Every finding on record at Ocean Grove Post Acute

Based on record review and interview it was determined that for one (R182) out of sixteen residents reviewed for abuse the facility failed to ensure the resident was free from involuntary seclusion. Findings include: Review of R182's clinical record revealed:10/2/24 - R182 was admitted to the facility with multiple diagnoses including anxiety and depression. 10/7/24 - An admission MDS assessment documented R182 as cognitively intact with a BIMS score of 15. There were no behaviors and no diagnosis of dementia documented.3/24/26 - R182 was transferred from a long-term care unit to the facilities locked dementia unit. 3/24/26 11:36 AM - A social services progress note in R182's clinical record documented, SW spoke with [R182's] daughter via telephone. SW informed daughter that [resident] will be changing rooms to room (xxx). Daughter verbalized understanding and is agreeable to room change. SW spoke with [R182] regarding room change. Resident verbalized understanding and is agreeable to room change. 3/25/26 12:24 PM - A progress note in R182's clinical record documented Resident evaluated by psyche; Resident continues to refuse any intervention for increased anxiety. Nursing will continue to monitor mood, behavior, and sleep in new environment. Resident transferred to another unit.3/25/26 untimed - A psychiatric evaluation and consultation written by E34 (PMHNP) in R182's clinical record documented, Seen for routine psychiatric follow-up. She expresses distress regarding her move to dementia unit. Per staff, resident has a history of difficulty getting along with roommates and is being transitioned to the dementia unit for better support and management. Adjustment difficulty related to environmental changes (unit transfer).3/30/36 1:49 pm - A psychological progress note in R182's clinical record written by E35 (LCSW) documented, [R182] observed in new room on the dementia unit and reported that she is still adjusting to the new environment. She expressed discomfort with her current situation.4/5/26 untimed - A psychiatric evaluation and consultation written by E34 (PMHNP) in R182's clinical record documented, Resident reports difficulty coping with recent transfer to the dementia unit, stating 'I don't' belong over here' .Per staff she is tearful, frequently isolating, and exhibits emotional outburst. She demonstrates anxiety symptoms and distress related to the unit transition. Resident is alert and oriented .though process is logical. No evidence of psychosis. Adjustment reaction with anxiety and mood lability related to unit transfer.4/6/26 9:21 AM - A psychological progress note in R182's clinical record written by E35 (LCSW) documented, [R182] alert and oriented throughout the session .verbalized significant dissatisfaction with her placement on the dementia unit stating that she does not feel she belongs there and believes she still has all her mental faculties. 4/6/26 10:26 AM - A progress note in R182's clinical record written by E4 (RN) documented Resident evaluated by psych NP. Resident is Alert and oriented to [person, place, time, situation] with anxiety, tearfulness, and mood lability related to recent transfer to the dementia unit, exhibiting perseveration, social isolation, and intermittent emotional outbursts without psychosis . 4/7/26 - A quarterly MDS assessment documented that R182 exhibited verbal behaviors one to three days during the assessment period. The assessment did not document dementia as a diagnosis, physical behaviors or elopement risk.7/30/26 2:00 PM - Findings reviewed with E1 (NHA) and E2 (DON) during the exit conference.

Based on record review and interview, it was determined that for four (R1, R32, R184 and R188) out of twenty-six residents reviewed for abuse and neglect, the facility failed to identify and report the allegations of abuse, neglect or suspicion of a crime to the State Agency within appropriate timeframe. Findings include: The facility policy on abuse last updated May 2026, indicated, The facility will have written procedures that include: 1. Reporting of all violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g. law enforcement when applicable) within specified time frames. 1. Review of R184's clinical record revealed: 1/26/26 - R184 was admitted to the facility with multiple diagnoses including dementia and cognitive communication deficit. R184 was admitted with Medicare Advantage insurance coverage and an admission agreement that was signed by RP1, R184's POA since of June 2010. 2/1/26 - An admission MDS assessment documented that R184 has severe cognitive impairment and upper extremity impairments of range of motion on both sides. 2/26/26 - A disenrollment form was completed and dated by E18 (BOM) and signed by R184. 3/16/26 1:10 PM - A social services note in R184's clinical record documented, Family expressed concerns regarding insurance being converted and are upset about the change. 7/27/26 1:24 PM - During an interview, RP 1 confirmed that R184's insurance coverage was disenrolled to change to another insurance provider without permission. 7/28/26 9:57 AM - During an interview, E18 (BOM) stated, [R184] was able to sign. A lot of times residents won't do the date, so I plug that in for them. When asked if R184's responsible party was consulted prior to the disenrollment E18 confirmed that [RP1] was not consulted prior to the disenrollment to change R184's insurance provider. E18 (BOM) confirmed documenting the date next to the signature on R184's insurance disenrollment form and that now a resident's mental status is reviewed prior to obtaining signatures. 7/28/26 10:07 AM - During an interview, E1 (NHA) confirmed that the facility was aware that RP1 did not sign consents to change insurance providers for R184 and that E18 (BOM) assisted with R184, a cognitively impaired resident with signing the insurance disenrollment form. E1 did not recognize this as suspicion of the crime of forgery and subsequently did not report the incident to the State Agency. 7/30/26 2:00 PM - Findings reviewed with E1 (NHA) and E2 (DON) during the exit conference. 2. Review of R32's clinical record revealed: 9/5/24 - A physician's order was written for R32 to have their blood sugar checked at 2:00 AM for diabetes. 3/16/26 - R32's MAR documented that at 2:00 AM a blood sugar level was obtained with a result of 225. 2. Review of R188's clinical record revealed: 2/25/26 - A physician's order was written for R188 to have their blood sugar checked at 6:00 AM for diabetes. 3/16/26 - R188's MAR documented that at 6:00 AM a blood sugar level was obtained with a result of 235. 7/27/26 10:36 AM - The surveyor requested a copy of any investigations involving allegations that included R32 and R188 from E2 (DON). 7/27/26 11:00 AM - A statement written by E2 (DON) on 3/20/26 documented Two LPN's came to the DON office expressing concerns about blood sugars for residents .They believed the results were inaccurate and possibly made up. 7/27/26 11:43 AM - During an interview E2 (DON) stated, On March 16th two nurses came and said we don't' believe [E46 (LPN)] is doing the blood sugars correctly on [R32] and [R188]. There were a lot of suspicions, but I believe it was the nurse wanted the full-time position given to [E46]. E2 confirmed that the facility did not recognize the allegation as neglect and as a result did not report the allegation to the State Agency. 3. Review of R1's clinical record revealed: 5/2/25 - R1 was admitted to the facility. 3/4/26 6:45 PM - An incident alleging that a staff member pushed R1 when attempting to get up from the floor post fall. 3/5/26 11:27 AM - A facility reported incident was submitted to the State Agency. 7/28/26 12:01 PM - During an interview, E2 (DON) stated the staff member failed to recognize the incident as an allegation of abuse. E2 confirmed that the report was not submitted to the agency within the appropriate timeframe. E1 (NHA) and E2 stated facility wide education was completed regarding recognizing abuse and reporting requirements. 7/29/26 2:00 PM - Findings reviewed with E1 (NHA) and E2 (DON) during the exit conference.

Based on observation, interview and record review it was determined that the facility failed to ensure protection of resident rights to promote dignity and respect when residents were not notified of mealtimes. Additionally, for one (R155) out of seventy-four residents sampled the facility failed to promote care in a manner that maintained or enhanced dignity and respect. Findings include: 1. 7/20/26 – During entrance conference, the facility provided a copy of its meal schedule indicating lunch on Unit One was scheduled from 12:00 PM to 12:08 PM and in the Main Dining Room at 12:00 PM. 7/20/26 10:19 AM - During an interview, R161, a resident on unit one reported the meals are never on time. 7/20/26 12:17 PM - During an interview, R80, a resident on unit one reported lunch is never on time. 7/20/26 1:00 PM - During an interview, R158, a resident on unit one, reported meals served at inconsistent times. Observed lunch cart deliver times on unit one: 7/20/26 1:06 PM - 1:16 PM 7/21/26 12:53 PM - 1:04 PM 7/22/26 12:57 PM - 1:00 PM 7/24/26 12:09 PM - Observations on unit one, unit two, unit three and unit four and the facility main dining room lacked evidence of posted mealtimes notifying residents of current mealtimes. 7/24/26 12:30 PM - During an interview, R168 (acting RCP) stated that a change of mealtimes was communicated at the Food Committee Meeting but not posted. 7/24/26 1:58 PM - During an interview E13 (Dietary Director) provided a second copy of the facility mealtimes. Review of the mealtimes indicated that lunch would be served on unit one at 12:45 PM - 12:50 PM with the Main Dining room continued to open at noon. E13 stated the meal schedule had been changed in 2026 and that R168 (acting RCP) was informed. E1 (NHA), who was present during the interview, confirmed the revised meal schedule had not been posted for residents. 2. Review of R155's clinical record revealed: 11/15/23 - R155 was admitted to the facility. 5/7/26 - A quarterly MDS assessment documented that R155 had a BIMs of 12 indicating moderate cognitive impairment. The MDS also documented that R155 required supervision or touching supervision for ADL's and lower body dressing. 7/20/26 6:35 AM - A direct observation of E10 (CNA) providing ADL care to R155 in the corner of the room with the door open and curtain open. R155 was not clothed and E10 was washing, drying and assisting R155 into a clean brief. 7/20/26 6:43 AM - During an interview, E10 confirmed that R155 received ADL care with the door and curtain open. E10 stated that the door and curtain should have been closed to maintain dignity. 7/29/26 2:00 PM - Findings reviewed with E1 (NHA) and E2 (DON) during the exit conference.

Based on interview and record review it was determined that for one (R184) out of seventeen residents reviewed for abuse the facility failed to ensure that the rights of resident representative were exercised. Findings include: Review of R184's clinical record revealed:1/26/26 - R184 was admitted to the facility with diagnoses that included dementia and cognitive communication deficit. The admission agreement was signed by RP1, who had served as R184's durable power of attorney since June 2010.1/26/26 6:54 PM - A progress note in R184's clinical record documented, Code status confirmed with spouse [RP1], demonstrating the facility recognized RP1 as the resident's decision-maker.2/1/26 - An admission MDS assessment documented that R184 had severe cognitive impairment.2/26/26 - A disenrollment form changing the resident's insurance coverage was completed by E18 (BOM) and signed by R184 rather than RP1.3/16/26 1:10 PM - A social services note in R184's clinical record documented, Family expressed concerns regarding insurance being converted and are upset about the change.'7/27/26 1:24 PM - During an interview, RP 1 confirmed that R184's insurance coverage had been changed without RP1's knowledge or permission. RP1 stated. When asked did the facility discuss the change prior to completing the disenrollment RP1 stated, No. They didn't say anything about it beforehand. I found out when I got a letter in the mail. Me and my daughter had told them after we found out to change it back!7/28/26 9:57 AM - During an interview E18 (BOM) confirmed that a disenrollment form was completed to change R184's insurance coverage without involvement of R184's responsible party, RP1. 7/30/26 2:00 PM - Findings reviewed with E1 (NHA) and E2 (DON) during the exit conference.

Based on record review and interview it was determined that for one (R17) out of two residents reviewed for behavioral/emotional condition the facility failed to ensure adequate monitoring of antipsychotic medication use. Findings include: Review of R17's clinical record revealed: 12/22/23 - R17 was admitted to the facility with multiple diagnoses including anxiety, schizophrenia, and depression. 6/25/25 - An AIM's assessment documented R17 as a 0.0 score indicating no side effects from use of antipsychotic medications. 9/17/25 - An AIM's assessment documented R17 as a 4.0 score indicating the presence side effects from use of antipsychotic medications. 11/19/25 - A psychiatric evaluation and consultation was completed for R17. The evaluation lacked documentation of R17's increased AIM's score, the AIM's section was blank and recommended continued use of antipsychotic medication. 12/10/25 - An AIM's assessment documented R17 as a 3.0 score indicating the presence side effects from use of antipsychotic medications. 12/25/25 - An annual MDS assessment documented that R17 experienced hallucinations, and delusions and received antipsychotic medications. 1/9/26 - A psychiatric evaluation and consultation was completed for R17. The evaluation lacked documentation of R17's AIM's score, the AIM's section was blank and recommended continued use of antipsychotic medication. 4/27/26 - An AIM's assessment documented R17 as a 27.0 score indicating the presence side effects from use of antipsychotic medications. 6/22/26 - R17s care plan for use of antipsychotic medications was reviewed. Interventions in the care plan included monitor for side effects. Monitor /document/report and adverse reactions of psychotropic medications. 7/6/26 - An quarterly MDS assessment documented R17 experienced hallucinations, and delusions and was given antipsychotics and antidepressant 9/26/25 9:32 AM - A progress note in R17's clinical record written by E4 (RN) documented, Resident seen by psych NP for auditory hallucinations, paranoia, recently starting Clozapine, lethargic, isolation and confusion. Resident stated he is constipated and has rash. Requests 1 chocolate milk with meals. Tremors noted. Resident reports auditory hallucination but cannot determine if they are worsening or getting better. Denies visual hallucination. Scored poorly on AIMS. Major fall risks, resident on precautions already. The note lacked evidence that the psych NP or R17's primary care provider were made aware of the AIMS assessments. 7/28/26 1:03 PM - During an interview, E4 (RN) confirmed completing R17's AIMS assessment. E4 stated, I usually would notify [E2 (DON)] and [E34 (PMHNP)] but [R17] waxed and waned sometimes more symptoms than others. E4 could not confirm notification of the increased side effects documented from R17's AIMS assessments. 7/28/26 2:52 PM - During an interview E2 (DON) confirmed the facility did notify R17's provider of the increased side effects of antipsychotic mediation use. 7/30/26 8:57 AM - During an interview, E34 (PMHNP) confirmed that the facility did not relay that R17 was having an increase in side effects related to antipsychotic medication use. E34 stated, I believe that the person who completed it should have notified me. 7/30/26 2:00 PM - Findings reviewed with E1 (NHA) and E2 (DON) during the exit conference.

