Every finding on record at Peoria Post Acute and Rehabilitation

Based on interviews, clinical record review, and review of facility policies and procedures, the facility failed to promote and facilitate the right to self-determination for one (#78) of three sampled residents regarding choices and preferences related to his care, treatment and discharge/transfer planning. The deficient practice could result in the resident's choices and preferences not being honored and limit the resident's ability to participate in decisions regarding their care, treatment and discharge/transfer planning.Findings Include:Resident #78 was admitted to the facility on [DATE], with diagnoses including osteomyelitis of vertebra, stage 4 pressure ulcer of the sacral region, paraplegia, polyneuropathy, chronic pain syndrome, opioid dependence, major depressive disorder, generalized anxiety disorder, acquired absence of the left leg above the knee, and post-traumatic stress disorder (PTSD).A care plan focus initiated March 30, 2023, identified Resident #78 wished to remain at the facility for long term care. Interventions included establishment of a pre-discharge plan with the resident, family/caregivers and evaluate progress and revise plan as needed; and Evaluation/recording abilities and strengths, with family/caregivers/IDT to determine gaps in abilities which affect discharge.A care plan focus initiated March 30, 2023, identified Resident #78 as being at risk for impaired cognitive function and/or impaired thought processes related, in part, to rejection of care and refusal of medications at times. Interventions included providing supervision and assistance with decision-making, maintaining a consistent routine and consistent caregivers when possible, and engaging the resident in simple, structured activities.A care plan focus initiated March 30, 2023, identified Resident #78 as having an ADL self-care performance deficit related to paraplegia, left above-knee amputation, muscle weakness, impaired mobility, and other medical conditions. The care plan documented that Resident #78 declined restorative nursing activities and sometimes refused care. Interventions included involving Resident #78 in decisions regarding his care and allowing him to participate in determining the timing and manner of care when possible.A care plan focus initiated October 9, 2023, identified Resident #78 as being at risk for re-traumatization related to PTSD. The care plan identified triggers including feeling that staff were dictating care to him. Interventions included approaching the resident calmly, explaining procedures before providing care, allowing the resident time to adjust to changes, attempting to de-escalate situations, implementing coping strategies, and including the resident in decision-making.A care plan focus initiated August 7, 2025, identified Resident #78 as having the potential to demonstrate verbally abusive behaviors related to ineffective coping skills, anxiety, depression, PTSD, poor impulse control, refusals of medications and restorative nursing activities, and a recent episode of verbal and physical behavior toward staff. Interventions included allowing the resident time to process information, allowing him to express his feelings, assessing and anticipating his needs, encouraging appropriate coping strategies, and including him in the plan of care and review of orders so he could make choices regarding his care.A care plan focus initiated November 25, 2025, identified Resident #78 as being resistive to care related to anxiety, PTSD, and a need to control his medications and care. Interventions included allowing Resident #78 to make decisions regarding his treatment regimen within reason, educating him regarding the possible outcomes of declining treatment or care, encouraging participation in care, explaining care activities before and during care, and negotiating care times when possible.A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #78 was cognitively intact. The MDS also documented rejection of care on 4 to 6 days during the assessment period, but did not identify physical, verbal, or other behavioral symptoms during the assessment period.A physician progress note dated July 8, 2026, at 4:46 p.m., documented that Resident #78 had demonstrated escalating behaviors and outbursts and had been difficult to redirect. The physician noted that Resident #78 was frustrated regarding his pain medication and did not want to be examined or discuss his concerns. The physician reviewed VA wound-care documentation, which did not identify concern regarding cellulitis.A nursing note dated July 8, 2026, at 5:26 p.m., documented that Resident #78 became upset regarding the administration and availability of his prescribed pain medication. Staff explained the medication order and pharmacy dispensing process to him. Resident #78 became agitated, requested that the staff member leave, and the staff member honored his request and exited the room. The physician subsequently attempted to assess and speak with Resident #78; however, Resident #78 declined the assessment and left in his electric wheelchair.A nursing note dated July 8, 2026, at 5:54 p.m., documented that the nurse