Every finding on record at Oaklawn Health Care, LLC

Based on interview and record review, the facility failed to ensure the consultant pharmacist identified and reported a medication irregularity during the required monthly drug regimen review for 1 of 1 residents (R1), when an unauthorized Haloperidol order remained active despite the resident's diagnoses of epilepsy and Parkinsonism. This failure resulted in the medication remaining on the resident's medication regimen from March through June 2026 without identification during the required monthly pharmacist reviews.R1's face sheet dated 6/17/26, identified diagnoses of localization related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures not intractable without status epilepticus (abnormal electrical activity begins in a specific area of the brain rather than the entire brain, hallucinations, and parkinsonism (condition that affects movement). R1's Medication Administration Record (MAR) dated 3/2026, identified an order for Haloperidol Lactate oral concentration (Haldol) 2 milligrams (mg)/milliliter (mL). Give 1.5 mL by mouth at bedtime for terminal agitation. Start 3/13/26 at 7:00 p.m. Review of R1's record identified no corresponding physician order to begin Haloperidol Lactate between 3/2026-6/2026 had been prescribed to R1. No corresponding progress note identifying the order or that a physician prescribed it. R1's MAR's for 3/2026, 4/2026, 5/2026, and 6/2026, identified that Haldol was given every evening beginning on 3/13/26 through 6/9/26. R1's Extended Care Visit Note dated 3/23/26, identified current orders reviewed which included Haldol 1.5 mL at bedtime. Additionally, R1 was seen by and current orders reviewed and signed which included the Haldol 1.5 mL at bedtime on 4/22/26, and 5/11/26. Hospice Current Plan of Care dated 3/26/26, did not identify a current order for Haloperidol. However, under additional services which was a capitulation of R1's record with hospice, it identified to discontinue all Haldol orders on 1/28/26. Additionally, the Hospice Current Plan of Care completed on 4/23/26, 5/7/26, 5/21/26, and 6/4/26, did not identify the order for Haldol that began on 3/13/26. R1's pharmacy recommendations dated 5/20/26, identified a recommendation that Haloperidol 2mg/mL (1.5 mL) is currently ordered nightly for agitation. Consider changing the order to as needed and discontinue if not used. During a return telephone interview on 6/24/26 at 9:16 a.m., consultant pharmacist (CP)-A stated she reviewed all current residents' medications once a month. CP-A stated she reviewed each resident's current medication list and certain medications should be monitored more closely, including psychotropics, medications requiring laboratory monitoring, and as needed antipsychotics. CP-A stated she reviewed her April recommendations for R1 and did not make any notes regarding Haldol and was uncertain why she did not. CP-A acknowledged she made a recommendation in May to change the medication to as needed and discontinue. During a telephone interview on 6/18/26 at 11:56 a.m., pharmacist (Ph)-B stated monthly drug regimen reviews are completed by the consultant pharmacist. Ph-B stated if she had completed the April review, she may have flagged the Haldol because of the resident's Parkinsonism and epilepsy. Ph-B stated antipsychotics are warned against for patients with Parkinsonism and epilepsy and if this represented a starting dose for Haldol it would be considered high for someone naive to the medication or who had been off the medication for some time. The pharmacy Consultant Pharmacist Services Provider Requirements dated 5/2022 identified regular and reliable consultant pharmacist services are provided to residents. The consultant pharmacist is responsible for identifying and evaluating medication-related issues, including prevention and reporting of medication errors, identifying contraindications, side effects and adverse effects, completing a monthly medication regimen review, communicating potential or actual medication-related problems to the responsible prescriber and facility leadership, reviewing medication administration records and physician orders at least monthly, and documenting resident-specific recommendations in the resident's active record.

Based on interview and record review, the facility failed to ensure 1 of 1 residents (R1) was free from a significant medication error when Haloperidol was entered into the facility's integrated electronic medication ordering system and administered to R1 from 3/13/26 through 6/9/26 without a valid and verified physician order.Findings include:The Nursing Home Incident Report (NHIR) submitted to the State Agency (SA) identified Haloperidol order intended for another resident was inadvertently entered into R1's chart. Medication was administered until review following seizure activity and discontinued upon discovery.R1's face sheet dated 6/17/26, identified diagnoses of localization related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures not intractable without status epilepticus (abnormal electrical activity begins in a specific area of the brain rather than the entire brain, hallucinations, and parkinsonism (condition that affects movement).R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had severe memory issues, no hearing issues and wore glasses, required some assistance with activities of daily living. R1 was taking antipsychotic medication on a regular basis with no gradual dose reduction attempted.R1's care plan dated 6/17/26 identified R1 had a seizure disorder with diagnosis of localization related symptomatic epilepsy with complex partial seizures and recent seizure activity. Interventions included: ensure a position to prevent injury during seizure activity, ensure open airway and document characteristics of seizure; monitor neurological status after any activity for residual impairment; notify medical doctor (MD) of any seizure activity; provide privacy and dignity during seizure activity; seizure medication management by hospice provider with scheduled and as needed Lorazepam; seizure medications will be administered as ordered, monitor for effect and side effects.R1's Pharmacist Recommendation dated 3/11/26, identified a pharmacy recommendation for Lorazepam. Handwritten note of prescribers response patient with high-risk seizure disorder-needs to have and signed by MD-A.R1's Medication Administration Record (MAR) dated 3/2026, identified an order for Haloperidol Lactate oral concentration (Haldol) 2 milligrams (mg)/milliliter (mL). Give 1.5 mL by mouth at bedtime for agitation. Start 3/13/26 at 7:00 p.m. with a discontinued date of 3/13/26 at 12:20 p.m. A second order Haloperidol Lactate oral concentration 2 mg/mL. Give 1.5 mL by mouth at bedtime for terminal agitation. Start 3/13/26 at 7:00 p.m.Review of R1's record identified no corresponding physician order to begin Haloperidol Lactate between 3/2026-6/2026 had been prescribed to R1. No corresponding progress note identifying the order or that a physician prescribed it.Review of R1's MAR's for 3/2026, 4/2026, 5/2026, and 6/2026, identified R1 was administered Haldol every evening from 3/13/26-6/9/26.During a telephone interview on 6/17/26 at 11:36 a.m., licensed practical nurse (LPN)-A stated on 3/12/26, she recalled going through orders for R1 and thought she took the Haldol order out of the system and put it back in the system. LPN-A recalled it was a hospice order. While transcribing it, she had gotten up from the computer and went to the medication cart to verify the strength. R1 still had a bottle of Haldol in the medication drawer from a prior order. LPN-A had not been aware that orders put in the electronic record go straight to the pharmacy to be filled. LPN-A could not recall if there was an order for a different resident and she transcribed it in R1's chart or how she ended up putting the order in R1's electronic record.During a telephone interview on 6/17/26 at 11:30 a.m., pharmacy technician (PhT)-A stated the facility was integrated with the pharmacy to directly fill the orders that were transcribed into the electronic health record. If the order was in the system, the facility did not have to send the pharmacy confirmation of order with a doctor signature. There was no way for pharmacy to verify the order written was correct. When the order was written in the electronic system a provider name had to be attached to the order. PhT-A was aware the electronic system allowed for any provider name to be attached to the order.R1's Extended Care Visit Note dated 3/23/26, identified current orders reviewed which included Haldol 1.5 mL at bedtime. Additionally, R1 was seen by and current orders reviewed and signed which included the Haldol 1.5 mL at bedtime on 4/22/26, and 5/11/26.Hospice Current Plan of Care dated 3/26/26, did not identify a current order for Haloperidol. However, under additional services which was a capitulation of R1's record with hospice, it identified to discontinue all Haldol orders on 1/28/26. Additionally, the Hospice Current Plan of Cares completed on 4/23/26, 5/7/26, 5/21/26, and 6/4/26, did not identify the order for Haldol that began 3/13/26.R1's progress note dated 4/22/26, identified R1 had an episode with full body tremors, stiffness in legs, arms, and hands accompanied by a blank stare.R1's pharmacy recommendations dated 5/20/26, identified a recommendation that Haloperidol 2mg/mL (1.5 mL) is currently ordered nightly for agitation. Consider changing the order to as needed and discontinue if not used.During a telephone interview on 6/18/26 at 11:56 a.m., pharmacist (Ph)-B stated drug regimen reviews are completed monthly on all residents by the consultant pharmacist (CP)-A. Ph-B stated if she had done the review in April she may have flagged the Haldol for Parkinsons and epilepsy but if the patient was doing well and did not have seizures or worsening motor issues she may not have flagged the medication. Ph-B stated antipsychotics are warned against for patients with Parkinsons and epilepsy. If that was a starting dose for Haldol, it would be considered high for someone that was naive to the medication or had been off of it for awhile.During a return telephone interview on 6/24/26 at 9:16 a.m., from a call on 6/18/26 at 11:26 a.m. when consultant pharmacist (CP)-A was not near a computer stated she reviewed all current residents medications once a month that are at the facility. CP-A would look at residents current medication list. Certain medications should be monitored more such as psychotropics, medications that require lab monitoring, and as needed antipsychotics. CP-A reviewed her recommendations for R1 in April and stated she did not make any notes about Haldol and was uncertain why she did not but did make a note on the May recommendation to change to as needed and discontinue.R1's Extended Care Visit Note dated 6/8/26, identified to discuss with hospice regarding Haldol use at bedtime to see if this could be tapered to 1 mL since there are no recent reports of agitation at bedtime.R1's record identified on 6/8/26, the pharmacy recommendation was reviewed by nurse practitioner (NP)-A with recommendation to discuss with hospice because hospice prescribed this medication.R1's progress note dated 6/9/26, identified at noon R1 was observed having a seizure. During seizure, R1 was gasping for air with very loud (snore-like) breathing. Following the seizure, R1 was very tired.R1's physician order dated 6/9/26, identified discontinue Haldol.During an interview on 6/17/26 at 8:42 a.m., registered nurse (RN)-A stated R1 had recently had three seizures. RN-A stated R1 had two seizures during the night on 6/9/26, and then the one at noon that she charted about. RN-A stated the seizure lasted approximately five minutes after she was in the room with R1. R1 had a hard time coming out of the seizure. Reviewed R1's Haldol order from 3/13/26, RN-A stated it was put in the system by LPN-A. RN-A could not locate an order that had been prescribed by a physician for the Haldol in the computer. RN-A was unsure how the bottle of Haldol could have come from the pharmacy without an actual order for it.During an interview on 6/17/26 at 3:46 p.m., nurse managers (NM)-A and B stated they were unaware that facility was integrated with pharmacy and that pharmacy could fill orders based off the order put in the system without a physical copy sent to them.During an interview on 6/17/26 at 9:06 a.m., Administrator stated regional nurse consultant (RNC)-A completed the investigation of the incident and believed the medication was intended for R2.During an interview on 6/17/26 at 9:18 a.m., RNC-A stated R2 had an order to discontinue Haldol when Ativan arrived and LPN-A had put that order in about the same time the order for R1 was written. The pharmacy is integrated with the electronic record and when an order is put in electronically the order is automatically transmitted to the pharmacy. Pharmacy can fill the order and send to facility without an actual physical order present unless it is a controlled drug, Intravenous medication, new admissions, hospital returns, or if the number of characters is too big in the order we put in. The facility had a safeguard in place for when the Health Unit Coordinator (HUC) placed orders in the electronic record that required a nurse to verify the order was correct prior to the order being live in the system. Medical doctor (MD)-A discontinued the Haldol for R1 because it lowers the seizure threshold. At 11:20 a.m., RNC-A stated pharmacy recommendations are reviewed on routine rounds with clinics on resident scheduled visits unless it was an urgent recommendation that needed to be addressed immediately.During an interview on 6/18/26 at 12:40 p.m., RNC-A stated facility, primary care providers, and hospice should be reviewing the residents charts to ensure accuracy.During a telephone interview on 6/18/26 at 11:06 a.m., hospice clinical director (CD)-A stated hospice should complete a medication reconciliation upon admission, every six months, and with medication changes hospice initiated. Routinely, and at a minimum every couple of weeks, hospice nurse should compare medication list with facility medication list to make sure they match. CD-A reviewed hospice records for R1. Hospice did not have any notes about medication reconciliation being completed in March, April, or May. In June, there was a note that facility was completing an internal investigation on Haldol medication that had been given to R1 since March. Knowledge and training of RN's and physicians should be that we check for Parkinsonism and history of seizures in patients.During a telephone interview on 6/17/26 at 3:09 p.m., pharmacist (Ph)-A stated Haldol 1.5 mL was three time the normal starting dose. Ph-A stated if R1 already had a history of seizures she could not say if this error would cause more seizures necessarily. Ph-A stated that based on the dose this would be considered a significant medication error.During a telephone interview on 6/18/26 at 9:36 a.m., medical doctor (MD)-A stated she discontinued the Haldol because it was not an appropriate medication for R1's diagnoses.During a telephone interview on 6/17/26 at 3:18 p.m., MD-A stated R1 had seizures and every time a person has a seizure there is neurological harm. Haldol is not advised in patients with seizure disorder as it lowers the seizure threshold or Parkinsons. Seizures/Parkinsonism could cause a lot of freezing with muscle issues. MD-A could not say with 100% certainty that R1's Haldol usage caused the seizure but the fact that we put him at any risk is not good. I just feel like he kind of got double whammied with the whole thing. MD-A was frustrated because the facility put the order under her name and she absolutely did not give the order.The facility Medication and Treatment Orders policy dated 2/2024, identified orders must be recorded on th Physicians Order Sheet in the residents chart. Such orders are reviewed by the consultant pharmacist. Orders for medications will be transcribed in a timely manner.The pharmacy Consultant Pharmacist Services Provider Requirements dated 5/2022, identified regular and reliable consultant pharmacist services are provided to residents. Assists with identification and evaluation of medication-related issues, including prevention and reporting of medication errors. Identifying one or more current medication references to facilitate the identification of medications and information on contraindications, side effects and/or adverse effects. Completing a monthly medication regimen review, communicating to responsible prescriber and facility leadership potential or actual problems detected and other findings related to medication therapy orders including recommendations for changes in medication therapy and monitoring of medication therapy as well a regulatory compliance issues. Reviewing medication administration records and physician orders at least monthly to ensure proper documentation of medication orders and administration to residents. Resident specific recommendations are documented in the residents active record.The facility Hospice policy dated 11/2023, identified it is the responsibility of the hospice agency to coordinate residents care as it relates to terminal illness and related conditions. It is the responsibility of facility staff to notify the hospice provider and primary care provider about significant change in condition or situations requiring a revision of the plan of care.The Physician Visits policy dated 8/2024, identified the attending physician must perform relevant tasks at the time of each visit, including a review of the residents total program of care and appropriate documentation.

Based on observation, interview, and record review the facility failed to remove discontinued medications from the active medication storage for 2 of 2 residents (R3, R4) creating the potential for inadvertent medication administration. Findings include: R3During an observation and interview on 6/17/26 at 12:36 p.m., Registered nurse (RN)-A opened the medication cart and went to R3's medication section. RN-A observed R3's Lidocaine patches and Quetiapine Fumarate (Seroquel) remained in the medication cart. RN-A reviewed R3's current medication orders and stated there was not a current order for Seroquel or Lidocaine patches. RN-A removed the medications from the medication cart and stated medications should be removed from the medication cart right away after the order was discontinued to avoid medication errors. RN-A stated it was basic nursing knowledge to remove discontinued medications from the medication cart. R3's face sheet dated 6/17/26, identified diagnoses of fracture of one right rib, other chronic pain, agoraphobia with panic disorder, and generalized anxiety disorder.R3's physician visit dated 6/8/26, identified an order to discontinue Quetiapine Fumarate (Seroquel) 25 milligram (mg) oral tablet.R3's progress note dated 6/8/26, identified nurse practitioner (NP) visited resident today with new orders given. NP would follow-up in one week.R3's physician visit dated 6/15/26, identified an order to discontinue lidocaine 4% external patch and the same order to discontinue Quetiapine Fumarate 25 mg as ordered on 6/8/26.R3's progress note dated 6/16/26, identified R3 was seen on rounds by NP. Orders to discontinue lidocaine patch for non-use, and discontinue Seroquel.R3's medication administration record (MAR) dated 6/2026, identified Quetiapine Fumarate was administered daily from 6/1/26-6/15/26. The Lidocaine patch was marked as 2-drug refused from 6/1/26-6/15/26.During an interview on 6/17/26 at 1:03 p.m., RN-B stated she reviewed physician dictation on 6/16/26, while working the night shift. RN-B stated she would remove the order from the electronic medical record, enter a progress note, and then remove the discontinued medication from the medication cart. RN-B stated she forgot to remove the medications after discontinuing the orders in the electronic system.R4During the observation and interview on 6/17/26 at 12:36 p.m., RN-A opened the medication cart and went to R4's medication section. RN-A observed Amlodipine remained in the medication cart after the medication had been discontinued. RN-A removed the medication from the medication cart.R4's face sheet dated 6/17/26, identified a diagnosis of essential (primary) hypertension.R4's progress note date 6/15/26, identified R4 was seen by physician on 6/11/26. Orders to discontinue Amlodipine 5 mg received.R4's MAR dated 6/2026, identified Amlodipine Besylate 5mg was provided to R4 from 6/1/26-6/15/26.During an interview nurse manager (NM)-B stated after discontinuing a medication it should be removed from the medication cart. NM-B would occasionally go through the medication carts and remove ones she was aware had been discontinued. Nurses are expected to pull discontinued medications when the order is discontinued.During an interview on 6/18/26 at 12:40 p.m., regional nurse consultant (RNC)-A stated she expected medications that were discontinued to be removed from the medication cart within a reasonable amount of time between five minutes to one hour after discontinuing the order. Not doing that could lead to potential medications errors and inadvertent administration.During a telephone interview on 6/18/26 at 9:36 a.m., medical doctor (MD)-A stated she expected the facility to review the entire dictation when it was sent to them so they are aware of all order changes.The facility Discontinuation of Medications policy dated 5/2022, identified medication are removed from the medication cart or active supply immediately upon receipt of an order to discontinue to avoid inadvertent administration.

