Every finding on record at Park Avenue Health and Rehabilitation Center

Based on interviews, review of clinical record, the State Agency (SA) complaint portal, and review of facility policy and procedure, the facility failed to ensure the facility investigation and medical record were complete and accurate for one resident (#2), and regarding an incident of abuse. The deficient practice could result in care team members not being adequately informed regarding the status of the resident and lead to missed or delayed care.Findings include:Resident #2 was admitted to the facility on [DATE], with diagnoses that include generalized muscle weakness, subsequent encounter for closed fracture with nonunion, other specific joint derangements of the right hip not elsewhere classified, and acute pain due to trauma.An admission Minimum Data Set (MDS), dated [DATE], indicated Resident #2 completed a Brief Interview for Mental Status (BIMS) and scored a 15, indicating the resident was cognitively intact.The SA complaint portal received an allegation related to Resident #2 being abused by a Certified Nursing Assistant (CNA/Staff #63) on Friday, October 3, 2025.Progress Notes revealed no evidence of entries related to the alleged employee-to-resident abuse that took place on October 3, 2025.A Condition Monitoring assessment, dated October 4, 2025, at 3:36 A.M indicated that the date of the original condition being monitored was September 30, 2025, for Resident #2's Right hand and Right thumb pain.Two other Condition Monitoring assessments, dated October 4, 2025, referenced the same September 30, 2025, incident and monitoring of the Right hand and thumb pain.Additional review of the clinical record revealed no evidence of resident assessments related to the Left arm/shoulder pain having been completed after the alleged incident took place on October 3, 2025. A facility Final Written Report, indicated that the initial report was made by the Administrator (staff #300) on October 5, 2025 at 5:58 PM via online reporting system. The final report revealed that on October 5, 2025 a nurse reported an allegation that occurred on October 3, 2025 regarding rough treatment by a CNA (staff #63). The report also revealed that the Administrator interviewed staff #63, and another CNA (staff #301) who was present at the time of the reported incident. The report included education of when incidents should be reported to the abuse coordinator. The report concluded that the allegation could not be verified. However, the report did not include any evidence that Resident #2 was interviewed by the Administrator regarding her allegation of rough treatment. A Care Plan, revised on October 8, 2025, indicated that Resident #2 had a potential for a psychosocial well-being problem related to alleged abuse being reported on October 5, 2025. Interventions included Social Services interviewing Resident #2 and determining no changes or referrals were needed, consulting with Pastoral care, social services, psychiatry services, and others, and allowing the resident time to answer questions and verbalize feelings, perceptions, and fears.An interview was conducted with Resident #2 on October 24, 2025, at 2:51 P.M. in her room. Resident #2 shared that Staff #63 was in her room with another CNA. After using a Hoyer Lift to put her back in her bed, Staff #63 pushed her left arm, and Resident #2 asked her to stop pushing her arm because she has damage in there. Resident #2 explained that Staff #63 acknowledged her and then grabbed her left arm and yanked it to have her turn to the side. At that point, Resident #2 shared that the staff was hurting her, but Staff #63 told the resident that she needed to be changed. Resident #2 added that after the incident, she had to get a muscle rub for the pain in her shoulder.An interview was conducted on October 24, 2025, with Licensed Practical Nurse (LPN/Staff #7) at 10:09 A.M. Staff #7 shared that she would document resident incidents, such as a change in condition, resident altercation, or an allegation of a resident altercation, into the resident's medical chart. She shared that she was not sure if it was the policy to do so, but she was always told to document. She also indicated that she is told to document what she sees, not what she hears.An interview was conducted on October 24, 2025, with LPN/Staff #51 at 10:29 A.M. Staff #51 shared that she would document anything, such as a resident having an issue with a roommate or resident complaints. When asked if this was a facility policy or her professional preference and she shared that she believed this was a standard process if there were any changes in her (residents). She identified that she knew that if there was a change in condition or physical issues with a resident, this would need to be documented but she was not sure if it was the policy and indicated that she would have to look at the policy itself. Staff #51 added that she would rather someone be over charted. Staff #51 shared that Resident #2 had mentioned to her that a staff member had pulled her arm and that she had made a complaint about it. Staff #51 shared that she would expect that the incident would be charted and then a change of condition charting is done afterwards so that additional monitoring can take place. This is done because it brings it to their attention if anything is different. Staff #51 reviewed Resident #2's clinical record and shared that she did not see anything related to the alleged incident in the progress notes. When asked what the risk to the residents would be if such documentation did not take place regarding an alleged incident, Staff #51 shared that if it was not documented, it did not happen. It's a rule to document. She added that it also indicates that the resident is not being closely monitored, and her shoulder is not being monitored for further injury. Staff #51 shared that she wouldn't have known that her shoulder needed to be monitored if Resident #2 had never told her about the incident.An interview was conducted on October 24, 2025, with the Assistant Director of Nursing (ADON/Staff #49) at 11:40 A.M. Staff #49 explained that an incident would be considered a change in a resident's condition, and charting for that change would be done for the next three days to monitor to see if something gets worse or better. Incidents that were to be documented in the resident's chart were described as life-changing situations or something that affects the resident. physically. If neither one of those things were applicable, then it is not documented in the chart. When asked if Resident #2's chart reflected the alleged incident, Staff #49 indicated that she was not aware of it being documented in the chart because it was an allegation. She explained that the facility does investigations before putting it in the chart, depending on the situation. She added that if it was crazy, then we'd document right away. Staff #49 explained that the allegation was not documented because of the outcome of the investigation. She shared that if they charted everyone's allegation, then there would be a lot in the chart, and the resident did not report pain as a result of the allegation.An interview was conducted on October 24, 2025, with the Director of Nursing (DON/Staff #99) at 11:58 A.M. Staff #99 explained that she did not consider a resident's allegation to be a change in the resident's condition. They would do an investigation and then refer the resident to Psychiatry or Social Services. If there were any psychosocial monitoring that needed to be done, it would be done going forward. However, if there were any physical injury, then they would document it. Staff #99 explained that internal documentation is not a part of a resident's medical record, but if there was a physical component identified during the investigation, it would be documented. She added that the Psychiatry provider is notified for any allegation that does not have a physical injury component. Staff #99 shared that their investigation found that Staff #63 did not harm Resident #2. When asked if Resident#2's clinical chart reflected the alleged incident, Staff #99 shared that it was updated in the Care Plan. When asked if there was any monitoring for Resident #2 put into place, Staff #99 indicated there was no monitoring outside of the psychosocial component. However, she indicated that she believed Resident #2 was examined after the allegation was made and checked the clinical record. After reviewing the clinical record, she shared that there was no assessment done. When asked to review the policy titled Abuse: Prevention of a Prohibition Against, specifically section F, subsection 3, Staff #99 was asked if that section of the policy took place, and she indicated that she did not see any documentation of an assessment being completed/conducted after the incident that occurred on October 4, 2025, and was not sure why it was not done. She added that at the time of the incident, Resident #2 did not complain of pain, and she had no injuries. The resident was alert and oriented. If she wasn't alert and oriented that she would go in and perform an assessment. She shared that she was not going to do an X-ray of the entire body based on an allegation, as that is not needed. The resident was able to be interviewed, and she was able to do a focused assessment as needed. Staff #99 indicated that the policy needed to be changed to as needed, as they are only documenting the things that they find.Review of the facility policy titled Abuse: Prevention of and Prohibition Against section F, subsection 3 states A licensed nurse will immediately examine the resident upon receiving reports of alleged physical or sexual abuse. The findings of the examination shall be recorded in the resident's medical record. The policy included that all identified events are reported to the Administrator immediately and the investigation will include an interview with the person reporting the incident, an interview with the resident. The policy indicated that if an allegation of abuse is reported the facility will respond immediately to protect the alleged victim, examine the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; make staffing changes is necessary and provide emotional support and counseling to the resident during and after the investigation, as needed. A facility policy titled, Reporting Reasonable Suspicion of a crime, included that the facility seeks to protect its residents from being subjected to incidents of crime, and to ensure that any such incident (or reasonable suspicion of such incidents) are reported in a timely manner to the State Survey Agency (SSA) and local law enforcement. The facility relayed that if the reportable event does not result in serious bodily injury, the staff member shall report the suspicion no later than 24 hours after forming the suspicion.

Based on observation, interviews, review of clinical record, and review of facility policy and procedure, the facility failed to ensure infection control policies were followed during therapy sessions for five residents (#44, #45, #55, #180, and #181). The deficient practice could lead to spread of infection.Findings include:An observation was conducted on August 21, 2025, at 10:10 a.m. of a group therapy session occurring in the first-floor lounge room. Residents #44, #45, #55, #180, and #181 were present in the lounge, and being led in various therapy activities by a Physical Therapy Assistant (PTA/ staff #100). There was no hand sanitizer or handwashing station/sink or sanitizing agents such as spray or wipes observed in the lounge room. The PTA removed an ankle weight off of a female resident in a wheelchair and set the ankle weight on a chair without sanitizing it. The PTA did not sanitize or wash his hands. Then, the PTA picked up the ankle weight off of the chair and without sanitizing it, placed the ankle weight on Resident #44's leg. The PTA did not wash or sanitize his hands, and set up a front-wheeled walker in front of Resident #55. Then, the PTA donned a gait belt around Resident #55's waist and used touching assistance to help Resident #55 in a standing therapy activity with the walker. The LPN did not wash or sanitize his hands, and touched Resident #181 and her wheelchair, unlocked the wheelchair, and pushed Resident #181 back to her room. The PTA set up Resident #181 with her personal items in reach, and did not assist the resident with cleaning her hands. The PTA did not wash his hands at the sink in the room or sanitize his hands with the sanitizing dispenser located directly outside Resident #181's door, and left the room and started to walk back down the hall toward the lounge.An interview was conducted with PTA (Staff #100) on August 21, 2025, at the time he was walking back toward the lounge from Resident #181's room. Staff #100 stated that he was leading a therapy group in the lounge. The PTA stated that regarding infection control policies, that if a resident is on standard precautions that therapy staff would wear gown and gloves while working with a resident, and that if a resident was on universal precautions then the staff would wear a gown and mask when working with the resident. If a resident did not have any isolation precautions, then staff would be expected to wash hands or use hand sanitizer before working with the next resident. The PTA stated the importance of this would be to make sure that staff do not spread infection between residents. Regarding equipment, Staff #100 stated that staff wipe down equipment with sanitizing wipes before using it on another resident. The surveyor then notified Staff #100 that it was observed that he had not sanitized his hands or cleaned equipment between residents during the group, and that in group therapy, he may overlook sanitizing, and use equipment between residents, and then after the group sanitize the equipment. The PTA stated that he believed that this would meet the facility's infection control policy.The observation continued and the PTA (staff #100) walked directly back to the group therapy in the lounge and picked up the gait belt that had previously been used, and without sanitizing it, placed it on Resident #45. Additionally, without sanitizing the front wheeled walker that was previously used, Staff #100 placed the walker directly in front of Resident #55 to use.An interview was conducted with a Certified Occupational Therapy Assistant (COTA / Staff #138) on August 21, 2025, at 10:32 a.m. Staff #138 stated that staff perform handwashing or hand sanitizing after treating or touching a resident and before working with another resident. Additionally, Staff #138 stated that gait belts and other equipment are sanitized with wipes after being used and prior to using them with another resident. The lounge was observed with Staff #138, and Staff #138 stated that there was no handwashing station or hand sanitizer in the lounge, and that the closest one would be down the hall. Staff #138 stated that he was not sure about the facility's infection control policy, but that he could find out.An interview was conducted with the Therapy Program Manager and Physical Therapy Assistant (TPM / Staff #11), who stated that the facility's infection control policy requires staff to wipe down therapy equipment such as exercise bands and weights with sanitizing wipes prior to using it on another resident, and to wash hands or sanitize hands in between providing care or treatment for residents. Staff #11 stated that a therapist not sanitizing hands between residents or sanitizing equipment used between residents would not meet the facility's policy for infection control. Staff #11 stated that regarding the observation of Staff #100, that he would be doing an in-service with the therapy team.An interview was conducted with the Director of Nursing, (DON / Staff #91) on August 21, 2025, at 11:25 a.m., who stated that her expectation regarding infection control would be for staff to sanitize hands or wash hands in between working with patients. The DON stated that equipment would be sanitized between patient use, and that if residents were in group therapy and tossing a ball back and forth then the residents would be encouraged to wash their hands prior to tossing the ball back and forth, and that the ball would be cleaned afterward. The DON was notified that a staff was observed not sanitizing hands between touching residents and not sanitizing therapy equipment between resident use, and the DON stated that this would not meet the facility's infection control policy. The DON stated that she was notified of this by Staff #11, and that the facility is already taking steps to correct the issue.An additional interview was conducted on August 21, 2025, at 11:28 a.m. with a Certified Nursing Assistant and Restorative Nursing Assistant (CNA/RNA/ Staff #47), who stated that gait belts are sanitized after each resident use, equipment is sanitized after each resident use, and staff are required to sanitize their hands prior to resident care. Staff #47 stated that the risk if sanitization is not done is that there could be cross contamination of microorganisms which could spread infection.An In-Service/Education Summary sign-in sheet dated August 21, 2025, revealed the topic of the in-service was Sanitization/Infection Control, and that the contents included the procedure for sanitizing all therapy equipment before and after use, all therapists and therapy aids are to wash hands with soap before and after therapy session with patient, and use of sanitization wipes in accordance with directions printed on bottle, and hand sanitizer for patients.Review of the facility policy titled Hand Hygiene, revised October 2022, revealed it is the policy of the facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene based on accepted standards. Hand hygiene is one of the most effective measures to prevent spread of infection. All personnel shall follow handwashing/hand hygiene procedure to help prevent the spread of infections. Hand hygiene is a general term that applies to hand washing, antiseptic hand wash, and alcohol-based hand rub. The procedure included to wash hands with soap and water when hands are visibly soiled and after caring for a resident with known or suspected Clostridioides Difficile or Norovirus infection. Additionally, the procedure included to use an alcohol-based hand rub containing at least 62% alcohol; or soap and water for the following situations: before and after coming on duty, before and after coming into direct contact with residents, after contacting a resident's intact skin, and after contact with objects in the immediate vicinity of the resident.Review of the facility policy titled IPCP Standard and Transmission-Based Precautions revealed Standard Precautions are infection prevention practices that apply to the care of all residents regardless of suspected of confirmed infection or colonization status. They are based on the principle that all blood, body fluids, secretions, and excretions may contain transmissible infectious agents. Standard Precautions include: proper selection and use of personal protective equipment (PPE), hand hygiene, environmental cleaning and disinfection, and reprocessing of reusable medical equipment. If common use equipment for multiple patients is unavoidable, clean and disinfect such equipment before use on another patient.