contacted Resident #78's psychiatric provider regarding increased behaviors and difficulty redirecting him during outbursts. The nurse and psychiatric provider reviewed his medications and plan of care, and no new orders were provided.A nursing note dated July 8, 2026, at 6:00 p.m., documented that the nurse spoke with the physician and nurse practitioner regarding Resident #78's escalating behaviors and refusal to allow staff to provide care. The nurse requested that the providers review an appropriate plan of care.A physician progress note dated July 9, 2026, at 4:20 p.m., documented that Resident #78 refused laboratory testing, vital signs, and a wound-care assessment. The physician documented that the benefits of treatment and risks of declining treatment were reviewed with Resident #78. The physician continued the plan of care, including wound-team involvement, outpatient psychiatric follow-up, attempts to redirect behavioral outbursts, pain management, tissue offloading, preventive skin care, nutritional support, and continued monitoring.A nursing wound-care note dated July 10, 2026, at 7:48 a.m., documented that Resident #78 declined to allow the nurse to evaluate and measure his wounds. Resident #78 stated that another nurse would perform the wound care at 2:00 p.m. His preference was respected and the refusal was reported to the charge nurse.A nursing progress note dated July 11, 2026, at 1:17 p.m., documented that Resident #78 refused frequent vital signs and an assessment of his leg and ischial wound. Staff educated him regarding the need for monitoring and treatment. The provider was notified, and an alternative medication regimen was ordered.On July 13, 2026, the facility issued Resident #78 a 30-day notice of transfer/discharge. The notice stated that: The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met at the facility.The notice identified another long-term care facility as the proposed receiving facility.During an interview on August 6, 2026, at 11:50 a.m., the State Ombudsman stated that facility representatives, including the ADON, Executive Director, and Social Services, had participated in a meeting regarding Resident #78's proposed discharge. The Ombudsman stated that facility representatives had been unable to identify the specific needs that could not be met. The Ombudsman stated that the facility's concerns involved Resident #78 becoming upset when his needs were not addressed at the time he wanted them addressed. The Ombudsman further stated that Resident #78 had the right to refuse care and seek care from his own physicians.During an interview on August 6, 2026, at 12:50 p.m., Resident #78 stated that he wanted to remain at the facility. Resident #78 stated that he had concerns regarding aspects of his wound care and had sought treatment through the VA. Resident #78 stated that he preferred certain providers and did not want certain staff members providing his care. He also described his PTSD symptoms and stated that being yelled at or feeling disrespected by staff could trigger his PTSD.Resident #78 stated that his refusals of care were specific to certain staff members and denied generally refusing wound care or assessments. He stated that he wanted to participate in decisions regarding his care and preferred to receive care from providers with whom he had established relationships.During an interview on August 7, 2026, at 8:26 a.m., CNA (Certified Nursing Assistant)/Staff #102 stated that Resident #78 could be rude, yell, or curse when he believed staff were not listening to or understanding him. Staff #102 stated that staff continued to provide the care Resident #78 needed despite his behaviors or occasional refusals. Staff #102 stated that Resident #78 sometimes refused wound care but did not consider him a danger to staff and believed he was receiving the care he needed at the facility.During a telephone interview on August 7, 2026, at 8:44 a.m., LPN (Licensed Practical Nurse) /Staff #102 stated that Resident #78 had never refused care from her. The LPN stated that she had heard other staff report difficulties with Resident #78 but had no specific concerns regarding his care. The LPN stated that she believed Resident #78 was safe at the facility and was receiving the care he needed.During a telephone interview on August 7, 2026, RN (Registered Nurse) /Staff #212 stated that she attempted to provide wound care to Resident #78 during the early morning hours. Resident #78 declined the wound care and continued sleeping.During an interview on August 7, 2026, at 12:39 p.m., ADON (Assistant Director of Nursing) /Staff #31 stated that Resident #78 had the right to seek care from providers of his choice but stated that his refusals of wound care and preference regarding which staff provided his care hindered the facility's ability to provide care. The ADON acknowledged that Resident #78 was receiving wound care and psychiatric services and stated that she believed he was receiving quality wound care despite his refusals.The ADON stated that Resident #78 had lost trust in facility staff and that she believed he might be more receptive to new providers at the proposed receiving facility. When asked what would happen at the proposed