Every finding on record at Park Meadows Post Acute

Based on facility policy review, Speech-Langauge Pathologist Therapist (SPT) job description review, admission Director job description review, Dietary Supervisor job description review, Clinical Dietician position description review, International Dysphagia Diet Standardization Initiative (IDDSI) manual review, Nutrition Care Manual (NCM)- Diet Manual, medical record review, Dietary Management Company menu review, hospital record review, and interview, the facility failed to provide care and services necessary to maintain the highest practicable physical, mental, and psychosocial well-being of residents when staff failed to prepare food in a form designed to meet individual needs for 1 of 6 (Resident #1) sampled residents reviewed for receiving a mechanically altered therapeutic diet. The facility's failure resulted in Immediate Jeopardy on 8/19/2026, when Resident #1, a vulnerable and severely cognitively impaired resident, who required partial/moderate staff assistance for eating, and who was at risk of choking, was admitted to the facility with an order for a minced and moist diet consistency, a diet consistency not used by the facility. The admission Director failed to clarify the order to ensure an appropriate and comparable diet was ordered; and Resident #1 was served a mechanical soft consistency meal for lunch on 8/19/2026, without supervision, after a Speech Therapy evaluation determined the resident was unable to safely manage a mechanical soft texture and recommended puree foods and close supervision for oral intake due to safety concerns. The Speech Therapist failed to notify staff of safety concerns and recommendations in a timely manner resulting in Resident #1 requiring suctioning and emergency transfer to the Hospital related to aspiration pneumonia where Resident #1 was intubated and placed in the Intensive Care Unit (ICU). The facility's failure to address safety concerns for mechanically altered meals resulted in Actual Harm to Resident #1. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and DON were notified of the Immediate Jeopardy for F-805 on 8/25/2026 at 6:09 PM in the Conference Room. The facility was cited Immediate Jeopardy at F-805. The facility was cited at F-805 at a scope and severity of J. The IJ began on 8/19/2026 and continued through 8/26/2026. The IJ was removed on 8/27/2026. A partial extended survey was conducted on 8/26/2026. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 8/26/2026 with an alleged removal date of 8/26/2026 and was validated on site by the surveyors on 8/26/2026 through medical record review, staff education review, staff interviews, and audit review. The facility's noncompliance at F-805 continues at a scope and severity of G for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the facility policy titled, Interdepartmental Notification of Diet (Including Changes and Reports), dated 10/2017, revealed .Nursing services shall notify the food and nutrition services department of a resident's diet orders, including any changes in the resident's diet, meal service, and food preferences.When a new resident is admitted , or a diet has been changed, the nurse supervisor shall ensure that the food and nutrition services department receives a written notice of the diet order.The food and nutrition services department will be notified verbally if the diet change or report occurs one hour or less before a scheduled meal.Nursing services shall notify the physician and dietitian .to initiate an appropriate process of clinical review for causes of the nutritional problem.Each nursing station shall maintain a supply of diet order/change in diet forms. Review of the facility policy titled, Nutritional Assessment, dated 10/2027, revealed .As part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impairment nutrition, shall be conducted for each resident.The multidisciplinary team shall identify, upon the resident's admission and upon his or her change of condition, the following situations that place the resident at increased risk for impaired nutrition.Chewing or swallowing abnormalities - onset or exacerbation of conditions of the mouth, teeth, gums pharynx or esophagus that affect the resident's ability to chew of swallow food. Review of the facility policy titled, Therapeutic Diets, dated 10/2027, revealed .Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences.A therapeutic diet must be prescribed by the resident's attending physician.Diet order should match the terminology used by the food and nutrition services department.A therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet, for example.altered consistency diet.If a mechanically altered diet is ordered, the provider will specify the texture modification.The dietitian, nursing staff, and attending physician will regularly review the need for, and resident acceptance of, prescribed therapeutic diets.The dietitian and nursing staff will document significant information relating to the resident's response to his/her therapeutic diet in the resident's medical chart. Review of the facility policy titled, Assisting the Impaired Resident with In-Room Meal, dated 9/2013, revealed.The purpose of this procedure is to provide appropriate support for residents who need assistance with eating.Review the resident's care plan and provide for any special needs of the resident.Check the tray before serving it to the resident to be sure that it is the correct diet ordered and that the food consistency is appropriate to the resident's ability to chew and swallow.The person performing this procedure should record the following in the resident's medical record.Any difficulty the resident had in feeding himself or herself, chewing, or swallowing. Review of the facility policy titled, Assisting the Resident with In-Room Meals, dated 12/2013, revealed .The purpose of this procedure is to provide appropriate assistance for residents who choose to receive meals in their rooms.Check the tray before serving it to the resident to be sure that is the correct diet ordered and that the food consistency is appropriate to the resident's ability to chew and swallow.Remove the tray when the resident has finished his or her meal. 2. Review of the Speech-Language Pathologist Therapist job description dated 2/2024 and signed by the Speech- Language Pathologist Therapist on 6/18/2026, revealed .The Staff Speech-Language Pathologist Therapist evaluates and treats patients, communicates with families, physicians and other health team members and maintains documentation of services in the medial records. Conducts in-services and training for facility staff on an ongoing basis .Essential Duties.Develop effective treatment plan and obtain approval for services from the referring physician.Treat patients per the physician treatment plan.Communicate with supervisor and other health team members regarding patient progress, problem and plans.Record treatment changes. Review of the Admissions Director job description dated 2/2024 and signed by the Admissions Director on 11/10/2025, revealed .The primary purpose of your job is to support facility operations by increasing the facility census.Manage the admissions process efficiently to ensure a positive experience for residents, families and supporting staff. Screens patients by comparing patients' condition to admission criteria.Admits patients by completing admission and financial responsibility forms.Working collaboratively with leaders of other facility departments to ensure timely communication of appropriate information.Oversees.completion of preminary [preliminary] paperwork for admissions.Obtain Applicant information by requesting complete applications and medical information; verifying and clarifying information; interviewing patients and family members.Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form. Review of the Dietary Supervisor job description dated 2/2024 and signed by the Dietary Supervisor on 6/30/2026, revealed .The Dietary Supervisor will direct and assist the preparation and service of regular meals and therapeutic diets.Processes new diet orders and diet changes when received from nursing staff and keeps diet cards updated.Check trays for accuracy before they are delivered.Coordinates dietary services with nursing services and activities director.Visit all residents to conduct nutritional assessment and screening. Review of the undated Clinical Dietician position description signed by the Clinical Dietician on 1/27/2026, revealed .The Clinical Dietician works in conjunction with the Food Service Director, Physician and DON to meet resident's nutritional Needs. The dietician plans modified diets, as requested by attending physician.Provides nutritional assessments for every resident in accordance with all state and federal regulations.Must be knowledgeable of dietary services practices and procedures as well as the laws, regulations, and guidelines governing dietary functions in the long-term care facility.Must have the ability to implement, and interpret the programs, goals, objectives, policies, and procedures of the Food and Nutrition Service department.Must be able to plan modified diets.Must be able to complete clinical assessments and input information accurately and timely.The Registered Dietician will also complete weekly meal rounds. 3. Revie of the IDDSI manual dated 4/2026, revealed .The International Dysphagia Diet Standardization Initiative.was founded in 2013 with the goal of developing new international standardized terminology and definitions to describe texture modified foods and thickened liquids used for individuals with dysphagia of all ages, in all care settings, and all cultures.4 [level 4] pureed.Description/characteristics. Usually eaten with a spoon (a fork is possible) Does not require chewing.Can be piped, layered or molded because it retains its shape, but should not require chewing if presented in this form.No lumps.Physiological rationale for this level of thickness.If tongue control is significantly reduced, this category may be easiest to control.Requires less propulsion effort than Minced and Moist (level 5), Soft & Bite-Sized (level 6) and Regular and Regular Easy to Chew (Level 7).No biting or chewing is required.Any food that requires chewing, controlled manipulation or bolus formation are not suitable.Missing teeth, poorly fitting dentures.5 [level 5].Minced & Moist.Description/characteristics. Can be eaten with a fork or spoon.Soft and moist with no sperate thin liquid.Small lumps visible within the food.Adult, equal to or less than 4mm [millimeters] width and no longer than 15mm in length.lumps are easy to squash with tongue.Physiological rationale for this level of thickness.Biting is not required.Minimal chewing is required.Tongue force alone can be used to separate the soft small particles in this texture.Tongue force is required to move the bolus.Missing teeth, poorly fitting dentures.When pressed with a fork the particles should easily be separated between and come through the tines/prongs of a fork.Can be easily mashed with little pressure from a fork [pressure should not make the thumb nail blanch to white].no regular, dry bread, sandwiches or toast of any kind.6 [level 6] Soft & Bite-Sized.Can be eaten with a fork, spoon or chopsticks.A knife is not required to cut this food, but may be used to help load a fork or spoon. Soft, tender and moist throughout but with no separate thin liquid.Chewing is required before swallowing.'Bite-sized' pieces as appropriate for size and oral processing skills.Adults, 15mm=1.5 cm [centimeters] pieces (no larger than).Biting is not required.chewing is required.Food piece sizes designed to minimize choking risk.Tongue force and control is required to move the food and keep it within the mouth for chewing and oral processing.Tongue force is required to move the bolus for swallowing.Missing teeth, poorly fitting dentures. Pressure from a fork held on its side can be used to 'cut' or break apart or flake this texture into smaller pieces.When a sample the size of a thumb nail (1.5x1.5 cm) is pressed with the tines of a fork to a pressure where the thumb nail blanches to white, the sample squashes, breaks apart, changes shape, and does not return to its original shape when the fork is removed.EC 7 [level 7] Easy to Chew. Description/characteristics.Normal, everyday foods of soft/tender textures that are developmentally and age appropriate.Any method may be used to eat these foods.Sample size is not restricted at Level 7, therefore, foods may be of a range of sizes.Smaller or greater than 15 mm - 1.5 cm pieces.Requires the ability to bite soft foods and chew and orally process foods for long enough that the person forms a soft cohesive ball/bolus that is 'swallow ready'. Does not necessarily require teeth.Requires the ability to chew and orally process soft/tender foods without tiring easily. This level could present a choking risk for people with clinically identified increased risk of choking, because food pieces can be of any size. Restricting foods piece sizes aims to minimize choking risk (.Level 4 Pureed, Level 5 Minced & Moist, Level 6 Soft & Bite-sized have food piece size restrictions to minimize choking risk).If the person needs supervision to eat safely, before using this texture level consult a qualified clinician to determine that person's food texture needs, and meal time plan for safety. People can be unsafe to eat without supervision due to chewing and swallowing problems.Where mealtime supervision is needed, this level should only be used under strict recommendation and written guidance of a qualified clinician.7 [level 7] Regular.Normal everyday foods of various textures that are developmentally and age appropriate.Foods may be hard and crunchy or naturally soft.Sample size is not restricted.Ability to bite hard or soft foods and chew them for long enough that they form a cohesive ball/bolus that is 'swallow ready'. 