Based on observations, clinical record review, resident and staff interviews, and review of facility policy, the facility failed to ensure that the catheter bag was covered for one resident (#176). The deficient practice could result in resident not being treated with dignity and respect.Findings include:Resident #176 was readmitted to the facility on [DATE], with diagnoses that included acute kidney failure, elevated white blood cell count, depression, and dysphagia.The Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The assessment also included that the resident had an indwelling catheter.The indwelling catheter care plan initiated on July 30, 2025, included interventions to position the catheter bag and tubing below the level of the bladder and away from the entrance room door. There was no evidence of a cover on the catheter bag. During an observation that was conducted on August 19, 2025, at 1:22 p.m., Resident #176 was observed lying on his bed in his room, with an indwelling catheter bag placed below the bladder hanging on the left side of the bed with yellow liquid visible from the entrance room door. There was no evidence of a cover on the catheter bag.A second observation was conducted on August 19, 2025, at 2:44 p.m., Resident #176 was lying on his bed in his room, with his indwelling catheter bag placed below the bladder hanging on the left side of the bed with yellow liquid visible from the entrance room door. There was no evidence of a cover on the catheter bag.In another observation conducted with a Certified Nursing Assistant (CNA/ staff #73) on August 20, 2025, at 7:52 a.m., Resident #176 was lying on his bed in his room, with his indwelling catheter bag placed below the bladder hanging on the right side of the bed with yellow liquid visible. The CNA stated that the resident's catheter bag was not covered and that this would be a dignity issue.In an observation conducted with a Licensed Practical Nurse (LPN, staff #142) on August 20, 2025, at 8:10 a.m., Resident #176 was lying on his bed in his room, with his indwelling catheter bag placed below the bladder hanging on the right side of bed with yellow liquid visible. The LPN stated that she observed that Resident #176's catheter bag was uncovered, and yellow liquid inside the bag was visible. The LPN then stated that resident #176 was readmitted to the facility from hospital with an uncovered catheter bag. The LPN further stated that the facility does not use an uncovered plastic bag for resident privacy and dignity concerns.An interview was conducted with an Infection Preventionist (IP, # 300), on August 20, 2025, at 11:02 a.m., who stated that the catheter bag should be covered for patient privacy and dignity.In an interview conducted with the Director of Nursing (DON/staff #91) on August 21, 2025, at 1:10 p.m., who stated that the catheter bag should be placed in a covered bag and secured to the side of the bed or under the wheelchair. The DON further stated that the catheter bag should be covered for dignity, especially when the resident is in a public area.A facility policy titled, Catheter Care, Indwelling, reviewed on July 7, 2024, revealed that catheter tubing should be kept below the level of bladder and the drainage bag should be covered with a privacy bag.

Based on clinical record review, interviews, facility documentation and review of the facility policy, the facility failed to ensure that a change of condition, for one resident (#3) out of 3 sampled, was immediately reported to the physician. The deficient practice could result in clinically adverse outcomes for the resident.Findings include:Resident #3 was admitted on [DATE] with diagnosis including muscle weakness, difficulty walking, pressure ulcer of the sacral region, type 2 diabetes mellitus with hyperglycemia, fluid overload, essential hypertension, pneumonia, acute on chronic systolic congestive heart failure, nonrheumatic mitral valve disorder, edema, acute respiratory failure with hypoxia, pleural effusion, sepsis and dyspnea.A review of discharge MDS (minimum data set) dated January 28, 2024 did not show evidence of a BIMS (brief interview of mental status) score, but did document that there were no potential indicators of psychosis or no evidence of behaviors.A review of the progress notes revealed that on January 28, 2024 at 6:35 AM an 'O2 SATS WARNING' (oxygen saturation warning) was documented, noting a value 88% oxygen saturation. A progress note dated January 28, 2024 at 6:49 AM by registered nurse, staff #37, noted that the writer was informed that the resident started coughing early in the morning at approximately 4:00 AM and had desaturated to 87% on liters of oxygen. The documentation further revealed oxygen saturation levels of 88% on 5 liters of oxygen. Staff #37 documented that the resident had persistent coughing and continued to desaturate. It was noted that night nurse, staff #45, reported that the resident had been seated-up and remained at 87% oxygen saturation since 4:00 AM.Documentation further revealed that 911 was contacted per the providers orders and that the resident was taken to the emergency room by Tucson Fire Department.An earlier progress note entered by the night nurse, staff #45 revealed that staff #45 had contacted the resident's daughter at 5:30 AM to relay that the resident had been coughing and expectorating slightly brownish phlegm.The progress notes revealed no evidence that the night nurse had contacted the physician regarding the resident's oxygen saturation levels.A review of the care plan revealed that the resident had congestive heart failure and a noted intervention included to check for breath sounds and monitor/ document labored breathing as well as monitor / document and report to the medical doctor any signs of congestive heart failure to include shortness of breath upon exertion, dry cough and or orthopnea (difficulty breathing when laying down).A telephone call was placed to RN (registered nurse), staff #37 on July 31, 2025 at 9:47 AM, a message was left on voicemail but no return call was received.A telephone call was placed to RN, staff #45 on July 31, 2025 at 9:50 AM. The phone rang but did not cycle to voicemail.An interview was conducted on July 31, 2025 at 10:24 with LPN (licensed practical nurse), staff #7. Staff #7 stated that residents on oxygen are generally monitored every 2 hours and depending on the medication they are on, sometimes more frequently. The LPN stated that if a resident's oxygen saturation was dropping, vitals should be checked and oxygen levels should be adjusted if the setting was initially low, such as 2 liters. Staff #7 stated that she would also sit the resident up, coach them to take deep breaths and would immediately contact the provider (physician). The LPN stated that waiting for 2 hours to contact the provider, when a resident is desaturating, is not acceptable. Staff #7 stated that the risk for not notifying the provider of the resident's change in condition, could cause a further decline in the resident's health.An interview conducted on July 31, 2024 at 11:34 AM with CNA (certified nursing assistant), staff #21. Staff #21 stated that if vitals are outside of baseline for oxygen saturation, below 90% saturation, she would notify the nurse. Staff #21 stated vitals should be checked at least once per shift or potentially more as ordered. Staff #21 stated that if the nurse is not notified and if the nurse doesn't notify the doctor then the risk could include the resident having to go to the hospital or even dying.An interview was conducted on July 31. 2024 at 10:41 AM with LPN, staff #71. Staff #71 stated that if a resident's oxygen saturation drops, the doctor should be notified right away. Staff #71 stated that sometimes a 'senior' may have low oxygen saturation levels. Staff #71 stated it would not be acceptable to wait 2 hours or more before contacting the doctor, as a resident's health could go 'south'. Staff #71 stated that if a resident's oxygen drops she would sit them up and take another reading and if the reading was still low, below 90, call the doctor immediately.An interview was conducted on July 31, 2025 at 11:10 AM with the DON (director of nursing), staff #82. Staff #82 stated that a change in vitals, to include oxygen saturation ranging between 87% and 88% , would warrant a call to physician. Staff #82 stated that a physician should be notified of a change in condition immediately, if not already addressed in the orders or if medications, as applicable, did not elicit a positive change in the resident's condition. Staff #82 reviewed the resident's file and stated that she did not see evidence in the electronic health record that the physician had been notified when the resident's oxygen saturation levels had initially dropped. Staff #82 stated that the risk for not notifying the physician could include a decline in the resident's mental stated and overall health.A review of the policy entitled Change of Condition Reporting, reviewed on July 2024, revealed that any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician. The policy further notes that all nursing actions are to be documented in the nursing progress notes as soon as possible after the resident's needs have been met. !!

Based on clinical record review, interviews, and policy and procedures, the facility failed to ensure that an allegation of abuse was reported to the state agency for one of of three residents. The deficient practice could further endanger the resident and impede an investigation.Findings include:Resident #7 was admitted on [DATE] with diagnosis including bipolar disorder, anxiety disorder, atherosclerotic heart disease, chronic pain, fibromyalgia, dependence on supplemental oxygen, dementia without behavioral disturbance, insufficient sleep syndrome and post-traumatic stress disorder.A review of the annual MDS (minimum data set) dated May 4, 2025 revealed a BIMS (brief interview of mental status) score of 01, indicating severe cognitive impairment. The total mood severity score noted was a 9, indicating mild depression. There were no noted potential indicators of psychosis or behaviors noted.An encounter note dated July 14, 2025 in the electronic health record revealed that in light of current accusations and the resident's inability to express herself appropriately regarding her feelings, it was recommended that staff use a two-person system and the 'utmost' care while documenting everything that the resident says or does.A review of the electronic health record revealed no documented evidence of an abuse allegation reported on July 24, 2025.A review of the submitted facility 5-day investigative reports revealed no evidence of an allegation of abuse that was reported on July 24, 2025 for resident #7.A review of the state agencies reporting portal revealed no evidence of an abuse allegation reported on July 24, 2025 for resident #7.An interview was conducted on July 31, 2025 at 11:05 AM with CNA (certified nursing assistant), staff #10. Staff #10 stated that there are many layers of abuse and these could include financial, verbal, physical and isolation. Staff #10 stated that as soon as he is made aware of an allegation of abuse, he would report it to the abuse coordinator (administrator). The CNA stated that abuse training is conducted at least once a year and periodically throughout the year.An interview was conducted on July 31, 2025 at 11:11 AM with RNA (restorative nursing assistant), staff #93. Staff #93 stated that abuse should never happen, but stated that if it does happen then it needs to be stopped and reported right away to the administrator and if necessary the police. Staff #93 stated that if not reported timely it could make the resident feel unsafe, cause more trauma and breach of trust. Staff #93 stated that there is regular abuse training annually and then additional training every couple of months.An interview was conducted on July 31, 2024 at 11:20 AM with LPN (licensed practical nurse), staff #76. Staff #76 stated that abuse can be verbal, physical, sexual or anything denying care to a resident. Staff #76 stated that if a resident reports an allegation of abuse, she would immediately report it to her supervisor. She stated that she would further call the doctor and notate a change of condition. An interview was conducted on July 31, 2025 at 12:27 PM with LPN, staff #5. The LPN stated that she is very passionate about resident care. She stated that if she was made aware of an incident of abuse, she would separate the parties involved, ensure their safety and report the incident forward. Staff #5 stated that resident # 7 had reported to her that staff #115 beat her up and hit her on the legs. The LPN stated that the incident had occurred the previous week and stated that the staff member was removed from caring for the resident and that it had been reported. Staff #5 stated that the director of nursing had been notified on July 24, 2025 at 12:56 PM via a text message and that this was when staff #115 had been removed from providing care for resident #7.An interview was conducted at 07/31/2025 at 1:45 PM with the DON (director of nursing), staff #82. Staff #82 stated that regardless of a resident's cognition or if allegatio9ns had been made in the past, an abuse allegation would always need to be reported to the state agency. Staff #82 stated that she thought the reporting timeframe was either 2 hours of 5 days, but then stated that it was 2 hours. Staff #82 stated that abuse could be physical, mental, emotional or financial. The DON stated that the flow of communication would be from staff to the DON and then to abuse coordinator. She further stated that her expectation is that abuse is always reported timely and immediately addressed.An interview was conducted on 07/31/2025 at 3:31 PM with the administrator/ abuse coordinator, staff #101. Staff #101 stated that he was not aware of an abuse allegation from resident #7 on July 24, 2025. He stated that the issue may have been one of miscommunication between staff and himself. The administrator stated that the expectation is report abuse as soon as possible, within 2 hours on an abuse allegation. He further stated that the risk could include that it could occur to other residents in the building and that the occurrence would not be mitigated.A review of the Resident Rights policy entitled Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment with a review date of September 2020 revealed that the facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported with two hours.

Based on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to ensure 1 of 14 sampled residents (Resident # 28) was free from abuse by another resident (Resident # 23). The deficient practice could result in other residents being abused. Findings include: -Regarding Resident (#23) Resident (#23) was admitted to the facility on [DATE], with diagnoses of dementia and altered mental status. A nursing note dated August 10, 2022 at 9:52 p.m., revealed that Resident (#23) was hallucinating stating she was going to die because she was told by two ladies that the building was falling down. The note also indicated that the Resident (#23) was combative towards staff and yelling in the hallway. A nursing note dated September 10, 2022 at 3:38 a.m. revealed Resident (#23) was very combative with staff and threatening to kill a Certified Nursing Assistant (CNA). A nursing note dated September 22, 2022 at 7:12 p.m., indicated staff attempting to administer eye drops and Resident (#23) became aggressive towards staff by punching, kicking, biting, flailing her arms, pulling staffs hair and using vulgar language. A nursing note dated October 4, 2022 at 6:26 p.m., revealed that nurse spoke to Nurse Practitioner regarding resident's aggressiveness and combative behavior. Nurse Practitioner gave verbal order to send resident to Hospital for geriatric psychological evaluation for being a danger to self and others. A nursing note dated October 4, 2022 at 7:35 p.m., revealed that transport company did not transport patient to emergency room because patient refused to get on the stretcher. A Psychotherapy Progress note dated October 10, 2022 at 11:51 a.m., revealed a plan of continued monitoring of Resident (#23) with coordination of staff regarding moods and behaviors including nonpharmacological treatments. A nursing note dated October 11, 2022 at 3:41 p.m., revealed that resident (# 23) was disturbing her roommate by yelling and taking blanket from roommate's bed. The Progress Note also revealed that the incident was reported to the author's supervisor, but no follow up was documented. A comprehensive care plan initiated November 5, 2022, revealed antidepressant medication use, related to depression as evidenced by angry outbursts, complicated by cognitive deficits and difficult to redirect. The interventions included to monitor and record occurrence of target behavior symptoms such as physical aggression and document per facility protocol. A Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impairment. The assessment also indicated wandering behaviors but no hallucinations or delusions. -Regarding Resident (# 28) Resident (# 28) was admitted to the facility on [DATE], with diagnoses of dementia, bipolar disorder, major depressive disorder, and anxiety disorder. A comprehensive care plan dated November 2, 2021, revealed that Resident (# 28) had impaired thought processes, memory, safety awareness impairments due to dementia. Interventions included staff identifying self when communicating and keeping a consistent routine. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 indicating mild cognitive impairment. The assessment did not indicate any behaviors. A Skin Evaluation performed on Resident (#28) dated October 29, 2022 revealed that skin was intact. There was no indication of bruising on Resident (#28) legs. A nursing progress note for Resident (# 28) dated, October 31, 2022 at 3:03 p.m., by Licensed Practical Nurse (LPN/Staff # 3) revealed that Resident (# 28) was sitting at the end of a hallway looking out the window when Resident (# 23) approached and called Resident (# 28) evil and the devil. Resident (# 23) began to hit at her and struck her a couple times. It was reported that Resident (# 28) said she was minding her business when Resident (# 23) approached and called her evil and the devil. Resident (# 28) informed LPN (#3) that Resident (# 23) stood over her and hit her. The progress note also revealed that a wound nurse evaluated resident for injuries. Wound nurse noted bruise to right thigh area. A nursing progress note for Resident (# 23) dated October 31, 2022 at 3:59 p.m., revealed that Resident (# 23) was combative on the shift which included screaming and hitting another resident in the hall. The incident was witnessed by a CNA (not identified). The progress notes also indicated that Resident (# 28) had a bruise on lower left extremity. A nursing progress note for Resident (#23) dated October 31, 2022 at 9:29 p.m., revealed that Resident (#23) was moved to a single room [ROOM NUMBER] bed B and continuously monitored every 15 minutes. Review of the facility investigation report dated November 4, 2022, revealed that on October 31, 2022 Resident (#28) was sitting at the end of the 200 unit, near the window when Resident (# 23) wheeled up behind Resident (#28) and hit her arm and leg calling her the devil. Even though the facility report confirmed contact was made on resident (# 28) the facility concluded that they could not substantiate any injuries despite the multiple nursing notes documenting the bruising on Resident's (#28) legs. A Skin Assessment for Resident (#28) dated November 5, 2022 revealed a resolving bruise to right anterior thigh. An interview was conducted with LPN #3 on June 5, 2025 at 2:18pm, who stated that it was reported to her that Resident (# 23) had delusions where she thought Resident (# 28) was the devil and wheeled over and hit her. LPN (# 3) stated that she came out when heard there was an incident and separated residents and assessed Resident (# 28). LPN (# 3) acknowledged that Resident (# 28) was bruised on the right leg by Resident (# 23). LPN (# 3) reported that staff wanted to move Resident (# 28) into another room further down the hall because after the incident Resident (# 28) started to obsess about Resident (# 23) walking by her room trying to provoke Resident (# 23). Instead, they moved Resident (#23) to another wing of the building and monitored her. An interview was conducted with the Executive Director (ED/Staff #164) on June 6, 2025 at 12:12 p.m. Staff (#165) stated that when there is an allegation of abuse staff will call or text the ED immediately. Sometimes if the Unit Manager LPN (#3) is working that day they will tell her and she will contact me. The ED stated that the investigation is conducted by a team, typically the Director of Nursing will do staff and resident interviews, while the ED contacts State Health Department and Ombudsman, usually the ED will instruct nursing to call police. ED (# 164) reviewed the facility report and stated that the facility did acknowledge that Resident (# 23) made contact with Resident (# 28) but unsubstantiated because there was no harm, despite the fact of numerous clinical reports of Resident (# 28) receiving a bruise on her thigh. A Policy and Procedure titled, Abuse: Prevention of and Prohibition Against, revised December 2023, stated the policy of the Facility is that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment.