receiving facility, the ADON stated that she did not know.During an interview on August 7, 2026, the Administrator/Staff #93 stated that the facility initiated the transfer/discharge because Resident #78 had prohibited staff from providing care, had lost trust in the facility's team, and the facility could no longer meet his needs.The Administrator stated that Resident #78's psychiatric needs and worsening outbursts were factors in the facility's decision. The Administrator stated that Resident #78 might be able to establish new relationships with providers at the proposed receiving facility and described the transfer as providing a fresh start with new relationships.The Administrator acknowledged that Resident #78 had the right to refuse care and exercise his resident rights.Review of the clinical record revealed that Resident #78's preferences, refusals, PTSD triggers, and behavioral responses had been known to the facility for several years and had been incorporated into his care plan. The care plan specifically directed staff to include Resident #78 in decision-making, allow him choices regarding his care, explain care before providing it, negotiate care times when possible, and use approaches intended to reduce his distress and promote cooperation.The record demonstrated that Resident #78 exercised his preferences by requesting care at times that were acceptable to him, requesting specific staff members for certain care, seeking wound-care services through the VA, and declining specific assessments or treatments. The record also demonstrated that facility staff continued to provide care and that Resident #78 continued to receive wound-care and psychiatric services.The facility's Resident Rights policy, reviewed January 2025, stated that residents had the right to choose a personal attending physician, participate in planning medical treatment, and refuse medical treatment. The policy further required the facility to honor these resident rights.The facility's discharge policy, reviewed February 2025, stated that transfers and discharges were to be safe, organized, structured, and to a setting that would meet the resident's highest practicable level of medical, physical, and psychosocial well-being.

Based on observations, clinical record review, resident and staff interviews, and review of facility policy, the facility failed to ensure resident (#119) and was not being treated in a dignified manner of one ( #119) resident. The universe was 33 residents. The deficient practice could result in resident's not being treated with dignity and respect.Findings include: Resident #119 was admitted on [DATE] with diagnosis of acute respiratory failure with hypoxia, acute kidney failure, atrial fibrillation, dysphagia oropharyngeal phase, cognitive communication and deficit, depression and anxiety disorder. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated intact cognition.Review of a care plan initiated on February 27, 2026 revealed resident #119 is at risk of malnutrition per MNA (Mini Nutritional Assessment) due to acute respiratory failure with hypoxia. Interventions included to:Provide assistance with meals as needed. An observation was conducted on March 17, 2026 at 9:21 AM. Resident #119 was lying flat on the bed with a breakfast tray next to her on the bedside table. The resident stated she needs help to raise her bed in an upright position and needs help with eating. An interview was conducted on March 17, 2025 at 9:25 AM with Licensed Practical Nurse (LPN/ staff #242) who stated she will check the chart for resident #119 because she is a bit confused sometimes. Staff #242 stated, she is not a 'feeder' and just wants to be fed sometimes, right outside of resident's room.An interview was conducted on March 18, 2026 at 12:33 pm with the staffing coordinator/Certified Nursing Assistant (CNA/staff #140) who stated a resident who needs assistance eating is called a 'feeder.' Staff #140 stated it is not appropriate to leave a tray bedside while a resident is in a laying position and that the resident should be assisted with bed positioning when needed.An interview was conducted on March 20, 2026 at 10:59 AM with Certified Nursing Assistant (CNA/ staff #188) who stated it is not appropriate to call residents 'feeders' because it can cause residents emotional harm.An interview conducted with a dietetic technician (staff #165) on March 20,2026 at 11:56 AM stated residents should not be called 'feeders' because it is a dignity issue and de-humanizing. Staff #165 stated it was a term more for animals so it is important to make sure staff do not use it in front of residents or even if they didn't hear it, the term 'feeders' should not be used. An interview with Director of Nursing (DON staff # 101)on March,20, 2026 at 11:03 AM stated it is not appropriate to call residents 'feeders' because it would be a dignity and respect issue. Staff #101 stated that it does not meet her expectations but that it is an opportunity to educate staff. Review of a facility policy titled, Resident Rights, reviewed on January 01, 2025 revealed the resident has the right to be treated with consideration, respect, and full recognition of his or her dignity and individuality.