4. Review of the NCM Diet Manual dated 1/12/2026, revealed .The NCM Diet Manual provides practical, usable knowledge that can be easily implemented in a multitude of nutrition care settings. It is intended to assist food and nutrition services departments with planning nutritionally adequate meals for their patients.Compare your facility's current diet order terminology and definitions with the NCM Diet Manual names.Identify NCM diets to be used at your facility in consultation with medical staff leadership and medical director, referring to evidence to support use of diets.Use the NCM Diet Manual Crosswalk Guide and the information gathered in NCM Diet Manual Crosswalk Worksheet completed in step two to customize the NCM Diet Manual to your facility.Transitioning from prescribing the National Dysphagia Diet (NDD) and other texture-modified diets to prescribing the International Dysphagia Diet Standardization Initiative.levels require careful planning.Mechanical Soft Diet.The mechanical soft diet is modified in consistency to reduce the amount of chewing required to consume food.This diet is intended for persons who may have difficulty chewing solid foods.Mechanical Soft Food Preparation.Place foods in the food processor to be Mechanically altered to the proper consistency.All meats with the exception of un-breaded baked fish should be mechanically altered using the food processor.Comparison of NDD and IDDSI levels. NDD.Dysphagia Level 3: Advanced or Mechanical Soft (Components of NDD Level 3 align with Level 7 Easy to Chew and Level 6 Soft & Bite-Sized).No hard sticky or crunchy foods.Foods should be moist.Mixed-consistency foods are not allowed if tolerated and should be assessed by clinician.Food particles are served in bite-sized pieces (less than 1 inch).Adequate dentition and chewing ability expected.[Compared to].IDDSI.Level 7 Easy to Chew.Soft, tender moist foods.There are no food size restrictions but may benefit from foods cut up at service.Level 6.Soft & Bite-Sized.Should be able to bit [bite] off food and chew without tiring easily.Soft, tender, moist foods; no mixed consistency; Foods should have a particle size no greater than 15 mm length by 15 mm width.Some chewing ability is required and tongue force to move food for oral processing is expected.Dysphagia level 2: Mechanically Altered or Ground.Foods should be moist, of soft texture and can be formed into a bolus easily.Meats are ground then softened and moistened by using gravies and sauces (served no larger than 1/4 inch pieces).Vegetables and fruits are soft cooked, and bite sized (served no larger than 1/4/ inch pieces).Some chewing required and tolerances of mixed textures should be assessed.[Compared to].Level 5 Minced &Moist.Minced, soft and moist foods; can be scooped and shaped.easily mashed by fork No mixed consistency. Food pieces with particle size no greater than 4 mm wide by 15 mm long for adults.Most foods are served in mildly, moderately or extremely thick sauce.and drain excess liquids.Bread is not allowed unless pureed or gelled throughout.Foods require minimal chewing and tongue force to move bolus and to separate the particles Biting is not required.Dysphagia Level 1:Pureed.All foods are pureed, blended, or strained for a smooth consistency with no lumps.Foods that require chewing or a bolus formation not allowed.[Compared to].Level 4 Pureed Food.Smooth, lump free; not firm or sticky; does not require chewing or bolus formation.No mixed consistency.No chewing or biting required nor ability to form bolus. 5. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including Aphasia (a brain related condition that makes it hard to talk,) Weakness, and Dysphagia (difficulty swallowing). Review of the Care Plan dated 8/8/2026, revealed .Observed for signs or symptoms of dysphagia.pocketing, coughing, choking, drooling, holding food in mouth.Speech Therapy: Resident requires Skilled SLP [Speech-Language Pathologist] [a healthcare professional who diagnoses and treats swallowing, communication, and cognitive disorders] (Swallow) due to Coughing or choking during meals or when swallowing medications, Dysphagia, Holding food in mouth/cheek or residual food in mouth after meals.Will utilize safe swallowing strategies to promote bolus clearance to reduce risk of choking/aspiration. Review of the admission Summary note for Resident #1 dated 8/8/2026 at 2:45 PM, revealed .admission Summary (Admit/Re-admit).Resident arrived to facility at approx. [approximately] 1330 [1:30 PM] via [by way of] EMT [emergency medical transport] from [Named Hospital] following hospitalization for dehydration, hypernatremia [high sodium levels in the blood], weakness, elevated troponin [protein found in heart muscles] and concern for UTI [urinary tract infection].Resident noted to be weak and frail with impaired mobility and requires assistance with transfer/ ADLs [activities of daily living].A&O [alert and oriented] X [times] 2 self and time. Resident is nonverbal. No acute distress noted at the time of admission. Respiration 19 BPM [breathes per minute] even and unlabored. VS [vital signs] BP [blood pressure] 122/82 HR [heart rate] 78 regular, O2 [oxygen] 98% [percent] RA [room air]. Resident admitted on a pureed diet per hospital recommendations. Encouraged PO [by mouth] fluids as appropriate d/t [due to] recent dehydration and high sodium. Swallowing precautions maintained as ordered.Author: Registered Nurse [(RN) C]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment, which indicated he was severely cognitively impaired. Resident #1 required partial to moderate assistance with eating. Resident #1 was coded for difficulty swallowing related to holding food in mouth or cheeks or residual food in mouth after meals, coughing or choking during meals or when swallowing medications, and received a mechanically altered diet. Review of admission Summary (Admit/Re-admit) note for Resident #1dated 8/17/2026 at 9:47 PM, revealed .Resident.readmitted to the facility at approximately 2035 [8:35 PM] via EMT.Upon arrival, resident noted to be weak and frail with impaired mobility and is bedbound, requiring assistance with transfers and activities of daily living (ADLs). Resident is alert and oriented to self only (A&O x1) and is nonverbal at baseline/current assessment. Resident unable to provide reliable verbal responses. No acute distress observed at time of readmission. Vital signs obtained: BP 139/80, HR 75 regular, RR 17 breaths/min, SpO [(oxygen saturation) the percentage of oxygen the blood is carrying] 96% on room air. Respirations even and unlabored. No signs of respiratory distress noted.Author: Licensed Practical Nurse [(LPN) F]. Review of (Named Hospital) Discharge Orders and Instruction, dated 8/17/2026, revealed .Diet.Cardiac Low-Sodium.Other Minced & [and] Moist . Review of the Physician's Order dated 8/17/2026 at 6:28 PM, revealed Regular diet, Mechanical Soft texture.Minced and moist. Review of the Physician's Order dated 8/17/2026 at 7:00 PM, revealed Observed loss of liquids/solids from mouth when eating or drinking.every shift for 5 Days. Review of the Physician's Order dated 8/17/2026 at 7:00 PM, revealed Observed holding food in mouth/cheeks or residual food in mouth after meals.after meals for 5 Days. Review of the Physician's Order dated 8/17/2026 at 7:00PM, revealed Observed difficulty or pain when swallowing.every shift for 5 Days. Review of the Physician's Order dated 8/17/2026 at 7:00 PM, revealed Observed coughing/choking during meals or medication administration.every shift for 5 Days. Review of the Baseline Care Plan dated 8/18/2026 revealed .Diet Order.Regular diet, Mechanical Soft texture.Nutritional Risks.Dental Issues.Difficulty Swallowing/Chewing.Mechanically Altered Diet. Review of the REHAB-DYSPHAGIA SCREENING FORM dated 8/18/2026, revealed .Readmission.Cognitive Deficit.Impairments.resident is unable to swallow on demand.yes.holding food in mouth/cheeks or residual food in mouth after meals.yes.coughing or choking during meals or when swallowing medications.yes.Is the resident receiving an altered diet.mech soft w[ with]/ thin.Diagnosis and clinical symptoms indicate presence of dysphagia.yes.recommendations.Swallow Evaluation by speech pathologist.ST [speech therapy] eval [evaluation] indicated.Signed By.[Speech Language Pathologist] .Signed Date. 8/19/2026. Review of the Dietary Interview/Pre-screen document dated 8/18/2026, revealed .spoke with.[Resident #1's] son.appetite.good.Diet Order.Regular Diet, Mechanical Soft texture.interpreter Needed.yes.Resident Dining Choice.Room.Resident is in agreement with the Diet/Consistency and Supplement/Fortified Order.yes.By.Dietary Supervisor.Signed Date.8/18/2026. Review of the [Named] 2026 Menu dated 8/18 [2026], revealed the following was served to Resident #1 for breakfast, lunch, and supper: a. Mechanical Soft.Breakfast.4 oz [ounces] Juice of choice.2 oz Egg of Choice.2 oz Gr [ground] Sausage.6 oz Cereal of Choices, No Raisin.2 oz Breakfast Potatoes.1 sl [slice] Toast. b. Mechanical Soft.Lunch.3 oz gr [ground] Marinated Orange Chicken.4 oz Rice.4 oz Peas & Carrots, soft.1 sl [slice] Apple Cake. c. Mechanical Soft.Supper.6 oz Gr Beef & Spanish Rice.4 oz Fluffy Steamed Rice.4 oz Canned Fruit.2 oz Flan. Review of the [Named] 2026 Menu dated 8/19 [2026], revealed the following was served to Resident #1 for breakfast and lunch: a. Mechanical Soft.Breakfast.4oz Juice of Choice.2 oz Gr Sausage.6 oz Cereal of Choice, No Raisin.2 ea [each] Pancakes.1 pk [packet] Butter/Margarine.1 pkt [packet] Syrup. b. Mechanical Soft.Lunch.3 oz Gr Meatballs/mushroom Gravy.4oz Buttered Noodles.4 oz Broccoli & Cauliflower.1 Biscuit.1 sl Chocolate Cream Pie. Review of the Physician's Order dated 8/19/2026 at 2:49 PM, revealed Regular diet, Pureed texture, Mildly Thick (Nectar) consistency- for Difficulties swallowing. Review of the Nurse's note dated 8/19/2026 at 3:14 PM, revealed .This nurse was made aware that resident [#1] was chocking [choking] on lunch. Resident is now Pureed and honey thick diet at this time. Resident is sitting 90 degrees up in bed with call light within reach. Will continue to monitor for aspiration precautions.Author: LPN E. Review of the Nurse's Note dated 8/19/2026 at 3:16 PM, revealed .Vitals noted 109/67 76, 18RR [respirations], 97.8temp [temperature], 94%RA [room air] No signs of distress noted at this time. Resident [#1] is sitting up in bed with eyes open and using non verbal ques shaking head no RT [related to] no pain. Call light within reach.Author: LPN E. Review of the SBAR (Situation, Background, Assessment, and Recommendations) Summary for Providers dated 8/19/2026 at 6:11 PM, revealed .At the time of evaluation resident/patient [#1] vital.Pulse Oximetry: O2 96.0 % .8/19/2026 02:20 [2:20 AM].Method: Room Air.Nursing observations, evaluation, and recommendations are: resident is not acting the same. not responding to people in the room.Recommendations: send to ED [emergency department].Author: LPN D. Review of the Nurse's Note dated 8/19/2026 at 7:06 PM, revealed .resident [#1] sent to ED for alerted mental status. and signs of aspiration. when ems [(EMS) - emergency medical services] arived [arrived] resident v/s [vital signs] are bp [blood pressure] 138/90 p [pulse] 120 r [respiration] 20 02 [oxygen sat] 51[51 percent] [normal oxygen saturation is 95%-100%] son was notified.Author: LPN D. Review of the Speech Therapy Medicare evaluation and Plan of Treatment documentation for Resident #1 dated 8/19/2026, revealed .order on admission: IDDSI: Foods/solids = [equals] Minced + [and] Moist Foods.Laryngeal/Pharyngeal Function Indicators.Reflexive Cough = Breathy, Other (weak cough); Volitional [an action done by conscious choice] Throat Clear = Not Elicited; Volitional Cough = Not Elicited.Clinical Bedside Assessment of Swallowing.Swallowing Abilities = Mod.Solids Assessed.IDDSI: Foods/Solids Assessed = Soft + Bite-Sized Foods.Pureed Foods.IDDSI: Clinical S/S [signs and symptoms] Dysphagia.[Named University] Swallow Protocol [a screening tool designed to identify aspiration risk] attempted. Fail with pt [patient] unable to follow directions to complete consecutive sips to finish assessment with throat clear observed, indicating aspiration risk. S/sx of airway compromise observed on approx. 75% of thin liquid trials, with no overt difference observed between cups vs [versus] straw sips.IDDSI Soft & [and] Bite Sized foods. Pt completed trials of mech soft with weak cough or throat clear observed on approx. 70% of trials. Perseverative mastication [prolonged chewing] noted throughout with and without bolus [food or substance] present in oral cavity. Moderate residue on medial [toward the center] tongue following majority of bites. Pt [Resident #1] unable to follow cue for volitional reswallow to clear bolus. SLP-administered liquid rinse cleared residue on approx. 40 % of attempts with moderate residue remining on 60% of trials. Significantly prolonged oral transit time with mech soft textures. Nursing/OT [occupational therapy] reported concerns for safety at meal requiring suction to prevent choking. Pt appears unable to safely manage mech [mechanical] soft diet at this time.IDDSI: Pureed Foods. Moderate.Puree side trials completed at meal with improved oral transit time as compared to mech soft trials and decreased residue. Cough/throat clear observed with approx. 70% of puree trials. Perseverative mastication noted with and following swallow of this texture as well. FOIS [functional oral intake scale] Level 4 [indicates a patient relies on a total diet of a single consistency].Current LRD [least restrictive diet] appears to be puree w/thin as safety concerns remain for mastication, bolus management, and clearance of mech soft textures .Assessment Summary.Clinical Impressions: very severe cognitive decline with dementia at baseline. Pt with decreased ability to communicate wants and needs at this time.Recommendations.Thin Drinks.IDDSI diet(s) recommended for patient to achieve optimal nutrition and swallow safety= Puree Foods.Supervision for Oral Intake= Close supervision. Review of the Nurse's Note dated 8/20/2026 at 7:50 AM, revealed .Resident [#1] is currently in ICU [intensive care unit], intubated [life-saving process where a breathing tube is inserted into a person's windpipe] and suctioning food out of residents mouth. Will call back for another follow up.Author: LPN E. 6. Review of (Named Hospital) Case Management Packets, dated 8/20/2026 at 2:40 PM, revealed .History and Physical 8/19/2026 22:20:59 [10:20 PM and 59 seconds] Chief Complaint.from [Named Facility], staff called for AMS [altered mental status] since 1500 [3:00 PM.] On EMS [Emergency Medical Services] arrival, pt [patient] oxygen saturation in 50's on room air.duoneb [breathing treatment] and tachycardic [elevated heart rate] in 150's.who presents to the ER [Emergency Room] from via [by way of] EMS for acute hypoxic [the body is not getting enough oxygen] respiratory failure. [Named Nursing Facility] skilled nursing facility contacted EMS due to altered mental status. When EMS arrived patient was reported to have severe hypoxemia [body does not have enough oxygen] with sats [saturations] in the 50's. He was given [named breathing treatment] and [in] route. It is noted that he reportedly has nausea and vomiting and [in] route as well. He was intubated in the emergency room. Imaging concerning for aspiration pneumonia with right side opacities [cloudy, hazy, or white spots that appear on an imaging scan where the area should normally look clear or dark]. ICU [Intens