Based on record review and interview it was determined that for three (R158, R180 and R182) out of fifty-seven (57) residents reviewed the facility failed to ensure accuracy of the MDS assessment. Findings include: 1. Review of R158's clinical record revealed: 6/8/26 - A quarterly MDS assessment documented that R158's cognitive status was not assessed and contained no BIM's score. 6/17/26 - A social services assessment was completed for R158, and the resident was documented with a BIM's score of 15 indicating cognitively intact. 7/23/26 12:02 PM - During an interview, E19 (RNAC) confirmed that R158's quarterly MDS assessment was inaccurate as evidenced by an omitted BIMS score. E19 stated The social worker did not complete it on time. 2. Review of R180's clinical record revealed: 8/20/25 4:13 PM - A progress note in R180's clinical record documented, Staff report resident witnessed cursing at and threatening female resident . 8/24/25 - A quarterly MDS assessment was completed for R180 who was assessed as having no behaviors. 7/29/26 11:10 AM - During an interview E19 (RNAC) confirmed that R180's 8/24/25 quarterly MDS was incorrect and that threatening should have been coded on the behavior segment of the assessment. 3. Review of R182's clinical record revealed: 4/7/26 - A quarterly MDS assessment section documented the resident had a BIMS score of 00. 4/8/26 - A social work assessment documented, Resident refused to answer assessment questions for BIMS. 7/29/26 11:10 AM - During an interview E19 (RNAC} confirmed that R184's 4/7/26 quarterly MDS assessment was incorrect and that a score of 99 should have been documented for refusal. 7/30/26 2:00 PM - Findings reviewed with E1 (NHA) and E2 (DON) during the exit conference.

Based on observations, interviews, record review and review of other facility records, it was determined that for two (R137 and R128) out of fifty-seven (57) residents reviewed for care plans, the facility failed to revise care plans for identified changes in care. Findings include:Cross Refer F677 1. R137's clinical record revealed: 7/12/25 – E137 was admitted to the facility. 7/16/26 – A review of an annual MDS assessment revealed R137 was dependent for personal hygiene. 7/21/26, 7/22/26 and 7/23/26 – Observations revealed R137 had visible facial hair growth to the upper lip, chin, cheeks and sideburns. 7/21/26 2:10 PM – R137's care plans were reviewed. The care plans lacked evidence that R137 refuses personal grooming services for facial hair. 7/23/26 9:05 AM – During an interview E11 (CNA) reported [R137] refuses personal grooming services for facial hair. 7/23/26 9:15 AM – During an interview and observation of R137's care plan with E12 (RN), it was revealed that R137's care plan lacked evidence documenting the resident's refusal to be shaved. E12 confirmed this during the review of the care plan and stated, I don't know if [R137] is care planned to refuse to be shaved. E12 further stated, No I don't see it in the care plan, but we can add it to the care plan. 2. Review of R128's clinical record revealed: 5/23/23 - R128 was admitted to the facility. 4/23/26 - A quarterly MDS documented that R128 was not on a mechanically altered diet. 4/23/26 10:28 AM - A progress note by E16 (Dietitian) documented that R128 was experiencing difficulty chewing certain foods, which is common in advanced age. They agreed to switch R128 to a mechanical soft diet to help with this issue. R128 will continue to be monitored. 4/23/26 10:36 AM - A dietitian ordered R128 to have a no-added-salt diet, mechanically soft texture, and thin liquid consistency for meals. 5/12/26 - A revised care plan goal documented that R128 would tolerate the current diet and liquid consistency, with one intervention being to provide a diet as ordered of no added salt, low concentrated sweets, regular texture, and thin liquids. 7/20/26 8:10 AM - An observation of R128's breakfast tray revealed mechanically soft food, and the meal ticket documented the mechanically soft diet. 7/23/26 - A quarterly MDS documented that R128 was on a mechanically altered diet. 7/24/26 12:46 PM - An observation of R128's lunch tray revealed mechanically soft food, and the meal ticket documented the mechanically soft diet. 7/27/26 1:51 PM - During an interview, E16 stated that on 4/23/26 R128 was downgraded to a mechanically soft diet due to difficulty chewing food with a regular diet with teeth. E16 confirmed that the care plan was not updated from a regular diet to a mechanically soft diet and that this would be corrected immediately. 7/29/26 2:00 PM - Findings reviewed with E1 (NHA) and E2 (DON) during the exit conference.

Based on observation, interview, and record review, it was determined that for three residents (R13, R76, and R137) out of eight residents reviewed for ADL's, the facility failed to provide care and services reviewed for dependent residents. Findings include:1. Review of R13's clinical record revealed: 6/24/26 - R13 was admitted to the facility with dementia. 6/30/26 - An annual MDS documented that R13 was severely cognitively impaired and was dependent on staff for bathing and hygiene. 7/2026 - The CNA's task list documented that R13's shower days were Tuesday and Thursday. 7/20/26 9:15 AM - The resident was observed with visible facial hair growth and an untrimmed beard. 7/21/26 10:00 AM - The resident was observed with visible facial hair growth and an untrimmed beard. 7/22/26 10:15 AM - The resident was observed with visible facial hair growth and an untrimmed beard. 7/24/26 9:30 AM - The resident was observed with visible facial hair growth and an untrimmed beard. 7/24/26 9:30 AM - During an interview, E5 (RN) confirmed that the resident had not been shaved and stated that the resident required an electric razor for shaving. 7/24/26 9:30 AM – During an interview, E7 (CNA) stated that when providing a complete bath, she cleans the resident's nails, washes the resident's hair, and shaves male residents. 7/24/26 9:45 AM – During an interview, E6 (CNA) stated that when providing a shower or bath, she washes residents from head to toe. She further stated that she washes residents' hair and shaves male residents as needed. 7/24/26 10:30 AM - During an interview, E2 (DON) confirmed that the resident had not been shaved and stated that he would ensure the resident was shaved. 2. Review of R76's clinical record revealed: 6/16/26 - A quarterly MDS assessment documented that R76 required staff to set up and assistance with eating meals. 7/9/26 - R76 was admitted to hospice care. 7/15/26 - A nutrition care plan was reviewed for R76. Interventions in the care plan included to provide and serve diet as ordered. 7/15/26 - A significant change nutrition assessment recommended pleasure feeds of food as tolerated. 7/15/26 11:59 PM - A functional abilities and goals evaluation documented, Significant Correction. Self-Care: Eating: Resident is dependent on staff assistance. 7/20/26 8:01 AM - 8:08 AM - During a dining observation R76's tray remained in the holding cabinet while other residents were served breakfast. When the surveyor inquired if anyone would be assisting R76 with breakfast E42 (CNA) and E43 (CNA) both stated that R76 would not be served breakfast because he's on hospice, comfort measures. 7/20/26 8:15 AM - During an interview E44 (RN) R76's assigned nurse reviewed R76's physicians orders with the surveyor. R76 confirmed that R76's did not have an order for food to be held. 7/20/26 12:20 PM - During an interview R76 responded verbally to the surveyor when called by name. 7/20/26 1:06 -1:20 PM- During a dining observation R76's tray remained in the holding cabinet while other residents were served lunch. R76's meal ticket was torn in half. E42 (CNA) confirmed that a torn ticket meant not to serve that resident's meal. 7/20/26 1:28 PM - During an interview E44 (RN) confirmed that R76 was alert and able to take medication by mouth that day without difficulty. E33 (LPN) unit manager confirmed that staff should have offered R76 both meals. E33 then checked R76's tray for warmth and instructed staff to attempt to feed R76 and verbally educated staff that hospice residents must still be offered their meal and assistance attempted. Cross Refer F657 3. R137's clinical record revealed: 7/12/25 – R137 was admitted to the facility. 4/16/26 – A review of a quarterly MDS assessment revealed R137 required substantial to maximum assistance by staff with showers, bathing, and personal hygiene. 7/16/26 – A review of the annual MDS assessment revealed R137 was dependent on staff for personal hygiene. 7/21/26 2:05 PM – During a telephone interview, FM1 (Family) reported I left plenty of shaving cream and razors for [R137] to be shaved. They told me [R137] won't allow them to do it. But I know [R137] likes a clean-shaven face. 7/21/26 2:21 PM – R137 was observed with visible facial hair growth on the chin, lip, cheeks and sideburns. 7/22/26 9:25 AM – During a second - day observation, R137 was sitting up in the wheelchair at the nurse's station with visible facial hair growth on the chin, lip, cheeks and sideburns. 7/23/26 9:00 AM – During a third-day observation, R137 was in bed and dressed. R137 was rubbing his facial hair and stated, I would like to be shaved. R137 then stated, It's too long. 7/23/26 9:05 AM – During an interview E11 (CNA) reported [R137] refuses to allow us and tells us not to shave him. The surveyor asked E11 was the resident's refusal to be shaved reported to anyone. E11 further stated, I report it to E12 (RN) or E14 (UM). 7/23/26 9:15 AM – During an interview, E12 (RN) reported, [R137] usually refuses to be shaved. [E12] further stated, We can attempt to shave [R137] today. 7/23/26 9:50 AM – An observation revealed R137 was being shaved by E11. 7/30/26 2:00 PM - Findings reviewed with E1 (NHA) and E2 (DON) during the exit conference.

Based on record review and interview it was determined that for two (R3 and R182) out of eight residents reviewed for infection control the facility to follow physicians' orders related to antibiotics. Findings include:1. Review of R182's clinical record revealed: 5/4/26 3:00 PM - An after care summary from a walk-in care clinic documented that R182, You are being treated for cellulitis of the right foot due to injury. Oral antibiotic prescribed take as directed. The antibiotic was called in to a local pharmacy near the facility. 5/4/26 10:43 PM - A nurses note in R182's clinical record documented, Resident approached this writer and reported that she had gone to urgent care for her right foot, where she was told she had an infection. Resident stated she was prescribed an antibiotic and provided the medication bottle to this writer. Per MD instructions, the antibiotic is to be held, and resident will be evaluated in the morning. 5/5/26 - E45 (NP) documented in a progress note in R182's clinical record, Verbal order given to nurse to start antibiotic [for foot]. 5/7/26 3:21 PM - A progress note in R182's clinical record documented, Chief Complaint: Seen in follow-up for ongoing right foot pain. History of Presenting Illness: As above seen in follow-up. Patient was on LOA with family a couple of days ago when she went to urgent care, they diagnosed her with an infection in her foot and prescribed [antibiotic]. She returned here and the next day was seen by nurse practitioner who did not feel she had an infection. He gave verbal order to start antibiotic after he could not convince her she was not infected (in order to prevent ER visit). The order was not put in. 5/7/26 - A physician's order was written for R182 to receive an antibiotic three times a day for seven days for infection of foot wound. Three days after the original prescription for an antibiotic to treat infection of R182's wound to the foot was provided by the walk-in clinic on 5/4/26 and two days after the verbal order provided on 5/5/26. May 2026 - Review of R182's MAR documented the resident was given the ordered antibiotic starting 5/7/26. 7/28/26 1:24 PM - During an interview, RP2 stated, I had to take my mom to a walk-in clinic because her foot was infected and they were ignoring it. Even after that I went and got the prescription filled and bought the antibiotic to the facility and they still didn't give it to her. 7/29/26 12:46 PM - During an interview E14 (LPN) confirmed that R182 received a prescription from the walk-in medical center for an antibiotic for infection of her foot wound. E14 stated that R182, Complained of discomfort. Her daughter took her to the ER or walk-in clinic. They prescribed her an antibiotic. 7/30/26 10:47 AM - During an interview E30 (RNICP) confirmed that the physicians order for an antibiotic to treat R182 was not completed upon receiving the verbal order. E30 stated, I spoke with the nurse, who's on vacation and she said the physician didn't give her all the information for the verbal order so it wasn't put in. 2. Review of R3's clinical record revealed: 9/7/21 - R3 was admitted to the facility. 5/10/26 5:22 PM - A provider's progress note documented R3 was seen by telehealth services with E24 (LPN) present during exam. The progress note documented that R3 had a purulent filled pustule noted to right upper arm with swelling, redness and warm to touch. The provider documented the following orders: warm compresses three times a day, wound culture of right upper extremity, labs in AM and Augmentin 875/125 mg one tablet by mouth for 10 days after obtaining wound culture. 5/10/26 5:39 PM - An Omnicell (emergency medication system) transcript documented that E24 removed 1 tablet of Augmentin 875/125 mg from the machine. 5/10/26 9:13 PM - A physician's order documented Augmentin 875/125 mg give one tablet by mouth every 12 hours for 10 days. The order was scheduled for a one-time administration and was documented as administered at 10:36 PM. 5/10/26 11:00 PM - A physician's order documented to obtain a wound culture of the right upper extremity abscess. 5/11/26 7:51 PM - An Omnicell (emergency medication system) transcript documented that E25 (LPN) removed 1 tablet of Augmentin 875/125 mg from the machine. 5/11/26 9:00 PM - A physician's order documented Augmentin 875/125 mg give one tablet by mouth every 12 hours for 10 days. 7/24/26 10:48 AM - During an interview, E26 (CNO) confirmed that the antibiotic was to be started after culture was obtained and that it was ordered for twice a day for 10 days. 7/24/26 1:46 PM - During an interview, E27 (LPN) stated the expectation when a nurse receives a verbal order to input the order as soon as possible into the EMR. 7/29/26 12:24 PM - During an interview, E24 stated that she was unable to recall if she was present on 5/10/26 during the telehealth visit for E3 and could not recall if she received the verbal order for the antibiotic. E24 stated the expectation that the nurse who receives the verbal order would place it in the EMR. E24 also stated she is usually the person who calls the on-call provider due to being familiar how to operate the telehealth system. The facility failed to transcribe, input and follow a physician's order for R3. 7/29/26 2:00 PM - Findings reviewed with E1 (NHA) and E2 (DON) during the exit conference.