Based on clinical record review, interviews, facility documentation and policy review, the facility failed to provide care and services in accordance with the resident's care plan for one resident (#34) regarding administration of scheduled medications as ordered by the physician. This deficient practice has the potential to result in residents not receiving necessary antibiotic treatment as planned, placing them at increased risk for unresolved infections and adverse health conditions. Findings include: Resident #34 was admitted to the facility on [DATE] with diagnosis that included Traumatic Brain Injury, seizures, sepsis, and Methicillin Susceptible Staphylococcus Aureus (MSSA) infection. A review of the admission Minimum Data Set (MDS), dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had was cognitively intact. A review of the physician's orders, dated September 28, 2022, revealed Resident #34 was to take Cefazolin Sodium (antibiotic) solution, 2 grams (GM) intravenously every 8 hours for MSSA for 10 days. The medication was scheduled to end on October 8, 2022. Review of the care plan dated September 30, 2022 stated the was on antibiotic therapy as a related to her MSSA infection. The care plan goals included that the resident will be free from discomfort or adverse reactions related to antibiotic therapy. The care plan interventions stated to administer medications as ordered and to monitor, during every shift, for side effects such as diarrhea, nausea, vomiting, and hypersensitivity/allergic reactions. A review of the September 2022 Medication Administration Record (MAR) revealed that a dose of the Cefazolin Sodium was not administered on September 30, 2022 at 10:00 PM. A review of Resident #34's progress notes did not reveal an entry indicating why the scheduled dose was missed or that a physician was contacted about the missed dose. A review of the October 2022 MAR revealed that a dose of the Cefazolin Sodium was not administered on October 2, 2022 at 10:00 PM. A review of Resident #34's progress notes did not reveal an entry indicating why the scheduled dose was missed or that a physician was contacted about the missed dose. An interview was conducted on June 5, 2025 at 11:38AM with Licensed Practical Nurse (LPN/Staff #66). Staff #66 explained that if she missed a dose of scheduled antibiotics for a resident, she would contact the provider and get instructions on what to do. She would also document the missed dose on the MAR and progress notes for that resident so that the next shift was aware. Staff #66 also explained that if she came onto shift and noticed the MAR did not identify if a resident took a medication or not, she would call the provider to see if the nurse from the previous shift informed them of the missed dose and then contact the Assistant Director of Nursing (ADON) or the Director of Nursing (DON). She added that if a resident were to miss two dosages of antibiotics, the resident would be at risk for re-infection. An interview was conducted on June 5, 2025 at 12:03 PM with LPN/Staff #55. Staff #55 explained that if she missed a dose of the resident's antibiotics, she would contact the provider and the provider would usually extend the antibiotics for an additional two days. She also stated that she would document the omission in the MAR as well as in a progress note. The documentation would also include a statement indicating the provider was notified. When asked what she would do if she noticed there was no documentation indicating an antibiotic was administered the previous shift, Staff #55 explained that she would follow up with the outgoing nursing to see why it was not administered. She would also notify the unit manager and document that she found that missed documentation. She also added that she would not administer the dose until she followed up with the provider because it could result in a double dosage for the resident. An interview was conducted on June 5, 2025 at 12:50 PM with the Director-in-Training (DIT/Staff #170). Staff #170 shared her expectations of staff related to missed doses of antibiotics. Staff #170 indicated that nurses were to let the resident know that antibiotic treatments would be extended, notify the provider of the missed dose, and to contact the pharmacy to ensure medications were in stock to administer the additional doses. Staff #170 also explained that nurses are to document the missed antibiotic doses in the resident's progress notes as well as information about the provider being notified, including the date and time the notification was made. When asked which shift was responsible for administering medications at 10:00 PM, Staff #170 shared that the outgoing shift was responsible for administering it before their shift ended at 10:00 PM. Staff #170 was asked to verify if Resident #34 was administered Cefazolin Sodium during September and October of 2022. After reviewing the MAR, Staff #170 confirmed there were two missed doses on September 30, 2022 and October 2, 2022. Staff #170 was not able to identify why there was no documentation on the MAR and progress notes regarding if the medication was given or not on both dates. When asked if this met her expectation, she indicated that it didn't and the risks to the residents for not administering multiple doses of antibiotics were the infection wouldn't be cleared up and the residents would need to extend their treatment. According to the policy titled, Physician's Orders, last reviewed in August 2024, indicated that orders must be accuartely implemented in addition to medication orders (treatment, procedures) only upon the order of a person duly licensed and authorized to do so in accordance with the resident's plan of care.

Based on interviews, records review, policy review, and the SA Complaint Tracking System the facility failed to ensure adequate supervision was provided to one resident (#5) to prevent injury/accident. The deficient practice could result in harm and injury. Findings include: Resident # 5 was initially admitted to the facility on [DATE] with diagnoses of vascular dementia, restlessness and agitation, and senile degeneration of brain. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 5 indicating the resident had severe cognitive impairment. The assessment also included that the resident used a wheelchair and can independently wheel 150 feet in a corridor or similar spaces. The history and physical note dated July 6, 2024 included that the resident had assessments of Chronic Obstructive Pulmonary Disease (COPD), cachectia, mutism and dementia. A psychotherapy evaluation dated July 21, 2024 released the resident had major depressive disorder, insufficient sleep syndrome, and unspecified dementia. It also included that the resident had mild but diffuse memory loss with difficulty remembering recent events and periods of confusion about details, had periods of confusion with disorientation and memory problems, had poor insight into problems, judgement appeared fair and had signs of anxiety. A nursing note dated July 26, 2024 at 12:52 p.m. included that the resident was found sitting in his wheelchair out on the patio with his head bent down and was not verbally responding. Vital signs included blood sugar of 179, temperature of 100.7 degrees Fahrenheit, heart rate (HR) of 151, blood pressure (BP) of 47/23 and oxygen saturation (O2 sat) of 88%. Per the documentation, the family and provider were notified and the resident was transferred to the hospital. A nursing note dated July 26, 2024 at 1:10 p.m. revealed that the nurse spoke with a family member and explained that the resident was on the patio; and that, the family member reported telling the resident it was too hot to go outside. The nursing note dated July 26, 2024 at 1:40 p.m. revealed the nurse was sitting at the nurses station when another floor nurse was rushing past the nurses station with a resident slumped over in wheelchair and stated that she needed help. The documentation included that the resident was rushed to the room at approximately 12:25 p.m.; and that, according to the floor nurse the resident who was clumped over was found outside in the courtyard under the trees with shade by the floor nurse. It also included that the resident was unresponsive while slumped over and had a rattled breathing; and that code blue/medical emergency and Emergency Medical Service (EMS) were called. Per the documentation, the resident was placed on the bed and vital signs were taken: BP was 52/30, HR at 151 beats/min, O2 sat was 88-89 % at room air, blood sugar was 179, and temperature via non-contact forehead was 100.7 degrees Fahrenheit. The note stated another nurse obtained a rectal temperature of patient at 106.6 degrees Fahrenheit, two nurses ran to get ice packs to put on patient at 12:28 p.m.; blood pressure was rechecked and noted at 47/23; and that, the resident was breathing. The documentation included that EMS arrived on site at 12:35 p.m. and obtained vitals: temperature via tympanic was 107.0 degrees Fahrenheit, heart rate at 162 beats/min, blood sugar 188; and, a highflow oxygen was placed via nonrebreather. According to the documentation, the resident was transported to the hospital at approximately 12:40 p.m.; and, the emergency contact, Director of Nursing (DON), and the physician were notified. Another nursing note dated July 26, 2024 at 2:36 p.m. included that the facility received a report from the hospital that the resident had a stable BP of 108/60 and was tachycardic in the 150s-160s. Review of documentation on tasks for wheeling 50 feet and 150 feet from July 3 through July 26, 2024, revealed that the resident could wheel 50 feet with two turns once resident was seated in wheelchair/scooter and was dependent on a helper for all of the efforts on more than 12 days. The documentation on task for chair/bed to-chair transfer from July 3, 2024 - July 26, 2024 revealed resident was dependent and that a helper did all of the effort for 12 days. The weather forecast for July 26, 2024 was a high temperature between 100-104 degrees Fahrenheit. The hospital record dated July 26, 2024 included a chief complaint of AMS (altered mental status)/shock. Per the documentation, the resident was found down in heat unconscious and unresponsive and EMS reported that on arrival, the resident's BP was 38/23 with a heart rate of 150, temporal temperature of 107 degrees Fahrenheit and O2 sat of 84% on room air. This record included that EMS had placed ice on the resident. It also included that the resident was sitting in a wheelchair in the parking lot of the facility and had been there for an unknown amount of time. Assessments included altered mental status, heatstroke and shock. The hospital physician progress note dated July 27, 2024 included that the resident was not responsive to verbal or painful stimuli and was in deep coma. The care plan dated July 27, 2024 revealed resident had COPD. Interventions included monitor for difficulty breathing (dyspnea) on exertion and remind resident not to push beyond endurance. The care plan dated July 27, 2024 revealed resident was at risk for impaired cognitive function related to diagnosis of dementia. Interventions included monitor/document/report to physician any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status. A care plan initiated on July 27, 2024 revealed resident had potential alteration in diversional activities related to preferring to initiate activities of choice independently with goals including encourage to choose and participate in his preferred leisure activities while in the facility. Interventions revealed it is important to resident to go outside for fresh air when the weather is good, resident can wheelchair independently, and to encourage resident to go outside for fresh air when weather is good. The nursing note dated July 27, 2024 revealed that the facility received a report from the hospital nurse that the resident was actively dying with a systolic BP of 40-50. The nursing note dated July 28, 2024 revealed the resident returned from the hospital with hospice and comfort measures in place. An interview was conducted on August 1, 2024 with Licensed Practical Nurse (LPN/staff #168) who stated that when she walked outside at 10:30 a.m. after her medication pass, resident #5 was not out at that time. The LPN stated that the certified nurse assistant (CNA) did pericare to the resident at 10:00 a.m. and 11:00 a.m. The LPN stated that 12:30 p.m. she went out to smoke and found resident #5 sitting where the little brick raised area was and had his head bent down. The LPN also said that she asked the resident if he ate lunch but the resident did not respond so she wheeled him inside for treatment. The LPN said that there was another resident in area where resident #5 was found; and that the other resident reported to the LPN that he had been out in the area for 20 minutes with resident #5 who was already outside even before the other resident came out of the patio. The LPN said that resident #5 just liked sitting outside and was never seen smoking. Further the LPN said that residents who are outside in the smoking area had to be checked every 30 minutes. A follow up interview included that the resident was found in the middle of the courtyard. In an interview with a CNA (staff #101) conducted on August 1, 2024 at 11:47 a.m., the CNA stated that staff gets resident #5 into his wheelchair and once in the wheelchair, resident #5 could get around on his own. He stated that he was the CNA assigned to the resident on the day of the incident. He stated that he saw the resident when he was passing breakfast, when he changed him in the morning; and, before lunch the resident was trying to get to his wheelchair and he told the resident not to do so until he change the resident. The CNA stated that after he changed the resident he put the resident in his wheelchair; and that, he did not see the resident in the dining room when he was passing lunch. The CNA further stated that the resident never goes outside and would always be in the dining room hanging out with his roommate. An interview was conducted on August 1, 2024 at 12:08 p.m. with a resident's family member who said that the facility staff told her that they check on the resident's every 30 minutes while they are outside and that the resident has dementia and has good moments and bad moments. An interview conducted August 1, 2024 at 12:52 p.m. with resident #60 included that the facility used to restrict time outside but that since the electric cigarette lighter was installed the residents can go out into the courtyard whenever they like. An interview conducted on August 1, 2024 at 1:09 p.m. with resident #5's roommate (#112), who said that residents can go outside whenever they want; and that, resident #5 liked to go outside and sleep in the sun. An interview was conducted on August 1, 2024 at 3:09 p.m. with another LPN (staff #52) who said that an LPN (staff #168) was heading outside for a smoke break, then came in wheeling resident #5 across the nurses station and that together they treated the resident including performing a rectal temperature which read 106.6 degrees Fahrenheit. An interview was conducted August 1, 2024 at 4:45 p.m. with the Director of Nursing, (DON/staff #161) who said that she felt that the rectal temperature must have been in error, which was why the facility did not report the incident to the relevant authorities. She said that patientswere rounded on every 2 hours; and, they have staff that go outside. However, the DON stated that they do not have a policy for residents monitoring while outside. She said that residents were allowed in the courtyard but that immobile residents were not left outside. The DON also said that the residents have access to shade and water; and that, resident #5 was able to move himself and was considered able to make his own decisions. A policy titled Resident Safety revised 5/2021 included that it is the policy of this facility to create a safe environment for the resident and that during the summer months, access to the patio/courtyard will be restricted from 10:00 a.m. to 5:00 p.m. and is subject to change as necessary. A policy titled Incidents and Accidents revised 8/2023 included that it is the policy of this facility to implement and maintain measures to avoid hazards and accidents.