Based on facility policy review, medical record review, observation, and interview, the facility failed to provide care and services to maintain an indwelling urinary catheter when nursing staff failed to follow physician's orders, provide care and services, care plan, and accurately code the Minimum Data Set (MDS) assessment for an indwelling urinary catheter for 1 of 2 (Resident #3) sampled residents reviewed for the use of an indwelling urinary catheters. The findings include: 1. Review of the undated facility policy titled, Indwelling Urinary Catheter, revealed .An indwelling urinary catheter shall be utilized only when a resident's clinical condition demonstrates that catheterization was necessary.Foley catheter is a flexible tube that passes through the urethra and into the bladder to drain urine.Who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary.Pertinent diagnoses.The use of an indwelling urinary catheter shall be in accordance with physician orders.shall include the diagnosis.size of the catheter, and frequency of change (if applicable).Indwelling urinary catheters.shall be utilized in accordance with current standards of practice, with interventions to prevent complications to the extent possible.The plan of care shall address the use of an indwelling urinary catheter, including strategies to prevent complications. Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, revealed .A comprehensive, person-centered care plan.to meet the resident's physical.needs is developed and implemented for each resident.The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.The comprehensive, person-center care plan.includes.which professional services are responsible for each element of care.reflects currently recognized standards of practice for problem areas and conditions.Services provided for or arranged by the facility and outlined in the comprehensive care plan are.provided by qualified persons.The interdisciplinary team reviews and updates the care plan.at least quarterly, in conjunction with the required quarterly MDS assessment. Review of the facility policy titled, Catheter Care, Urinary, dated 8/2022, revealed .The purpose of this procedure is to prevent urinary catheter-associated complication, including urinary tract infections.Review the resident's care plan to assess for any special needs of the resident.Review and document the clinical indications for catheter use prior to inserting.Nursing and the interdisciplinary team should assess and document the ongoing need for a catheter that is in place.Remove the catheter as soon as it is no longer needed.The following information should be recorded in the resident's medical record.The date and time that catheter care was given. 2. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE], with diagnoses including, Chronic Kidney Disease, Renal Dialysis, and Heart Failure. Review of the Physicians Order dated 2/9/2026, revealed .Insert Catheter after patient voids and Begin collection at 530am [5:30 AM] on Monday morning .end collection at 530am [5:30 AM] Tuesday morning.one time only for Dialysis Request 24 Hr [hour] Urine Collection for 1 Day. Review of the medical record revealed no documentation that the indwelling urinary catheter was discontinued on 2/10/2026 at 5:30 AM per physician orders. Review of the Physicians Order dated 3/27/2026, revealed .Document foley output q [every] shift. indicating the indwelling urinary catheter remained in place and was not discontinued on 2/10/2026. Review of an electronic medical administration (eMar) not dated at 3/31/2026 at 6:14 revealed, .Document foley output q shift.every shift for monitor output. Review an eMar dated 4/8/2026 at 20:08 revealed, .Document foley output q shift every shift for monitor output f/c emptied already. Review of the quarterly MDS assessment dated [DATE], revealed Resident #3 scored a 12 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was moderately cognitively impaired, no use of an indwelling catheter and always incontinent of bowel and bladder. Review of the Physicians Order dated 7/7/2026, revealed .Change foley catheter for leaking and discomfort. Review of and Alert Charting Note dated 7/7/2026 at 14:45 revealed, .Changed catheter, with 16 french, 30 ml [milliliter] water, tolerated well, no c/o pain or discomfort. Review of the Care Plan dated 7/8/2026, revealed, .Bladder Incontinence: Resident has intermittent incontinence.Revision on.3/2/2026. and no indication for the care and use of an indwelling urinary catheter. The facility failed to follow and provide orders for Resident #3 related to the monitoring and care for the use of an indwelling urinary catheter and failed to assess for the use of an indwelling urinary catheter for Resident #3. Observation in Resident #3's room on 7/13/2026 at 10:26 AM and at 2:45 PM, revealed an indwelling urinary catheter hanging on the bed frame, below bladder with a privacy bag. Observation in Resident #3's room on 7/14/2026 at 7:34 AM and at 10:46 AM, revealed an indwelling urinary catheter hanging on the bed frame, below bladder with a privacy bag. During an interview on 7/14/2026 at 4:06 PM, the Director of Nursing (DON) was asked if he was aware Resident #3 had an indwelling catheter. The DON stated, Yes. The DON was asked if there were any orders for Resident #3 related to indwelling catheter care. The DON stated, .I can't find any.they may have fell off [ the orders] but I'm not sure. The DON was asked who is responsible for making sure orders for residents were entered and correct. The DON stated, .the nurse and myself. The DON was asked if Resident #3 was care planned for an indwelling catheter and if she should be. The DON stated, I don't see anything and yes she should be. The DON was asked if the MDS assessment should reflect if Resident #3 had an indwelling catheter. The DON stated, Yes. The DON was asked should Resident #3 have orders, been care planned, and the MDS assessment reflect she had an indwelling catheter. The DON stated, Yes. During an interview on 7/14/2026 at 4:18 PM, MDS Coordinator A and MDS Coordinator B were asked if Resident #3's care plan and MDS assessment should reflect Resident #3 had an indwelling catheter. MDS Coordinator A stated, Yes, we are guilty, it is not on there . During an interview on 7/15/2026 at 7:58 AM, the DON was asked to review the initial order dated 2/9/2026, related to indwelling catheter, and if according to the order the indwelling catheter should have been removed after the 24 hours urine collection. The DON stated, .Looks like it should have been.it was her preference to keep it in because of her wounds. The DON was asked if there should have been an order placed to continue the indwelling catheter and orders for monitoring and care for the indwelling catheter. The DON stated, Yes.

Based on facility daily staffing posting sheets, observation, and interview, the facility failed to ensure posted staffing information was accurate for 33 of 36 days (6/11/2026, 6/12/2026, 6/13/2026, 6/14/2026, 6/15/2026, 6/16/2026, 6/17/2026, 6/18/2026, 6/19/2026, 6/20/2026, 6/21/2026, 6/22/2026, 6/23/2026, 6/24/2026, 6/25/2026, 6/26/2026, 6/27/2026, 6/28/2026, 6/29/2026, 6/30/2026, 7/3/2026, 7/4/2026, 7/5/2026, 7/6/2026, 7/7/2026, 7/8/2026, 7/9/2026, 7/10/2026, 7/11/2026, 7/12/2026, 7/13/2026, and 7/14/2026, and 7/15/2026) reviewed for staffing. The findings include: Review of the facility's Daily Staffing Posting sheets dated 6/11/2026, 6/12/2026, 6/13/2026, 6/14/2026, 6/15/2026, 6/16,2026, 6/17/2026, 6/18/2026, 6/19/2026, 6/20/2026, 6/21/2026, 6/22,2026, 6/23,2026, 6,24,2026, 6/25/2026, 6/26/2026, 6/27/2026, 6/28/2026, 6/29/2026, and 6/30/2026, revealed the facility failed to document the number of Registered Nurses (RN) and total number of RN hours. Review of the facility's Daily Staffing Posting sheets dated 7/3/2026, 7/4/2026, 7/5/2026, 7/6/2026, 7/7/2026, 7/8/2026, 7/9/2026, 7/10/2026, 7/11/2026, 7/12/2026, 7/13/2026, 7/14/2026, and 7/15/2026, revealed the facility failed to document the number of RNs and total number of RN hours. Observation at the front entrance desk on 7/13/2026 at 5:30 PM, revealed the Daily Staffing Posting sheet dated 7/13/2026 was blank for total RNs and total RN hours. During an interview on 7/15/2026 at 5:17 PM, the Regional Director of Quality Assurance and Monitoring was asked for a daily staff posting policy. The Regional Director of Quality Assurance and Monitoring stated, We do not have a posting policy. We use federal and state regulations. Observation and interview at the front entrance desk on 7/15/2026 at 6:16 PM, revealed the Daily Staffing Posting dated 7/15/2026 was blank for total RNs and total RN hours. The Director of Staff Development was asked who is responsible for daily staff postings. The Director of Staff Development stated, The staff postings are my responsibility. The corrections should be made by me for each shift. The Director of Staff Development was asked to explain the 7/15/2026 daily staff posting sheet. The Director of Staff Development confirmed no corrections had been made. The Director of Staff Development was asked if there was an RN currently working. The Director of Staff Development stated, Yes. The facility failed to ensure daily staff posting sheets were accurately completed for shift 7AM to 7PM on 7/15/2026 to reflect the number of RNs on duty. During an interview on 7/15/2026 at 6:29 PM, the Regional Director of Quality Assurance and Monitoring was asked to explain the facility's Daily Staff Posting sheets. The Regional Director of Quality Assurance and Monitoring stated, The projections for staff postings was posted. I asked [named Director Staff Development] why she did not correct the daily staff posting and she [Director of Staff Development] said she [Director of Staff Development] thought it was enough information She [Director of Staff Development] should check the number of staff and correct the daily staff posting with actual number of staff and actual hours of staff per shift. The Regional Director of Quality Assurance and Monitoring confirmed RN hours should not be blank on the Daily Staff Posting sheets and that the Daily Staff Posting sheets dated 6/11/2026, 6/12/2026, 6/13/2026, 6/14/2026, 6/15/2026, 6/16/2026, 6/17/2026, 6/18/2026, 6/19/2026, 6/20/2026, 6/21/2026, 6/22/2026, 6/23/2026, 6/24/2026, 6/25/2026, 6/26/2026, 6/27/2026, 6/28/2026, 6/29/2026, 6/30/2026, 7/3/2026, 7/4/2026, 7/5/2026, 7/6/2026, 7/7/2026, 7/8/2026, 7/9/2026, 7/10/2026, 7/11/2026, 7/12/2026, 7/13/2026, and 7/14/2026 were not accurately completed to reflect the number of RNs working and total number of RN hours.