Based on interview and record review it was determined that for one (R180) out of seventy-four residents reviewed the facility failed to ensure resident records were complete and accurately documented. Findings include:Review of R180's clinical record revealed: 7/24/25 12:15 PM - A progress note in R180's clinical record documented, Resident verbally agitated yelling .staff report concerns related to residents' anger towards them and felt threatened by his tone. July 2025 - Review of R180's behavior monitoring sheet lacked evidence documentation of any behaviors. 8/8/25 9:20 AM - A progress note in R180's clinical record documented, Staff reporting they are concerned for their safety related to resident's behavior of verbally harassing staff and threatening comments. 8/20/25 4:13 PM - A progress note in R180's clinical record documented, Staff report resident witnessed cursing at and threatening female resident .resident began making false accusations against staff. 8/21/25 11:12 AM - A progress note in R180's clinical record documented, Resident with re-occurring behaviors of verbal aggression towards staff. August 2025 - Review of R180's behavior monitoring sheet lacked evidence documentation of any behaviors. 7/28/26 12:10 PM - During an interview E2 (DON) confirmed that R180's behavior monitoring was incomplete as evidenced by lack of documentation in the point of care task sheets to reflect R180s' episodes of behaviors. 7/30/26 2:00 PM - Findings reviewed with E1 (NHA) and E2 (DON) during the exit conference.

Based on record review and interview, it was determined for one (R1) out of three residents in the investigative sample the facility failed revise the care plan. Findings include:[DATE] - R1 was admitted to the facility. [DATE] - A care plan documented that R1 was a full code status and accepting of CPR. [DATE] - A physician's order documented that R1 was a DNR and RN to pronounce. [DATE] - A care plan documented that R1 made the following end of life decisions: Do not resuscitate, do not hospitalize and do not intubate. [DATE] - A review of the care plan showed both aforementioned care plans were activeXXX[DATE] 2:58 PM - During an interview, E3 (LPN) stated that the Social Worker is expected to update care plans in regards to code status and confirmed that the care plan had not been updated for R1 when reviewed. The facility failed to discontinue the care plan that documented that R1 was a full code. [DATE] 3:00 PM - Findings were reviewed with E1 (NHA) and E2 (DON) during the exit conference.

Based on observation and interview it was determined that the facility failed to ensure food was stored, prepared, and served in a manner that prevents food borne illness to the residents. Findings include: 6/23/25 - 9:46 AM - During a tour of the kitchen, observation of the walk-in refrigerator revealed a considerable amount of rust on the interior side of the door, numerous areas of rust and food debris on the food storage shelving and the walls and floor, as well as a significant number of areas of rust on and adjacent to the waterpipes located on the walk-in refrigerator ceiling. 6/23/25 - 9:53 AM - During observation of the kitchen office, a large area of standing water was noted. An interview with E35 (Assistant Food Services Director) confirmed the water was leaking from a broken air conditioner located in the kitchen office area. 6/23/25 - 9:53 AM - The pipes and the floor surrounding the floor drain under the two compartment sink adjacent to the walk-in freezer were observed to have a significant unsanitary build-up of black and brown substances, rust, and other debris. 6/23/25 - 11:00 AM - During a tour of the kitchen, there was one (1) compromised food can with dented sides, which was not separated from the cans of food being served to the residents. 6/23/25 - 11:08 AM - A steady stream of water was pouring out of the spigot on the wall creating running and standing water on the floor under cooking equipment. A large slotted cooking spoon was laying on top of the water hoses on the floor adjacent to the standing water. 6/23/25 - 11:10 AM - Under the shelving in the dry storage room was a large dark colored dried spill. 6/23/25 - 11:10 AM - During a tour of the kitchen food debris, small bits of paper, and other discarded items were observed on all areas of the kitchen floor, as well as crumbs and other food debris on several food prep surfaces. Observation of the kitchen revealed rust stains and food debris on the walls and dried food on the stove top. Two of the hot water pans on the steam table were found to contain bits of food and scraps of paper. 7/2/25 2:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON) during the exit conference.

Based on interview and record review, it was determined that for three (R16, R101 and R102) out of thirty-two residents in the investigative sample, the facility failed to revise and update the care plan for R16 and R101 to reflect resident's current needs. Additionally, the facility failed to have all the required interdisciplinary members present at R102's care plan meetings. Findings include: Cross refer F695 and F700 1a. Review of R16's clinical record revealed: 9/17/15 - R16 was admitted to the facility. 11/25/21 - A care plan documented that R16 was resistive or non-compliant with wearing an arm band and oxygen with the following interventions that R16 may have arm band placed on bed rail for assistance in identification. 3/17/25 - A (current) physician's order documented for continuous oxygen at 2L/min every shift. 6/23/25 1:23 PM - During an interview, E26 (LPN) confirmed that R16 was non-compliant with oxygen use and would remove the nasal cannula from her face. E26 stated that staff was expected to check to see if R16 was utilizing oxygen throughout the shift and replace if not on R16's face. E26 was unable to identify any further interventions related to oxygen use. 6/30/25 11:52 AM - During an interview, E10 (RN UM) confirmed that R16's care plan had not been updated since 2023 and did not include interventions on refusal of oxygen use. b. 9/18/15 - A care plan last updated 9/15/21 documented that R16 had an ADL self deficit related to impaired balance, weakness, and seizure disorder with the following interventions: two-person hoyer lift, foam built up and divided plate, functional status per therapy recommendations, PT/OT evaluation and treatment per physician's orders, and encourage resident to fully participate possible with each interaction. 6/30/25 11:52 AM - During an interview, E10 (RN UM) confirmed that R16 used a grab bar (bed rail) for positioning and mobility and confirmed that the care plan did not reflect this use. E10 stated the care plan had not been updated since 2021. 2. Review of R101's clinical record revealed: 3/4/25 - R101 was admitted to the facility. 3/4/25 - A care plan documented that R101 was at risk for developing complications related to needing assistance with ADL's related to cognitive impairment and with the following interventions noted: functional status per therapy recommendations, referral to PT/OT as needed for decline in function, and nursing to provide care as needed related to deficits to ensure ADL care is being met. 6/30/25 11:52 AM - During an interview, E10 (RN UM) confirmed that R101 used a grab bar (bed rail) for positioning and mobility and confirmed that the care plan did not reflect this use. E10 stated the care plan had not been updated since admission. 3. Review of R102's clinical record revealed: 3/1/24 - R102 was admitted to the facility. 12/5/24 - A comprehensive resident centered care plan conference form documented the following staff members or input were not present: dietary services. 3/6/25 - A comprehensive resident centered care plan conference form documented the following staff members or input were not present: CNA and dietary services. 6/5/25 - A comprehensive resident centered care plan conference form documented the following staff members or input were not present: dietary services. 6/30/25 11:52 AM - During an interview, E10 (RN UM) confirmed that during the aforementioned meetings all required members were not present or had input provided. 7/2/25 2:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), and E7 (IP) during the exit conference.

Based on record review, policy review and interview it was determined that the facility failed to implement an effective infection prevention program to prevent the spread of infection. Findings include. 1. The infection control policy last updated March/2025 indicated, Surveillance: A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents . May 2025 - Review of the facility's infection control log [line listing] that documented surveillance of infections in the facility revealed that R35, R108, and R123 were placed on contact precautions, and treated for skin rashes with a medication typically used to treat scabies. The surveillance log lacked documentation of the date of symptom onset for all three residents, the area was blank. 6/27/25 10:54 AM - During an interview E7 (ICP) confirmed that the documentation regarding R35, R123, and R108 scabies infection in the May 2025 line listed was incomplete. 2. The facility infection control policy last updated 3/25 indicated, All staff shall use personal protective equipment (PPE) in according to established facility policy governing use of PPE. 5/28/25 - R164 was admitted to the facility with a feeding tube. 5/28/25 - A physician's order was written for R164 to be placed on Enhanced Barrier Precautions: Related to [feeding tube] G tube 1. Gown 2. Mask 3. Face Shield (if splattering expected to occur) 4. Gloves every shift. 5/28/25 - A care plan was created for R164 to be placed on Enhanced Barrier Precautions: resident at increased risk for infection related to feeding tube. Interventions indicated, enhanced barrier precautions as ordered. Gloves and gown required for all high-contact activity including:feeding tube. 6/24/25 10:49 AM - During an observation of feeding tube administration E29 (LPN) was observed administering liquid nutrition to R164 wearing gloves and a mask. E29 did not wear a gown or face shield for potential splattering. E29 immediately confirmed the finding. 6/25/25 1:18 PM - During an observation of feeding tube administration E26 (LPN) was observed administering liquid nutrition to R164 wearing a gown, gloves, and a mask. E26 was not wearing a face shield to prevent contamination for splattering. E26 immediately confirmed the finding. 7/2/25 2:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON) during the exit conference.

Based on observation and interview, it was determined that the facility failed to maintain a safe and sanitary environment for staff. Findings include: 6/23/25 1:47 PM - Several pipes in the ceiling area of the clean laundry room were dripping onto the floor and into a trash can that had been placed under a portion of the leaking area. All of the leaking pipes had numerous areas of black and brown staining, peeling paint, damaged drywall, and several areas which appeared fuzzy in some sections. Both floor drains in the soiled laundry room had broken covers and the fan on the wall contained a significant build-up of dust and other debris in the protective covering. 6/23/25 1:56 PM - During an interview, E36 (Laundry Staff) confirmed the dripping and standing water and stated that the water had been dripping from the pipes and pooling on the floor for quite some time. 7/2/25 2:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON) during the exit conference.

Based on observation and interview, it was determined that for one out of four resident units the facility failed to provide a clean and homelike environment. Findings include: 7/2/25 9:27 AM - During an observation on the Ocean Gardens unit, room [ROOM NUMBER] was noted to have two areas approximately 6 in length, brown in color by the air conditioning unit. 7/2/25 9:33 AM - During an interview, E4 (Maintenance) confirmed the air conditioning unit in room [ROOM NUMBER] was leaking and recently just replaced. E4 confirmed the two large areas, brown in color next to the air conditioning unit. 7/2/25 9:37 AM - During an observation on the Ocean Gardens unit, room [ROOM NUMBER] was noted to have approximately six circular areas, brown in color, linear pattern noted on the ceiling. room [ROOM NUMBER] also noted to have a large area, approximately 12 long, brown in color noted in the closet. 7/2/25 9:50 AM - During an observation on the Ocean Gardens unit, room [ROOM NUMBER] was noted to have a leaking shower head in the bathroom. While observing the leaking shower head, it was noted that the tiles in the shower were covered with a pink and gray substance, slippery in consistency. Also noted that multiple tiles and the baseboard lining was missing from the bathroom wall and floor. 7/2/25 10:28 AM - During an interview, E5 (Maintenance Director) and E6 (Maintenance Corporate) confirmed the aforementioned areas in room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] were in disrepair and would put in a work order to complete. 7/2/25 2:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), and E7 (IP) during the exit conference.

Based on interview and record review, it was determined that for one (R102) out of thirty-two residents in the investigative sample, the facility failed to complete a comprehensive assessment after R102 had a significant change in status. Findings include: Review of R102's clinical record revealed: 3/1/24 - R102 was admitted to the facility. 11/27/24 - A quarterly MDS was completed for R102. 12/5/24 - A physician's order was written for a consultation with hospice. 12/13/24 - A signed hospice contract documented that R102 was admitted for hospice services. 2/27/25 - An annual MDS was completed for R102. 7/1/25 10:42 AM - During an interview, E8 (MDS Coordinator) stated that the expectation for a significant change MDS to be completed would occur when a resident had a decline in ADL's, improvement in ADL's, change in cognition, increase in behaviors, or admission to hospice. E8 confirmed that R102 should have had a significant change MDS completed when admitted to hospice and confirmed one was not completed. 7/2/25 2:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), and E7 (IP) during the exit conference.

