Every finding on record at NHC Healthcare, Franklin

Based on Facility Assessment Tool review, policy review, Falls Management Process Resource review, medical record review, Emergency Medical System (EMS) report review, Hospital record review, observation, and interview, the facility failed to ensure all nursing staff possessed the competencies and skill sets necessary to provide nursing and related services to safely meet the residents' needs for 2 of 7 (Resident #3 and Resident #6) sampled residents reviewed. On 5/28/2025, Resident #3 had an unwitnessed fall and was found on the floor lying next to her bed on her right side with her arm under her back. Resident #3 was unable to move her right arm. Licensed Practical Nurse (LPN) F moved Resident #3's arm from behind the resident's body and the LPN felt/heard Resident #3's bones popping/grinding together. Resident #3 stated, My arm is broken! several times. Resident #3 reported pain in all 5 fingers on her right extremity. On 9/10/2025, Resident #6 presented with a facility acquired stage 2 pressure ulcer/injury (open skin injury that involves the outer layer and middle layer of the skin) to her sacrum (lower back/tailbone area) region. The sacral wound progressed to an unstageable ulcer (pressure ulcer with full thickness and muscle loss) and required debridement (removal of damaged tissue from a wound) from Physical Therapy on 2 treatments. On 10/8/2025, 10/12/2025, and 10/13/2025, reviews of the Medication Administration Record (MAR) revealed Santyl [an ointment that breaks down dead tissue quickly] was not available and Medihoney [antibacterial ointment used for gentle removal of dead tissue] was used instead without obtaining a physician's order for the use of alternative wound care. On 10/16/2025, Registered Nurse (RN) D was observed providing water through a 3-milliliter (ml) syringe to Resident #6. RN D acknowledged she was providing fluids through a syringe since Resident #6 was unable to drink from a straw. Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified related to the facility's failure to provide nursing staff who possess competencies and skill sets necessary to determine if a resident who had fallen should be moved and repositioned to prevent further injury, failure to adhere to the physician's wound care orders, and failure to ensure appropriate means of hydration were provided. The Administrator, Regional Nurse, and Regional Nurse Assistant were notified of the Immediate Jeopardy for F-726 on 10/17/2025 at 6:40 PM, in the Conference room. The facility was cited at F-726 at a scope and severity of J. A partial extended survey was conducted from 10/17/2025 through 10/24/2025. An acceptable Removal Plan, which removed the immediacy of the Jeopardy for F-726 was received on 10/21/2025. The Removal Plan was validated onsite by the surveyor on 10/24/2025, through audit review, medical record review, observation, review of education records, and staff interviews. The IJ began on 5/28/2025 and was removed on 10/25/2025. The facility's noncompliance at F-726 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the undated Facility Assessment Tool revealed, .The purpose of the assessment is to determine what resources are necessary to care for patients competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to the patients in your center. Using a competency-based approach focuses on ensuring each patient is provided care that allows the patient to maintain or attain their highest practicable physical, mental and psychosocial well-being. 2. Review of the facility policy titled, 205 Incident and Accident Process, dated 7/2025, revealed .An incident or accident is defined as any occurrence that is outside the norms or any happening that is not consistent with the routine operation of the center or care of a particular patient.Some examples of incidents/accidents are: Falls Found on floor.All patient incidents should be documented in the EHR [Electronic Health Record].When any incident results in injury, as defined below, and/or there is evident of negligence, they must be reported to clinical risk management. Injury is defined.Significant injury including: Fracture or dislocation of bones or joints.Any condition requiring medical treatment outside the center that is inconsistent with the routine management of the patient's preexisting condition(s) The DON [Director of Nursing] should review all incidents for accuracy and complete documentation.Review EHR [Electronic Health Record] documentation for all patients incidents - is data complete and thorough.Were the proper notifications completed and documented.Is alert charting taking place.Was a significant injury identified after completion of the.fall event and if so, was the event edited to include the significant injury.Was hospitalization necessary to treat the patient.Was the care plan updated to reflect the incident.Follow-up is according to Alert Charting policy.Documentation that addresses the status and/or progress of the patient in relation to the incident/accident is to be completed at least every shift for 72 hours.After 72 hours, the Alert Charting can be discontinued if the condition/event is resolved.If it is not resolved, the Alert Charting will continue until assessment shows resolution. Review of the facility Falls Management Process Resource dated 10/2023, revealed .The Falls Management Program (FMP) is an interdisciplinary quality improvement initiative. It is designed to assist centers in providing individualized, person-centered care, and improving their fall processes and outcomes.The FMP includes two primary approaches to the management of falls and injuries. The first is through an immediate response to patients who fall. When a fall occurs, careful evaluation and investigation, along with immediate intervention during the first 24 hours, can help identify risk, contributing factors, and prevent future incidents. The second approach is long-term management. Here, screening at admission, quarterly, annually and change of condition are key in identifying patients at high risk of a fall. Review of the facility policy titled, Skin Integrity Prevention and Management Introduction, dated 3/2025, revealed .To ensure that patients having pressure injuries receive the necessary treatment and services to promote healing and prevent infection and prevent new pressure injuries from developing.To provide guidelines for immediate and ongoing communication with physicians. Review of the facility policy titled, Nursing Services, dated 5/2025, revealed .DOCUMENTATION GUIDELINES Orders The center must ensure that the written medical care of each patient is supervised by a physician. Written and verbal orders constitute the attending physician's directions for the treatment of the patient in the center. General policies for orders: All orders should be directly entered into the EHR upon receipt, or if handwritten by a provider, should be entered into the EHR from the written orders. All written orders will be scanned into the EHR. Review of the facility policy titled, Administration, dated 3/2025 revealed, .The administrator will be responsible to see that there are.in-service and continuing education programs for the development and improvement of skills of all of the center's personnel, addressing the center's patient population, and appropriate for their job functions to assure partner competency in each area. 3. a) Review of the medical record revealed Resident #3 admitted to the facility on [DATE], with diagnoses which included Parkinson's disease, History of falling, Hypertensive Chronic Kidney disease, Atherosclerotic Heart disease, and long-term use of antithrombotics/antiplatelets (blood thinning medications). Review of Resident #3's Event Report completed by LPN F dated 5/28/2025, revealed .Found on floor.PAIN OBSERVATION.Yes (location) - right shoulder.On a scale of 0-10 [0 being no pain and 10 the highest level of pain], how does the patient rate intensity of pain.9.Injury.Yes.right shoulder.Type of injury.Bone Fracture.Further description.right shoulder; painful and unable to complete ROM [range of motion] of RUE [right upper extremity].Level of Consciousness.Alert.Upper Left Extremity Movement/Grasps.Flaccid [hanging loosely].Pulse 100/per minute [normal range 60-100].Blood Pressure 159/80 [normal range less than 120/80].11:24PM Pt [patient] observed on floor lying next to bed. She was lying on hr [her] right side with her arm under her back. Pt assisted to a sitting position and was unable to move her arm without nurse's assistance. When I moved her arm from behind her to the front of her body. I could feel and hear bones popping/grinding together. Pt c/o [complain of] pain at level 10. Mild bleeding noted. Area cleansed with normal saline and gauze. Injury in which caused the bleeding not visible.Pt stated: My arm is broken! several times. Also reports pain in all 5 fingers on right extremity. 911 [medical emergency number] called and transported pt to [Hospital] for further eval/tx [treatment] of right extremity. Pt left apprx [approximately] 11:15pm [evening] via [by way of] EMS [Emergency Management Service]. POA [power of attorney] contacted.MD [Medical Doctor] notified. Review of Resident #3's facility Progress Notes dated 5/29/2025 at 6:35 AM, revealed, .returned from [Named Hospital] via EMS. New dx [diagnoses] of right shoulder fx [fracture]. Norco [medication given for moderate to severe pain] prescribed PRN [as needed] for pain.ER [Emergency Room] gave her a dose of fentanyl [used to relieve severe pain during and after surgery] for pain. Review of Nurse Practitioner #4's Progress Note dated 5/29/2025 at 2:18 PM, revealed .Patient fell at approximately 1130 [11:30 PM] last night.Immediately complained of pain to her right arm and was sent to the ED. Noted with right proximal humerus fracture [right upper arm] .Patient does have hematoma to right side of her head above her eyebrow.Ortho [Orthopedic] follow-up tomorrow. Also has order for as needed Norco. BP mildly elevated at 151/68 this morning. Review of Resident #3's comprehensive care plan with an edit date of 10/1/2025, revealed .Problem.Falls.recent fall with right shoulder fracture.Goal.Will have risk of falls with injury addressed and minimized.Approach.Signage in room to remind patient to use her call light to ask for assistance ambulating to the bathroom. Review of the significant change in status Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated no cognitive impairment. Resident #3 required set up or clean up assistance with eating, substantial/maximal assistance with toileting, shower/bathing, lower body dressing, and partial/moderate assistance with upper body dressing. Resident #3 had 1 fall without injury since the most recent assessment. 3. b) Review of the EMS run report dated 5/28/2025, revealed .[Named Resident #3].Signs & Symptoms Injury to shoulder and upper arm (Primary) Arm pain Extremity Pain.Fall from bed - 5 ft [feet].Mechanism of Injury Blunt.Trauma.Time 23:24 [11:24 PM].Alert.BP 150/100.23:26 [11:26 PM].Alert.149/119.23:35 [11:35 PM].Alert.168/130.Obvious deformity to upper Right arm. Pain 6/10.Right Arm.Upper Deformity.Pain.Tenderness.dispatched by 911 and responded immediately.for reported 90 y/o [year old] female that fell.Arrived on scene to find.female sitting on the floor in her bedroom with [Named] FD [Fire Department].NH [Nursing Home] staff believed that the fall happened in the last hour. Patient has a [an] obvious deformity to her upper right arm.ASSESSMENT.patient has a deformity at the humoral head of her R [right] upper arm. Patient rate pain at 6/10.TRANSPORT Patient move to EMS cot via a 4 person sheet lift. 3. c) Review of the Hospital Emergency Department (ED) note dated 5/29/2025, revealed, .Patient fell at [Named Facility] was not witnessed she has a bruise on her shoulder brought in by EMS. She is comfort care only. She is also a DO NOT RESUSCITATE.Reviewing record she has Parkinson's, dementia, frequent falls.Physical Exam.Patient has a large hematoma [collection of clotted blood] proximal right anterior shoulder.She has some scattered purpura [reddish-purple spots on the skin].Impressions.Shoulder X-Ray.5/29/2025 00:09 [12:09 AM].Acute, obliquely oriented and minimally comminuted/displaced fracture [a bone that is broken in at least two places usually caused by severe traumas] involving the proximal right humeral metadiaphysis [the upper arm bone between shoulder and elbow].Medical Decision Making.Patient with dementia on comfort measures but had a fall suffering fracture to her right shoulder.This is not operative. She can follow-up with orthopedics.I have sent a prescription for pain medication.Patient will be transported back via EMS.Would recommend holding her Plavix [medication given to prevent blood clots] for 2 days due to the swelling and bruising. 3. d) LPN F was called on 10/14/2025 at 5:00 PM and 10/15/2025 at 3:30 PM, and a message was left requesting a return call. LPN F did not return the call. During an interview on 10/15/2025 at 3:40 PM, LPN J was asked what she would do if a resident had an unwitnessed fall. LPN J stated, .immediately assess the patient, if having pain, I wouldn't want to move them. They could have neck injuries or a fracture, call EMS to transfer the resident out, let the family and doctor know. During an interview on 10/16/2025 at 9:55 AM, RN K was asked if a resident had an unwitnessed fall and was experiencing pain what would he do. RN K stated, .assess the resident, take vital signs, I wouldn't want to get them up right away until I know they are not injured, if significant amount of pain I would call EMS and the family. During a telephone interview on 10/21/2025 at 2:58 PM, LPN Q was asked if a resident has an unwitnessed fall and complains of pain should the resident be moved. LPN Q stated, .first assess the resident and if the pain is consistent, No, you should not move the patient, try to find out where the pain is and call EMS. During an interview on 10/22/2025 at 8:40 AM, Certified Nursing Assistant (CNA) U was asked what she would do if a resident has had an unwitnessed fall. CNA U stated, .I would call for a nurse. CNA U was asked if the resident was complaining of pain, should the resident be moved. CNA U stated, .the nurse shouldn't move the patient, if in pain make them as comfortable as you can until EMS arrives. During an interview on 10/22/2025 at 12:00 PM, MD #2 was asked when Resident #3 had an unwitnessed fall, complained of pain, and reported to the nurse, My arm is broken! should the nurse move her arm. The MD #2 stated, .I think it depends on whether an obvious deformity is present.if I didn't see deformity gently, barely move it.if I heard grinding or popping, I would certainly stop. MD #2 was asked what the popping and grinding could possibly indicate. MD #2 stated, .evidence of fracture.it just seems humane to move the arm back into a comfortable position. During an interview on 10/22/2025 at 4:50 PM, RN W was asked if a resident has an unwitnessed fall, complains of arm pain, and resident is unable to move the arm would she move the resident's arm. RN W stated, .No, I would be worried it could be fractured, and