11 does not speak, but communicates with a board or yes/no questions. She has right sided weakness and requires supervision during meals. She tends to have coughing episodes, and tends to put food in her mouth too fast. On 4/9/24 at 10:44 AM, V3 Assistant Director of Nursing (ADON) said R11 likes to feed herself, she is on an altered diet and staff should be checking on her when she is eating. Staff should be checking R11's mouth for any food residual and signs of aspiration. The facilities Swallowing Guidelines undated Policy states, swallowing guidelines: verbiage periodic: check in during meals. RN or CNA to check in every 5-10 minutes during meals. RN or CNA to confirm resident is eating meal without difficulty. RN or CNA intervene if swallow difficulties are noted .

Based on interview and record review the facility failed to ensure a resident was free of abuse which applies to 1 of 5 residents (R1) reviewed for abuse in a sample of 5. The findings include: R1's undated Face Sheet showed R1 is a [AGE] year old male resident admitted to the facility on [DATE] with diagnoses which include: Cerebral Palsy. On 10/30/23 at 11:00 AM, V4 Certified Nursing Assistant (CNA) stated on 10/13/23 she was getting R1 up for breakfast. V4 asked V3 CNA to assist her with getting R1 into the wheelchair. V3 appeared annoyed she was asked to help. V4 stated during the transfer R1 reached over to hold V3's hand. V3 pulled her hand away and told R1 to not pinch her. V3 then slapped R1's hand 3 times which was loud enough to here the slaps. V4 stated R1 was upset and shook his finger at V3. On 10/20/23 at 11:50 AM, V12 Social Services assisted with interviewing R1 due to R1's communication deficits. V12 used yes/no questions, hand gestures, and a touch alphabet sheet to ask if R1 remembered the incident from a few weeks ago. R1 nodded yes to remembering the incident, being slapped on the hand, and spelled the work aid on the letter sheet. The facility's Final Incident Report dated 10/18/23 showed the facility's investigation substantiated the allegation of abuse and V3 was terminated. The facility's Abuse Policy dated 3/1/23 showed physical abuse includes but not limited to hitting, slapping, punching, biting and kicking.

Based on observation, interview, and record review, the facility failed to ensure pressure related skin changes were reported and assessed, and interventions were implemented for 1 of 3 residents (R5) in the sample of 11 reviewed for pressure injuries. The findings include: R5's Minimum Data Set (MDS) dated [DATE] shows R5 is cognitively intact, requires extensive assistance with bed mobility and transfers, and is at risk of developing pressure ulcers/injuries. R5's current care plan provided by the facility showing an admitted [DATE] shows R5's diagnoses include, but are not limited to, protein malnutrition, failure to thrive, chronic kidney disease, hypertension, and hypothyroidism. R5's same care plan shows nursing is to observe for signs of skin irritation and/or breakdown and report to the physician, nursing is to perform and document skin check, notify the physician and treatment team of any integumentary (skin) changes, encourage proper positioning and relief on pressure points and time off her back when in bed. R5's last Skin Assessment was documented on 5/27/23 and showed her skin was WDL (within defined limits) and she had a low air loss mattress in place There is no mention of any redness or skin changes to R5's spine. On 6/5/23 at 10:15 AM, R5 was lying on her back on top of her bed covers with a pillow under her knees. R5 did not have a low air loss mattress on her bed. R5 said she was told she had a red area on her spine and they would need to keep an eye on it. On 6/5/23 at 10:22 AM, V6, Certified Nursing Assistant (CNA), assisted R5 to allow observation of her spine. R5's spine was reddened over an area where her spine was curved and the bones of her spine were very prominent. V6 said, It's just some redness. On 6/5/23 at 1:53 PM, V2, Director of Nursing (DON)/Wound Care Nurse, said the CNAs report any skin changes to the nurse, the nurse does a head to toe assessment of the resident's skin and notifies her of the skin change. V2 said the nurse can look at their flow sheet and will implement treatment based on the flow sheet. V2 said not all risk factors for a resident to be a high risk of skin breakdown are captured in the Braden scale. Other conditions can trigger staff to implement the Pressure Injury Prevention Protocol. Skin breakdown can develop rapidly with residents who are thin, elderly with poor nutrition with very little tissue to cover the bony prominences and decreased mobility. On 6/6/23 at 09:01 AM R5 was lying on her back, asleep in bed with no low air loss mattress on her bed. On 6/6/23 at 09:06 AM, V3, Registered Nurse (RN), said R5 has no pressure related skin changes. V3 said the CNAs let the nurse know about any skin changes including any redness, scratches, marks, or bruises, and the nurse would check any skin changes and do an assessment, and take any wound measurements. V3 said the nurse does the resident's skin assessment every week. On 06/07/23 at 10:31 AM, V11 and V12, CNAs both said they let the nurse know about any redness or any skin change at all, then the nurse will come look at the area of concern. V11 said pressure sores all start with redness. On 6/6/23 at 12:49 PM, when Surveyor reported to V2 that R5 had redness to her spine, V2 replied, This is the first I'm hearing about it. V2 assessed R5's spine and said R5 has blanchable redness along her spine which shows there is pressure there; if you don't get the pressure off of it, it will become a pressure sore. V2 said as soon as we see redness, we definitely want to do a preventative intervention. The facility's Skin Assessment Policy, last reviewed 2/23, shows the CNA will perform daily skin check and report any unusual findings to the licensed nurse and the RN will perform head to toe skin assessments weekly and as needed and document the findings under SNF Skin.