Based on interview and record review, it was determined that for one (R13) out of three residents reviewed for PASARR, the facility failed to ensure that a referral for a PASARR Level II evaluation was completed in response to a new mental health diagnosis. Findings include: 10/6/17 - A PASARR screening was completed for R13 with a diagnosis including, but not limited to, schizo affective disorder and seizures. 10/10/18 - R13 was admitted to facility with diagnoses including, but not limited to, major depressive disorder and seizures. 10/10/18 - A PASARR Level 1.5 was completed and submitted to the state agency. Diagnoses included schizophrenia and intellectual disability. R13 did not require a Level II PASARR at this time. 6/17/25 - A quarterly MDS documented the following new diagnoses for R13 to include non-Alzheimer's dementia and anxiety. 6/25/25 11:29 AM - During an interview E8 (Social Worker) stated that when a resident has a new mental health diagnosis, a PASARR level 1.5 should be re-submitted to the state agency for a PASARR level II evaluation and determination. Additionally, E8 confirmed that a PASARR level 1.5 had not been resubmitted to the state agency for a PASARR level II evaluation and determination for R13. The facility lacked evidence that R13, a resident with a new mental health diagnosis, was referred to the state agency for a PASARR level II evaluation and determination. 7/2/25 2:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), and E7 (IP) during the exit conference.

2. Review of R102's clinical record revealed: 3/1/24 - R102 was admitted to the facility. 3/4/24 - A baseline care plan was initiated for R102. 12/13/24 - A signed hospice contract documented that R102 was admitted for hospice services. 2/27/25 - An annual MDS was completed for R102 and documented R102 was receiving hospice services. 6/30/25 - A review of R102's care plan lacked evidence that a care plan for hospice was developed and implemented. 7/1/25 11:45 AM - During an interview, E10 (RN UM) confirmed that R102 did not have a care plan developed for Hospice. 7/2/25 2:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), and E7 (IP) during the exit conference. Based on record review and interview it was determined that for two (R102 and R225) out of thirty-two residents investigated the facility failed to ensure development of a person-centered care plan identified needs. Findings include: 1. Review of R225's clinical record revealed: 6/9/25 - R225 was admitted to the facility with multiple diagnoses including difficulty swallowing. 6/9/25 - A care plan for R225 was created for need of assistance with ADL's related to weakness the care plan lacked evidence on interventions related to R225's dependence of staff assistance with meals. A care plan for nutrition was created related to weakness and difficulty swallowing. The nutrition care plan lacked evidence of interventions related to R225's dependence on staff assistance to complete meals. 6/16/25 - An admission MDS assessment documented that R225 was dependent on staff assistance for eating. 6/25/25 - Review of R225's Kardex in the eating/nutrition section lacked evidence that staff needed to assist the resident with eating. 6/23/25 3:13 PM During an interview R225 stated, They are not helping me do anything, there's no assistance during meals. 6/26/25 11:55 AM - During an interview E20 (RN) unit manager confirmed the finding. R20 stated, Therapy should have updated the Kardex and care plan to show [R225] was dependent for eating.

Based on record review and interview it was determined that for one (R163) out of two residents reviewed for wound care, the facility failed to ensure that wound care was performed in accordance with the physician's ordered frequency. Findings include: 1. The facility policy on wound treatment and management last updated 3/25 indicated, Wound treatments will be provided in accordance with physicians orders .treatments will be documented in the electronic health record. Review of R163's clinical record revealed: 5/22/25 - R163 was admitted to the facility with multiple wounds including on the right hip, leg and foot related to diabetes, and poor circulation resulting in some areas of dead tissue. 5/22/25 - A care plan for skin impairment was created for R163 with the intervention to administer treatment per physician's order. 5/26/25 - An admission MDS assessment documented R163 was cognitively intact and having multiple wounds that required care. May 2025 - R163's TAR lacked evidence that daily wound care treatments were completed on 5/30/25. R163's progress notes lacked documentation regarding resident absence or refusal for that date. 6/18/25 - A Physician's order was written for R163 to receive daily wound care treatments and dressing changes to the right hip, right lower leg, right ankle and right heel. June 2025 - R163's TAR lacked evidence that daily wound care treatments were completed on 6/12, 6/13, 6/19, and 6/20. R163's progress notes lacked documentation regarding resident absence or refusal on those dates. 6/23/25 11:16 AM - During an interview R163 stated, They don't always have enough staff, so my dressing is not changed every day like it's supposed to be. 6/26/25 10:00 AM - During an interview E28 (LPN) wound care nurse stated I told [R163] before if someone doesn't do it during the day then ask them to do it at night or tell me because sometimes, I am assigned to do other things. E28 then reported that R163 was compliant and wants to heal. E28 then confirmed the blank areas on R163's TAR to indicated missed treatments. 6/26/25 11:58 AM - During an interview E20 (RN) unit manager confirmed the findings and stated, I was unaware it wasn't always being done.

Based on record review, interviews and review of other facility documentation, as indicated, the facility failed to ensure that code status was accurate and congruent in all facility documents for two (R35 and R138) out of 167 sampled residents. This discrepancy put these two (R35 and R138) residents at immediate jeopardy (IJ) of a serious adverse outcome by not having a confirmed, accurate code status in the event of a medical emergency. These inaccuracies could result in CPR being administered to a resident requesting to not be resuscitated (DNR) or CPR not being performed on a resident requesting that all life sustaining measures be performed (Full Code). The IJ was identified on [DATE] at 5:25 PM and was abated on [DATE] at 8:00 PM. Findings include: The facility policy entitled, Advanced Directives/CPR Policy (last revised [DATE]), does not address how staff should verify code status. With regard to procedure, the policy stated the following: 3 .A resident admitted without advanced directives . will be deemed a full code 5. Upon admission to the facility, the admitting nurse will ask resident desired code status. If the resident is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advanced directive, the facility may give advanced directive information to the individual's resident representative . 10. Information about whether or not the resident has executed an advanced directive shall be displayed prominently in the medical record. 1. [DATE] 12:14 PM - A review of R35's care plan and documents in his chart reflected do not resuscitate (DNR), yet R35's computerized orders reflected that he was a full code. The electronic chart code status display ribbon was blank and did not list either DNR or a full code status. 2. [DATE] - untimed - A review of R138's hard chart and computerized profile confirmed that she was a DNR, yet the sticker on the front of her chart reflected that R138 was a full code. It was unclear how staff would know whether to administer life saving measures or not in the event that R35 or R138 was found unresponsive. The following interviews were conducted with staff about determining the code status of residents in the facility: [DATE] at 3:00 PM - An interview with E21 (UM) revealed that only (residents with a) DNR will have an advanced directive (section in the chart). Full code (charts) will be blank, meaning the code status was clarified. [DATE] at 4:05 PM - An interview with E13 (Unit Manager) revealed that in order to confirm code status, one staff member would check the profile on the computer and another staff member would check the paper chart. [DATE] at 5:15 PM - E4 (RN Supervisor) reported that she looks in the EHR, looks for a DNR sticker on the chart, an advanced directive clarification on the signed treatment Limitation DNR order form, and on the computer next to the resident's name. E4 stated that the doctor's order auto-populates the code status in the EHR (next to the resident's name). [DATE] at 5:17 PM - An interview with E23 (LPN) revealed that she looks in the EHR resident profile for the code status. [DATE] 5:20 PM - An interview with E22 (LPN) stated that she looks in the EHR, hard chart, report sheet, sticker on the front of the chart, the advanced directive section of the hard chart, and by the signed treatment limitations DNR form in the hard chart. [DATE] - untimed - An interview with E24 (LPN) revealed that she would check the sticker on the front of the hard chart or the EMAR for code status. [DATE] - at approximately 5:40 PM - E1 (NHA), E2 (DON) and E17 (Regional Nurse Consultant) were notified by the survey team that an IJ was identified when two current residents reviewed were found to have inconsistencies in DNR / full code status. [DATE] at 7:44 PM - E1 (NHA) provided the abatement plan for the I[NAME] [DATE] at 8:00 PM - The IJ was abated after the following was completed: all resident records were audited by the facility; R35's and R138's code statuses were verified and updated; the facility policy was revised to reflect the location of each resident's code status; facility staff present were educated on the location of each resident's code status; and no staff would work until they were educated on the current policy for determining code status. These findings were reviewed during the exit conference on [DATE] beginning at 10:15 AM with E1 (NHA), E2 (DON), E17 (Regional Nurse Consultant) and E21 (Assistant NHA).

Based on observation, record review and interview it was determined that the facility failed to ensure the environment remained free of accident hazards for 2 (R18 and R47) out of 54 residents. R18 had an order for [REDACTED]. In addition, the facility failed to thoroughly investigate R18's fall on 11/1/17 and does not currently follow the order and care plan for two person assistance in bathing. The facility failed to ensure R47's environment was without accidental hazard while she was in the facility's beauty salon. Findings include: Cross refer F657 example 1 and F849 1. Review of R18's clinical record revealed: 6/12/12 - R18 admitted to the facility. 6/20/12 - Care Plan for ADL Self Care Performance Deficit related to Dementia with limited attention span and ability to follow direction, weakness and poor endurance included a goal that R18's self-care needs will be met by staff daily x 90 days. Interventions included: - Provide assistance with incontinent care q 2 hours and prn. - Provide maximum assistance to complete bathing, personal hygiene and dressing tasks. - Transfer status: As per functional status in MD orders. The required number of staff needed for assistance in bathing was not specified in the care plan interventions from 6/20/12. Bed mobility assistance was not defined on the facility's care plan. 3/21/17 - physician's orders [REDACTED]. 6/28/17 - MDS quarterly assessment documented that R18 was totally dependent needing the physical support of two or more people for both bed mobility (how resident .turns side to side .while in bed) and bathing. 3/22 - 11/1/17 - Care Tracker Resident Profile (Care Plan used by CNAs) documented bathing as total assistance by staff (resident unable to assist) and bed mobility as total assistance by staff (resident unable to assist). The required number of staff needed for assistance was not specified on the Care Tracker Resident Profile and failed to reflect the physician's orders [REDACTED]. 9/21/17 - Fall Risk Evaluation (Quarterly) documented R18 was at a moderate risk for a fall with a score of 13.0. 10/17/17 - The Hospice CNA Care Plan documented bathing - bed bath and Activity Tolerance - Assist to turn and position in bed. The required number of staff needed for assistance was not specified for above activity. 10/26 - 10/31/17 - ADL Flow Sheet Log Nine out of nine times R18 was bathed, in bed, R18 was listed as total dependence with two or more staff physical assistance. 11/1/17 at 9:24 AM - Nursing progress note documented that the hospice CNA (H1) turned R18 while providing morning care and the resident kept rolling and fell out of the bed, hitting head on floor. R18 was transported to the hospital via EMS. 11/1/17 at 10:00 PM - Nursing progress note - Resident received 7 sutures to left forehead due to fall earlier today. 11/1/17 through 11/6/17 - The facility's investigative file was reviewed. The facility's investigation lacked evidence, that they identified an order for [REDACTED]. 9/26/18 at 1:43 PM - During an interview, E2 (DON) confirmed that H1 (Hospice CNA) was giving R18 a bed bath and turning R18 alone the day of the accident. H1 was the only staff member turning R18 that day. R18 fell and sustained a laceration requiring 7 sutures. E2 defined maximum assistance as weight bearing assistance, with one staff member, unless otherwise specified. Likewise, E2 stated that bed mobility was also one person assistance when it is not defined in the facility's care plan. Additionally, E2 confirmed that the above order dated 3/21/17, did indicate 2 staff person assistance for bed mobility. 9/26/18 at approximately 2:45 PM - During an interview with E30 (CNA), who was the facility's day shift CNA, E30 verbalized that for repositioning in bed (bed mobility), R18 required one staff person and that after the 11/1/18 fall, two staff assistance was required. 9/27/18 10:25 AM - During an interview, E2 (DON) further explained that the order was not followed as the facility follows therapy orders in cases of mobility. An Occupational Therapy/OT Evaluation & Plan of Treatment, dated 3/7/17, was provided and it stated bathing/transfers and bed mobility = did not test (patient is dependent all care at baseline). E2 explained that this is entered into the Cerner system by Therapy. Cerner is the system used by CNAs. R18 had a physician's orders [REDACTED]. R18's bed mobility and bathing were both coded as total dependence with two or more person assistance on the most recent MDS. R18's ADL Flow sheet reveals that, every time R18 was bathed the week leading up to the accident, R18 was bathed as totally dependent with two or more staff. On 11/1/17, the resident fell , while being turned during a bed bath, by one staff member. The fall resulted in harm to R18 when the resident sustained [REDACTED]. 12/22/17 - 6/20/12 Care plan interventions remained in place and an additional intervention for 2 person staff when providing bedside care, with turning and repositioning was added. 6/25 - 9/25/18 - ADL Flow Sheet Log documented that 97 out of 108 times R18 was bathed, in bed, R18 was listed as total dependence with one staff physical assistance. 9/26/18 at 1:43 PM - During an interview with E2 (DON) revealed that the fall was due to momentum. 9/27/18 at 12:30 PM - During an interview E2 (DON) confirmed that the 3/21/17 order for two person assistance for bed mobility was never discontinued. After the 12/22/17 update to R18's care plan for two person assist when receiving bedside care, the facility continues to give R18 bed baths with only one person assisting. R18 had an order for [REDACTED]. The resident fell to the floor, sustaining an injury. The facility failed to thoroughly investigate R18's fall on 11/1/17. In addition, between (MONTH) and (MONTH) (YEAR) the facility failed to follow the order and (12/22/17) updated care plan for two person assistance in bed mobility. 2. Observations and interviews revealed : 9/18/18 at approximately 9:15 AM - A random observation of the beauty salon, revealed R47 was sitting in a chair, under a hair dryer that was on medium heat. R47 had on nasal cannula, with oxygen being administered at 1 liters per minute via a portable oxygen tank. 9/18/18 at approximately 9:20 AM - An interview with E14 (Beautician) was held. The surveyor inquired, how far should the heat source needed to be from the nasal cannula, E14 verbalized that she did not know and that she had never had a problem and guessed, 18 to 20 inches. The distance from R47's nasal cannula to the hair dryer's heat source was 14 inches when measured by the surveyor. 9/18/18 at approximately 10:10 AM - An interview with E1 (NHA) and E2 (DON), revealed that the facility had no policy to address the acceptable distance from the heat source and the nasal cannula. E1 was aware the heat source needed to be at least 12 inches away from the nasal cannula and verbalized that she would develop the policy immediately. 9/18/18 at approximately 11:15 AM - The facility provided a copy of such policy indicating the heat source must be at least 12 inches away from the nasal cannula and evidence of education with the E14 . These findings were reviewed with E1 and E2, during an exit conference on 9/28/18 beginning at 2:30 PM.