Based on clinical record reviews, staff interviews, and facility policy and procedures, the facility failed to ensure that care and services related to pressure ulcers was provided for two residents (#535 and #537). The deficient practice resulted in lack of thorough pressure ulcer assessments and/or identifying wound deterioration timely. The facility census was 101 and the sample was 22. Findings include: -Resident # 535 was admitted on [DATE] with diagnoses of osteomyelitis, acute respiratory failure with hypoxia, muscle weakness, dysphagia, pressure ulcer of sacral region, Stage 4, Type 2 DM, encephalopathy, bacteremia, idiopathic aseptic necrosis of unspecified toes, and nutritional anemia. Review of the clinical record revealed that there were three ulcers present upon admission on [DATE], that included: -Coccyx pressure ulcer, stage 4 -Left heel pressure ulcer, deep tissue injury (DTI) -Left outer foot pressure ulcer, non-stageable. A care plan dated [DATE] revealed the resident had diabetes mellitus and had potential or actual impairment to skin integrity. The Goal was that the resident would be free from injury. Interventions includied to monitor/document location, size and treatment of skin injury, report abnormalities, failure to heal, signs/symptoms maceration, etc. to MD (medical doctor); to monitor/document/report to MD as needed for poor wound healing, and to monitor/document/report to MD for signs/symptoms of infection to any open areas: redness, pain, swelling or pus formation. An admission MDS (Minimum Data Set) assessment dated [DATE], included that resident had a BIMS (Brief Interview for Mental Status) score of 13, which indicated intact cognition. The assessment revealed the resident required extensive assistance from two or more persons for turning body side to side and to position body while in bed; and was dependent for left to right rolling. The MDS included that there were 3 pressure ulcers (PU) present on admission: one stage 4 PU, one unstageable PU and one deep tissue injury pressure. A Braden Skin assessment dated [DATE] revealed the resident was a moderate risk for the development of pressure sores. Further review of the clinical record revealed that a new sacral pressure ulcer was identified on [DATE], which was non-stageable and was facility acquired. REGARDING THE COCCYX PRESSURE ULCER: The wound assessment details report dated [DATE] revealed undermining ,d+[DATE] o'clock, measurements 5 centimeters (cm) x 4 cm x 2 cm, pain scale 6 and application of NPWT (Negative Pressure Wound Therapy) . The physician order dated [DATE] revealed for NPWT (Negative Pressure Wound Therapy) to stage 4 coccyx ulcer black foam 125mmhg continuous change Tuesday-Thursday-Saturday. (Discontinue date of [DATE]) The wound assessment details report dated [DATE] included no evidence of undermining, measured 5 cm x 4 cm x 2 cm, pain scale 6 and application of NPWT. The physician order dated [DATE] revealed that the NPWT to coccyx ulcer was changed to Monday and Friday. Review of the provider progress note dated [DATE] revealed no documentation of an assessment/presence of the coccyx. The wound assessment details report dated [DATE] included undermining ,d+[DATE] o'clock, measured 5 cm x 4 cm x 2 cm, pain scale 6 and application of NPWT. The wound assessment details report dated [DATE] revealed no evidence of undermining, had measurements of 5 cm x 4 cm x 2 cm, pain scale 6 and application of NPWT. The wound assessment details report dated [DATE] revealed no evidence of undermining, had measurements 5 cm x 4 cm x 2 cm, pain scale 6; and that, NPWT was discontinued due to 50% eschar, Vasche wet to dry applied. It also included that the provider was notified. The physician order revealed that the NPWT to the coccyx was put on hold from [DATE] through [DATE]. Review of physician orders revealed no evidence of a treatment order for coccyx dressing changes from [DATE] through 18, 2020. The physician order included for Vashe Damp Gauze, as needed (PRN) for NPWT failure (order date [DATE] through [DATE]) The Wound Administration Record (WAR) for [DATE] revealed no documentation that wound dressing/treatment provided to the coccyx pressure ulcer from [DATE] through 17, 2020. Continued review of the WAR revealed no evidence that the PRN Vashe damp gauze had been administered [DATE] through 17, 2020. The clinical record revealed no documentation why the treatment was not provided as ordered; and that, the physician was notified. The physician order [DATE] revealed a treatment order for the medihoney to the coccyx, change daily every Monday, Tuesday, Wednesday, Thursday and Friday. A physician order dated [DATE] included the treatment order for medihoney to the coccyx was changed to every evening shift on Saturday, and Sunday. The wound assessment details report dated [DATE] revealed no evidence of undermining, had measurements of 5 cm x 4 cm x 2 cm and pain scale 6. It also included that NPWT was resumed. However, the physician order revealed that the NPWT to the coccyx was put on hold from [DATE] through [DATE]. The wound assessment details report dated [DATE]m included undermining circumferentially at 3 cm, and a new observation of tunneling at 3 o'clock of 5 cm. It also included that the wound measurements increased to 7 x 4 x 2.5 cm; and, wound dressing was medihoney gel. There was no evidence on the wound assessment form that the physician or family had been notified of the change in the wound's condition. Review of progress notes revealed no evidence that the provider or family had been notified of the change of condition regarding the coccyx wound. REGARDING THE SACRAL PRESSURE ULCER: The wound assessment details report dated [DATE] revealed no evidence of a completed assessment for the newly identified sacral pressure ulcer. The progress note dated [DATE] revealed a new sacral pressure ulcer was identified. Further review of the progress notes on [DATE], revealed no evidence that the provider or family were notified regarding the identification of a new sacral pressure ulcer. The wound assessment details report dated [DATE] revealed that a new pressure ulcer on the sacrum was identified on [DATE]. The assessment included erythema, pain level of 6, and presence of eschar and slough. The wound had measurements of 2.5 cm x 3 cm with a dressing of medihoney. The form was marked unable to determine for signs of infection present; however, the assessment revealed presence of erythema and odor. Review of a wound assessment details report form dated [DATE], revealed presence of erythema to the periwound tissue, odor, slough and eschar to the wound, with measurements of 2.5 cm x 3 cm. Per the documentation medihoney gel dressing was applied to the sacral pressure ulcer. The form was marked unable to determine for signs of infection present; however, the assessment revealed presence of erythema, odor and undermining. The documentation did not include the provider or family had been notified regarding the change of condition. The provider progress notes from [DATE] through 29, 2020 revealed no evidence of any assessment/treatment for new sacral ulcer identified on [DATE]. Review of the clinical record revealed no evidence of any physician order for a wound dressing/treatment to the sacral ulcer from [DATE] through 29, 2020. Further review of clinical record revealed no evidence the provider or family was notified of the sacral pressure ulcer from [DATE] through 29, 2020. The certified nursing assistant (CNA) pressure reducing devices task flow sheets from [DATE] through [DATE] revealed the following information: -Multiple daily entries that were marked with an M which indicated the resident had pressure reducing devices; and, -Multiple daily entries that were marked 1 (did you turn and reposition) that indicated the resident had been turned/repositioned. However, continued review of the flow sheets revealed there were four shifts in which there was no evidence that the resident had been turned/repositioned during the night shift (10:00 PM - 6:00 AM) on [DATE], [DATE], [DATE] and [DATE]. During the interview with a wound nurse(staff #18) conducted on [DATE] at 12:40 p.m., a review of the clinical record was conducted with the wound nurse who stated that the coccyx wound assessments could be inaccurate as the initial evaluation on [DATE] had been assessed to have undermining; but that, undermining was not observed again until [DATE], when the wound had worsened. She stated that in her experience with wounds, undermining of 3 cm would not be healed within one week, so this could have been inaccurate assessments. She further stated that the coccyx ulcer had worsened and measured larger on the [DATE]; and she would have expected that the provider would have been notified. However, the wound nurse stated that she did not see any evidence in the clinical record that this occurred. The wound nurse stated she did not find any evidence or documentation that the resident's wounds had been assessed/evaluated by the provider; and that, there was no evidence that the coccyx wound had received any wound treatment/dressings between [DATE] and [DATE]. The wound nurse also said the provider had not been notified regarding the identification of the sacral pressure ulcer on [DATE], or of the signs/symptoms of infection (erythema) that had been assessed at that time. Regarding turning and repositioning, the wound nurse said that the facility policy was to turn/reposition residents every 2 hours or with care, and document every shift. She the clinical record revealed no evidence that the resident had been turned/repositioned during the night shift on four occasions; and that, this could have had a bearing on a wound not healing or of new wounds appearing. The wound nurse stated this did not meet the facility expectations regarding wound care/treatment; and that, the risk of not providing wound treatments could result in the wound worsening and possible infection. An interview was conducted on [DATE] at 1:15 p.m. with the DON (staff #74) regarding resident #535. She reviewed the clinical record and stated that there was no evidence that the family or provider had been notified regarding the worsening coccyx ulcer on [DATE], and again on [DATE]. The DON also stated that she expected the provider and family would have been notified. She also stated that she would have expected the provider and family would have been notified on [DATE] when the sacral wound was identified, and again on [DATE] when the wound worsened. She further stated that she expected CNA's do document turning/repositioning in the clinical record every shift, and that that there was no evidence that this had occurred on four occasions in [DATE]. She reviewed the WAR/TAR and stated that there was no evidence that the coccyx ulcer had received wound treatments [DATE] through [DATE]. She further stated that the coccyx ulcer was then assessed as worsening with signs of infection including erythema. She stated that based on this review the resident's wound care treatment did not meet the standard of care regarding wounds. -Resident #537 was admitted on [DATE] with diagnoses of ESRD (end-stage renal disease) , muscle weakness, diabetes, and hemiplegia/hemiparesis related to cerebral infarction affecting left non-dominant side. Review of the clinical record revealed evidence the resident was admitted with a sacral pressure ulcer. Review of a care plan initiated on [DATE] revealed the resident had a pressure ulcer or potential for pressure ulcer development coccyx related to poor mobility. Interventions included to assess/monitor/record wound healing, report improvements and declines to the doctor; and to monitor/document/report to doctor as needed (PRN) changes in skin status: appearance, color, wound healing, signs/symptoms of infection, wound size and stage. The wound assessments details report form for the sacral pressure ulcer dated February 10, 2021 revealed the wound measured 12 cm x 11 cm, with undermining 9:00 - 1:00 o'clock at 3 cm, with presence of erythema. The form documented no for no signs of infection and documented evidence of erythema, maceration and undermining present. The report did not include that the physician or family had been notified of the findings regarding erythema, maceration and undermining. The care plan initiated on February 10, 2021 revealed the resident had insulin dependent diabetes mellitus (DM) and had an actual impairment of skin integrity related to sacral pressure ulcer. Interventions included to check all of body for breaks in skin and treat promptly as ordered by doctor; and, to monitor/document location, size and treatment of skin injury and to report abnormalities, failure to heal, signs/symptoms of infection, maceration etc. to doctor. The physician order dated February 12, 2021 revealed Vashe dampened gauze to the sacrum change daily every day shift every Monday, Tuesday, Wednesday, Thursday and Friday. The admission MDS assessment dated [DATE] revealed a BIMS score of 5, which indicated severe cognitive impairment. The skin/wound progress note dated February 17, 2021 revealed an unstageable pressure ulcer on the sacrum with 90% eschar, and evidence of erythema and maceration noted. The wound assessments details report form for the sacral pressure ulcer dated February 15, 2021 included wound measurement of 12 cm x 11 cm, undermining 9 - 1 o'clock at 3 cm, with additional tunneling at 12 o'clock at 3 cm, erythema, maceration, and a pain level of 6. The form reported no signs of infection present as no, but documented evidence of erythema, maceration and undermining present. The form documented no for no signs of infection and documented evidence of erythema, maceration and undermining present. The report did not include that the physician or family had been notified of the findings regarding erythema, maceration and undermining. A nursing progress note dated February 22, 2021 revealed non-blanchable areas on scapula and spine. The physician order dated February 22, 2021 included to apply hydraguard D to periwound, then apply Vashe dampened gauze, change twice every day shift every Saturday and Sunday. The wound assessments details report form for the sacral pressure ulcer dated February 23, 2021 revealed the wound measured 8 cm x 9 cm x 5 cm, with erythema, odor, purulent drainage, pain level of 10, tunneling of 5 cm at 12 o'clock and undermining at 10 - 3 o'clock of 5 cm. The form reported no signs of infection present as no, but documented evidence of erythema, maceration and undermining present. The physician order dated February 23 , 2021 revealed Vashe dampened gauze to the sacrum twice daily every day shift every Monday, Tuesday, Wednesday, Thursday and Friday. The wound assessments details report form for the sacral pressure ulcer dated February 24, 2021 revealed that there were four new areas of skin breakdown identified in the scapula and spine areas. A physician order dated February 24 , 2021 included an order for medihoney/hydrogel to the sacrum and to change every shift Despite documentation of the wound to the sacrum, the clinical record revealed no evidence that the provider and family were notified of the progress, status and worsening of the wound from February 17 through February 24, 2023. The skin/wound note dated February 25, 2021 revealed necrotic tissue present on the sacral wound; and that, medihoney was applied. It also included that four new areas of skin breakdown to the scapula and spine with dark purple non-blanchable areas; and that, the provider was notified Per the documenation, the sacral wound needed debridement. The note did not include measurements of the sacral wound or assessment of the surrounding tissue. Review of the change of condition progress note dated February 25, 2021 revealed the resident was transported to the hospital; and that, the provider or family were notified of the worsening wound. The CNA task documentation for February 2021 revealed the resident was: -Turned and repositioned every shift except for the evening shift on February 13, 2021, and on the day shift February 25, 2021; and, -Had a pressure reducing device in place each shift except on the day shift on February 13, 2021 and the day shift on February 24, 2021. An interview Registered Nurse (RN/Staff #80) conducted on [DATE] at 12:22 p.m., the RN stated that when an open area on the skin is identified, the wound nurse is informed immediately. She stated that only the wound nurse does the wound treatments, unless treatment was ordered PRN (as needed). The RN stated the signs/symptoms of infection could include fever, drainage, redness around the wound, warmth, increased pain, and/or odor. She stated that if any of these were assessed the provider and wound nurse should be notified as this would be a change of condition. The RN stated that the expectation was for staff to inform the provider and family for a change in condition that includes worsening of a wound, and/or when a new wound is identified; and, document in the clinical record. During the interview with a wound nurse(staff #18) conducted on [DATE] at 12:40 p.m., the wound nurse said that the expectation was to conduct a assessment for any new wound that is identified; and that, she would inform the provider right away regarding identification any new wounds, or if there was a change to any current wounds. The wound nurse further stated that the assessment and notification will be documented in the clinical record. She also stated that during the years, 2020 and 2021, the provider wound not assess all wounds; and, would sometimes just look at photographs. The wound nurse stated that all wound dressing applications were expected to be documented on the WAR or TAR (Treatment Administration Report). She also stated that signs and symptoms of infection could include observations of any redness/erythema, odor, excess drainage, fever, increased pain change in size/depth/color, presence of undermining/tunneling. She stated that if any of these were observed/assessed the expectation would be to notify the provider and document on the wound assessment detail report, and/or progress notes. Regarding resident # 537, the wound nurse reviewed the clinical record and stated that the non-blanchable areas had been identified on the scapula and spine by nursing staff on February 22, 2021. She further stated that there was no evidence of any skin/wound notes of these areas being assessed/monitored until February 25, 2021; and that, this did not meet the facility policy regarding assessment of new skin issues. The wound nurse stated she would have expected to have been notified on February 22, 2021 when the non-blanchable tissue were identified; and, based on the clinical record, the areas had worsened and developed into open areas between February 22 and when she assessed them on February 25, 2021. She stated that if she had been informed earlier she may have been able to keep them from worsening and progressing into open areas. The wound nurse stated the presence of erythema as well as undermining on the sacral wound was identified on February 10, 2021; and, she should have notified the provider at that time. She stated that the wound assessment details report dated February 15, 2021 had marked no for signs of infection; but, it was inaccurate and should have been marked as yes for signs of infection present. She stated the presence of erythema, maceration, undermining and tunneling could be signs of infection, and they were documented on this assessment. She said that based on the clinical record, the sacral ulcer had progressed to include signs/symptoms of infection: odor, increased pain, purulent drainage and erythema on February 23, 2021; and that, the documentation that signs of infection present was unable to be determined was inaccurate. Further, the wound nurse said that there was no evidence in the clinical record that the provider or family had been notified of the status and worsening of the wound until February 25, 2023 when it was documented that the provider was notified of the four new areas identified on the scapula and spine, but not of the worsening and possible infection of the sacral ulcer. The wound nurse stated that the risk of not accurately notifying the provider regarding changes in a wound could result in the wound worsening, and the resident could become septic. An interview was conducted on [DATE] at 1:15 p.m. with the Director of Nursing (DON/staff #74), who stated that the Medical Director does wound rounds, but does not see every wound, they pick a sample. She further stated that when wound rounds are conducted she would expect it to be documented in the clinical record, including the stage and progress of the wound, was well as any signs/symptoms of infection. The DON stated that signs and symptoms of infection could include any of the following: odor, increased drainage, redness/erythema, larger wound measurement, tunneling and undermining. She further stated that not all of the signs/symptoms wound need to be present for the wound to be infected. The DON stated that if any of the signs/symptoms are observed during the wound assessment she would expect that the provider and family would be notified. She also stated that the provider should be notified regarding any change in condition including new wounds, or any changes in a wound, and this should be documented in progress notes. She further stated that all wound treatments are documented in the TAR or WAR, and that physician orders are followed as written. Regarding resident #537, the Director of Nursing (DON/staff #74) reviewed the clinical record and stated that four new areas of non-blanchable tissue were identified on progress notes dated February 21, 2021, but there was no evidence of a wound assessment until February 25, 2021. She stated that she would have expected wound care to assess the areas sooner. She further stated that there was no evidence that the provider had been notified on February 10, 2021 regarding the erythema identified on the sacral ulcer. She also stated that this did not meet her expectations. She reviewed the Wound Assessment Details Report dated February 15, 2021 and stated that it was inaccurate, and should have be documented as yes for presence of infection, regarding the presence of erythema and tunneling. She further stated that there was no evidence that the provider or family had been notified regarding the change of condition in the wound at that time. She also stated that the wound worsened and that there was no evidence in the clinical record that the provider or family had been notified. She stated that on February 23, 2021 the wound was assessed as becoming progressively worse, and there was no evidence in the clinical record that the provider or family had been notified. She stated that the risk could include presence of infectious process with the wound and no changes in treatment. She also stated that per her review of the clinical record the resident was sent to the hospital on February 25, 2021 for possible cellulitis related to skin breakdown. She stated that this may have been prevented if the provider had been notified earlier, and this did not meet the standard of care for wounds. Review of the facility policy titled, Wound Management, revealed that a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable sores from developing. The facility provides care and services to promote the prevention of ulcer development, promote the healing of pressure ulcers that are present, including prevention of infection to the extent possible, and prevent the development of additional, avoidable pressure ulcers. All wound or skin treatments should be documented in the resident's clinical record at the time they are administered. Review and/or evaluate existing treatment regimen in connection with the resident's clinical presentation, to include current interventions and care plan considerations, if any wound is non-healing or not showing signs of improvement after a given time or any time a wound is worsening.