Based on observation, interview and record review the facility failed to ensure oxygen equipment was changed weekly for 1 of 2 residents (R7) reviewed for oxygen administration in the sample of 11. The findings include: On 06/05/23 at 10:04 AM, R7 was lying in her bed with oxygen flowing through a nasal cannula. R7's oxygen tubing nor humidification bottle were dated. On 06/07/23 at 10:07 AM, V8, Licensed Practical Nurse (LPN), said oxygen tubing and the humidified water are supposed to be changed weekly. The facility's Oxygen Concentrator Policy/Procedure, last reviewed 2/23, shows the oxygen tubing is to be changed weekly. The facility was unable to provide documentation to show when R7's oxygen tubing and humidified water bottle was last changed.

Based on observation, interview, and record review, the facility failed to provide incontinence care for 1 of 1 residents (R3) reviewed for incontinence care in the sample of 12. The findings include: R3's electronic face sheet, printed on 4/13/22, showed R3 has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's facility assessment, dated 1/28/22, showed R3 has severe cognitive impairment, requires 1 staff assist for personal hygiene, and is occasionally incontinent of bladder. R3's care plan, dated 1/24/22, showed, (R3) was incontinent during her hospital stay. Offer toileting upon request and during rounds. Ensure that incontinence care is completed after every episode. On 4/12/22 at 1:14PM, V3 (Certified Nursing Assistant) provided toileting assistance and incontinent care to R3. V3 assisted R3 to sit on the toilet and removed R3's soiled incontinence brief. V3 confirmed R3's incontinence brief was soiled with urine, and R3 touched the brief and stated, Oh! This is wet. V3 applied a clean incontinence brief and clean pants for R3. V3 then stood R3 up off the toilet, wiped R3's perineal area with dry toilet tissue and pulled her clean brief and pants up, without providing incontinence care. V3 stated, I cleaned her with toilet paper because she did not have any stool on her. I only need to provide incontinence care when a resident has stool on them, not just urine. On 4/13/22 at 11:27AM, V2 (Director of Nursing) stated, Residents should be receiving incontinence care after every incontinent episode, failure to do this could lead to odor and skin breakdown. All of our certified nursing assistants are educated regarding incontinence care upon hire and throughout the year we perform competencies to ensure staff are performing incontinence care for all incontinent residents. The facility's policy titled, Incontinence Care, dated 4/2022, showed, The facility's mission is to promote patient/resident dignity, comfort, preserve skin integrity and reduce the risk of infection due to incontinence. The purpose of this procedure is to accomplish that mission through an effective incontinence care program, allowing our patients/residents a means to receive necessary comfort, cleanliness and prevent infections. Policy: .Cleanse entire perineal area following incontinence with non-rinse foam cleanser and dry area completely, using a front to back method.

Based on observation, interview, and record review, the facility failed to ensure the quat sanitation was maintained at the appropriative level for disinfecting in the kitchen. This applies to all residents residing in the facility. The findings include: On April 5, 2021 at 8:48 AM, a tour of the kitchen was performed with V5 (Dietary Manager). V5 tested the red quat sanitation bucket with the test strip. V5 said the test strip reading shows the sanitation bucket was at 100 ppm (parts per million). V5 said it should be at 200 ppm, and the sanitation buckets should be changed every two hours. The Resident Census and Conditions of Residents form, dated April 5, 2021, shows 18 residents residing in the facility. The facility's Kitchen Sanitation Policy, revised on January 2020, states To evaluate the cleanliness of the equipment, work areas and surfaces within the department .The department is to be inspection ready at all times .Each station will have a red sanitizer bucket. Sanitizer buckets will be changed every two hours or as needed The Manufactures guidelines states, 150-400 ppm Efficacy range for conventional sanitization.

Based on observation, interview, and record review, the facility failed to perform COIVD-19 testing weekly for a staff member. This applies to all residents residing in the facility. The findings include: The Resident Census and Conditions of Residents form, dated April 5, 2021, shows 18 residents residing in the facility. The laboratory COVID-19 test for V6 (CNA) was performed on 2/22/21, 3/1/21 and 3/15/21 (14 days later). The facility's schedule for the week of 3/7/21 to 3/13/21 shows V6 worked on 3/9/21, 3/10/21, and 3/12/21. On April 5, 2021 at 2:23 PM, V2 (Assistant Administrator) said V6 missed her test date on 3/8/21. V2 said V6 continued to work until she was testing the following week on 3/15/21. V2 said staff should be taken of the schedule until they are tested . On April 5, 2021 at 12:50 PM, V3 (Interim DON) said staff are tested according to the county positivity rate; above 5% staff should be tested weekly. The facility's Infection Preventions Supplement COVID-19 Policy dated March 2020, states Regular staff testing CMS has ordered based on QSO 20-38-NH a requirement for staff to be tested at a regular frequency .When positivity is between 5.0% and 9.9%, testing is completed weekly.

