Every finding on record at Optalis Health & Rehabilitation of Ionia

This citation pertains to intake 2634030. Past Non-Compliance was determined appropriate by the state agency for this citation. Plan outlined below. Based on interview and record review, the facility failed to follow policies and procedures to report misappropriation of resident money for 1 (R34) of two residents reviewed for misappropriation. Findings include:Review of a Facility Reported Incident (FRI) submitted to the State Agency (SA) on 9/22/25 when an allegation regarding Activities Aide (AA) K took $135.00 from R34. Review of a Concern Form dated 9/19/25 at 7:45 PM revealed the daughter reported to staff that AA K took $143 dollars from R34 earlier in the week. AA K was to take the money to buy R34 a phone and then used it for her daughter's birthday instead. R34 and her daughter were very upset. In an interview on 3/25/26 at 12:32 PM, the Nursing Home Administrator (NHA) reported any abuse including misappropriation should have been reported immediately and she did report it on 9/22/25 when she was notified of the incident. The NHA verified the incident was reported to staff on 9/19/25. Review of the Abuse policy last updated 5/24/23 revealed: Residents have the right to be free from abuse, neglect, exploitation, mistreatment, and misappropriation of resident property. PROTECTION: . Any allegation of abuse must be immediately reported to the supervisor and the Abuse Prevention Coordinator. INITIAL REPORTING: The facility will ensure that all allegations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of resident property, and crimes are reported immediately to the Administrator and: . Reported to the State Survey Agency no later than 24 hours if the allegation does not involve abuse and does not result in serious bodily injury . On 3/25/26 the surveyor verified the following interventions were put into place and were effective in bringing the facility into compliance: - Facility policy and procedures for abuse were reviewed.- All staff were educated on the facility policy for abuse and when to report allegations to the NHA. -All residents affected and/or potentially affected were assessed and no negative outcomes were noted.-The NHA verified there were no other allegations/incidents that were reported late to ensure compliance. -During this survey, this surveyor reviewed documentation, conducted interviews, and made observations that the preceding interventions were completed prior to the survey and no continuing issues related to this citation were noted. A determination of past non-compliance was approved by the State Agency as of 1/27/26.

This citation pertains to intake 2634030. Past Non-Compliance was determined appropriate by the state agency for this citation. Plan outlined below. Based on interview, and record review, the facility failed to prevent misappropriation of money for 1 (R34) of 2 residents reviewed for misappropriation.Findings include:Review of a Face Sheet revealed R34 had pertinent diagnoses of major depressive disorder, diabetes, and heart failure. Review of the Care Plan for R34 revealed the resident had behaviors of making false accusations against staff or family and at times can be delusional and confabulates if she does not recall events or remembers where she puts stuff. Review of a Facility Reported Incident (FRI) submitted to the State Agency (SA) on 9/22/25 when an allegation regarding Activities Aide (AA) K took $135.00 from R34. Review of a Concern Form dated 9/19/25 at 7:45 PM revealed the daughter reported to staff that AA K took $143 dollars from R34 earlier in the week. AA K was to take the money to buy R34 a phone and then used it for her daughter's birthday instead. R34 and her daughter were very upset. Review of a written Statement dated 9/20/25 from AA K revealed: This is what you gave me $135.00; I got 140 in here. Your daughter said I'm stealing it when you offered to help with my daughter party. I'm no thief. I'm quitting after I give you the money. I thought we were on same page. In an interview on 3/24/26 at 1:30 PM, R34 reported she remembered when AA K took her money from her but did not recall getting the money back. During an interview on 3/25/26 at 11:40 PM, Social Worker (SW) D assisted with reaching out to R34's daughter who was with R34 and able to witness when AA K gave $140.00 back to R34. In an interview on 3/25/26 at 12:32 PM, the Nursing Home Administrator (NHA) reported during her investigation R34 did receive her money back and AA K quit her job and did not come back to work at the facility. Review of the Abuse policy last updated 5/24/23 revealed: Residents have the right to be free from abuse, neglect, exploitation, mistreatment, and misappropriation of resident property. On 3/25/26 the surveyor verified the following interventions were put into place and were effective in bringing the facility into compliance: -Facility policy and procedures for abuse were reviewed.-All staff were educated on the facility policy for misappropriation and taking money from residents.-All residents affected and/or potentially affected were assessed and no negative outcomes were noted.-The NHA conducted weekly audits after the incident to ensure compliance and no concerns were noted.-During this survey, this surveyor reviewed documentation, conducted interviews, and made observations that the preceding interventions were completed prior to the survey and no continuing issues related to this citation were noted. A determination of past non-compliance was approved by the State Agency as of 9/22/25.

Based on observation, interview, and record review the facility failed to ensure safe transfer practices for 1 resident (R94) of 3 residents reviewed for accidents and falls.Findings include:Review of a Face Sheet revealed R94 admitted to the facility on [DATE] with pertinent diagnoses which included dementia, difficulty walking, and lack of coordination.Review of a current activities of daily living Care Plan intervention for R94, initiated 3/21/2026, directed staff that R94 required physical assistance of one staff member and a gait belt for transfers and ambulation.During an observation and interview on 3/23/2026 at 11:20 AM in R94's room, R94 ambulated into her bathroom using her walker without the assistance of staff. Competency Evaluated Nursing Assistant (CENA) B observed R94 ambulating without assistance and walked her the rest of the way into the bathroom without using a gait belt. CENA B stayed with R94 in the bathroom and then assisted her back to bed after toileting without using a gait belt. CENA B stood behind R94 as she walked and was not holding onto R94 in any way. After exiting the room, CENA B reported R94 required the assistance of 1 staff and a gait belt for ambulation. CENA B reported she was unable to find a gait belt in the room and did not have a gait belt on her person to use.During an interview on 3/25/2026 at 12:44 AM, the Director of Nursing (DON) reported staff were required to use gait belts to assist residents that require assistance with ambulation. The DON reported gait belts should be in the room. The DON reported that if staff find themselves in a bathroom with a resident without a gait belt in reach, they could pull the call light to gain assistance from other staff in finding a gait belt to use during the transfer.Review of facility policy/procedure Gait Belt Use, reviewed 2/3/2026, revealed .To maintain a safe working environment, gait belts shall be used when transferring/lifting and walking a resident, unless otherwise indicated. It is recommended that a gait belt be worn by the resident during manual staff assisted transfers, lifting, and ambulating a resident.

Based on observation, interview, and record review the facility failed to 1) maintain proper enhanced barrier precautions for two residents (R14 and R41) of 5 residents reviewed and 2) fully implement a water management plan.Findings include:On 03/23/2026 at 2:50PM, observed two water lines, 6 inches out from the wall surface, that are not in use coming out of the wall, under the dirty dish table. The water lines were capped; one had a faucet handle on it and the other had the hardware to place a faucet handle on the line. Maintenance Director (MD) L was asked the status of the water lines; MD L stated that the lines were not currently on the flushing schedule and was unsure if the lines had access to water. On 03/24/2026 at 8:22AM, MD L, states the capped water lines under the dirty dish table, do have access to water. MD L removed the cap and used the faucet handle to turn on the line and water was observed coming out of the line. Record review of the undated Water Management Program Policy states an annual review and risk assessment will take place. R14 During an observation on 3/23/26 at 10:30 AM, Competency Evaluated Nursing Assistant (CENA) E and Hospice Competency Evaluated Nursing Assistant (CENA) G entered room [ROOM NUMBER] bed 1 to complete a transfer with R14. CENA E did not don (put on) gloves or a gown. CENA G donned gloves but no gown. The two staff members proceeded to transfer R14 using a lift into her chair. CENA E then donned gloves and emptied R14's foley catheter cleansing the tip with an alcohol pad. CENA E then sanitized her hands. CENA G returned to room [ROOM NUMBER] bed 1 and made R14's bed without donning a gown or gloves. In an interview on 3/23/26 at 10:40 AM, CENA E reported that the Enhanced Barrier Precautions sign on 30 bed 1's door meant she should have been wearing a mask during care. CENA stated that almost all the resident's doors have these signs and she was unsure why. When asked if CENA E received education regarding Enhanced Barrier Precautions she stated no. In an interview on 3/23/26 at 10:41 AM, Hospice CENA G reported that he did not realize what the sign was for. Hospice CENA G was asked if he received education related to Enhanced Barrier Precautions and he stated no. Review of Active Orders on 3/23/26 revealed R14 had orders for Enhanced Barrier Precautions related to an indwelling catheter. During an observation on 3/24/26 at 8:24 AM CENA C and CENA H entered room [ROOM NUMBER] bed 1 to complete a transfer using a lift. CENA C and CENA H donned gloves but no gown. Transfer for R41 was completed and the two staff exited the room after using sanitizer on their hands. In an interview on 3/24/26 at 8:30 AM CENA C stated that the sign on the door meant to gown up just with catheter care for R41. In an interview on 3/24/26 at 8:31 AM CENA H stated that the sign on the door meant to gown up just with catheter care for R41. Review of Active Orders on 3/24/26 revealed R41 had orders for Enhanced Barrier Precautions related to an indwelling catheter. Review of Enhanced Barrier Precautions posting on R14 and R41's door revealed staff were required to don gloves and a gown for high contact resident care activities including dressing, bathing, showering, transferring, changing linens, providing hygiene, changing briefs, and catheter care. In an interview on 3/24/26 at 10:00 AM the Director of Nursing (DON) reported that her expectation for staff would be to follow the Enhanced Barrier Precautions policy. Review of facility policy Enhanced Barrier Precautions revised 2/6/26 revealed that Enhanced barrier precautions required gown and glove use during high-contact resident activities.

Based on interview and record review, the facility failed to provide adequate notice of non-coverage and maintain documentation for two residents (Resident #33 and Resident #78) of 3 residents. Findings include:R33 Review of a Face Sheet revealed R33 admitted to the facility on [DATE] with pertinent diagnosis which include Cerebral Infarction (blocked blood flow to the brain), hypertension, and heart failure. Review of R33's admission Evaluation Assessment dated 3/5/26 revealed R33's discharge goal was to discharge to prior living setting. Review of R33's Social Work progress note dated 3/12/26 revealed her discharge plan was to return home alone. Further review of R33's progress notes dated 3/13/26 revealed the social worker spoke with R33 and her discharge was confirmed for 3/18/26. Review of R33's Discharge Summary dated 3/17/26 revealed R33 had worked with PT/OT (Physical Therapy and Occupational Therapy) and met goals to return home with family support and was stable to discharge. Review of R33's Weekly Medicare Note dated 3/17/26 revealed R33 had progressed well and would be discharged home on 3/18/26. Review of a Beneficiary Notification Review for R33 provided by the Nursing Home Administrator (NHA) on 3/25/25 revealed a Notice of Medicare Non-coverage (NOMNC) was not provided to R33 at the end of her Medicare A coverage. In an interview on 3/25/26 at 10:00 AM the Director of Therapy (DT) F reported that the facility had a weekly Medicare meeting in which planned discharges were discussed and when residents would be cut (when a resident reached goals and no longer skilled to utilize Medicare A) from therapy. DT F reported that R33 had obtained the goals that were planned and R33 was killing her goals before she was discharged home. DT F reported that therapy should have initiated a NOMNC for the end of therapy. R78 Review of a Face Sheet revealed R78 admitted to the facility on [DATE] with pertinent diagnosis which included heart failure, acute respiratory failure, and malnutrition. Review of R78's admission Evaluation Assessment dated 9/10/25 revealed discharge goal was to discharge to prior living setting. Review of R78's Weekly Medicare Note dated 9/16/25 revealed her goal was to discharge home with daughter and resident had made functional gains with therapy. Review of R78's Weekly Medicare Note dated 9/23/25 revealed her goal remained to discharge home with daughter and she continued to make functional gains with therapy. Review of R78's Weekly Medicare Note dated 9/30/25 revealed she continued to make functional gains. Discharge plan was to transfer home with granddaughter and therapy noted resident had ambulated 60 ft with a 2 wheeled walker and minimal assistance with a potential LCD (last covered day) being 10/9/25 with a discharge on [DATE]. Review of R78's Weekly Medicare Note dated 10/7/25 revealed her plan was to discharge home with granddaughter on 10/10/25 with LCD 10/9/25. Review of R78's Discharge Summary dated 10/9/25 revealed she had worked with PT and met goals to return home with family support and that resident was stable for discharge. Review of a Beneficiary Notification Review for R78 provided by the Nursing Home Administrator (NHA) revealed a NOMNC was not provided to R78 at the end of her Medicare A coverage. In an interview on 3/25/26 at 10:00 AM Director of Therapy (DT) F reported that the facility had a weekly Medicare meeting in which planned discharges were discussed and when residents would be cut (when a resident reached goals and no longer skilled to utilize Medicare A) from therapy. DT F reported that R78 had obtained the goals that were planned. DT F reported that therapy should have initiated a NOMNC for the end of therapy. In an interview on 3/25/26 at 10:30 AM Social Service Director (SSD) D reported that the facility held a weekly Medicare meeting in which residents receiving Medicare A benefits are discussed along with discharge date s and equipment, home health and other equipment a resident may need after discharge. SSD D stated that R33 and R78 did not have a NOMNC provided to them. Review of a NOMNC form CMS-10123 revealed Skilled nursing facilities must provide the notice when all Medicare-covered skilled services end. This protocol is intended to evaluate a nursing home's compliance with the requirements to notify Medicare beneficiaries when the provider determines that Medicare Part A coverage is ending or when services may no longer be covered.