Based on the facility policy review, medical record review, observations, and interview, the facility failed to ensure infection control practices to prevent the spread of communicable diseases during medication administration when 1 of 4 staff (Licensed Practical Nurse (LPN) C) failed to use personal protective equipment (PPE) for 2 of 2 (Resident #57 and Resident #127) sampled residents reviewed for enhanced barrier precautions (EBP). The findings include: 1. Review of the facility policy titled, Enhanced Barrier Precautions, dated December 2024, revealed .Enhanced barrier precautions (EBP) are utilized to reduce the transmission of multi-drug resistant organisms (MDRO) to residents.during high contact resident care activities.EBP apply when.a resident is not known to be infected or colonized with any MDRO, has a wound or indwelling medical devices.Indwelling medical devices include central lines, urinary catheters, feeding tubes, and tracheotomies.EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities.Gloves and gown are applied prior to performing the high contact resident care.Personal protective equipment (PPE) is changed before caring for another resident.Examples of high contact resident care activities requiring the use gown and gloves.device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator.EBP are in place for.discontinuation of the indwelling medical device.Staff are trained prior to caring for residents on EBPs.Signs are posted on the door or wall outside the resident's rooms which communicate the type of precautions and PPE required.PPE and alcohol-based hand-rub are readily accessible to staff . Review of the facility policy titled, Administering Medications, dated April 2019, revealed .Staff follows established facility infection control procedures .handwashing, antiseptic technique, gloves, isolation precautions .for the administration of medications. Review of the facility policy titled, Administering Medications through an Enteral Tube [a method of delivering liquid nutrition directly into the stomach], dated November 2018, revealed .equipment and supplies.necessary.Personal Protective equipment .gowns, gloves, mask. 2. Review of the medical record revealed Resident #57 was admitted to the facility on [DATE], with diagnoses including Malnutrition, Spastic Quadriplegic Cerebral Palsy, and Gastro-Esophageal Reflux Disease. Review of the Physician Order dated 1/23/2025, revealed .Enhanced barrier precautions every shift for Enteral Feeding. Review of the Physician's Order dated 4/7/2026, revealed the following medications may be administered (by way of) gastrostomy tube (G-Tube, plastic tube inserted into the stomach to deliver food, medications and water): a. Baclofen Tablet 20 MG (milligrams). Give 1 tablet via G-Tube three times a day for spastic quadriplegic cerebral palsy b. Gas Relief Oral Tablet Chewable (Simethicone) Give 250 milligram via (by way of) PEG-Tube three times a day for gas Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #57 was unable to complete the Brief Interview for Mental Status (BIMS) assessment, which indicated she was severely cognitively impaired. Observation during medication administration outside of Resident #57's room on 7/15/2026 at 12:18 PM, revealed LPN C knocked and entered the room, washed her hands in resident's bathroom and filled 1 cup with water before returning to the medication cart to gather her supplies. LPN C laid paper towel barrier on top of cart, removed a Baclofen 20mg tablet placed into a plastic sleeve, crushed the medication and then placed the bag into a plastic cup. LPN C removed a Gas Relief chewable tablet 250mg placed into a plastic sleeve, crushed and put the plastic sleeve into a medication cup. After all meds were ready she locked the cart, entered the room, and explained the process to Resident #57. LPN C washed her hands, put on gloves, paused and unhooked the enteral feeding, removed the syringe from the plastic bag, and checked placement and residual, and flushed the g-tube with 30 ml (milliliters) of water. LPN C administered each medication flushing with 15ml of water after each medication. LPN reconnected the enteral feeding, entered the bathroom and rinsed the syringe before placing back into the plastic bag, disposed of her trash, removed her gloves and placed into the trash can, washed her hands and exited the room. During an interview on 7/15/2026 at 12:30 PM, LPN C was asked what she should have done since the resident was in Enhanced Barrier Precautions. LPN C stated, I forgot to put a gown on. 3. Review of the medical record revealed Resident #127 was admitted to the facility on [DATE], with diagnoses including Metabolic Encephalopathy, Infection and Inflammatory Reaction due to Internal Right Knee Prosthesis, and Local Infection of the Skin and Subcutaneous Tissue. Review of the admission MDS assessment dated [DATE], revealed Resident #127 scored a 15 on the BIMS assessment, which indicated she was cognitively intact. Review of the Physician Order dated 7/8/2026, revealed Enhanced barrier precautions related to wound. Review of the Physician Order dated 7/8/2026, revealed Cefepime (antibiotic used for infections) HCl (hydrochlorothiazide (powder medication mixed with normal saline [ns] to treat an infection) Intravenous (IV) Solution 1 GM (gram)/50ML (Cefepime HCl) Use 1 gram intravenously every 6 hours for Knee Joint Infection for 6 Weeks. 0.9% ns, instilled into Cefepime vial attached to ns bag from pharmacy and mixed to reconstitute. Observation during medication administration outside of Resident #127's room on 7/15/2026 at 12:00 PM, revealed LPN C gathered her supplies to administer the following medication of Cefepime HCI 1 GM/50mL via intravenous (within or entering by way of a vein (IV)) to Resident #127. LPN C knocked and entered Resident #127's room, verified who the resident was and explained the process, washed her hands, donned gloves, and 0.9% Normal Saline bag was connected to the Cefepime HCL 1gm vial from pharmacy and mixed together, connected the IV tubing, cleared the line of any air, labeled and dated the medication, washed her hands and donned clean gloves, and placed the medication on the IV pole. LPN C cleansed the midline IV access site to the right upper extremity with an alcohol prep, flushed the site with 10ml of normal saline, and attached the IV tubing. LPN C set the rate to be administered at 100ml/hour, removed her gloves and disposed of trash in the trash can, documented the medication administration, and washed her hands. LPN C failed to don a gown in the EBP room when administering the medication through an IV line. During an interview on 7/15/2026 at 12:30 PM, LPN C was asked what she should have done since the resident was in Enhanced Barrier Precautions. LPN C stated, I forgot to put a gown on. During an interview on 7/15/2026 at 3:38 PM, the Director of Nursing (DON) was asked, should nurses administering IV medications or medications in a Gastrotomy tube wear a gown. The DON stated, Yes.

Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared and served under sanitary conditions as evidenced by opened and undated food items, staff wearing mask below their nose, and staff handling plates with their bare hands. The facility had a census of 95, with 92 of those residents receiving a meal tray from the kitchen. The findings include: The facility's policy titled, Dietary: Food Service, dated 7/12/2021, revealed .Opened food items . should be stored in a closed container to prevent contamination . Observation in the Kitchen on 5/2/2022 beginning at 10:29 AM, revealed the following: a. a plastic container with cornmeal unlabeled and undated b. a plastic container with flour unlabeled and undated c. a plastic container with sugar unlabeled and undated Observation in the Kitchen on 5/3/2022 beginning at 7:57 AM, revealed the following: a. The Regional Registered Dietician standing in the Kitchen talking with the Surveyor without her mask on. b. The Regional Director of Nutritional Services walking from the back of the Kitchen with her mask below her nose c. The Cook standing over the steam table serving breakfast with her mask below her nose d. A dietary staff member standing over the tray line assisting with breakfast with her mask below her nose Observation in the Kitchen in the Dry Food Storage room on 5/3/2022 beginning at 7:57 AM, revealed the following: a. 1 pack of taco seasoning opened and undated and not repackaged in a plastic bag b. 6 dinner rolls on a bread rack in the dry food storage room opened and undated and not repacked in a plastic bag During an interview on 5/4/2022 at 11:03 AM, the Regional Director of Nutrition was asked how should dietary staff wear their mask while in the Kitchen. The Regional Director of Nutrition confirmed that mask should cover the mouth and nose at all times. The Regional Director of Nutrition was asked how should the dinner rolls and taco seasoning have been stored once they were opened. The Regional Director of Nutrition confirmed once an item is opened, it should be repackaged in a plastic bag and dated. Observation in the Kitchen on 5/4/2022 beginning at 11:26 AM, revealed Dietary Staff #2 walked out of the dish room and walked over to the plate caddy, pushed down the plates with her bare hands, walked back into the dish room, returned with a stack of clean plates and placed a few of them in the plate caddy, pushed the existing plates down with her bare hands and placed another stack of clean plates in the plate caddy for 2 repetitions. In between each repetition, she used her bare hands to push the plates down into the plate caddy. During an interview on 5/4/2022 at 3:34 PM, the Kitchen Supervisor confirmed that staff should transport plates using the sides of the plates or placing their hands underneath the plates or they should use gloves.

Based on policy review, medical record review, and interview, the facility failed to ensure investigations, neurological (neuro) checks, and assessments were completed for 3 of 3 sampled residents (Resident #11, #28, and #248) reviewed for falls. The findings include: Review of the facility's policy titled, Fall Risk - Fall Prevention, revised on 2/20/2020, revealed .To provide a coordinated system to identify Residents at risk for falls .The fall risk assessment will be completed by a licensed nurse .After a fall . Review of the medical record, revealed Resident #11 was admitted on [DATE] with diagnoses of [CONDITION(S)], [CONDITION(S)], Heart Disease, and [CONDITION(S)]. Review of the Clinical Note dated 1/11/2022, revealed .CNA [Certified Nursing Assistant] discovered resident [Resident #11]on floor. Resident noted to be sitting up on floor next to bed. When asked resident stated she wasn't sure what happened . Review of the annual Minimal Data Set (MDS) assessment dated [DATE], revealed Resident #11 had a Brief Interview for Mental Status score (BIMS) of 6, indicating she was severely cognitively impaired, required extensive assistance with Activities of Daily Living (ADLs) including transfers, and had 1 fall with injury since the last assessment. Review of the Clinical Note dated 3/8/2022, revealed .Resident [Resident #11] notified MDS nurse that she had fallen in bathroom in AM [morning] and not notified staff and self transferred back in to chair . The facility was unable to provide neuro checks for the fall on 1/11/2022 and 3/8/2022. Review of the medical record, revealed Resident #28 was admitted to the facility on [DATE] with diagnoses of Dementia, Muscle Weakness, Dizziness and Giddiness, History of Falling, and Unsteadiness on Feet. Review of the Clinical Notes Report dated 3/2/2022, revealed .upon entering resident's [Resident #28's] room she was observed on the floor .resident states .slipped fell .hitting her head . Review of the facility's Neurological Check Flow Sheet, revealed there was no documentation that neurochecks were completed for Resident #28 after the fall on 3/2/2022. During an interview on 5/4/2022 at 2:50 PM, Assistant Director of Nursing (ADON) #2 confirmed staff should conduct neuro checks after an unwitnessed fall, if the resident had a BIMS of less than 12, or is unable to tell staff if they hit their head or not. Review of the medical record, revealed Resident #248 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses of Above the Knee Amputation of Left Leg, Dyspnea, [CONDITION(S)], Repeated Falls, and Depression. Review of the Clinical Notes dated 2/3/2022, revealed .At 0500 [5:00 AM] .observed to be calling out for help. upon entrance resident [Resident #248] was noted to be sitting on floor bedside .resident stated he slid off bed trying to stand up . Review of the 5-day MDS assessment dated [DATE], revealed Resident #248 had a BIMS score of 10, indicating moderate cognitive impairment, required assistance with transfers, and had 1 fall since admission. The facility was unable to provide an event note, a fall risk assessment, or an investigation related to Resident #248's fall on 2/3/2022. During an interview on 5/4/2022 at 11:25 AM, the Director of Nursing confirmed staff should complete an event note and a fall risk assessment following a fall and that all falls should be investigated.