Based on observation, interview, and record review, the facility failed to have fall interventions in place for a resident at high risk for falls. This applies to 1 of 8 residents (R12) reviewed for safety in the sample of 8. The findings include: R12's Fall Incident Report, dated 1/14/21, shows R12 fell in her room. R12's Fall Risk Screening, dated 4/5/21, shows she received a score of 11 (5 or higher is high risk for falls). On 4/5/21 at 9:00 AM, R12 was transferred to a reclining chair in her room. At 9:19 AM, V7, Certified Nursing Assistant (CNA), left the room without giving R12 the call light. R12's call light was plugged into the wall on the lower left side of her bed and the cord was hanging vertically down the wall and was not laying across the bed. R12's reclining chair was located on the upper right side of the bed. At 9:48 AM, R12 was in the reclining chair in her room. The call light was still not within reach. At 3:00 PM, R12 was still in her reclining chair and the call light was not within reach. On 4/6/21 at 8:42 AM, V8 (CNA) said R12 is able to use her call light. V8 said R12 does try and get up sometimes, especially if she has to use the restroom. On 4/6/21 at 12:50 PM, V4 (MDS Coordinator) said nurses come up with interventions to prevent future falls after a resident has a fall. V4 said fall interventions for R12 include: frequent rounding and keeping her call light within reach at all times. R12's Fall Care Plan shows an intervention of Frequent reminders to call for assistance-show her the call light was added after her fall on 1/14/21. The fall care plan also includes the intervention of, Keep call light in reach at all times. The facility's Fall Risk Assessment and Prevention Policy, revised on 1/2020, shows, Fall Prevention Interventions .Resident specific interventions must be used as identified on the care plan.

Based on observation, interview, and record review the facility failed to implement pressure reducing interventions for a resident with deep tissue injuries to both heels. This applies to 1 of 5 residents (R177) reviewed for pressure ulcers in the sample of 16. The findings include: On (MONTH) 13, (YEAR) at 3:17 PM, R177 was lying on her back in bed. Both of her heels were lying on the mattress. There were pressure reducing boots lying on the dresser across the room. R177 stated, I only wear those at night. They protect my heels from developing sores on them. The wound care flowsheet for R177 dated (MONTH) 7, (YEAR) shows, left heel, Treatment: [MEDICATION NAME] foam every 72 hours and PRN (when needed), offload, air mattress. Size: 3.5 centimeters (cm) X 4 cm, unstageable, black/brown eschar (devitalized tissue) in color. The wound care flowsheet for R177 dated (MONTH) 7, (YEAR) shows, right heel, Treatment: [MEDICATION NAME] froam every 72 hours and PRN, offload. Size: 2 cm X 3 cm, unstageable, black/brown eschar in color. The care plan for R177 dated (MONTH) 7, (YEAR) shows, Presence of pressure injury, Stage: unstageable, location: heels bilateral . Approaches/Interventions: Heels off bed with pillows while in bed. The facility's pressure ulcer prevention policy dated (MONTH) (YEAR) shows, Protocol: 1. The responsibility of all caregivers is to prevent, care for, and provide treatment for [REDACTED]. This plan may include: Nursing: 3. Use foot protector boot/or pillows to support the heels and decrease shearing pressure.

Based on observation, interview and record review the facility failed to perform incontinence care in a manner to prevent infection. This applies to 2 of 16 residents (R11, R173) reviewed for incontinence care in the sample of 16. The findings include: 1. R11's Minimum Data Set assessment dated (MONTH) 26, (YEAR) shows R11 is totally incontinent of bowel and bladder functions. On 08/13/18 at 01:40 PM, R11 was in bed. There was a strong urine odor permeating from R11. V3 (Certified Nursing Assistant-CNA) removed R11's incontinent brief. R11's incontinent brief was totally saturated with urine. V3 used a disposable incontinent wipe and wiped R11's frontal area only once. Then V3 applied a new incontinent brief. V3 did not cleanse R11's thigh/periareas or buttocks. On 08/14/18 09:44 AM V3 (CNA) said she did not cleanse R11's thighs, periareas or buttocks. V3 stated I wiped once, then folded the incontinent wipe to dry her. I thought that one wipe would have covered all the areas. R11's careplan dated (MONTH) 26, (YEAR) shows R11 has [DIAGNOSES REDACTED]. Keep clean clean and dry. 2. On (MONTH) 13, (YEAR) at 1:14 PM, V3 CNA took R173 to the bathroom. R173 had urinated in her adult brief. There was a strong urine odor. V3 wiped R173 without using soap and water. On (MONTH) 14, (YEAR) at 1:23 PM, V2 Director of Nursing stated, we don't have a policy (on incontinence care/perineal care) but we do have foam that they (the CNAs) can use with a dry cloth (to clean residents). The facility's CNA annual competency skills checklist shows, staff must be checked off for perineal care-must return demo.