Based on observation and interview, the facility failed to provide a homelike environment for 11 rooms of 11 rooms reviewed for cleanliness and maintain comfortable temperatures in the Memory Care Unit.Findings include:On 03/23/2026 at 2:43PM, observed a temperature difference between the hallway and the spa room on the Memory Care Unit. The spa room felt cooler than the hallway and temperature readings were taken to determine temperature of the room. An air temperature was taken using a rapid read digital thermometer, temperature read 69F. A separate temperature was taken using an infrared thermometer off the tile wall, temperature was 64F. Maintenance Director (MD) L said that 69F seemed cool for a shower room. MD L indicated that there were heating fixtures on the walls in the spa room that could be turned on for additional heat. Equipment was not turned on at time of observation. On 03/23/2026 at 2:45PM observed temperature in hallway of the Memory Care Unit, was at 70F. Temperature was taken using an infrared thermometer, next to the entrance to the Spa room. MD L stated the thermostat on the wall by the nurses' station controlled the temperature for the Memory Care unit On 03/23/2026 at 2:46PM, observed the thermostat was set at 71F. During an observation on 3/23/26 at 9:33 AM, the initial tour of the facility revealed rooms 31-42 (11 rooms total) had dirty floors with debris and a heap of caked on dirt that outlined the floor tiles and scattered caked on dirt that was not easily removable. During an Observation and an interview on 3/24/26 at 12:48 PM, Housekeeper (HK) I reported the floors were hard to clean but they do sweep and mop the floors. HK I reported the floor buffer machine has not been used for at least 6 months. At this time, we entered room [ROOM NUMBER] and HK I verified the flooring had a caked-on dirt outlining the tiles and reported it just didn't come off the floor. During an observation and an interview on 3/24/26 at 12:56 PM, HK J reported rooms 31-42 looked dirty because they were sealed and waxed without stripping the floors first and now the dirt will not come up off the floors. At this time a paper towel was used to try to wipe away the heaped-up dirt in the cracks of the tile and the scattered dirt caked on top of the tile without success. The bathroom lighting fixture had 3 bugs trapped in the fixture, the toilet had a sealant around the base that was cracked and peeling.

This citation pertains to Intake #2566577 and #2575897. Based on interview and record review, the facility failed to ensure dignified care was provided for 2 residents (R100 and R101) of 4 residents reviewed for dignity. Findings include:R100 Review of an admission Record revealed R100 admitted to the facility on [DATE] with pertinent diagnoses which included fibromyalgia, difficulty in walking, and left hip contusion. Review of a Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) assessment for R100, with a reference date of 7/8/2025 revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15, out of a total possible score of 15, which indicated R100 was cognitively intact. Further review of the same MDS assessment revealed R100 was occasionally incontinent of urine and required staff assistance with toileting. Review of a current activities of daily living (ADL) Care Plan intervention for R100, initiated 7/7/2025, revealed resident required the assistance of 1 staff with ADLs. In a telephone interview on 8/21/2025 at 11:13 AM, R100 reported when Competency Evaluated Nursing Assistant (CENA) A awaked her for a meal she realized that she had been incontinent of urine and requested assistance to be changed. R100 reported CENA A stated maybe you should have gotten up before you wet yourself. CENA A left the room and told R100 she would return after she finished passing meal trays. R100 reported CENA A never returned to the room to assist and she ended up getting up and changing herself an hour later, knowing that she was not supposed to do this without assistance. R100 reported this event made her feel frustrated, helpless, and depressed. R100 stated It seemed like they didn't want to take care of me, I called my mom crying multiple times. In an interview on 8/26/2025 at 2:35 PM, CENA A reported she went into R100's room with a meal tray and R100 reported she was wet. CENA A reported she told R100 that she would return after she finished passing trays but forgot to return. CENA A reported she did this with another resident at a later date and a supervisor told her that she needed to stop passing meal trays to clean up a wet or soiled resident rather than waiting until she was done passing trays. In an interview on 8/29/2025 at 9:10 AM, the Director of Nursing (DON) reported CENAs should stop passing meal trays to assist residents that are wet or soiled to provide care. R101 Review of an admission Record revealed R101 admitted to the facility on [DATE] with pertinent diagnoses which included depression and apraxia (difficulty with skilled movement). Review of a Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) assessment for R101, with a reference date of 7/10/2025 revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15, out of a total possible score of 15, which indicated R101 was cognitively intact. Further review of the same MDS assessment revealed R101 required staff assistance with toileting. Review of a current ADL Care Plan intervention for R101, initiated 2/3/2022, revealed R101 required the assistance of 1 staff for toileting. In an interview on 8/26/2025 at 9:30 AM, R101 reported she waited up to 30 minutes for help after pressing the call light. R101 reported the previous week that she pressed her call light and waited over 20 minutes for staff to respond. R101 reported she wet herself while waiting and this made her feel dehumanized. Review of facility/procedure Resident Rights, issued 11/12/2024, revealed residents have a right to a dignified existence including to .be treated with dignity and respect. reasonable accommodation of needs and preferences.

This citation pertains to Intake #2575897. Based on interview and record review, the facility failed to provide showers for 2 dependent residents (R101 and R103) of 4 residents reviewed for accommodation of needs. Findings include:R101 Review of an admission Record revealed R101 admitted to the facility on [DATE] with pertinent diagnoses which included depression and apraxia (difficulty with skilled movement). Review of a Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) assessment for R101, with a reference date of 7/10/2025 revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15, out of a total possible score of 15, which indicated R101 was cognitively intact. Further review of same MDS assessment revealed R101 required staff assistance with showering. Review of a current ADL Care Plan intervention for R101, initiated 2/3/2022, revealed R101 required the assistance of 1 staff with showering. Review of the facility Back Unit Shower List revealed R101 was scheduled to receive showers on Sunday and Thursday evenings. In an interview on 8/29/2025 at 9:36 AM, R101 reported she went for a couple weeks in July without receiving her scheduled shower. R101 reported this made her feel dirty. Review of R101's shower documentation revealed she received a bed bath instead of a shower on scheduled shower days on 7/10/2025, 7/17/2025, 7/24/2025, 7/31/2025, 8/7/2025, and 8/17/2025. Further review revealed R101 went without a shower for two weeks from 7/13/2025 until 7/27/2025. Review of R101's Concern Form, dated 7/31/25, revealed .No shower for two weeks July 14th through July 26th. R103 Review of an admission Record revealed R103 admitted to the facility on [DATE] with pertinent diagnoses which included depression, anxiety, and history of falling. Review of a Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) assessment for R103, with a reference date of 7/12/2025 revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 14, out of a total possible score of 15, which indicated R103 was cognitively intact. Further review of the same MDS assessment revealed R103 required staff assistance with showering. Review of a current ADL Care Plan intervention for R103, initiated 1/3/2023, revealed R103 required the assistance of 1 staff with showering. Review of the facility Back Unit Shower List revealed R103 was scheduled to receive showers on Monday and Friday evenings. In an interview on 8/26/2025 at 2:10 PM, R103 reported she preferred to receive showers and not bed baths but about 3 times a month she received bed baths instead of showers. R103 reported receiving bed baths instead of showers made her feel dirty and like her hair wasn't clean. Review of R103's shower documentation revealed she did not receive a shower or bed bath on 8/1/2025. Further review revealed R103 received a bed bath instead of a shower on scheduled shower days on 8/15/2025, 8/18/2025, and 8/25/2025. In a telephone interview on 8/29/2025 at 8:05 AM, Competency Evaluated Nursing Assistant (CENA) G reported staff try to give scheduled showers instead of bed baths but sometimes they have staffing issues or resident care issues that prevent them from being tied up in the shower. CENA G reported staff will give bed baths instead of showers in these circumstances. In an interview on 8/29/2025 at 9:45 AM, CENA J reviewed R103's shower documentation from 8/18/2025 and reported she was working a double that day, staffing was short, and sometimes she will provide a bed bath instead of a shower if there is not enough time to provide a shower. In an interview on 8/29/2025 at 9:10 AM, the Director of Nursing (DON) reported resident preference for showers over bed baths should be met. Review of facility/procedure Resident Rights, issued 11/12/2024, revealed residents have a right to a dignified existence including to .be treated with dignity and respect. reasonable accommodation of needs and preferences.