Based on clinical record review, staff interviews, facility documentation, and policy and procedure, the facility failed to ensure the resident representative was notified after a change in condition for one resident's (#537). The deficient practice could result in resident representative not notified and the required decisions for the resident are not made. The facility census was 101, and the sample was 22. Findings include: Resident #537 was admitted on [DATE] with diagnoses of ESRD (end stage renal disease), muscle weakness, diabetes, hemiplegia/hemiparesis related to cerebral infarction affecting left non-dominant side. The care plan initiated on February 9, 2021 revealed the resident had a pressure ulcer or potential for pressure ulcer development, coccyx, related to poor mobility. Interventions included to assess/monitor/record wound healing; to report improvements and declines to the doctor; and, to monitor/document/report to doctor as needed (PRN) changes in skin status: appearance, color, wound healing, signs/symptoms of infection, wound size and stage. Review of a care plan initiated on February 10, 2021 included the resident had insulin dependent diabetes mellitus and had an actual impairment of skin integrity related to sacral pressure ulcer. Interventions to check all of body for breaks in skin and treat promptly as ordered by doctor; to monitor/document location, size and treatment of skin injury and to report abnormalities, failure to heal, signs/symptoms of infection, maceration etc. to doctor. A review of a social services progress note dated February 10, 2021 revealed that the resident's family/representative (RR) will come to sign Advanced Directives for resident who was not able to do so. The wound assessments details report dated February 10, 2021 revealed the sacral pressure ulcer measured 12 cm (centimeters) x 11 cm, had 3 cm undermining at 9:00 - 1:00 o'clock, with presence of erythema Per the report, there were no signs of infection present; but documentation included that evidence of erythema, maceration and undermining present. Per the documentation, the physician or family had been notified of the findings regarding erythema, maceration and undermining. The wound assessments details report dated February 15, 2021 included the wound had measurement of 12 cm x 11 cm, undermining 9 to 1 o'clock at 3 cm, with additional tunneling at 12 o'clock at 3 cm, erythema, maceration, and a pain level of 6. The form reported no signs of infection present as no; and, documented evidence of erythema, maceration and undermining present. The documentation did not indicate that the physician or family had been notified of the findings regarding erythema, maceration and undermining and new onset of tunneling. A nursing note dated February 15, 2021 revealed that the RR was notified of an update on the resident's condition. The admission Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 5, which indicated severe cognitive impairment. The skin/wound progress note dated February 17, 2021 revealed unstageable pressure ulcer to sacrum with 90% eschar, and evidence of erythema and maceration noted. Review of a progress note dated February 17, 2021 revealed no evidence that the provider or family had been notified regarding the status of the sacral wound regarding signs/symptoms of infection that included erythema and maceration. The nursing note dated February 22, 2021 revealed identification of non-blanchable areas on scapula and spine. The wound assessments details report for the sacral pressure ulcer dated February 23, 2021 revealed the wound had a measurement 8 cm x 9 cm x 5 cm, erythema, odor, purulent drainage, pain level of 10, tunneling of 5 cm at 12 o'clock and undermining at 10 - 3 o'clock of 5 cm. The form reported no signs of infection present as unable to determine, but documented evidence of erythema, maceration, undermining, tunneling, and odor as present. The documentation did not include the physician or family/RR was notified of the findings regarding erythema, maceration and undermining and new onset of tunneling. The wound assessments details report for the sacral pressure ulcer dated February 24, 2021 revealed that there were four new areas of skin breakdown on the scapula and spine areas were identified. The nursing progress note dated February 24, 2021 included there was an open area to coccyx, and blanchable redness to bilateral shoulder and mid back Review of Skin/Wound Notes dated February 25, 2021 revealed necrotic tissue present on the sacral wound, and medihoney applied. The notes also revealed four new areas of skin breakdown to the scapula and spine with dark purple non blanchable areas. Despite documentation of skin breakdown/findings, review of the clinical record revealed no documentation that the provider or family/RR were notified of the presence of new non-blanchable areas to the spine and scapula until February 25, 2021. The change of condition progress note dated February 25, 2021 revealed the resident was transported to the hospital; and that, the RR was notified. An interview was conducted on May 17, 2023 at 11:41 a.m. with a registered nurse (RN/staff #80), who stated that if a change of condition was observed/assessed the policy was for the facility was to notify the provider and family. In an interview with the Director of Nursing (DON/staff #74) conducted on May 17, 2023 at 12:58 p.m., the DON stated that after a change of condition had been identified, the provider is notified; and the provider makes the decision to either keep resident in house or move them to the hospital. The DON stated that they would then notify the family. In another interview Registered Nurse (RN/Staff #80) conducted on May 17, 2020 at 12:22 p.m., the RN stated that when an open area on the skin is identified, the wound nurse is informed immediately. She stated that only the wound nurse does the wound treatments, unless treatment was ordered PRN (as needed). The RN stated the signs/symptoms of infection could include fever, drainage, redness around the wound, warmth, increased pain, and/or odor. She stated that if any of these were assessed the provider and wound nurse should be notified as this would be a change of condition. The RN stated that the expectation was for staff to inform the provider and family for a change in condition that includes worsening of a wound, and/or when a new wound is identified; and, document in the clinical record. An interview was conducted on May 17, 2023 at 12:40 p.m. with a Wound Nurse (staff #18) who stated that a wound assessment will be conducted for any new wound that was identified.; and that, she would inform the provider right away regarding an identification any new wounds, or if there was a change to any current wounds. The wound nurse further stated that this would be documented in the progress notes and the Wound Assessment Details Report form. She also stated that signs and symptoms of infection could include observations of any redness/erythema, odor, excess drainage, fever, increased pain change in size/depth/color, presence of undermining/tunneling; and that, if any of these were observed/assessed the expectation would be to notify the provider and document on the Wound Assessment Detail Report, and/or progress notes as a change of condition. During the interview a review of the clinical record was conducted with the wound nurse who stated that according to the wound assessment details report dated February 10, 2021 for the sacral wound, erythema and undermining were identified. She stated that she should have notified the provider at that time; however, she could not find any progress notes in the medical record that the provider or family/RR was notified. The wound nurse further stated that this would have been a change of condition. She stated that the wound assessment details Report dated February 15, 2021 should have been marked as yes for signs of infection present; however, it was marked no. The wound nurse stated that the presence of erythema, maceration, undermining and tunneling could be signs of infection, and they were documented on this assessment. Further, the wound nurse said that there was no evidence in the clinical record that the provider or family/RR was notified of the wound status; and that, the wound had worsened and was a change of condition. She stated that by February 23, 2021 the sacral ulcer had progressed to further signs/symptoms of infection that included odor, increased pain, purulent drainage and erythema; and that, the wound assessment form had been marked as unable to determine for signs of infection present. The wound nurse stated the clinical record revealed no evidence that the provider or family/RR was notified of the worsening of the wound. The wound nurse also said that a skin/wound note dated February 25, 2023 documented the provider was notified of the four new areas identified on the scapula and spine, but not of the worsening and possible infection of the sacral ulcer. The wound nurse further stated that the risk of not notifying the provider regarding changes in a wound could result in the wound worsening, and the resident could become septic. During an interview with the DON (staff #74) conducted on May 17, 2023 at 1:15 p.m. the DON stated that signs and symptoms of infection could include odor, increased drainage, redness/erythema, larger wound measurement, tunneling and undermining; and that, not all of the signs/symptoms wound need to be present for the wound to be infected. She also stated the provider should be notified regarding any change in condition including new wounds, or any changes in a wound, and this should be documented in progress notes. The DON stated that if any of the signs/symptoms are observed during the wound assessment she would expect that the provider and family/RR would be notified as this was a change of condition. A review of the clinical record of resident #537 was conducted during the interview. The DON stated there was no evidence found in the clinical record that the provider was notified of the erythema identified on the sacral ulcer on February 10, 2021; of the change of the condition in the wound on February 15, 2021; and of the wound becoming progressively worse on February 23, 2021. The DON stated that this did not meet her expectations. She stated that the risk could include presence of infectious process with the wound and no changes in treatment. The DON further stated that based on the clinical record, the resident was sent to the hospital on February 25, 2021 for possible cellulitis related to skin breakdown; and that, this may have been prevented if the provider had been notified earlier. Further, the DON stated that this did not meet the standard of care for wounds. Review of the facility policy on Change of Condition Reporting revealed that all changes in resident condition will be communicated to the physician and documented. Unusual signs and symptoms will be communicated to the physician promptly. A licensed nurse will inform family/responsible party of change of condition and document notification. All nursing actions, physician contacts and resident assessment information will be documented in the nursing progress notes.

Based on observation, clinical record review, staff interviews, policy and procedures review, the facility failed to ensure one resident (#68) was free from restraint. The deficient practice could result in harm to a resident secondary to restricted mobility of extremities. Findings include: Resident #68 was readmitted on [DATE] with diagnoses of muscle weakness, cerebral infarction, pruritus, end stage renal disease, aphasia and flaccid hemiplegia affecting the left side. Review of the clinical record revealed the resident had an order for a DPM (Dr Pillow Mattress) mattress to enhance boundary awareness. The nursing progress note dated March 13, 2023 included resident was scratching and opening skin with fingernails; and that, the resident had a glove on right hand and still managed to break skin open. The quarterly minimum data set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) a score of 0, indicating the resident had severe cognitive impairment. The assessment included was rarely/never understood, required extensive assist/two+ person assist with bed mobility and total dependence/one-person physical assessment with dressing. The MDS also included the resident had functional limitation in range of motion and impairment on one side; and that, limb restraints were not used while resident is in bed. The care plan dated May 2, 2023 revealed the resident required tube feeding related to a swallowing problem and had independently removed their gastrostomy (G-tube) on April 11, 2023 and May 3, 2023. Continued review of the care plan revealed the resident had impaired cognitive function related to cerebral vascular accident, aphasia and encephalopathy, increasing risk of further declines. Review of Skin/Wound Note dated May 17, 2023 revealed the resident's right hand had small fluid filled blisters and dry hard areas to palm of hand. Per the documentation, dry areas were noted between first, second and third finger, had erythema (redness) present; and that, the provider was notified. A Braden Score was obtained on May 18, 2023 revealed a score of 11 indicating the resident was high risk of skin breakdown. There was no evidence in the clinical record that the resident uses any forms of physical restraint. Further review of the clinical record revealed no evidence that the resident had orders for or was care planned for any form of restraints, including the use of a sock or mitt over the right hand. However, during an observation conducted on May 15, 2023 at 11:53 a.m., the resident had a slip-resistant sock covering her right hand while lying in bed. In another observation conducted on May 18, 2023 at 8:00 a.m., the resident had a slip-resistant sock covering her right hand while lying in bed with her eyes closed. An observation was conducted on May 18, 2023 at 9:02 a.m., with a certified nursing assistant (CNA/staff #70) present. The resident had the slip-resistant sock on her right hand. The CNA then removed the sock and revealed that the resident's palm was red with multiple fluid-filled blisters and between the index and middle finger. It also revealed that the skin was peeling, and there was a scabbed and dark red colored blistered area between the middle and ring finger. The CNA (staff #70) stated that it looked like the blisters popped. In an interview with the CNA (staff #70) conducted on May 18, 2023 at approximately 9:15 a.m., the CNA stated the sock was removed every day; and, the sock becomes soiled because the hand was moving as the resident scratches the area frequently. The CNA stated the resident receives a shower 4x a week and the sock was removed for all showers. However, the CNA was unable to specify how often or how long the sock was on each day because she typically was scheduled to work on another unit in the facility. She stated that the resident previously wore a mitten rather than a sock over the right hand; and that, the mitten was utilized during a hospitalization and continued at facility until the mitten became soiled and it was discarded. The CNA said that if skin breakdown was observed, she would report it to the nurse. During an interview conducted with licensed practical nurse (LPN/staff # 88) on May 18, 2023 at approximately 09:00 a.m., the LPN stated that she would refer to her supervisor for information regarding the restraint policy; however, she stated none of her residents were using restraints. Staff #88 stated that the procedure for utilizing restraints would require the supervisor obtaining authorization for use of restraints; and that, restraints were not used in the facility. Regarding resident #68, the LPN said she was not sure who requested or ordered the sock to be worn over the right hand; and that, resident #68 had a physician order for wearing a sock over the right hand because the resident removes her G-tube. However, the LPN was unable to provide a physician order for the use of a sock or mitten over the resident's right hand. An interview with the director of nursing (DON/staff #173) was conducted on May 18, 2023 at approximately 9:30 a.m. The DON stated that the facility does not use restraints on residents. A review of the clinical record was conducted with the DON during the interview. The DON stated that there was no physician order found in the clinical record for any limb restraint; and that, she was not aware of why the sock was being used or who initiated the use of the sock on resident #68. The DON stated that the resident's care plan did not include interventions that would describe the use of the sock; and that, the use of the sock was not care planned. The DON was unable to specify the benefits of the use of the sock on the resident's hand; but, stated the risks include restricting mobility of resident's extremity. Further, the DON was not aware of any measures that were attempted prior to the sock being applied or how often it was applied or the circumstances in which it was being used. The DON stated that the expectation was that any device including a sock used as a restraint to a resident would need to be evaluated for appropriateness and should have a clear indication for use. In a later interview conducted on May 18, 2023 at approximately 11:00 a.m., the DON stated the sock was being used as a deterrent for scratching but that the resident could easily remove the device. The facility policy on Restraints, Physical/Safety Devices revised May 2022, revealed that it is their policy that the resident has the right to be free from any physical or chemical restraints imposed for the purposes or convenience, and not required to treat the resident's medical symptoms. Restraints are defined as any manual method or physical or mechanical device, material or equipment or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. A physician's order is necessary for the use of a physical restraint. The use of the device must first be explained to the resident, family member or legal representative. Potential negative outcomes must be explained. Medical symptoms that warrant the use of restraints must be documented in the resident's medical record, ongoing assessments and care planned.