Based on clinical record review, staff interviews, and review of other documentation as indicated, it was determined that the facility failed to provide the care and services necessary to promote the highest level of physical well-being for 7 (R9, R2, R3, R5, R4, R1, R6) out of 12 sampled residents. R9, a brittle diabetic, who was experiencing significant changes in his medical condition the facility failed to adequately and comprehensively assesses the resident during these status changes and failed to notify the physician. R9 had vomited at approximately 4:30 PM on 2/8/17. The scheduled tube feeding was held, however, the facility administered 17 units of Humalog (short acting insulin) on 2/8/17 at approximately 5:00 PM. At 7:30 PM, R9 had further significant changes in his condition, as evidenced by [MEDICAL CONDITION] activity [MEDICATION NAME] approximately 3 minutes and low pulse oximetry of 86%, requiring oxygen administration. Despite the fact that R9 had significant changes in condition, the facility failed to ensure adequate and comprehensive clinical assessment and failed to notify the physician of these changes. Due to these multiple failures, R9 was found unresponsive at approximately 9:30 PM with severe [DIAGNOSES REDACTED] with Finger Stick Blood Sugar (FSBS) of 20 and recheck of 21. The facility administered [MEDICATION NAME] injection but failed to provide evidence that the FSBS was rechecked In addition, when glucose paste was administered, the facility failed to provide evidence of a recheck of the FSBS. Due to the multiple failures, R9 required transfer to the hospital for treatment. R2, R3, R5, R1, and R4 were admitted to the facility from the hospital and the facility failed to have an established system to ensure medications were administered, as ordered. R6 had an order from a specialist office , which indicated to discontinue an antibiotic and failed to have an established system to ensure timely execution of the order. Findings include: 1. Review of the facility's policy titled Nursing Care of the Resident with Diabetes Mellitus documented for Management of [DIAGNOSES REDACTED]: 3. For symptomatic (lethargic, drowsy) but responsive (conscious) residents with [DIAGNOSES REDACTED] (less than 70 mg/dl or less than the physician ordered parameters): b. if he/she is unable to swallow: (1) immediately administer oral glucose paste to the [MEDICATION NAME] mucosa, intramuscular [MEDICATION NAME], or IV 50% [MEDICATION NAME], per facility protocol; (2) recheck blood glucose in 15 minutes; and (3) repeat protocol if indicated, recheck in 15 minutes. c. remain with the resident; d. place resident in a comfortable and safe place (bed or chair); e. monitor vital signs; f. hold all diabetic medication; and g. if no improvement, notify the physician for further orders. The following was reviewed in R9's clinical record: 1/19/17 R9 admitted to the facility from an acute care hospital with a [MEDICAL CONDITION] and was totally dependent on nutritional feeding through a percutaneous endoscopic gastrostomy (PEG) tube. 1/20/17 Care plan for diabetes mellitus with goal that R9 will have no complications related to diabetes within the next 30 days. Interventions included: Monitor/document/report to MD as needed signs and symptoms of [DIAGNOSES REDACTED]: sweating, tremor, increased heart rate ([MEDICAL CONDITION], nervousness, confusion, slurred speech, lack of coordination, staggered gait. 2/1/17 through 2/6/17 Medication Administration Record [REDACTED] 7:30 AM: High of 362 on 2/5/17 and low of 237 on 2/3/17 11:30 AM: High of 351 on 2/5/17 and low of 240 on 2/3/17 4:30 PM: High of 428 on 2/1/17 and low of 195 on 2/4/17 9 PM: High of 374 on 2/2/17 and low of 152 on 2/3/17 2/2/17 E14 (NP) Progress Note, documented, [DIAGNOSES REDACTED]. Plan: continue plan of care and monitor. 2/6/17 New order to increase Humalog 15 units four times a day. 2/7/17 through 2/8/17 MAR indicated [REDACTED] 7:30 AM: 229 and 114 respectively 11:30 AM: 105 and 134 respectively 4:30 PM: 122 and 214 respectively 9 PM: 127 and 159 2/8/17 physician's orders [REDACTED]. [MEDICATION NAME] (long acting insulin) 20 units subcutaneously (SQ) at bedtime scheduled for 9:00 PM with initial start date of the order as 2/2/17. Humalog insulin 15 units SQ scheduled four times a day at 7:30 PM, 12:30 PM, 5:00 PM, and 9:00 PM, with initial start date of the order as 2/6/17 with the first dose administered at 9:00 PM on 2/6/17. Humalog insulin sliding scale coverage, to be administered before meals and at bedtime based on the results of the FSBS. 2/8/17 Progress Note, by E11(LPN), dated 2/9/17 and timed 00:05 (12:05 AM) documented: Around 4:30 PM today, I came into the room to give the patient his feeding and found him with his head laying on his table with vomit all over. Called the aides and we clean him up. At that time his vitals were 153/87, 104 P, R 14 and temp 97.9. 2/8/17 MAR indicated [REDACTED] Humalog 15 units scheduled for 5 PM was administered at 5:04 PM. A sliding schedule coverage for FSBS of 214 of Humalog 2 units was administered to R9 at 5:15 PM. 2/8/17 MAR indicated [REDACTED]. 2/8/17 the Progress Note timed at 00:05 AM, by E11, further documented the following: Then around 7:30 we heard (another resident) calling out for help. When (E12, Name of CNA), (E13, Name of another CNA) and myself came in the room, the resident was having a [MEDICAL CONDITION] that lasted 3 min and temp. was 100.1 and oxygen dropped to 86%. Put on NC and put it on 2L oxygen. Continued my respiratory and o2 checks and patient stable. 2/8/17 Progress Note dated 2/8/17 and timed 10:35 PM by E11 documented that she had checked R9's blood sugar and it was 20 before E11 gave the [MEDICATION NAME], .so the [MEDICATION NAME] didn't get administered, thus, [MEDICATION NAME] was not administered by E11. 2/8/17 MAR indicated [REDACTED] Glucerna, a nutritional supplement, 474 ccs were administered through the PEG tube which was scheduled at 9:00 PM. FSBS scheduled for 9 PM was documented as 159. Humalog 15 units scheduled for 9 PM was documented as being administered at 10:35 PM. The sliding scale Humalog scheduled for 9 PM was not required due to the above FSBS of 159. 2/8/17 Progress Note, dated 2/9/17 and timed 00:05 AM, by E11, further documented: Entered the room at 9:30 to give rest of the meds and checked his blood sugar and it was 20, rechecked it again and it read 21. Called for help and for the night supervisor. [MEDICATION NAME] and instant glucose paste was administered and 911 was called. Sent to (Name of the hospital and Name of the attending physician's on call service) was notified. Vitals before leaving T101.1, P113, R20, o2 sat 95%, BP 168/102. 2/8/17 Review of the Emergency Medical Services (EMS) report, dated 2/8/17, documented that the EMS was notified by the facility at 10:18 PM and arrived at the patient at 10:41 PM. Narrative .pt. was found by nursing staff to have FSBS of 20 mg/dl and was given [MEDICATION NAME] X2 IM which brought his FSBS to 67mg/dl. Unknown how long he was hypoglycemic. .patient is found to be warm, diaphoretic and altered mental status. Upon exam, the pt. is responsive to painful stimuli and will move his eyes. Further review of the report documented initial FSBS at 10:42 PM of 90mg/dl. 2/8/17 Hospital emergency room records indicated blood glucose of 102, primary [DIAGNOSES REDACTED]. 2/21/17 Review of information from Drug.com, indicated that Humalog . is a fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours. In addition, to Administer the dose of Humalog U-100 . within fifteen minutes before a meal or immediately after a meal by injection into the subcutaneous tissue of the abdominal wall, thigh, upper arm, or buttocks. Dosage adjustments may be needed with changes in physical activity, changes in meal patterns, .changes in renal or hepatic function or during acute illness. Review of facility Progress Notes, on 2/22/17 at 10 AM, revealed a lack of documentation regarding: the completion of a comprehensive clinical assessment; the idenfication of the need to notify the physician of a significant change in condition; and, the identification of the need to discuss alteration in treatment. In addition, although the tube feeding was held for the 5 PM administration secondary to the vomiting, the facility staff administered the routine and sliding scale coverage Humalog of 17 units. From 4:30 PM to 7:30 PM on 2/8/17, there is no evidence of close clinical monitoring of temperature and lung sounds. As the Progress Note, documented, R9 continued to have additional significant changes in condition, as evidenced by [MEDICAL CONDITION] activity that lasted approximately 3 minutes and change in oxygen saturation to 86%, requiring oxygen via nasal cannula at 2 liters per minute. Again, there is no documented evidence of a comprehensive clinical assessment, notification of the physician of the resident's change in condition or close monitoring of the resident's condition. At 9:30 PM, E11 entered the room to administer R9's medication and R9's FSBS was 20. Recheck was 21. R9 (RN Nurse Supervisor), was called and [MEDICATION NAME] and instant paste were administered and 911 called. The Progress Note lacked evidence that the facility followed facility policy, which directed to recheck FSBS 15 minutes after the administration of the [MEDICATION NAME] injection and/or the glucose paste. 2/22/17 at 2:40 PM, an interview with E11 revealed, that R9 had vomited a large amount of what appeared to be tube feeding, which covered the over-head bedside table and some on the floor. E11 verbalized that this was the first time that she can recall that R9 had vomited while being in the facility. E11 relayed that she did not notify the RN supervisor, E9 when R9 vomited. E11 described R9's [MEDICAL CONDITION] activity, as the entire body in a jerking motion for approximately 3 minutes. E11 verbalized that E9 was notified, however, E11 did not recall whether E9 had completed a comprehensive assessment. E11 verbalized that she did not administer routine bedtime dose of [MEDICATION NAME] scheduled for 9:00 PM. Although documented as given, E11 denied administering Humalog at 10:35 PM on 2/8/17. E11 described the documentation as a mistake. 2/22/17 at 2:45 PM, an interview with E3 (DON), confirmed that when R9 vomited at 4:30 PM, the facility failed to conduct a comprehensive clinical assessment and failed to notify the physician of the change in the resident's condition, including the need to alter the resident's treatment significantly at 4:30 PM and 7:30 PM. E3 confirmed that when R9 experienced further changes in condition, as evidenced by [MEDICAL CONDITION] activity [MEDICATION NAME] approximately three minutes and decrease in oxygen saturation to 86%, again, the facility failed to conduct a comprehensive clinical assessment, failed to notify the physician of the change in condition, including the need to alter the resident's treatment significantly. Lastly, when R9 was found with FSBS of 20-21, the facility failed to have evidence of recheck of the FSBS post administration of glucose paste as well as [MEDICATION NAME] injection. 2/22/17 at 3:20 PM, an interview with R9's with E5 (Medical Director), confirmed that the facility failed to notify the physician when R9 vomited. E5 related that if he was notified, he would have had an opportunity to reduce the Humalog insulin doses scheduled for 5 PM; both the routine dose and sliding scale. E5 further verbalized that the 3 minute [MEDICAL CONDITION] activity may not have been [MEDICAL CONDITION] activity, however, he should have been notified of the 7:30 PM condition of the resident. 2/23/17 at 11:30 AM, an interview with E12 (CNA), who was assigned to R9 on 2/8/17, during the 3PM-11 PM shift, revealed that R9 was sitting up in his wheelchair at her first round at 3 PM and R9 was awake, alert, and watching the television. E12 verbalized that when R9 vomited, R9 appeared to be weak, skin was clammy and E12 had observed R9 twitching. In addition, she was present when R9 had the [MEDICAL CONDITION] activity and the resident was sweating and R9's clothing had to be changed secondary to the sweating. E12 related vital signs were obtained. Subsequently, R9 vomited again and E12 notified E11, although Progress Note failed to include that E5 was notified of the additional vomiting. 2/25/17 at 11:00 AM, an interview with E9, revealed that E9 was informed by E11 that R9 had vomited and was informed by E11 that it was not much. E9 did not assess R9 nor observe the vomit. E9 further related that R9 appeared to be normal from distance. E9 verbalized that she would not have contacted the attending physician for vomiting alone. E9 further related that she was not aware of R9's [MEDICAL CONDITION] activity at approximately 7:30 PM. E9 verbalized that she was contacted by E11 when R9 was found unresponsive with FSBS of 20 and she (E9) had administered [MEDICATION NAME] IM and the glucose paste. E9's verbalized that she recalled the FSBS increasing to 38, after the administration of one of the interventions, however, did not recall any additional recheck results of the FSBS. E9 verbalized that she did not recall if she had completed a comprehensive clinical assessment before R9 left the facility at approximately 10:30 PM. 2/28/17 at approximately 10:35 AM, the surveyor was approached by E5 for additional interview. E5 verbalized that the total Humalog of 17 units administered to R9 at 5:04 PM would have peaked and dissipated in 4-5 hours. E5 reiterated that he should have been notified when R9 vomited on 2/8/17 at 4:30 PM and tube feeding was held, as he would have considered adjusting the Humalog scheduled for 5 PM, possibly cutting it in half. 2/28/17 at approximately 3 PM, review of the MAR, relating to low trending FSBS beginning on 2/7/17 at 11:30 AM of 105, provided no evidence of nursing or medical assessment of lower FSBS. 3/2/17 at 3 PM, the surveyor received an e-mail from E3 . I know we have discussed this resident many times. I just would like to request if you can please consider our conversation with (E5). I absolutely agree with the nurse not notifying MD at 4:30 pm. Although she did not, there was no negative outcome as evidenced by fingers tick at 9 pm was still 159. At 9 pm, the nurse followed physicians order by checking FS (159) and gave the bolus and Humalog as ordered. The impression attached indicated [DIAGNOSES REDACTED] due [MEDICAL CONDITION]. Review of the 2/9/17 consultation note, attached to the above e-mail was reviewed. The 2/9/17 note documented while R9 was in the ICU, He was noted to have blood sugar of 4 at that time. Review of the Impression documented, 7. Diabetes mellitus with [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED] likely was caused due [MEDICAL CONDITION]. 3/6/17 Surveyor received a typed statement from E11, as follows: Around 1630 (4:30 PM) I went into the patient's room and he had vomited on his over the bed table and had his head lying down on the table. At that time I checked his finger stick and it was 214, I then administered 2 units of Humalog and continue to monitor. At approximately 1700 (5:00 PM) I gave the patient his (sic) and 15 units of Humalog. Then around 19:30 (9:30 PM) I called into the patients room because of [MEDICAL CONDITION] activity, vital signs were stable and continued to monitor the patient. A little after 2000 (8:00 PM) I checked the patients blood sugar and it was 159, no coverage was needed and patient stable. After this time is when I gave the patient his bolus feed and patient tolerated the feeding well. I returned to the patient's room at approximately 2130 (9:30 PM) to finish the administration of medication and checked the patient's blood sugar and it was about 20, rechecked again and it was 21. That is when I called out down the hall to get the supervisor. No medication was administered and [MEDICATION NAME] and Humalog were held. The supervisor gave the emergency [MEDICATION NAME] and glucose paste and we stayed with the patient until the paramedics arrived. 3/13/17 Surveyor received an e-mail statement from E3. The written e-mail statement was completed by LPN (E19) who was working on 2/8/17 in a different unit during the 3:00 PM-11 PM shift: Writer was completing evening tasks at approximately 21:45(9:45 PM)-22:00(10:00 PM}, when an overhead page was called for supervisor to station 4 stat. Since writer was done passing medications and treatments, I decided to go over and offer assistance if needed to staff on station 4. When I approached station 4, I observed multiple CNAs at the door of (R9's room number), and another CNA paged another overhead page for assistance. Writer entered room and observed E11 attempting to help resident, and had just checked his blood sugar. She reports a reading of 20. Writer instructed other nurse from station 4, LPN (E20) to call 911 which she did at that time. Writer immediately left room and went to med room to obtain IM [MEDICATION NAME] as E11 stayed in room and cared for resident, attempting to administer oral glucopaste. He began actively vomiting at that time, and she had him sitting up in bed. Writer came back and administered IM [MEDICATION NAME] to left thigh. Supervisor (E9) entered room at that time and rechecked blood sugar. I am not able to recall the exact results of the fingerstick, but I recall being higher than it was previously. Writer then obtained crash cart (emergency cart) and hooked up suction. E11 suctioned residents mouth to prevent aspiration while E9 continued to monitor blood sugar. Writer went to entrance door and directed paramedics to room at that time, who took over resident care after receiving report from E11 and E19. Family and MD (medical doctor) were notified. The facility failed to: 1) Conduct a adequate and comprehensive assessment after R9 had vomited at 4:30 PM. 2) Notify the attending physician when R9 had experienced [MEDICAL CONDITION] activity and had decrease in oxygen levels at 7:30 PM. 3) Recheck FSBS of 20-21 and was administer [MEDICATION NAME] and glucose paste when administered at 9:30 PM after R9 was found with a FSBS of 20 and 21. Findings reviewed with E2 (NHA2), and E3(DON), on 3/1/17 at approximately 3:20 PM 2. The following was reviewed in R2's clinical record: 1/8/17 Progress Note documented that R2 was admitted to the facility at 2:45 PM from the hospital. 1/8/17 admission orders [REDACTED] -Oral medication for indication of diabetes, scheduled for 4 PM on 1/8/17. -Humalog insulin, based on sliding scale insulin coverage, to be administered based on the FSBS prior to dinner at 4:30 PM on 1/8/17 for indication of diabetes. -Aerosol spray scheduled for 4 PM on 1/8/17, for indication of [MEDICAL CONDITIONS]. -NPH Insulin 15 units SQ scheduled for evening of 1/8/17 for an indication of diabetes. -Second aerosol spray, scheduled for 8 PM on 1/8/17 for an indication of [MEDICAL CONDITION]. 1/8/17 MAR for the above medications, revealed a documentation of 8-Other. In addition, X was documented, for the 4:30 PM FSBS. 1/8/17 Progress Note dated 1/8/17 lacked evidence whether the medication was administered or not. In addition, there was lack of evidence that FSBS was completed as ordered. 1/9/17 Further review of the MAR indicated [REDACTED]8-Other. 1/9/19 Further review of the Progress Note lacked evidence whether the medication was administered, as ordered for 12:00 PM. 2/14/17 at approximately 11 AM, an interview with E5 (LPN, UM), confirmed that the facility had no evidence that the above medications were administered after R2 was admitted to the facility. 2/15/17 at approximately 11:15 AM, an interview with DON (E3) revealed that the attending physician should have been notified when the above medications were not available for administration. Additionally, E3 verbalized that the facility's electronic Medication Administration Record [REDACTED]. Thus, the staff are expected to document in the Progress note, in the facility's electronic Medical Records system (eMR), however, E3 confirmed the lack of documentation of the above medications. The facility failed to provide the care and services necessary to ensure the provision of medications listed in the admission orders [REDACTED] Findings reviewed with NHA2 (E2) and E3(DON), on 3/1/17 at approximately 3:20 PM. 3. The following was reviewed in R3's clinical record: 2/8/17 Progress Note documented that R3 was admitted to the facility at approximately 5 PM from the hospital. 2/8/17 Admission order revealed that R3 had an order for [REDACTED]. 2/8/17 MAR indicated [REDACTED]. 2/8/17 Progress Note lacked evidence whether the medication was administered, as ordered for 8 PM. 2/9/17 MAR indicated [REDACTED]. 2/9/17 Progress Note timed 10:24 PM documented, notified pharmacy for this medication. 2/14/17 at approximately 1:30 PM, an interview with E3, confirmed that the facility had no evidence that the above two doses of anti-[MEDICAL CONDITION] medications were administered. In addition, E3 confirmed that the facility failed to provide the care and services necessary to ensure the provision of medication listed on the admission order for R3. 4. The following was reviewed in R5's clinical record: 2/12/17 Progress Note documented that R5 was admitted to the facility on [DATE] at 5:00 PM from the hospital. 2/12/17 Admission order revealed that R5 had an oral medication for an indication of heart failure scheduled for 7 PM on 2/10/17. 2/12/17 MAR indicated [REDACTED]. 2/12/17 Progress Note lacked evidence whether the medication was administered. 2/14/17 at approximately 1:35 PM, an interview with E3, confirmed that the facility had no evidence that the above medication was administered, In addition, E3 confirmed that the facility failed to provide the care and services necessary to ensure the provision of medication listed on the admission order for R5. Findings reviewed with E2 (NHA2) and E3 (DON) on 3/1/17 at approximately 3:20 PM. 5. The following was reviewed in R4's clinical record: 2/9/17 Progress Note documented that R4 was admitted to the facility on [DATE] at 5:41PM. 2/9/17 Admission order revealed that R4 had the following orders: An oral medication, [MEDICATION NAME], for an indication of abnormally high concentration of fats or lipids in the blood, scheduled for 8 PM on 2/9/17. An oral antibiotic, for an indication for infection, scheduled to be administered every 12 hours and next doses scheduled for 9:00 PM on 2/9/17 and 9 AM on 2/10/17. an order for [REDACTED]. 2/9/17 MAR indicated [REDACTED]. 2/9/17 Progress Note timed 3:05 PM documented per unit manager this shift, medication will be coming from pharmacy. Not here at this time. 2/13/17 at approximately 3:20 PM, an interview with LPN, E10, who was assigned to R4 during the 3:00 PM - 11:00 PM shift, revealed that the orders were not entered in the eMAR by the RN Shift Supervisor, thus, medications were not available for administration. 2/14/17 at approximately 9:15 AM, an interview with E3, confirmed that the above medications were not available, thus, was not administered. The facility failed to provide the care and services necessary to ensure the provision of medication listed on the admission order for R4. Findings reviewed with E2 (NHA2) and E3 (DON), on 3/1/17 at approximately 3:20 PM. 6. The following was reviewed in R1's clinical record: 1/21/17 Progress note documented that R1 was admitted to the facility at 2:45 PM from the hospital. 1/21/17 Admission order included an oral blood thinning medication to be administered twice a day at 8:00 AM and 8:00 PM. 1/21/17 MAR indicated [REDACTED]. 1/21/17 Progress Note timed 10:26 PM lack documentation. 1/22/17 MAR indicated [REDACTED]. 1/22/17 Progress Note timed 10:50 AM documented that the medication was not available and the pharmacy was notified. 3/10/17 at approximately 10:00 AM, an interview with E3 confirmed that the above medications were not administered due to unavailability. The facility failed to provide the care and services necessary to ensure the provision of medication listed on the admission order for R1. Findings were reviewed with E3 on 3/10/17 at approximately 10:00 AM. 7. The following was reviewed in R6's clinical record: 2/1/17-2/28/17 Order Summary Report documented the following antibiotics: [MEDICATION NAME] capsule with meals four times a day scheduled for 7:30 AM, 12:00 PM, and 4:30 PM daily, with an original order date of 1/27/17. [MEDICATION NAME] IV, continuous infusion for bone infection with an original order date of 1/31/17. 2/7/17 A three page fax, containing three Approved Prescription documentation, from a specialist office sent to the facility on [DATE] at 11:59 AM. These pages included orders to discontinue two antibiotics; [MEDICATION NAME] and [MEDICATION NAME] in addition to start a new antibiotic. 2/7/17 through 2/8/17 MAR indicated [REDACTED] [MEDICATION NAME], total of five additional doses from 2/7/17 at 12:00 PM through 2/8/17 at 4:30 PM. [MEDICATION NAME] was held beginning 2/7/17 during the 3 PM-7 PM shift. 2/14/17 A written statement by E8 (Unit Clerk), documented that she had received a call from the specialist office to stop two medications and to continue with another antibiotic. E8 subsequently gave the message to the E6 (LPN, UM). In addition, E8 had documented that she did not recall the fax documentation from the specialist office on 2/8/17 or 2/9/17. 2/14/17 A written statement by a different UM, E7 (LPN, UM), documented that she had received a fax for R6. Upon receiving this fax, E7 called and spoke with someone in the unit, where R6 resided to ensure that R6 was still in the unit. E7 documented that she told this individual that she had the paperwork for R6 and will be faxing this to them, however, E7 did not recall the date of this conversation. 2/14/17 A written statement by E6, documented that he had received a note late in the afternoon on 2/7/17 from E8, which indicated that the specialist wanted to stop the [MEDICATION NAME] and the [MEDICATION NAME]. The note further documented that E6 had called between 4:30 PM and 5 PM on 2/7/17, after the specialist office had closed and the specialist was on a no contact list on weekends and after hours except for hospital patients. On 2/8/17, E6 documented that he had spoken with the nurse at the specialist office later that day and the nurse stated that the specialist wanted to stop the [MEDICATION NAME] and the [MEDICATION NAME] . E6 proceeded to ask the nurse to fax over the orders. 2/14/17 at approximately 11:15 AM, an interview with E8, confirmed that she did receive a call from the nurse at the specialist office the morning of 2/7/17 and verbalized usually, E8 transfers the call to the facility nurse. In this situation, she had written a note and provided this to E7 before 11:30 AM on 2/7/17. 2/14/17 Although the specialist office sent an order to discontinue the above antibiotics on 2/7/17 via the fax, the facility's system failed to ensure that these orders were forwarded to R6's attending physician for consideration. In addition, when a verbal order was communicated by the specialist office nurse, an LPN, to E6 on 2/8/17, the facility failed to ensure that R6's attending physician was informed of the orders to discontinue the [MEDICATION NAME]. The facility failed to provide the care and services necessary to ensure that R6 received medications in accordance with the specialist and Medical Director's plan. Findings reviewed with E2 (NHA2) and E3 (DON), on 3/1/17 at approximately 3:20 PM.