Based on observation, interview, and record review, the facility failed to implement a) Accurate monthly infection surveillance, b) Conduct an outbreak investigation, and c) Properly store oxygen supplies according to the facility Infection Control plan, program and policies for one resident (R25) of six residents reviewed for Infection Control. Findings: During a comprehensive interview pertaining to the facility Infection Control Program, on 3/6/25 beginning at 9:30 AM, Infection Control (IC)/Licensed Practical Nurse (LPN) reported that he organized a monthly infection report and presented the findings during the monthly Quality Assurance Process Improvement (QAPI) meetings. A review of the IC process revealed that when a resident is prescribed an antibiotic, a review of McGeer's criteria (a set of clinical laboratory definitions used to diagnose and monitor infections in long-term care facilities) is conducted and supporting documentation is obtained and/or validated. Once a diagnosed infection is identified, IC/LPN C maps the infections and includes the infections on a line listing. During an interview on 3/6/25 at 9:30 AM, Infection Control (IC)/Licensed Practical Nurse (LPN) C reported that in January 2025 both R1 and R64 had been sent to the hospital for suspected infections. IC/LPN C reported the hospital sent the residents back with orders for antibiotics which were continued in the facility despite laboratory and x-ray analysis that would not indicate either resident had an infection. IC/LPN C reviewed the Electronic Medical Record (EMR) for each resident and did not identify evidence the facility provider documented a rationale for continuing the antibiotic treatment. The facility infection mapping and infection line list reflected that despite neither resident having an infection, the residents were included in the overall rate of infection for the month of January, 2025. During the Infection Control interview on 3/6/25 beginning at 9:30 AM, IC/LPN C reported the facility had a COVID-19 outbreak in December of 2024. IC/LPN C reported they had not conducted an Outbreak Investigation per policy and had not incorporated an investigation into employee illnesses that may have impacted the spread of COVID-19 amongst residents. IC/LPN C said they did not distinguish COVID-19 from other respiratory illness on the mapping tool used to identify trends, cluster and/or outbreaks at the facility. Review of the facility policy Outbreak Investigation reflected C. The Infection Preventionist will gather and compile date related to the infection(s) as follows: 1. Conduct case finding (review ongoing surveillance charts of other patients at risk and microbiology reports) to determine whether there have been other cases of infection. 2. Evaluate previous experience with the infection. 3. Prepare a line listing of cases to include: resident, room number, date of admission, date of infection onset, site culture results, and physician. 4. Plot number of cases by date of onset (epidemic curve). 5. Review charts of cases and interview involved personnel for various factors that conceivably may have played a role in transmission of an infection, e.g., geographic locations of residents, specific personnel having contact with residents, medications and treatments administered. 6. Review various infection prevention techniques (hand hygiene, use of standard precautions, etc.) as actually practiced in the facility. 7. Maintain surveillance for occurrence of any further infections. VII. ANALYSIS OF DATA - The data collected in the preliminary investigation are reviewed by the investigators to determine whether a common source of infection, break in technique, etc., can be implicated as a cause of the epidemic. A preliminary written report will be prepared. A final written report of the investigation, outlining findings and recommendations, is prepared by the investigation coordinator and issued to the infection prevention committee, others participating in the investigation, medical director, attending physician(s), director of nursing, and others as needed. 31771 Resident #25 R25 Review of the medical record reflects R25 admitted to the facility 4/21/21 and has pertinent diagnoses that include heart failure, chronic obstructive pulmonary disease (COPD) and pneumonia. On 3/4/25 at 9:59 AM an observation and interview were conducted with R25 in his room. R25 reported he uses oxygen all of the time and has a tank on his wheelchair to use when he is out of bed. An oxygen tank was observed in a holder on his wheelchair. The tank had nasal cannula tubing attached and was draped over his wheelchair. Next to the bed on a chair a nebulizer machine was noted with a nebulizer mask laid on a paper towel and rested on a depression on the top of the nebulizer machine. An empty clear plastic storage bag was observed tied to the handle of the nebulizer machine. Review of the Medication Administration Record (MAR) for March 2025 for R25 reflected a nebulizer treatment was administered 3/3/25 at 8:54 PM and the mask remained un-stored as of the observation on 3/4/25 at 9:59 AM. On 3/5/25 at 9:28 AM an observation was made in the room of R25 that the nasal canula tubing and the nebulizer mask remained un-stored and open to air as observed on 3/4/24 at 9:59 AM. Review of MAR for March 2025 for R25 reflected the Resident has received a nebulizer treatment by third shift on 3/5/25 at 5:30 AM and the nebulizer mask remained un-stored as of 9:28 AM, as noted. On 3/5/25 at 2:24 PM in an interview was conducted with the Director of Nursing (DON) in her office. The DON reported an expectation that oxygen tubing and devices are to be stored in a plastic bag when not in use. On 3/5/25 at 2:39 PM an interview was conducted with Infection Control Preventionist (ICP) C. ICP C reported that from an infection control perspective oxygen equipment should be stored in the clear plastics storage bags when not in use. ICP C reported nebulizer masks are cleaned following a nebulizer treatment and air dried first but should be stored in the clear storage bags shortly after cleaning. On 3/6/25 at 7:40 AM the nasal cannula tubing attached to the oxygen tank on the wheelchair of R25 was observed to be draped over the chair and not stored in a clear plastic bag. On 3/5/25 at 10:03 AM a request was emailed the Nursing Home Administrator (NHA) for the facility policies for Oxygen, Oxygen Devices - CPAP, tubing, etc. The policy provided by the facility titled Subject: Oxygen Therapy dated 7/11/2018 was reviewed. This policy reflected Precautions and/or possible complications . 5. Bacterial contamination associated with certain nebulizers and humidifiers may occur And All O2 equipment will be checked daily by Respiratory Therapist/Nurse for proper function, prescribed flow rate. However, this policy does not provide direction for safe storage of O2 equipment when not in use. The policies provided by the facility titled CPAP/BIPAP Support (oxygen devices used primarily while sleeping) dated 7/26/2018 and the facility policy titled Infection Prevention and Control .Subject: Oxygen Use revised 9/24/2018 were reviewed and neither policy provided direction on the safe storage of oxygen equipment when not in use. No other oxygen care related policies were provided by the facility. On 3/6/25 at 10:52 AM during an interview Licensed Practical Nurse (LPN) E indicated oxygen tubing and devices must be stored in the plastic bags when not in use and are changed out weekly usually by third shift. LPN E was informed that none of the policies provided by the facility provided instruction on the proper storage of oxygen devices and was asked how she knew to do this? LPN E reported she knows how to properly store oxygen equipment because of years of being a nurse and indicated this is a infection prevention practice.

Based on observation, interview, and record review, the facility failed to investigate, analyze, and implement meaningful interventions to prevent repeated falls for two Residents (R32 and R117) of three residents reviewed for accident hazards. Findings include: R32 Review of R32's face sheet dated 3/5/25 revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included dementia, lack of coordination, falls, restlessness and agitation. She was not her own responsible party. R32 was observed in bed on 03/04/25 at 10:04 AM. R32 had her eyes open, she was holding a hairbrush. R32 did not respond to her name or any questions. R32 had bruises covering a large portion of her face and forehead. R32 was observed on 3/5/25 at 9:12 AM up in her wheelchair in a hall in the facility. She was not near her room and there were no staff in sight of her location. R32 did not have a comb or brush in her hand. R32 did not respond to any questions. Review of R32's care plan, initiated on 11/8/2019, revised 9/30/2024 revealed R32 had the cognitive capacity of a 2-year-old. Review of R32's fall care plan dated 8/31/22 revealed, Potential for injury to falls d/t (due to) developmental delayed (functional age of 2 yo (year old) dementia, no safety awareness, impulsive, little to no ability to communicate needs, needs for assistance for safe transfers, psychotropic medications, seizures, hx (history) of falls, attempts to reach things on the floor, place self on floor to retrieve dropped items and returns unassisted to w/c (wheelchair). There were no interventions to provide supervision or to offer supervised activities when R32 was awake located in R32's medical record. During an interview with the Director of Nursing (DON) on 3/5/25 at 4:23 PM, the surveyor questioned if all the information related to R32's falls was provided as requested. The only documentation that was received was incident and accident reports. The reports did not include any investigation, interventions, staff statements, analysis or interventions placed after the fall. The incident and accidents were just a summary of what the nurse saw when R32 was found on the floor and any initial injuries noted. There was no indication of R32's care or condition prior to the fall. The DON said she had some statements and a post fall tool for some of the falls, however the Certified Nurse Aides (CNA's) were not consistent at filling out the post fall tool. The DON said the post fall Interdisciplinary (IDT) notes would have more information. The surveyor asked where the IDT was getting the information to implement interventions if they did not have information on the resident's condition prior to the fall and the DON did not have any information. The DON said she would look for all additional information. Review of R32's incident and accident report dated 12/22/24 at 18:00 (6:00 PM) revealed the resident was found on the floor in her room next to her toy box and her toys were scattered throughout the room. No injury noted. Review of R32's Interdisciplinary Team (IDT) Note dated 12/23/24 at 9:25 AM revealed the same information as the incident report dated 12/22/24 at 6:00 PM with the additional information that R32 was sent to the Emergency Department (ED) for treatment of an acute condition. No information on the acute condition was provided. No information on fall prevention was provided. Review of R32's incident and accident report dated 1/3/25 at 19:30 (7:30 PM) revealed. This nurse was standing at med (medication) cart in the hallway when I heard a crash, went to check on it an observed patient on the floor in her room just inside the doorway, I want a coke. Resident had a bruise on her forehead and was sent to the ED (emergency department) for evaluation. Review of R32's incident and accident report dated 2/22/25 at 00:00 (midnight) revealed, CNA (certified nurse aide) yelled out that she needed help in pt's (patients) room. Upon arrival pt (patient) was lying on the floor bleeding from above her left eye. Pt (patient) states that she dropped her combs and was trying to pick them up. Vital signs obtained and abrasion cleaned. No CNA statement found or information on R32's condition prior to the fall was located. Review of a late IDT note dated 2/24/25 at 13:21 (1:21 PM) revealed the same information in this note as the incident and accident report dated 2/22/24 at midnight and additional information of R32 being sent to the emergency department at 18:50 (6:50 PM). 18.5 hours after the fall with injury because R32 required treatment for a laceration. No indication of the size or location of the laceration was documented. The only intervention was emergency treatment of the laceration. No future fall prevention interventions were located. Review of a Post incident CNA report for R32 dated 2/22/25 reflected R32 was weak from being sick and the CNA (Certified Nurse Aide) recommended R32 be supervised in her room when she was in her wheelchair. Review of R32's fall care plan revealed no supervision intervention in place when resident is up in her wheelchair. Review of R32's incident and accident report dated 3/1/25 at 18:00 (6:00 PM) revealed, summons to room by staff pt (patient) was lying near her activity table, toys were scattered, pt (patient) Comb comb Combs were in her hand, pt (patient) was assessed to no apparent injuries, hips palpated symmetrical, no internal or external rotation was noted, no change in LOC (level of consciousness) or Neuro's (neurological), resident was clean and dry, gripper socks on, no environmental factors involved, CNA (Certified Nurse Aide) was with bed 1 and was not witnessed, pt (patient) was assisted to bed by staff, on call provider and DPOA (durable power of attorney) was notified, table to be removed as had previous incidents with her table and toys, staff to ensure she has her combs, toy table to be assessed by therapy for safety concerns. The DON provided one post incident CNA report dated 3/1/25 and revealed resident was last observed on 3/1/25 at 4:55 PM and R32 was in her room at that time. The floor was clean, and no toys were dropped. No recommendations were made for prevention of future falls. Review of R32's IDT note dated 3/3/25 at 9:19 AM revealed the same information that was in the incident report dated 3/1/25 at 6:00 PM with the additional information of limiting combs and attaching the activity table to the wall. No intervention for supervision on increased assistance was located. During an interview with the DON and Nursing Home Administrator (NHA) on 3/6/25 at 9:45 AM. The facility policy and procedure for Falls was reviewed. The policy did not provide any information on investigation, analysis, or care planning of meaningful interventions after a fall. The focus of the policy was with dealing with injuries related to assessing the resident for injuries after a fall. There was no mention of prevention of further falls. The 4 falls R32 had from 12/22/24 to 3/1/25 were reviewed and they said they had provided all information they had related to those falls. They confirmed that R32 was severely cognitively impaired and had no safety awareness. They could not locate any interventions for supervision when she was up in her wheelchair or any supervised activities. They said at one point her toys were placed in the hall but that became a concern for another resident. No other activity or supervision was placed after R32's toy were placed in her room. R117 Review of R117's Minimum Data Set (MDS) dated [DATE] revealed R117 was [AGE] years old and was admitted to the facility on [DATE] with diagnoses that included stroke and dementia. R117 had a Brief Interview of Mental Status (BIMS) score of 15/15 indicating normal cognitive status. R117 was observed sleeping in bed on multiple occasions on 3/4/25 and did not awaken to calling her name. R117 was observed in bed on 3/5/25 at 12:20 PM and confirmed she slept most of the day 3/4/25 stating she has been ill and was still tired. R117 had no recall of falling on 3/1/25. The only fall she could recall was falling in the therapy department but was not sure how long ago. R117 did not have any walking assistive devices in the room and said she cannot walk anymore without help. R117's wheelchair was next to her bed. The wheelchair had standard brakes, and they were in the locked position. R117 could not think of anything the facility could do to keep her safe from falling. Review of R117 incident and accident report dated 9/26/24 at 10:45 AM revealed R117 fell in the therapy room. The therapist was in the room and observed R117 walking fast with a walker, R117 sat at the side of the chair. The plan was to have R117 continue to work with Occupational Therapy to improve safety awareness. Review of the IDT note dated 9/27/24 at 9:21 AM revealed the same information as the incident and accident report along with vital sign monitoring and follow-up with Cardiology. No mention of increased assistance or supervision. Review of R117's incident and accident report dated 1/12/25 at 17:00 (5:00 PM) revealed R117 was found lying on the floor in her room. R117 said she was trying to get dressed, and her left leg gave out. No indication of resident's status prior to the fall was located. Review of the IDT meeting note for R117 dated 1/13/25 at 9:34 AM revealed the same information as the incident and accident report dated 1/12/125 at 5:00 PM with the additional information of physical therapy was to evaluate. No increase in supervision or assistance was mentioned. Review of R117's incident and accident report dated 1/27/25 at 6:45 AM revealed, R117 was found on the floor. She reported that she was trying to get into her wheelchair to go to the restroom, but she felt weak and lowered herself to the floor. The room had poor lighting and resident was drowsy. No new interventions were mentioned, no staff statements were located. No additional assistance or supervision were mentioned. Review of R117's IDT noted dated 1/27/25 at 9:29 AM revealed the same information along with ruling out any acute condition and continue therapy. No new intervention for increased assistance or supervision were located. Review of R117's incident and accident report dated 3/1/25 at 8:00 AM revealed R117 was found on the floor in her room near the foot of her bed. R117 had oxygen tubing along the bed and under her along with 4 shoes and a pillowcase were found next to the bed. The wheelchair brakes were locked. R117's call light was not in use. Predisposing Physiological Factors included: incontinent, gait imbalance and impaired memory. Review of R117's IDT note dated 3/3/25 at 9:10 AM revealed the same information that was in the incident and accident report dated 3/1/25 at 8:00 AM with the addition of a wheelchair with auto locking brakes. (observation on 3/5/25 at 12:20 PM revealed this intervention was not in place). The reports also documented R117's wheelchair brakes where functioning and locked at the time of the incident. No new interventions for increased assistance or supervision were located. Review of R117's fall care plan dated revision on 12/12/24 revealed auto-locking wheelchair brakes were to be placed on 3/3/25 (observed not in place 3/5/25). No interventions for assistance with any activities of daily living or any supervision. During an interview with the facility Social Worker (SW) D on 3/5/25 at 12:28 PM, SW D confirmed R117 was her own responsible party. This surveyor informed her that R117 had no recall of the fall she had on 3/1/25 (4 days ago) and reported that she had dementia. SW D confirmed that R117 did have dementia, and she was aware of fluctuations in R117 mental status. SW D confirmed that she saw R117 on 3/1/25 and confirmed that R117's wheelchair brakes were functional. SW was not aware of any increased supervision or assistance implemented for R117 after her fall on 3/1/25. During an interview with the DON and NHA on 3/6/25 at 9:50 AM they confirmed they had provided me with all R117's fall information for her falls from 9/27/24 to 3/1/25. They were aware of R117's mental status fluctuations. They were not able to locate any information on increased assistance with activities of daily living or of any increased supervision being provided for R117.