Based on observations, clinical records, facility documents, resident and staff interviews, the facility failed to ensure the necessary dermatology appointment was scheduled for one resident (#104). The deficient practice could result the resident missing the appointment and not receiving the appropriate and necessary treatment. Findings include: -Resident #104 was admitted on [DATE] with diagnoses of abrasion of other part of the head, candida stomatitis and anxiety disorder. A Social Services note dated September 1, 2022 included that dermatology appointment was rescheduled September 20, 2022 at 8:40 a.m. The appointment/procedure note dated October 19, 2022 included that dermatology appointment was scheduled for October 25, 2022 at 11:50 a.m. However, there was no evidence found in the clinical record that the resident went to the dermatology appointment as scheduled for October 25, 2022. The undated care plan revealed the resident had an actual impairment to the skin integrity related to an abrasion to the chin; and, the resident had potential impairment to skin integrity related to non-compliance with wound care, removal of dressings and immobility. The skin/wound note dated March 10, 2023 included abrasion to the right chin with pink tissue present. Per the documentation, the resident non-compliant with wound care. The skin committee IDT (interdisciplinary team) note dated March 17, 2023 included that the resident had an abrasion to the right chin, wound bed was pink with inflammation to wound edges and the resident was non-compliant with dressing and wound care. A wound care note dated April 12, 2023 included that at this time, still waiting on referral to dermatologist. The clinical record revealed no evidence that the resident was seen by a dermatologist or was scheduled for dermatology consult after October 19, 2022. The quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 15 indicating the resident had intact cognition. An interview was conducted on May 15, 2023 at 10:20 a.m. with resident #104 who said that she had been told approximately 10 months ago that she needed to see a skin specialist; and that, she had not seen one. An interview with a wound nurse (staff #18) was conducted on May 17, 2023 at 2:17 p.m. The wound nurse stated that she did not know what the wound was as the resident informed her initially that the wound was a dog bite and later on told her that it was cancer. She said that at one point the resident went to a dermatology appointment with an order for a hydrocolloid to be applied 3 times a week; however, the wound nurse said that she was not sure. Further, the wound nurse stated that she does not have any proof that the resident went to the dermatology appointment. In an interview conducted with a Social Services staff (staff #98) on May 17, 2023 at 1:57 p.m., staff #98 stated that the resident had a note on October 25, 2022 for an appointment; however, staff #98 was not able to find any note that stated that the resident went to this appointment. During the interview, a review of the clinical record was conducted with staff #98 who stated that there was no documentation found that the resident went to the appointment. She also stated that at that time, she was not coordinating transportation for residents to and from appointments; therefore, she was not able to get any further transportation notes. In another interview with the wound nurse (staff #18) conducted on May 19, 2023 at 8:43 a.m., the wound nurse stated that the clinical record revealed a wound care note dated April 12, 2023 and she thought this note was referencing prior dermatology appointment. The wound nurse said that because of this, she did not call and followed up on this. During the interview, a review of the clinical record was conducted with the wound nurse who said that she was not able to find any documentation that this resident went to and had been to a dermatology appointment. An interview was conducted on May 19, 2023 at 11:00 AM with the clinical resource/acting Director of Nursing (staff #171) who said that the appointment was through their wound consultant and that they did not follow up on it because the wound consultant would do so. The Facility Assessment included that the nursing department is supported by the medical records director who is responsible for appointments and transportation.

Based on observations, staff interviews, Influenza Vaccine Manufacturer's Guidelines and the Centers for Disease Control and Prevention (CDC)guidelines, the facility failed to ensure expired medications were not readily accessible for resident use; and, the facility failed to ensure open multi-dose vials were dated and discarded according to manufacturer's guidelines. The deficient practice could result in alterations in the effectiveness of the medications that the residents are receiving. Findings include: During an observation of a medication cart in 300 hall conducted with a licensed practical nurse (LPN/staff #171), there was large white bottle of sodium bicarbonate (alkalinizing agent) 650 milligrams with an expiration date of January 2023. The bottle was marked as a house supply and was 3/4 full of white tablets. The LPN (staff #171) stated the sodium bicarbonate was expired; and that, it should have been placed in the expired bin located in the medication room so that it was not available for the nurses to use. In an observation of the medication refrigerator in the medication room in 300 hall conducted with a registered nurse (RN/ staff #80) on May 17, 2023 at 9:07 a.m., there was an opened box of Tubersol (diagnostic agent) multi dose vial and was marked as house stock. The rubber stopper of the vial had multiple needle punctures indicating that it had been accessed multiple times; however, the vial did not have an open date. There was also an open of influenza vaccine with a sticker marked with an open date of March 21, 2023. The rubber stopper had multiple needle punctures and the vial contained approximately 2 milliliters of medication. An interview with the RN (staff #80) was conducted immediately following the observation. The RN stated that there was no open date found on the vial; and that, multi-dose Tubersol vial was good only for 30 days after opening and she would dispose the vial immediately. The RN stated that the vial was available for use because the nurses get the PPD (purified protein derivative) for TB (tuberculosis) skin test from this medication refrigerator. Regarding the influenza vaccine vial, the RN stated that the vial indicated an open date of March 21, 2023; and that, the multiple needle punctures indicated the vial had been accessed. The RN further stated that the flu vaccination season was over; however, she was not sure how long an opened via of flu vaccine was good for. A phone interview with the RN (staff #80 and the pharmacist (staff #176) was conducted on May 17, 2023 at 9:20 a.m. The pharmacist stated a multi-dose medication vial that had been accessed through needle puncture must be discarded in 28 days from the open date unless otherwise specified by the manufacture guidelines. The RN (staff #80) stated she would discard the remaining medications in the vial and would in-service all the nurses regarding the open date and discard date of multi-dose medication vials. An interview was conducted with a clinical resource (staff #177) on May 19, 2023 at 9:43 a.m. Staff #177 stated the process of maintaining the medication carts/ medication room refrigerator included the nursing staff removing expired medications, dating, and disposing of multi dose medication vials within 28 days from the open date. She stated the nurses were responsible for checking the expiration date of all medications prior to their use. A review of the Influenza Vaccine Manufacturer's Guidelines (medication insert) revealed no specified guidelines in terms of opened vial. Review of the Centers for Disease Control and Prevention (CDC) guideline on Multi-Dose Vials with last reviewed date of June 20, 2019, indicated that medication vials should always be discarded whenever sterility is compromised or cannot be confirmed. Further, the guideline included that if a multi-dose vial has been opened or accessed (example, needle-puncture) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.

Based on clinical record review, resident and staff interviews and facility assessment review, the facility failed to ensure that assistance in making the necessary dental appointment was provided for one resident (#81). The deficient practice could result in resident having dental complications. Findings include: Resident #81 was admitted on [DATE] with diagnoses of hemiplegia, and cerebral infarction due to thrombosis of cerebral artery. The annual Minimum Data Set (MDS) assessment dated [DATE] included that resident had intact cognition. A progress note dated March 5, 2023 revealed the resident had his first dose of Amoxicillin for dental abscess. A dental visit note with dental clinic/services dated March 27, 2023 included the resident had a chief complain of bottom left pain and dental recommendation was to schedule the resident for dental extraction of tooth #20. However, the clinical record revealed no evidence that the resident was scheduled for or had the dental extraction procedure as recommended until May 19, 2023. A physician order dated May 19, 2023 included scheduled appointment for dental services on June 7, 2023 for teeth extraction. An interview was conducted on May 15, 2023 at 11:47 a.m. with resident #81 who stated that the dentist told him he needed a tooth removed; however, the dentist never came back. He said he had been in pain and had told the nurse about it, but nothing was done. Resident #81 further stated that it was hard for him to eat because of his broken tooth. In an interview conducted with a Social Services staff (staff #98) on May 17, 2023 at 1:57 p.m., staff #98 stated she was responsible for scheduling appointments. Regarding resident #81, she said that the resident sometimes used the in-house dentist; and that, the previous scheduler would have made the note regarding the dental appointment. However, staff #98 said that she did not have any record of the appointment or a note in the resident's electronic record. A review of the clinical record was conducted with staff #98 who stated that she was not able find that resident #81 had been scheduled for tooth extraction since it was noted in the dental notes in March 27, 2023. During an interview with the acting Director of Nursing (DON/ staff #171) conducted on May 19, 2023 at 11:00 a.m., the DON stated that that a dental extraction was scheduled for June 7, 2023 which was just made today. She said the expectation was that resident appointment/s would be scheduled for as close to the date it was recommended or ordered as possible; and that, the time gap from the time dental extraction was recommended/order and the time it was scheduled for resident #81 did not meet her expectation. The Facility Assessment included that the medical records director is responsible for appointments and transportation.

Based on clinical documents, staff interviews, facility documents, and facility policy, the facility failed to ensure that a resident's funds were not misappropriated for 1 resident (#12). This practice could result in financial exploitation of vulnerable adults. Findings include: Resident #12 was admitted on [DATE] with diagnoses of dementia and altered mental status. A Quarterly Minimum Data Set, dated dated dated [DATE] included that the resident's Brief Interview for Mental Status (BIMS) summary score was 10, which indicated that the resident was moderately impaired. This document included that the resident required supervision with 1 person physical assist to walk in a corridor and limited 1 person assistance for transfers. A care plan dated May 25, 2022 included that the resident had impaired thought processes related to hyponatremia, adjustment to new environment, and diagnosis of dementia. A Complete Evaluation/Nursing Home from Arizona Total Care Certified Physician's Assistant dated June 29, 2022 included After extensive evaluation of the patient, an assessment of her executive skills in particular, and additional history from staff, it is my professional opinion that this patient is not capable of making sound financial medical or legal decisions. An Application for Representative Payee with Project H.O.M.E dated June 29, 2022 included that Arizona Total Care Certified Physician's Assistant did not believe that the patient is capable of managing or directing the management of benefits in her own best interest. A physician's order dated September 9, 2022 included to place wander guard to left ankle related to poor safety awareness to alert staff of patient attempting to exit facility unsupervised. A review of the clinical record did not find any record that a business office assistant (staff #5) took this resident out of the facility to her bank and obtained a cashier's check for $27,819.22 to pay the resident's balance at the facility. A 5-day report dated October 17, 2022 included that it was confirmed that a transaction occurred with resident #12 and a business office assistant (staff #5) on September 16th, 2022 at Wells Fargo and that a cashier's check in the amount of $27,819.22 was made from Resident #12's checking and savings accounts payable to Park Avenue Health and Rehabilitation. This document stated that staff #5 did not follow the proper process of successfully applying for a public fiduciary to manage Resident 12's financial matters and she did not make anyone at Park Avenue Health and Rehabilitation aware of her actions until after she had completed them. This document included that the facility concluded that this staff member did not commit a crime as she did not financially benefit and that the staff member was let go. This document included an interview conducted by the Operations Manger (staff #20) and the Executive Director (staff #57) in which Resident #12 stated that staff #5 had not taken her to the bank yet and that she did not remember ever going to the bank with her. An interview was conducted on March 17, 2023 at 1:55 PM with staff #5 who said that she had worked as a business office assistant and that her primary duties were scanning, uploading patient information and filing. She said that resident #12 did not have family and that she was helping her. She said that she assisted resident #12 with her rent and that it was something that she did off the clock to assist her because she was going to become homeless. She said that she knew that she was having difficulty with finances and that she reached out to the resident's granddaughter but she was not willing to do it. She said that she felt that she was being interrogated for something that she did wrong when all she did was give her a ride, and she got the resident her check so she wouldn't be put out on the street. This staff was asked if she knew if the resident was mentally competent and she said that she is not a doctor. She stated again that I did give her a ride I did bring her bill and I did get the check. An interview was conducted on March 17, 2023 at 2:25 PM with the Business Office director (staff #9) who said that if a resident is not competent to make financial decisions and they do not have a financial guardian then if the resident has Arizona Long Term Care System (ALTCS), they have a physician's statement done which includes the reason for lack of competence, and then an application is send to Project H.O.M.E and Project H.O.M.E becomes their payee. She said that resident #12 did not qualify for ALTCS as she was over resources. She said that they made multiple attempts with this resident's family, however they were not successful. She said that a doctor had said that this resident is not competent, that the resident now has a public fiduciary and that they are trying to become her guardian. She said that staff #5 did obtain a check and that she did not know that staff #5 did until after it happened. She said that they contacted the corporate office and let the Executive Director (staff #57) know and then staff #5 was terminated. She said that business office people should not bring people to the bank. She said that she saw the check in the deposits and thought that staff #5 was able to reach the resident's granddaughter, so they deposited it. She said that when she next saw staff #5, she asked about it and was told that staff #5 and the resident went to the bank. She said that's when they contacted corporate and they said to refund it so we did. An interview was conducted on March 17, 2023 at 2:56 PM with the Executive Director (staff #57) who said that resident #12 came in without next of kin or at least a responsible party. He said that the facility has made many attempts with the resident's family and with the public fiduciary. He said that they finally got a lawyer involved as it is difficult when they can't get reimbursed. He said that staff #5 was a kitchen staff prior and that she worked in the business office. He said she got all of the documentation and took her to the bank and showed the bank the statement which included the balance. He said that they received the payment and thought it was family but then found it was not the case. He said that when staff #5 informed the Business Office Director how she went about it, he contacted family and did the self-report. He said no additional money has been withdrawn and no one benefited from this. He said that the corporate service center wrote the check and that he personally went to the resident's bank and returned it. He said that in a sense it wasn't misappropriation of funds as no one benefited. He said that when a resident cannot make decisions on their own, then they cannot do something like that. A policy titled Reporting Alleged Violations of Abuse, Neglect, Exploitations or Mistreatment included that misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.