Based on observations, interviews, a review of a clinical record and relevant facility documents, it was determined that the facility staff failed to provide adequate supervision for 1(R3) of 5 sampled residents during a moist hot pack treatment to prevent an accidental burn which required wound treatments lasting at least 2 1/2 months. In addition, the facility staff failed to ensure an assessment was done prior to treatment and obtain a physician's orders [REDACTED]. Findings include: Rehabilitation Services Policies and Procedures: 7/1/12 (effective) with revision date 12/31/13 - Policy Title Evaluation Section 5.4 indicated that upon receipt of a physician's orders [REDACTED]. 10/12/12 (effective) with revision date 12/31/13 - Policy Title Hot Packs Section 7.3 reflected that clinicians will identify appropriate patients for hot pack treatment according to indication, contraindication and precautions. The policy also indicated that residents who receive the treatment must be kept in line of site supervision at all times. Provide adequate supervision by checking the patient's skin every 5 minutes. Ask the patient for level of comfort. Add more insulating layers if the skin becomes very red and/or patient complains of being hot. The following was reviewed in R3's clinical record: A care plan focus/problem identified by staff initiated 6/11/12 and currently in effect reflected that R3 was at risk for injury and burns related to decreased sensation secondary to progressive disease process. Interventions included the resident will request staff assistance to heat liquids to the resident's desired temperature and to set up all hot and cold beverages at all meals; and securing the cup lid. 11/30/15 MDS showed the resident was totally dependent on staff for most activities of daily living except eating. The resident uses a power wheelchair for mobility. 1/29/16 MDS showed the resident as alert with a BIMs score of 14 out of 15. 2/2/16 at 14:35 a nurses note -the writer was called to resident room, and noted 2 reddened areas to resident right and left side of back with peeling skin, nurse practitioner was called and new orders given for treatment. The son was made aware. 2/2/16 at 14:48- nurses note- notified by CNA of marks on resident's back. Upon assessment 2 reddened superficial areas to right upper back and left lateral back. The Unit Manager was made aware and assessed. Hydrogel Ag applied per wound care nurse. 2/2/16 16:58- late entry documented by the nurse practitioner indicated R3 was seen at the request of nursing. Resident developed a small mid scapular sebaceous cyst. Nursing had implemented hot pack treatment to the area. Unfortunately, the patient developed burn below the scapula; The resident has been seen by the wound care nurse and was recommended for Silvadene dressings. No complaints of persistent pain to the area. Examination showed two [DIAGNOSES REDACTED]tous patches, one below the left scapula (5 cm x 3 cm) and one in the mid thoracic vertebra area (3 cm x 3 cm). Both appear to have been slightly blistered and have ruptured. The practitioner's assessment also reflected that the resident had second degree burns. A facility reported incident dated (2/2/16) and follow-up investigative report submitted to the State Agency reflected R3 sustained burns on the back when a staff person applied a moist heat pack on 2/1/16 without physician's orders [REDACTED]. E6 (COTA) reportedly thought the nurse was going to monitor the resident after the hot pack was applied to the resident's back area. The LPN's (E19) written statement of 2/8/16 indicated that she did not agree to monitor the use of the hot pack. 2/3/16 - care plan focus/problem area was added- impaired skin integrity issue related to burn on right upper back and left lateral back. 2/3/16 to 4/18/16 -this skin/wound note showed that R3 had received treatments to the burns in accordance with physician's orders [REDACTED]. 4/19/ 16 to 4/22/16 - skin/wound note showed that the left lateral back wound continues to be granulated tissue, and was described as superficial with a very small amount of drainage. An interview on 4/18/16 with R3 at approximately 9:12 am revealed that the resident did verify that a staff person applied a hot pack a while ago and as a result R3 had burns on the back. R3 stated that a treatment still continues and E6 has not been involved in the resident's care since the incident. The surveyor interviewed E5 (Physical Therapy Director) on 4/18/16 at approximately 1:40 pm - E5 stated that E6 did not follow the Rehabilitation Services Policies and Procedures because E6 did not have an order; there was no evaluation; and did not provide supervision while the hot pack was in use by R3. E6 was retrained and passed a competency test. An interview with the Director of Nursing (E2) on the same day at approximately 1:45 pm revealed that E6 did not follow procedures and received disciplinary action for the hot pack incident. 4/22/16 at 9:05 am - Surveyor observed wound treatment. The E13 (Wound Care Consultant) measured the wound (1.5 x 1.3 cm). The wound care nurse changed the dressing and applied the treatment as ordered. Cleansed with normal saline, applied Medihoney to the wound bed and redressed the wound. The wound bed had granulated tissue and showed improvement per the nurses. The facility implemented the following plan of correction: All residents receiving hot pack treatments were assessed on 2/12/16. Most staff were retrained on the use of moist hot packs and the policies/ procedures between 2/11/16 and 2/15/16. E6 received disciplinary action, reeducation and passed a competency test. Weekly audits were done for a period of time by the ADON (E3) or designee to ensure warm compress and hot pack applications had corresponding orders or were part of a therapy modality; then monthly audits for the next quarter. E5 performed weekly audits of rehabilitation staff performing hot pack treatments for a period of time. These findings were confirmed at the exit conference on 4/22/16 at 1 PM with E1 (NHA), E2 and E3.