Based on observation, interview and document review, the facility failed to ensure a safe, sanitary and comfortable environment for 1 of 1 residents (R2) whose room was unkept and had resident care items placed on the floor. In addition, the facility failed to perform daily cleaning in the kitchen which had the potential to affect 54/56 residents who received food from the kitchen. Findings include:R2R2's face sheet received on 6/10/26, included diagnoses of diabetes, dementia, and chronic gastritis (inflammation of stomach lining).R2's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood. R2 was able to eat independently and required substantial assistance or was dependent on staff for activities of daily living (ADLs). R2 did not walk. R2's physician orders dated 9/24/25, indicated to apply foot to calf wraps (black) at bedtime. Orders dated 3/23/26, indicated Ready Wraps firm and snug around foot, ankle, and calf in the morning. R2's care plan dated 3/11/26, indicated an alteration in mobility related to diagnoses and transferred with a mechanical lift with assist of two staff using a large sling. During an interview and observation on 6/8/26 at 12:06 p.m., R2 was sitting in her recliner. Observed a number of items on the carpeted floor at the foot of her bed: mechanical lift sling, pillow without a pillowcase, blankets, heel boots. Behind the recliner was a piece of wood resembling a slider board, cloth tote bag, blanket. Along with a TV, the top of the built-in credenza was entirely covered with various items: R2's personal items such as stuffed animals, empty vases, candle, figurines, three pair of slipper socks, two denture cups and mail. In addition, facility supplies: two stacks of briefs, two packages of wipes, gait belt, partial package of 4 x 4 dressings, a spray bottle of wound cleanser and chux (absorbent disposable pads). R2 stated staff didn't have time to straighten up her room. During an observation and interview on 6/9/26 at 1:39 p.m., together with nursing assistants NA-A, NA-B, and the director of nursing (DON), entered R2's room to observe items on the floor and the clutter on the credenza. Informed of observation the morning prior with items on the floor. The items that had been on the floor were now heaped on R2's bed. The DON stated staff took items off R2's bed in the evening and put them in her recliner and in the morning, put them back on her bed. With regard to the credenza, the DON stated she expected nurses to put wound supplies away in cupboard and for NAs to put briefs and wipes away. The DON stated extra blankets should be put in her closet. The DON admitted the room lacked storage surfaces for things like heel boots and the sling. During an interview on 6/9/26 at 1:44 p.m., NA-B stated R2 liked lots of blankets because she was usually cold, adding there wasn't enough room for everything and admitted staff could do a better job putting away their supplies. NA-B stated the blankets that had been on the floor the day prior were sent to laundry. During an interview on 6/9/26 at 6:55 p.m., R2 stated she didn't like when staff put things on the floor and didn't like all of the items on the credenza, adding she didn't have the ability to clean up it up herself. R2 stated staff should put their things away.During an interview on 6/10/26 at 7:35 a.m., housekeeper (H)-A stated she cleaned R2's room, and frequently there were items on the floor. H-A acknowledged seeing blankets, pillow, sling and heel boots on the floor, every day. If R2 was in bed, she put those things on her recliner and if she was in her recliner, put things on her bed -- adding there weren't enough places to store things. To clean under everything on the credenza, H-A stated she picked up one item at a time, wiped under it and set it back down. H-A stated briefs and wipes were commonly on the credenza. During an interview and observation on 6/10/26 at 9:40 a.m., the credenza had about 50% less items/clutter on it. R2 stated it was much better, I like it. No medical supplies/briefs/wipes were on the credenza. Heel boots, pillow, etc., were on the bed. Facility Personal Belongings policy dated 5/2026, indicated residents were encouraged to personalize their rooms to create a home-like environment. Residents had the right to retain and use personal clothing and possessions as space permitted, provided they did not infringe on the health, safety, or rights of others. At times, a resident's room may need to be cleaned or reorganized.KITCHENDuring initial kitchen tour on 6/8/26 at 6:25 a.m., with cook (C)-A, observed a dusty 8-inch black fan blowing toward food prep area on center island (no food was being prepped at that time). Observed smudges/smears on upper and lower metal cabinet doors, microwave door, and dried liquid drippings down the side of metal cabinet next to the oven. Crumbs on ledge of oven door. Crumbs on the bottom shelf of metal transport cart, crumbs on shelving inside lower metal cabinets. Box fan sitting on top of a yellow rubber receptable on wheels, not turned on, but with grayish material on the blades. Observed the solid surface flooring with non-skid surface; original color appeared to be taupe, but many areas were gray/blackish. Crumbs and debris were on the floor prior to food prep starting for the day. C-A stated dietary staff cleaned the kitchen daily and did a deep clean twice a year. During an interview on 6/9/26 at 10:29 a.m. dietary director (DD)-E and regional culinary director (CD)-F, were informed of concerns with cleanliness in the kitchen. Initially DD-E stated the reason was nursing staff entering the kitchen after hours but admitted that wouldn't account for crumbs inside cupboard shelves, and dirty stainless steel cupboard doors. CD-F stated the responsibility fell to him too; he was supposed to come monthly for a mock survey, but due to his workload, hadn't been able to. DD-E stated there were daily cleaning duties assigned to the cook and dietary aide. Reviewed completed checklists from a folder in her office, titled Closing List for Culinary. One half of the checklist indicated duties for the dietary aide and the other half for the cook. Duties included sweeping, wiping down counters and microwave inside and out, mopping, wiping down all sliding cabinet doors. For June, checklists indicated duties were done on only 6/1/26, 6/3/26, and 6/8/26, and of those, only the aides completed their duties; the cook duties were not initialed as having been completed. DD-E stated if the form had not been completed, she would assume the duties had not been done. Completion of daily Closing List for Culinary: April - completed 15/30 days, May - completed 19/31 days, and June partially completed 3/8 days. During a telephone interview on 6/9/26 at 11:38 a.m., registered dietician (RD)-G was informed of findings related to cleanliness. RD-G stated she was more on the clinical nutrition side and CD-F did the kitchen audits. RD-G had not been aware CD-F had not been able to do the audits due to workload. RD-G was not aware the kitchen had a daily end of shift checklist to complete for the day and evening staff. RD-G stated she would discuss concerns with DD-E and CD-F. During an interview on 6/10/26 at 10:47 a.m., with administrator, DD-E and CD-F, informed of cleanliness findings. The administrator had not been aware and stated they would address it. Facility Cleaning and Disinfection policy dated 9/12, indicated countertops, work surfaces and hard surfaces were to be wiped of excess particle of food, sprayed with a disinfectant solution and re-washed and wiped dry. Facility Sanitization policy dated October 2008, indicated the food service area would be maintained in a clean and sanitary manner. All kitchen areas would be clean. All counters and shelves would be kept clean.

Based on observation, interview and document review, the facility failed to ensure nutrient and/or calorie substantive snacks were offered after the evening meal and before bedtime, for 2 of 2 residents (R2, R42) when there had been more than a 14-hour lapse between the dinner meal and breakfast the following day. This had the potential to affect 54 of 56 residents who ate meals at the facility. Findings include:R2R2's face sheet received on 6/10/26, included diagnoses of diabetes, dementia, and chronic gastritis. R2's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood. R2 was able to eat independently but required substantial assistance or was dependent on staff for activities of daily living (ADLs). R2 did not walk. R2's physician orders dated 1/20/26, included Con/CHO (controlled carbohydrate) 2-gram sodium diet, regular.R2's care plan dated 3/11/26, indicated potential for alteration in nutrition related to diagnoses. During an observation on 6/9/26 at 9:08 a.m., observed R2's breakfast tray delivered to her room. During an interview on 6/9/26 at 5:52 p.m., R2 who preferred to eat meals in her room, stated she went from supper and until breakfast the following day without food and got hungry. R2 stated she would like to eat breakfast earlier in the morning as her breakfast tray arrived late. R42R42's face sheet received on 6/10/26, included diagnoses of diabetes, duodenal ulcer, and chronic kidney disease. R42's quarterly MDS dated [DATE], indicated intact cognition, clear speech, could understand and be understood, and was independent with ADLs.R42's physician orders included consistent carbohydrate diet, regular texture. R42's care plan dated 5/20/26, indicated a potential for alteration in nutrition related to diagnoses. During an interview on 6/8/26 at 10:23 a.m., R42 stated he ate in his room, adding it was pretty typical to eat breakfast around 9:30 a.m. R42 stated he was rarely offered a snack after supper before bed and would like that sometimes. During an observation on 6/9/26 at 9:01 a.m., observed breakfast tray delivered R42's room. During an interview on 6/9/26 at 10:29 a.m., with dietary director (DD)-E and regional culinary director (CD)-F, reviewed a document titled Dietary Service Hours, which indicated the following mealtimes for each unit: BREAKFAST ends at 10:00 a.m.7:30 a.m. dining room opens7:45 a.m. west unit delivery8:15 a.m. east unit delivery8:45 a.m. north unit delivery LUNCH ends at 1:00 p.m.11:30 a.m. dining room opens11:45 a.m. west unit delivery12:15 p.m. east unit delivery12:30 p.m., north unit delivery SUPPER ends at 6:15 p.m.4:45 p.m. dining room opens5:00 p.m. west unit delivery5:30 p.m. east unit delivery6:00 p.m. north unit delivery The dietary service hours indicated 14 hours and 45 minutes between supper one day and breakfast the next morning. DD-E admitted some residents complained about receiving breakfast trays to their room too late in the morning but were told they could come to the dining room for breakfast in order to be served sooner. DD-E stated dietary staff would accommodate resident requests to receive a room tray at a particular time. During an interview on 6/9/26 at 3:28 p.m., registered dietician (RD)-G was unaware of scheduled mealtimes, adding it was her understanding there should be no more than 14 hours between supper and breakfast the following day unless a nutritious snack was provided to residents. Informed the snacks available to residents at bedtimes included unsweetened apple sauce, zero sugar pudding, snack-size bags of pretzels and goldfish crackers, fig bars, cookies, and glazed buns. RD-G acknowledged those snacks wouldn't be considered nutritious.During an interview on 6/10/26 at 10:47 a.m., the administrator, DD-E and CD-F were informed of the concern of more than 14 hours between the supper meal and breakfast the next day without a nourishing snack. The Dietary Service Hours sign was given to the administrator for review. Informed there should be no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime. The dietary manager acknowledged the snacks available to residents at bedtime would not be considered nourishing. The administrator was unaware and stated mealtimes would be addressed. Facility Mealtime policy dated 9/2012, indicated it was the policy to serve meals to meet the standards of the surveying agencies specifying no more than 14 hours between the evening meal one day and the breakfast meal of the next day.

Based on interview and document review the facility failed to ensure appropriate follow-up of urine culture and sensitivity results and failed to ensure antibiotic therapy was reviewed for effectiveness for 1 of 1 resident (R32) reviewed for antibiotic use. In addition, the facility failed to ensure a nutritious snack was offered for the management of low blood sugar and failed to inform the dietician of concerns with blood sugar levels for 1 of 1 resident (R50) reviewed for food.Findings include: Antibiotic Use R32's significant change in status [NAME] Data Set (MDS) assessment dated [DATE], indicated moderately impaired cognition, utilized a wheelchair, required supervision or touching assistance with toileting hygiene and personal hygiene, diagnoses included bladder cancer, hydronephrosis (urine doesn't fully empty from the body), and hematuria (blood in urine). R32's care plan dated 5/5/26, indicated alteration in elimination d/t (due to) weakness and assist with 2 staff and transfers, bladder cancer and prostate cancer assist of 2 with toileting, monitor urine for increased blood or pain with urination, will continue to have follow up appt with urology as scheduled, provide assistance with peri-cares AM (morning), HS (bedtime) and PRN (as needed), monitor foley catheter output, change foley catheter per policy, foley catheter care per policy. R32's urinalysis microbiology results dated 6/1/26, indicated greater than 100,000 colony forming units per milliliter (CFU/mL) of gram-negative rods with identification and sensitivity pending (lab has confirmed the bacteria's species in the urine and is still running tests to see which antibiotics will work against it). R32's medication administration record (MAR) dated 6/1/26-6/30/26, indicated: Start date 6/1/26, UA/UC (urinalysis/urine culture) one time only for possible UTI (urinary tract infection) Start date 6/4/26, Ciprofloxacin (antibiotic) give 500 mg (milligrams) by mouth two times a day related to hematuria, for 5 Days, and discontinued 6/8/26. Start date 6/8/26, Sulfamethoxazole-Trimethoprim (antibiotic) give 1 tablet by mouth two times a day for UTI (urinary tract infection) for 7 days R32's urine culture and sensitivity report dated 6/3/26, identified the organism as resistant (R) to ciprofloxacin. On 6/8/26 at 1:46 p.m., licensed practical nurse (LPN)-B stated urine culture results were typically reviewed by the facility nursing staff and the provider would be expected to be notified if an organism was resistant to the prescribed antibiotic. LPN-B stated nursing staff were expected to address culture results and communicate concerns to the provider. On 6/8/26 at 1:56 p.m., the director of nursing (DON) reviewed R32's urine culture results dated 6/3/26, and confirmed the organism was resistant to ciprofloxacin. The DON confirmed R32 was currently prescribed ciprofloxacin. The DON stated nursing staff were expected to review culture and sensitivity reports, verify the prescribed antibiotic was susceptible to the identified organism, and notify the provider when resistance was identified. The DON stated they would have expected the provider to be notified regarding the resistant organism prior to 6/8/26. The DON further stated nursing staff was expected to place the paper copy of resident's culture in her office mailbox or under her office door as the she was the infection prevention nurse to include on her surveillance of infections. On 6/8/26 at 2:05 p.m., registered nurse (RN)-E, hospice nurse, stated ciprofloxacin had been ordered for R32 on 6/3/26, to provide coverage until culture results were available and stated facility nursing staff would be expected to notify hospice or the provider when culture results demonstrated resistance. On 6/8/26 at 2:12 p.m., LPN-C stated facility staff were expected to contact the provider when culture results indicated the prescribed antibiotic did not cover the identified organism. LPN-C stated she recalled receiving the culture results, signed off that they were reviewed, and provided the results to the hospice nurse for follow-up but did not document provider notification or the specific culture findings. On 6/8/26 at 2:44 p.m., LPN-B stated staff would generally assume culture results had been addressed if the paper copy was signed, and stated there was no process ensuring follow-up occurred after review of the culture results. On 6/8/26 at 3:28 p.m., RN-F, hospice nurse, stated R32's urine culture results were forwarded to the provider but acknowledged there was a breakdown in communication regarding review of the sensitivity report between the provider, hospice nurse and the facility. RN-F stated when the order was received for R32's cipro antibiotic hospice had not clarified if the provider had reviewed the culture results before continuing the antibiotic. On 6/8/26 at 3:43 p.m., the DON stated culture and sensitivity results should be reviewed to ensure the prescribed antibiotic is effective against the identified organism and acknowledged R32 was not included on the facility's infection tracking log. On 6/9/26 at 3:22 p.m., R32 stated he felt fine and denied urinary symptoms. Facility Antibiotic Stewardship Program Policy dated 11/24, indicated The Infection Preventionist, (IP), or designee, will review all antibiotic orders to determine if treatment is appropriate. Treatment is not appropriate if: The organism is not susceptible to the antibiotic chosen. The organism is susceptible to a narrower spectrum antibiotic. Therapy was ordered for prolonged surgical prophylaxis. Therapy was started awaiting culture, but no organism was isolated after 72 hours The provider will be notified of the review findings and recommendations and a response will be documented in the resident's medical record. The Infection Preventionist, along with the Consultant Pharmacist, will monitor antibiotic use by utilizing a facility approved infection/antibiotic surveillance tracking form and thru monthly medication reviews. The information gathered will include: Resident name Unit and room number Date symptoms appeared name of antibiotic Start date of antibiotic Pathogen identified Site of infection Date of culture Stop date Total days of therapy Outcome Adverse events, if applicable. Management Of Low Blood Sugar R50's face sheet dated 4/18/26, indicated diagnoses of infection of skin tissue, type two diabetes mellitus with foot ulcer, moderate protein-calorie malnutrition, abnormal weight loss, long term use of insulin. R50's admission Minimum Data Set (MDS) assessment dated [DATE], indicated impaired cognition, no behaviors or rejection of care, use of wheelchair, independent with eating, partial assistance with dressing. R50's care plan printed 6/10/26, indicated potential for alteration in blood sugar related to diagnosis of diabetes. Resident will be free from hyper/hypo glycemic episodes. Monitor for signs of hyper/hypoglycemia, diet as ordered. R50's physician's orders dated 6/4/26, indicated orders for continuous blood glucose sensor, metformin, Mounjaro, Jardiance, and Lantus (diabetic medications), consistent carbohydrate diet, follow standard house orders for blood sugars, monitor for signs of hyper/hypoglycemia, blood sugars before meals and at bedtime. During interview on 6/9/26 at 3:03 P.M., R50 stated he was happy with the care he received at the facility, but worried about his blood sugars. R50 stated supper was served at 4:45 p.m., and that was too early for him to eat to sustain his blood sugar through the night. R50 further stated that sometime he didn't get breakfast until 9:00 a.m., and his blood sugar would be lower throughout the night and in the morning. R50 stated he was not offered a substantial evening snack to help keep his blood sugar up through the night, but he had his daughter bring some snacks in for him to have in his room. R50 stated he did not like the feeling of low blood sugar and it worried him when it happened. R50 stated a blood sugar reading in the 90's or lower made him worry he was going to drop even more throughout the night and before breakfast without a substantial snack. Review of R50's blood sugar readings from 5/31/26 through 6/9/26, indicated the following readings he was not comfortable with: 5/31/26 at 9:10 a.m.: 87 6/4/26 at 10:10 p.m.: 88 6/5/26 at 8:02 a.m.: 86 6/8/26 at 7:06 a.m.: 65 6/9/26 at 7:33 p.m.: 86 During interview on 6/8/26 at 3:20 p.m., registered nurse (RN)-B stated there was an evening snack cart but there was nothing designated specifically for diabetic residents and nothing to indicate who should be offered a snack in the evening. RN-B further stated there were mostly carbohydrate snacks on the cart, no order for a substantial evening snack for diabetic residents, but that R50 could ask for something if he wanted a snack. On 6/8/26, the snack cart included unsweetened applesauce, zero sugar pudding, pretzels, goldfish crackers, fig bars, cookies, and honey buns. During interview on 6/9/26 at 3:03 p.m., RN-G stated there were no specific orders for a substantial evening snack for diabetic residents, but a snack cart was put out each evening. RN-G stated nothing was offered specifically to diabetic residents to ensure their blood sugar did not drop overnight or prior to breakfast. During interview on 6/9/26 at 3:23 p.m., director of nursing (DON) stated she was aware R50's blood sugar had been dropping consistently overnight and the provider had been notified to make medication changes, but had not considered providing an evening snack and had not contacted the dietician. DON stated providing diabetic snacks was not something they did, they just had a snack cart available for all residents. DON stated there was nothing labeled on the snack cart for diabetic residents to ensure they were offered a snack. DON stated she would have to add that order for diabetic residents to help maintain blood sugar overnight. During interview on 6/9/26 at 3:30 p.m., registered dietician (RD) stated she was newer to the facility and was not sure what was offered on the snack cart. RD stated she would expect snacks offered to diabetic residents after supper and they should include a carbohydrate and protein source. RD stated she would expect to be notified if a resident was having difficulty with blood sugar management so she could provide an order for a diabetic snack at night. RD stated she had not been made aware of any concerns with R50's blood sugar levels. Facility Snack Carts policy dated 9/2012, indicated facility policy to provide a nourishing snack daily. The hospitality staff will set up the cart and each cart will include these items: snacks, bars, cookies, fruit, crackers, sandwiches, beverages. These carts will be brought around to the resident's rooms by the nursing assistants.