Based on interview and record review, the facility failed to follow it's Antibiotic Stewardship policy for two residents (R1 & R64) out of 16 residents reviewed for antibiotic stewardship. Findings: R1 Review of an Admission Record reflected R1 originally admitted to the facility on [DATE] and readmitted to the facility after a hospitalization on [DATE]. Review of an Infection Report Form completed by LPN/IC C reflected R1's suspected infection was urinary tract as evidenced by confusion, dysuria, increased (up arrow) incont. (incontinence). The report indicated a UA was obtained and the culture showed no bacterial growth, however R1 was prescribed Keflex (antibiotic) 500 mg (milligram)/TID (three times a day)/PO (per os, orally) - Start date: 1/10/25 - Stop Date: 1/18/25. Further review of the documentation revealed Resident (R1) sent to the ED (Emergency Department) per family request r/t confusion. ED dx (diagnosed ) PNA (pneumonia) & UTI (Urinary Tract Infection) & ordered antibiotics x (times) 8 days. Following the notes and a review of McGeer Criteria (a set of clinical laboratory definitions used to diagnose and monitor infections in long-term care facilities), were UA culture results from the hospital and a chest x-ray. The urine culture resulted in Mixed flora. No significant pathogens isolated. The chest-ray result indicated R1 had Interstitial as well as hazy opacities in both lungs. The chest x-ray result was followed by a Physical Exam Subjective: (R1) denies SOB (shortness of breath), chest pain, pressure/pleuritis/nausea/vomiting/constipation/diarrhea . The Objective exam revealed R1's lungs were clear to auscultation (listening to internal sounds), no wheezed or crackles. R64 Review of an Admission Record indicated R64 readmitted to the facility from a hospital on 1/26/2025 diagnosed with Infection and Inflammatory Reaction. Review of an Infection Report Form reflected R64 was admitted with a diagnosis of UTI and was prescribed Amoxicillin 500 mg/TID/PO - Start Date: 1/26/25 - Stop Date- 1/30/25. The report indicated the U/A (urinalysis) '-' (negative). Hospital documentation reflected a urinalysis that did not indicate R64 had white blood cells count that would indicate a treatable infection, and few bacteria were identified. No culture was attempted based on the urinalysis. R64's blood was cultured in the hospital and showed No organism isolated. During an interview on 3/6/25 at 9:30 AM, Infection Control (IC)/Licensed Practical Nurse (LPN) C reported that for both R1 and R64, the hospital sent the residents back with orders for antibiotics which were continued in the facility despite laboratory and x-ray analysis that would not indicate either resident had an infection. IC/LPN C reviewed the Electronic Medical Record (EMR) for each resident and did not identify evidence the facility provider documented a rationale for continuing the antibiotic treatment. Review of the facility Antibiotic Stewardship policy adopted 7/11/18 reflected It is the policy of this facility that antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. The policy specifies 10. When a culture and sensitivity (C&S) is ordered lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued.

Based on interview and record review, the facility failed to administer a COVID-19 vaccine after receiving consent for the vaccine for two residents (R12 and R29), out of 5 residents reviewed for immunizations. Findings: R12 Review of an Admission Record reflected R12 admitted to the facility on [DATE] and was their own responsible party. Review of a COVID-19 Vaccine Consent Form reflected CONSENT FOR VACCINATION: I have been educated on and understand the risks, benefits and potential side effects of the updated COVID-19 vaccine and hereby give consent to receive the Spikevax Moderna COVID-19 vaccine. The consent for vaccination was signed by R12 on 1/17/2025. R29 Review of an Admission Record reflected R29 readmitted to the facility on [DATE] and was not their own responsible party. Review of a pharmacy Immunization Consent Form for the Updated (2023-2024 Formula) Covid-19 Vaccine reflected I/responsible party attest that all criteria defined by the CDC (Centers for Disease Control and Prevention) have been net to receive a COVID-19 vaccine on this day, and consent to receiving the COVID-19 vaccine. The consent form was signed by R29's Durable Power of Attorney (DPOA) on 5/24/2024. During an interview on 3/4/25 at 9:30 AM, the Infection Control (IC) Licensed Practical Nurse (LPN) C reported that when an immunization is consented to by a resident/responsible party, the order for the vaccine should be entered into the Electronic Medical Record (EMR) and the vaccine should be administered shortly thereafter. IC/LPN C reviewed the clinical record for both R12 and R29 and could see the COVID-19 vaccine had NOT been administered to either resident, there was no supporting documentation explaining why the vaccine was not given and was an oversight. Review of the facility policy Immunizations-COVID-19 Vaccine updated 11/1/2024 reflected It is the policy of this facility, that in collaboration with the medical director, to have an immunization program against COVID-19 in accordance with national standards of practice.

This citation has 2 Deficient Practice Statements (DPS) DPS 1 Based on interview and record review, the facility failed to implement an effective and current system of surveillance of staff illnesses to identify possible communicable diseases and infections to prevent the spread of an illness/outbreak. Findings: An infection control program interview on 3/6/24 at 10:07 AM with Unit Manager/Infection Control Preventionist (UM/ICP) B and Director of Nursing (DON) revealed the following: DON reported that she was responsible for the tracking/surveillance of facility employee illnesses. DON reported that employee illnesses were tracked on the Respiratory Surveillance Line List only if they tested positive for COVID. No other Surveillance Line Lists were utilized. DON reported that employee illnesses were tracked via the Employee Absence Form. All staff include maintenance, housekeeping, nursing, dietary, management, reception, and activity staff. Review of the Employee Absence Forms tracked in the Infection Control Program for employee surveillance from December 2023-present (3/6/24) revealed: 5 Employee Absence Forms for December 2023 2 Employee Absence Forms for January 2024 1 Employee Absence Forms for February 2024 DON reported that when staff called off of work the Employee Absence Form was completed by the person who took the call, sent to the scheduler, and then forwarded by the scheduler to the DON. DON reported that if a staff member had 2 symptoms present (elevated temperature, vomiting, cough, sore throat, diarrhea, open wound, swelling, muscle/joint soreness), they were then tested for COVID. If the COVID test was negative, they could return to work when symptoms resolved. DON reported if a staff member reported a fever, they could not return to work until they were 24 hours fever free without the use of an antipyretic. There were no criteria for staff to return to work following nausea, vomiting, and/or diarrhea. DON reported that employees were tracked for COVID and confirmed no other illnesses were included such as gastrointestinal (norovirus), respiratory (influenza and/or RSV), contagious skin conditions, etc. During an interview on 3/6/24 at 11:30 AM, Scheduler (S) C reported that she would receive the Employee Absence Forms and forward the form to the DON only if the employee had 2 symptoms present or had called off of work 2 days in a row. If those criteria were met the employee was to report to the facility parking lot for COVID testing. S C reported if the employee only exhibited 1 symptom, and/or called in for 1 shift, they were not required to test. S C confirmed there was no required return to work date/time for employees who exhibited symptoms of other respiratory or gastrointestinal illnesses. S C reported employees were aware of the criteria and would often report only 1 symptom in order to avoid COVID testing. A copy of all Employee Absence Forms for the month of February 2024 was requested and received. On 2/3/24 a CNA (Certified Nursing Assistant) was sent home for vomiting. On 2/4/24 that CNA called off of work due to her children are vomiting indicating the possible exposure to residents of a contagious gastrointestinal illness. CNAs provide direct care to residents which increases the risk of the spread of an illness to the vulnerable population. On 2/10/24-2/11/24 a CNA called off of work for throwing up. The form did not include a date she could return to work without the risk of the spread of a gastrointestinal illness. On 2/18/24 and 2/19/24 a nurse called off of work for elevated temperature, sore throat, and muscle pain. On 2/21/24 the nurse called off for bronchitis, blood nose, fever. There was no return to work date documented. On 3/6/24 at 2:00 PM Nursing Home Administrator reported that the nurse returned to work on 2/22/24. There was no indication that the DON ensure she was 24 hours fever free prior to returning to work. On 2/22/24 a CNA called off of work for throwing up. The form did not include a date she could return to work without the risk of the spread of a gastrointestinal illness. On 2/29/24 a housekeeping employee called off of work for vomiting. The form did not include a date she could return to work without the risk of the spread of a gastrointestinal illness. On 2/29/24 and 3/1/24 a confidential staff member called off of work for a cough and sore throat. It was identified on 3/1/24 at 10:15 PM that the staff member tested positive for influenza A. This employee was not included in the Infection Control Program/employee surveillance reviewed with the DON and was not listed on the Respiratory Surveillance Line List. On 2/28/24 and 2/29/24 a CNA had called in for vomiting. This employee was not included in the Infection Control Program/employee surveillance reviewed with the DON. There were 24 employee call-offs for sick for the month of February 2024. Review of the facility policy, Infection Prevention and Control Surveillance adopted 7/11/18revealed, PURPOSE: To conduct surveillance of resident and employee infections to guide prevention activities. POLICY: The Infection Preventionist/designee does surveillance of infections among residents, employees, volunteers and visitors. I. The Infection Preventionist/designee does surveillance of healthcare-associated infections by .D. Review of the Infection Report Form, 24 Hour Report, or morning clinical/stand-up meeting E. Personal consultation with volunteers, employees and visitors F. Follow-up on communicable disease exposure G. Maintenance of the employee infection record . Surveillance documentation is maintained on the: A. Line Listing of the Monthly Infection Surveillance Log *Monthly Infection Surveillance Summary Report *Monthly Summary Infection Control Graph B. Log of Employee/Volunteer/Visitor Infections. 38905 DPS 2 Based on interview and record review, the facility failed to have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in water borne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all of the residents in the facility. Findings include: During a review of the facilities documentation of their Water Management Plan, provided by Maintenance Director D, at 12:55 PM on 3/4/24 it was found that the facility tests for free chlorine every two weeks and flushes some minimum use fixtures weekly. Further review of the total free chlorine checks found numerous results of 0.00 parts per million (ppm) from tested hot water samples over the last year. When asked what was to be done if any of the samples came back as 0.00 ppm, DM D stated that he was just told to document the results and was not sure if there was any corrective action. An interview with MD D, at 10:30 AM on 3/5/24, found that the facilities policy and procedure was pretty short and that it didn't give much guidance on how to carry out the Water Management Plan. The facility was not able to provide a completed CDC toolkit, and provided no reference to following: the American Society of Heating, Refrigeration, and Air Conditioning Engineers (ASHRAE) Guidelines for the reduction of Legionella, having done an annual assessment, or documentation of having a water management team assigned.