Based on interview and record review the facility failed to follow its abuse policy by not immediately reporting an alleged abuse. This applies to 2 of 10 residents (R3, R7) reviewed for abuse. The findings include: The facility's Abuse Policy and Prevention Program dated February 2017 states, . Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe hear about or suspect to the administrator immediately. The facility's abuse investigation involving R3 reported to E14 (Social Worker) the black girl that works night shift twisted my arm the other time. R3 also reported to E14 she did not like the girl (staff) with the long black hair that has a back problem. R3 refused care during the night shift on August 17, 2017. R3 reported to E14 she was worried the CNA's would hurt her. Name of accused staff were identified as Z1 (Agency CNA) and E15 (CNA). During the abuse investigation E11, E12, E13 (CNA's) reported to E1 (Administrator) and E2 (Director of Nursing) knowledge of mistreatment from the night staff without reporting to E1 immediately. E11's interview statement dated August 18, 2017 states, she heard in CNA report that night shift were treating resident's rough. E11 and E13 (CNA) asked R3 how the night shift staff were treating her. R3 told E11 the night shift staff was rough with her. E5 then reported this to E2 (DON) and E14 (Social Worker). E11's interview statement stated, I feel bad because they work hard and I don't want them to lose their jobs E11 stated yes I know you can get in trouble for abuse, I guess I should have reported it during report but I reported it as soon as I asked R3 about it. E12's undated interview statement stated R7 told E12, E15 (CNA) on the the night shift was a little rough one night. (E12 did not report this information). E13's written interview statement dated August 18, 2017 stated, she witnessed E15 being a little rough with patients. E13 also reported hearing from resident themselves telling her certain staff were rough and rude to them during the overnight shift. (E13 did not report this information). During the abuse investigation R7 reported to E14, E15 (CNA) on the night shift pull my legs apart like I'm a frozen chicken or something and sometimes it hurts. R2 said I'm not afraid of them but I am reluctant to put on my call light. On September 12, 2017 at 10:20 AM, E1 (Administrator) said staff should report abuse or hear say of suspected abuse immediately. Staff have been consoled and re-educated on the abuse policy.

Based on observation, interview and record review the facility failed to honor resident's choices by not applying hearing aids upon awakening. This applies to 1 of 8 residents (R6) reviewed for choices in the sample of 10 and 1 (R13) in the supplemental sample. The findings include: 1. R6's Physician order [REDACTED]. R6's Minimum Data Set (MDS) dated [DATE] shows R6 has no cognitive impairment. The same MDS also shows that R6 uses hearing aids. On September 11, 2017 at 8:30AM, during the tour, R6 was sitting in her wheelchair in her room. R6 stated I cannot hear you; they (staff) took my hearing aids last night, they have not brought them back to me. On September 11, 2017 at 10: 20 AM, R6 said she would like to have her hearing aids as soon as she wakes up in the morning. R6 said she cannot hear anything without her hearing aids. R6's careplan dated August 11, 2017 shows R6 has hearing loss and uses bilateral hearing aids. R6's careplan approaches include: properly place (hearing aids) to both ears. 2. R13's MDS dated [DATE] shows R13 has no cognitive impairment. The same MDS shows R13 uses hearing aids. On September 11, 2017 at 8:35 AM, during the initial tour, R13 was in his room sitting in his wheelchair. R13 said they have not brought back his hearing aids yet, the nurse took his hearing aids last night. I can't hear you. On September 11, 2017 at 10:15 AM, when E3 (Registered Nurse) entered the room to give R13's medications. R13 sounded frustrated and stated I need my hearing aids! I have been waiting since this morning. I need them, I was beginning to think this is Sunday but it's not, today is Monday. On Sundays they always bring my hearing aids late or not at all. I want them as soon as I wake up in the morning. R13's careplan dated June 19, 2017 shows R13 has loss of hearing and wears bilateral hearing aids with approaches that include check that hearing aids are properly placed in both ears. On September 11, 2017 at 10:18 AM, E3 RN, said the staff that got R13 up, should have applied R13's hearing aids as soon as they got him up or sooner whenever the resident chooses to have them. On September 12, 2017 at 10:00 AM, E2 (Director of Nursing) said the residents should have their devices upon waking up. The staff (nurse or CNA) should apply the hearing aids soon as the resident is awake in the morning. The facility policy entitled Hearing Aid care dated July 2012 shows 3. Each AM, hearing aids will be placed in the residents' ear after daily cares or on resident's request.

Based on observation, interview and record review the facility failed to provide restorative services for a resident who requires extensive assist with daily living. This applies to 1 of 3 residents (R1) reviewed for restorative services. The findings include: 1. The Minimum Data Set assessment dated [DATE] shows R1's cognition is intact and requires extensive assist with transfer mobility. The Physical Therapy Discharge Summary dated September 2, 2017 shows R1's treatment [DIAGNOSES REDACTED]. Physical therapy recommends R1 to continue with therapy services at home following his discharge. R1's Discharge Care Plan dated initiated on August 25, 2017 shows R1's discharge was cancelled on September 5, 2017. On September 11, 2017 at 8:30 AM, R1 was lying in bed. R1 said he is not getting therapy anymore and staff do not get him up very often and walk him. R1 has had no restorative services from September 3, 2017 to September 11, 2017 (9 days). On September 11, 2017 at 2:45 PM, E2 (Director of Nursing) said R1's physical therapy was discontinued on September 2, 2017. R1 should be on a restorative program once discharged from therapy. R1 is not on a restorative program we must have forget to place him on a restorative plan. E2 said she will have physical therapy screen R1 and place him on a restorative walking program. R1's Rehabilitation Screening Form dated September 11, 2017 shows R1 should be walked twice a day with two staff assist and a walker. The facility's Rehabilitative and Restorative Program Nursing Policy dated February 2014 states, The Department of Nursing Services provides a program of preventative, rehabilitative, restorative and supportive nursing care and is integrated into the resident's daily care Restorative nursing services are provided 24 hours a day, 7 days a week .