Based on policy review, medical record review, and interview, the facility failed to ensure the completion of a Discharge Summary with a recapitulation of the resident's stay, the disposition status of the resident at the time of discharge, a post discharge plan of care, and a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Review of the facility's policy titled, Transfer and Discharge, revised on 11/2021, revealed .Orientation for transfer or discharge must be provided and documented to ensure safe and orderly transfer or discharge from the facility .Other necessary information, including a copy of the resident's discharge summary .to ensure a safe and effective transition of care .Obtain physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .A member of the interdisciplinary team completes relevant sections of the Discharge Summary. The nurse caring for the resident at the time of discharge is responsible for ensuring the Discharge Summary is complete . Review of the medical record, revealed Resident #98 was admitted to the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Treatment/Order Update/Change in Condition dated 2/15/2022, revealed .Transfer to Hospital 1 Time Daily for 1 Day .Transfer to ER [emergency room ] via [by] 911 for eval [evaluation] and treatment . Review of the Discharge summary completed on 5/3/2022, revealed Resident #98 was discharged to the hospital on 2/15/2022. Resident #98 did not return from the hospital. The facility was unable to provide a completed Discharge Summary and a transfer form for Resident #98. During an interview on 5/4/2022 at 10:58 AM, Assistant Director of Nursing (ADON) #1 confirmed that the transfer form and the discharge form should be completed timely. ADON #1 confirmed the forms were not completed until 5/3/2022. Review of the medical record, revealed Resident #100 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Clinical Notes Report dated 3/1/2022, revealed .pt's [patient's (Resident #100's)] spouse decided to transport her [Resident #100] home today . Review of the medical record, revealed the facility failed to complete a Discharge Summary with a recapitulation of the resident's stay and failed to obtain a written physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the medical record, revealed Resident #251 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Telephone Order dated 3/24/2022, revealed .Discharge 3/24/2022 . Review of a Clinical Notes Report dated 3/24/2022 revealed, .Pt's [Resident #251's] family plan on pt [patient] discharging home today . Review of the medical record, revealed the facility failed to complete a Discharge Summary with a recapitulation of the resident's stay. Review of the medical record, revealed Resident #252 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Telephone Order dated 3/25/2022 revealed .Patient to discharge home on 03/25/2022 . Review of a Clinical Notes Report dated 3/25/2022 revealed .Pt [Resident #252] returned home today with her daughter . Review the facility's Discharge Instructions revealed the form was incomplete and undated. Review of the medical record, revealed the facility failed to complete a Discharge Summary with a recapitulation of the resident's stay. During an interview on 5/4/2022 at 6:28 PM, the Director of Nursing (DON) was asked what was the process when a resident was discharged home or back to the community. The DON confirmed staff should obtain a written physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on medical record review, observation, and interview, the facility failed to ensure a resident was assisted with Activities of Daily Living (ADLs) for 1 of 1 sampled resident (Resident #8) reviewed for ADLs. The findings include: Review of medical record, revealed Resident #8 was admitted to facility on 10/15/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan dated 1/28/2022, revealed .Self care deficit .bathing .hygiene .bathing 3 times per week .Assist resident with dressing .Assist with hygiene .Assist with combing/fixing hair . Review of quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated he was moderately cognitively impaired, required extensive to total assistance from staff for ADLs except supervision for eating, and was totally dependent upon staff for bathing. Review of the ADL Verification Worksheet dated 3/1/2022 to 5/3/2022, revealed Resident #8 did not receive showers or bed baths from 3/2/2022 to 3/11/2022 and from 4/22/2022 to 4/30/2022. Observation in the hallway on 5/2/2022 at 10:47 AM, and on 5/3/2022 at 4:49 PM, revealed Resident #8 was in a wheelchair, face unshaved, wearing soiled blue shorts, and green sweatshirt with a dried, crusted, tan substance on the front of the shorts and shirt. Observation in resident's room on 5/3/2022 at 9:15 AM, revealed Resident #8 dressed wearing soiled blue shorts, and green sweatshirt with a dried, crusted, tan substance on the front of the shorts and shirt, his face was unshaved, and his hair was not combed. Observation in the resident's on 5/4/2022 at 7:45 AM, revealed Resident #8 lying in the bed wearing a green sweatshirt with a dried, crusted, tan substance on the front of the shirt. During an interview on 5/4/2022 at 3:25 PM, Certified Nursing Assistant (CNA) #3 confirmed the residents are showered or bathed every other day and clothes should be changed daily. During an interview on 5/4/2022 at 6:31 PM, the Director of Nursing confirmed residents should receive a bath or shower twice a week, should not wear the same clothes for three days, and their clothes should be changed if they are visibly soiled.

Based on policy review, medical record review, and interview, the facility failed to revise the Care Plan to reflect the residents' current status for 2 of 2 sampled residents (Resident #11 and #28) reviewed for falls. The findings include: Review of the facility's policy titled, Fall Risk- Fall Prevention, revised on 2/20/2020, revealed .An 'At Risk For Fall' care plan may need to be created or updated for Residents .after a fall .quarterly .to address items identified on the fall risk assessment as needed .Scheduling IDT [Interdisciplinary Team] care plan meetings to review the plan of care and include the Resident's risk for falls and current interventions to reduce/eliminate falls . Review of the medical record, revealed Resident #11 was admitted to the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan dated 1/2/2022, revealed Resident #11 was at risk for falls related to [CONDITION(S)] with [CONDITION(S)] and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Clinical Note dated 1/11/2022, revealed .CNA [Certified Nursing Assistant] discovered resident [Resident #11 on floor. Resident noted to be sitting up on floor next to bed. When asked resident stated she wasn't sure what happened . Review of annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #11 had a Brief Interview for Mental Status (BIMS) of 6, indicating she was moderately cognitively impaired. Review of the Clinical Note dated 3/8/2022, revealed .Resident [Resident #11] notified MDS nurse that she had fallen in bathroom in AM [morning] and not notified staff and self transferred back in to chair . Review of the Care Plan, revealed the Care Plan was not updated after Resident #11's fall. Review of the medical record, revealed Resident #28 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS assessment dated [DATE], revealed Resident #28 had a BIMS score of 9, which indicated she was moderately cognitively impaired. Review of the Clinical Notes Report dated 3/2/2022, revealed .upon entering resident's [Resident #28's] room she was observed on the floor .resident states .slipped fell .hitting her head . Review of the Care plan dated 3/4/2022, revealed Resident #28 was at risk for falls related to a history of falls and the Care Plan was not updated after Resident #28's fall on 3/2/2022. During an interview on 5/4/2022 at 2:50 PM, Assistant Director of Nursing #2 confirmed that Care Plans should be updated after each fall.

Based on medical record review and interview, the facility failed to ensure 2 of 19 sampled residents (Resident #93 and #148) or their families were invited to participate in planning their care. The findings include: Review of the medical record, revealed Resident #93 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #93 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. Review of the medical record, revealed Resident #93's last Care Plan meeting was held on 4/29/2021. Review of the medical record, revealed Resident #148 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE], revealed Resident #148 had a BIMS score of 12, which indicated she had moderate cognitive impairment. Review of the medical record, revealed Resident #148's last Care Plan meeting was held on 12/23/2020. During an interview on 5/3/2022 at 6:04 PM, the Interim Administrator confirmed Resident #93 and #148 had not had quarterly Care Plan meetings and stated, .don't know why it got dropped . During an interview on 5/4/2022 at 8:14 AM, the Social Worker confirmed Resident #93's last Care Plan meeting was on 4/29/2021 and Resident #148's last Care Plan Meeting was on 12/23/2020. The Social Worker confirmed Care Plan meetings should be quarterly.

Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored in 2 of 95 resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) when medications were found at the bedside unattended and unsecured during the facility tour. The findings include: Review of the facility's policy titled, Medication Administration: Medication, Controlled and Biological Storage, Night/Emergency Box and Backup Pharmacy, dated 9/20/2021, revealed .All drugs and biologicals will be stored in locked compartments ( .medication carts, cabinets, drawers, refrigerators, medication rooms) . Observation in room [ROOM NUMBER] during the facility tour on 5/2/2022 beginning at 11:50 AM, revealed the following medications on the night stand unattended and unsecured: a. 5 packages of peri guard ointment [moisture barrier ointment to prevent skin breakdown] on the nightstand b. 3 normal saline sodium flushes [irrigation used for cleaning wounds] c. 5 [MEDICATION(S)] suppositories [medicated suppository used for constipation] d. 4 lubricating jelly packets Observation in room [ROOM NUMBER] during the facility tour on 5/2/2022 at 12:15 PM and 3:12 PM, revealed a [MEDICATION(S)] [MEDICATION(S)] Inhaler [inhaler used for chronic lung problems] on the over bed table unattended and unsecured. Observation in room [ROOM NUMBER] on 5/2/2022 at 3:12 PM, revealed a [MEDICATION(S)] [MEDICATION(S)] Inhaler on the over bed table. During an interview on 5/3/2022 at 5:21 PM, the Director of Nursing confirmed that the medications should have been locked in the medication cart or in the medication room and should not have been left in a resident's room unattended and unsecured.

Based on medical record review, observation, and interview, the facility failed to follow the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Review of the medical record, revealed Resident #8 was admitted to facility on 10/15/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated he was moderately cognitively impaired and he received oxygen therapy. Observation in the Dining Room on 5/2/2022 at 11:32 AM, revealed Resident #8 was receiving oxygen per nasal cannula at 0 L/min. Observations in resident's room on 5/2/2022 at 2:55 PM, and on 5/3/2022 at 7:53 AM and 9:15 AM, revealed Resident #8 was receiving oxygen per nasal cannula at 3.5 L/min. Observation in hallway on 5/3/2022 at 10:19 AM and 2:55 PM, revealed Resident #8 was receiving oxygen per nasal cannula at 1.5 L/min. During an interview on 5/3/2022 at 5:01 PM, Licensed Practical Nurse (LPN) #2 confirmed Resident #8's oxygen rate should be 2 L/min. During an interview on 5/4/2022 at 6:31 PM, the Director of Nursing (DON) confirmed that staff should follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on policy review, medical record review, and interview, the facility failed to document meal percentages for 1 of 5 sampled residents (Resident #74) reviewed for nutrition. The findings include: Review of the facility's policy titled, Dietary: Weight Monitoring, revised on 11/9/2021, revealed .Documentation: Meal consumption information should be recorded . Review of the medical record, revealed Resident #74 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Activity of Daily Living (ADL) Verification Worksheet dated 3/1/2022- 5/4/2022 revealed the following meal intakes were not documented: a) 3/1/2022 no documentation for breakfast and dinner. b) 3/2/2022 no documentation for breakfast and lunch. c) 3/17/2022 no documentation for breakfast and lunch. d) 4/4/2022 no documentation for breakfast and lunch. e) 4/5/2022 no documentation for lunch and dinner. f) 4/10/2022 no documentation for dinner. g) 4/30/ no documentation for lunch and dinner. h) 5/2/2022 no documentation for dinner. No breakfast, lunch, or dinner meal percentages were recorded for the entire day on 3/4/2022-3/7/2022, 3/9/2022, 3/12/2022-3/16/2022, 3/18/2022-3/23/2022, 4/1/2022-4/3/2022, 4/7/2022, 4/9/2022, 4/11/2022-4/19/2022, 4/21/2022-4/29/2022, 5/1/2022, and 5/3/2022. During an interview on 5/4/2022 at 6:03 PM, Assistant Director of Nursing #2 confirmed the ADL Verification Worksheets were incomplete for Resident #74 and the meal percentages should have been documented for each meal.