Based on interview and record review, the facility failed to follow professional standards of nursing practice for medication administration for 5 of 8 residents (Resident #17, #23, #43, #46, and #62), reviewed for the provision of nursing services, resulting in lack of vital sign and blood sugar assessments prior to medication administration, medications improperly administered, and management of controlled substances. Finding: Resident #17 (R17) Review of an Admission Record revealed R17 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: seizure disorder. Review of R17's Order Summary revealed, Lacosamide Oral Tablet 50 MG (Lacosamide) Give 1 tablet by mouth every 12 hours for seizures. Review of R17's Controlled Substance Proof of Use form revealed on 3/2/24 a dose of lacosamide was administered at 8:20 AM. There was no evening dose documented as pulled/administered. Review of R17's March Medication Administration Record revealed on 3/2/24, 2 doses of lacosamide was documented as administered. During an interview on 3/6/24 at 12:32 PM, Director of Nursing (DON) confirmed that there was a medication error and R17 received only received 1 dose of lacosamide on 3/2/24. Resident #23 (R23) Review of an Admission Record revealed R23 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: hypertension. Review of R23's Order Summary revealed, Lisinopril Tablet 10 MG Give 1 tablet by mouth in the morning for hypertension Hold if SBP <90 (systolic blood pressure/top number is less than 90). Review of R23's February Medication Administration Record revealed all 29 doses of lisinopril were administered. Review of R23's March Medication Administration Record (reviewed on 3/5/24 at 12:00 PM) revealed all 5 doses of lisinopril were administered. Review of R23's Blood Pressure Summary revealed R23's blood pressure was not assessed on 2/10/24, 2/15/24, 2/17/24-3/1/24, and 3/3/24-3/5/24. Indicating a blood pressure assessment was not completed prior to the administration of the lisinopril to ensure R23's blood pressure was within the provider ordered parameters. Resident #43 (R43) Review of an Admission Record revealed R43 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: hypertension. Review of R43's Order Summary revealed, Metoprolol Succinate ER Tablet Extended Release 24 Hour 25 MG-Give 1 tablet by mouth in the morning related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) hold for SBP<100 P<60 (systolic blood pressure less than 100 and pulse less than 60). Review of R43's February Medication Administration Record revealed all 29 doses of metoprolol were administered. Review of R43's March Medication Administration Record (reviewed on 3/4/24 at 12:00 PM) revealed all 4 doses of metoprolol were administered. Review of R43's Pulse Summary revealed R43's pulse was not assessed on 2/15/24, 2/16/24, 2/18/24-2/24/24, 2/26/24, 3/1/24, and 3/3/24. Indicating a pulse assessment was not completed prior to the administration of the metoprolol to ensure R43's pulse was within the provider ordered parameters. Resident #46 (R46) Review of an Admission Record revealed R46 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: diabetes. Review of R46's Order Summary revealed, LANTUS SOLOSTAR 100U/ML-Inject 16 unit subcutaneously in the morning for DM hold for BS<100 (for diabetes mellitus. Hold for blood sugar less than 100). Review of R46's February Medication Administration Record revealed all 29 doses of Lantus were administered. Review of R46's March Medication Administration Record (reviewed on 3/4/24 at 12:00 PM) revealed all 4 doses of Lantus were administered. Review of R46's Blood Sugar Summary revealed R46's blood sugar was not assessed from 2/1/24-2/4/24, 2/6/24-2/11/24, 2/13/24-2/18/24, 2/20/24-2/25/24, and from 2/27/24-3/3/24. Indicating a blood sugar assessment was not completed prior to the administration of the Lantus to ensure R46's blood sugar was within the provider ordered parameters. During an interview on 03/06/2024 at 10:26 AM, Director of Nursing (DON) reported that any narcotic administration errors would be immediately reported to her. If there are errors identified randomized audits would be completed to ensure nursing compliance with medication administration. Unit Manager (UM) B reported that the facility nurses should be administering medications as ordered by the provider which would include assessing vital signs and blood sugars prior to the administration of medications that had ordered parameters. DON and UM B were notified of the medication administration concerns for 8 residents on 3/6/24 at 10:44 AM. At the time of survey exit there was no documentation provided reflecting R23, R43, and R46 had had vital signs/blood sugar assessments prior to the medication administration listed above. Review of the facility policy Medication Administration subject Administration of Drugs last updated 12/19/19 revealed, POLICY: It is the policy of this facility that medications shall be administered as prescribed by the attending physician. Procedure .2. Medications must be administered in accordance with the written orders of the ordering/prescribing physician. 31771 R62 R62 was originally admitted to the facility 6/6/23. Review of the medical record reflected R62 had current Doctors Orders for two types of insulin and an order for a fentanyl transdermal patch that is to be changed every 72 hours. On 3/6/24 at 8:04 AM an observation was conducted with Registered Nurse (RN) E who was preparing medication for R62. In addition to oral medication, this preparation included two types of insulin and a fentanyl patch. After entering the room of R62 the oral medications were administered to the Resident. To administer the insulin RN E first exposed the abdomen of R62 and cleansed an administration site. When it was observed that RN E was proceeding to the injection of insulin the RN was asked if gloves were available. RN E pointed to a glove dispenser mounted on the wall above the nightstand of R62 and stated Right there. All the rooms have them. RN E continued, without gloves, to administer the two types of insulin near one another to the left of the Resident's umbilicus. It was observed that that first site bled. RN E immediately covered both sites by the Resident's clothing after the second injection was administered without observing for bleeding or addressing the bleeding from the first injection. RN E then removed a dated fentanyl patch from right upper chest and applied a new fentanyl patch to the area that was prepped on the left upper chest. The discarded patch had been crumpled and placed in a medication cup. Upon returning to the medication cart RN E was asked if she wears gloves when administering insulin. RN E stated No. RN E was then observed to place the medication cup containing the discarded fentanyl patch into the top drawer of the medication cart which is not equipped to be double locked. RN E reported when she completes her morning medication pass, she will discard the old fentanyl patch with another nurse. On 3/6/24 at 10:54 AM an interview was conducted with the Director of Nursing (DON) in her office. The medication administration and post- administration observations of RN E were discussed with the DON. The DON reported that gloves are expected to be worn when a administrating injections. The DON reported that the discarded fentanyl patch should immediately destroyed with another nurse and not left in the medication cart. The DON reported that a used/ dirty patch should not be placed in a clean drawer. The DON acknowledged that controlled substances are to be securely stored. The policy provided by the facility titled Licensed Nursing Procedures, Subject: Injections Insulin last updated 4/19/22 was reviewed. The Procedure reflected 13. Wash hands. Apply gloves. And 20. Apply firm pressure over the site with alcohol pad or cotton ball. And #23. Remove gloves, wash hands. The policy provide by the facility titled Medication Administration, Subject: Controlled Drugs last updated 5/14/20 was reviewed. The policy reflected, Procedure: Narcotic Box: A separate locked compartment for controlled drugs is provided within a locked cabinet .

Based on interview and record review, the facility failed to follow the facility policy for pressure injury/wound management for 1 out of 6 residents (Resident #41) reviewed for pressure injury monitoring and treatment, resulting in incomplete and late wound assessments. Findings: Resident #41 (R41) Review of an Admission Record revealed R41 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: acute cerebrovascular insufficiency (affects blood flow to the brain). Review of R41's General Progress Note dated 1/30/24 revealed, pt (patient) has a 2.5x3 (cm) shearing to left buttock, pt had been previously sitting at side of bed with therapy, triad cream applied. Review of R41's Skin Progress Note dated 2/3/24 revealed, Location: B/L (bilateral) buttocks Type of Skin Change/Impairment: MASD (moisture associated skin damage) Measurement(s): Left outer 3.5x2 (cm) Left inner 2x1.5 Right 1x0.7 Description .wound beds are red in color, scant bleeding noted, surrounding skin is pink and flaky, blanchable Current Treatment(s):: cleanse with NS/WC (normal saline/wound cleanser), pat dry, apply collagen to wound bed, cover with silicone foam dressing, change daily . The measurement did not identify the shearing injury identified on 1/30/24. There were no wound measurements completed on 2/6/24 (7 days from the identification/measurements of shearing on 1/30/24) or on 2/10/24 (7 days from the MASD measurements) per the facility policy. Review of R41's Skin Progress Note dated 2/14/24 revealed, Location: Left and right buttock Type of Skin Change/Impairment: (blank) Measurement(s): Left Outer: 3.3 x 2 (cm) Left Inner 2 x 1.4 Right .9 x1 Description .Red wound beds scaley around Current Treatment(s): cleanse with NS/WC, pat dry, apply collagen to wound bed, cover with silicone foam dressing, change daily . The type of impairment (MASD and/or shearing) was not identified in the assessment. There were no wound measurements completed on 2/21/24, 2/28/24, or 3/6/24 (as of 1:00 PM). During an interview on 3/6/24 at 1:07 PM, Unit Manager/Wound Care Nurse (UM/WCN) A reported that shearing wounds and MASD should be measured weekly. UM/WCN A reported that R41 moved from the Front Unit to the Back Unit on 2/14/24 and the wound tracking was unintentionally discontinued at that time. UM/WCN A reported a wound assessment would be completed and documented immediately. Review of the facility policy Skin Monitoring and Management-Pressure Ulcer adopted 7/11/18 revealed, .Assessment of wounds on admission, readmission AND discharge: *A licensed nurse (which may be the Wound Nurse) must assess/evaluate a resident's skin on admission. All areas of breakdown, excoriation, or discoloration, or other unusual findings, must be documented in the Admission Assessment. *A licensed nurse (which may be the Wound Nurse) must assess/evaluate each wound that exists on the resident. This assessment/evaluation should include but not be limited to: *Measuring the wound *Staging the wound *Describing the nature of the wound (e.g., pressure, stasis, surgical wound) *Describing the location of the wound *Describing the characteristics of the wound A. Assessment of wounds identified after admission: *A licensed nurse (which may be the facility Wound Nurse) must assess/evaluate a resident's skin at least weekly. All areas of breakdown, excoriation, or discoloration, or other unusual findings must be documented in the resident's clinical record. B. A licensed nurse (which can be the facility Wound Nurse) must assess/evaluate at least weekly each wound, whether present on admission or developed after admission, which exists on the resident. This assessment/evaluation should include but not be limited to: *Measuring the wound *Staging the wound *Describing the nature of the wound (e.g., pressure, stasis, surgical wound) *Describing the location of the wound *Describing the characteristics of the wound *Describing the progress with healing, and any barriers to healing which may exist *Identifying any possible complications or signs/symptoms consistent with the possibility of infection .

Based on observation, interview, and record review, the facility failed to ensure adherence to proper medication administration guidelines for two Residents (R15 and R62) resulting in a medication administration error rate of greater than five percent. Findings Resident #15 (R15) Review of the medical record reflected R15 originally admitted to the facility 7/28/19 and a pertinent diagnosis of End Stage Renal Disease (ERSD) and is on Hemodialysis. Review of the Doctor's Orders for R15 revealed an order for Sevelamer Oral Tablets 800 milligram (mg) Give 2 tablet by mouth before meals for high phosphorous levels. On 3/5/24 at 8:10 AM a medication administration observation was conducted with Licensed Practical Nurse (LPN) F. LPN F was observed to administer 2 tabs of Sevelamer 800 milligrams ordered to be given before meals to R15. R15 reported she had eaten her breakfast earlier. Review of the manufacturer's product information sheet reflects sevelamer is to be taken with meals. The section titled Clinical Pharmacology reflects that taken with meals (the medication) has been shown to decrease serum phosphorus concentrations in patients with ESRD who are on hemodialysis. Under the Patient Counseling section of the manufacturer's literature it is reinforced to Inform patients to take (sevelamer) with meals. Resident #62 (R62) Review of the medical record reflects R62 admitted to the facility 6/6/23 with pertinent diagnoses that included Blindness, History of Stroke, and Hemiplegia/Hemiparesis (weakness or paralysis to one side of the body). Review of the Doctor's Orders for R62 reflected an active order for Fluticasone Propionate Nasal Suspension 50 micrograms (mcg) 2 sprays in each nostril in the morning. The manufacturer's product information sheet instructions for use for fluticasone propionate nasal spray was reviewed. The instructions for use reflect Step 1. Blow your nose to clear your nostrils. Step 2. Close 1 nostril, Tilt your head forward slightly . The direction for use included an illustration of one nostril being held closed and the nasal spray applicator inserted into the other nostril. On 3/6/24 at 8:04 AM a medication administration observation was conducted with Registered Nurse (RN) E in the room of R62. Upon entry to the room R62 was in bed lying back at approximately a forty-five-degree angle. RN E administered oral medication to the resident. RN E then placed the nasal applicator in the left nares of the Resident and gave three successive sprays of Fluticasone Nasal Suspension 50 mcg. R62 appeared to flinch with the insertion of nasal applicator and the sudden administration of sprays as if unprepared. Three sprays of the medication were then administrated into the R nares which R62 appeared to tolerate well. RN E did not have R62 tip her head forward or ask R62 to blow her nose prior to the administration. RN E did not hold closed the opposite nares when the nasal spray was administered. On 3/6/24 at 11:35 AM a follow up interview was conducted with R62 in her room. R62 indicated she doesn't recall ever being asked to blow her nose prior to the administration of the nasal spray but reported that she often does have a stuffy nose. R62 reported that staff administer the nasal spray to her because she doesn't have the hand strength to do so. R62 indicated that she is not always prepared for the sudden spray up her nose stating,, it does catch me by surprise sometimes.