Based on observation, interview and record review the facility failed to safeguard medical records from potential water damage. This applies to all residents reviewed for medical record storage. The findings include: The facility's Resident Census and Condition of residents report dated September 11, 2017 shows a census of 22 residents residing in the facility. 1. On September 12, 2017 at 9:15 AM, during the environmental tour. Medical records were stored in a storage room on an open shelving unit filing up two rows of paper files. In this same room there were four card board boxes containing medical records. A sprinkler was located above the unprotected medical records. A second area containing fourteen cardboard boxes filled with medical records with an sprinkler above the unprotected medical records. On September 12, 2017 at 9:30 AM, E1 (Administrator) said medical records should be stored in a manner protected from potential water damage. E1 said the medical records will be placed in storage tubs. The facilities Records, Retention, Transfer and Staff Responsibility Policy dated January 2002 states, Medical Records personnel are responsible for assuring that the clinical records are maintained, completed, and preserved.

Based on observation, interview, and record review the facility failed to honor a resident's preference for gravy at the evening meal on October 3, 2016. This applies to 1 of 9 residents (R8) reviewed for choices in a sample of 10. The findings include: On October 4, 2016 at 10:05am, Z1 (R8's family member) said all I ask is that R8 is kept comfortable. I come so I can feed her. I choose all of her meals. Last night R8 received a ground hotdog. I requested gravy because R8 loves gravy. The dietary girl said there was no gravy and just gave me a packet of catsup. On October 4, 2016 at the noon meal, R8 was assisted by staff to eat mashed potatoes with gravy. On October 5, 2016 at 8:10am, E3 (CDM-Certified Dietary Manager) said, That shouldn't have happened gravy is always available. On October 5, 2016 at 12:10pm, E5 said, Gravy is served to R8 unless the CNA's tell us not to. R8's care plan dated April 29, 2016 shows, Problem: Unplanned weight loss related to end of life stage, dementia. Resident is on Hospice care with expected decline related to end of life. Approaches include: Provide preferences and consistency as resident and family desires. An approach added August 1, 2016 documents, Add gravy to all ground meats and mashed potatoes. R8's care plan dated May 3, 2016 documents, R8 was a good cook and a caterer in her younger years. Z1 has given us some suggestions to make her food more appetizing and what her favorite foods are. The tray card shows R8 has a mechanical soft diet with preferences for lunch and dinner which includes: Gravy on all chopped food. The facility's Resident Rights booklet revised March 2011, documents, Your facility must make reasonable arrangments to meet your needs and choices.