you could cause further injury. During a telephone interview on 10/22/2025 at 7:20 PM, CNA O was asked if Resident #3 could voice her needs and if she is in pain. CNA O stated, .She can tell you she is in pain and usually where she is hurting. During a telephone interview on 10/23/2025 at 5:40 PM, LPN P was asked if she was working on 5/28/2025, when Resident #3 fell. LPN P stated, .I was in the building working on another hall, the nurse on that hall was [Named LPN F], the nurse asked me to come over and assess her.you could clearly tell the arm was broken. LPN P was asked if she heard the popping and grinding that LPN F had noted in the progress note. LPN P stated, .No, when I got in the room, [Named Resident #3] was yelling, crying, didn't want you to touch her arm.I didn't know she moved the arm. During an observation on 10/24/2025 at 9:30 AM, Resident #3 was in her bed sitting up finishing up her breakfast. Resident #3 was asked if she has had any falls. Resident #3 stated .yes, I hurt my shoulder.I still have shoulder pain, it keeps me up at night. Resident #3 did not recall if the nurse moved her arm but did remember pain in her arm with the fall. 4. a) Review of the medical record revealed Resident #6 admitted to the facility on [DATE], with diagnoses which included Displaced Intertrochanteric Fracture of left femur (left femur or thigh bone fracture), History of falling, Neuromuscular Dysfunction of bladder, Retention of Urine, and Muscle Weakness. Review of the Occupational Therapy (OT) notes dated 9/10/2025, revealed .Patient rolls to L [left] side with min A [minimal assist] and side lies with SBA [stand by assist] utilizing grab rail assist for support. While in side lying [lying on her side], noted open wound on patient's sacral area. Nurse immediately notified and came in to assess. ADON [Assistant Director of Nursing] reports to allow regional wound care nurse to assess.prior to getting patient OOB [out of bed] . Review of Resident #6's Wound Management Detail Report dated 9/10/2025, revealed a Stage 2 pressure injury, 2 centimeters (cm) long, 2.5 cm wide, and 0.1 cm deep with epithelial tissue (tissue that was lighter in color than surrounding tissue with a shiny pearl like appearance) noted. Review of the Physician's Orders revealed, .9/11/2025.STAGE 2 PI [Pressure Injury] SACRUM: Cleanse with vashe [wound cleanser], pat dry. [Named skin protectant] to periwound [tissue surrounding a wound]. Polymem [wound dressing for cleansing, moistening, and absorbing drainage] adhesive dressing over wound. May leave in place up to 7 days unless soiled. Once A Day on Thu [Thursday] 08:00 AM. Review of the care plan dated 9/11/2025 revealed, .PressureUlcer/Injury .Approach .Treatments as ordered . Review of MD #2's Progress Notes dated 9/12/2025 at 3:16 PM, revealed .This is follow-up due to concern for.her pressure injury.Pressure injury is inspected and shows some slough [dead tissue that appears stringy or fibrous layer on a wound bed] in the wound bed but no surrounding erythema [redness] and no significant swelling.Pressure injury-continue wound care with Medihoney and foam dressing. There was no physician's order to apply Medihoney to Resident #6's pressure injury. Review of the Physician's Orders revealed, .9/15/2025.Santyl.ointment; 250 unit/gram/amt [amount]: nickel-thick layer; topical Once A Day.Special Instructions: nickel thick to sacral wound bed.SACRUM: Cleanse with [Named] wound cleanser, pat dry. Apply Santyl nickel thick to wound bed. Cover [with] bordered foam dressing. Once A Day.PRN [as needed] . Review of the Annual MDS dated [DATE], revealed Resident #6 had a BIMS score of 13, which indicated intact cognitive abilities. Resident #6 required staff set up or clean up assistance with oral hygiene, partial/moderate assistance with toileting, and shower/bathing. Resident #6 had no skin issues noted on the MDS. Review of the Wound Management Detail Report dated 9/16/2025, revealed an unstageable pressure injury measuring 2.2 cm long, 2.7 cm wide, and 0.1 cm deep with slough noted. The wound length and width increased in size, and dead tissue was present to the wound bed. Review of MD #2's Progress Notes dated 9/16/2025, revealed .Patient also noted with stage II [Stage 2 pressure injury] to sacrum.Addendum: 1400 [2:00 PM] - assessed pt's wound with ADON [Assistant Director of Nursing] - slough noted in wound bed - agree with using santyl and nursing to consult with therapy for possible sharps wound debridement. Review of the Physician's Order revealed, .9/19/2025.UNSTAGEABLE PI SACRUM: Cleanse with [Named wound cleanser], pat dry. Santyl nickel thick to wound bed. LIGHTLY pack with 4x4 [4 by 4] sheet of xeroform [a non-adherent gauze pad impregnated with a blend of petrolatum protective barrier to prevent moisture loss] and 3% [percent] bismuth tribromophenate [an agent that kills bacteria] - some xeroform will hang out and extend onto health [healthy] skin. Cover with sacral bordered foam. Ensure foam is smooth. Review of the Wound Management Detail Report dated 9/24/2025, revealed a decline in the pressure injury. The sacrum wound measured 2 cm long, 2.7 cm wide, and 1.7 cm deep with slough present. The sacrum wound now had undermining (the edges of a wound separate from the underlying tissue, creating a cavity beneath the skin) present and measured 0.6 cm. Review of Resident #6's Wound Management Detail Report dated 10/01/2025, revealed the sacrum wound measured 2.3 cm long, 3.1 cm wide, and 0.3 cm deep with slough present. The sacrum wound undermining now measured 0.4 cm and the wound had purulent (milky; sometimes green) drainage which was opaque (difficult to see through). Review of the Progress Notes dated 10/1/2025 at 11:40 AM, revealed .Patient seen for sacral wound that has undergone 2 rounds of debridement. Next round of debridement will occur after LET [Lidocaine, Epinephrine, Tetracaine - topical anesthetic used to numb skin before procedures] arrives. Wound has thin slough covering most of wound bed, small areas of red granulation [new tissue] tissue noted. Wound depth measuring 0.3 cm.Undermining present from 9 o'clock and 11 o'clock to wound edges. Review of Resident #6's Physical Therapy (PT) note dated 10/6/2025, revealed .PT skills required to perform Sharp debridement to selectively remove the devitalized [dead tissue no longer able to heal] tissues from the wound on the Sacral PU [Pressure Ulcer] as indicated, to enhance and facilitate wound healing.Nursing had reported that patient was given pain meds already and L.E.T. [Lidocaine, Epinephrine, Tetracaine] gel 0.05-0.5 % amt [amount].applied 30 minutes prior to debridement for pain management. Review of the MAR dated 10/8/2025, revealed .Santyl.ointment; 250 unit/gram; Amount to Administer: nickel-thick layer; topical.Not Administered: Drug/Item Unavailable Comment.used Medihoney, reordered. Review of the MAR revealed no order for the use of Medihoney for wound care. Review of the Progress Notes dated 10/8/2025 at 8:27 AM, revealed .Weekly Wound Assessment. Patient seen for sacral wound that has undergone 3 rounds of debridement.25% slough. Epibole [wound - healing complication where the edges of an open wound roll or curl under, creating a thickened, raised lip that prevents the wound from closing] still noted at 7 o'clock and 11 o'clock to wound edges. The Progress Notes revealed Resident #6's wound continued to decline. Review of the Wound Management Detail Report dated 10/01/2025, revealed the sacrum wound measured 2.3 cm, long, 3.1 cm wide, and 0.3 cm deep with slough present. The sacrum wound undermining measured 0.4 cm, had purulent drainage which was opague, milky and sometimes green. Review of the Wound Management Detail Report dated 10/8/2025, revealed the sacrum wound measured 2 cm long, 2.1 cm wide, and 0.2 cm deep with moderate serosanguineous (pale red to pink, thin and watery drainage). Review of the MAR dated 10/12/2025 revealed, .Santyl.ointment; 250 unit/gram; Amount to Administer: nickel-thick layer; topical.Not Administered: Drug/Item Unavailable Comment: has been requested from pharmacy, medi honey used in place. Review of the MAR revealed no order for the use of Medihoney for wound care. Review of the Physician's Order revealed, .10/13/2025.UNSTAGEABLE PI SACRUM: Cleanse with vashe, pat dry, Santyl nickel thick to wound bed. Cover with sacral bordered foam. Ensure foam is smooth and does not press buttocks together Once A Day - PRN. Review of the MAR dated 10/13/2025, revealed, .Santyl.ointment; 250 unit/gram; Amount to Administer: nickel-thick layer; topical.Not Administered: Drug/Item Unavailable Comment: using medi honey until delivered. Review of the MAR revealed no physician's order for the use of Medihoney for wound care. Review of MD #2's Progress Notes dated 10/14/2025 at 1:35 PM, revealed .I was asked.to have a look at her wound which is suspected to be infected due to increasing purulent drainage as well as odor.wound is inspected and indeed has what appears to be exudate [drainage form a wound] with some liquid appearing component as well as significant odor.Concerns for infected decubitus [pressure injury]. Keflex [antibiotic] 500 mg [milligram] 3 times a day with a stop date next Wednesday [10/22/2025. Review of the Wound Management Detail Report dated 10/14/2025, revealed the sacrum wound measured 2.5 cm long, 3.3 cm wide, and 0.4 cm deep with slough present. The sacrum wound drained a heavy with purulent (opaque, milky, and sometimes green) drainage with soft wound edges rolled under and thickened. 4. b) During an observation and interview on 10/14/2025, Resident #6 was in bed with Family Member (FM) B at the bedside. FM B stated, .she has a wound on her bottom, it's not getting any better. During a telephone interview on 10/17/2025 at 9:15 AM, Nurse Practitioner (NP) #4 was asked if a nurse could use Medihoney in place of Santyl if the facility is out of Santyl. NP #4 stated, .the nurse would need an [a physian's] order to change the wound care. During an interview on 10/17/2025 at 9:35 AM, Unit Manager I, was asked about Resident #6's sacral wound. Unit Manager I stated, .her skin was ok when she admitted , it is a facility acquired wound. Unit Manager I was asked if Resident #6 had a physician's order to use Medihoney to her sacral wound. Unit Manager I stated, I don't see an order for Medihoney. Unit Manager I was asked if a nurse could use Medihoney in place of the physician's order for Santyl. Unit Manager I stated, .the nurse would need to get an [a physician's] order to use the Medihoney. During an interview on 10/22/2025 at 12:00 PM, MD #2 was asked if a nurse can use Medihoney in place of Santyl without a physician's order. MD #2 stated, .we sign off on all treatment orders.I do trust our nurses.I would expect the nurse to put in the order, and I will review the order and sign it.If I see the order quickly.I usually check for orders every morning and in the night on occasions. During a telephone interview on 10/22/2025 at 3:18 PM, Pharmacist #1 was asked if Medihoney can be used interchangeably with Santyl. Pharmacist #1 stated, .they both debride but you would need a physician's order. During a telephone interview on 10/23/2025 at 9:40 PM, Pharmacist #2 was asked if Medihoney and Santyl perform the same way when being applied to a wound. Pharmacist #2 stated, .Santyl's an enzyme [a protein that speeds up chemical reactions] that breaks down dead tissue fast for debridement, while Medihoney's more about antibacterial action and gentle debridement with honey. It's like having an order for a statin [medication used to lower cholesterol levels that requires a physician's order] but you give the patient red yeast rice [over the counter medication that may lower cholesterol and does not require a physician's order]. Works towards the same end but different and not interchangeable. 5. a) Review of Resident #6's Hospital record prior to admission to the facility dated 9/2/2025, revealed .Closed comminuted intertrochanteric fracture of left femur [fractured hip].Swallowing difficulty.Acute.Dysphagia type [difficulty swallowing].ST [Speech Therapy] evaluated, started on modified diet [altered from a regular diet due to swallowing difficulties]. Resident #6 admitted to the facility on [DATE]. Review of the ST Screen dated 9/4/2025 at 7:31 AM, revealed .Pt [patient] resents [presents] to rehab s/p [status post] treatment for left hip fracture. Pt reportedly receiving and tolerating a regular/thin liquid consistency diet. Medical documentation indicates no cognitive/linguistic processing or swallowing concerns. ST services not indicated at this time . The ST screen did not reflect her diagnoses of Dysphagia noted from the hospital records. Review of the Progress Notes dated 9/15/2025, revealed .25 % [percent] of meals consumed. Pt is a very slow eater; daughter reports mouth pain with front, upper temporary retainer. Pt is able to feed herself with meal tray setup/assist as needed. Review of the Annual MDS dated [DATE], revealed a BIMS score of 13, which indicated intact cognitive abilities. Resident #6 required set up or clean up assistance with oral hygiene and was able to eat independently. Review of the Progress Notes dated 9/19/2025, revealed .Nutrition Spoke with family during care plan regarding her current nutrition and plan of care for her nutrition goals. Pt does c/o [complain of] front mouth pain/retainer and daughter agrees to try ground meats. Pt continues to eat 25% of most meals, likely unable to meet her daily nutrition needs. Weight has been obtainable [unobtainable] d/t [due to] pain.will down grade diet to mech soft ground meats [meat that is minced into small pieces] and add 4 oz [named nutritional shake] BID [twice per day] daily to provide add'l [additional] nutrition. Review of the Progress Notes dated 9/21/2025 at 5:56 PM, revealed .Pt noted w [with] decreased appetite today. pt picked at breakfast and refused lunch and dinner.encouraged pt to eat dinner. Pt waved arm and shook head at RN and then turned over in the bed. Review of the Progress Notes dated 9/22/2025 at 11:35 AM, revealed .Pt conts w [continues with] decreased appetite and refused PT [Physical Therapy] today d/t pain.Discussed code status with pt daughter.[Named Family Member B] is going to discuss pt [patient] condition with her family. Review of the Progress Notes dated 9/22/2025 at 2:27 PM, revealed, .Nutrition/Skin Patient with decreased intake per nursing d/t increased pain.She tends to eat more sweets, ice cream and dessert.minimal intake from meals.Family is aware of decreased appetite.CBW [Current Body Weight] unknown d/t [due to] pain.Pt remains at increased risk of malnutrition, dehydration, unavoidable weight loss.and overall decline. POC [plan of care] updated and to be followed. Review of Family Nurse Practitioner (FNP)'s Progress Notes dated 9/28/2025 at 8:44 AM, revealed .Patient is seen sitting up in a wheelchair next to her bed.states she is eating poorly. Review of the Registered Dietitian's' Progress Notes dated 10/3/2025 at 1:58 PM, revealed, .Continue with current diet as tolerated with decreased intake/appetite since admission despite interventions in place. Pt has increased p