Based on record review, interview and review of facility policy, it was determined that the facility failed to ensure appropriate treatment and services to restore and/or maintain bladder function were implemented for 2 (R201 and R318)out of 42 sampled residents. The facility failed to assess bladder function for these residents after incontinence was identified and failed to provide interventions, treatment and services to assist in maintaining or improving as much urinary continence as possible for these residents. This resulted in R201, who was admitted with only occasional incontinence in January 2015, progressed to being frequently incontinent. R318 progressed from frequently incontinent in April, 2015 to being always incontinent in June, 2015. Findings include: Facility policy (undated) entitled Urinary and Bowel Incontinence - Evaluation and Management included the following policy interpretation and implementation: * Nursing staff will initially screen for information related to urinary and bowel incontinence utilizing the Bowel and Bladder Evaluation. * Upon completion of the Bowel and Bladder Evaluation, should the history indicate anything other than continent, a three day, 24 hour, voiding and elimination diary will be implemented. * The diary will be initiated upon completion of the Bowel and Bladder Evaluation. The resident will be checked every hour for three days. The diary will be scored using a separate key, one for bowel and one for bladder. * Should the resident be asleep at any time, they will not be awakened. However, should the resident require incontinence care during any time of the check, care will be provided immediately. * Subsequent to the completion of the three day diary, an analysis of the data collected will be completed and trends will be reviewed to determine the appropriateness of a toileting program for bowel or bladder or both. * Upon evaluation of the data collection from the three day elimination diary, a decision will be made to determine the type of toileting program appropriate for the individual resident. * A plan of care developed specifically to meet the resident toileting needs. * Periodically (as required and when there is a change in pattern of elimination), staff will re-evaluate each individual's level of continence. Cross Reference F279, example #4 1. R201 was admitted [DATE] to the rehabilitation unit from the hospital after falling at home and developing acute renal (kidney) failure in the hospital. Besides multiple medical conditions, the resident had a history of [REDACTED]. Admission progress note on 1/14/15 at 8:10 PM by E12 (LPN) documented the resident was continent of urine. Bladder and Bowel Evaluation on 1/14/15 recorded a history of frequent incontinence and that the resident was unaware of bladder urges. Mobility devices included walker, raised seat and bed pan. Bladder summary showed incontinence (initiate voiding diary). The voiding diary from 1/15/15 through 1/17/15 showed R201 was continent of urine during this time frame. There were no documented episodes of incontinence and the resident was continent of bladder (used toilet) 4 to 5 times per day. MDS assessment dated [DATE] (5-day) and 1/28/15 (14-day) documented the resident was occasionally incontinent of urine and was not on a urinary training program. R201 required extensive assistance (staff provide weight-bearing support) with one person for bed mobility, transfer and toilet use. Resident balance when moving from seated to standing position and moving on/off the toilet was not steady, only able to stabilize with staff assistance. BIMS (Brief Interview for Mental Status, tool used to score mental ability) score was 15 out of 15 (15/15) showing the resident's cognition (thinking) was intact. A 1/22/15 progress note at 11:03 AM E5 (Unit Manager) documented analysis of the voiding diary as continent of urine. Resident Bowel and Bladder by Shift report (based on CNA documentation) for the month of January, 2015 showed the resident had urinary incontinence 19.6% of shifts. Progress note on 2/4/15 at 9:14 AM by E4 (Physician) documented that the resident complained of increased depression. On 2/4/15 at 7:46 PM E13 (Director of Social Services) documented R201 did not want to go to therapy (physical and occupational therapy) and that the resident wanted more assistance (from staff) and was really down (depressed mood). Care plan (last revised 7/10/15, initiated 1/19/15) contained the problem entitled ADL Self Care Performance Deficit related to impaired balance with the goal of maintaining or improving the current level of function. Approaches included front wheel walker which resident was not to have walker in the room; Assist of 1 with transfers, resident noncompliant, education provided to resident related to safety and calling for assistance; Encourage resident to discuss feelings about self-care deficit; Encourage resident to participate to fullest extent possible with each interaction, encourage to use call bell for assistance. Care plan problem entitled Resident has unstageable pressure ulcer related to impaired mobility and nutritional status contained these approaches Provide incontinence care after incontinence episode; and Apply barrier cream as needed. Interventions about the resident's toileting or promoting continence were not documented in the care plan. MDS assessment (30-day) dated 2/11/15 documented the resident was frequently incontinent of urine, an increase of incontinence frequency. On 2/13/15 at 4:56 PM E4 (Physician) wrote since increasing an antidepressant medication, the patient's mood seems to be better. On 2/22/15 at 4:11 PM E14 (RN) documented that R201 used the call bell today when needing assistance with ADLs. On 2/24/15 the resident moved to the Long Term Care unit. Resident Bowel and Bladder by Shift report for the month of February, 2015 showed the resident had urinary incontinence 31.3% of the shifts. Progress notes revealed [MEDICAL TREATMENT] (cleansing of blood by artificial means when kidneys have failed) started three times a week on 3/21/15 and R201 was hosptalized on [DATE] at a psychiatric facility for increase in depression with suicidal thoughts. Resident Bowel and Bladder by Shift report for the month of March, 2015 showed the resident had urinary incontinence 51.1% of the shifts. Bladder and Bowel Evaluation dated 4/10/15 (date resident returned from psychiatric hospital) by E6 (Unit Manager) documented the resident had frequent incontinence and was not aware of bladder urges. Mobility devices included ambulatory, walker, raised toilet seat, bed pan, grab bars. Bladder summary was incontinent (initiate voiding diary). A voiding diary was not in the medical record. On 4/10/15 E9 (Physician) ordered to apply house barrier cream to peri-area (area between thighs and the anus) and buttocks after each incontinence episode and as needed. On 4/10/15 the resident's BIMS score remained 15/15 according to the clinical record. On 4/13/15 at 8:38 AM by E7 (Nurse Practitioner) documented R201 was still somewhat flat (affect), monotone in communication. Underlying issue seemed to be recently starting [MEDICAL TREATMENT]. The resident did not want to return to the psychiatric hospital. MDS dated [DATE] (5-day) showed the resident was frequently incontinent of urine and not on a urinary training program. Amount of staff assistance and resident balance remained unchanged from January. On 4/27/15 at 2:54 PM by E21 (LPN) documented the resident continues to say she can't do something when in fact she can and wants the staff to do it all for her. E7 documented on 4/28/15 at 10:49 AM that R201 continually reports that she is unable to do things yet when left alone, she will stand and pivot to get in and out of bed on her own. The resident was alert but very monotonic (monotone voice) and seemed to have little motivation. Resident Bowel and Bladder by Shift report for the month of April, 2015 showed the resident had urinary incontinence 65% of the shifts. Resident Bowel and Bladder by Shift report for the month of May, 2015 showed the resident had urinary incontinence 85.7% of the shifts. Resident Bowel and Bladder by Shift report for the month of June, 2015 showed the resident had urinary incontinence 100% of the shifts. Bladder and Bowel Evaluation on 7/4/15 at 3:11 PM (quarterly) by E16 (LPN) documented the resident as always incontinent, a further decline from April. Mobility devices included ambulatory and grab bars. Bladder summary was incontinent (initiate voiding diary). A voiding diary was not in the resident's record. On 7/14/15 at 3:10 PM E6 informed the surveyor she updated the care plan. Review of the resident's care plan found the pressure ulcer problem including the approach for providing incontinence care after an incontinence episode and to apply barrier cream had been discontinued/removed. On 7/15/15 at 8:55 AM E6 confirmed there was nothing in the care plan about toileting strategies or incontinence measures. At 9:10 AM E6 verified the only three day diary in the chart was from January and stated she would check in medical records for voiding diaries conducted after the Bladder and Bowel Evaluations in April and July. On 7/15/15 at 12:15 PM E6 informed the surveyor she edited the care plan again. Review of R201's care plan found the approach of performing incontinence care every 2 hours and as needed was added to the problem entitled ADL Self Care Performance Deficit related to impaired balance. Approaches addressing the resident's motivation issues, toileting strategies to promote continence or using barrier cream ordered by the physician were not included in the care plan. Resident Bowel and Bladder by Shift report for the month of July, 2015 (through 7/16/15) showed the resident had urinary incontinence 91.7% of shifts. On 7/20/15 at 8:15 AM E6 stated she usually would receive an email from the RNAC whenever the MDS assessment showed a decline in continence and would initiate the voiding diary and place the diary form in the CNA binder. E6 commented she reviewed her emails the day prior and denied receiving email notification about the decline in bladder function. E6 confirmed no three day diaries were done. and added they should have been done. E6 added that she often had to talk with the resident when it was time to get out of bed since the resident often refused to get up for the aides. When I go in, she stands right up. On 7/20/15 at 8:30 AM the surveyor talked with R201 about her continence status. R201 offered no reason for the decline in bladder function and denied feeling the urge to urinate prior to doing so. The resident admitted that it was easier to get cleaned up in bed versus getting up to go to the bathroom. At 8:45 AM E15 (QA Director) informed the surveyor she reviewed R201's record the day prior (Sunday) and talked with staff, who informed her the resident refused to get out of bed to use the bathroom but pressed the call bell after the resident was incontinent. Following a decline in urinary function identified during MDS assessments the facility failed to plan for, and provide, interventions, treatment and services to assist in maintaining or improving as much urinary continence as possible for this resident. This resulted in the resident who was admitted with only occasional incontinence progressing to being frequently incontinent. These findings were reviewed on 7/20/15 at approximately 2:15 PM with E1 (NHA) and E2 (DON). 2. The following information was found in R318's clinical record; 3/26/15- R318 was admitted to the facility with multiple diagnoses, including [MEDICAL CONDITION] ([MEDICAL CONDITION] disorder), history [MEDICAL CONDITION](stroke), malnutrition, weakness, and dementia. 4/1/15 through 4/3/15 a Three day voiding diary was begun. The diary was blank, indicating missed entries on: -4/1/15 from 3:00 PM through 10:00 PM -4/2/15 from 11:00 AM through 2:00 PM -4/3/15 from 3:00 PM through 10:00 PM. 4/2/15 -An admission MDS Assessment indicated R318 was frequently incontinent of bladder. 5/21/15- An order was written for an antibiotic with the [DIAGNOSES REDACTED]. 6/15/15- A quarterly MDS Assessment indicated R318 was always incontinent, a decline from the previous MDS assessment in April. There was no evidence that a voiding diary was done following this assessment. Review of R318's clinical record revealed the facility did not develop a care plan to address the initial level of incontinence, assessed in April at the time of the admission MDS assessment nor following the quarterly MDS assessment in June. During an interview on 7/17/15 at 10:50 AM with E8 unit manager it was confirmed that the voiding diary documentation was incomplete and that a new diary should have been done as well as a care plan to address R318's incontinence. During an interview on 7/20/15 at 10:05 AM E8 confirmed that there were no clinical interventions or responses initiated by the facility to address R318's decline in continence as indicated by being assessed as frequently incontinent on admission in April, then declining to always incontinent in June. E8 stated she was not notified of R318's decline in continence but did receive notification via e-mail on 6/18/15 from the RNAC that R318 had an overall clinical decline. an order for [REDACTED]. Based on the resident's comprehensive assessment the facility failed to ensure that R318, once identified as incontinent of urine was provided appropriate treatment and services to achieve and maintain as much normal urinary function as possible. Following two comprehensive assessments the facility failed to provide evidence that R318 received interventions, treatment, and services to assist in maintain as much urinary continence as possible. These findings were reviewed on 7/20/15 at approximately 2:15 PM with E1, and E2.