Based on observation, interview and record review the facility failed to ensure that raw turkey breast roasts were cooked to the recommended internal temperature of 165 degrees Fahrenheit (F) to minimize the risk of foodborne illness, failed to monitor the cool down of the turkey roast and other roasts, and failed to ensure that the recipes indicated the proper final internal temperature of potentially hazardous food. The facility failed to ensure that potentially hazardous food was reheated quickly to minimize the risk of foodborne illness. The facility failed to ensure that food was stored, handled and prepared in a manner to minimize the risk cross-contamination; failed to ensure that staff utilized proper hand washing practices to prevent food contamination; failed to ensure that the sanitizing agent in the dish machine was at the appropriate concentration; and failed to sanitize the food thermometer prior to placing into the food. The facility failed to provide ongoing in-services in sanitation, hand washing and food preparation. These failures have the potential to place 18 elderly residents at risk for foodborne illness. An Immediate Jeopardy was identified on 12/29/11 at 4:55 PM. The facility Administrator was notified on 12/29/11 at 5:00 PM. The Immediate Jeopardy began on 12/4/11 at 2:30 PM due to the facility's failure to cook turkey breasts to an internal temperature of 165 degrees F, due to their failure to properly cool the turkey and other meat roasts, and due to the instruction on the recipes to cook raw turkey to an internal temperature of 140 degree F. These failures are magnified due to the overall poor sanitation and food preparation practices observed in the kitchen and lack of staff training. Although the immediacy was removed on 12/30/11 the facility remains out of compliance at a severity level 2 due to the need to evaluate the implementation of new policy and procedures and QA/QI monitoring tools for monitoring potentially hazardous foods (PHF), proper cooling of PHF foods, proper reheating of PHF foods, proper hand washing, proper food handling , proper storage and proper sanitizing. The findings include: On 12/29/11 at 9:30 AM E14 (Food Service Supervisor) was interviewed regarding the facility's quality assurance program in the kitchen related to the poor sanitation and food preparation practices that were observed during the survey on 12/27 and 12/28/11. E14 stated that Cooks Temperature Log Sheets are maintained and reviewed daily to assure that foods are being cooked to the appropriate temperatures and cooled down properly. E14 presented temperature log sheets for the month of December 2011. The temperature log sheet dated 12/4/11 documents that turkey was cooked to an internal final cooking temperature of 150 degrees F. Temperature log sheet dated 12/13/11 documents that the turkey was cooked to an internal temperature of 145 degrees F. Temperature log sheet dated 12/25/11 documents that the turkey was cooked to an internal final cooking temperature of 148 degrees F. There were no cool-down temperatures recorded beyond the 2 hour check on all 3 dates (12/4, 12/13, 12/25). The turkeys went through the temperature danger zone again when they were reheated and served on 12/5/11, 12/14/1 and 12/26/11 per the menu. E14 confirmed that the turkeys were reheated and served the next day. The product invoice sheet shows that a case containing 2 - 10 pound raw turkey breasts were purchased by the facility on 11/20/11 and 12/18/11. The facility's Roast Turkey with Gravy recipe instructs to cook the raw turkey breast (128 ounce) to an internal temperature of 140 degrees F. E14 stated that she developed the recipes and that the Dietitian reviewed the recipes. The Illinois Food Code 77.750 (2008) and the FDA Food Code (2009) instructs to cook potentially hazardous food like raw turkey to an internal temperature of 165 degrees F. The facility failed to record the cool down of other roasts (pork and beef) cooked on 12/16/11, 12/17/11 and 12/21/11 according to the facility's Cooks Temperature Log Sheets. On 12/29/11 at 2:00 PM E20 (Registered Dietitian) stated that she does not review the facility's recipes and is not involved in foodservice other than to review menus for nutritional adequacy. E20 said her focus in on clinical nutrition. The following observations were made on 12/27/11 and 12/28/11: On 12/28/11 at 9:50 AM E13 (AM Cook) was at the food prep counter in the kitchen preparing to make the mechanically altered diets. E13 said she was going to use left-over pork roast that was frozen and defrosted to make the mechanical/ground pork. The left-over pork roast was labeled "Rst Pork 10/4/11." An additional label on the pork roast indicated that it was pulled from the freezer on 12/20/11 and that it should be used by 12/26/11. E13 stated that she still planned to use the defrosted roast pork to make the ground diets even after it was pointed out to her that the "use by" date was 12/26/11. At 9:55 AM E14 (Foodservice Supervisor) instructed E13 that she could not use the outdated meat. E13 responded by asking, "what is today's date?" E13 then proceeded to make the mechanical/ground pork with meat from a pork roast (that was cooked on 12/27/11) that was sliced and panned on the counter. The temperature of the pork roast slices measured 56.3 degrees Fahrenheit (F). After grinding up 8 slices of roast pork, E13 placed the pan of ground pork into the holding cart. The thermometer gauge on the holding cart was not working. E13 said that she didn't know the temperature inside the holding cart. A meat thermometer placed inside of the cart showed a temperature of 148 degrees F. E13 said she was going to reheat the ground pork in the holding cart. On 12/28/11 at 10:40 AM E14 (Foodservice Supervisor) said that leftovers should be reheated in the oven at 350 degrees F. E14 said that food should never be reheated in the holding cart. The facility's policy titled "Preparation and Holding of Foods and Leftovers" (4/15/11) states "Leftovers will be heated quickly in the oven..." On 12/28/11 at 9:56 AM E13 (AM Cook) washed her soiled hands for 7 seconds. At 10:07 AM E13 tested the doneness of 4 baked potatoes by pressing on them with soiled oven mitts. At 10:26 AM E13 rinsed her soiled hands in the food prep sink and dried them; no soap was used. At 10:34 AM E13 placed soiled plastic wrap and foil into the garbage and pushed it down using her bare hand. E13 then coughed into her hand, touched the door knob on the door going out to the storage and walk-cooler area. E13 returned to the kitchen holding a plastic bag of frozen grilled chicken breast. E13 also picked up a large stainless steel bowl from the storage shelf by placing her soiled fingers inside the bowl to grasp it. E13 then washed her hands for 5 seconds at the hand washing sink. E13 then used her bare hands to remove the frozen chicken breasts from the plastic bag and place them on a pan. The facility's Room Service Menu lists grilled chicken breast as an entree available to residents in the care center. The facility's Handwashing policy and procedure (6/14/11) instructs to lather hands and clean nails, arm, tops of hands, bottom of hands, wrists and lower arms up to elbows and to wash for 15-20 seconds using friction. On 12/27/11 at 12:00 PM the spinach balls on the steam table in the dining room measured an internal temperature of 120 degrees Fahrenheit (F). After measuring the temperature of the spinach balls, E11 (Dietary Aide) proceeded to touch all of the spinach balls with her gloved hand. Prior to touching the spinach balls, E11 touched the handle of the reach in cooler and several condiment packets with the same gloved hand. While placing the thermometer into the food items on the steam table E11 was holding a pen in the same hand as the thermometer. The pen appeared to come in contact with some of the foods. On 12/28/11 at 