Based on policy review, medical record review, and interview, the facility failed to ensure Care Plan conference meetings were held at least quarterly for 1 of 21 (Resident #33) sampled residents reviewed for care plan meetings. The findings include: Review of the facility's DOCUMENTATION GUIDELINES, dated October 2021, revealed .SECTION VII PATIENT CARE PLANS .Patient's goals for care and preferences will be determined and used to develop their plan of care .The patient care plan schedule will be developed first to accommodate the patients' and patient representative' schedule/ability to attend .All clinical assessments will be completed before the meeting is convened and will be used to inform the care plan development .Patient/patient representative participation will continue to be documented via [by way of] the care plan approval form in the EHR [Electronic Health Record] .Care plans are updated as needed but are reviewed completely by the interdisciplinary team on a quarterly basis within 7 days of the completion of the clinical MDS assessment . Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #33 had a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. The facility was unable to provide documentation a care plan conference was held with Resident #33 within 7 days of the completion of the 10/14/2021, 1/13/2022 or 4/12/2022 quarterly MDS assessments. During an interview on 9/28/2022 at 5:53 PM, the Director of Social Services confirmed there were no care plan meetings held with Resident #33 for the quarterly MDS assessments dated 10/14/2021, 1/13/2022 and 4/12/2022.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure interventions were implemented to maintain nutritional status for 2 or 2 residents (Resident #29 and #65) reviewed for nutrition and failed to ensure skin assessment documentation was not completed for 1 of 2 residents (Resident #49) reviewed for non-pressure related skin conditions. The findings include: Review of the facility's policy titled, .Weight Monitoring, revised 3/2021, revealed .Interventions will be determined by the Dietician or designee based on the individual patient needs .The interdisciplinary team will play an active role in combating insidious .weight loss through routine involvement in the patient's plan of care . Review of the facility's policy title, .Obtaining Weights, dated 3/2021, revealed .Weights will be obtained upon admission, weekly times four weeks, and then monthly . Review of the medical record, revealed Resident #29 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #29 was severely cognitively impaired, required extensive assistance of staff for eating, and received a mechanically altered diet. Review of a Registered Dietician (RD) Note dated 9/7/2022 revealed, .Resident continues with current diet .Pt [Patient] seems to have had a decline in the past couple of weeks aeb [as evidenced by] increased weakness and more lethargic during meals. Pt is very slow with self feeding and tends to drop a lot of food in her lap. CBW [Current Body Weight] this week is 137# [137 pounds] indicates a 4# loss x [times] 2 weeks d/t [due to] decreased intake .Let patient eat food first, then offer supplements/shakes . Observation in the resident's room on 9/27/2022 at 7:59 AM, revealed Resident #29 was sitting up in bed and her breakfast tray was on the overbed table in front of her. Resident #29 was confused and talking about past events and reaching for items on the breakfast tray but was unable to hold them. Resident #29 tried to pick up a half of a biscuit with jelly and dropped it in her lap, attempted to drink her cranberry juice but couldn't hold the container and dropped it in her lap. Resident #29 attempted to take a drink from her water jug and dropped it in her lap and attempted to hold her fork and dropped it in her lap. The facility failed to ensure staff assisted Resident #29 with her breakfast meal between 7:59 AM and 8:45 AM. Observation in the resident's room on 9/27/2022 at 8:45 AM, revealed Certified Nursing Assistant (CNA) #1 asked Resident #29 if she was finished with her breakfast. CNA #1 picked up all the items from the resident's lap, placed them on the tray, and put the tray on the dirty tray cart. CNA #1 did not attempt to assist Resident #29 to take a bite of the breakfast food or take a drink of her supplement. Observation in the resident's room on 9/28/2022 at 8:27 AM, revealed Resident #29 was sitting up in bed and there was no breakfast tray in her room while her roommate was eating breakfast in the room. Resident #29's breakfast tray was found on the dirty tray cart. None of the beverages, including the supplement had been opened and one bite of scrambled eggs appeared to have been eaten. The RD confirmed the breakfast tray was put on the dirty cart and confirmed Resident #29 had taken one bite of scrambled eggs and the drinks had not been opened. During an interview on 9/28/2022 at 3:51 PM, the Director of Nursing (DON) confirmed the CNA should assist Resident #29 with her meals. Review of the medical record, revealed the Resident #65 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS dated [DATE] revealed Resident #65 was severely cognitively impaired, required extensive assistance with Activities of Daily Living and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Care Plan dated 9/4/2022, revealed .Obtain weight weekly and intervene if significant weight change . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 8/1/2022 to 8/31/2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's Vital Results Weight sheet from 8/26/2022 to 9/26/2022 revealed .9/1/2022 .Weight Admission .198.4 . Review of the 9/2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 9/28/22 at 3:11 PM, the DON confirmed a weight should be obtained on admission and then weekly for 4 weeks. The DON confirmed Resident #65 should have had weights on 9/7/2022 and 9/14/2022. Review of the facility's Documentation Guidelines Section VII: Nursing Services, dated October 2021, revealed The goal of nursing documentation is to provide a timely recording of pertinent information regarding the safe and appropriate treatment, interventions, and responses in the patient's individual medical record . Review of the facility's undated Weekly Skin Assessments guidelines revealed .When should weekly Skin Assessments be completed .On Admission .within 24 hours, as part of the nursing assessment . Review of the medical record, revealed Resident #49 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan dated 9/28/2022, revealed .to observe for signs and symptoms of .excess bruising . Review of the facility's Progress Note dated 9/23/2022 and was recorded as a late entry on 9/28/2022, revealed the facility failed to document the bruise to Resident #49's left arm upon the resident's admission to the facility. Review of the facility's Weekly Skin Observation assessment dated [DATE] revealed, .Bruising/Discoloration .Yes .If YES, bruise /discoloration location required .(blank) . The facility failed to complete the Weekly Skin Observation assessment to reflect the bruise to Resident #49's left arm. Observation in the resident's room on 9/26/22 at 11:21 AM, 9/27/22 at 8:31 AM 9/28/22 at 8:09 AM, and on 9/28/22 at 12:09 PM, revealed a large dark deep purple and blue bruise extending from the top of the resident's left wrist to the middle of the resident's left upper arm. Observation in the resident's room on 9/28/22 at 4:45 PM, revealed Registered Nurse #1, washed her hands, donned clean gloves, measured the bruise to the resident's left arm with results of 31.5 cm (centimeters) x 26 cm and stated That is pretty big . During an interview on 9/27/22 at 10:59 AM, Resident #49 confirmed the bruise to her left arm was present when she was admitted to the facility on [DATE]. During an interview on 9/28/22 at 12:22 PM, the DON confirmed that staff should have documented that the bruise was present on admission and should be documenting on the bruise until it starts to show signs of subsiding. The DON confirmed that the bruise should have been captured on the resident's Weekly Skin Observation assessment with the location completed on the assessment sheet and documentation in the medical record to support the findings.