Based on record review and interviews it was determined that the facility failed to accurately assess, care plan, and implement measures to prevent the development of a new pressure ulcer (PU) for one (R34) resident and failed to assess the wound weekly for two (R34 and R35) out of 39 sampled residents. The facility failed to accurately assess R34's risk for development of a new PU when R34 was readmitted from the hospital. This failure resulted in the lack of interventions being implemented and R34 acquired a new unstageable left heel PU. Findings include: Cross refer F279, F282, F386 example #1 The facility's policy and procedure for Pressure Ulcer risk assessment documented under assessment "Skin assessment. Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently. Assessment 3.c. Nurses will conduct skin assessments at least weekly to identify changes." 1. R34 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/25/11, R34 was readmitted from the hospital after treatment for [REDACTED]. Skins checks prior to the hospitalization identified no concerns with the left heel and foot. Review of R34's "Braden Scale for Predicting Pressure Sore Risk" dated 1/25/11 revealed that R34 was assessed at "13 or moderate risk" for development of new PU. Interviews with E7 (Wound Care Nurse/WCN) and E3 (Director of Nursing/DON) on 3/11/11 at 10:30 AM revealed that the Braden Scale was incorrectly scored since R34 ' s skin was often moist due to incontinence and should have been assessed as " 12 or high risk. " Review of the nursing "Admission Evaluation and Interim Care Plan" dated 1/25/11 documented that R34 had a pinpoint open area of her sacrum (stage II PU) and that R34's bilateral heels were assessed as "boggy." In addition on 1/28/11 (three days after readmission), E7 documented that when she assessed the heels, they were boggy, however, the heels were blanchable, thus, it was not assessed as PU. Review of R34's care plans revealed that a care plan for "Risk of Pressure Ulcer related to impaired mobility, incontinence, terminal illness, and disease conditions of IDDM and [MEDICAL CONDITION]" was implemented on 8/16/10 with goals that R34 will have intact skin, free of redness, blisters, or discoloration over a bony prominence. On 2/15/11, it was documented that the care plan was reviewed (after the new PU was identified on 2/13/11). Interventions/approaches included: -Weekly skin assessment - Float heels when in bed - Keen heel lift and skin prep. (skin sealant placed topically on skin) implemented on 9/10/10 In addition, on 2/26/11, the above care plan was updated to include the left heel wound with the following interventions implemented on the following dates: -2/14/11 no shoes to bilateral feet secondary to heel wounds -2/26/11 dressing to area and WCN (E7) to assess -3/6/11 bilateral lift heel boot for both feet over a bony prominence. Although the above "Risk for Pressure Ulcer" care plan was updated on 2/26/11 with the actual new PU of the left heel, the facility failed to implement an actual care plan until 3/8/11 (approximately 22 days after the identification of the PU on 2/13/11). Review of the [DATE] readmission orders [REDACTED] - Skin prep. topically to bilateral heel bid (twice a day) - Turn and reposition every two hours - Weekly skin check on Wednesday Review of the January 2011 Treatment Administration Record (TAR) from 1/25/11 through 1/31/11 documented that the skin prep. was administered for five out of 12 scheduled administrations. The "Wound Management Record" dated 1/25/11 documented the presence of one, stage II PU of the sacrum which was reassessed on 1/27/11, 1/31/11, and healed on 2/9/11. R34's quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed that the resident was cognitively impaired for daily decision making, required extensive assistance of two persons for bed mobility and required total assistance for transfer. In addition, R34 had one, stage II PU (location of the PU was the sacrum per the above Wound Management Record dated 1/25/11). Review of R34's current "Certified Nursing Assistant" (CNA) Kardex dated 8/20/10 (with no revision date) (communication utilized to direct care delivery) noted interventions to turn and reposition R34 with assist of two staff members and in addition for "positioning devices", heel lift boot to right heel (no evidence of revision). Although R34 was care planned to float heels in bed and to use the Keen heel lift, the Kardex failed to include these interventions. Review of the January 2011 CNA Resident Care Flowsheet (RCF) record from 1/25/11 through 1/31/11 lacked any evidence of interventions including heel elevation and the use of a Keen heel lift to prevent a new PU. Review of the "Weekly Skin Assessment Record" noted on 1/27/11, skin was intact. The subsequent assessment dated [DATE] (approximately 20 days later) noted " Skin intact, blood blister left heel." Interview with E3 on 3/11/11 at 10:30 AM confirmed that the facility failed to complete the weekly skin assessment. Review of the February 2011 monthly physician's orders [REDACTED]. Review of February 2011 TAR documented that the skin prep. was administered to the heels twice a day for the entire 28 days. A nurse's note (NN) dated 2/13/11 and timed 2:10 PM documented the presence of a dark area on the left heel measuring 5 cm. in length (L) and 4 cm. in width (W) and that the supervisor was notified. In addition, a communication was sent to the E7 (WCN). Record review lacked evidence of a thorough assessment and description of this new PU, notification of attending physician, or the dietician. Interview with the writer of the above NN, E20 on 3/11/11 at 12:35 PM revealed that she recalled the skin was intact and it was not fluid filled such as a blister. In addition, R34 had a heel lift boot on the right heel, however, there was no Keen lift to offload the heels. Subsequent NN dated 2/13/11 and timed 11:30 PM documented "Area to left heel, R/P (responsible party) aware. Tender to touch, elevated off the bed surface. Skin prep. continue." An interview with the writer of this NN, E8 on 3/11/11 at 2 PM revealed that R34 had a heel boot on the right and pillows were being used in an attempt to relieve pressure from the heels, however, with R34's left lower extremity movement, it was determined with discussion with R34 ' s family member that the Keen lift would provide more support in an effort to float the left heel. E8 related that Keen lift was obtained from the supply department since this was not in the resident ' s room and not in use until 2/13/11. An interview with R34 ' s family member on 3/10/11 at approximately 5 PM revealed that on 2/13/11, another family member visited R34 and observed a bed comforter which was rolled up and placed under R34 ' s knees. The family member requested that R34 ' s comforter not be used in an effort to off load the left heel since the heel was directly on the bed and that the family requested the facility to obtain a device to properly relieve pressure. On 2/14/11, new orders were obtained including use of Keen heel lift at all times while in bed, ensure heel elevation. No shoes to bilateral feet secondary to heel wounds. A NN dated 2/23/11 and timed 3:20 PM noted that a CNA (certified nursing assistant) alerted the nurse to drainage on R34's bed linen coming from left heel. The nurse "looked at wound care notes to see if the area was new, according to notes it was viewed by the WCN (E7) the day before and was a brown scab. Area appears large blood blister draining serosanguineous. DSD (dry sterile dressing) applied to absorb drainage and M.D. requested WCN to look at , wound communication sent to WCN and dietician. Daughter at BS (bedside) and aware of site." An interview with E7 on 3/9/11 at approximately 11 AM revealed that she was not working in the facility from 2/20/11 to 2/28/11, thus, she became aware of the new PU on 2/28/11 upon her return to the facility. Subsequently on 3/1/11 (approximately 16 days after initial identification), E7 assessed the new skin impairment as a "blood blister." E7 further relayed that in her absence, the staff nurses and unit managers were responsible to complete the assessment of the new skin impairment, however, no evidence was provided during the survey that this was completed. Although E7 reported that she was not working on the above dates, WCN NN dated 2/22/11 noted that E7 assessed the right lateral foot which had a brown scab and did not mention the new PU of the left heel. Review of R34's "Wound Management Record" dated 3/1/11 documented a new in house acquired left heel firm intact blood blister with dimensions of 3 cm. L and 5 cm. W. Review of February 2011 TAR and CNA RCF revealed that beginning on 2/14/11 through 2/28/11, the interventions of " Keen heel lift at all times while in bed. Ensure heel elevation " were initialed by both licensed nursing staff and CNAs indicating that these interventions were consistently implemented. Although E7 recalled that the Keen heel lift was re-implemented upon R34's readmission on 1/25/11, interviews with E20 and E8 on 3/11/11 as noted above and interviews with three CNAs (E18, E17, and E21) who provided care to R34 between 2/11/11-2/13/11 revealed that they do not recall a Keen heel lift being used to off load the left heel. One of the CNA's reported to the surveyor that the CNAs had expressed concerns that the CNA Kardex and the CNA RCF are not current and does not reflect the current care needs of the residents for whom they provide care, however, the facility has not acted upon these concerns. An additional E24 (CNA) who provided care to R34 on 2/13/11 was interviewed on 3/21/11 and informed the surveyor that she recalled that the Keen heel lift was always utilized when R34 was in bed including on 2/13/11 when the unstageable PU was noted on R34's left heel. E24 related that the CNAs would document on the RCF if the intervention, such as a Keen heel lift was implemented. Record review and staff interviews lacked evidence that the facility implemented interventions to relieve pressure from R34's left heel, thus, resulting in a new unstageable PU of the left heel. Review of March 1, 2011 orders noted the following additional interventions were implemented: -Skin prep bilateral heels TID (three times a day) -Float heels at all times -Heel lift boot to R/L (right and left) at all times (The left heel boot to relieve pressure) -Assess for proper placement of boots every shift Review of care plan for "...left heel PU" implemented 3/8/11 (approximately 23 days after the identification of this new PU on 2/13/11) included the following approaches: - Bilateral heel boots and to float heels - Keen heel lift implemented on 3/11 (actual order and implementation date of 2/14/11) On 3/8/11 at 10:45 AM, the surveyor accompanied E7 to observe R34's left heel. The left heel had the presence of a 2 cm. (L.) by 3 cm. (W.) unstageable PU with eschar. Subsequent review of R34's "Wound Management Record" for the left heel noted that late documentation entry was made following the above observation on 3/8/11 which incorrectly noted that the stage of the PU on 3/1/11 was stage II. 2. Cross refer F386-example 2 R35 had [DIAGNOSES REDACTED]. Review of R35's wound sheets dated 9/13/10 revealed R35 acquired a sacral decubitus. The wound was assessed and documented on 9/13, 9/20 and then 10 days later on 9/30/10. On 10/14/10 (10 days later) R35's wound sheet documented her sacral wound was macerated and deteriorated. The facility failed to assess R35's sacral wound weekly as indicated by their policy and procedures. Review of the weekly skin assessment record for R35 dated 9/22/10 revealed there was no documentation concerning the assessment of R35's sacral wound. Review of the physician progress notes [REDACTED]. Review of the documentation and clinical record on 3/9/11 at 11:30 AM with E7 (wound nurse), E10 (nurse), and E3 (DON) confirmed that on two separate occasions 9/30/10 and 10/14/10 R35's sacral wound was not specifically assessed and documented weekly as indicated in their policy and procedure.