Based on policy review, medical record review, and interview, the facility failed to provide Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Review of the facility's policy titled, Indwelling Urinary Catheter, revised on 3/30/2022, revealed .The use of an indwelling urinary catheter will be in accordance with physician orders, which will include the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record, revealed Resident #15 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan dated 8/24/2021, revealed Resident #15 was at risk for infection related to indwelling catheter and urinary retention. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Maintain indwelling catheter .Catheter site care .Change Foley Catheter . There was no order for the size of the catheter or frequency of the catheter change. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #15 had a Brief Interview for Mental Status (BIMS) of 15, indicating he was cognitively intact and had an indwelling urinary catheter. During an interview on 5/4/2022 at 10:39 AM, Assistant Director of Nursing (ADON) #1 confirmed Resident #15 should have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record, revealed Resident #46 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS assessment dated [DATE], revealed Resident #46 had a BIMS of 11, indicating she was moderately cognitively impaired and had an indwelling urinary catheter. Review of the Care Plan dated 4/6/2022, revealed Resident #46 was at risk for infection related to an indwelling catheter and urinary retention. There was not a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 5/4/2022 at 3:04 PM, ADON #2 confirmed Resident #46 should have an order for [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on policy review, medical record review, and interview, the facility failed to provide information regarding a resident's right to develop an Advance Directive for 4 of 19 sampled residents (Resident #28, #56, #66 and #91) reviewed for Advance Directives. The findings include: Review of the facility's policy titled, .Advance Directives ., revised on 10/18/2021, revealed .Resident will be informed, and written information provided, during the admission process, regarding the right to accept or refuse medical or surgical treatment . Review of the medical record, revealed Resident #28 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #28 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated she was moderately cognitively impaired. Review of Resident #28's medical record, revealed there was no Advance Directive present and there was no documentation the resident or her legal representative was informed or provided written information regarding her right to develop an Advance Directive upon admission. Review of the medical record, revealed Resident #56 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE], revealed Resident #56 had a BIMS score of 5, which indicated he was severely cognitively impaired. Review of Resident #56's medical record, revealed there was no Advance Directive present and there was no documentation the resident or his legal representative was informed or provided written information regarding his right to develop an Advance Directive upon admission. Review of the medical record, revealed Resident #66 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE], revealed Resident #66 had a BIMS score of 3, which indicated she was severely cognitively impaired. Review of Resident #66's medical record, revealed there was no Advance Directive present and there was no documentation the resident or her legal representative was informed or provided written information regarding her right to develop an Advance Directive upon admission. Review of the medical record, revealed Resident #91 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE], revealed Resident #91 had a BIMS score of 15, which indicated she was cognitively intact. Review of Resident #91's medical record, revealed there was no Advance Directive present and there was no documentation the resident or her legal representative was informed or provided written information regarding her right to develop an Advance Directive upon admission. During an interview on 5/3/2022 at 10:59 PM, the Admission Coordinator confirmed that Resident #28, #56, #66, and #91 did not have Advance Directives and there was no documentation the residents or legal representatives were informed or provided written information regarding their right to develop an Advance Directive upon admission.

Based on the Centers for Disease Control and Prevention (CDC) guidelines, agency daily time punches, and employee and vendor screening logs, the facility failed to properly prevent and/or contain COVID-19 when 53 of 82 agency staff members (Licensed Practical Nurse (LPN) #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, and #26, Certified Nurse Assistant (CNA) #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26 and #27) did not complete the screening log for COVID-19 prior to working on 7 of 7 days (9/26/2021 - 10/2/2021) reviewed. This could have affected the 96 residents residing in the facility. The finding include: Review of the Centers for Disease Control and Prevention (CDC) document titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 9/10/2021, revealed .Establish a process to identify anyone entering the facility, regardless of their vaccination status .so that they can be properly managed .Options could include .individual screening on arrival at the facility .before entering the facility. Review of the agency staff daily time punches and Employee and Vendor Screening Logs, revealed the following Agency employees worked on the following days and failed to screen for signs and symptoms of COVID-19: a. 9/26/2021 - LPN #1, #2, #3, #4, #5, #6, #7, CNA #1, #2, #3, #4, #5, #6, #7, and #8. b. 9/27/2021 - LPN #8, #9, #10, #11, #12, #13, #15, CNA #4, #5, #9, #10, #11, #12, #13, #14, #15, and #16. c. 9/28/2021 - LPN #8, #14, #15, #16, #17, #18, #19, #20, CNA #5, #9, #11, #13, #14, #17, #18, #19, and #20. d. 9/29/2021 - LPN #4, #8, #11, #12, #14, #15, #21, #22, CNA #4, #13, #14 #16, #20, #21, and #22. e. 9/30/2021 - LPN #4, #8, #11, #14, #19, #20, CNA #5, #10, #11, #12, #13, #14, #20, #21, and #23. f. 10/1/2021 - LPN #1, #6, #9, #11, #15, #23, #24, #25, CNA #2, #4, #11, #20, #24, and #25. g. 10/2/2021 - LPN #1, #6, #7, #9, #12, #26, CNA #5, #9, #11, #12, #19, #22, #26, and #27. During an interview on 10/14/2021 at 7:30 PM, the Administrator confirmed the dates of the screening logs that she had provided to the surveyors. The Administrator was asked if she would expect agency staff not to screen prior to working. The Administrator stated, No. The Administrator was asked if this was an effective screening tool for the agency staff. The Administrator stated, No, Ma'am.

Based on the Nursing Home Licensure Checklists and working schedules, the facility failed to schedule a Registered Nurse (RN) for at least 8 consecutive hours a day for 11 of 42 days (8/20/2021, 8/24/2021, 8/28/2021, 8/31/2021, 9/1/2021, 9/2/2021, 9/25/2021, 9/26/2021, 9/27/2021, 9/29/2021, 9/30/2021) reviewed. The facility had an average census of 42 during this time period. The findings include: Review of the Nursing Home Checklist and working schedules revealed there was not at least 8 consecutive hours a day of RN coverage on the following dates: a. 8/20/2021 b. 8/24/2021 c. 8/28/2021 d. 8/31/2021 e. 9/1/2021 f. 9/2/2021 g. 9/25/2021 h. 9/26/2021 i. 9/27/2021 j. 9/29/2021 k. 9/30/2021 During an interview on 10/14/2021 at 6:30 PM, the Administrator confirmed there was no RN coverage for the dates listed above. The Administrator stated, .we failed to schedule an RN on those dates .