Based on policy review, medical record review, observation, and interview, the facility failed to monitor oxygen administration and oxygen tubing maintenance for 1 of 3 residents (Resident #56) reviewed for respiratory services. The findings include: Review of the facility's policy titled, Respiratory Manuel, dated 1/2005, revealed .Assessment Focus .oxygen monitoring .change .maintenance of equipment . Review of the medical record, revealed Resident #56 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation in the resident's room on 9/26/2022 at 11:25 AM, revealed Resident #56 was receiving oxygen through a binasal cannula. Observation in the resident's room on 9/27/2022 at 8:30 AM, revealed Resident #56's oxygen humidification bottle was empty and was dated 8/13. During an interview on 9/28/2022 at 3:00 PM, the Director of Nursing confirmed oxygen was not being monitored and they should have orders to maintain the binasal cannula tubing.

Based on facility policy review, medical record review, observation, and interview, the facility failed to provide care and services to maintain an indwelling urinary catheter when nursing staff failed to obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Review of the facility's policy titled Catheter Care, revised September 2014, revealed .The purpose of this procedure is to prevent catheter-associated urinary tract infections . Review of the medical record, revealed Resident #58 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set, dated dated dated [DATE] revealed Resident #58 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's Progress Note dated 8/22/2022, revealed .Placed a 16 F [French]/30ml [milliliter] cath [catheter] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Start Date 8/23/2022 .End Date .Open Ended .Catheter Care once per shift and document output twice day . Review of the August 2022 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed the facility failed to document catheter care for the use of an indwelling urinary catheter from 8/23/2022 to 8/25/2022. Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .on the 9th of the Month .16 fr with 10 ml bulb . Review of the September 2022 MAR and TAR revealed the facility failed to document catheter care for the use of an indwelling urinary catheter from 9/9/2022 to 9/28/2022. Review of the facility's Output sheet from 8/22/2022 to 9/28/2022 revealed the facility failed to obtain urinary output for the use of an indwelling urinary catheter for Resident #58 on 9/9/2022, 9/10/2022, 9/11/2022, 9/12/2022, 9/13/2022, 9/16/2022, 9/17/2022, 9/18/2022, 9/19/2022, 9/20/2022 9/22/2022, 9/23/2022, 9/24/2022, 9/25/2022, 9/27/2022, and 9/28/2022. Observations on 9/26/22 at 11:27 AM, 2:46 PM, 4:32 PM, and 9/27/2022 at 8:33 AM, 1:11 PM, and 9/28/2022 at 8:11 AM, revealed an indwelling urinary catheter contained in a privacy bag draining dark amber colored urine. During an interview on 9/28/22 at 3:11 PM, the Director of Nursing (DON) was asked should there be an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated, Yes . The DON confirmed that indwelling catheter care should be performed every shift by the certified nursing assistant and the nurses should document it on the MAR or TAR. The DON confirmed that the Certified Nursing Assistant should obtain the urinary output for the use of an indwelling urinary catheter and it should be recorded every shift.

Based on policy review, medical record review, and interview the facility failed to notify the resident representative of a skin tear for 1 of 2 sampled residents (Resident # 29) reviewed for non pressure related skin conditions. The findings include: Review of the facility's policy titled, Change in a Resident's Condition or Status, revised February 2021, revealed .Our facility promptly notifies the resident .and the resident representative of changes in the resident's medical/mental condition and/or status .Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status . Review of the medical record revealed Resident #29 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #29 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated she had severely impaired cognition. Review of a Resident Progress Note dated 9/17/2022 at 6:55 AM, revealed While CNA cleaning and changing patient's diaper and clothes, pt. [patient] became combative and suffered skin tears on both of her hands. Left hand has 2inch [2 inch] long tear and right hand has a small tear. Patient has been combative while doing Wound care and dressing. Patient also refused her medicines. The facility was unable to provide documentation the resident representative was notified of Resident #29's skin tears. During a telephone interview on 9/28/2022 at 5:53 AM, Licensed Practical Nurse #1 confirmed she did not notify Resident #29's resident representative about the skin tears. During an interview on 09/28/22 03:12 PM, the DON confirmed staff should have notified Resident #29's family immediately after finding the skin tear on her hand.