12:05 PM E11 touched a hamburger patty with her gloved hand. The hamburger patty was served to R3. Prior to touching the hamburger patty, E11 touched the handle to the reach in refrigerator and the outside of several containers. On 12/28/11 at 12:02 PM a 32 ounce carton of cream was on the table in the dining room. At 12:30 PM the cream measured a temperature of 63 degrees F. On 12/27/11 at 11:00 AM the ice machine in the Diet Room was noted to have a pink substance, accumulated along the full length of the edge of the ice shield, inside of the machine. Condensation was noted on the soiled ice shield, which dripped onto the ice in the bin. Additionally, the ledge of the ice bin was noted to be soiled. On 12/27/11 at 4:30 PM, E1 (Administrator) stated that Facility Maintenance is responsible for cleaning the ice machine. On 12/28/11 at 9:25 AM E5 (Facility Maintenance) stated that the ice machine is cleaned once every 2 months. E5 said the cleaning included cleaning of the coils and wiping down the inside and outside of the machine. E5 could not specifically say when the last time the ice machine was emptied and sanitized. E5 said that he did not have documentation regarding the sanitizing of the ice machine. The manufacturer recommends to clean and sanitize the machine every 6 months according to the manufacturer instruction booklet. On 12/27/11 between 5:45 and 6:10 PM E8 (PM Cook) was observed during food preparation in the kitchen. During this time E8 removed her soiled gloves three times and applied new gloves without first washing her hands. E8 touched multiple potentially contaminated surfaces (door handle, phone, food containers, sanitizing bucket) with her gloved hands and then touched ready to eat food (lettuce and bread) with the same gloved hands. At 6:10 PM E8 washed her hands for 5 seconds at the handwashing sink. The facility's Handwashing Policy (review date 6/14/11) states that hands should be washed using soap and friction for 15 - 20 seconds. On 12/27/11 at 9:30 AM the reach-in freezer in the kitchen was over-stuffed with food items and did not allow for sufficient air flow. A loaf of bread was noted with a heavy accumulation of frost/ice build up. A bag labeled "birthday cupcakes" dated 4/27/11 and a box of open (undated) gluten free waffles were among the items in the freezer. The facility's food storage policy dated 5/10/11 states that leftovers may be stored for "up to 6 months." On 12/27/11 at 10:00 AM the walk-in freezer shelves were over-stuffed with food items and did not allow for sufficient air circulation. Several boxes were also stacked on a crate in the middle of the freezer. On 12/27/11 at 9:35 AM 1 dented #10 can was noted on the can rack. On 12/28/11 at 9:45 AM, E12 (Dietary Aide) was observed to touch dirty dishes and proceed directly to clean dishes without washing her hands or changing her gloves. E12 was asked to test the sanitation concentration in the dish machine. E12 did this by touching the test strip against a drop of water on a tray that had just come out of the dish machine. The test strip registered 200 ppm. E12 said that the correct concentration is between 100 - 150 ppm. On 12/27/11 at 9:45 AM E9 (Dietary Aide) was loading the dishes into the chlorine chemical sanitizing dish machine. E9 tested the sanitation solution strength by dipping the test strip into the water in the reservoir. The test strip registered 200 ppm. E9 stated that it should be between 100 and 200 ppm. The log titled "Chlorine Sanitizer Strip 50 - 100" shows that staff documented that the sanitizer concentration was consistently 150 - 200 ppm during the months of October, November and December 2011. E10 (Foodservice Team Lead) said that the concentration should be between 50 - 100 ppm. The dish machine manufacturers installation and operation manual (April 13, 2006) states "Chlorine titration should be between 50 and 100 PPM. Adjust cam timer if the chlorine level in not correct." The facility's policy dated 4/15/11 documents "The sanitizer chlorine strips are maintained at 50-100 ppm." Additionally, the policy states to test the concentration of the sanitizer by dipping the test strip into the water. The facility's policy titled "Removal of clean dishes from dish machine" (4/15/11) states that it is "imperative " that proper hand washing and changing of gloves be done when moving from soiled to clean. On 12/27/11 at 9:25 AM the Robot Coupe was noted wet on the inside, indicating that it had not been air dried before being placed back on its base. On 12/27/11 at 6:15 PM a badly stained and scratched cutting board was noted stored on a cart holding clean cutting boards and pans. On 12/27/11 at 11:00 AM the refrigerator in the Diet room was inspected. The refrigerator is labeled "Employee Food Only." A 46 fluid-ounce container of nectar thickened water was in the refrigerator. The container was open and undated. The manufacturer's label instructs to use within 5 days of opening. The refrigerator was visible soiled with dried spills and crumbs. On 12/27/11 at 4:30 PM E1 stated that resident products should not be stored in the employee refrigerator. On 12/27/11 at 3:00 PM the refrigerator in the resident's dining room was inspected. A 32 fluid-ounce open container of Med Pass 2.0 dated 2/28/11 was in the door compartment. The manufacturer's label states to use within 48 hours of opening. Two 46 fluid ounce containers of nectar thickened water were on the shelf in the refrigerator. The containers were open and undated. The manufacturer's label states to use within 5 days of opening. One of the boxes had an red-colored drips on the outside of the container. The refrigerator and freezer were soiled with drips and crumbs. The under counter cabinets in the Diet Room were visibly soiled on the inside and outside with multiple drips. A tray of resident mugs and juice glasses were inside the cabinet. The facility's policy titled "Dating and Labeling of Stored Food Items" (4/15/11) states "Once food packages are opened, the package will be labeled with the date..." On 12/27/11 and 12/28/11 E13 (AM Cook) was noted to not clean her thermometer prior to testing food items prepared for the lunch meals. E13 only cleaned the thermometer before placing it back into its sleeve. The facility's policy titled "Temperature Checks for Food" states "All thermometers should be cleaned and sanitized before testing food. Clean with an alcohol pad before and after each food item." The facility's dietary in-service documentation shows that no in-services were given regarding the proper reheating of potentially hazardous food and only 1 inservice was given regarding proper handwashing over the past year. On 12/29/11 at 7:20 PM the surveyor confirmed that the facility took the following steps to remove the immediacy of the situation: 1) The roast turkey recipe has been revised to reflect a final cooking internal temperature of 180 degrees F. 2) All evening food service staff were immediately re-educated on the proper cooking temperatures. 3) Kitchen staff were immediately given direct supervision by the Food Service Supervisor. 4) The Food Service Supervisor was supervised by the Hospital and Skilled Nursing Center Administrators. Staff were monitored for hand washing and cross-contamination. 5) The Food Service Director arrived in the facility and continued monitoring of staff. 6) On Friday December 30, 2011 all staff were in-serviced with return demonstration performed on proper food handling and sanitation by the Director of Food and Environmental Services and Infection Control Nurse. Dietary staff were also in-serviced on cross-contamination and techniques to avoid it; proper food temperatures and monitoring thereof; monitoring food dates and disposal of outdated food items; proper sanitation of equipment in the kitchen (meat cutter); and proper dish machine chemical composition and monitoring thereof.