Based on Centers for Disease Control (CDC) and Prevention guidelines, policy review, job description review, medical record review, observation, and interview, the facility failed to properly prevent the potential for COVID-19 when 5 of 5 staff members (Certified Nursing Assistant (CNA) #1, CNA #2, CNA #3, CNA #4, and Physical Therapist (PT) #1) failed to wear the appropriate Personal Protective Equipment (PPE), failed to perform hand hygiene, the facility failed to have isolation signage on the isolation room doors, the facility failed to have PPE available outside of the isolation rooms, and residents were not moved off of the New/Readmission Isolation Hall (100/200/300 Hall) after their 14 day quarantine period. The facility did not have COVID-19 in the facility but the potential of a possible COVID-19 outbreak could have affected the 33 residents residing in the New/Readmission Isolation Hall. The facility had a census of 81. The findings include: Review of the facility's policy titled, Transmission-Based Precautions, revised 2/2020, showed, .It is our policy to take appropriate precautions to prevent transmission of infectious agents .Droplet Precautions: d. Healthcare personnel wear a mask or a mask with a shield, gown and gloves for close contact with infectious resident . Review of the facility's policy titled, Hand Hygiene, revised 3/2020, showed, .Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .Hand hygiene is a general term that applies to either handwashing or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR) .Hand Hygiene Table: between resident contacts, after handling contaminated objects .before applying and after removing personal protective equipment (PPE), including gloves .before and after handling clean or soiled dressings, linens, etc .before and after providing care to residents in isolation . Review of the undated Charge Nurse-Licensed Practical Nurse (LPN) job description showed, .Essential Functions: Follow the established universal precautions and isolation procedures . Review of the CNA job description dated 4/27/2020, showed, .Job Requirements: Follow infectious disease precautions to prevent spread of infections . Review of the CDC and Prevention guideline titled, Coronavirus Disease 2019 (COVID-19) Responding to Coronavirus (COVID-19) in Nursing Homes updated 4/30/2020, showed .Considerations for new admissions or readmissions to the facility: .managing new admissions and readmissions whose COVID-19 status is unknown .all recommended COVID-19 PPE (personal protective equipment) should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e. goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown .a single negative test upon admission does not mean that the resident was not exposed or will not become infected in the future. Newly admitted or readmitted residents should still be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE . Review of the medical record, showed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's March 2021 physician's orders [REDACTED]. Observation of the 100 Hall on 3/9/2021 at 12:45 PM, showed the following: Resident #1's room with no isolation sign on the door and no PPE or isolation cart was outside of the room. Review of the medical record, showed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's physician's orders [REDACTED]. Observation of the 100 Hall on 3/9/2021 at 12:45 PM, showed the following: Resident #2's room with no isolation sign on the door and no gowns were in the isolation cart outside of the room. Review of the medical record, showed Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's physician's orders [REDACTED]. Observation of the 100 Hall on 3/9/2021 at 12:45 PM, showed the following: Resident #3's room with no isolation sign on the door and no PPE or isolation cart was outside of the room. Review of the medical record, showed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's physician's orders [REDACTED]. Observation of the 100 Hall on 3/9/2021 at 12:45 PM, showed the following: Resident #4's room with no isolation sign on the door and no PPE or isolation cart was outside of the room. Review of the medical record, showed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #5's March 2021 physician's orders [REDACTED].#5 was still in the 14-day quarantine period). Observation of the 100 Hall on 3/9/2021 at 12:45 PM, showed the following: Resident #5's room with no isolation sign on the door and no PPE or isolation cart was outside of the room. Review of the medical record, showed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #6's physician's orders [REDACTED]. Observation of the 200 Hall on 3/9/2021 at 12:00 PM, showed the following: Resident #6's room with no isolation sign on the door, and no gowns were in the isolation cart outside of the room. Review of the medical record, showed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #7's March 2021 physician's orders [REDACTED].#7 was still in the 14-day quarantine period) Review of the medical record, showed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #8's physician's orders [REDACTED]. Observation of the 200 Hall on 3/9/2021 at 12:00 PM, showed the following: Resident #8's room with no isolation sign on the door, and no gowns were in the isolation cart outside of the room. Observation in the resident's room on 3/9/2021 at 12:05 PM, showed CNA #2 entered Resident #8's isolation room without performing hand hygiene and did not don a gown and gloves. She set up Resident #8's lunch tray, exited room and did not perform hand hygiene. Review of the medical record, showed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #9's physician's orders [REDACTED].#9 was still in the 14-day quarantine period). Observation of the 200 Hall on 3/9/2021 at 12:00 PM, showed the following: Resident #9's room with no isolation sign on the door, and no PPE or isolation cart was outside of the room. Review of the medical record, showed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #10's physician's orders [REDACTED]. Observation of the 200 Hall on 3/9/2021 at 12:00 PM, showed the following: Resident #10's room with no isolation sign on the door and no PPE or isolation cart was outside of the room. Review of the medical record, showed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #11's physician's orders [REDACTED]. Observation of the 200 Hall on 3/9/2021 at 12:00 PM, showed the following: Resident #11's room with no isolation sign on the door, no gowns were in the isolation cart located outside in the hallway between Resident #11's room and room [ROOM NUMBER]. Observation in the resident's room on 3/9/2021 at 12:07 PM, showed CNA #1 enter entered Resident #11's isolation room without performing hand hygiene and did not don a gown and gloves. Observation in the resident's room on 3/10/2021 at 11:14 AM, showed CNA #3 entered Resident #11's isolation room with no gown or gloves, exited the room and did not perform hand hygiene. Observation in the resident's room on 3/10/2021 at 11:25 AM, showed CNA #4 was providing care to Resident #11. Resident #11 was in droplet isolation and CNA #4 did not don a gown while providing care. CNA #4 exited the room, removed her gloves and did not perform hand hygiene. Observation in the resident's room on 3/10/2021 at 11:25 AM, showed PT #1 was providing care to Resident #11. PT #1 did not don a gown and pushed the Hoyer lift out of the room into the hall. PT #1 returned to Resident #11's room and began to comb her hair. PT #1 did not don a gown and when she exited the isolation room, she did not perform hand hygiene after glove removal. Review of the medical record, showed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #12's physician's orders [REDACTED]. Observation of the 200 Hall on 3/9/2021 at 12:00 PM, showed the following: Resident #12's room with no isolation sign on the door and no PPE or isolation cart was outside the room. During an interview on 3/9/2021 at 12:00 PM, Registered Nurse (RN) #1 stated, .that resident (Resident #12) got here last night .they should be on droplet isolation. She confirmed there was no sign, no PPE, and no isolation cart outside of the room. Review of the medical record, showed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #13's physician's orders [REDACTED]. (Resident #13 was still in the 14-day quarantine period). Observation of the 200 Hall on 3/9/2021 at 12:00 PM, showed the following: Resident #13's room with no isolation sign on the door and no PPE or isolation cart was outside of the room. During an interview on 3/9/2021 at 12:00 PM, RN #1 stated, .new patient (named Resident #13) should be in droplet isolation . She confirmed there was no sign, no PPE, and no isolation cart outside of the room. Observation in the residents' rooms on 3/10/2021 at 11:14 AM, showed CNA #3 exited Resident #11's isolation room and entered Resident #13's isolation room without performing hand hygiene, did not don a gown or gloves, and exited the isolation room without performing hand hygiene. Review of the medical record, showed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #14's physician's orders [REDACTED]. Observation of the 300 Hall on 3/9/2021 at 12:35 PM, showed the following: Resident #14's room with no isolation sign on the door and no PPE or isolation carts were outside of the room. Review of the medical record, showed Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #15's physician's orders [REDACTED]. Observation of the 300 Hall on 3/9/2021 at 12:35 PM, showed the following: Resident #15's room with no isolation sign on the door and no PPE or isolation cart was outside of the room. Review of the medical record, showed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #16's physician's orders [REDACTED]. Observation of the 300 Hall on 3/9/2021 at 12:35 PM, showed the following: Resident #16's room with no isolation sign on the door and no PPE or isolation cart was outside of the room. Review of the medical record, showed Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #17's physician's orders [REDACTED]. Observation of the 300 Hall on 3/9/2021 at 12:35 PM, showed the following: Resident #17's room with no isolation sign on the door and no PPE or isolation cart was outside of the room. Review of the medical record, showed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #18's physician's orders [REDACTED]. Observation of the 300 Hall on 3/9/2021 at 12:35 PM, showed the following: Resident #18's room with no isolation sign on the door and no gowns were in the isolation cart outside of the room. Review of the medical record, showed Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #19's physician's orders [REDACTED]. Observation of the 300 Hall on 3/9/2021 at 12:35 PM, showed the following: Resident #19's room with no isolation sign on the door and no PPE or isolation cart was outside of the room. There were 14 other residents residing on this hall that had an admission or readmitted that was past 14 days, and they had not been moved from the New/Readmission Isolation Hall. Observation of the 200 Hall on 3/9/2021 at 12:00 PM, showed the following: room [ROOM NUMBER] with a droplet isolation sign on the door and no PPE was outside of the room. During an interview on 3/9/2021 at 12:00 PM, RN #1 stated, .he (resident in room [ROOM NUMBER]) shouldn't be in isolation .that sign needs to come off the door . Observation of the 300 Hall on 3/9/2021 at 12:35 PM, showed the following: room [ROOM NUMBER] with an isolation cart outside of the room. During an interview on 3/9/2021 at 12:35 PM, LPN #1 stated, .I don't think 301 (resident in room [ROOM NUMBER]) is in isolation .I think the cart is just in the hallway .No, I don't know who all is in isolation on this hall (300) . During an interview on 3/9/2021 at 12:20 PM, RN #1 stated, .I think only one person on 100 Hall is in isolation . When she was asked what residents she takes care of, she stated, .I take care of 100 and 200 Hall residents . She confirmed there were no PPE, gowns, or masks on the 100 Hall, 200 Hall and 300 Hall. She stated, .they quit giving out surgical mask, we have to ask . She confirmed she and her CNAs were not wearing a gown or gloves into the isolation rooms. She stated, .we should wear a gown and gloves .we need to get some gowns . RN #1 was asked if she knew who was in isolation. She stated, .yes and no .no, I don't have a list . RN #1 was asked where to get PPE if it was not available on the halls. She stated, .I don't know . During an interview on 3/9/2021 at 12:35 PM, LPN #1 stated, .I work this hall (300 Hall) all the time. I don't know who is in isolation and who is not .I don't know how to find out. I can look in the chart but don't know where to look . The RN came over and showed him. LPN #1 stated, .I didn't know. We don't deal with it (isolation) . LPN #1 was asked where to get PPE if it was not available on the halls. He stated, .I don't know . During an interview on 3/9/2021 at 1:22 PM, the Infection Preventionist was asked how did she know what residents were in isolation and when the isolation was to be discontinued. She stated, .I don't know .the Administrator keeps up with it .No, I don't get any of that information . During an interview on 3/9/2021 at 2:25 PM, CNA #1 stated, .We don't know where gowns or PPE is (are) kept. I just found out today since you been here there is a code upstairs to get it, but we don't have the code and still don't .No, I didn't go ask for gowns this morning. I just come in and do my job .Yeah, I know supposed to wear a gown, mask, gloves for isolation (droplet) but you know those call lights start when we come in and I get to doing my job and if gowns not there I keep working .I used to have a face shield but busted up and haven't asked for another . When asked when does she wash her hands during resident care, CNA #1 stated, .Between every 2 patients .no, I don't have any alcohol gel .the dispensers are so far away who has time to use them unless directly beside them, I don't . During an interview on 3/10/2021 at 11:25 AM, CNA #4 confirmed she did not wear a gown while providing care to Resident #11 who was in droplet isolation and did not perform hand hygiene after glove removal. She stated, .no, I did not wear a gown .yes, I know she (Resident #11) is in isolation .no, I did not wash my hands or use (alcohol) gel after taking my gloves off . During an interview on 3/10/2021 at 11:37 AM, Assistant Director of Nursing (ADON) stated, .expect staff to perform hand hygiene when enter the building, enter patient's room, exit room, after patient care, after glove removal, and use soap and water when visibly soiled .the facility does provide pocket alcohol gel and it is also mounted on the wall at each end of the halls .staff should use ABHR before and after tray pass and if touches surfaces . She was asked what was the expectation for droplet isolation. She stated, .sign on door, bin outside of the door with PPE, staff to wear gloves, mask, gowns, eye protection goggles or face shield and we also provide shoe protectors .expect them to don before going in the room and doff when exit and wash hands . The ADON was asked what was the expectation when the facility has new admissions or readmissions. She stated, .14 days droplet isolation and we do a COVID swab 72 hrs after admission .the DON (Director of Nursing) or myself keeps up with who is in isolation or not . She was asked how residents in isolation are communicated to staff. She stated, .Admission notifies the nurse, they receive the patient and protocol automatically places the patient in 14 day isolation . The ADON was asked who was responsible for setting up the isolation carts, PPE, and isolation signs on the doors. She stated, .the staff that receive the new patient, the nurse and CNA are to get the supplies . She was asked who was responsible for keeping the carts stocked and PPE available for staff. She stated, .we are (Nursing Management) and the staff, they should know where to get it .Maintenance can go upstairs and bring a case down . She was asked was Maintenance here every day/every shift. She stated, .No . During an interview on 3/10/2021 at 12:15 PM, the Administrator was asked who was responsible for communicating to all departments and staff which residents were in isolation and when isolation was to be discontinued. She stated, .I tell the department heads in stand up (meeting) how many residents are in isolation, but not who (residents) . When the Administrator was asked how the residents in isolation was communicated to the staff. She stated, .they should know who is in isolation because of new admission and based on signs on the doors and things like that .

Based on policy review, medical record review, and interview, the facility failed to provide consistent communication for COVID-19 information to Responsible Parties for 1 of 4 sampled residents (Resident #1) reviewed. The facility had a census of 89 residents residing in the facility. The findings include: Review of facility's policy titled, Notification of Change, revised 11/2017, showed that the facility must inform the resident, and notify the resident's family member when there is a change requiring such notification. Review of facility's policy titled, Coronavirus 2019 (COVID-19) Response Plan and Facility Policy and Protocol, revised 6/26/2020, showed that the facility will make the appropriate notifications of confirmed or suspected COVID-19 cases among Residents and staff in accordance with CMS (Centers for Medicare and Medicaid Services) guidance. Review of the closed medical record, showed Resident #1 had a [DIAGNOSES REDACTED]. Review of Resident #1's laboratory (lab) test results collected on 7/21/2020 and resulted on 7/23/2020 confirmed a positive COVID-19 test. Review of the Social Worker's Progress Note dated 7/22/2020, confirmed that the Resident #1 was discharged home. During a telephone interview on 7/28/2020 at 10:16 AM, Family Member #1 confirmed that he and his father arrived at the facility on 7/22/2020 to pick up Resident #1. Family Member #1 confirmed that the facility did not notify them that Resident #1 had been tested for COVID-19 virus due to being exposed to a positive COVID-19 staff member. Family Member #1 confirmed that the facility did not notify the family that Resident #1 had tested positive for the COVID-19 virus until 7/24/2020. During a telephone interview on 7/28/2020 at 10:59 AM, Family Member #2 confirmed that the facility did not notify him that Resident #1 had been tested for the COVID-19 virus after being exposed to a positive COVID-19 staff member. Family Member #2 confirmed that the facility did not notify him that Resident #1 had tested positive for the COVID-19 virus until mid-day on 7/24/2020. During a telephone interview on 7/28/2020 at 11:47 AM, the Medical Director confirmed that the family should have been notified of any outstanding lab results before discharge. The Medical Director confirmed that the resident should not have been discharged home before receiving the COVID-19 virus lab results. During an interview on 7/28/2020 at 2:52 PM, the Administrator confirmed that Resident #1 should not have been discharged home until they received the COVID-19 virus lab results. The Administrator confirmed that the family should have been notified before discharge that Resident #1 was tested for the COVID-19 virus. During a telephone interview on 7/29/2020 at 11:10 AM, Register Nurse (RN) #1 confirmed that she did not inform the family members that Resident #1 had been tested for the COVID-19 virus when Resident #1 was discharged .