Based on review of the facility's contracted housekeeping proposal, Maintenance Supervisor's Job Description review, Housekeeping Supervisor Job Description review, policy review, observation, and interview, the facility failed to provide effective housekeeping services and maintenance services to maintain a sanitary, orderly, and comfortable environment as evidenced by trash and debris lying on the floors, sticky floors with a buildup of dirt and grime, dust and cobwebs in the corner behind a door, exposed wires, dirty fall mats and overbed table bases, telephones lying on the floor, dirty bathroom floors and toilet, missing privacy curtains, and a fan covered in thick gray dust in 7 of 46 resident rooms (Room #102, #410, #411, #503, #507, #508, and #510) observed. The findings include: Review of the facility's contracted housekeeping proposal dated 6/9/2022 revealed, .keeping your property well-maintained and exceptionally clean is extremely important .[Named Housekeeping Company] uses the very latest cleaning technologies to provide an unsurpassed level of clean .so every square foot of your business conveys quality and value .The objective of our cleaning process is not only to clean well, but also to clean for improved health .Cleaning Schedule .Patient Rooms .Thoroughly vacuum all carpeted areas including mats and rugs .Thoroughly damp mop all hard surface floors being sure to get into all corners and edges .Pull out any moveable furniture and decor to clean behind .High dust all surfaces not reached during regular cleaning . Review of a Maintenance Supervisor job description revised on 1/2010 revealed, .Inspects all equipment and systems regularly for proper functioning and safety .Regular inspection of property and equipment for compliance with safety regulations . Review of a Housekeeper job description revised on 1/2010 revealed, .This position is responsible for the cleanliness of the patient rooms .Clean patient bathrooms including sinks, toilets, tubs and showers .Clean patient rooms, including mopping and/or buffing floors, dusting furniture both on top and underneath .sweeping up debris .clean walls, furniture and equipment .to provide a clean pleasant environment for patients . Review of the facility's undated policy titled, .General Environmental Cleaning revealed, .Clean spills of blood or body fluids immediately .Use fresh cleaning cloths at the start of each cleaning session . Observation in Room #503 on 9/26/2022 at 11:05 AM and 2:41 PM, and on 9/27/2022 at 7:59 AM, revealed a medicine cup, spoon, and cup, and 2 telephones lying on the floor, the floor was sticky and covered with a buildup of black scuff marks, and brown and gray substances, the fall mat was covered in black and gray grime and gray dust, and the overbed table base had a layer of built-up brown grime and gray dust. Observation in Room #503 on 9/28/2022 at 9:52 AM, revealed 2 telephones lying on the floor, the floor was sticky and covered with a buildup of black scuff marks, and brown and gray substances, the fall mat was covered in black and gray grime and gray dust, and the overbed table base had a layer of built-up brown grime and gray dust. During an interview on 9/28/2022 at 9:53 AM, in Room #503, the Housekeeping Supervisor confirmed the floor and fall mat were dirty, the overbed table base needed to be cleaned, and telephones should not be in the floor. Observation in Room #507 on 9/26/2022 at 11:38 AM, on 9/27/2022 at 8:26 AM, and on 9/28/2022 at 9:41 AM, revealed a cable cover torn away from the wall with the cable wires exposed, the floor was covered with dust, and a buildup of crumbles and dust, and the fall mat had a buildup of dark gray grime and black marks. During an interview on 9/28/2022 at 9:42 AM, in Room #507, the Housekeeping Supervisor confirmed the floor and fall mat were dirty and needed to be cleaned. The Maintenance Supervisor confirmed the cable wires should not be exposed and the cable cover should be replaced. Observation in Room #508 on 9/26/2022 at 11:40 AM, and on 9/28/2022 at 9:44 AM, revealed black scuff marks and a buildup of a brown substance on the floor in the room and in the bathroom, and the overbed table base had a buildup of a brown substance and gray dust. During an interview on 9/28/2022 at 9:45 AM, in Room #508, the Housekeeping Supervisor confirmed the floor in the room and bathroom were dirty and needed cleaning, and the overbed table needed to be cleaned. Observation in Room #411 on 9/26/2022 at 11:43 AM and 2:50 PM, on 9/27/2022 at 8:45 AM, and on 9/28/2022 at 9:25 AM, revealed a tan colored substance splattered on the floor near the doorway in the room, the toilet had a tan substance on the inside of the toilet bowl, on the water closet of the toilet and across the toilet seat, the floor had a buildup of a dark gray substance and black scuff marks. During an interview on 9/28/2022 at 9:26 AM, in Room #411, the Housekeeping Supervisor confirmed the floors needed to be cleaned and the bathrooms and toilets should be clean. Observation in Room #410 on 9/26/2022 at 11:45 AM, on 9/27/2022 at 8:30 AM and 4:35 PM, and on 9/28/2022 at 9:34 AM, revealed a buildup of gray dust and grime along the edges of the base boards, the floor had a build up of a brown and gray substance and was sticky, there was a pile of gray dust and cobwebs behind the door, and the privacy curtain was missing for the bed beside the door. During an interview on 9/28/2022 at 9:35 AM, in Room #410, the Housekeeper confirmed the floor next to the baseboards had the build up of gray dust and grime, and the floor needed to be cleaned. She confirmed there should not be a pile of gray dust and cobwebs behind the door and the privacy curtain should be replaced. Observation in Room #102 on 9/27/2022 at 8:22 AM, 11:15 AM, and 2:16 AM, and on 9/28/2022 at 9:32 AM, revealed a fan covered in dark gray dust blowing in the room, the overbed table base was covered in a build up of brown grime and gray dust, the fall mats were covered in black and gray marks and grime, and the floor was covered in black and gray marks and grime. During an interview on 9/28/2022 at 9:33 AM, in Room #102, the Housekeeping Supervisor in Room 102, the Housekeeping Supervisor confirmed the fan was dirty and dusty, the overbed table base needed to be cleaned, and the fall mats and the floor was dirty. Observation in Room #510 on 9/26/2022 at 11:49 AM, on 9/27/2022 at 8:30 AM, and on 9/28/2022 at 9:35 AM, revealed the fall mats had a build up of a black and gray substance, 2 telephones were lying on the floor, and the floor was sticky and had a buildup of a brown and gray substance. During an interview on 9/28/2022 at 9:36 AM, in Room #510, the Housekeeping Supervisor confirmed the fall mats needed to be replaced, the floor was dirty, and stated, .phones should be on the bedside tables or the overbed table, not in the floor . During an interview on 9/29/2022 at 12:23 PM, the Administrator was asked when she last made a tour of the resident rooms. She stated, .the week of August the 8th . She confirmed every resident should have a privacy curtain. She confirmed the floors in the Resident rooms and bathrooms should be clean and free of debris, cobwebs, and layers of dust should not be built-up behind the doors. She confirmed overbed table bases and floor mats should be clean. She was asked if telephones should be in the floor. She stated, No. They should not.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure 1 of 8 sampled residents (Resident #1) reviewed for medication administration were free from significant medication errors. The findings include: Review of the facility's policy titled, MEDICATION ADMINISTRATION-GENERAL GUIDELINES, with a revision date of 1/1/2019, showed, .Before administering a medication, the nurse should assure he/she is administering to the correct patient, verify the medication, dose, time and route . Review of the facility's policy titled, PREPARATION AND GENERAL GUIDELINES, with a revision date of 1/1/2019, showed, .Medications are not pre-poured either in advance of the med [medication] pass or for more than one resident at a time .Residents are identified before medication is administered by using a method of identification. Possible methods of identification include .Checking photograph attached to medical record .Calling resident by name (except in residents with cognitive impairment) .Having resident verify his/her last name .If necessary, verifying resident identification with other facility personnel . Review of the medical record, showed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Review of the Progress Note dated 2/15/2021 at 8:37 PM, showed, .At around 6:45PM resident received roommates [roommate's] medication by error. Pt [Patient] informed along with daughter .and DON [Director of Nursing] .Called NP [Nurse Practitioner] and inform [informed] of incident .orders received to do V/S [vital signs] Q [every] 4 hours .Pt [Pt's] family insist on sending to hospital . Review of the hospital records with an admitted [DATE], showed, .Patient accidentally received her roommates medications .received [MEDICATION(S)] [blood pressure lowering medication] 60 mg [milligrams], [MEDICATION(S)] [blood thinner] 5 mg, [MEDICATION(S)] [cholesterol lowering medication] 10 mg, [MEDICATION(S)] [allergy/asthma medication] 10 mg, [MEDICATION(S)] [beta-blocker, blood pressure lowering medication] 5 mg, and losartan [blood pressure lowering medication] 50 mg .normally takes [MEDICATION(S)] [vitamin supplement] 1 mg, [MEDICATION(S)] [cholesterol lowering medication] 10 mg, [MEDICATION(S)] [nerve pain medication] 150 mg, [MEDICATION(S)] [immunosuppressant medication used for some type of arthritis] 5 mg, [MEDICATION(S)] [laxative] as needed, [MEDICATION(S)] [antidepressant and nerve pain medication] 150 mg nightly, [MEDICATION(S)] [heartburn/reflux medication] 20 mg, oxycodone/acetaminophen [[MEDICATION(S)], a pain medication] 7.5/325 mg every 4 hours as needed, solifenacin [bladder relaxant medication] 10 mg, [MEDICATION(S)] [anticonvulsant and nerve pain medication] 300 mg twice daily .She has had all her medicines today except for her nightly [MEDICATION(S)]. Her last [MEDICATION(S)] was at 1:56 PM .Medical Decision Making .Discussed with poison control who recommends 6-hour observation for the beta-blocker [[MEDICATION(S)]] and [NAME] [Angiotensin receptor blocker, losartan] but a 12 to 23-hour observation for the [MEDICATION(S)] .Will admit for further observation .Clinical Impression .S/P [status post [MEDICAL RECORD OR PHYSICIAN ORDER] .Condition: Stable .Prescriptions/Amb Orders .No Action .patient was hemodynamically stable .Labs [laboratory values] were overall non-acute/stable .EKG [electrocardiogram] was overall non-acute .Vital signs .Pulse .67-88 .BP [Blood Pressure] .85-115/48-71 .Pulse Ox [Oximetry] .96-100 [percent] . During an interview on 2/21/2021 at 3:59 PM, Resident #1 confirmed Licensed Practical Nurse (LPN) #1 had administered her roommate's medications to her on 2/15/2021, and she was transferred to the hospital emergency department per her and her family's request. During an interview on 2/21/2021 at 4:30 PM, the Director of Nursing (DON) was asked what happened when Resident #1 received the wrong medications. The DON stated, .The night shift nurse called me and told me she had given all of the meds for 1 patient to the patient's room mate .The nurse called me back a few moments later and the nurse said the daughter wanted her to go to the ER [emergency room ] .EMS [Emergency Medical Services] got here probably less than an hour and were able to transport her .She stayed for observation . The DON was asked how she expected the nursing staff to identify the residents. The DON stated, Each person has a photo, so I expect them to look at the photo to know if it's A bed or B bed .Call them by name .They look like their photo . During an interview on 2/21/2021 at 6:55 PM, LPN #1 was asked what happened when Resident #1 received the wrong medications on 2/15/2021. LPN #1 stated, I pulled up her roommate's meds. Then I had the 100 Hall, and a particular patient if you don't get his meds when he wants them he will throw himself on the floor. I heard him screaming, so I put her name on the cup and put it back in the cart actually put the pill packs and set the cup on top of them .When I came back I took the pills to the wrong patient .