Based on observation, interview, and document review the facility failed to assess and implement interventions to maintain and/or prevent loss of range of motion (ROM) for 1 of 1 resident (R21) reviewed for ROM.Findings include: R21's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated moderately impaired cognition, no rejection of care, utilized a wheelchair, independent with eating, setup or clean-up assistance with oral hygiene, dependent with toileting hygiene, sit to lying, chair to bed transfer, toilet transfer, lower body dressing, substantial/maximal assistance with shower/bathe self, roll left and right, upper body dressing, and partial moderate assistance with personal hygiene; limitation range of motion on both sides of lower extremity and no impairment on upper extremity; diagnoses included non-Alzheimer's dementia, depression, Parkinsonism and not receiving a restorative nursing program.R21's quarterly MDS assessment dated [DATE], indicated moderately impaired cognition, no rejection of care, utilized a wheelchair, with eating, setup or clean-up assistance with eating, dependent with oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, personal hygiene, roll left and right, sit to lying, chair to bed transfer, toilet transfer; limitation range of motion on both sides of lower extremity and no impairment on upper extremity; diagnoses included non-Alzheimer's dementia, depression, Parkinsonism and not receiving a restorative nursing program.R21's care plan dated [DATE], indicated Parkinsonism, age-related physical debility, pain, osteoarthritis, history of falling, and weakness and interventions included PT (physical therapy) per MD (medical doctor)order, follow PT instructions, A (assist) x2 using mechanical lift for transfers, assist with movement in bed and in/out of bed, OT (occupational therapy) per MD order, follow OT instructions, assist with bathing with assist of 1 staff, assist with dressing with assist of 1 staff, assist with personal hygiene with assist of 1 staff.R21's document review failed to indicate documentation of interventions to maintain or prevent loss of ROM or strength of lower extremities.On [DATE] at 7:13 a.m., R21 stated, I've asked about a stationary bike and weights, but get brushed off. I would like to keep my flexibility. R21 stated they do not walk, received no exercise to their joints, and expressed concern about losing her ability to move her joints freely.On [DATE] at 2:24 p.m., R21 was observed lying in bed and stated the facility did not provide exercises for the upper or lower body to maintain strength and stated they would participate if exercises were offered.On [DATE] at 2:28 p.m., nursing assistant (NA)-A, NA-B, NA-C stated exercise and restorative interventions would be documented in the electronic medical record (EMR) if in place. The nursing assistants reviewed the EMR and therapy communication book and confirmed there were no orders, tasks, or documentation indicating exercises, range of motion interventions, or restorative services for R21. NA-A, NA-B, NA-C further confirmed R21 required a mechanical lift and assistance of two staff for transfers.On [DATE] at 2:31 p.m., registered nurse (RN)-A, known as nurse manager, and licensed practical nurse (LPN)-A, known as a care coordinator, stated R21 was not on restorative program. RN-A stated therapy will pick residents up for for services if there is a specific need but services may be discontinued once a resident plateaus and confirmed there was nothing specific in place for R21 to maintain their strength.On [DATE] at 3:50 p.m., LPN-A stated if a resident had a decline in ADLs (activities of daily living) the decline would typically be discussed during routine Medicare meetings and therapy referrals would be considered if a decline was identified. When asked what interventions were currently being implemented to prevent decline, LPN-A stated she would need to look into it and noted that long-term care residents generally decline over time. RN-A stated the facility practice was for therapy to evaluate residents once a decline was observed.On [DATE] at 11:13 a.m., RN-B stated R21 required a wheelchair, assistance of two staff, and a mechanical lift for transfers, and further stated R21 was not receiving therapy services, had no range of motion program, and had no interventions in place to maintain strength.On [DATE] at 11:14 a.m., RN-C stated therapy would write any orders related to exercises or ROM programs if staff were expected to complete ROM with a resident and confirmed there were no ROM interventions for R21.On [DATE] at 11:15 a.m., NA-B stated R21 currently had nothing in place to maintain their strength such as ROM or exercises.On [DATE] at 11:16 a.m., RN-A and LPN-A stated they were unsure whether an order was required for ROM interventions and stated residents were typically referred to therapy after a decline was identified and confirmed there was currently nothing in place to prevent decline for R21.On [DATE] at 11:24 a.m., R21 was observed in bed and stated she was not offered exercises but would participate if they were available. R21 stated exercises would be nice to keep her strength up. R21 stated there were weights under my clothes across the room and stated she could not reach them. Two hand weights were observed across the room from R21's bed and found underneath clothing. R21 stated she would use the weights if they were placed within reach. R21's fingers on the right hand were curled inward toward the palm, the resident could open and close both hands, wiggle toes, but was unable to raise either leg from the bed.On [DATE] at 11:32 a.m., RN-A confirmed R21 had weights and exercise bands in their room, but was unsure where they had originated and if R21 was supposed to use them.On [DATE] at 11:34 a.m., the director of nursing (DON) stated residents were expected and should be encouraged to do as much as possible independently. DON stated therapy typically provided ROM exercises if a resident was expected to complete exercises and staff should report changes in condition to therapy. The DON further stated staff were expected to address declines and not simply capture them through MDS documentation. The DON stated exercises were important to keep the strength a resident has and maintain the strength. The DON stated if R21 had ROM limitations, would expect nursing to alert therapy to ensure interventions were in place for R21.On [DATE] at 1:38 p.m., the director of rehabilitation (DOR) stated they reviewed R21's information and stated therapy would typically provide recommendations for upper- or lower-extremity exercises as needed. DOR stated it was beneficial for residents to have a restorative nursing program to maintain current abilities and indicated that interventions to help prevent decline would have been warranted for R21.On [DATE] at 9:03 a.m., OT (occupational therapist)-A [NAME] stated the facility had a transition of therapy companies and was unable to find documentation on whether R21 previously had exercise orders; however, OT-A stated they would have expected interventions to be in place due to R21's decreased lower-extremity function and limited range of motion. OT-A stated R21 had not walked for a long time and would expect PT (physical therapy) recommendations for lower-extremity exercises and reported PT had been asked yesterday to reassess the resident for possible restorative programming.On [DATE] at 10:00 a.m., RN-D, known as regional nurse consultant, stated the facility could not locate a previous physical therapy discharge recommendation, and further stated with the transition to a new PT provider the documentation was not readily available. RN-D stated R21 was evaluated by PT yesterday ([DATE]). The Facility Activities of Daily Living (ADLs)/Maintain Abilities Policy dated [DATE], indicated1. Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility will provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable.2. The facility will ensure a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living.3. The facility will provide care and services for the following activities of daily living: a. Hygiene -bathing, dressing, grooming, and oral care, b. Mobility-transfer and ambulation, including walking, c. Elimination-toileting, d. Dining-eating, including meals and snacks, e. Communication, including: i. Speech, ii. Language, and iii. Other functional communication systems.4. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; and basic life support, including CPR, when the resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives.

Based on observation, interview, and document review the facility failed to ensure a comprehensive care plan for diabetic management that included goals and individualized interventions was developed or 1 of 3 residents (R2) reviewed for care plans.Findings include:R2's face sheet dated 2/27/26, identified diagnoses of type 2 diabetes with hyperglycemia.R2's quarterly Minimum Data Set (MDS) dated [DATE], identified R2 had no cognitive deficits, was on a therapeutic diet, and took hypoglycemic medications (used to lower blood glucose).R2's medication administration record (MAR) for January 2026, identified an order from 9/12/24, that was for a FreeStyle Libre 2 Sensor continuous blood glucose monitoring system sensor to be applied every 14 days.R2's care plan current at the time of survey included R2's diagnosis of diabetes as a related factor of the focus which included (but not limited to) falls, vulnerable adult, nutrition, skin integrity, however, R2's care plan did not include diabetic focus that identified R2's blood glucose range goals, use of the continuous blood glucose monitoring system, interventions for responding to high or low blood glucose levels, or monitoring and reporting parameters for abnormal glucose readings. The care plan also did not include individualized interventions related to R2's hypoglycemic medications or monitoring for signs and symptoms of hyperglycemia or hypoglycemia.R2's blood glucose readings were reviewed between 1/1/26 through 2/27/26 in conjunction with progress notes and MAR documentation. The blood glucose record identified low blood glucose readings but there was no documentation indicating R2 was assessed for sign/symptoms and monitored for signs/symptoms of hypoglycemia in addition to timely rechecks of blood glucose, and no documentation of intervention to raise R2's blood sugar. Examples included: -1/3/26 at 8:44 a.m. of 53mg/dl, no subsequent checks until 12:09 p.m. when it was 75 mg/dl.-1/13/26 at 7:12 a.m. of 68, not checked again until 12:45 p.m.-1/15/26 at 9:17 a.m. and 11:21 a.m. both at 70.-2/22/26 at 10:09 a.m. 59 with no recheck until 1:45 p.m.During an interview on 2/27/26 at 12:53 p.m., licensed practical nurse (LPN)-B, who is the care coordinator, stated acceptable blood glucose ranges would range from 80-110 or 90-120. Low range would be below 70 or 80. LPN-B would consider anything above 150 high. R2's blood glucose goes low frequently and that was why the continuous glucose monitor was kept by her. The continuous glucose monitor would beep if the blood glucose was running low or high and an arrow would point either up or down showing which way the blood glucose was going. Blood glucose should be checked 30 minutes to an hour after interventions of a small glass of orange juice or protein, typically something with peanut butter was given. Low and high ranges should be passed on in shift report, so the oncoming nurse was aware. Provider would not be notified if the blood glucose was able to go up after interventions but if it was not working, the provider should be notified. Standing orders identify that glucagon should be given, and provider notified if blood glucose is less than 60 and higher than 500. LPN-B expected that nurses would check blood glucose more frequently if the numbers were low and follow protocol. During a subsequent interview on 2/27/26 at 1:26 p.m., LPN-B reviewed R2's care plan and could not find anything specific to diabetic management for staff to follow.During an interview on 3/3/26 at 4:13 p.m., director of nursing (DON) stated care plans are updated with significant change and reviewed quarterly with MDS. Care plans should include diabetic management.The facility Care Planning policy reviewed 11/2024, identified the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Care plan shall be used in developing the residents daily care routines and will be utilized by staff personnel for the purposes of providing care or services to the resident

Based on observation, interview, and record review, the facility failed to ensure staff implemented proper peri care techniques, including use of Enhanced Barrier Precautions (EBP), appropriate glove changes, and hand hygiene, to prevent or mitigate the risk of urinary tract infections for 2 of 2 residents (R2, R4) reviewed for peri care.Findings include:Findings include:R2's face sheet dated 2/27/26, identified diagnoses of cystitis without hematuria (bladder infection commonly caused by Escherichia coli (commonly entered into the urinary tract through contamination of feces), neuromuscular dysfunction of the bladder (nerve damage impairs bladder control), and personal history of urinary tract infections (UTI).R2's quarterly Minimum Data Set (MDS) dated [DATE], identified R2 had no cognitive deficits, dependent on staff for toileting needs, resident had a urinary catheter with occasional bowel incontinence.R2's care plan dated 4/19/24, identified Enhanced Barrier Precautions (EBP) related to indwelling foley catheter. Interventions included staff to follow EBP, use appropriate communication to follow EBP, explain reason for use of EBP, staff to put on/take of personal protective equipment (PPE) per EBP when providing high contact cares.R2's nursing order dated 4/11/25, identified staff to follow EBP while providing urinary catheter maintenance, contact with the catheter, tubing, collection bag, and other high contact care activities.R2's care plan dated 8/29/23, identified alteration in elimination related to inability to urinate independently, diarrhea as evidenced by foley catheter and occasional incontinence of bowel. Interventions included assist of two with toileting every 2-3 hours and as needed, provide assistance with peri-cares AM, HS (bedtime) and as needed, provide incontinent products and assist to change as needed, monitor skin integrity, monitor for signs/symptoms of UTI, diagnosis of diabetes increases risk for UTI.R2's nursing assistant care sheet undated, identified CONTACT PRECAUTIONS: DIARRHEA AND INDWELLING FOLEY CATHETERR2's nursing order dated 2/3/26, directed staff to encourage increased oral fluid intake as tolerated, provide perineal care frequently, keep peri-area clean and dry to reduce bacterial growth. Additionally, monitor and chart for signs/symptoms of UTI: dysuria (pain or discomfort with urinating), frequency, urgency, supra-pubic discomfort, foul smelling or cloudy urine, hematuria (blood in urine), or new confusion/behavior changes.R2's progress notes from 2/4/26-2/7/26, identified R2 had amber colored urine with a foul odor, Physician was notified and instructed to increase fluid intake and call back if symptoms worsened or if UTI symptoms were noted. R2 continued to have amber colored urine and provider was notified again on 2/7/26 and recommended to continue monitoring and report any changes to provider.R2 was hospitalized from [DATE]-[DATE], for a fall.R2's Hospital Discharge summary dated [DATE], identified urinalysis was attempted but initially unable to be processed due to hematuria and purulent material; repeat collection showed evidence for UTI and R2 was started on intravenous (IV) ceftriaxone (antibiotic).R2's progress note dated 2/19/26, identified R2 complained of pressure down there.During a continuous observation on 2/26/26 from 2:21 p.m. to 3:25 p.m. R2 had an EBP sign on her door that directed the usage of gown and gloves. R2 was in her room, lying in bed. Nursing assistant in training (NA)-A was in the room with gown on cleaning R2, after R2 had an incontinent loose stool. NA-A completed peri cares and placed a new brief on R2. NA-A removed gloves and applied a new pair without sanitizing hands. NA-A removed mechanical lift sling from behind R2, tied trash bag with incontinent material from garbage can, moved cellphone from overbed table, lowered bed, removed gloves and then sanitized hands. NA-A removed the garbage from the can and left the room. At 3:05 p.m., NA-B entered the room without EBP and R2 stated she had diarrhea and needed changed. NA-B did not wash hands before putting on gloves and did not put on a gown. NA-B lifted the bed with the remote to a higher level. NA-B removed tabs from R2's brief and folded the brief between R2's legs. Dark brown liquid stool was pooled over R2's vagina and up into her abdominal folds. R2 had both a disposable and cloth pad under her in which liquid stool had seeped onto both pads. Stool went onto NA-B's gloved hand while she was cleaning it. Then NA-B touched R2's left thigh with the glove contaminated with stool which left an outline of stool on her leg. NA-B cleaned the stool from R2's thigh with a wipe. R2 did not change gloves and sanitize hands. NA-B rolled both pads toward the middle of R2's back so R2 could be rolled over the soiled pads and they could be removed from the opposite side while placing a clean pad underneath in the same position. During the care, R2 stated, Don't be surprised if we get all changed and I have it again. Once the clean pad was placed under R2, NA-B began wiping stool from around the vaginal folds and the catheter area. NA-B did not change gloves or perform hand hygiene prior to providing this care. While cleaning the area, NA-B wiped the catheter toward the vaginal area. The end of the catheter tubing closest to the meatal surface appeared very dark in color compared to the portion of tubing farther away, which was light yellow. NA-B continued wiping stool toward the vaginal area using wet wipes. NA-B then applied powder under R2's abdominal fold without changing gloves or performing hand hygiene. Afterward, NA-B repositioned the brief and pulled it up in the front. NA-B returned the container of wet wipes to a drawer and stated she was going to look for another pad. While still wearing the same gloves, NA-B opened cupboards in R2's room and moved items around while searching. NA-B then took R2's call lights and attached them to her blanket. NA-B removed the used garbage bag from the trash can and placed a new bag in the can. NA-B then left the room carrying the garbage and dirty linens while continuing to wear the same gloves and stated she would be right back.During an interview and observation on 2/26/26 at 3:26 p.m., registered nurse. RN-A entered R2's room without putting on gown and gloves RN-A took a stethoscope and listened to R2's abdomen at all four quadrants without wearing EBP. RN-A placed a blood pressure cuff on R2's right arm and got a reading. RN-A placed cuff on R2's left arm and stated the blood pressure was still a little low and that she was going to get a manual cuff to check it. RN-A left the room and returned with a manual cuff. RN-A did not put on EBP. RN-A stated EBP should be worn if a resident has a catheter, and there would be a sign on the door explaining when to wear EBP. RN-A stated anytime gloves are soiled they should be changed and hand hygiene should be done between glove changes.R4R4's face sheet dated 3/3/26, identified hemiplegia affecting left nondominant side.R4's comprehensive MDS dated [DATE], indicated R4 did not have cognitive impairment. R4 was frequently incontinent of urine and always incontinent of bowels.R4's care plan dated 4/6/21, identified R4 was incontinent of bowel and bladder. Interventions included assist of one with peri cares AM, HS (before bed), and as needed.During an observation on 2/27/26 at 7:38 a.m., R4 was in bed. R4 stated she had a bowel movement. NA-D applied gloves then wiped R4's bottom that had stool on it, and removed the soiled brief. NA-D did not remove gloves and perform hand hygiene before she obtained a new brief from R4's drawer. NA-D then had roll towards the wall and touched R4's shirt with dirty gloves. R4 rolled onto her back. NA-D took a wipe and applied Tena cream. NA-D used the wipe and wiped R4's inner thighs and around vaginal area back to front, front to back, and under abdominal fold. NA-D took another wipe from the container, and wiped the same areas again. NA-D placed a new brief on R4. NA-D removed gloves but did perform hand hygiene before she removed two clean shirts from R4's closet. NA-D gave R4 choices for which one to wear and put the other one back in the closet. NA-D continued to dress R4 and transferred R4 to the wheelchair. NA-D then removed her gloves and sanitized hands when she was leaving the room with R4.During an interview on 2/27/26 at 10:15 a.m., RN-B indicated she did not complete audits or supervise NA's to ensure proper peri care was completed to reduce the risk of UTIs. During an interview on 2/27/26 at 12:53 p.m., licensed practical nurse (LPN)-B, who is the care coordinator, indicated she did not complete audits or supervise NA's to ensure proper peri care was completed to reduce the risk of UTIs. During an interview on 3/3/26 at 4:13 p.m., director of nursing (DON), who also is the facility Infection Preventionist (IP) stated she has not identified any trends with UTI's at the facility. Residents are to the emergency room and diagnosed with UTI. DON does not get a UA/UC report from the hospital and has not went online and attempted to get the information. DON would audit if an issue was noted such as multiple UTI's on the same wing or a concern of peri cares not being done correctly. Females should always be wiped front to back. Gloves should always be changed when soiled, after finishing, and handwashing/sanitizing completed before putting on or after removing gloves. EBP should be used on anyone with medical devices.The facility Catheter Care policy dated 11/2019, identified a step-by-step guide to performing catheter care. 2. Wash hands and apply gloves. 6. Wipe downward away from urethral opening. 7. Wash genital area from front to back. 11. Remove gloves and wash hands.The facility Infection Prevention and Control Program policy dated 11/2024, identified surveillance tools are used for recognizing the occurrence of infections, recording their number and frequency. Culture reports, sensitivity data, and antibiotic usage reviews are included in surveillance activities. Important facets of infection prevention include educating staff and ensuring that they adhere to proper techniques and procedures, implementing appropriate isolation precautions when necessary; and following established general and disease-specific guidelines