A) Based on observation, interview and record review, the facility failed to assess, monitor, evaluate and obtain a physician order [REDACTED]. As a result of this failure, R7 developed an open wound underneath the skin fold on the abdomen. Findings include: R7 is a [AGE] year-old resident with multiple [DIAGNOSES REDACTED]. R7 is totally dependent on staff for all toileting and hygiene needs according to the Minimum Data Sets ((MDS) dated [DATE]. Review of the "Braden Scale " assessment dated ,[DATE] showed that R5 is at moderate risk for developing skin alteration. On 12/28/2011 at 2:45 P.M., R7's skin condition was checked in the presence of E4(Registered nurse), E18(Licensed Practical Nurse) and E17 (CNA-Certified Nurse Assistant). When surveyor asked E18 to lift R7's skin fold on the abdomen, it revealed that R7 has a very raw, reddened, excoriated area underneath the skin fold. E18 measured the excoriated area. The measurement shows 20 cm in length and 7 cm in width . In the middle of the reddened area was an open wound that measured 6 cm in length and 0.5 in width. Furthermore, there was a cheesy like moist substance noted on top of the open wound. There was a white, dry flaky substance on the reddened area. During the observation, E17 stated that R7's abdominal fold has been reddened for " quite some time, maybe a couple of months and we (CNA's) just apply Sensicare (skin moisture barrier cream)." E17 also stated that she did not inform nurse about R7's skin irritation on the abdominal fold. During the observation, E18 stated that R7's skin irritation on the abdominal fold has been ongoing and that the Sensicare has been applied. During the observation, E4 stated that staff was unaware when was R7's open wound on the abdominal fold had developed. E4 confirmed that there was no assessment, monitoring of R7's skin irration on the abdominal fold. As E4 added, there was no evaluation done to determine if the Sensicare was the appropriate treatment nor a physician order [REDACTED]. Review of the facility's policy for skin care, documents that at risk resident will be check daily for skin alterations and that CNA will report to the charge nurse any change in resident skin condition but not limited to: skin tears, bruises, redness, and rashes and new skin breakdown. B. Based on observation, interview and record review the facility failed to have an agreement with the [MEDICAL TREATMENT] provider for the coordination of care for 1 resident receiving [MEDICAL TREATMENT]; and failed to have a plan for providing and recording fluid intake for the resident's fluid restriction. This is for 1 of 1 residents (R3) reviewed for [MEDICAL TREATMENT] in the sample of 8. The findings include: R3 was admitted to the facility on [DATE] with multiple diagnoses, including End Stage [MEDICAL CONDITION], and is receiving [MEDICAL TREATMENT] 3 times a week according to documentation in the medical record. R3 went out to the [MEDICAL TREATMENT] center on 12/27/11 for [MEDICAL TREATMENT]. On 12/28/11 R3's chart was reviewed for documentation/communication from the [MEDICAL TREATMENT] center. There was no documentation in the record. The Unit Clerk stated that R3 returned from [MEDICAL TREATMENT] late in the day on 12/27/11 and that the [MEDICAL TREATMENT] center did not send a progress note back with her. The Unit Clerk called the [MEDICAL TREATMENT] center and requested that a progress note be faxed to the facility. The progress note titled "[MEDICAL TREATMENT] Treatment Record" documents that R3 had an episode of emesis after her [MEDICAL TREATMENT] treatment. The progress note also documents the medication that R3 received during [MEDICAL TREATMENT]. On 12/27/11 at 4:20 PM E1 (Administrator) stated that the facility does not have an agreement with the [MEDICAL TREATMENT] center that R3 visits. R3 has a physician's orders [REDACTED]. Distribution form in the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 12/28/11 at 8:40 AM, R3 had a 300 mL cup of ice water with breakfast. R3 consumed 100% of the water. On 12/28/11 at 9:10 AM, a 480 mL cup of ice water was on R3's bedside table. On 12/28/11 at the lunch meal, R3 received a 120 mL supplement drink and 120 mL of apple sauce on her tray. The facility's Food/Fluid monitor Sheet documents that R3 consumed 240 mL of fluid at breakfast and 240 mL of fluid at lunch on 12/26/11. There is not documentation for the amount of fluid consumed at dinner, or for the amount of fluid consumed with medications. The facility's policy titled "Liberalized Diets" (05/11) documents that nursing will collaborate with the dietitian to determine how the fluid will be distributed. There were no dietary notes in R3's record.