Based on policy review, observation, and interview, the facility failed to ensure practices were maintained to prevent the potential spread of infection when 1 of 3 (Registered Nurse (RN) #1) nurses failed to properly clean the nebulizer equipment after use during medication administration, 2 of 16 (Certified Nursing Assistant (CNA) #1) and (Licensed Practical Nurse (LPN) #2) staff members touched the residents' food during dining, and Respiratory Therapist (RT) #1 failed to perform appropriate infection control practice during [MEDICAL CONDITION] care. The findings included: 1. The facility's SPECIFIC MEDICATION ADMINISTRATION PR[NAME]EDURES policy dated 6/2016 documented, .Rinse and disinfect the nebulizer equipment .Wash pieces (except tubing) with warm, soapy water .Rinse with hot water .Allow to air dry completely on paper . Observations in Resident #174's room on 12/18/18 at 8:34 AM, RN #1 washed her hands and performed the nebulizer treatment as ordered. RN #1 failed to clean the nebulizer equipment after use, and placed the uncleaned nebulizer equipment into a plastic bag at the resident's bedside. Interview with the Director of Nursing (DON) on 12/18/18 at 2:24 PM, at the nursing station, the DON was asked if it was acceptable to not clean the nebulizer equipment after use during medication administration. The DON stated, .No. 2. Observations on the 200 hall during dining on 12/17/18 at 11:51 AM, CNA #1 set up Resident #9's meal tray. CNA #1 removed a roll with his bare hands from the resident's meal plate and placed it on the tray. Observations in the restorative dining room on 12/17/18 at 12:23 PM, revealed Resident #27 was seated at the table when LPN #2 put the chicken patty on the bun with a fork and then with her bare hands, LPN #2 cut the chicken sandwich in half. LPN #2 picked up half of the sandwich with her bare hands and placed the sandwich in Resident #27's hand. Interview with the DON on 12/20/18 at 6:36 PM, on the 300 hall, the DON was asked if it was appropriate for the staff to touch the resident's food with their bare hands. The DON stated No, it is not, never. 3. The facility's .Tracheotomy Care policy revised 7/14 documented, .procedures are sterile and are performed by the RT, RN or LPN .Put a sterile glove on the dominant hand and a nonsterile glove on the nondominant hand . The facility's policy .Using Gloves revised 9/2010 documented .To prevent the spread of infection .Putting on Sterile Gloves .with one hand, grasp a glove by the inside of the cuff. Insert the opposite hand into the glove .Pick up the remaining glove with gloved hand. Insert ungloved hand into the second glove .Pull up cuffs of the glove .Removing Gloves .Wash hands. The facility's policy Handwashing/Hand Hygiene with a revised date of 8/2015 documented, .When applying, remove one glove from the dispensing box at a time . 4. Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].CLEAN WITH TRACHE ([MEDICAL CONDITION]) CARE KIT ONCE DAILY AND AS NEEDED . Observations in Resident #8's room on 12/19/18 at 9:25 AM, RT #1 removed the breakfast tray and other items from the bedside table, laid her [MEDICAL CONDITION] care kit and a package containing a split 4 x 4 gauze dressing on the bedside table without sanitizing the table and putting down a barrier. RT #1 removed a pair of gloves from her jacket pocket, donned the pair of unsterile gloves, opened the pack of sterile gloves, donned the sterile gloves on top of the unsterile gloves and continued with [MEDICAL CONDITION] care. Interview with the DON on 12/20/18 at 4:12 PM, in the DON's office, the DON was asked if it was acceptable when preparing for [MEDICAL CONDITION] care not to sanitize the bedside table and not to lay a barrier down before putting supplies down for [MEDICAL CONDITION] care. The DON stated, .No. The DON was asked if it was acceptable to pull a pair of gloves out of your pocket and use them. The DON stated No. The DON was asked is it acceptable to don sterile gloves over a pair of unsterile gloves. The DON stated, No.

Based on policy review, medical record review, review of fall investigation reports, and interview, the facility failed to ensure that fall investigations were completed for 1 of 18 (Resident #57) sampled residents reviewed for falls. The findings included: 1. The facility's PROTECTION/PREVENTION PROGRAMS-FALLS PREVENTION PROGRAM policy revised 8/13/13 documented, . (Named facility) takes a person centered approach to falls prevention. Comprehensive assessment and root cause analysis are two very important tools in the prevention of falls and the recurrence of falls .a Falls Committee .monitors falls and utilizes data to systemically address falls . 2. The facility's INCIDENT AND ACCIDENT PR[NAME]ESS revised 8/13/13 documented, .Investigation into the incident/accident: -Obtain information on what happened-what was actually seen or heard. If not witnessed, get patient's statement about what happened .Document all known facts, results of assessment including complete description of injuries, treatment, notification of physician and family. Gather statements from persons having information that may be pertinent . 3. Medical record review revealed Resident #57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of fall investigations for resident #57 dated 11/13/18, 12/2/18, and 12/10/18 revealed the fall investigation was incomplete. Interview with the Director of Nursing (DON) on 12/20/18 at 6:17 PM, in the 300 hall, the DON confirmed that the fall scene investigation was not attached to the 11/13/18, 12/2/18, and 12/10/18. The DON was asked if the fall investigations were complete. The DON stated, .no these are not complete .

Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual v1.15R October 1, 2017, medical record review, and interview, the facility failed to ensure a significant change in status assessment (SCSA) was completed and completed timely related to hospice services for 2 of 20 (Resident #35 and 74) sampled residents reviewed. The findings included: 1. The MDS 3.0 RAI Manual v1.15R p. 23-24 documented .A SCSA is required to be performed when a terminally ill resident enrolls in a hospice program .The MDS completion date (Item Z0500B) must be .no later than 14 days after the determination that the criteria for a SCSA were met . 2. Medical record review revealed Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].(Named) Hospice . Medical record review revealed there was no significant change MDS assessment completed when Resident #35 was admitted to hospice. Interview with the MDS Coordinator on 2/28/18 at 12:00 PM, in the MDS office, The MDS Coordinator was asked if a change of status MDS was completed when Resident #35 was admitted to hospice. The MDS Coordinator stated, No, I do not have one. 3. Medical record review revealed Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A significant change MDS, related to hospice services, with an Assessment Reference Date (ARD) of 10/10/17 documented a completion date of 10/23/17. A physician's orders [REDACTED].>Interview with the MDS Coordinator on 1/28/17 at 2:30 PM, in the MDS office, the MDS Coordinator was asked if the 10/10/17 MDS was completed within 14 days of the resident being admitted to hospice. The MDS Coordinator stated No, Ma'am

Based on medical record review and interview, the facility failed to ensure each resident was involved in developing the care plan and making decisions about his or her care for 2 of 2 (Resident #34 and 44) sampled residents reviewed of the 11 residents interviewed about participation in care planning. The findings included: 1. Medical Record review revealed Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] and the quarterly MDS dated [DATE] documented a Brief Interview for Mental Status score of 15, indicating Resident #34 was cognitively intact. Medical record review revealed no documentation Resident #34 participated in care planning meetings. Interview with Resident #34 on 2/26/18 at 3:45 PM, in Resident #34's room, Resident #34 was asked if she participated in her care planning meetings. Resident #34 stated, No .I have asked to be there, but have not been invited yet. Resident #34 was asked if she wanted to go to the meetings. Resident #34 stated, Yes. 2. Medical record review revealed Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS dated [DATE] and the quarterly MDS dated [DATE] documented a Brief Interview for Mental Status score of 15, indicating Resident #44 was cognitively intact. Review of the facility's Focus Meeting Form dated 6/1/17 revealed no interdisciplinary team signatures. Resident #44 had not signed the form. Review of the care plan for Resident #44 revealed that the care plan was revised on 1/26/18. Interview with Resident #44 on 2/26/18 at 5:04 PM, on the front lawn of the facility, Resident #44 stated that he had not been invited to participate in care planning meetings. Interview with the Social Services Director on 2/28/18 and 8:25 AM, in the Social Services office, the Social Services Director confirmed that there were no interdisciplinary team signatures on the Focus Meeting Form and confirmed that Resident #44 had not signed the form. The Social Services Director confirmed that Resident #44 had not participated in any care planning meetings since that time. 3. Interview with the Director of Nursing (DON) on 2/28/18 at 9:10 AM, in the DON office, the DON was asked if she expected alert and oriented residents to participate in their care planning meetings. The DON stated, Yes, absolutely. The DON was asked if residents or family members should be invited to care planning meetings on a quarterly basis. The DON stated, Yes. Interview with the MDS Coordinator on 2/28/18 at 8:35 AM, in MDS office, the MDS Coordinator was asked if residents and family members should be invited to the care plan meetings. The MDS Coordinator stated, Yes, Absolutely.