Based on observation, interview, and record review the facility failed to ensure professional standards of practice were followed during administration of eye drops for 3 of 3 residents (R12, R15, R106) observed for medication administration. Findings include: R12's annual Minimum Data Set (MDS) assessment dated [DATE], indicated R12 was cognitively intact, no rejection of care, required, maximal assistance with personal hygiene, and diagnoses included progressive neurological conditions, hemiplegia or hemiparesis (weakness or partial paralysis on one side of the body), and multiple sclerosis (central nervous system autoimmune condition. Damage to myelin causes symptoms like muscle weakness and vision changes) . R12's care plan dated on 4/1/25, did not indicate any care needs related to her eyes. R12's medication review report printed 4/15/25, indicated Artificial Tears Ophthalmic Solution 1-0.3% (Propylene Glycol-Glycerin) instill one drop in left eye three times a day for dry eye and instill two drop in right eye as needed for as needed for dry eyes. R15's quarterly MDS dated [DATE], indicated R15 had moderately impaired cognition, no rejection of care, dependent on staff for personal hygiene and diagnosis included hemiplegia or hemiparesis. R15's care plan dated on 4/1/25, did not indicate any care needs related to her eyes. R15's medication review report printed 4/15/25, indicated Refresh Plus Ophthalmic Solution (Carboxymethylcellulose Sodium) instill one drop in both eyes four times a day for red puffy eyes. On 4/14/25 at 7:05 p.m., R15 was laying in bed and registered nurse (RN)-C placed gloves on both and explained to R15 she was administering her eye drops. RN-C placed the tip of the eye drop bottle at the inner corner of each eye to instill the drops. RN-C was not observed to pull down either lower eye lid to administer the eye drop in the pocket of the lower eye lid. On 4/14/25 at 7:23 p.m., RN-C stated the correct technique for eye drop administration included pulling the lower eye lid down and creating a pocket of the lower eye lid to place the eye drop. RN-C confirmed during R15's eye drop administration she did not pull the lower eye lid down to create a pocket. On 4/15/25 at 8:08 a.m., R12 was laying in bed and trained medication aide (TMA)-A stated she had R12's eye drops. TMA-A placed gloves on both hands and placed the tip of the eye drop bottle at the inner corner of each eye to instill drops. A drop was observed to run down R12's right side of her face. TMA-A was not observed to administer the eye drop in the pocket of the lower eye lids or attempt to place the drop in the pocket of the lower lid. On 4/15/25 at 8:47 a.m., TMA-A confirmed she administered R12's eye drops without pulling down the lower lids, and stated the correct administration for eye drops was to pull down the lower lid of the eye. TMA-A stated R12 does not like when we touch her face. On 4/15/25 at 8:50 a.m., R12 stated she would not care if staff touched her eye lids when administering eye drops if staff wore gloves. On 4/15/25 at 8:57 a.m.,, licensed practical nurse (LPN)-B, known as the care coordinator, stated the correct eye drop administration included pulling the lower eye lid down to make a pocket. LPN-B stated R12 was known to not want her eyes touched and would expect staff attempt to pull the lower eye lid down during the administration of eye drops. On 4/15/25 at 10:32 a.m., the director of nursing (DON) stated during eye drop administration the lower eye lid was expected pulled down to form a pocket in the center of the lower eye lids. The DON stated R12 is known not to like her face touched, however would expect stuff to attempt to pull the lower lid down and explain the process to R12 and expected the care plan to address R12's refusal of her face touched during eye drop administration. The DON confirmed R12's care plan did not include R12's refusal of her face touched during eye drop administration. The DON stated R15's eye drop was expected performed with the lower lid pulled down to create a pocket for the eye drop administration. The DON stated during staff orientation eye drop administration was completed. 42073 R106's facesheet printed on 4/16/25, included diagnoses of glaucoma and ocular pain in right eye. R106's admission MDS assessment dated [DATE], indicated R106 was cognitively intact, had clear speech, could understand and be understood. R106's relied on staff for assistance with most activities of daily living. R106's physician orders included Latanoprost Ophthalmic Solution 0.005 % instill 1 drop in both eyes at bedtime for glaucoma. R106's care plan, last reviewed on 4/1/25, did not include diagnosis of glaucoma. During an observation and interview on 4/14/25 at 7:19 p.m., observed TMA-A place an eye drop into each of R106's eyes. TMA-A placed the tip of the bottle in the inner corner of both eyes and instilled the drops, rather pulling down the lower lid and placing the drop midline in the lower lid pocket. TMA-A stated she was trained to place eye drops in the inner corner. TMA-A was unaware of facility policy regarding instilling eye drops. During an interview on 4/16/25 at 10:25 a.m., the DON described the steps of properly instilling drops in the eye, including having the resident tilt their head back, gently pulling down the lower lid and placing the drop in the pocket of the lower lid. The DON stated proper administration of eye drops was something a nurse or TMA would have learned in training. Facility Eye Drop, Ointment, and Gel Medication Administration policy undated, indicated with a gloved finger, gently pull-down lower eyelid to form pouch, while instructing resident to look up. Place other hand against resident's forehead to steady. Hold inverted medication bottle between the thumb and index finger and press gently to instill prescribed number if drops into pouch near outer corner of eye. Do NOT let the tip of the dropper touch the eye or any other surface. If resident blinks or drop lands on cheek, repeat administration

Based on observation, interview and document review, the facility failed to provide shaving for 1 of 1 resident (R45) who was dependent on staff for assistance with grooming and personal hygiene. Findings include: R45's facesheet dated printed 4/16/25, indicated diagnoses included muscle weakness, pain, high blood pressure, and heart failure. R45's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R45 was cognitively intact, used a wheelchair, independent with eating, dependent for bathing and personal hygiene. R45's care plan printed 4/16/25, indicated R45 required staff assist of one for toileting, oral care, bathing, and personal hygiene. During interview and observation on 4/14/25 at 1:53 p.m., R45 had 6 visible chin hairs measuring varying lengths up to 1/2 inch long. R45 had a razor on her bedside table. R45 stated she did not like having chin hairs and wanted staff to shave her chin but thought staff were too busy. During interview and observation on 4/15/25 at 8:39 a.m., R45 was seated in her wheelchair eating breakfast. R45 was fully dressed and groomed for the day, but still had visible chin hairs. R45 stated staff had not offered shaving of her chin hairs while assisting her with grooming that morning. During interview on 4/15/25 at 9:44 a.m., nursing assistant (NA)-E stated she was unaware R45 had long chin hairs. NA-E stated she had heard someone talking about shaving R45 yesterday and they were going to take care of it (shaving) on evening shift. NA-E further stated she did not notice R45 needed to be shaved this morning, did not offer to shave her chin hairs when she assisted her with morning grooming, and she should have shaved her chin if that was what R45 wanted. During interview and observation on 4/15/25 at 1:40 p.m., R45's chin had been shaved. R45 stated she felt so much better and asked if she looked better. R45 was smiling throughout the conversation and showing her chin. During interview on 4/16/25 at 12:31 p.m., registered nurse (RN)-D stated she expected residents to be shave at least weekly and not have visible chin hairs if they did not want chin hairs. RN-D further stated shaving should be part of morning cares. During interview on 4/16/25 at 12:41 p.m., director of nursing (DON) stated she would expect shaving weekly and if a resident wanted to be shaved they should be shaved, especially if chin hair was visible to others. A facility policy on shaving and grooming was requested by not received.

Based on observation, interview and document review, the facility failed to ensure a safe smoking area, extinguishing of cigarettes in designated container, and monitoring of designated smoking area for 2 of 2 residents (R20 and R18) reviewed for smoking. Findings include: R18's facesheet printed 4/16/25, indicated diagnoses of spina bifida, nicotine dependence, and obesity. R18's admission minimum data set (MDS) assessment dated [DATE], indicated intact cognition, use of wheelchair, dependent for bathing, and setup assistance for personal hygiene. R18's care plan printed 4/16/25, indicated resident currently smoked and would smoke safely in designated areas per facility policy. R20's face sheet printed 4/16/25, indicated diagnoses of type two diabetes mellitus and malnutrition. R20's annual MDS dated [DATE], indicated intact cognition, use of wheelchair, substantial assistance with toileting hygiene, and partial assistance with personal hygiene. R20's care plan printed 4/16/25, indicated resident currently smoked and would smoke safely in designated areas per facility policy. During observation on 4/16/25 at 7:14 a.m., R18 and R20 were outside in the designated smoking area at the facility. R18 and R20 were smoking independently and extinguished cigarettes safely in designated disposal container. On and surrounding the designated smoking area were approximately 100 cigarette butts (ends of smoked cigarettes) in the grass, under trees, and on the patio. During interview on 4/16/25 at 8:46 a.m., R18 stated he always put his cigarette butt in the designated container and was not sure where the loose cigarette butts came from. During interview on 4/16/25 at 9:04 a.m., R20 stated there was a previous resident who threw her cigarette butts everywhere and never put them in the designated disposal container. The previous resident had discharged from the facility in December 2024 and had not returned. R20 further stated staff would not know about the mess because they never go back on the smoking patio. During interview on 4/16/25 at 10:00 a.m., housekeeping director stated that she thought maintenance would have been overseeing the smoking area, but no one had done it. Housekeeping director further stated her staff had not been monitoring the smoking area or any outside areas but had been asked to pick up all the cigarette butts in the smoking area few minutes ago. During interview on 4/16/25 at 8:35 a.m., administrator stated the facility was labeled as a non-smoking facility by signs on the facility door stating non-smoking facility and by notice in the facility policy, but they did let residents smoke. Administrator further stated there was a canister for disposing of cigarettes on the patio and that was where residents were to put their extinguished cigarettes. Administrator was unaware of the cigarettes being thrown on the dry grass, leaves, and under the trees. Administrator agreed cigarettes could potentially start fires if not disposed of properly and could be a safety concern, and confirmed no staff routinely check on the condition or safety of the smoking area. Administrator further stated the maintenance director was new and had not been trained to clean up the smoking area. Facility Oaklawn Rehabilitation Center Smoking Policy dated 8/15/24, indicated the following: Policy Statement: It is the policy of Oaklawn Rehabilitation Center to provide a safe an healthy environment for tenants, staff, and visitors by limiting the use of tobacco and e-cigarette products on it's campus, while also being respectful of the right of each resident to exercise his/her autonomy regarding what they consider to be an important facet of their life. Oaklawn is designated as a non-smoking facility, but due to the lack of safe access to a smoking area off the facility grounds, the back north patio will be designated as a safe smoking location for residents to smoke and dispose of smoking waste. 3. Resident Smoking -Residents are required to use appropriate disposal containers for smoking materials, such as cigarette butts and matches. 5. Enforcement and Compliance -Staff members are responsible for enforcing this policy and addressing any violations. Residents, staff, and visitors found in violation of this policy will be subject to corrective actions, which may include verbal warnings, written notices, or other measures as deemed appropriate by management.

Based on interview and document review, the facility failed to ensure that in the absence of a full-time registered dietician (RD), the culinary services director (CSD)-B was certified to oversee nutrition and food services. This had potential to affect all 45 residents who received meals from the kitchen. Findings include: During the initial kitchen tour on 4/14/25 at 9:40 a.m., CSD-B who had been employed in this role for two years, stated she was not a certified dietary manager (CDM). CSD-B stated she had been enrolled in the course at one time but was not able to complete it. During an interview on 4/15/25 at 11:25 a.m., CSD-B stated the administrator had registered her for the CDM course that morning (4/15/25), and she was now enrolled to take the course. During an interview on 4/15/25 at 2:39 p.m., registered dietician (RD)-C stated she worked part-time at the facility, usually one or two days a week, and communicated frequently with CSD-B via email or phone. RD-C acknowledged CSD-B was new to resident clinical issues, such as monitoring resident weights, but did well on the kitchen side. Facility Culinary Services Director job description, undated, indicated qualifications included: must be a graduate of or currently enrolled in an approved culinary services course that meets the requirements for State and Federal long-term regulations.

Based on observation, interview, and document review, the facility failed to ensure 2 of 2 refrigerator/freezers designated for resident food brought into the facility, were monitored to ensure food items were properly stored, labeled, and dated to reduce the risk of contamination and/or foodborne illness. This had the potential to affect any resident who utilized the refrigerator/freezers. In addition, the facility failed to ensure a culinary services cook (CSC)-A wore covering over beard to prevent hair from contaminating food, surfaces and utensils. This had the potential to affect all 45 residents who ate food prepared in the kitchen. Findings include: North Wing Resident Refrigerator: During an observation on 4/14/25 at 2:54 p.m., the resident refrigerator on the North wing was a side-by-side refrigerator/freezer. On the outside of the refrigerator was a sign that indicated: All items placed in this refrigerator must be in a sealed container with name and date. Perishable items are kept for 3 days. A sign on the freezer indicated: All items placed in refrigerator and freezer must be dated and labeled with room number or it will be discarded per department of health guidelines. In the refrigerator were the following items: -- Pizza in a box with a resident name but no date. -- Small Styrofoam container of an orange-colored substance. The container was not covered. No name or date were on the container. -- Small plastic dish of something unidentifiable, with a spoon in it and covered with plastic wrap. No name or date. -- Small cup of dark colored juice with a residents name and dated 4/9 (five days prior). -- Open bottle of Fairlife protein drink; no name or date. -- DoorDash meal in a bag with name but no date. -- Small container of orange substance with cover. No date, no name. -- Soup in a large Ziplock bag, name but no date. In the freezer: -- A light green frozen drink. No name or date. -- Multiple packages of opened frozen hamburger patties - room number, but no date. South Wing Resident Refrigerator: During an observation on 4/14/25 at 3:15 p.m., on the South wing, the culinary services director (CSD)-B was standing with the refrigerator door open, preparing to mark food with a marker. Prior to doing so, the following items were noted in the refrigerator: -- 3 small Ziploc bags of peeled, overripe bananas; no name or date. CSD-B stated a staff member was going to take them home to make banana bread. -- Store bought container of cantaloupe with room number and no date opened. Seal indicated best by 4/5/25. -- Store bought container of watermelon with room number and no date opened. Seal indicated best by 4/3/25 -- Store bought mixed berries, no name or date. -- Plastic container with food - pasta with sauce - no name or date. CSD-B stated it was likely an employee's food and shouldn't be in the refrigerator. CSD-B stated no one was assigned to monitor the resident refrigerator/freezers - it was everyone's responsibility to monitor them and discard food items not meeting requirements. During subsequent observations on 4/14/25 at 6:42 p.m., (north wing) and at 7:34 p.m., (south wing), the refrigerators and freezers were almost empty after being cleaned out by CSD-B. Hairnet During an observation and interview on 4/14/25 at 11:58 a.m., observed CSC-A who had a full beard, carrying resident meals from the kitchen to the dining room without a beard cover. CSD-B stated she did not know if CSC-A was supposed to cover his beard, and didn't know if the facility had a policy on that. In the meantime, CSD-B gave CSC-A a hairnet to place over his beard. CSC-A also stated he did not know his beard should be covered. Facility Food Brought into Facility policy dated 9/2012, indicated the policy was to address food brought in from the outside with the intent to serve it to all residents. The policy did not include food brought in from the outside for individual residents and stored in resident refrigerator/freezers in common areas. Facility Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices policy dated 10/2017, indicated hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens. Facility Food Preparation and Service policy dated 4/2019, indicated food and nutrition services staff wear hair restraints (hair net, hat, beard restraint) so that hair does not contact food.