Based on policy review, medical record review, observation, and interview, the facility failed to follow treatment orders for a medicated cream for 1 of 3 sampled residents (Resident #1) reviewed with skin conditions. The findings include: Review of the medical record, showed Resident #1 had a [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED]. Review of the (MONTH) 2020 Treatment Administration Record (TAR), showed that Resident #1 did not get the [MEDICATION NAME]-[MEDICATION NAME] cream twice a day on the following days: 2/13/2020, 2/14/2020, 2/15/2020, 2/16/2020, 2/17/2020, 2/18/2020, 2/19/2020, and 2/20/2020. Observation in the resident's room on 2/20/2020 at 10:50 AM, showed Resident #1 had a moderate red rash under her left and right upper arms and a small red rash to the bilateral sides of her rib cage. During an interview on 2/20/20 at 1:48 PM, Registered Nurse (RN) #1 confirmed that he did not apply the cream as prescribed. During an interview on 2/20/2020 at 4:03 PM, the Director of Nursing (DON) confirmed that Resident #1 did not receive her cream as prescribed.

Based on review of the "National Pressure Advisory Panel (NPUAP) Pressure Ulcer Prevention QUICK REFERENCE GUIDE," policy review, medical record review, observation and interview, it was determined the facility failed to prevent and identify the development of pressure ulcers for 1 of 5 (Resident #3) sampled residents in the complaint investigation. The failure to identify and prevent skin breakdown prior to the development of two pressure ulcers with eschar resulted in actual harm to Resident #3. The findings included: Review of the "National Pressure Advisory Panel (NPUAP) Pressure Ulcer Prevention QUICK REFERENCE GUIDE," documented, "...Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown... Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV... Skin Assessment... Educate professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, [MEDICAL CONDITION], and induration... Inspect skin regularly for signs of redness in individuals identified as being at risk of pressure ulceration. The frequency of inspection may need to be increased in response to any deterioration in overall condition... Ongoing assessment of the skin is necessary to detect early signs of pressure damage... Document all skin assessments, noting details of any pain possibly related to pressure damage... Accurate documentation is essential for monitoring the progress of the individual and to aiding communication between professionals..." Review of the facility's "Skin Care Guidelines" policy documented, "...OBJECTIVES... The following skin care guidelines are recommended: a) To identify "at risk" patients and implement preventative care to reduce the risk of pressure ulcer development, and b) To maintain skin integrity and promote wound healing using a systematic approach and monitoring process... All patients identified at high risk will be referred to the Skin/Nutrition Focus Team. Preventative measures must be implemented as soon as the patient is identified as high risk. All efforts should be made to make these interventions patient specific... Patients who score a 14 or less on the Braden Scale are at risk for developing pressure ulcers and are identified as a candidate for the Pressure Redistribution Program... These individualized programs should be care planned... The Skin/Nutrition Focus Team is responsible for monitoring skin problems and interventions weekly during the Skin/Nutrition Focus Team meeting... The Weekly Wound Progress Note (Form 4334) should be reviewed during the meeting..." Medical record review for Resident #3 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the "BRADEN SCALE" dated 2/1/13 documented, "...Total score of 12 or less represents HIGH RISK... TOTAL SCORE...12..." Resident #3 was assessed as being a high risk for development of pressure ulcers. Review of the comprehensive care plan dated 2/1/13 documented, "...PROBLEMS / STRENGTHS... Risk for impaired skin integrity. Patient requires extensive assist for bed mobility due to [MEDICAL CONDITION], late effects of [MEDICAL CONDITION], and arthritis... Goals... Will promptly identify skin breakdown and implement interventions as indicated... INTERVENTIONS... Skin assessed weekly and monitored daily with care... Monitor skin for redness... 3/1 (2013)... Recheck placement of brace. Re-enforce padding..." Review of a physician's orders [REDACTED]. physician's orders [REDACTED]. [REDACTED]. CHECK SKIN FOR BREAK DOWN EVERY 8 HOURS AND AS NEEDED..." Review of the "Office/Outpatient Visit" from the orthopedic clinic dated 1/24/13 documented, "...She (Resident #3) is beginning to have skin breakdown from the immobilizer so bandage change was performed today in the office..." Review of the "Office/Outpatient Visit" from the orthopedic clinic dated 2/25/13 documented, "...They (facility) will continue to performed (perform) routine skin checks and bandage changes. She (Resident #3) is beginning to have skin breakdown from the immobilizer so bandage change was performed today in the office... OBJECTIVE: Exams... Skin breakdown with mild [DIAGNOSES REDACTED] noted medially..." Review of the "Weekly Wound Progress Note" dated 3/4/13 documented, "...Location: L (left) ankle x (times) 2... Date of Onset: 3/1/13... Size: (in cm (centimeters))... L (length) 1... W (width) 1... D (depth) UTD (unable to determine)... Tissue Type... (check mark) Necrotic/Eschar... Other description/comments: Pt (patient) has 2 small areas to her ankle that is a result of the imobilizer (immobilizer) brace..." Review of the "Weekly Wound Progress Note" dated 3/4/13 documented, "...Location: L calf... Date of Onset: 3/4/13... Type of Ulcer... Pressure (circled)... For Pressure Ulcer: Stage DTI (deep tissue injury) appears as Stage DTI... Size: (in cm)... L 5.5... W 2... D UTD... Tissue Type... (check mark beside) Necrotic/Eschar... Other description/comments: Wd (wound) R/T (related to) immobilizer..." Review of the "Weekly Wound Progress Note" dated 3/4/13 documented, "...Location: L Medial Knee... Date of Onset: 3/4/13... Type of Ulcer... Pressure (circled)... For Pressure Ulcer: Stage DTI appears as Stage DTI... Size: (in cm) L 2.5... W 1.5... D UTD... Tissue Type... (check mark beside) Necrotic/Eschar... Other description / comments: Wd Bed c (with) eschar R/T imobilizer (immobilizer) Brace..." Review of the "PHYSICAL THERAPY SCREENING FORM" dated 3/4/13 documented, "...Referral Source: per nursing 2 (secondary) skin breakdown from knee immobilizer... WOUNDS... L medial knee... L posterior ankle... L lower lateral leg... RECOMMENDATIONS... PHYSICAL THERAPY NOT INDICATED AT THIS TIME SECONDARY TO: NWB L & (and) knee immobilizer on except for skin checks..." Review of the "DOCTOR'S PROGRESS NOTE" dated 3/12/13 documented, "...Problems... Patient complains of: New pressure wound @ (at) splint site. Unstageable at this time. Eschar... EXAM... Eschar LLE (left lower extremity) @ (at) splint site. post. (posterior) calf..." Review of a page provided by the facility listing current in-house pressure ulcers on 3/12/13 at 8:30 AM documented, "...(name of Resident #3)... Sta (stage) Susp (suspected) DTI... L Medial Knee... 2.5 X (by) 1.5 X UTD (I) (developed in-house)... 3/4/13 (date of onset)... Susp (suspect) DTI... L calf... 5.5 X 2 X UTD (I)... 3/4/13... Susp DTI... L (symbol for upper) outer ankle... 1 X 1 X UTD (I) ...3/1/13... Susp DTI... L (lower) outer ankle... 1 X 1 X UTD (I)...3/1/13..." Review of the "Physical Therapy Certification" dated 3/21/13 documented, "...Past Medical History... Pt. (patient) a resident of this facility who had a fall 12/26/12 and had resultant left knee pain. Pt. transferred to ER (emergency room ) and found to have a left knee closed supracondylar femur fx. Pt. returned to facility without admission to hospital with left knee immobilizer to be on at all times except for skin checks..." Review of the "TREATMENT RECORD" dated March 2013 documented, "...KEEP BRACE AND CHECK SKIN FOR BREAK DOWN EVERY 8 HOURS AND AS NEEDED..." The skin checks are documented as follows: a. March 1 - 6 AM, 2 PM, 10 PM - initialed as done. b. March 2 - 6 AM, 10 PM - initialed as done, 2PM - no documentation. c. March 3 - 6 AM, 10 PM - initialed as done, 2 PM - documented resident refused. d. March 4 - 6 AM - initialed as done. There was no documentation for any of these skin assessments for any alteration in skin integrity or condition. During an interview in Resident #3's room on 3/12/13 at 10:40 AM, the Wound Care Nurse was asked how the nurses were to assess the skin under Resident #3's knee immobilizer. The Wound Care Nurse stated, "...remove every 8 hours and check the skin..." During an interview in the conference room on 3/12/13 at 1:45 PM, the Director of Nursing (DON) was asked how nurses checked Resident #3's skin every 8 hours. The DON stated, "...nurses on the hall for the day... take it (knee immobilizer) off and look..." The DON was asked about the condition of Resident #3's wounds to her left lateral calf and left medial knee when the areas were first discovered. The DON stated, "...first found on March 4th (2013)... right after the morning meeting... about 9:30 (AM)... when first found... there was eschar (eschar present when first discovered)..." During an interview in the A wing nurses' station on 3/12/13 at 2:20 PM, Nurse #1 was asked how to address skin assessment when a resident has an immobilizer. Nurse #1 stated, "...look at the order... make sure there's an order for [REDACTED]. During an interview on the 300 hall on 3/12/13 at 2:30 PM, Nurse #3 was asked how the nurses take care of a resident with an immobilizer. Nurse #3 stated, "...skin assessment... look at the chart for an order..." During a telephone interview on 3/28/13 at 10:15 AM, Resident #3's Primary Physician was asked if Resident #3's wound was a pressure ulcer. Resident #3's Primary Physician stated, "...mix of arterial insufficiency and pressure ulcer... one predisposes to the other..." Resident #3's Primary Physician was asked about the development of the wound. Resident #3's Primary Physician stated, "...it may start with a hue or a tint... a slightly darker appearance... you should be able to see it..." Resident #3's Primary Physician was asked if Resident #3's skin could go from completely normal skin (documented on 3/4/13 at 6 AM) to eschar in 3 and a 1/2 hours (as stated by DON that wounds first discovered on 3/4/13 at approximately 9:30 AM). The Primary Physician stated, "No... I would disagree with that..." Resident #3's Primary Physician stated that the nurses may have missed the discoloration of Resident #3's skin as the wound developed due to the poor lighting in the residents' rooms and Resident #3's immobility. The failure to identify and prevent skin breakdown prior to the development of two pressure ulcers with eschar resulted in actual harm to Resident #3. Review of the "National Pressure Advisory Panel (NPUAP) Pressure Ulcer Prevention QUICK REFERENCE GUIDE," documented, "...Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown... Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV... Skin Assessment... Educate professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, [MEDICAL CONDITION], and induration... Inspect skin regularly for signs of redness in individuals identified as being at risk of pressure ulceration. The frequency of inspection may need to be increased in response to any deterioration in overall condition... Ongoing assessment of the skin is necessary to detect early signs of pressure damage... Document all skin assessments, noting details of any pain possibly related to pressure damage... Accurate documentation is essential for monitoring the progress of the individual and to aiding communication between professionals..."