Based on policy review, observation and interview, the facility failed to ensure food was prepared, stored and served in a safe and sanitary manner, as evidenced by staff and visitors entered the kitchen multiple times with exposed hair. On 12/12/16, the facility had a census of 71, with 68 of those residents receiving a meal tray from the kitchen. On 12/14/16, the facility had a census of 71, with 69 of those residents receiving a meal tray from the kitchen. The findings included: 1. The facility's [MEDICATION NAME] (hygienic) & SAFETY PRACTICES policy documented, .Dietary partners shall wear hair restraints .that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single service and single-use articles . 2. Observations in the kitchen revealed the following: a. 12/12/16 at 11:00 AM, and 12:20 PM: The Registered Dietician (RD) had long strands of hair exposed outside the hair restraint. b. 12/12/16 at 11:00 AM: Dietary Staff #1 had exposed hair outside the hair restraint. c. 12/12/16 at 11:00 AM, 11:44 AM, and 12:00 PM: Certified Nursing Assistant (CNA) #1 had exposed hair outside the hair restraint. d. 12/12/16 at 11:00 AM, and 11:34 AM: The Assistant Director of Nursing (ADON) had exposed hair outside the hair restraint. e. 12/12/16 at 12:06 PM, and 12:33 PM: Licensed Practical Nurse (LPN) #1 had exposed hair outside the hair restraint. f. 12/12/16 at 12:07 PM, and 12:12 PM: Registered Nurse (RN) #1 had exposed hair outside the hair restraint. g. 12/12/16 at 12:07 PM, 12:12 PM, and 12:15 PM: CNA #2 had exposed hair outside the hair restraint, and had no beard covering over his facial hair. h. 12/12/16 at 12:19 PM: Dietary Staff #2 served food from the tray line with exposed hair. i. 12/12/16 at 12:20 PM: CNA #3 had exposed hair outside the hair restraint. j. 12/12/16 at 12:23 PM: The Activities Director had exposed hair outside the hair restraint. k. 12/14/16 at 11:00 AM: Dietary Staff #1 had exposed hair outside the hair restraint. l. 12/14/16 at 11:10 AM: RN #2 had no beard covering over his facial hair. m. 12/14/16 beginning at 11:11 AM: The Director of Nursing (DON) entered the kitchen multiple times with exposed hair while retrieving and serving trays in the dining room. n. 12/14/16 at 11:13 AM: Dietary Staff #2 served food from the tray line with exposed hair. o. 12/14/16 beginning at 11:14 AM: LPN #2 entered the kitchen multiple times with exposed hair and no beard covering over his facial hair, while retrieving and serving trays in the dining room. p. 12/14/16 at 11:38 AM: 2 female visitors entered the kitchen with exposed hair and obtained beverages from the DM. 3. Interview with the DM on 12/15/16 at 3:30 PM, in the kitchen, the DM was asked if it was acceptable for hair to be exposed in the kitchen. The DM stated, No.

Based on review of a job description, observation and interview, the facility failed to ensure a clean and sanitary environment was maintained as evidenced by mold on the shower floors and walls, broken tiles, peeling wallpaper, and light bulbs burned out in 2 of 2 (200 Hall Central Bath and 300 Hall Central) central baths. The findings included: 1. The facility's Housekeeping Supervisor job description documented, .DUTIES AND RESPONSIBILITIES .Ensure that housekeepers clean patient bathrooms including sinks, toilets, tubs and showers .Ensure that walls, furniture and equipment are cleaned, as needed, to provide a clean pleasant environment for patients, staff and visitors . 2. Observations in the 200 Hall Central Bath on 12/13/16 at 11:31 AM, and on 12/15/16 at 9:01 AM, revealed dirt and grime on the floor, dirt and grime build-up on the shower floor, and a black substance in the tile grout on the shower wall and on the shower floor. Observations in the 300 Hall Central Bath on 12/12/16 at 11:27 AM, 12/13/16 at 11:29 AM, and on 12/14/16 at 9:21 AM, revealed a black substance in the tile grout in the shower, and deteriorating caulk with a black substance around the edges of the bathtub. There was no working light in the bathtub area. Observations in the 300 Hall Central Bath on 12/15/16 at 9:30 AM, revealed 3 broken tiles lying in the floor outside the shower with the inner wall exposed, and a large section of wallpaper coming off the wall above the broken tiles. Interview with Housekeeper (HK) #1 on 12/15/16 at 9:11 AM, in the 300 Hall Central Bath, HK #1 was asked to describe what she saw in the shower stall. HK #1 stated, .over the years, a touch of mildew .dirt build up over the years .the discoloration has been there a long time .neglected several years ago. HK #1 was asked about the lack of lighting in the bathtub area. HK #1 stated, The bulb probably went out. HK #1 was asked about the caulk around the tub. HK #1 stated, .needs to be cleaned . HK #1 was asked about the broken tiles. HK #1 stated, This is completely busted out and the wallpaper is coming off .the tile been busted out and caused the wallpaper to come loose at the bottom . Interview with Housekeeper #1 on 12/15/16 at 9:23 AM, in the 200 Hall Central Bath, HK #1 was asked to describe the appearance of the floor. HK #1 stated, The floor in here, same thing, dirt build-up between the grout and tiles. HK #1 was asked to describe the shower stall. HK #1 stated, Mildew build-up. HK #1 was asked if having mildew in the showers was acceptable. HK #1 stated, No Ma'am. Interview with the Director of Housekeeping (DOH) on 12/15/16 at 9:34 AM, in the 200 Hall Central Bath, the DOH was asked about the floor. The DOH stated, It could use some work. The DOH was asked about the black substance in the shower tile grout. The DOH stated, It could be mold. The DOH was asked if it was acceptable for mold to be present in the shower. The DOH stated, No. The DOH was asked if the shower was clean. The DOH stated, No. Interview with the DOH on 12/15/16 at 9:38 AM, in the 300 Hall Central Bath, the DOH was asked about the broken tiles next to the shower stall. The DOH stated, It looks like they rammed into the wall and didn't tell nobody. The DOH was asked if the broken tiles and loose wallpaper were acceptable. The DOH stated, No. The DOH was asked about the lack of light in the bathtub area. The DOH stated, It's not working . The DOH was asked about the black substance on the caulk around the rim of the bathtub. The DOH stated, Mold. Interview with the Maintenance Director on 12/15/16 at 9:42 AM, in the 300 Hall Central Bath, the Maintenance Director was asked about the broken tiles and loose wallpaper next to the shower stall. The Maintenance Director stated, We've had water decay in that wall from years of showering. I see they knocked the bottom part of the wall out with the broken tiles, the wallpaper is releasing from the wall. The Maintenance Director was asked if the Central Bath was acceptable. The Maintenance Director stated, No. Interview with the Administrator on 12/15/16 at 9:55 AM, in the 300 Hall Central Bath after touring the 200 and 300 Hall Central Baths, the Administrator was asked if it was acceptable to have mildew in the showers and bathtub, and broken tiles and missing wallpaper. The Administrator stated, No .this is an issue we've been dealing with, the moisture damage .

Based on National Pressure Ulcer Advisory Panel (NPUAP) reference guide, policy review, medical record review, observations and interview, the facility failed to put preventative measures in place prior to the development of pressures ulcers, failed to timely identify pressure ulcers, failed to accurately assess a wound and/or failed to have bilateral moon boots in place as ordered for 2 of 4 (Residents #80 and 89) sampled residents reviewed of the 4 residents with pressure ulcers. The facility failed to put preventative measures in place prior to the development of metatarsal (toe) pressures ulcers, failed to timely identify, accurately assess and/or treat pressure ulcers resulted in actual harm to Resident #80. The findings included: 1. Review of the NPUAP quick reference guide defined an Unstageable pressure ulcer as, .Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown, or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; by it will be either a Category/Stage III (3) or IV (4) . 2. Review of the facility's SKIN INTEGRITY PREVENTION AND MANAGEMENT policy documented, .Weekly skin assessments are completed on all patients by the licensed nurse and documented on a weekly basis . 3. Medical record review revealed Resident #80 was admitted on [DATE] with [DIAGNOSES REDACTED]. An Admission Nursing Assessment dated 8/31/15 documented, .Has skin desensitization problems: Skin sensitization to pain/pressure less than 50% (percent) body Condition of Feet: Other: dry, red and blanchable . Skin Treatment / Interventions: Pressure reducing devices - bed . Turning and re-positioning Heel Floats . Skin Assessment: Insert body diagram & (and) mark all applicable areas noted during physical assessment . The stick man diagram documented 2 open areas to left buttocks and no open areas to feet with a note feet were red and blanchable, the resident was always incontinent of bowel and bladder and the resident had functional limitation and was impaired in the upper and lower extremity on one side. A nurses note dated 9/1/15 documented, .Requires extensive assist with Activities of Daily Living (ADLs) . Maximum assist with ADLs and transfers . Resident #80's Braden Risk Assessment Reports (indication for risk at developing pressure ulcers) dated 9/6/15 documented a Braden score of 14 indicating the resident was a moderate risk level for developing pressure ulcers. Review of the admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #80 was cognitively intact and was coded for 1 stage 2 pressure ulcer present on admission, 2 unstageable wounds present on admission and 2 unstageable wounds suspected DTI (deep tissue injury) evolution present on admission. The care plan dated 9/17/15 documented, .Problem . Skin Integrity, Alteration and Risk for Alteration r/t (related to) l (left) / e (extremity) [MEDICAL CONDITION], RA ([MEDICAL CONDITION] Arthritis), weakness, Pus (pressure ulcers). Incontinent . High Risk meds (medicines) . Braden Scale per protocol . Weekly Skin Assessment per protocol . A weekly wound assessment dated [DATE] documented an unstageable wound on the 2nd metatarsal (toe) and the lateral 5th metatarsal of Resident #80's right foot. This wound was not identified until it was assessed as unstageable. A weekly wound assessment record dated 10/1/15 documented the following wound measurements: a. 2nd metatarsal right foot - L (length) 0.5 centimeters (cm) x (by) W (width) 0.5 cm b. 5th metatarsal right foot - L 0.5 cm x W 0.5 cm A weekly wound assessment progress note dated 10/1/15 documented, .R (right) foot 2nd metatarsal (lateral aspect) unstageable r/t 100% (percent) slough . Exfoliated feet & (and) noticed open wound. Toes curled into each other causing pressure. Review of a wound assessment progress note dated 10/9/15 documented, .R foot 5th metatarsal lateral aspect unstg (unstageable) r/t 100% eschar tissue . A monthly Nursing Summary Report dated 10/4/15 documented, .Skin . Skin Condition: Wound requiring treatment (refer to wound documentation) . Condition of feet: No problem . This monthly nursing summary was inaccurate when wounds on the 2nd and 5th metatarsal of the right foot which were first identified as unstageable on 10/1/15. Observations in Resident #80's room on 10/14/15 at 3:40 PM, revealed a wound on Resident #80's right foot second toe around 2 centimeters in diameter with slough, the wound was moist and had no odor. The 5th toe of her right foot was 1 cm in diameter, dry with eschar and had no odor. Interview with the Director of Nursing (DON) on 10/14/15 at 9:20 AM, in the hall beside the DON office, the DON was asked if the aides do skin assessments. The DON stated, Anytime the CNAs (certified nursing assistants) see something on the skin they are to immediately tell the nurse. The DON was asked if the nurses are the only ones that do skin assessments. The DON stated, Yes, the nurses do weekly skin assessments. Interview with Registered Nurse (RN) #2 on 10/14/15 at 1:30 PM, in room [ROOM NUMBER], RN #2 stated, (Named Resident #80) was admitted on [DATE]. The new ones (wounds) are on her right foot lateral aspect 5th metatarsal unstageable 100% eschar and on 10/9/15 it was still eschar. Her right foot 2nd metatarsal was unstageable with 100% slough and on 10/9/15 it was a stage 3. RN #2 was asked if there were standing orders for wound treatments. RN #2 stated, We have clinical guidelines for treatment. Every nurse is responsible for the wounds. I do a full head to toe assessment, she (Resident #80) has toes that curl in and lay on top of her other toes. I found the wound on her toes after I put lotion on her foot and it was 100% slough. RN #2 was asked if the CNAs told her about the wound prior to her finding the wounds. RN #2 stated, No, and I told them about it. I told the CNAs, the nurses, everybody now knows what to look for. RN #2 was asked did Resident #80 have any preventative measures in place prior to you finding the unstageable wounds on her toes. RN #2 stated, No. RN #2 was asked since she had the knowledge of the two toe wounds what should be done. RN #2 stated, Cleaning daily and maybe something like a gauze rolled up and placed between her toes. RN #2 was asked if there was anything in place now for prevention of pressure. RN #2 stated, No. She (Resident #80) is high risk anyway, maximum assist, she cannot move by herself. She wears moon boots all the time and they should be taken off 1 time a day for bathing. Let me look at her H/P (history and physical) for a [DIAGNOSES REDACTED]. No, nothing related to cause the pressure ulcers or wounds none of her meds, no I don't see anything. RN #2 was asked if the CNA should separate her toes during her bath. RN #2 stated, I would think so. Interview with CNA #3 on 10/14/15 at 2:00 PM, at the nurse's station, CNA #3 was asked if she provided care to Resident #80. CNA #3 stated, I assist her with feeding. I give her bath and get her up. CNA #3 was asked if Resident #80 got a full bed bath. CNA #3 stated, Yes ma'am. CNA #3 was asked what she washed when she gives a full bed bath and if she washed between the resident's toes. CNA #3 stated, Yes ma'am, her face, her hands and her feet. The facility failed to put preventative measures in place prior to the development of pressure sores and nurses failed to timely identify and assess skin which resulted in actual harm when Resident #80 developed unstageable pressure ulcers to the 2nd and 5th toes of Resident #80's right foot. 4. Medical record review revealed Resident #89 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].BILATERAL FEET: APPLY MOON BOOT . Observations in the 200 hall on 10/13/15 at 8:09 AM, revealed Resident #89 sitting in a wheelchair in the hallway with a moon boot on the left foot only. Observations in the activity room on 10/13/15 at 10:08 AM, revealed Resident #89 sitting in a wheelchair with a moon boot on the left foot only. Observations in Resident #89's room on 10/14/15 at 2:28 PM, revealed Resident #89 lying in bed with a moon boot on the left foot only. Interview with RN #2 on 10/14/15 at 2:30 PM, in Resident #89's room, RN #2 was asked if there was a moon boot on Resident #89's right foot. RN #2 stated, No, it's not. I will put it on now.