Based on observation, interview, and document review, the facility failed to ensure personal protective equipment (PPE) was donned (put on) and doffed (removed) appropriately for 1 of 1 resident (R206) who had been in transmission-based precautions (TBP) due to testing positive for Covid-19. Findings include: R206's facesheet printed on 4/16/25, indicated R206 was admitted on [DATE], with a diagnosis of Covid-19. R206's physician orders dated 4/11/25, indicated: due to Covid positive status, R206 was to remain on enhanced respiratory precautions and strict isolation during the contagious stage. R206's care plan dated 4/11/25, indicated R206 was on enhanced respiratory precautions related to Covid-19 infection. Staff would follow enhanced respiratory precautions. During an observation on 4/14/25 at 6:25 p.m., observed nursing assistant (NA)-A don PPE to go into R206's room. NA-A donned all appropriate PPE except eye protection. At 6:28 p.m., NA-A exited the room with all PPE having been removed prior to exiting the room. Following this observation, a sign on R206's door indicated R206 was in Enhanced Respiratory Precautions, and gown, facemask or N95, eye protection, and gloves were required when entering the room. NA-A did not don eye protection. There was no eye protection in or on the PPE cart outside R206's room. Further, NA-A had doffed her N95 mask in the room rather than after exiting the room, as directed by the CDC (Centers for Disease Control and Prevention) doffing guidance. NA-A was no longer available for interview. During an interview on 4/14/25 at 7:13 p.m., NA-B stated the required PPE for entering R206's room was gown, N95 mask, face shield and gloves. While standing together looking at R206's PPE cart, NA-B stated, there were no face shields on the cart and went and obtained some, putting them on the top of the cart. During an interview on 4/15/25 at 7:39 a.m., registered nurse (RN)-A, who was also the nurse manager for the unit on which R206 resided, was informed of the observation of an NA entering R206's room without eye protection. RN-A stated they must have run out of eye protection. RN-A stated she would expect staff to know to don all required PPE, including eye protection before entering the room of a resident in TBP for Covid-19. When asked how PPE should be doffed, RN-A looked at CDC doffing instructions and stated PPE should be doffed before exiting the resident room except for the respirator (N95 mask); the respirator (N95 mask) should be removed after leaving the resident room and closing the door. RN-A stated staff should be aware of that - removing the N95 mask after exiting the room as the doffing instructions were posted on the back side of R206's door for them to utilize. RN-A acknowledged with the small size of the print; staff might not notice those instructions. RN-A also acknowledged staff had training on doffing but could have forgotten that step. During an observation and interview on 4/15/25 at 9:46 a.m., observed licensed practical nurse (LPN)-A exit R206's room with all PPE doffed, including N95 mask. LPN-A stated she wasn't aware she should doff the N95 mask after exiting the room, adding, I guess I just forgot that. During an observation and interview on 4/15/25 at 5:12 p.m., observed NA-B exit R206's room with all PPE doffed, including N95 mask. NA-B acknowledged she removed all the PPE including the N95 mask before exiting the room. NA-B stated she wasn't aware she should doff the N95 mask after exiting the room. During an interview on 4/16/25 at 4:49 p.m., the director of nursing (DON) and RN-B, who was also the regional nurse consultant were informed of findings. RN-B stated staff were trained on donning and doffing and would expect they adhere to proper procedure. Facility policy on doffing for TBP was requested and the CDC guidelines were received. The guidelines were undated and titled: HOW TO SAFELY REMOVE PERSONAL PROTECTIVE EQUIPMENT (PPE) EXAMPLE 2 and indicated: to remove all PPE before exiting the patient room except a respirator, if worn. Remove the respirator after leaving the patient room and closing the door. 50764

Based on interview and document review, the facility failed to ensure the pneumococcal (PCV20) vaccine was offered or administered as recommended by the Centers for Disease Control (CDC) for 1 of 5 residents (R157) reviewed for immunizations. Findings include: R157's facesheet printed on 4/16/25, indicated and admitted [DATE], and diagnoses of heart failure, muscle weakness, fatigue, and obesity. R157's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition and no rejection of care. R157's physician's orders printed on 4/16/25, indicated a past history of pneumonia, unspecified organism. R157's care plan dated 4/7/25, indicated a self care deficit related to weakness and visual impairment and need for assistance with dressing, personal hygiene, and bathing. During record review, there was no documentation in R157's EMR (electronic medical record) for the PCV 20 vaccine or evidence the vaccine had been offered or refused. During interview on 4/16/25 at 2:56 p.m., director of nursing (DON) stated she expected the PCV 20 vaccine to be offered to all residents based on current CDC guidelines and was not sure why this was missed for R157. DON later stated she had now offered the PCV 20 vaccine to R57. DON further stated R157 accepted and would receive the offered vaccine. Facility Pneumococcal Policy updated 2/2024, indicated the following: It is the practice of the Health Care Facility to offer all residents the pneumococcal vaccines to aid in the prevention of pneumococcal/pneumonia infections. The policy further indicated the facility would follow recommendations of the CDC.

Based on observation, interview, and document review, the facility failed to coordinate an appointment with a dental provider for 1 of 1 resident (R8) who requested a dental appointment for dentures. Findings include: R8's significant change in status Minimum Data Set (MDS) assessment dated [DATE], indicated R8 had moderately impaired cognition, required partial/moderate assistance with oral hygiene, no natural teeth or tooth fragment(s)and diagnoses included arthritis, non-Alzheimer's dementia, anxiety disorder, depression, and macular degeneration (eye disease that affects vision). R8's care plan dated 8/8/23, indicated self-care deficit related to wedge compression fracture, DM2 (diabetes type two), asthma and HTN (hypertension) AEB (as evidenced by) assistance with ADL (activities of daily living) and interventions included assist with personal hygiene with assist of one. R8's oral/dental evaluation dated 12/28/23, licensed practical nurse (LPN)-A indicated R8 had mouth or facial pain that does not impair chewing, upper full denture, edentulous (absent teeth), upper dentures in good condition and is edentulous on bottom, does have some c/o (complaints/of) pain when chewing on the bottom gums but does not effect chewing and/or swallowing and no redness or s/s (signs/symptoms) of infection to the gums/tongue/cheeks, regular texture/regular thin liquids with no issues noted this look back period, resident would like to have a dental appointment set up at this time to look into getting bottom dentures in place, will set up appointment at this time, will continue to monitor and update plan of care as needed. R8's Care Conference form dated 12/27/23, indicated R8 wanted a dental appointment set up, been over [AGE] years. On 3/4/24 at 9:21 a.m., R8 was seated on the bed with a breakfast tray. R8 had upper dentures present and no lower dentures or teeth. R8 confirmed she had upper dentures and no lower teeth or lower dentures. R8 stated she would like lower dentures and needed an appointment to see the dentist. R8 stated chewing big pieces of food was difficult with no bottom teeth. On 3/4/24 at 2:01 p.m. nursing assistant (NA)-A stated R8 had upper dentures and no bottoms dentures. On 3/4/24 at 2:36 p.m., LPN-A stated she was the care coordinator for R8, completed R8's last dental assessment and was present at R8's last care conference. LPN-A confirmed R8 did not have lower dentures, and stated she was responsible to make dental appointments for R8. LPN-A confirmed a dental appointment had not been scheduled or attempted as requested by R8 at her last dental evaluation and care conference. On 3/5/24 at 2:53 p.m., during an interview the director of nursing (DON) stated staff were expected to coordinate a dental appointment and assist R8 to obtain dental care when R8 requested lower dentures. On 3/6/24 at 8:57 a.m., registered nurse (RN)-A, known as the regional nurse consultant, stated the facility did not have a policy related to dental appointments and dental assessments, and expected the facility to provide residents dental services to meet the needs of the resident and resident requests.

Based on observation, interview, and document review the facility failed to ensure safe mechanical lift transfers were completed along with following manufacturer guidelines for Med Care lift that expired, and ensuring correct sling/harness sizes for 7 of 7 residents (R4, R5, R6, R7, R8, R9, R10) who utilized this mechanical lifts. This resulted in an immediate jeopardy (IJ) for R1 who fell from the Med Care sit to stand lift resulting a fractured right femur (thigh bone) on [DATE]. This had the likelihood for serious harm, impairment or death for R4, R5, R6, R7, R8, R9 and R10 who continued to use this Med Care sit to stand lift. In addition, the facility failed to ensure a preventive lift maintenance program was followed and staff had knowledge of using the correct size harness/sling size for their mechanical lifts. The IJ began on [DATE] at 9:05 p.m., when facility staff did not use two staff to transfer R1 in accordance with the care plan and follow manufacturer guidelines for Med Care lift that had expired. The regional director of operations (RDO), Administrator, the Interim director of nursing (DON) and regional nurse consultant (RNC) were notified of the IJ on [DATE] at 4:19 p.m. The IJ was removed on [DATE] at 12:30 p.m., but the deficiency remained at a lower scope and severity of a E with no actual harm with potential for more than minimal harm that was not immediate jeopardy. Findings include: R1's facility reported incident (FRI) dated [DATE], indicated nursing assistant (NA)-A transferred R1 via sit to stand to toilet. R1 became weak and fell from the lift. NA-A notified registered nurse (RN)-A immediately. RN-A assessed the resident noted to be in pain and called 911 for transfer to the emergency department (ED). R1's face sheet indicated diagnoses of dementia, right sided weakness from stroke, disorientation, restlessness, agitation, and fractured lower right femur ([DATE]). R1's quarterly Minimal Data Set (MDS) dated [DATE] indicated R1 required extensive assist of two staff for bed mobility, transfers, toileting, and dressing. R1 did not walk and used a wheelchair. No history of falls and no range of motion (ROM) impairments. The cognition section was not identified on this assessment, or [DATE] assessment. For the significant change MDS assessment dated [DATE], indicated R1 had intact cognition and had no behaviors. R1's care plan for transfers dated [DATE], indicated assist of two staff with mechanical lift. No indication of which lift or sling/harness size. Review of facility's Care Sheet (sheet for NAs to direct resident care) dated [DATE], after the fall, indicated R1 required assist of 3 staff and mechanical lift. Care sheet did not mention which mechanical lift or size of sling/harness to use. R1's progress note dated [DATE], identified the following: Review of R1's progress notes indicated on [DATE]: -11:10 p.m. call placed to Mayo ER (emergency room ) department and spoke with the ER nurse and stated resident did have a fractured right femur and was admitted to the hospital. -11:38 p.m. resident was being helped with bedtime cares by staff when this writer was called to resident's room. Upon arrival, resident was lying down on the floor on his back crying and stating I think I broke my leg it hurts so bad. Assessment done, resident was unable to move his right leg and with passive range of motion. Resident kept screaming stating it hurts. Right leg was warm to touch and slightly bent sideways. Nurse manager and agreed resident to send R1 to ER, family member informed of the incident. Emergency Medical Services arrived at the facility at 9:40 p.m. and left accompanied with paramedics at 9:56 p.m. to the ER. -[DATE] at 1:40 a.m., above incident happened on [DATE] at 9:05 p.m. Facility incident report dated [DATE], did not identify a causal factor to the fall for R1. R1's hospital discharge summary dated [DATE], indicated on [DATE] R1 had a fall from a hoyer lift and per x-ray was found to have a broken distal (bottom end) right femur (thigh bone) that also involved his right knee replacement. R1 had surgery to fix the fracture and returned to the facility on [DATE] with non-weight bearing (NWB) status to the right leg. During an observation of transfers with R1 on [DATE] at 4:29 p.m., R1 was assisted by three staff members to transfer from his wheelchair to a recliner in the commons area via EZ full body lift. The lift sling was already under him and the 3 staff members, one to support R1's right leg, one to pull R1 back into the recliner and one to run the lift. Sling loops were attached to the lift and double hooked. During the transfer the sling was incorrectly placed too high as a result R1's upper buttocks was hanging through the sling and his pants were sliding down. The sling should be two inches below R1's tail bone and the top of the sling parallel to the base of the neck per manufactures recommendations. NAs did not stop the transfer or lower resident to reposition the sling. R1 stated, everyone can see my butt. Staff lowered R1 into the recliner, removed the loops from the EZ full body lift and raised the foot of the recliner and left the sling under R1. Review of the EZ Way Sling Sizing Chart (undated) identified the sling should be two inches below R1's tail bone and the top of the sling parallel to the base of the neck. During an interview on [DATE] at 10:23 a.m., NA-T stated he worked the day of R1's fall on [DATE] at 9:05 p.m. NA-T heard R1 scream and went to R1's room and saw R1 on the floor next the head of the bed with the Med Care sit to stand in front of him. NA-A was holding the harness. NA-T stated he had gone over the care sheets with NA-A making sure to let NA-A know that R1 was assist of two staff for all transfers, at the beginning of the shift and gave NA-A a radio to call and ask questions. He could not remember what size sling R1 was using at time of the fall. NA-T also stated the nurse manager assessed the resident to determine the correct harness size. If this was not on are the care sheet,he would ask the nurse or nurse manager. During interview on [DATE] at 11:24 a.m., RN-A stated she was working the shift of R1's fall. RN-A was at the nurses' station when NA-A came out of R1's room and asked for help. RN-A stated NA-A was transferring R1 from wheelchair to commode with the Med Care sit to stand lift by herself when R1 slid down to the floor. RN-A stated the care plan stated transfer with assist of 2 staff with sit to stand lift. RN-A could not articulate who decided what size sling/harness to use or what size harness R1 used at the time of the fall. During observation on [DATE] at 4:03 p.m., the facility identified they were using the following mechanical lifts for their current resident: -Med Care - Care Stand Total support Model number 400002, six lifts all with a large size harness hanging across the lift. Seven residents used these lift (the facility refers to this lift as EZ stand in their documentation). -EZ Lift total body lift, 3 lifts, slings located on residents or in their rooms, 14 residents used this lift. R4 R4's face sheet indicated the following diagnoses, dementia with behavioral disturbances, osteoporosis and history of falling. R4's quarterly MDS dated [DATE], indicated R4 had impaired cognition and required extensive assist of one for transfers, bed mobility and toileting. R4's had one fall without injury prior to assessment and used a wheelchair. R4's care plan therapy recommendations R4 was assist of 1 staff with EZ stand (Med Care Stand) for all transfers including toileting, dated [DATE]. Care plan lacked identification of what size harness to use. Review of the R4's facility's care sheets [DATE] indicated transferred with EZ stand (Med Care Stand) and assist of one but did not identify the size of harness R4 required for safe transfer. R4's Lift and Mobility status form dated [DATE], indicated R4 was assist of one staff with EZ stand (Med Care lift). There was no harness size identified. R5 R5's face sheet indicated the following diagnoses of cervical disc disorder with myelopathy and severe sepsis with septic shock. R5's nursing assessment dated [DATE], indicated an intact cognition and transferred with physical assist of two staff, had ROM impairments to his lower extremities, used a wheelchair and no history of falls. R5's care plan dated [DATE], direct staff to transfer R5 with mechanical lift and max assist of two for bed mobility. Review of the facility's care sheets for R5 dated [DATE], indicated R5 transferred with mechanical lift and max assist of two for bed mobility. Care sheets did not indicate which mechanical lift or the size of sling/harness to use for R5. R5's record lacked a comprehensive assessment to determine which mechanical lift including sling/harness R5 required to ensure they were safe during these transfers. R6 R6's face sheet indicated the following diagnoses vertebrogenic low back pain, systemic lupus erythematosus, osteoporosis, and wedge compression fracture of fifth vertebra. There was no MDS available for R6. R6's alteration in mobility care plan indicated R6 transferred with mechanical lift and assist of two staff, start date of [DATE]; TLSO (ridged back brace) to be worn when out of bed and when head of bed greater than 30 degrees, no bending, twisting or lifting greater than 10 pounds, start date of [DATE]. Care plan did not indicate which mechanical lift to use for R6. Review of the facility's care sheet [DATE] indicated R6 transferred with EZ stand (Med Care) and assist of two staff. Care sheets lacked the size of harness R6 used for safe transfer. R6's lift and mobility status assessment dated [DATE], indicated R6 transferred with assist of two staff and EZ stand (Med Care lift). The lift harness size was not identified. R7 R7's face sheet indicated the following diagnoses acute kidney failure and weakness. R7's care plan indicated an alteration in mobility related to acute kidney injury, chronic obstructive pulmonary disease, major depressive disorder and atrial fibrillation as evidenced by needing assistance with cares, dated [DATE]. The following interventions were in place: -assist of one staff for ambulation, start date [DATE], -assist of one staff with movement in and out of bed, start date [DATE], -maximal assist of two staff for transfers, use mechanical lift stand from low surfaces. Max assist of two staff for bed mobility, does not ambulate at this time. Transfers with assist of two staff and two wheeled walker in room. Can use EZ stand (Med Care) if patient is tired in evening, start date [DATE]. There was no mention of the harness size. Review of the facility's care sheet indicated R7 transferred with assist of two and a two wheeled walker in and R7 could use the EZ stand (Med Care) if tired in the evening. There was no mention of harness size. R7's lift and mobility assessment dated [DATE], indicated R7 transferred with maximal assist of two and mechanical stand per therapy recommendations. Staff to continue to monitor for safety. There was no mention of which mechanical lift or harness size to use for R7. R8 R8's face sheet indicated the following diagnoses of spondylosis without myelopathy or radiculopathy, cervical region, weakness, osteoporosis, and spinal stenosis cervical and lumbar region. R8's quarterly MDS dated [DATE], indicated R8 required assist with transfers and did not walk. R8 used a wheelchair. Cognition section not filled out for this assessment, previous quarterly assessment dated [DATE], indicated intact cognition. R8 had no history of falls. R8's alteration in mobility care plan indicated R8 transferred with EZ stand (Med Care), assist of two with movement in bed and in/out of bed, dated [DATE]. There was no mention of harness size for R8. Review of the facility's care sheet dated [DATE], R8 was assist of one with EZ stand (Med Care). There was no mention of harness size to use for R8. R8's record lacked a comprehensive assessment to determine which size sling/harness R8 required to ensure they were safe during these transfers. R9 R9's face sheet indicated the following diagnoses of stroke, and cervicalgia. R9's annual MDS dated [DATE], indicated an intact cognition and required maximal assist with transfers and did not walk. R9's alteration in mobility care plan indicated R9 transferred with assist of 1 and EZ stand (Med Care), did not ambulate, and assist of one with movement in bed and in/out of bed, start date of [DATE]. Review of the facility's care sheet dated [DATE], indicated R9 transferred with EZ stand (Med Care) with assist of one staff with medium harness. Even though the facility only had large harnesses on the floor in use as a result of the observation on [DATE] at 4:03 p.m R9's record lacked a comprehensive assessment to determine which size sling/harness R9 required to ensure they were safe during these transfers. R10 R10's face sheet indicated the following diagnoses of weakness, and age-related disability. R10's quarterly MDS dated [DATE], indicated R10 was dependent on staff for transfers, no history of falls, did not walk and used a wheelchair. R10's fall risk care plan indicated R10 was assist of two staff and EZ stand (MedCare), start date [DATE]. Transfer care plan indicated EZ stand (Med Care) and assist of one staff, dated [DATE]. Review of the facility's care sheet dated [DATE], indicated R10 transferred with EZ stand and assist of two staff. Care sheet lacked what size of harness R10 needed to transfer. R10's record lacked a comprehensive assessment to determine which sling/harness size, R10 required to ensure they were safe during these transfers. During an interview on [DATE] at 9:31 a.m., NA-R stated staff follow the care plan/care sheets to transfer residents. NA-R looked at the care sheet and stated it did not state which harness size to use with the Med Care sit to stand lift. NA-R could not remember when she last had training on the lifts the facility used. NA-R stated the sit to stand lifts should say on the care sheet whether one or two staff needed and there are always two staff with the EZ lift. During an interview on [DATE] at 9:39 a.m. NA-S and NA-A stated they would look at the care sheets for how to transfer any resident, if not there they would ask the nurse manager. During an interview on [DATE] at 12:55 p.m., speech therapist (ST)-A, director of therapy, indicated therapy does an initial assessment of new admissions for proper transfer techniques for resident. Therapy would tell nursing which type of mechanical lift to use but nursing would have to identify the sling/harness size to use as part of their nursing assessment. There is no formal assessment kept in our therapy notes for the lift they are to use, we just recommend the lift type to nursing staff. During an interview on [DATE] at 2:40 p.m., NA-T stated nurse managers indicated the size of harness used for the EZ stand (Med Care ) and there was a chart on the EZ lift to determine what sling to use. During an interview on [DATE] at 2:56 p.m., licensed practical nurse (LPN-B) who was the nurse manager, stated sling/harness sizes should be in the therapy orders as therapy does the transfer assessment. If not, they would base it off resident weight in their chart and put on the care sheet. NAs could look at therapy notes as well. During an interview on [DATE] at 3:00 p.m., RN-C stated she would rely on the NA's as they are competent on knowing what size of sling/harness to use. RN-C would check therapy notes as therapy does an assessment when residents admitted . If residents are on the LTC side then the nurse assessment should show which size to use. The facility's copy of the manufacture's operation manual, revised date ,d+[DATE], page 9 - 11, informed reader how to operate the Med Care - Care Stand, but there was no sizing guide for harnesses even though the facility had other sizes. The facility also did not use a guide or any reference to determine harness size for each resident who used Med Care lift. Preventative Maintenance During an interview on [DATE] at 8:15 a.m. MM-A indicated preventative maintenance (PM) was completed monthly on all the lifts. Review of facility's form labeled, Weekly audit for functionality for all facility lifts and stand wear/tear on slings. The form had four areas labels: stand/lift number, location, functioning properly yes/no and slings in good working condition yes/no. Under stand lift identified the stand number (Med Care) and lifts (EZ Lift). The location was identified as east, west or north wing. Functioning properly column identified a yes or no. The column slings in good working condition only identified the stands (Med Care) as yes, there were no notion if the EZ lift slings were reviewed. MM-A stated he would test the buttons of the lift so they would go up and down, tested the emergency stop button and made sure the lifts rolled well by rolling it around in a circle. MM-A was not able to articulate the manufactures recommendations for PM and did not use manufactures provided check list for PM. MM-A completed PM on [DATE] on all lifts per his checklist and was unsure if the lift involved in R1's incident was removed from the floor until MM-A performed PM on it before returning it to the floor for use. He was unable to articulate the age of the lifts in use or other specific about the required maintenance by the manufacturer. Review of the Med Care's manufacture's operation manual model number 400002, revised ,d+[DATE], on page ,d+[DATE] indicated the routine maintenance was a vital component to keeping the equipment in safe operating condition. A machine that is not properly maintained could create potentially hazardous situations for nursing staff and patients. Check list were to used for PM. The PM checklist had two column, pass or fail. Under general maintenance indicated the following: -Actuator and connections- check the operation of the actuator. Remove bolts and check for lithium grease. If none present, apply and re-insert. Use of a thread locker is recommended when re-attaching nut to bolt. -Actuator- check the up and down movement. If it makes noise or wobbles, it should be inspected. -Actuator cover- clean and check for wear and tear. -Base cover- clean and check for cracks and sharp edges. -Boom/arm pivot pins and bushings- check the area where the arm or boom meets the mast. Be sure the nut and bolt are securely attached. If not operating smoothly, remove bolt and apply lithium grease. Re-insert the bolt; apply thread locker, and secure nut. -Front casters- clean debris from casters and test for smooth rolling. -Hand control- check for smooth operation. -Leg covers- clean and check for sharp edges- -Leg bolts- remove base cover and check to make sure bolts are flush with the base. If not, tighten. Periodically remove bolts, apply lithium grease, and re-insert using thread locker on the threads. -Leg spreader pivot bar- check the bolt on the base and make sure the nut is at least 2 threads inside the end. This nut may be adjusted to your preferred tension. -Mast/base bolts- check bolts to make sure they are re tight. If not, remove, apply thread lock and re-tighten. -Rear casters- clean and remove debris. Check to make sure the brakes are working properly and that the wheels are firmly attached. -Receiver box- clean and check for operation. Check that the on/off switch is functioning properly. Try out the toggle switch, and verify both the up and down motion of the actuator. -Batteries- check for damage to plug, and check voltage. -Slings/harness and belts- inspect slings/harness and belts for wear and tear before every use. Immediately remove any damaged slings/harness and belts from service and replace. Under the stand maintenance it indicated the following: -Foot platform- remove the platform and clean. Be sure to remove the plastic footplate cover and clean underneath. Pay attention to the plastic and check for sharp edges. -Knee pad assembly- check for tears and clean the leg strap and surface of pad. -Padded hand grips- clean hand grips, and check that they are pushed all the way on. -Arm pads- clean and check for wear and tear. -Foot pedal- check for smooth operation. In addition, the manufacture recommended replacement of the following: -Actuators to be replaced after 4 years of use -Support bar on lifts replace when excessive wear is apparent -Slings to be replaced after 2 years of use. During an interview on [DATE] at 4:38 p.m., Med Care representative (CSR-A) stated the harness sizing was based on the resident's waist measurements. The Med Care lift, model number 400002 (the lift the facility used) were manufactured in 2009 was discontinued in 2015. All the facilities that had this lift received a Tech Bulletin identifying the manufacture would continue to supply parts for 7 years after the discontinuation date (2021). The unit should not be used longer than this date, they could not ensure the safety of the resident during transfers with these lifts. CSR-A identified Med Care's expectation is the facility would report any incident involving their equipment to them. During an interview on [DATE] at 1:04 p.m., DON could not state the Med Care sit to stand lift R1 fell from was removed from the floor until the next morning when MM-A inspected it. DON also stated that the facility did not have a mechanical lift policy but followed the manufactures recommendations. During a clarification interview on [DATE] at 8:35 a.m., DON confirmed that all Med Care harness were size large that were on the floor. Other sizes were stored in the basement and available if needed. DON was not able to identify how the harness or sling size was determined for each resident. She was also unaware the Med Care- Care Stand Total support, model number 400002 was retired in 2015 and no longer supported by the company. During an interview on [DATE] at 10:11 a.m., RDO and Administrator both acknowledged they did not know there was a life span to lifts or that the Med Care- Care Stand Total support lift the facility was using was discontinued in 2015. Further more, they were not aware the facility did not have a system in place for harness sizing for safe transferring of residents with the Med Care- Care Stand Total support, model number 400002. During an interview on [DATE] at 1:37 p.m., the food and drug administration (FDA), stated the Med Care Stand, model number 400002 was no longer registered with the FDA. If the facility continued to use the unregistered device, the facility needed to have someone that supported the product to render it safe to use. The FDA further stated that if the expired device was involved in an incident that may have resulted in serious harm or death, the device would need to be reported to the FDA by the manufacturer under 42 CFR 803.3, it did not matter if the incident was caused by operator error or equipment failure. During an interview on [DATE] at 3:31 p.m., with EZ Way Lift representative stated the sling sizes was based on the sizing charts that are on each lift. The slings are color coded per size based on weight. The chart also explains and shows how to place the slings properly for a safe transfer of the resident. The immediate jeopardy that was identified on [DATE] at 4:19 p.m., was removed on [DATE] at 12:30 p.m., when it was verified, the facility implemented the following corrective actions: -Review manufacture's recommendations in conjunction with their mechanical lift transfer policy and procedures -Revise policy/procedure to ensure they are being used according to manufacture guideline -Remove all Med Care standing lifts that are not supported by manufacturer from the floor -Inspect all lifts for safe operation according to manufactures recommendations -Develop and educate nursing/physical therapy (PT)/ occupational therapy (OT) on completing comprehensive harness/sling assessments in accordance with manufacture's recommendations and develop/revise care plans as appropriate -Educate staff on appropriate positioning of the slings/harness and immediately removing equipment from service following an incident -Complete a return demonstration after education on all staff who use the mechanical lift, to ensure they are following facility policy and manufacture guidelines for a safe transfer.