Based on observation, interview, and record review, the facility failed to properly label and store chemicals, properly store personal items, and maintain clean food contact surfaces, resulting in the potential contamination on equipment and food, affecting all residents in the facility. Findings include: On 3/21/23 at 5:54 AM, a water pitcher was observed to be sitting in the sink basin of the handwashing sink, located next to the walk-in cooler. According to the 2017 FDA Food Code Section 5-205.11 Using a Handwashing Sink. (A) A HANDWASHING SINK shall be maintained so that it is accessible at all times for EMPLOYEE use. Pf (B) A HANDWASHING SINK may not be used for purposes other than handwashing. Pf (C) An automatic handwashing facility shall be used in accordance with manufacturer's instructions. Pf On 3/21/23 at 6:04 AM, two working spray bottles were observed in the dish washing area with no label to identify the contents. One spray bottle was observed on the drying rack, stored above clean equipment. At 7:10 AM, Dietary Manager C was observed to move the spray bottles to the dish machine drain board. According to the 2017 FDA Food Code Section 7-102.11 Common Name. Working containers used for storing POISONOUS OR TOXIC MATERIALS such as cleaners and SANITIZERS taken from bulk supplies shall be clearly and individually identified with the common name of the material. On 3/21/23 at 6:05 AM, three employee jackets were observed to be stored on three different rolling carts, all located in food prep areas. One cart was located on the cook line, directly next to the stove top/oven. At 7:10 AM, Dietary Manager C stated that the staff have a separate area to store their personal belongings. According to the 2017 FDA Food Code Section 7-209.11 Storage. Except as specified under SS 7-207.12 and 7-208.11, EMPLOYEES shall store their PERSONAL CARE ITEMS in facilities as specified under 6-305.11(B). On 3/21/23 at 6:06 AM, the can opener blade was observed to be soiled with food debris accumulation. According to the 2017 FDA Food Code Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. Pf (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.

Based on observation, interview, and record review, the facility failed to store equipment and supplies safely, maintain ventilation systems, and provide backflow protection devices to control pluming cross connections, resulting in the potential contamination of equipment and the domestic water supply, and potential for odors, affecting all residents in the facility. Findings include: On 3/21/23 at 6:27 AM, a box of toilet paper was observed to be stored on the floor in the housekeeping closet next to resident room [ROOM NUMBER]. On 3/21/23 at 6:30 AM, a box of toilet paper was observed to be stored on the floor in the storage room next to resident room [ROOM NUMBER]. On 3/21/23 at 6:31 AM, the fish tank in the B South Dining Room was observed to have significant algae accumulation. At 10:15 AM, the Administrator stated that a few specific facility staff are responsible for maintaining the fish tank. On 3/21/23 at 6:35 AM, the exhaust vent in the B South Spa was observed to not be working, tested with a paper towel to determine if exhaust force is adequate. The exhaust vent was not able to pull the paper towel. Additionally, the light shield for the florescent lights in the Spa was observed to be missing. At 10:20 AM, Maintenance Director D said that he knew the motor burnt out last week and hasn't had a chance to replace it. On 3/21/23 at 6:37 AM, two boxes of air life prefilled humidifier systems were observed to be stored on the floor in the nursing supply storage room on B South. On 3/21/23 at 10:25 AM, the B South Storage room was observed to have a box of cups stored on the floor. On 3/21/23 at 10:40 AM, a hose fixture, located behind the laundry washers, was observed to not be provided with a backflow prevention device to prevent any backflow of solid, liquid, or gas contaminants into the domestic water supply. At this time, Maintenance Director D stated that he will remove the hose from the fixture. During an interview on 3/22/23 at 10:19 AM, the Administrator said that the motor for the Roof Top Unit providing exhaust ventilation for the B South hall was ordered on 3/21/23, as noted on a shipping confirmation document provided by the facility.

Based on observation, interview, and record review, the facility failed to: 1.) ensure residents received consistent and comprehensive physician led wound care, 2.) notify the physician of a change of condition and medication errors, and 3.) ensure residents received care in accordance with professional standards for medication administration in 3 (Resident #11, #35, and #37) reviewed for quality of care, resulting in the potential for the decline of a physical condition and the worsening of symptoms and the potential for wound complications and infection. Findings: Review of the Fundamentals of Nursing revealed, The National Coordinating Council for Medication Error Reporting and Prevention (2018) defines a medication error as any preventable event that may cause inappropriate medication use or jeopardize patient safety. Medication errors include inaccurate prescribing, administering the wrong medication, giving the medication using the wrong route or time interval, administering extra doses, and/ or failing to administer a medication. Preventing medication errors is essential. Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia A.; Hall, Amy. Fundamentals of Nursing - E-Book (p. 605). Elsevier Health Sciences. Kindle Edition. Review of the Fundamentals of Nursing revealed, If a patient refuses a medication or is undergoing tests or procedures that result in a missed dose, explain the reason that a medication was not given in the nurses' notes .notify the health care provider when a patient misses a dose. Be aware of the effects that missing doses may have on a patient (e.g., with hypertension or diabetes). Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia A.; Hall, Amy. Fundamentals of Nursing - E-Book (p. 614). Elsevier Health Sciences. Kindle Edition. Review of the Fundamentals of Nursing revealed, When you identify the presence of a skin wound or pressure injury, closer assessment is required. Assess the type of tissue in the wound base so that you can plan appropriate interventions. The assessment includes the amount (percentage) and appearance (color) of viable and nonviable tissue. Granulation tissue is red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing. Soft yellow or white tissue is characteristic of slough (stringy substance attached to wound bed), and it must eventually be removed by a qualified clinician or by an appropriate wound dressing before the wound is able to heal. Black, brown, tan or necrotic tissue is eschar, which also needs to be removed before healing can occur. Measurement of the wound size provides information on overall changes in dimensions, which is an indicator for wound healing progress ([NAME], 2016). This includes measuring the length and width of a wound, as well as determining its depth (see Skill 48.2). Use a disposable wound-measuring device to measure wound width and length. This approach offers a uniform, consistent method for measuring meaningful comparisons of wound status across time (EPUAP, NPIAP, PPPIA, 2019b). Measure depth by using a cotton-tipped applicator in the wound bed (see Skill 48.2). Note that if a deep laceration exists it will likely require suturing by a qualified clinician. Assessment of wound exudate should describe the amount, color, consistency, and odor of wound drainage. Excessive exudate indicates the presence of infection. Wound pain, including the location, distribution, type, quality and intensity, and any aggravating or relieving factors, also should be assessed ([NAME], 2016). Examine the skin around the wound (periwound) for redness, warmth, and signs of maceration, and palpate the area for signs of pain or induration. The presence of any of these factors on the periwound skin indicates wound deterioration. Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia A.; Hall, Amy. Fundamentals of Nursing - E-Book (p. 1247). Elsevier Health Sciences. Kindle Edition. Resident #11 (R11) Review of an Admission Record revealed R11 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a Minimum Data Set (MDS) assessment for R11, with a reference date of 3/31/22 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated R11 was cognitively intact. Review of R11's Care Plan revealed, observe/document/report PRN (as needed) any risk for harm to self .stockpiling pills .Date Initiated: 09/04/2019 . Review of a Statement written by Certified Nursing Assistant (CNA) R dated 4/6/22 revealed, Date of Incident: 4/2/22 .(R11) rang and she said she had knocked over her colored pencil container. As I was cleaning them up I noticed 2 pills in the mess I took them to the nurse. I went back to continue cleaning them up between me and (name omitted) we found 19 more pills and gave them to the nurse . During an interview on 04/21/2002 at 8:18 A.M., CNA R reported that the nurse and the administrator were immediately notified of the concerns regarding R11 and the 19 pills found in her room. CNA R reported she immediately documented the incident in a witness statement. Review of R11's Progress Notes revealed no documentation that the physician as notified of the 19 pills found in R11's room or documentation of what medications were not administered. Review of R11's Physician Notes revealed no documentation of a comprehensive and complete assessment of R11 following the 19 pills found in her room (medication review, labs, symptoms, etc). Review of R11's Incident Reports revealed no documentation that the medication errors/missed medications had been investigated or that a root cause analysis had been identified. During an interview on 04/21/22 at 12:41 P.M., LPN Q reported that she was the nurse on duty when the medications were found in R11's room. LPN Q reported that at that time she did not notify the provider and had not written a progress note regarding the multiple missed medications/medication stockpiling. LPN Q reported that the statement she had completed on 4/21/22 was the first statement she had made regarding the incident. During the interview, Unit Manager (UM) F directed LPN Q to backdate a progress note regarding the missed medications/medication stockpiling. Review of a Statement written by Licensed Practical Nurse (LPN) Q (handwritten statement was dated 4/6/22) revealed, Date of Incident: 4/3/22 .CENA brought me a cup full of pills that she stated were found in this residents room inside a wooden jewelry box she keeps on her table. Pills were noted as Tylenol 500mg (and) Omeprazole. Resident questioned about pills and she stated she put them there because she didn't want to become a drug addict. Resident educated on purpose of the those meds and that they were not addictive, also to let nurse know if she does not want her pills and nurse will dispose of them properly. Resident stated understanding. (Note date of incident discrepancy). Resident #35 (R35) Review of an Admission Record revealed R35 was an [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for R35, with a reference date of 2/16/22 revealed a Brief Interview for Mental Status (BIMS) score of 12, out of a total possible score of 15, which indicated R35 was moderately cognitively impaired. Review of Skin Conditions revealed, R35 had no venous or arterial ulcers and had 1 Stage II pressure ulcer. During an interview on 04/25/22 at 10:27 A.M., R35 reported that he had new wound on his left heel that required treatment. R35 reported that it was painful when treatments were being completed. R35 was sitting up in a chair next to his bed. His left heel was resting on the ground. He had no pressure offloading device in place. Review of R35's Care Plan revealed no documentation of a left heel wound. Review of R35's Physician Notes revealed no documentation that the facility provider had comprehensively assessed R35's left heel wound. Review of R35's Progress Notes revealed no documentation of routine comprehensive wound assessment/measurement of R35's left heel wound. Review of R35's Weekly Skin Assessments dated 3/17/22, 3/24/22, 3/31/22, 4/7/22, 4/14/22, and 4/21/22 revealed no documentation/measurements of R35's left heel wound. Review of R35's Skin Sweep assessment dated [DATE] revealed, .lateral heel-vascular-1.3 (cm length) x 1.4 (cm width) x 0.1 (cm depth). Review of R35's Skin Sweep assessment dated [DATE] revealed, .lateral heel-vascular-1 (cm length) x 1.2 (cm width) x 0.1 (cm depth). Review of R35's Left Heel Timeline revealed: 2/28/22-3/11/22 new order skin prep and foam dressing change every 3 days 3/9/22 skin sweep 3/11/22-3/17/22 scab off new order calcium alginate with dry dressing 3/17/22 to current-new order daily dressing collagen premoistened with hydrogel, dry dressing 4/5/22 skin sweep with improvement During an interview on 04/25/22 at 12:09 P.M., Unit Manager (UM) F reported that the wound care documentation is not where it's supposed to be. UM F reported that she had documented R35's as a vascular wound and would be having the wound care provider follow R35's wound progression/healing. UM F reported that the facility physician had not visualized the wound on R35's left heel. UM F was a Licensed Practical Nurse and was not wound care certified. During an interview on 4/25/22 at 1:40 P.M., Nursing Home Administrator (NHA) reported that R35 would be followed by the wound care provider and that the facility provider would follow up with R35's wound on 4/25/22. NHA reported that the podiatrist had not assessed the wound on R35's heel but R35 was ordered a podiatry consult in February 2022. NHA verified that there were no physician assessments or wound diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R35's Physician Note dated 4/25/22 at 1:47 P.M. revealed, .left (lateral) heel open 1.5 (cm length) x 1.5cm (width) .Vascular wound left foot . (Note increase in wound length and width). Resident #37 (R37) Review of an Admission Record reflected R37 admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment dated [DATE] reflected R37 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 00/15 and was totally dependent on two people for bed mobility, dressing and toilet use. The assessment reflected R37 never transferred during the lookback period. Section M - Skin Conditions reflected that R37 was at risk for pressure ulcers based on clinical assessment and had one stage 4 pressure ulcer that was present on admission. No additional skin conditions were reflected in the assessment. During an observation on 4/20/22 at 12:59 PM, R37's left heel was observed with the assistance of Certified Nurse Aide (CNA) T and CNA U. A nickel sized skin alteration was observed. There was no dressing on the area. Registered Nurse (RN) V entered the room and reported staff had been applying [MEDICATION(S)] solution to a scab twice a day and thought it looked like the scab had come away from the skin alteration. During a follow-up observation on 4/21/22 at 9:47 AM, R37 was observed in bed, his heels were not elevated off the bed. A CNA assisted in an observation of an undated bandage on R37's left heel. Licensed Practical Nurse (LPN) F entered the room and reported that she applied the bandage to R37's left heel the day before and forgot to date it. When asked, LPN F reported there was not current documentation in R37's clinical record to describe the current course of treatment or measurements for R37's heel alteration but that she would add notes backdated to when the alteration was first discovered. During a follow-up interview on 4/25/22 at 11:45 AM, LPN F reported that there was no weekly wound documentation or skin assessment of R37's existing left heel skin alteration prior to 4/20/2022. According to LPN F, R37 had sustained an abrasion to his left heel two weeks prior but that a risk management report had not been completed to identify a root cause.