Based on medical record review, observation, and interview, the facility failed to revise the care plan related to pressure ulcers for 2 of 28 (Residents #80 and 89) sampled residents included in the stage 2 review. The findings included: 1. Medical record review revealed Resident #80 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 9/17/15 had not been revised to include interventions for the prevention of pressure ulcer development between the resident's toes. 2. Medical record review revealed Resident #89 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].BILATERAL FEET: APPLY MOON BOOT . The care plan dated 10/5/15 documented, .Moon boot to L (left) foot . The care plan had not been revised to include the intervention of bilateral moon boots. Observations in the 200 hall on 10/13/15 at 8:09 AM, in the activity room on 10/13/15 at 10:08 AM, and in Resident #89's room on 10/14/15 at 2:28 PM, revealed Resident #89 with a moon boot on the left foot only. Interview with Registered Nurse (RN) #2 on 10/14/15 at 2:45 PM, in the conference room, RN #2 was asked if the current care plan had been updated to include the new order for application of moon boots to bilateral feet. RN #2 looked at the care plan and stated, No, it's not on here.

Based on policy review, medical record review, and interview, the facility failed to obtain monthly weights for 1 of 3 (Resident #5) sampled residents of the 7 residents reviewed with nutritional issues. The findings included: The facility's documentation guidelines policy documented, .Weights .Time Frames . At least monthly, unless ordered on a more frequent schedule by the physician, nurse, or dietician . If unusual variation still exists, report to licensed nurse who reports to physician and dietician . Intervene as appropriate/ordered . Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set ((MDS) dated [DATE] documented Resident #5 had a Brief Interview for Mental Status (BIMS) score of 13, indicating no cognitive impairment. The MDS documented Resident #5 required total staff assistance for bathing, and extensive staff assistance for all other activities of daily living (ADLs). The MDS documented Resident #5's height was 65 inches and weight was 114 pounds (#). A dietary note dated 8/8/15 documented, .Noted pt (patient) has fear of gaining wt (weight). BMI (Body Mass Index) = 18.9, very low end . MNA (mini-nutritional assessment) continues to suggest that pt is at a risk for malnutrition . The comprehensive care plan dated 8/20/15 documented Resident #5 was at nutritional risk and had a risk for malnutrition. The care plan documented, .APPROACHES . weigh weekly . Resident #5's Vitals Report documented Resident #5's weight was obtained at 111# on 6/16/15, and 114# on 8/2/15. No weights were documented between 6/16/15 and 8/2/15. Interview with the Director of Nursing (DON) on 10/14/15 at 7:50 AM, in the conference room, the DON was asked for Resident #5's weight for July 2015. The DON stated, We don't have one. I've looked in every possible place, and we just don't have one. Interview with the Registered Dietician (RD) on 10/14/15 at 2:00 PM, in the MDS office, the RD was asked how often Resident #5 should be weighed. The RD stated, It (weight) should be once a month. It is monthly now. The RD was asked about the month of July, 2015 where no weight was obtained. The RD stated, Unfortunate. The RD was asked whether Resident #5 should have been weighed between 6/16/15 and 8/2/15. The RD stated, Yes, she should have been.

Based on review of Certified Nursing Assistant (CNA) certification status and interview, the facility failed to ensure 1 of 37 (CNA #1) CNAs employed had an active certification. The findings included: The CERTIFIED NURSES ASSISTANTS LICENSE INFORMATION documented, .(Named CNA #1) . Expiration Date . [DATE] . Interview with the Administrator on [DATE] at 5:50 PM, at the nurses station, the Administrator was asked if CNA #1 certification had expired. The Administrator stated, Yes, that is correct. Her license expired. The Administrator was asked if CNA #1 was working on the floor on today ([DATE]). The Administrator stated, Yes, she was working on the floor today.

Based on policy review, observation and interview, it was determined the facility failed to ensure food was prepared and distributed under sanitary conditions as evidenced by a family member entered the kitchen during the noon meal without wearing a hair cover in 1 of 2 (8/25/14) days of observations in the kitchen. The findings included: Review of the facility's "Personal Hygiene" policy documented, "...Hair Restraints... partners shall wear hair restraints such as hats, hair coverings, or nets... that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils..." Observations in dining room on 8/25/14 at 11:25 AM, revealed a family member of Resident #5 entered the kitchen without wearing a hair net. A box of hair nets, beard covers, and hand sanitizer was observed on a table in the main dining room just outside the kitchen door. During and interview at the nurses' station on 8/26/14 at 9:00 AM, the Administrator was asked what the policy was for hair restraints in the kitchen. The Administrator stated, "I decided about a year ago that no one would go into the kitchen without a hair net. We have been working diligently to get everybody on board. We have in-serviced staff and family members." During an interview at the nurses' station on 8/26/14 at 9:30 AM, the Dietary Manager (DM) was asked what the facility's policy was for hair restraints in the kitchen. The DM stated, "...No on is allowed in the kitchen without hair nets on."

Based on medical record review, observation and interview, it was determined the facility failed to revise the comprehensive care plan to reflect interventions for falls and skin care for 1 of 20 (Resident #8) sampled residents reviewed of the 38 residents in the Stage 2 review. The findings included: Medical record review for Resident #9 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the "Post Falls Nursing Assessment" dated 7/4/12 documented, "...What immediate interventions were initiated to prevent future falls? ...concave mattress.." Review of a "Patient Care Plan Update" dated 7/4/12 documented, "...hx (history) of recent fall... Approaches... concave mattress..." Review of a "Patient Care Plan Update" dated 7/10/12 documented, "...Stage 1 Pressure Ulcer to coccyx... Approaches Provide treatments as ordered. Sensicare to coccyx BID (twice daily) & (and) prn (as needed). Observe for s(signs) / s (symptoms) nonhealing/infection, Enc (encourage) /assist c (with) T (turn) & R (reposition) q (every) 2 hrs (hours) and W (while) I (in) B (bed)..." The care plan was not revised to include pressure relief mattress and removal of the concave mattress. Observations in Resident #8's room on 7/16/12 at 11:00 AM and 12:35 PM and on 7/17/12 at 4:00 PM and 5:00 PM, revealed a pressure relief mattress on the bed but there was no concave mattress on the bed. During an interview at the nurses station on 7/17/12 at 5 PM, Nurse #3 was asked if Resident #8 had a concave mattress on his bed. Nurse #3 stated, "...no, he has an air mattress on his bed because he has a stage 1 wound." The surveyor then asked for clarification of what type mattress was on this resident's bed. Nurse #3 stated, "An air Mattress..." During an interview at the nurses station on 7/17/12 at 5:05 PM, the Director of Nursing (DON) stated, "...I see the interventions (for falls) in the nurses notes but we did not update the care plan, it still has concave mattress... the Air mattress was initiated on the 13th of July and the concave mattress on the 4th of July..." The DON then stated, "...the concave mattress was on the bed before the air mattress was placed on the bed..."