Based on interview and record review the facility failed to ensure timely reporting to the State Agency (SA) was completed when 1 of 1 resident (R1) fell from a mechanical lift as a result of NA not following the care plan which resulted in a right femur fracture. Findings include: Facility reported incident (FRI) submitted to the SA on 10/10/23, at 4:35 p.m. identified R1 had a fall from the mechanical lift on 10/9/23, at 9:05 p.m. that resulted in R1 fracturing his right femur, when NA-C transferred R1 via sit to stand to toilet. R1 became weak and fell from lift. NA-C notified nurse immediately. Nurse came immediately assessed that R1 was in pain, called 911 for transfer to emergency room (ER). Provider and family made aware. R1's quarterly Minimum Data Set (MDS) dated [DATE] indicated R1 had diagnoses of monoplegia (weakness) of the right side, unspecified dementia, cerebral infarction (stroke), anxiety, and depression. The cognition section was not completed for this assessment, however, MDS dated [DATE], indicated R1 did not have cognitive impairment. R1's progress notes dated 10/9/23, included R1 was being assisted by staff and had a fall. R1 was lying on the floor on his back crying, stating I think I broke my leg it hurts so bad Call placed to the nurse manager and agreed resident to send R1 to ER. Ambulance arrived at 9:40 p.m., R1 was transferred to the hospital at 9:56 p.m. Notes indicated a call was placed to the ER, facility was notified R1 sustained a right femur fracture and admitted to the hospital During an interview on 10/25/23 at 1:04 p.m. DON stated she was made aware of the incident on 10/10/23, when she arrived at work around 8:00 a.m. DON explained the required time frame for reporting incidents was 2 hours for abuse or serious injury. During an interview on 10/25/23 at 10:05 a.m., Administrator stated he was aware they did not report the incident timely as they were more focused on ensuring the safety of their residents. Additionally, we were doing education with staff on the use of mechanical lifts used by the facility and their investigation. Administrator was aware of the reporting requirement. Review of the facilities policy Abuse Prohibition/Vulnerable Adult Policy dated 9/2023 indicated avoidable falls with serious injury shall be reported to the SA through the online reporting process immediately but not later than 2 hours after identifying the injury.

Based on observation, interview and record review the facility failed to ensure proper catheter cleaning and storage was provided to prevent possible urinary tract infections (UTIs) for 4 of 6 residents (R1, R3, R5 and R15) observed for catheter use. Findings included: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had diagnoses of neurogenic bladder (define what this is), cancer, urinary tract infections (UTI) in the last 30 days, diabetes, and stroke. R1 had an indwelling urinary catheter and was always continent of bowel. R1's bowel and bladder care plan 7/7/22 indicated R1 had altered elimination related to impaired mobility and function due to hemiplegia and hemiparesis following right sided stroke, history of UTIs, sepsis, and bladder cancer scope done on 4/3/23 that showed friable tissue over posterior bladder wall. Additionally, R1 had history of TURBT (trans urethral resection of bladder tumor) on 5/16/23 with significant hematuria (blood in urine) and indwelling urinary catheter placement. Corresponding interventions included: -Followed by urology, start date 7/722. -assist of 2 with toileting, start date 7/7/22 -provide assist with peri cares a.m., HS (bedtime) and as needed, start date 7/7/22 -monitor for signs and symptoms of UTI, start date 11/29/22, -monitor foley output, start date 8/8/23 -Foley (brand of indwelling urinary catheter) catheter care to be done twice daily with no pressure from the catheter on the tip of his penis, start date 8/8/23 Review of the facilities care guide (abbreviated care plans used by nursing assistants) dated 10/24/23, directed for the catheter to be anchored to leg at all times to avoid pulling, toilet every 2-3 hours and as needed, catheter output every shift. R1's physician orders included: -Change Foley catheter every 30 days and as needed, 16 French (Fr) 10 milliliters (ml) at bedtime every 30 days make sure catheter is silicone, start date 9/22/23 -Foley catheter output three times daily, start date 9/22/23 R1's hospital discharge summaries indicted R1 had a history of UTI's with urosepsis (infection in the blood from UTI) with hospitalization s and emergency room (ER) visits from 12/30/22 through 10/24/23: -R1's hospital discharge summary dated 1/5/23, indicated R1 was admitted to the hospital on 12/30/23 with diagnoses of sepsis urinary tract infection (UTI). Lab results showed infectious bacteria found in R1's blood and urine were Staphylococcus Aureus. The summary indicated R1 was discharged from the hospital on 1/5/23, with intravenous antibiotic (IV). -R1's emergency room (ER) after visit summary dated 2/6/23, identified R1 was seen for UTI, and returned to the facility on oral antibiotics. -R1's hospital discharge summary dated 5/5/23, indicated R1 was admitted on [DATE] for UTI, sepsis, and confusion. R1's lab results showed infections bacteria of proteus mirabilis in urine. R1 was discharged back to the facility on [DATE], with oral antibiotics. -R1' hospital discharge summary dated 7/12/23, indicated R1 was admitted on [DATE], for altered mental status. R1's lab results showed infectious bacteria of staphylococcus Aureus from urethra wound and Escherichia coli (E. coli) and proteus mirabilis in his urine. R1 was discharged back to the facility on [DATE], with a Foley catheter and a midline intravenous access for IV antibiotics. -R1's hospital discharge summary dated 8/25/23, indicated R1 was admitted to the hospital on 8/23/23 for sepsis. R1's labs showed infectious bacteria E. coli in his urine. R1 was discharged back to the facility on [DATE], with oral antibiotics. During an observation on 10/24/23 at 5:16 p.m., in R1's bathroom, there was an overnight urine collection bag sitting in a pink basin on a shelf above the toilet. The tubing connector was not capped. The bag was not dated. Above the toilet was a sign taped to the wall for Indwelling Catheter Care Procedure and Disinfection of Urinary Drainage, instructions on how to change out the legs bag and the overnight urine collection bag, as well as the cleaning instructions. At 5:20 p.m. director of nursing entered R1's bathroom, DON looked into the basin and stated the connecting tubing was not capped. DON also verified placement of sign on the wall to direct staff to disinfect drainage bags. DON then took an alcohol swab and wiped the end of the tubing and applied the blue cap, did not throw the bag away or disinfect the bag. During an observation on 10/26/23 at 8:35 a.m., had DON, RN-B and NA-M verified the bed bag was not capped or washed was sitting in the pink basin in R1's bathroom. There was also a small amount of yellow fluid present in the bag and in the bottom of the bin. NA-M stated she had not had time to return to clean the bag. When asked what the importance of capping the bed bag before placing in the clean pink bin, DON responded, to prevent contamination of the catheter bag and introducing bacteria to the resident. It was the DON's expectation the urinary collection bags were cleaned prior to being placed into the pink basin as this was a clean basin. During an interview on 10/24/23 at 4:29 p.m., FM-A stated that R1 was prone to UTI's and had been hospitalized ,d+[DATE] times this year with sepsis and UTI's. FM-A stayed to visualized cares being done on R1 in the evenings and felt staff were not following their own policies for catheter care. FM-A sent pictures from her phone of the pink basin sitting on the floor in R1's bathroom with the overnight bag uncapped in the basin or the connection tubing end on the floor uncapped. R3's annual MDS dated [DATE], identified R3 had diagnoses of multiple sclerosis (MS) and neurogenic bladder. R3 did not have cognitive impairment. Additionally, the MDS, identified R3 did not have a catheter and was frequently incontinent of bladder and always continent of bowel. R3's physician orders included the following: -Foley output every shift for catheter, start date 10/2/23 -Place foley catheter 16 Fr with 10 milliliters (ml's) balloon. Change on 2nd of every month and as needed (PRN) for overflow incontinence, start date 10/2/23. R3's bowel and bladder care plan dated 4/17/2018, indicated R3 had altered elimination related to diagnoses of MS, weakness, and flaccid neurogenic bladder. Corresponding interventions included: -Straight cath as needed for inability to void or empty bladder fully, start date 3/5/2020. -Total assist of 2 via full body mechanical lift for toileting every 2-3 hours and as needed, start date 4/17/18. -Monitor and report for signs and symptoms for UTI, start date 4/17/2018. In review of R3's care plan, it was not evident the care plan was revised to include goals and interventions for the care of the indwelling urinary catheter. Additionally, R3's nursing assistant care guide did not identify R3 required an indwelling catheter. During an observation and interview on 10/26/23 at 8:46 a.m., R3 was sitting in electric wheelchair with a bed bag hooked on the bottom of the wheelchair. The bag was dated 10/12/23. There was a milky white liquid substance in the tubing and a white flaky substance on the walls of the tubing. The catheter was not secured to either of R3's legs. R3 stated that at times that bed bag [overnight collection] got caught on her wheels and the bag popped. This pulls on the tubing but has not pulled out the foley catheter. RN-B confirmed that the catheter bag should be changed weekly on bath days and that there was sediment built up in the tubing. R5 R5's 5-day MDS dated [DATE], indicated intact cognition with diagnoses of sepsis with septic shock, UTI in the past 30 days, benign prostatic hyperplasia (BPH)and urinary retention. R5 had an indwelling catheter and was always incontinent of bowel. R5's physician orders included the following: -change foley catheter (16fr with 10 ml's balloon) monthly and as needed. One time a day starting on the 1st and ending on the 1st each month for foley catheter cares, start date 10/24/23, -change foley/suprapubic catheter bag on hsower day in the morning every Tuesday, start date 10/20/23, -change graduate used for catheter output weekly, in the morning every Tuesday. R5's 10/24/23 care plan indicated alteration in elimination related to BPH with lower UTI symptoms. The following intervention were in place: -monitor foley catheter output, start date 10/24/23, -change foley catheter per policy, start date 10/24/23, -foley catheter care per policy. During an observation on 10/26/23 at 8:13 a.m. R5 sat in his recliner, his catheter bag dated 10/18/23, was lying on the floor next to the chair. R15 R15's 5-day MDS dated [DATE], indicated an intact cognition and diagnoses of cerebral palsy and BPH. R15 had an indwelling catheter and was always continent of bowel. R15's physician orders included the following: -change foley/suprapubic catheter bag on shower day, in the morning every Monday, start date 9/2/23, -change graduate used for catheter output weekly, one time a day every Monday, start date 9/2/23, -monitor catheter ourput every shift, start date 9/2/23. R15's 9/8/23 care plan indicated no alteration in elimination as R15 is continent of bowel. There following interventions were in place: -monitor foley catheter output, start date 9/8/23, -change foley catheter per policy, start date 9/8/23, -foley catheter care per policy. During an observation on 10/26/23 at 8:24 a.m., R15 had a catheter bag dated 10/16/23. Foley was secured to his left leg with an undated device. During an interview on 10/26/23 at 8:56 a.m., registered nurse (RN)-B stated catheter cares was the responsibility of the NA taking care of the resident. There was no place found on the MAR/TAR for nursing to sign off on catheter cares, just the changing out of the catheter itself on a monthly basis. During an interview on 10/27/23 at 9:31 a.m., nurse manager (NM)-A stated the nursing assistants (NAs) trade out the overnight bags to the leg bags when the resident was out of bed, NAs would then wash out the bags with vinegar, hang to dry, and then place them into a pink basin. The process of changing out the bags was completed per resident's preference and the bags were changed out weekly on the resident's bath day. NM-A reviewed the facility policy and indicated step 5 to uncap bottom outlet of bag, drain urine into measuring container, then recap outlet. NM-A stated wiping the outlet with an alcohol wipe prior to re inserting or closing the outlet should be part of the process. NM-A stated this voided step could lead to the introduction of bacteria/infection to the resident. During an interview on 10/25/23 at 5:17 p.m., DON stated it was her expectation staff complete catheter cares as the policy procedure stated. Recently has done one on one training with all staff. Review of the facilities policy Disinfection of Urinary Drainage Bag indicated should be completed daily when the urinary drainage bag was removed from the resident to leg bag and vice versa with the following steps: 5. uncap bottom outlet of bag, drain urine into measuring container, then recap the outlet. (Should be wiped with alcohol prior to recapping per NM-A interview on 10/27/23.) 16. Remove top cap. Partially fill the bag with 55-65 millimeters (ml's) of vinegar. 17. Shake the bag gently so the entire inside is rinsed well. 18. Drain vinegar from bag, store bag on clean towel or in clear plastic bag until next use; allowing exterior to air dry. 20. Change out bag for a new appliance on bath day.