Based on observation, interview and record review, the facility failed to fully implement a policy regarding use and storage of resident foods brought in from outside sources. This deficient practice resulted in unknown discard dates and potentially hazardous foods being held passed their discard date, increasing the risk of contamination and food borne illness among residents who store food in the resident refrigerator. Findings Include: During a tour of the resident refrigeration unit, with Dietary Manager B, starting at 10:25 AM on 4/18/22, it was observed the following items were found not dated or held beyond their discard date: a takeout container of fish and chips with a resident name and a date of 4/12/22, a takeout container of breaded shrimp and cocktail sauce with no resident name and no date, a small takeout container with a resident name and date of 4/8/22, and a pizza box with a residents name and a date of 4/8 to 4/14. At this time, it was noted that the inside of the unit had an accumulation of sticky debris on the bottom shelf and in the left side pull out shelf. When asked who cleans the unit, Dietary Manager B stated that sometimes housekeeping cleans the fridge and sometimes dietary staff. A review of signage located on the front of the resident refrigeration unit, at 10:30 AM on 4/18/22, found that staff are expected to put an opened and use by date on items in this fridge and Items not labeled with a resident name and date will be immediately thrown out. Further review of signage posted on the fridge, found that Once a food item is opened it is only good for 3 days . and outdated items must be discarded.

Based on observation, interview and record review the facility failed to prevent the development of pressure sores for one resident (Resident #37), out of 4 residents reviewed for pressure ulcers, resulting in an avoidable pressure sore and the potential for all facility resident to develop pressure sores. Findings include: Resident #37 was admitted to the facility 11/1/19 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] reflected Resident #37 did not require assistance for locomotion and had full range of motion of all extremities. The MDS also reflected Resident #37 was at risk for pressure sores but the Resident's skin was intact with no healed or unhealed pressure sores. Review of the Kardex (a summary of resident care needs) reflected Resident #37 was independent for ambulation with an assistive device. At the onset of the annual recertification survey the facility provided documentation that Resident #37 had two pressure sores that were acquired after admission to the facility. Review of the facility, Skin Observation Tool(s) dated 11/8/19, 11/15/19, and 11/29/19, reflected the skin of Resident #37 was intact, and no new changes were observed. During an interview and observation of dressing change conducted on 1/6/2020 at 9:44 AM in the Resident's room Registered Nurse (RN) S reported Resident #37's bottom started getting bad because of being bedridden with pneumonia. Review of the facility wound care documentation dated 12/4/19, reflected that measurable open areas on the left and right buttocks of Resident #37 were identified on 12/3/19 and described as acquired. On 1/8/2020 at 4:00 PM, during an interview and record review Unit Manager (UM) C reported Resident #37 became ill, began refusing hydration, refused to eat, and refused to sit up. Review of the medical record did not reflect documentation the facility identified a mobility concern or implemented new measures to prevent skin breakdown. UM C was asked to provide any undiscovered documentation that indicated interventions were put in place to prevent skin breakdown or promote healing of the new pressure sores. UM C reported Physical Therapy (PT) and Occupational Therapy (OT) had been engaged for this Resident's mobility concerns and would review the medical record for this and the other documentation requested. Review of the current and Resolved Care Plans for Resident #37 revealed a Resolved Care Plan initiated 12/2/19 that, The resident has pneumonia (page 13 of 22). Review of this Care Plan did not reflect any interventions were implemented as the result of impaired mobility. Review of all Care Plans did not reflect a change of mobility at the time of the pneumonia Care Plan. Further review reflected a current Care Plan with the focus of Potential for unavoidable impaired skin due to pressure related to decreased mobility .aging skin ., (page 4 of 22) but was initiated on 11/4/19 and not when diagnosed with [REDACTED].#37 was, able to change position without assistance. Care Plans for the right buttock wound (page 20 of 22) and left buttock wound (page 21 of 22) were initiated on 12/3/19. Review of the wound documentation for Resident #37 reflected an initial measurement of the left buttock wound of 2.5 x 0.7 x 0.0 centimeters (cm) on 12/4/19, that increased to 2.4 x 1.4 x 0.1 cm on 12/18/19. The initial measurement of the right buttock wound of 1.0 x 0.5 x 0 cm on 12/4/19, increased to 1.9 x 1.9 x 0.1 cm on 12/18/19. Both wounds were identified as stage 2 on 12/18/19. It was noted that the initial Doctor Ordered treatment had changed with the increased wound measurements, but no Care Plan revisions were made to support the new treatment, prevent the sores from worsening, promote healing, or prevent additional pressure sores from developing. Review of the medical record reflected wound documentation that an acquired , pressure, open area on the left buttock distal was identified on 12/24/19. The medical record reflected a separate Care Plan (page 22 of 22) was initiated for this new area. On 1/8/202 4:56 PM, prior to Survey Exit UM C provided two Therapy documents that UM C referred to in the interview and record conducted 1/8/2020 at 4:00 PM. Both documents provided reflected one-time evaluations of Resident #37 conducted by OT and PT on 12/19/19, which is 16 days after the identification of the right and left buttock wounds (identified on 12/3/19), and 17 days after the implementation of the pneumonia Care Plan (initiated 12/2/19). UM C referenced the Care Plan titled Potential for unavoidable impaired skin due to pressure related to decreased mobility . (page 4 of 22), initiated 11/4/19, and reported she believed she put unavoidable as a blanket to cover the [MEDICAL CONDITION] issue the Residents forehead that is not being treated. At the time of Survey Exit no further documentation or information was provided by the facility regarding measures put in place to prevent or promote the healing for pressure sores for Resident #37.

This citation pertains to MI 230. Based on observation, interview and record review, the facility failed to conduct root cause analysis to prevent falls and failed to implement new interventions to prevent falls for 1 (Resident #5) of 3 reviewed for falls, from a total sample of 6, resulting in the potential for continued falls and major injury. Findings include: Review of the facility Admission Record, dated 5/15/18 at 1:15 PM, reflected that Resident #5 was an [AGE] year old female, readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 3/28/18 reflected that Resident #5 was independent for transfers and ambulation. She scored 6 out of 15 on the Brief Interview for Mental Status (BIMS) assessment, which indicated that she had severe cognitive impairment. During an interview and observation on 5/15/18 at 8:00 AM, Resident #5 was seated in a recliner in her room. A splint was observed to her right leg, below the knee. Her walker was to the right of her recliner with many personal items stacked on it. Resident #5 stated that she was horrible with her broken leg. She did not recall how she received the injury but stated that it must have happened at the facility. Resident #5 stated that she no longer walked. Review of a facility incident report reflected that on 3/25/18 at 1:00 PM, the resident was sitting on the floor in the rehab dining room. The resident had been at the buffet, bending over to show her family a puzzle. When she stood back up, she lost her balance and fell . Resident #5 hit her head and her left arm during the fall. The cause of the incident was determined to be that the resident lost her balance after bending over. The corrective action was to consult with activities to move the puzzles up from under the buffet to avoid having to bend over to retrieve them. An incident report reflected that on 4/5/18 at 8:00 PM, the resident was bending over to get a puzzle piece off the floor and fell . She was observed lying on her back. The resident stated that she fell to her knees, then fell forward and bumped her head on the heat vent, then fell backwards and bumped her head on the floor. The cause of the incident was determined to be that the resident became dizzy while trying to pick something up from the floor. The corrective action was listed that the resident was sent to the hospital to evaluate her head injury. There was no indication that the facility attempted to identify the cause of the dizziness that led to the fall. A progress note for 4/5/18 at 8:41 PM reflected that the resident was educated about the transfer (to the hospital) and not to pick things up from the floor without assistance. The Care Plan was not updated with an intervention. Resident #5's BIMS score suggested that she had severe cognitive impairment. She likely would not have been able to retain the education. During an interview on 5/15/18 at 4:10 PM, Director of Nursing (DON) B stated that the immediate action for the fall on 4/5/18 was to send the resident to the hospital. She believed that the immediate intervention was that notes were put up to call for assistance and not to bend over. DON B also stated the staff reminded her not to bend over when she was up. She stated that the nurses would not have done anything to assess the cause of the dizziness due to the resident being transferred to the hospital, otherwise they would have done an SBAR (Situation-Background-Assessment-Recommendation tool). An incident report for 4/9/18 at 11:13 PM, reflected that Resident #5 walked to the nurses station with her walker and was noted to have a skin tear on her left forearm. The resident stated the skin tear was the result of a fall. The cause of the incident was listed as, res. (resident) stated she fell . The corrective action was that treatment was done on the skin tear. There was no documentation supporting that a root cause analysis was conducted for the fall. The Care Plan was not updated with a new intervention to prevent falls. During an interview on 5/15/18 at 4:10 PM, DON B acknowledged that a root cause analysis was not done and that there was not a Care Plan intervention put in place. An incident report for 4/26/18 at 10:10 AM, reflected that the resident was sitting on her walker seat, near the end of her bed when the Certified Nursing Assistant (CNA) entered the room. She told the CNA that she had been calling for help, and she showed her ankle to the CNA. Upon entering the room, the nurse observed bone protruding against the skin on Resident #5's right ankle. The incident cause was determined to be that the resident was leaning over, looking in her bottom drawer when she lost her balance due to her ankle giving out. She then crawled to her walker and called for help. The corrective action section of the report reflected that the ankle was stabilized, the physician was contacted, and an order was obtained to send the resident to the hospital. The Care Plan reflected a focus area of, At risk for injuries r/t (related to) falls due to potential medication side effects .alzheimers .weakness, impaired balance, impaired safety awareness .impaired problem solving . An intervention for, cue card on dresser reminding res to ask for assistance w/ (with) obtaining items from bottom drawers had a date initiated of 4/27/18. The date created was 5/7/18, which was 4 days after the resident returned from the hospital after surgical repair of her fracture. During an interview on 5/15/18 at 4:10 PM, DON B stated that the nurses were supposed to put an immediate intervention in place to prevent further falls. On 5/15/18 at 12:27 PM, CNA F stated that Resident #5 was pretty independent before her fall with a fracture (on 4/26/18). She was independent with transfers and ambulation with a walker and was independent with toileting. CNA F stated that since the fracture, Resident #5 was non-ambulatory, non-weight bearing on her right leg and used a Sara lift (mechanical lift) for transfers and used a wheelchair. A Significant Change in Status MDS assessment was in progress with an ARD of 5/10/18.