Based on clinical record review, staff interviews, and review of policy, the facility failed to ensure one resident (#3) was provided care and services, consistent with professional standards of practice, to prevent, treat and/or heal a pressure ulcer. The sample size was 3. The deficient practice could result in pain, worsening and/or infection of pressure ulcers. Findings include: Resident #3 admitted to the facility 09/28/22 with diagnoses including type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene, morbid (severe) obesity due to excess calories and quadriplegia. A Skin/Wound Note dated 09/29/2022 12:02 included an initial visit with the resident. The note revealed that the resident has a Braden scale score of 15 [at risk for the development of pressure ulcers]. A healed stage 2 pressure injury with scarring was noted to the sacral area. A physician ' s order dated 09/29/22 included to cleanse the denuded area on sacrum with soap and water. Apply Triad (triamcinolone/corticosteroid) hydrophilic cream twice daily, every day and evening shift. A potential impairment to skin integrity care plan dated 09/29/22 related to scarring to sacrum and total bowel and bladder incontinence had a goal to be free from injury. Interventions included to monitor/document location, size and treatment of skin injury, report abnormalities, failure to heal, signs or symptoms of infection, maceration, etc. to the medical doctor. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 14 on the brief interview for mental status, indicating intact cognition. The resident required extensive 2+ person physical assistance for most activities of daily living and he did not have a pressure ulcer/pressure injury noted on the assessment. A physician's order dated 10/11/22 included a low air loss mattress to bed frame to promote skin integrity, every shift. Another order from the same date revealed wedges to assist with repositioning every shift as tolerated. An IDT (Interdisciplinary Team) Skin Review dated 10/12/22 included MASD (Moisture Associated Skin Damage) to the resident's sacrum with treatment in place. Physician's Order dated 10/14/22 included to cleanse the denuded area on sacrum with soap and water, apply Medi-honey (enzyme), adhesive foam, Change 3 times per week, every day shift on Monday, Wednesday and Friday. On 10/16/22 the resident's care plan was updated to include actual impairment to skin integrity related to MASD to the resident's sacrum. An IDT Skin Review dated 10/19/22 included MASD to sacrum with skin loss; pink tissue with epithelial tissue to wound edges noted. On 10/19/2022 at 7:48 a.m. a Skin/Wound Note included that the resident was seen for wound rounds that morning. The note indicated the resident had MASD to his sacrum with skin loss. The note further identified the wound bed with some slough present along with pink granulation tissue, and stated the area was resolving. The physician ' s orders included continuing with Medihoney and Hydrogel, and to cover with an adhesive foam dressing change 3 x week. However, a complete evaluation of the wound, including measurements and description of exudate and peri wound was not completed. An IDT Skin Review dated 10/26/22 included the resident had MASD to the sacrum with shearing present. Treatment included Medihoney gel and adhesive foam dressing. Review of the October 2022 Wound Administration Record revealed dressing changes were completed in accordance with the physician ' s orders. On 11/01/22 at 8:39 a.m. a Skin/Wound Note included that the resident's family was notified that the denuded area to the resident ' s sacrum had not responded well to treatment. The note indicated that the resident was compliant with dressing changes, but at times non-compliant with repositioning. The note included that the current dressing was not assisting with drainage and that the order was changed to assist with drainage. The wound had developed an odor and eschar. Provider notified. A Wound assessment dated [DATE] at 5:20 p.m. revealed a sacral wound measuring 15 cm (centimeters) x 10 cm x UTD (unable to determine), moderate serous exudate, and odor. The note indicated that a drastic change to the wound bed, drainage and odor was identified. The note included that the provider had been notified and that the resident had been sent to the hospital. Review of the Nurse Home to Hospital Transfer Form revealed the resident was sent to the ER related to an infected wound of the sacrum. On 02/07/23 at 4:22 p.m. an interview was conducted with the wound care nurse (staff #43). She stated that the resident had been admitted to the facility with MASD to the sacrum. However, after review of her own admission progress note, she did not respond when asked if her documentation had correctly identified a healed stage 2 pressure ulcer with scarring to the resident's sacrum. She stated that all of her wound assessments were listed under the IDT (Interdisciplinary Team)/Skin Meeting Notes. She stated that they do not use the weekly skin/wound templates in the facility. She stated that she will just describe the assessments in a progress note. On 02/08/23 at 8:50 a.m. an interview was conducted with a Registered Nurse (RN/staff #40). She stated that the CNAs (Certified Nursing Assistants) are the eyes and ears of the nurses. If the CNAs see a wound, they will come and let the nurse know. She stated that once she is aware, she will assess/observe the wound herself. Then, she stated she would inform the doctor, the wound nurse, the DON (Director of Nursing) and the resident's family. She stated that the wound nurse would complete a full assessment and notify the IDT for further review. She stated that if there is a change in the wound, she would notify the wound nurse and doctor and document it in a progress note. An interview was conducted on 02/08/23 at 12:09 p.m. with the DON (staff #17). She stated that a wound assessment should include wound measurements, a description of the wound bed, wound edges, peri wound, exudate and whether or not there was an odor. She stated that if a healed pressure ulcer reopened, someone would have to assess what stage it was, but that it would make sense that a re-opened stage 2 pressure ulcer would be considered to be a stage 2 pressure ulcer. She stated that the wound IDT meets weekly to discuss all the wound rounds and whether or not the interventions are working. She stated that if the resident was discussed, it would be in the IDT notes. She reviewed the resident's clinical record and noted that the resident had been discussed on 10/19/22 and 10/26/22. She stated that per the Wound Administration Records, treatments were provided 3 times per week as ordered. She reviewed the photograph of the wound dated 11/01/22 and stated that the wound did not appear to be MASD. On 02/08/23 at 1:26 p.m. a follow-up interview was conducted with the wound care nurse (staff #43). She stated that once an open area was identified on the resident ' s skin, she would assess it. She stated that if she was the one who identified it, she would notify the resident's family, the provider and DON. She stated that the open area and notifications should be documented in a progress note, and that she would like to think that she had documented it. She stated that she would ensure that a treatment was in place, if needed, and that it would be updated depending on the wound. She stated that she would complete an assessment on a weekly basis, or if an issue was identified. She stated that based on her assessment, she would ask for additional orders and that she would document that in the progress notes. She stated that she would notify dietary for a worsening of a pressure ulcer so that they could implement additional supplements. She stated that wound assessments include measurements, description of wound bed, peri wound, exudate and whether or not there was any odor. She stated that she identified MASD to the resident's sacrum as opposed to a stage 2 pressure ulcer because there was a lot of moisture in that area related to incontinence and/or sweating. She stated that there was one open area to the resident ' s sacrum. She stated that she did not measure it and that she did not assess the wound bed or the exudate. She stated that she completed the treatments as ordered and that if she had assessed it, the assessment would be in the IDT notes. She stated that once a wound has been identified as MASD, the wound program would not allow for reclassification. She stated that if she could have, she would have reclassified it as an unstageable pressure ulcer. However, she stated that the wound program had locked her into the MASD classification. The Wound Management policy, revised 08/2022, included that a resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the resident ' s clinical condition or other factors demonstrate that a developed pressure ulcer was unavoidable; and a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable sores from developing. The Complex Wound Management policy, revised 06/2022, included that it is the policy of the facility to have a flow sheet to enable medical staff to evaluate the status of wounds. A complex wound includes a pressure ulcer. Each wound will be measured in centimeters weekly. Measurements, size and depth, drainage, odor, color and a short statement on progress (or lack of) will be documented on the Skin Pressure Ulcer Weekly or Skin Ulcer Non-Pressure Weekly UDA. Treatments ordered by the physician will be used. If no improvement, the physician will be called for an evaluation.

Based on clinical record review, staff interviews, and review of policy, the facility failed to ensure one resident (#3) was provided services to prevent an accident. The census was 134. The deficient practice increases the risk for residents to sustain injury through preventable accidents. Findings include: Resident #3 admitted to the facility 09/28/22 with diagnoses including type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene, morbid (severe) obesity due to excess calories and quadriplegia. The Initial Admission Record dated 09/28/22 included the resident had weakness in both his right and left legs. A self-care performance deficit care plan dated 09/28/22 included conditions such as quadriparesis related to cervical cord compression with myelopathy status post cervical C2 laminectomy had a goal to show improvement in level of function. Interventions included staff participation to reposition and turn in bed. A Nurse Practitioner / Physician ' s Assistant (NP/PA) progress note dated 09/29/22 at 11:17 a.m. included that the resident had multiple hospital/skilled nursing stays within the past few months, that he was having progressively worsening weakness of the upper and lower extremities, and that he was found to have quadriparesis due to cervical cord compression with myelopathy. The note indicated the resident had undergone a posterior cervical C2 laminectomy, discectomy and fusion and had received inpatient rehabilitation for ongoing physical and occupational therapy (PT/OT). According to the note, the resident made very minimal progress with PT/OT and still required maximal assistance x2 and the Hoyer lift for transfers. The daily skilled note dated 09/30/22 at 3:59 p.m. included that the resident was totally dependent for bed mobility and that he required 2+ persons physical assistance. On 10/02/22 at 1:10 p.m. a daily skilled note indicated the resident required extensive 2+ person physical assistance with bed mobility. An NP/PA progress note dated 10/03/22 at 12:55 p.m. included that the resident had incomplete quadriplegia 2/2 cervical cord compression, was non-ambulatory with limited use of upper extremities. The note indicated there had been no significant change over the past few months and the expectation was that this condition would be the resident ' s new baseline. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 14 on the brief interview for mental status, indicating intact cognition. The resident required extensive 2+ person physical assistance for most activities of daily living (ADLs) including bed mobility. A daily skilled note dated 10/07/22 at 1:10 p.m. revealed the resident was totally dependent for bed mobility and required 2+ person physical assistance. A physician ' s order dated 10/11/22 included a low air loss mattress to the bedframe to promote skin integrity. A Physical Therapy Treatment Encounter Note dated 10/11/22 revealed the resident required substantial/maximal assistance to roll left and right for bed mobility. On 10/11/22 at 11:57 a.m. an NP/PA progress note included that the resident ' s strength in his lower extremities was assessed to be 0 out of 5. The Occupational Therapy Evaluation conducted on 10/12/22 included that the resident completed bed mobility including rolls left to right with maximal assistance, and initiated with bilateral upper extremities to cross reach across midline. The note further indicated that the resident required assistance at the hips to hold position for wound dressing and brief change. A daily skilled note dated 10/13/22 at 9:14 a.m. indicated the resident required extensive to total assistance for range of motion, ADL care, locomotion, and assistive device use. The note included that range of motion for upper and lower body was limited and no musculoskeletal changes had been observed. Review of the Weights and Vitals report dated 10/20/22 revealed the resident ' s weight had been documented at 227.0 pounds. A nursing progress note dated 10/22/22 at 9:40 a.m. included that a Certified Nursing Assistant (CNA) notified nursing that the resident was on the floor. Per the CNA, the resident had rolled off the bed while the CNA was providing care. Upon arrival of the nurse, the resident was observed laying on the floor with a noticeable hematoma on the left side of his head. The note indicated that the resident complained of pain to his head and left knee. The Director of Nursing (DON), charge nurse, and therapist came into the room to assist the resident back into his bed with the Hoyer lift. On 10/26/22 at 9:48 a.m. an interdisciplinary progress note included that the resident was sent to the ER for a computed tomography (CT) scan of the hematoma. The resident returned to the facility with no new orders. The note revealed that the resident would be placed onto a larger bed. An interview was conducted on 02/07/23 at 2:24 p.m. with a CNA (staff #20). She stated that she remembered the resident as being a large and a tall man. She stated that on the night of the incident (10/21/22), she was providing incontinence care to the resident in his bed. She stated that she thinks she was standing on the left side of the resident's bed and that the resident was turned onto his right side, facing away from her. She stated that while the resident was on his side, he reached up with his hand to grab the headboard to help her. She stated that when he grabbed up for the headboard, he turned over too far and flipped off the side of the bed. She stated that this was the first time she had worked with this resident and that she had only been on duty for a couple of hours. She stated that she had been told that the resident was a one-person assist for bed mobility during report at the start of her shift. She stated that after the resident fell off the bed she went to get the nurse. She said the nurse assessed the resident and she took the resident ' s vitals. She stated that a nurse manager and a physical therapist came into the room to help get the resident back into bed. She stated that they ended up using a Hoyer lift to get him back into bed because he was so big. She stated that the resident had hit his head and had some blood on his forehead. She said he had a little bump there and a small amount of bleeding from the area. She stated that after the resident had been assisted back into bed he was sent to the ER for evaluation. On 02/08/23 at 8:50 a.m. an interview was conducted with a Registered Nurse (RN/staff #40). She stated that she would anticipate seeing 2 people in the room to give care to a larger resident, especially a quadriplegic or someone who required extensive assistance. Stated that would include almost all ADLs, and definitely peri and/or incontinence care. She stated that if she sees that the resident requires extensive 2-person assistance in the care plan, she will let the CNA know so that they can provide care safely for both the resident and themselves. She stated that it could potentially be a danger to the resident and themselves if the CNA changed a larger, disabled resident by themselves. On 02/08/23 at 9:04 a.m. an interview was conducted with a CNA (staff #22). She stated that sometimes she will check in with therapy to determine the number of staff necessary during care, or if the resident looks larger, she will be able to just see that the resident needs 2-3 people for care. She stated that it would be a safety issue to change a large resident by herself. She stated that if the resident was new to her, she would receive instructions during report. She stated that a very large person with extensive muscle weakness and/or quadriplegia would not be able to assist with turning and/or to stop themselves from rolling off the bed, especially if they have an air mattress. She stated that it would not be safe to try to provide incontinence care by herself. At 10:06 a.m. on 02/08/23 an interview was conducted with the MDS nurse (staff #15). She stated that she gets information for the MDS assessment from information such as the CNA Point of Care notes, as well as the user defined notes, and compares it to the therapy charting. She stated that she would anticipate that the care plan would identify the resident as dependent on the ADL care plan. She stated that she would anticipate that the resident's care plan would indicate that 2 staff were required for ADL care, such as incontinence care. Because the resident was a quadriplegic/extensive 2-person assist, she stated that risks would include falls or injury to the resident and/or staff if there was only one person providing care. She stated that nursing staff identify residents with 2 staff requirements through the care plan and through report. An interview was conducted on 02/08/23 at 11:45 a.m. with an RN (staff #18). She stated that she is responsible for writing the care plans. She stated that she gets information for the comprehensive care plan from the baseline care plan and from doctor and nursing notes. She stated that MDS information is also a source. She stated that in the case of a resident who is a quadriplegic and/or requires extensive staff assistance, she will just indicate that the resident requires staff participation or staff assistance. She stated that since she's been creating care plans, she has never specified how many staff. She stated that she's just used to not specifying. She stated that risks to the resident might include falling out of bed and maybe getting injured. On 02/08/23 at 12:09 p.m. an interview was conducted with the DON (staff #17). She stated that she did not remember the resident being a quadriplegic. She stated that how much assistance the resident required would depend on how well he was able to roll over. She stated that she was not sure how well the resident rolled. She stated that she would think that the resident's care plan would match the MDS assessment. She stated that she wouldn't understand why it wouldn't match. However, she stated that she would not think that it would matter to patient care if the MDS did not match the care plan. She stated that in nursing school it matters, but in the real world it doesn't. She stated that the care plan would not state that the resident required 2-person physical assistance. She said they don't put that into the care plan. She stated that the MDS gets their information from the Plan of Care CNA documentation, and nursing and provider notes based on the level of care the resident has required according to the rule of 3 [three or more instances of the most extensive care the resident required.] She said she would not say that if the resident's clinical record (POC/nursing/provider notes) revealed that the resident required 2-person extensive assistance, and it was stated as such in the resident's MDS assessment, that the resident had been assessed to require 2-person extensive assistance. The Incidents and Accidents policy, revised 05/2021, included that it is the policy of the facility to implement and maintain measures to avoid hazards and accidents. Should an accident/incident occur, the resident will be provided immediate attention by a licensed nurse, who will notify the medical provider, family member, EMS, etc. as appropriate.