Based on observation, interview and document review, the facility failed to assess, monitor and implement pressure relieving interventions for 1 of 1 resident (R84) reviewed who had a stage 4 pressure ulcer with known risks for pressure ulcer development. The facility's failures resulted in R84 sustaining harm when the resident developed an unstageable pressure ulcer to the left heel. Findings include: Pressure ulcer stages, identified from the National Pressure Ulcer Advisory Panel (NPUAP): Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [CONDITION(S)] or fluctuate) on the heel or scenic limb should not be softened or removed. R84 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During observation and interview on 4/5/21, at 5:00 p.m. R84 was sitting in his wheelchair eating. R84 was noted to have a redistribution boot on the left foot and a sock on the right foot. R84's right heel was pressing against the foot pedal of the wheelchair. R84 stated he had a sore on his left heel, but was unsure about the right heel. R84 confirmed staff had been putting a protective device on only the left heel. R84 stated he had frequent pain in both heels. R84 further indicated he had an open sore on his coccyx area. Review of the Admission Data Collection sheet dated 8/4/20, identified R84 as requiring extensive assistance with mobility, having clear speech, able to understand and able to be understood, with good memory recall. The admission skin assessment was left blank therefore not identifying R84's current skin condition. Review of a weekly wound evaluation dated 8/7/20, identified R84 as having a stage 4 pressure ulcer on the coccyx. The ulcer was identified as measuring 2.5 centimeters (cm) in length, 1.0 cm in width, and 2.5 cm in depth. The ulcer was further described as having full thickness tissue loss with adipose exposure, margins severely macerated (skin is soft and moist around the edges of a wound), wound edges slightly rolled, heavy yellowish drainage present, undermining (when tissue under the wound edges becomes eroded) and as having a foul odor. Interventions implemented included: pressure redistribution cushion on wheelchair, pressure relieving mattress and a repositioning schedule. In addition, the assessment indicated R84 was admitted with a significant pressure wound on 8/4/20, which was first assessed by facility staff 8/6/20. Review of a skin assessment dated [DATE], identified R84's left and right heels were boggy. No other description of the heels was documented. In addition, no additional interventions were implemented to prevent breakdown of the heels. Review of a weekly wound evaluation dated 9/2/20, identified R84's left and right heels were boggy. No other description of the heels was documented. Also, no additional interventions were implemented to prevent breakdown of the heels. Review of a weekly wound evaluation dated 9/14/20, did not address R84's heels which had been identified to be boggy 8/24/20 and 9/2/20. There were no additional interventions identified to prevent breakdown of the heels. Review of a weekly wound evaluation dated 9/25/20, identified a suspected deep tissue injury to the left heel. Measurements were 3.4 cm in length, 5.5 cm in width and 0.0 cm in depth. The area was described as being purplish red in color and skin being soft and boggy. Interventions implemented included: pressure redistribution boots on at all times and air mattress on bed. Although R84 was first identified as having boggy heels 8/24/20, no new interventions were implemented until this evaluation 9/25/20. Review of a weekly wound evaluation dated 10/12/20, identified R84's left heel as blistering and worsening. The evaluation indicated R84's heels and feet were pressing against the footboard of the bed. The pressure ulcer to the left heel was described as having partial tissue loss, discolored skin and scant serosanguinous drainage. Measurements were identified as 5.0 cm length by 4.5 cm width and 0.0 cm depth, and the wound was identified as unstageable. Review of R84's admission Minimum Data Set (MDS) assessment dated [DATE], identified R84 as having a baseline interview for mental status (BIMS) score of 15 (no cognitive impairment). The MDS identified R84 as requiring extensive assistance with bed mobility and positioning, indicated R84 as at risk for pressure ulcers, and indicated R84 had a current stage 4 pressure ulcer. Interventions included: pressure reducing mattress, chair cushion, turn and repositioning program and pressure ulcer care. Review of R84's quarterly MDS assessment dated [DATE], identified R84 as having a BIMs score of 15. The MDS identified R84 as requiring extensive assistance with bed mobility and positioning, indicated R84 as at risk for pressure ulcers, and indicated R84 had a current stage 4 pressure ulcer, and an unstageable pressure ulcer. (The unstageable pressure ulcer was not present on admission) (right heel). Interventions included: air mattress, chair cushion, turn and repositioning program and treatment dressing. Review of the admission Braden scale dated 8/7/20, identified R84 as having mild to moderate risk for pressure ulcers. The assessment identified R84 as having a stage 4 pressure ulcer on the sacrum. In addition, R84 was identified to require extensive assistance with ADL's (activities of daily living) that included lifting legs in and out of bed. Interventions identified included: turning and repositioning program, redistribution cushion in chair, air mattress, weekly wound assessments and a protein supplement twice daily. Review of the R84's admission care plan dated 8/26/20, identified R84 as being at risk for skin breakdown related to acute kidney failure, limited mobility and current pressure ulcers. Interventions were identified as including: monitor skin integrity weekly, turn and reposition every 2 hrs (hours) and as needed (PRN), pressure redistribution cushion to chair, air bed, weekly wound measurement to sacrum and follow wound care. Review of the current plan of care dated 2/12/21, identified R84 as having alteration in skin integrity related to pressure ulcers on the coccyx and left heel. Interventions included: offload left heel with a donut cushion at all times, weekly wound assessments, monitor skin daily, turn and reposition every 2 hours, pressure reduction cushion to chair, air mattress and encourage R84 to accept cares, due to occasional refusals. Review of the nursing assistant (NA) resident care sheet dated 4/2/21, indicated R84 requires assistance with ADLs, reposition every 2 hours/ remind the resident to reposition, may be up in chair no more than 2 hours at a time and blue heel donut to the left heel at all times. There were no preventative measures identified for the right heel. Review of the current physicians orders dated 4/8/21, included skin /pressure ulcer orders. These orders included: ensure heels are floated and pressure relief boots are in place. ensure feet are not rested on the foot board, weekly skin audits, wound care every 3 days and as needed to coccyx and wound care to left heel daily and off load at all times. During observation and interview on 4/6/21 at 4:00 p.m., R84 was observed to be sitting outside the facility with a staff person. R84 was in the wheelchair with both feet resting on the foot pedals. R84 was observed to have thick socks on both feet but did not have a redistribution device on either feet. R84 stated he was not sure if they were needed when he was up in his chair. During observation and interview on 4/8/21 at 11:00 a.m., R84's left heel pressure ulcer was measured by licensed practical nurse (LPN)-A. The left heel ulcer measured 5.6 cm by 5.0 cm by 0.0 cm. The area was identified by LPN-A to be covered with 80% eschar, 10% slough and 10% granulation. There was an increase in depth from the previous week, but the width and length had improved. During this time, R84 was resting in bed and noted to have a blue heel doughnut under the left heel, but did not have any kind of redistribution device under the right heel. The right heel was resting on the bed. The surveyor asked LPN-A to check the resident's right heel that was covered with a sock. LPN-A described the right heel as soft, slightly pink in color, with hardened skin around the edges. The center area measured a 1/4 inch of discoloration and blanchable. There were no visible open areas. R84 stated he was having pain in both feet. Interview with LPN-A at this time, confirmed R84 did not have any orders for a pressure redistribution device to R84's right heel and that there had been no previous redness in the area. LPN-A stated the wound nurse is currently responsible to monitor R84's skin. During interview on 4/7/21, at 9:30 a.m. NA-A and NA-B indicated R84 will reposition self most of the time, but staff need to remind him occasionally. NA-A and NA-B confirmed R84 was to have a blue heel donut to his left heel at all times when in bed. NA-A and NA-B also verified R84 did not have any kind of pressure reduction device for the right heel. NA-A and NA-B stated R84 utilizes the blue heel donut when in bed, but verified staff are not always able to place the donut properly when R84 is up in the wheelchair. During interview with RN-A on 4/8/21, at 1:00 p.m. RN-A confirmed R84 did not have orders for a pressure redistribution device to the right heel, even though R84 was at risk for pressure ulcers. RN-A confirmed R84's admission skin assessment identified boggy heels with no interventions implemented, to prevent skin breakdown. RN-A verified after R84 was identified with boggy heels, R84 developed an unstageable pressure ulcer to the left heel 6 weeks later. The Director of Nursing (DON) and administrator were interviewed at 1:30 p.m. on 4/8/21. The DON confirmed R84 was admitted without a skin assessment completed until 3 days later. The DON also verified R84 was at risk for skin breakdown. The DON stated when R84's heels were identified to be boggy interventions should have been implemented. The DON further stated she would expect staff to assess the resident's skin on admission in order to determine interventions needed to prevent skin breakdown. The facility's 7/18 policy Skin Assessment and Wound Management, included: Initiate a weekly pressure wound evaluation when a pressure ulcer is identified, notify the wound nurse and update provider. Provide information regarding clinical identification of pressure ulcers/injuries and associated risk factors.

Based on observation, interview and document review, the facility failed to follow the Centers for Disease Control (CDC) guidelines to prevent and/or minimize the transmission of COVID-19 resulting in an immediate jeopardy (IJ) due to the increased risk for transmission of COVID-19 for 9 of 12 residents (R2, R3, R4, R5, R6, R7, R8,R9, R11) reviewed for infection control practices. This had the potential to affect all 60 residents who resided in the facility. The IJ began on 12/2/20, when the facility failed to implement transmission based precautions (TBP) utilizing all necessary personal protective equipment (PPE) including gowns, for 14 days for newly admitted residents and residents readmitted from the hospital who required quarantine. The administrator, director of nursing (DON), infection preventionist (IP) and registered nurse consultant (RNC), were notified of the immediate jeopardy at 7:11 p.m. on 12/2/20. The immediate jeopardy was removed on 12/3/20, when the facility implemented corrective action, but noncompliance remained at the lower scope and severity level of an E, pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R2 was readmitted to the facility on [DATE], with quarantine identified as ending 12/3/20. On 12/2/20, at 2:22 p.m. the door to R2's room was observed shut with no signage on the door to indicate R2 was on TBP. In addition, there was no PPE set up in place outside of the resident's room. R3 was admitted to the facility on [DATE], with quarantine identified as ending 12/16/20. On 12/2/20, at 2:22 p.m. the door to R3's room was observed open with R3 sitting inside the room. There was no signage on the door to indicate R3 was on TBP. In addition, there was no PPE set up in place outside of the resident's room. R4 was readmitted to the facility after hospitalization on [DATE], with quarantine identified as ending 12/10/20. On 12/2/20, at 2:22 p.m. the door to R4's room was observed open with R4 sitting inside the room. There was no signage on the door to indicate R4 was on TBP. In addition, there was no PPE set up in place outside of the resident's room. R5 was admitted to the facility on [DATE], with quarantine identified as ending on 12/8/20. On 12/2/20, at 2:23 p.m., the door to R5's room was observed open with R5 sitting inside the room. There was no signage on the door to indicate R5 was on TBP. In addition, there was no PPE set up in place outside of the resident's room. R1 was readmitted to the facility after hospitalization on [DATE]. On 12/2/20, at 2:23 p.m. the door to room was observed shut with PPE supplies in a cardboard container hanging outside the door. The door also had signage related to use of PPE when entering R1's room. R1's care plan revised 9/14/20, indicated the resident was on contact precautions r/t (related to) VRE ([MEDICATION NAME]-resistant [MEDICATION NAME]- a type of bacteria called [MEDICATION NAME] that have developed resistance to many antibiotics, especially [MEDICATION NAME]) in the urine. R6 was admitted to the facility on [DATE], with quarantine identified as ending 12/5/20. On 12/2/20, at 2:23 p.m. the door to R6's room was observed open with R6 sitting inside the room. There was no signage on the door to indicate R6 was on TBP. In addition, there was no PPE set up in place outside of the resident's room. R7 was admitted to the facility on [DATE], to room [ROOM NUMBER]. R7's quarantine was to end on 12/8/20. On 12/2/20, at 2:23 p.m. the door to R7's room was observed shut with no signage on the door to indicate R7 was on TBP; also, no PPE was observed outside of the resident's room. R8 was readmitted to the facility following hospitalization on [DATE], following hospitalization , to room [ROOM NUMBER]. R8's quarantine was to end on 12/12/20. On 12/2/20, at 2:24 p.m. the door to R8's room was observed open with R8 sitting inside the room. There was no signage on the door to indicate R8 was on TBP. In addition, there was no PPE set up observed outside of the resident's room. R9 was admitted to the facility on [DATE] with quarantine scheduled to end on 12/10/20. On 12/2/20, at 2:24 p.m. the door to R9's room was observed open with R9 sitting inside the room. There was no signage on the door to indicate R9 was on TBP. In addition, there was no PPE set up observed outside of the resident's room. R10 was admitted to the facility on [DATE]. On 12/2/20, at 2:25 p.m. the door to R10's was observed shut with PPE supplies in a cardboard container hanging from the outside of the door. The door also had signage related to use of PPE when entering R1's room. Review of R10's medical record revealed R10 was tested for COVID-19 on 11/30/20, and received a positive result on 12/1/20. R10's progress note dated 12/1/20 at 17:06 (5:06 p.m.) included the following: Resident was updated has tested positive for COVID-19 and will be in quarantine and on precautions. R11 was admitted to the facility on [DATE], with quarantine scheduled to end on 12/15/20. On 12/2/20, at 2:26 p.m. the door to R11's room was observed open with R11 sitting inside the room. There was no signage on the door to indicate R11 was on TBP. In addition, there was no PPE set up observed outside of the resident's room. R12 was readmitted to the facility on [DATE], following hospitalization . R11's quarantine was to end on 12/8/20. On 12/2/20, at 2:26 p.m. the door to R12's room was observed shut with PPE supplies in a cardboard container hanging from the outside of the door. The door also had signage related to use of PPE when entering R12's room. Review of R12's progress note dated 11/24/20, at 12:31 p.m. indicated R12 had visited family after discharge from the hospital prior to return to the facility and the family member had tested positive for COVID-19 within the last 1-2 weeks. The note further indicated R12 would be placed on precautions. When interviewed on 12/2/20, at 2:33 p.m. nursing assistant (NA)-A stated new admissions or residents that returned to the facility following hospitalization were identified on a worksheet at the nurses' station, and and also by a sign on their room doors. When asked what the signage would look like, NA-A pointed to R12's room which had PPE hanging over the door and signs with instructions for PPE use prior to entering the room. NA-A stated she was new to her position but thought that all new admissions and readmits from the hospital would have PPE and the signs on their doors, but wasn't sure. When interviewed on 12/2/20, at 2:39 p.m. registered nurse (RN)-A confirmed new admits or residents that were returning from the hospital, were quarantined to their room for 14 days. RN-A stated those residents were identified on a worksheet at the nurses' station and were also identified on a report in the computer which included the date the resident could come off of quarantine. RN-A stated residents on quarantine did not have signage on their door unless they were on TBP that included gowning and gloving with direct care. RN-A further confirmed room doors should be closed for residents on quarantine and NA's should be aware of that. RN-A stated only 3 of the 12 residents on quarantine that were on transmission-based precautions due to known such as R12 who had a known COVID exposure, R10 who had a COVID positive test, and R1 who had another infections requiring TBP due to an infection in the urine. On 12/2/20, at 3:40 p.m. NA-A was observed entering R6's room. NA-A did not don a gown or gloves prior to entering the room. Upon exiting R6's room at 3:50 p.m., the surveyor asked NA-A if R6 was quarantined with TBP. NA-A stated she didn't think so, because there wasn't a sign on the outside of the door to his room. When asked where the information was kept that identified residents on quarantine, NA-A went to the nurses' desk but was unable to locate the worksheet of quarantined residents. NA-A then asked NA-B where to find the information. NA-B showed NA-A where to locate the documented worksheet of quarantined residents which was located in a binder at the nurses' desk. The worksheet confirmed R6 was quarantined. NA-B acknowledged being aware of which residents were quarantined, and confirmed only the residents with PPE set ups on the door outside their room were on TBP. NA-B further confirmed when doing direct cares with quarantined residents without the PPE set ups, staff did not don gowns prior to care such as bathing and toileting. When interviewed on 12/2/20, at 4:35 p.m. NA-C confirmed residents who were new admissions or were readmitted from the hospital were quarantined to their room for 14 days. NA-C stated staff were informed during report if there was a new admission or readmission from the hospital. NA-C could not state off the top of her head which residents were still on quarantine other than stating, The ones with PPE outside of their room. NA-C confirmed R10 was recently put on TBP after testing positive for COVID-19. NA-C was not aware of which residents remained on quarantine other than the 3 with PPE outside of their room, and did not know where to locate the information identifying who was on quarantine. NA-C stated, other than the residents with PPE set ups, staff did not don gowns when providing direct cares such as bathing and toileting. NA-C was unable to state where staff could obtain extra PPE but thought it may be available downstairs or in the nurses' office. When interviewed on 12/2/20, at 4:45 p.m. the director of nursing (DON) confirmed staff had not been directed to implement TBP for all new admissions and readmissions from the hospital as they were trying to conserve their gowns in case of an outbreak of COVID-19. The DON further confirmed there was no signage on the resident's doors to identify new admissions or readmissions from the hospital, and stated moving forward they would be adding that information to the the NA's care sheets. The facility's policy Coronavirus (COVID-19) revised 11/24/20, included: Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Options include placement in a single room or in a separate observation area so the resident can be monitored for evidence of COVID-19. Resident can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. All recommended COVID-19 PPE should be worn during care of residents under observation which includes: use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown (if facility supplies allow). At a minimum, facemask and eye protection should be utilized. The immediate jeopardy that began on 12/2/20, was removed on 12/3/20 at 9:35 a.m., when it could be verified the facility had developed and implemented interventions to ensure newly admitted , and hospital readmissions, were appropriately quarantine with TBP implemented. In addition, the facility had placed PPE set ups outside of the quarantine residents rooms along with a Welcome sign to indicate resident on quarantine. The facility also initiated training to ensure all staff were knowledgeable regarding quarantine, and use of TBP, prior to starting their next shifts.