Based on observation, interview and record review, the facility failed to assess one resident (Resident #45) for skin changes, out of 2 residents reviewed for pressure ulcers, from a total sample of 21 residents, resulting in the development of a stage 3 coccyx pressure ulcer and the potential for ongoing unrecognized and assessed skin changes. Findings include: According to a facility face sheet dated 12/15/17 at 11:40 AM, Resident #45 was an [AGE] year old female admitted to the facility on [DATE] with the Diagnoses: [REDACTED]. During a phone interview on 12/15/17 at 09:26 AM, Resident #45's family member (FM) EE stated that Resident #45's heel sores (pressure ulcers) are doing better, left heel mostly (affected) and the Resident #45 had a GRADE 3 sore on her bottom. FM EE stated facility staff have been lying her down in bed more often. FM EE stated Resident #45 needs closed caption TV and has that, she likes magazines and loves music activities. FM EE stated Resident #45 was attending Bingo but not right now, focusing more on healing 'sores'. A stage 3 pressure ulcer is, Category/Stage 3: Full thickness skin loss: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occipital and malleolus do not have (adipose) subcutaneous tissue and Category/Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/ On 12/13/17 at 10:37 AM, Resident #45 was observed with wound vac control hanging on the handles on her wheelchair. She was observed to have an inflated back rest on the wheelchair back. Review of a facility document for Resident #45 titled, Admission/Readmission Screen dated 10/24/17 (no time noted) reflected, Baseline Care Plan Pressure Ulcer: Site: Left buttock - White area that is not open, Right heel - dark area that is not open with mepatel (an occlusive) dressing applied .pressure ulcers present? No was observed to be checked. There were no wound measurements noted upon admission by LPN/RN (Licensed Practical Nurse and Registered Nurse, document esigned and lists staff as this) QQ. There was no documentation of a coccyx or left heel pressure area. A Braden skin risk assessment score on this screen indicated Resident #45 had a score of 14 indicating she was at moderate risk for developing skin break down. Review of a facility document for Resident #45 titled, Pressure Ulcer dated 10/27/17 (4 days after admission) by UM O reflected, Site: Left Buttock: noted as white area on left buttocks in admission assessment. The is a pressure area measuring 0.3 cm (centimeters) by 3.8 cm with a small open area granulation tissue noted at it's center -- 0.8 cm by 1.0 cm by 0.1 cm (deep). Right heel: dark purple/red non blanchable area right heel measuring 1 cm by 2 cm. Left heel: dark purple/black area on left heel measuring 4.6 cm by 4.3 cm. IDT (interdisciplinary team) met to review res(ident) skin on 10/27/17. See skin note for 10/27/17. According a facility progress note for Resident #45 titled, Skin dated 10/27/17 reflected, IDT met to review res(idents) skin. Resident admitted on [DATE] with various skin issues. This resident has a history [MEDICAL CONDITION] (infection through out the blood), dementia, hypertension, UTI (urinary tract infection), diverticulitis (inflammation in pockets of weak areas in the large intestine), pressure injury. She admitted on an antibiotic for pneumonia, has malnutrition, [MEDICAL CONDITION] (low blood count). Prior to admission this resident was noted in a wound note from (name of hospital) of having bilateral heel deep tissue injuries. Resident admitted to facility with bilateral foot splints/braces and a hinged knee stabilizing brace in place with the hinged knee stabilizer maintained in place--assessment of bilateral heels finds a stage 1 pressure ulcer on resident right foot measuring 1 cm by 2 cm, kin intact dark purple/red not blanching and an unstageable boggy dark purple/black area on left heel measuring 4.6 cm by 4.3 cm. These areas are consistent with notes received from (name of of hospital) , new treatment to apply [MEDICATION NAME] barrier (cream) to bilateral heels. Resident with stage 2 pressure ulcer to left buttocks measuring 3 cm by 3.9 cm with a small open area with granulation tissue noted at it's center measuring 0.8 cm by 1 cm by 0.1 cm. Previous treatment order discontinued to buttock and buttocks crease. New order Replicare (dressing) in place .No documentation was noted regarding a pressure wound to the buttocks crease in the 10/27/17 Pressure Ulcer assessment. A facility document for Resident #45 titled, Braden Scale for Predicting Pressure Sore Risk dated 11/4/17 reflected a score of 14 indicating Resident #45 continued to be at a moderate risk for skin break down even though Resident #45 was documented as being malnourished and as having possibly 4 pressure areas. This assessment was completed by LPN P. A progress noted for Resident #45 titled, Skin dated 11/3/17 by UM O reflected, IDT review of skin on 10/27/17 and 11/2/17 with no open are (sic) to coccyx or right buttock. A facility document for Resident #45 titled, Braden Scale for Predicting Pressure Sore Risk dated 11/11/17 reflected a score of 14 indicating Resident #45 continued to be at a moderate risk for skin break down even though Resident #45 was documented as being malnourished and as having possibly 4 pressure areas. This assessment was completed by LPN P. A facility progress note for Resident #45 titled, Skin dated 11/16/17 at 3:26 PM reflected, IDT met to review residents skin .Resident remains at risk for unavoidable skin breakdown due to multiple co morbidities. Resident continues with Stage 1 pressure ulcer on right heel measuring 1 cm by 1.3 cm by less than 0.1 cm. Skin intact dark purple/red not blanching. Surround skin normal and intact, blanching with return. Unstageable boggy dark purple/black area on left heel measure 4 cm by 4.9 cm by less than 0.1 cm surrounding skin normal, intact, blanching with return, new treatment for [REDACTED]. Resident resolving stage 2 pressure ulcer to left buttock measures 1.2 cm by 1.7 cm by less than 0.1 cm previous small open are (sic) to wounds center has healed with new skin noted. Immediate surrounding skin grayish in appearance, beyond this skin normal, intact, blanching with return, continue with current treatment .Will continue to observed this resident for changes. A facility document for Resident #45 titled, Braden Scale for Predicting Pressure Sore Risk dated 11/24/17 reflected a score of 13 indicating Resident #45 continued to be at a moderate risk for skin break down even though Resident #45 was documented as being malnourished and as having possibly 4 pressure areas. A score of less than 12 indicates high risk for skin breakdown. This assessment was completed by UM O. A progress note for Resident #45 titled, Skin dated 11/24/17 by UM O reflected, Stage 3 pressure ulcer coccyx are measuring 1.3 cm by 1.4 cm by 0.1 cm. A facility document for Resident #45 titled, Pressure Ulcer dated 11/24/17 completed by UM O reflected, Coccyx: Stage 3 pressure ulcer coccyx are measuring 1.3 cm by 1.4 cm by 0.1 cm, yellow slough wound bed. On 12/15/17 around 10:34 AM, during an observation and interview with LPN R for wound vac dressing change, LPN R was asked when the dressing changes to the Pressure Ulcers would be completed and she stated later in the shift. This surveyor asked that she be notified when this would be completed and LPN R stated she would do this. No notification was received on 12/15/17 of the dressing change to pressure ulcers by LPN R. On 12/14/17 at 10:30 AM, during an interview with UM O, she revealed Resident #45 had multiple areas of skin break down (pressure ulcers) when she was admitted into the facility. One pressure ulcer developed here, UM O stated, the coccyx wound. UM O revealed two pressure wounds were on heels - one unstageable left heel (has made great improvement), stage 1 right heel (almost healed), stage 2 on left buttock (healed), stage 3 coccyx (was not admitted with this wound) UM O stated the stage 3 coccyx wound was first noted 11/24/17. UM O stated she does weekly skin assessments. On 12/14/17 at 10:45 AM, during a review of a treatment record for Resident #45 it reflected, Marathon (cream) to bilateral heels after cleansing daily for 7 days, then weekly 11/16/17. Cleanse coccyx wound with normal saline, pat dry, apply med honey wound gel and cover with [MEDICATION NAME] wound dressing daily and prn on 11/24/17 noted discontinue on 12/6/17. Then cleanse coccyx wound with normal saline, pack wound with packing strip soaked in Dakin's solution (0.125% percent bleach mixture to decrease bacteria count within the wound) and cover with [MEDICATION NAME] (dressing) bid (twice a day) and prn (as needed) . 12/19/17 at 1:17 PM, during an interview with UM O regarding the development of a stage 3 pressure ulcer and the interventions in place before and assessments of the coccyx area before development, UM O confirmed resident was at moderate risk for skin break down. UM O stated Resident #45 had a pressure relieving mattress and pressure relieving cushion to her wheelchair (medical grade). UM O stated CNA (Certified Nurses Aids) report on skin sheets twice to 3 times a week and nurses followed up on these skin sheets. UM O stated if there is a change in skin, nurses alerted the UM. Review of the Kardex (care plan) for Resident #45 reflected that CNA's perform, frequent turns or positioning. UM O stated Resident #45's care plan said to reposition PRN. UM O stated the word frequent means every 2 hours or less. On 11/24/17 UM O stated a coccyx wound was noted as a 3 (stage) (she staged it herself). UM O stated there was a treatment over the area (Replicare), and she was unsure the if the area was observed without the treatment. Review of CNA skin sheets with UM O reflected on 10/25/17, an open was the stage 2 to the buttock and has since healed. UM O stated the Replicare patch was being noted by CNA, and changed every 3 days (Replicare) by nursing. UM O stated the Replicare treatment began on 10/30/17 when reviewing the Treatment Administration Record. UM O confirmed that all of the Replicare treatments were signed out as completed by nursing as well as prn's (as needed). From 10/30/27 to 11/24/17 (almost 1 month) UM O was not sure and can not provide documentation of the coccyx area being assessed for any skin changes by the CNA's or nursing staff. UM O was asked for CNA documentation regarding turning and reposition of Resident #45. UM O stated she will look for this. UM O confirmed that skin checks are for CNA's are done with the resident's showers. UM O did not provide daily nursing assessments of pressure ulcer areas done before 11/24/17. When UM O was asked if treatment for [REDACTED]. No nursing staff had alerted this surveyor that a pressure ulcer wound treatment needed to be completed. This was a second request to observe the pressure ulcer dressing changes/treatments. No documentation regarding the turning and repositioning of Resident #45 was produced by the facility by exit on 12/19/17 at 6:00 PM. Review of a facility policy titled, Skin Practice Guide dated 1/2013 reflected, Phase 1: Assess. Complete Skin risk section of patient admission/readmission screen and Braden scale .Pressure ulcers are caused by pressure and typically occur over bony prominence's in bed or chair bound individual. It is important to identify any primary etiology such as diabetes, [MEDICAL CONDITION] or moderate to severe vascular disease. risk factors for the development of skin alterations are dependent on the type of alteration .pressure ulcer-immobility, friction and shear forces, excessive moisture conditions .Initial evaluation: Review the hospital discharge records, transfer sheets or other data regarding the patient's history of, or risk factors for skin alterations and pressure ulcer development .Admission skin evaluation: A comprehensive skin evaluation is completed upon admission. Upon completion of the admission evaluation if there is no skin alteration, the patient is monitored for changes in risk factors. The Braden scale (skin risk for pressure ulcer) is completed on admission and then weekly for an additional 3 weeks (4 weeks total), quarterly, with a significant change in condition and as clinically indicated complete the Patient Admission/Readmission Screen in Point Click Care (the electronic medical record) including a head to toe full body audit to identify the presence of pressure ulcers or other skin alterations. Document findings on the Patient Admission/Readmission Screen and complete the initial Braden scale. After completion of the initial plan of care, the Patient Information worksheet, Kardex and Task List are updated. A weekly skin evaluation is completed by the licensed nurse for those patients identified as at risk for skin breakdown .Daily skin evaluations are completed by the licensed nurse for those patients with pressure ulcers. Documentation is completed on the Treatment Administration Record. Review of the Pressure Ulcer Prevention Pathway in the Skin Practice Guide reflected, Current of healed pressure ulcer: Document pressure ulcer - location, length, width, depth, PUSH (The Pressure Ulcer Scale for Healing) tool, wound team - stage, obtain order for treatment from physician and obtain consultations as needed, daily body audit, Braden scale . Review of an IDT (interdisciplinary team) note dated 12/11/17 (no time noted) on a pressure ulcer timeline complied by the facility reflected, .Res(ident) with stage 3 ulcer of coccyx 75 % (percent) wound bed with yellowish slough (shedding of dead tissue within the wound) 25% granulations tissue (new tissue, healing), wound measures 2.4 cm by 1.8 cm by 0.6 cm, no exudate (Exudate: A fluid rich in protein and cellular elements that oozes out of blood vessels due to inflammation and is deposited in nearby tissues. https://www.medicinenet.com/script/main/art.asp?articlekey=9900) noted at the of assessment, scant amouth of serousangenous (mixture of blood and serum) noted on old dressing . This timeline also reflected, 12/18/17 Per PA (physician's assistant) discontinue current treatment start cleanse coccyx wound with normal saline, pat dry, apply Santyl (a [MEDICATION NAME] ointment) to 2 by 2 gauze, lightly pack gauze directly in wound bed, cover with [MEDICATION NAME] with border. Change every day and prn (as needed). Resident #45 was not assessed daily for new changes to her skin by nursing from her admission on 10/23/17 until the development of a stage 3 pressure ulcer of the coccyx on 11/24/17.