Based on clinical record review, staff interviews, and review of policy, the facility failed to ensure that one resident ' s (#3) comprehensive care plan accurately reflected his needs. The sample size was 3. The deficient practice could result in a lack of care provided to meet the resident ' s needs. Findings include: Resident #3 admitted to the facility 09/28/22 with diagnoses including type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene, morbid (severe) obesity due to excess calories and quadriplegia. A self-care performance deficit care plan dated 09/28/22 included conditions such as quadriparesis related to cervical cord compression with myelopathy status post cervical C2 laminectomy had a goal to show improvement in level of function. Interventions included staff participation to reposition and turn in bed. However, the number of staff or the extent of physical assistance was not identified in the plan of care. A Nurse Practitioner / Physician ' s Assistant (NP/PA) progress note dated 09/29/22 at 11:17 a.m. included that the resident had multiple hospital/skilled nursing stays within the past few months, that he was having progressively worsening weakness of the upper and lower extremities, and that he was found to have quadriparesis due to cervical cord compression with myelopathy. The note indicated the resident had undergone a posterior cervical C2 laminectomy, discectomy and fusion and had received inpatient rehabilitation for ongoing physical and occupational therapy (PT/OT). According to the note, the resident made very minimal progress with PT/OT and still required maximal assistance x2 and the Hoyer lift for transfers. An NP/PA progress note dated 10/03/22 at 12:55 p.m. included that the resident had incomplete quadriplegia 2/2 cervical cord compression, was non-ambulatory with limited use of upper extremities. The note indicated there had been no significant change over the past few months and the expectation was that this condition would be the resident ' s new baseline. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 14 on the brief interview for mental status, indicating intact cognition. The resident required extensive 2+ person physical assistance for most activities of daily living and he did not have a pressure ulcer/pressure injury. A Physical Therapy Treatment Encounter Note dated 10/11/22 revealed the resident required substantial/maximal assistance to roll left and right for bed mobility. On 10/11/22 at 11:57 a.m. an NP/PA progress note included that the resident ' s strength in his lower extremities was assessed to be 0 out of 5. The Occupational Therapy Evaluation conducted on 10/12/22 included that the resident completed bed mobility including rolls left to right with maximal assistance, and initiated with bilateral upper extremities to cross reach across midline. The note further indicated that the resident required assistance at the hips to hold position for wound dressing and brief change. A nursing progress note dated 10/22/22 at 9:40 a.m. included that a Certified Nursing Assistant (CNA) notified nursing that the resident was on the floor. Per the CNA, the resident had rolled off the bed while the CNA was providing care. Upon arrival of the nurse, the resident was observed laying on the floor with a noticeable hematoma on the left side of his head. The note indicated that the resident complained of pain to his head and left knee. The Director of Nursing (DON), charge nurse, and therapist came into the room to assist the resident back into his bed with the Hoyer lift. On 10/26/22 at 9:48 a.m. an interdisciplinary progress note included that the resident was sent to the ER for a computed tomography (CT) scan of the hematoma. The resident returned to the facility with no new orders. The note revealed that the resident would be placed onto a larger bed. An interview was conducted on 02/07/23 at 2:24 p.m. with a Certified Nursing Assistant (CNA/staff #20). She stated that she remembered the resident as being a large and a tall man. She stated that on the night of the incident (10/21/22), she was providing incontinence care to the resident in his bed. She stated that she thinks she was standing on the left side of the resident ' s bed and that the resident was turned onto his right side, facing away from her. She stated that while the resident was on his side, he reached up with his hand to grab the headboard to help her. She stated that when he grabbed up for the headboard, he turned over too far and flipped off the side of the bed. She stated that this was the first time she had worked with this resident and that she had only been on duty for a couple of hours. She stated that she had been told that the resident was a one-person assist for bed mobility during report at the start of her shift. She stated that a nurse manager and a physical therapist came into the room to help get the resident back into bed. She stated that they ended up using a Hoyer lift to get him back into bed because he was so big. At 10:06 a.m. on 02/08/23 an interview was conducted with the MDS nurse (staff #15). She stated that she gets information for the MDS assessment from information such as the CNA Point of Care notes, as well as the user defined notes, and compares it to the therapy charting. She stated that she would anticipate that the care plan would identify the resident as dependent on the ADL care plan. She stated that she would anticipate that the resident's care plan would indicate that 2 staff were required for ADL care, such as incontinence care. Because the resident was a quadriplegic/extensive 2-person assist, she stated that risks would include falls or injury to the resident and/or staff if there was only one person providing care. She stated that nursing staff identify residents with 2 staff requirements through the care plan and through report. An interview was conducted on 02/08/23 at 11:45 a.m. with an RN (staff #18). She stated that she is responsible for writing the care plans. She stated that she gets information for the comprehensive care plan from the baseline care plan and from doctor and nursing notes. She stated that MDS information is also a source. She stated that in the case of a resident who is a quadriplegic and/or requires extensive staff assistance, she will just indicate that the resident requires staff participation or staff assistance. She stated that since she's been creating care plans, she has never specified how many staff. She stated that she's just used to not specifying. She stated that risks to the resident might include falling out of bed and maybe getting injured. On 02/08/23 at 12:09 p.m. an interview was conducted with the DON (staff #17). She stated that she did not remember the resident being a quadriplegic. She stated that how much assistance the resident required would depend on how well he was able to roll over. She stated that she was not sure how well the resident rolled. She stated that she would think that the resident's care plan would match the MDS assessment. She stated that she wouldn't understand why it wouldn't match. However, she stated that she would not think that it would matter to patient care if the MDS did not match the care plan. She stated that in nursing school it matters, but in the real world it doesn't. She stated that the care plan would not state that the resident required 2-person physical assistance. She said they don't put that into the care plan. She stated that the MDS gets their information from the Plan of Care CNA documentation, and nursing and provider notes based on the level of care the resident has required according to the rule of 3 [three or more instances of the most extensive care the resident required.] She said she would not say that if the resident's clinical record (POC/nursing/provider notes) revealed that the resident required 2-person extensive assistance, and it was stated as such in the resident's MDS assessment, that the resident had been assessed to require 2-person extensive assistance. The Care Planning policy, reviewed 09/2022, included that it is the policy of the facility that the IDT shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident ' s medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will be developed within 7 days of completion of the resident MDS and will include the resident's needs as identified in the comprehensive assessment.

Based on observations, staff interviews, facility documentation, policies and procedures, the facility failed to ensure that one staff (#4) completed the COVID-19 screening process prior to working in the facility. The facility census was 127 and there were 11 COVID-positive cases. The deficient practice increases the risk for transmission of COVID-19. Findings include: During the entrance conference conducted on July 5, 2022 at 9:26 a.m. with the Director of Nursing (DON/staff #37) and the Infection Preventionist (IP/staff #17), they stated that the COVID unit was located in the 100 hall and the PPE (personal protective equipment) was located on room [ROOM NUMBER]. According to both staff, there were 2 nurses and 2 CNAs (certified nurse assistants) who were dedicated to work at the COVID unit. They also said KN95 masks, goggles, gown and gloves were the required PPE on the COVID unit. Findings include: A Review of the punch detail from June 7 through 30, 2022 revealed a CNA (staff #4) revealed that the CNA worked her shifts on June 8, 9, 10, 11, 12, 14, 15, 17, 18, 19, 20, 21, 22, 23 and 24. However, review of the staff screening logs from June 7 through 30, 2022 revealed that staff #4 only completed screening on June 9, 12, 14, 18, 19 and 23. There was no evidence found that staff #4 was screened on the other dates in June 2022 that staff #4 was documented to have worked his shift. On 07/05/22 at 3:22 p.m., an interview was conducted with the IP (staff #17) who stated that staff are expected to do COVID screening in upon entering the facility and before every shift. She stated staff may screen in through the kiosk at the front desk or use a QR code on their phone. She stated that the risks of not screening in would include transmission of COVID to residents and staff. In an interview with the receptionist (staff #72) conducted on July 6 at 10:42 a.m., she stated that when visitors enter the facility, she will let them know that the facility is on an outbreak status. She stated the acility use portals and/or a QR code for screening; and that, all the screening information is entered into the system. During an interview with the DON conducted on July 6, 2022 at 11:40 a.m., the DON stated that staff have been educated to do screening before their shifts. She stated that it would not meet her expectations for staff to go directly to the floor for their shifts without screening in. Further, she stated the risks would include working sick or transmission of infection. The facility policy on Screening Process included that any person entering the facility at any time will be screened for COVID-19 symptoms following current CDC guidelines. Any person not complying with the screening requirements will not be permitted to enter. Any person with yes answers to screening or with a fever, will not be permitted to enter, unless secondary screening by the Director of Nursing Services or the clinical leader on call reveals it is related to the individual's chronic condition and is not a deviation from the baseline.

Based on clinical record reviews, staff interviews, and policy review, the facility failed to ensure three residents (#53, #415 and #426) and their representatives were provided a summary of the baseline care plan. The sample size was 24. The deficient practice could result in a summary of the baseline/comprehensive care plan not being provided to residents and their representatives. Finding include: -Resident #53 was admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record revealed a care plan initiated on February 3, 2022 that the resident has acute pain related to surgical incision and ADL (Activities of Daily Living) Self-Care Performance Deficit. The care plan also included the resident has potential/actual impairment to skin integrity related to an abrasion to the right and left breasts, surgical wounds to the abdomen, unstageable pressure ulcer to the right hip, and a PEG (percutaneous endoscopic gastrostomy) tube to abdomen initiated on February 4, 2022. Review of the clinical record did not reveal evidence that the facility provided a summary of the care plan to the resident and their representative. During an interview conducted with the resident on March 28, 2022 at 12:51 PM, the resident stated that she did not recall receiving any sort of care plan in writing. -Resident #415 was admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record revealed a care plan initiated on March 21, 2022 that the resident is at for risk falls and malnutrition, has ADL Self-Care performance deficit, and has acute/chronic pain. The care plan also revealed the resident has actual skin impairment related to an abrasion to the right elbow and a skin tear to the left elbow initiated on March 22, 2022. Review of the clinical record did not reveal evidence that the facility provided a summary of the care plan to the resident and their representative. During an interview conducted with the resident on March 29, 2022 at 8:57 AM, the resident stated she was not sure that she has seen any care plans, but her son who is coming in frequently and who has been talking to the staff and administration might have it. -Resident #426 was admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan initiated on March 21, 2022 revealed the resident had ADL Self-Care Performance Deficit, is at risk for falls, and has acute/chronic pain. The care plan also revealed the resident has potential/actual impairment to skin integrity related to an abrasion to the left knee initiated on March 22, 2022. Review of the clinical record did not reveal evidence that the facility provided a summary of the care plan to the resident and their representative. During an interview conducted with the resident on March 29, 2022 at 9:36 AM, the resident stated that she does not recall receiving any documentation of any plan of care from the staff. During an interview conducted on March 30, 2022 at 12:35 PM with a Licensed Practical Nurse (LPN/staff #151), she stated that the care plans are started by the Registered Nurse (RN) and then the other nurses can modify the care plan. The LPN further stated that the initial care plan is started by the charge nurse or admissions nurse and that an RN will review the care plan with the resident. In an interview conducted with an LPN/MDS (Minimum Data Set Coordinator (staff #39) on March 30, 2022 at 12:42, she stated that she develops the residents' care plans. Staff #39 stated that she has not been completing the baseline care plans as she is behind in the process and has not been doing them for the current admissions. During an interview conducted on March 30, 2022 at 12:50 with the Director of Nursing (DON/staff #141), she stated that her expectation is that a baseline care plan is initiated by the admissions nurse upon admission for a resident, and then completed by the MDS Coordinator. The DON stated that the MDS Coordinator is to be completing the baseline care plan process and that the Social Services staff was assisting in obtaining the acknowledgements signed by the residents. Review of the facility's policy for Baseline Care Plan revealed that the interdisciplinary team shall develop and implement a baseline care plan for each resident within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care. The facility team will provide a written summary of the baseline care plan to the resident or the resident representative.

Based on clinical record review, staff interviews, and review of facility policies and procedures, the facility failed to ensure one resident (#28) did not develop a pressure sore. The sample size was four. Findings include: Resident #28 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident's clinical record revealed Personal Identifying Information dated February 8, 2011, which revealed the resident's skin was intact on admission. The resident's clinical record revealed a Braden Scale - For Predicting Pressure Sore Risk dated February 8, 2011 which revealed the resident's total score was a 16, a mild risk for developing a pressure sore. A review of the resident's clinical record revealed a physician's orders [REDACTED]." The resident's clinical record revealed an Minimum Data Set (MDS) assessment dated [DATE]documented that the resident did not have a pressure sore but was at risk for developing a pressure sore. The resident's clinical record revealed a Skin Integrity care plan dated February 22, 2011, which documented "At risk for impaired skin integrity" as a problem. An approach documented for the problem was "Float heels when in bed." The resident's clinical record revealed a Physician's Progress Note dated March 3, 2011, which stateed that the resident's skin was intact Treatment Records in the resident's clinical record revealed a weekly skin check was performed on February 10, 17, and 24, 2011. There was no evidence in the Treatment Record that a skin check was performed on March 3, 2011. Weekly Skin Evaluations in the resident's clinical record revealed a weekly skin check was performed on February 10, 17, and 24, 2011. There was no evidence in the Weekly Skin Evaluation that a skin check was performed from February 24 until an entry was made on March 8, 2011. The resident's clinical record revealed Interdisciplinary Progress Notes dated March 8, 2011 which documented "Skin: Seen this a.m. for skin alert to left heel. 5 x 5 cm (centimeter) area intact dry eschar noted." The resident's clinical record revealed a Nutrition Progress Note dated March 11, 2011 which documented "Resident now with UTS (unable to stage) PU (pressure ulcer) to left heel 5 x 5 UTS depth." The resident's clinical record revealed a Physician's Progress Note dated March 16, 2011 which documented "Left heel with skin breakdown." An interview was conducted with an LPN (licensed practical nurse) on June 8, 2011. The LPN stated that if there is a physician's orders [REDACTED]. An interview was conducted with the DON (director of nursing) on June 9, 2011. The DON stated that she was unable to find documentation that the resident's weekly skin check was completed on March 3, 2011. A review of the facility's policy Wound Management documented "It is the policy of this facility that a resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the individual's clinical condition or other factors demonstrate that a developed pressure ulcer was unavoidable."