Based on observation, interview and document review, the facility failed to implement interventions to promote comfort and reduce pain for 1 of 3 residents (R2) reviewed for pain management. This resulted in actual harm for R2 who experienced severe pain and hospitalization when staff failed to provide ordered pain control medication(s) and non pharmacological interventions on a consistent and timely basis. Findings include: A facility report dated 8/8/19, indicated R2's family member (FM)-A came to facility to meet with the administrator regarding some concerns her mother was experiencing while at the facility. The report indicated R2 was admitted to the hospital with [REDACTED]. The report indicated FM-A had come in to discuss concerns related to the facility nurses not taking R2's pain seriously and reported there were two instances where R2 had felt she was not being heard. The family reported the first instance concern was the resident was asked why she wanted to use the phone to call her family, and why she needed to call them. FM-A stated R2 had felt she wasn't allowed to use the phone. The second instance was when R2 asked to go to the emergency department for symptoms of pain and the nurse on the floor had told her, They would just send you back to the facility anyway. FM-A stated R2 was nervous to return to the facility because she was afraid no one would take her pain seriously. R2's face sheet dated 8/22/19, indicated R2 was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. Additional [DIAGNOSES REDACTED]. R2's admission Minimum Data Set (MDS) assessment dated [DATE], indicated she had intact cognition. A 14 day MDS dated [DATE], indicated R2 had frequent pain that interfered with sleep and limited daily activities. That MDS indicated R2 rated pain at 9/10. R2's 30 day MDS dated [DATE], indicated she suffered frequent pain rated at 7/10, that limited daily activities and interfered with sleep. The MDS indicated she required only supervision with activities of daily living (ADL's). An MDS dated [DATE], a 5 day assessment, indicated R2 required extensive assist of one with bed mobility and ADL's and limited assist with locomotion. Review of R2's care plan dated 8/12/19, identified R2 was cognitively intact. She required assistance for moving in bed and in and out of bed, and all transfers, and activities of daily living, related to her compression fracture. Further the care plan identified a fall risk because of her compression fracture, and she required physical therapy. R2's discharge goal was identified for her to return to home. The care plan did not include management of her pain. R2's Order Summary Report dated 8/22/19, and MAR's dated July and August 2019, identified the following PRN pain medications: [REDACTED] 7/8/19 to 7/18/18, Tylenol 650 mg every 12 hours as needed for pain rated 8-10/10. 7/18 to 8/8/19, Tylenol 500 mg every four hours as needed for pain rated 3-5/10. Utilized only three of 28 potential doses. 7/11/19 to 8/8/19, [MEDICATION NAME] 5 mg every four hours as needed. Utilized only one time per day for 15 of 20 days and two times one of 20 days. 8/8/19, Icy hot extra strength cream 10-30% apply to affected area topically every 8 hours as needed for pain, not used until 8/14/19, and used only 9/14 times, even though R2 rated her pain as high as 10, it was only used 1 x per day. 8/12/19, [MEDICATION NAME] 2.5 mg was started every 4 hours as need for pain rated 7-10, from 7/13 to 7/22 it was given 4 times per day. The record lacked evidence the resident's pain was assessed every 4 hours. R2's treatment sheet for July 8-31, 2019, included an order for [REDACTED].>1. Ice - provided 0 out of 72 shifts 2. Heated blankets - provided 10 times out of 72 shifts 3. Massage- provided 1 out of 72 shifts 4. Repositioning - provided 60 out of 72 shifts 5. Music -was not attempted 6. Essential oils- was not attempted 7. Food/drink - provided 6 out of 72 shifts 8. Relaxation breathing -was not attempted Review of R2' facility Progress Notes and correlating Medication Administration Record [REDACTED] 8/3/19, Progress Note indicated R2 rated pain 7/10, scheduled and PRN (as needed) medications were given. Uses a warm blanket for comfort. R2's MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED]. 8/4/19, Progress Note indicated R2 indicated she did not want to use the bathroom and stated, I am having a lot of pain. I do not want to move, I am comfortable when I am not moving. Nursing staff suggested R2 use the bathroom and help move the joints and stretch her muscles. R2 was incontinent and used the call light multiple times to request staff assistance to repositioned and change incontinent brief and R2 declined therapy. R2's MAR indicated [REDACTED]. 8/5/19, Interdisciplinary team (IDT) met with R2 and family members (FM)-A. R2 stated she was having a lot of pain and stated, I would just like to die. R2 stated she felt down related to all of the pain she was having. During the meeting R2 expressed increased pain in her lower back, stomach and sides. R2 described the pain as constant and aching and indicated the pain caused a simple task such as blowing her nose to be painful. The physician was contacted and suggested R2 be sent to the emergency department for acute symptoms. The hospital discharge summary dated 8/5/19 to 8/8/19, indicated R2 was admitted with complaints of severe lower back pain that had been worsening over the last few days, and she was experiencing increased urination. R2 felt her pain was out of control and was found to have a new T11 and T12 compression fracture. R2 was treated with intravenous antibiotics for acute bacterial [MEDICATION NAME]. During a computed tomography (CT or CAT scan allows doctors to see inside your body) of the abdomen and pelvis she was found to have pancreatic cystic [MEDICAL CONDITION], and [DIAGNOSES REDACTED]. R2 was given, scheduled Tylenol 1000 mg three times per day, heat/ice therapy, [MEDICATION NAME] 5% applied at 8 a.m., and removed at 8 p.m., every day, and physical therapy and occupational therapy. Antibiotic medication was started, and referred to outpatient in Rochester for her cystic pancreatic lesion. R2's back brace was to be evaluated because R2 felt it came up too far on her neck. During a interview with the administrator and the director of nursing (DON) on 8/21/19, at 8:54 a.m., they stated R2's family member, FM-A, had brought concerns to their attention 8/8/19, before R2 returned to the facility: 1. R2 was not allowed to use the telephone to call her daughter. R2 had told her daughter registered nurse (RN)-A questioned her, who are you going to call, what are you going to tell them. R2 felt that her right to talk to her daughter was not allowed. 2. R2 was afraid to return to the facility and concerned the nurse was not going to take her pain seriously. R2 told her daughter that when she requested to go to the hospital the nurse responded they are just going to send you back anyway. The administrator and DON stated they had initiated an investigation into the concerns. During the investigation, RN-A told the administrator when she'd called the daughter the daughter had declined hospitalization for R2 however, the DON confirmed the medical record lacked documentation to corroborate that. The administrator and DON indicated they had offered to go to the hospital to speak with R2 to offer her care from another nurse, and that had ultimately satisfied R2. They further indicated they had changed RN-A's assignment and had met with staff regarding pain management and resident rights to hospitalization when requested. They confirmed further training would be provided to nurses related to active listening, empathy, and trusting residents' complaints of pain. During the interview, the DON stated it was her expectation staff would comprehensively assess R2's pain to determine a pain management plan to help decrease the pain, utilizing the multiple physician orders [REDACTED]. Furthermore, the DON expected timely and consistent action upon R2's complaints of pain with movement that affected her comfort and progress in therapy if not controlled. During interview on 8/21/19, at 11:00 a.m., R2 was observed laying on her left side with a pillow propped at her back. R2 had just completed therapy and described her pain as a 7/10. R2 stated said she always had pain and an acceptable to her was a 3 or 4/10. R2 indicated that she was frustrated with the lack of understanding of the nurses and said, When I've had all the medications I can have, the only thing to do is to lay still to not make the pain worse. R2 stated she had a fracture in her vertebrae. During the conversation, R2's eyebrows were furrowed with a grimaced look. R2 was unaware and unsure of the last time she'd received pain medications and indicated a warm heated blanket helped her to relax when the pain was bad. The facility provided an undated policy Pain Management Protocol, for review: Purpose, To ensure that resident's with pain or at risk for pain, hade an effective pain management plan in place with individualized interventions that are consistent with the resident's goals for comfort. Pain Management is defined as the process of alleviating the resident's pain to a level that is acceptable tot he resident and is based on his or her clinical condition and established treatment goals. Treatment and Management: 1. With input from the resident and/or resident representative, the provider and staff will establish goals of pain treatment: for example, freedom from pain with minimal medication side effects, and improved functioning, mood, and sleep. 2. Nursing will evaluate for appropriate non pharmacological interventions to address the individuals pain.

Based on observation, interview and document review, the facility failed to assess, monitor and implement pressure relieving interventions for 1 of 3 residents (R14) reviewed who were at risk for pressure ulcer development/deterioration. The facility's failure resulted in R14 sustaining harm when the resident developed an unstageable ulcer (slough and/or eschar known but not stageable due to coverage of wound bed by slough and/or eschar) to the coccyx. Findings include: R14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of R14's admission Minimum Data Set (MDS) assessment dated [DATE], identified R14 as having a baseline interview for mental status (BIMS) score of 11 (indicates moderate impaired cognition).The MDS further indicated R14 required extensive assistance with mobility needs which included positioning; R14 was at risk for pressure ulcers and had a stage 1 pressure ulcer (intact skin with non-blanchable redness of a localized area usually over a boney prominence) that was not present on admission, and a stage 2 pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer) that was present on admission. Interventions included: pressure reducing device on bed and wheelchair, repositioning program, and ulcer care treatment. Review of a 30 day MDS assessment dated [DATE], identified R14 as requiring extensive assist with mobility that include positioning. R14 was at risk for pressure ulcers, and had a stage 2 pressure ulcer that was present on admission. Interventions included: pressure reducing device on bed and wheelchair, repositioning program and ulcer care treatment. Review of an unspecified MDS dated [DATE], indicated R14 had 2 stage 2 pressure ulcers, 1 which was present on admission. Interventions inlcude: pressure reducing device on bed and wheelchair, repositioning program, and ulcer care treatment. Review of the admission data collection form dated 12/27/19, indicated R14 had a stage 2 pressure ulcer on the coccyx and a stage 1 pressure ulcer on the left heel. There were no description/measurements of the pressure ulcers. Review of a Tissue evaluation dated 1/3/19, indicated R14 had a stage 2 pressure ulcer on the coccyx and a stage 1 pressure ulcer on the left heel. Interventions included: skin prep to left heel, [MEDICATION NAME] (self-adherent, soft silicone foam dressing) to coccyx every 3 days, pressure reducing mattress on bed, gel cushion in wheelchair and turning and repositioning schedule. Monitor skin daily with cares and weekly by licensed staff. There was no description/measurement of the pressure ulcers. Review of R14's Braden Scale for Predicting Pressure Sore Risk dated 1/3/19, identified R14 as mild risk for developing pressure ulcers. The Braden indicated R14 required extensive assistance with bed mobility and positioning. Interventions were identified as including: pressure reducing mattress on bed, pressure reducing cushion on wheelchair, monitor skin daily with cares, and weekly by a licensed nurse. The Braden Scale did not include R14's current pressure ulcers identified on the tissue tolerance evaluation of the same date. Review of R14's initial comprehensive plan of care dated 12/27/18, indicated R14 required extensive assistance with activities of daily living (ADL's) that included mobility. The care plan also indicated R14 had a pressure ulcer (no description related to the stage/size or the location of the pressure ulcer). Interventions included: air mattress on bed, pressure redistribution cushion to wheelchair, turn and reposition every 2 hours and as needed (PRN), weekly/skin body audits and routine skin cares. The care plan did not include heel lift boots on admission, which were implemented on 3/6/19. Review of the nursing assistant (NA) plan of care, indicated R14 required assistance of staff with all ADL's. Reposition every 2 hours and monitor air mattress on bed. Review of a weekly skin inspection dated 1/1/19, identified R14 with 3 open areas on the coccyx with a scant amount of purulent drainage on the dressing. The assessment included no description/measurements of the open areas identified on the coccyx. Review of the weekly pressure wound evaluation dated 1/11/19, identified R14 with a stage 2 pressure ulcer on the coccyx that measured 6.25 centimeters (cm) in length by 3.5 cm width and no depth. The wound bed was described as reddened with a slight yellowish tint in the center of the ulcer with a scant amount of yellow drainage. [MEDICATION NAME] treatment every 3 days per standing order (SO). Review of a weekly skin inspection dated 1/23/19, identified R14 with a pressure ulcer on the coccyx . [MEDICATION NAME] treatment was applied. No description/measurement of the pressure ulcer was noted. Review of a weekly skin inspection dated 1/29/19, identified R14 with a pressure ulcer on the coccyx. The skin around the ulcer was red. [MEDICATION NAME] dressing applied. No description/measurement of the pressure ulcer was noted. Review of a weekly pressure wound evaluation dated 2/4/19, identified R14 with a stage 2 pressure ulcer on the coccyx that measured 0.5 cm in length by 0.5 cm in width by 0.1 cm in depth. The wound bed was red with no drainage. [MEDICATION NAME] treatment to coccyx twice daily (BID) per SO (standing orders). Although the pressure ulcer improved in the length and width from 1/11/19, it had worsened in depth to 0.1 cm. Although the weekly pressure wound evaluation included the description/measurements of the pressure ulcer on the coccyx on 1/11/19 and 2/4/19, there was no description or measurements of the pressure ulcer when it was identified on admission on 12/27/19 until 1/11/19, (2 weeks) nor was there weekly monitoring that identified the description/measurements of the pressure ulcer for signs of healing/worsening from 1/11/19 to 2/4/19 (3 weeks). Review of the physician progress notes [REDACTED]. The progress note indicated chronic [MEDICAL CONDITION] at the site of the coccyx. The physican progress note of 1/24/19, did not address the right heel ulcer. Review of the weekly wound evaluations from 2/12/19 to 3/10/19, R14's pressure ulcer on the coccyx measured 0.5 cm length by 0.5 cm width by 0.1 cm depth. The wound bed was red and moist. Review of the physician progress notes [REDACTED]. The note indicated R14 had a foam dressing over the coccyx ulcer, and that the pressure ulcer was larger and was unstageable. The physician indicated R14 had a donut cushion on the wheelchair that was uncomfortable for the resident to sit on. The physician further indicated a donut cushion was not recommended for sacral pressure ulcers. New physician orders [REDACTED]. Review of the weekly wound evaluations from 3/19/19 to 3/31/19, indicated R14's pressure ulcer on the coccyx measured 2.0 cm in length by 0.5 cm in width and 0.1 cm in depth. The length of the pressure ulcer had worsened from 3/10/19. The description of the pressure ulcer on 3/31/19, indicated the wound bed was moist and black. The edges of the ulcer were white and rolled with no drainage. [MEDICATION NAME] treatment applied. The physician was not been notified of the newly blackened necrotic area and the treatment remained unchanged. Observation and interview on 4/3/19, at 9:17 a.m. R14 was observed to be sitting up in his wheelchair. R14 stated that he had a sore on his bottom, that had caused him pain since admission. R14 stated the sore hurt when he sat a certain way and repositioning would relieve the discomfort. R14 further indicated he was unable to reposition himself and needed assistance from staff. Observation and interview on 4/3/19, at 9:37 a.m. R14's pressure ulcer on the coccyx was observed as well as the right heel with licensed practical nurse (LPN)-C. R14 was observed to have a pressure ulcer on the mid coccyx area that was covered with a [MEDICATION NAME] dressing. The pressure ulcer was very odorous prior to the removal of the dressing. The dressing had a small amount of brownish colored drainage on it. The center of the ulcer had a blackened necrotic area with large maceration of the skin around the edges that was very reddened. A whitish blistered area on the upper portion of the ulcer was noted. The pressure ulcer on the coccyx measured 3.0 cm in length by 1.5 cm in width and 1.0 cm in depth. Observation of R14's right heel noted to have an area that measured 2 inches in diameter that was non-blanchable. R14 was observed to have socks on both feet. No heel lift boots had been applied while R14 was in bed. LPN-C stated she was currently unsure of R14's treatments for the pressure ulcers because she was just helping out with positioning needs. Review of the physician progress notes [REDACTED]. The pressure ulcer measured 3.0 cm in length by 1.5 cm in width and 1.0 cm in depth. The ulcer was observed to have necrotic tissue and a debridement was performed of the dermis and epidermis. The wound size after the debridement was 4.5 square cm. The pressure ulcer was identified as unstageable. Interview with NA-A and NA-E on 4/3/19, at 9:44 a.m. both indicated R14 had a pressure ulcer on the coccyx/left heel and required assistance with repositioning every 2 hours. NA-A and NA-E further indicated R14 complained of a sore bottom frequently. Continuous observation on 4/3/19, from 9:37 a.m. to 12:40 p.m. R14 was observed to be positioned on his left side in bed at 9:37 a.m. without repositioning/off loading until 12:40 p.m. The resident did not have heel lift boots on while in bed. Interview with NA-F and NA-B on 4/3/19, at 12:34 p.m. stated they would not be positioning R14 until getting him up for dinner, because he was still sleeping. NA-F and NA-B both indicated they let him sleep until resident wakes up. Interview with LPN-D on 4/3/19, at 12:36 p.m. verified R14 had not been repositioned for 3 hours after the surveyor brought it to her attention. LPN-D at this time directed the staff to reposition the resident. LPN-D further confirmed R14's plan of care include repositioning every 2 hours as well as wearing heel lift boots in bed. Interview on 4/4/19, at 9:00 a.m. with registered nurse (RN)-D (facility wound nurse) indicated she had not been aware of R14's pressure ulcer on the coccyx until 2/4/19. RN-D confirmed R14's pressure ulcer had not been assessed appropriately to monitor the healing/worsening of the pressure ulcer on admission or from 1/11/19 to 2/4/19 (3 weeks). RN-D verified on 3/31/19, she noted R14's pressure ulcer on the coccyx to be odorous with blackened necrotic tissue observed in the center of the ulcer. RN-D also confirmed she failed to notify the physician of the worsening of the pressure ulcer and the treatment remained unchanged until 4/3/19. RN-D further indicated she was unsure if she was accurately measuring the depth of the pressure ulcer, because it appeared larger than the measurements she obtained each week. Interview with the director of nursing (DON) on 4/4/19, at 9:30 p.m. confirmed the above findings that included the failure of assessing R14's pressure ulcers on admission and weekly thereafter. The DON also confirmed R14's plan of care had not been followed to included repositioning every 2 hours, weekly skin assessments and heel lift boots when in bed. The DON indicated when the pressure ulcer worsened and necrotic tissue was identified, she would expect the staff to notify the physician for further treatment when it was identified. The facility's 7/18 policy, Skin Assessment and Wound Management, included: initiate a weekly pressure wound evaluation when a pressure ulcer is identified, notify the wound nurse and update provider.