Based on clinical record review, staff interviews, review of facility documents, and review of facility policy, the facility failed to ensure that a physician's order to treat a low blood pressure for one resident (#160) out of 33 sampled residents was followed. The universe was 168. The deficient practice could place a resident health at risk for illnesses. Findings include:Resident #160 was admitted to the facility on [DATE] with diagnoses that included Orthostatic Hypotension (sudden drop in blood pressure), Paraplegia, Major Depressive Disorder, and Anxiety Disorder.A care plan for the Resident receiving a medication for hypotension was initiated on January 3, 2023. The goal was for the Resident to remain free of complications related to hypotension. The interventions included administer the medication as ordered, monitor for side effects and effectiveness, monitor and record vital signs as ordered, and provide consistency in care to promote comfort with activities of daily livings (ADLs).A review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15.0, indicating that the Resident was cognitively intact. The order summary review revealed an order dated January 11, 2026, for Midrodrine Hydrochloride 5 MG (milligram), give 2 tablets by mouth three times a day for Hypotension, and to hold the medication for a systolic blood pressure (SBP) greater than 120.The March 2026 Medication Administration Record (MAR) review revealed a transcribed order for Midrodrine Hydrochloride 5 MG give 2 tablets by mouth three times a day for Hypotension, and to hold the medication for a systolic blood pressure greater than 120. Further, the MAR revealed that on: -March 5, 2026, Midrodrine Hydrochloride 5 MG give 2 tablets by mouth three times a day for Hypotension, and to the hold the medication for a systolic blood pressure greater than 120. The medication was documented as administered when the Resident's blood pressure was 126/70 at midday; -March 6, 2026, Midrodrine Hydrochloride 5 MG give 2 tablets by mouth three times a day for Hypotension, and to the hold the medication for a systolic blood pressure greater than 120. The medication was documented as administered when the Resident's blood pressure was 139/85 in the morning, and when the Resident's blood pressure was 128/78 at bedtime; -March 7, 2026, Midrodrine Hydrochloride 5 MG give 2 tablets by mouth three times a day for Hypotension, and to the hold the medication for a systolic blood pressure greater than 120. The medication was documented as administered when the Resident's blood pressure was 128/78 in the morning, and when the Resident's blood pressure was 145/80 at midday; -March 8, 2026, Midrodrine Hydrochloride 5 MG give 2 tablets by mouth three times a day for Hypotension, and to the hold the medication for a systolic blood pressure greater than 120. The medication was documented as administered when the Resident's blood pressure was 128/81 in the morning; -March 11, 2026, Midrodrine Hydrochloride 5 MG give 2 tablets by mouth three times a day for Hypotension, and to the hold the medication for a systolic blood pressure greater than 120. The medication was documented as administered when the Resident's blood pressure was 148/86 in the morning; -March 16, 2026, Midrodrine Hydrochloride 5 MG give 2 tablets by mouth three times a day for Hypotension, and to the hold the medication for a systolic blood pressure greater than 120. The medication was documented as administered when the Resident's blood pressure was 133/82 in the morning, at midday when the Resident's blood pressure was 121/56, and at bedtime when the Resident's blood pressure was 132/52; and -March 20, 2026, Midrodrine Hydrochloride 5 MG give 2 tablets by mouth three times a day for Hypotension, and to the hold the medication for a systolic blood pressure greater than 120. The medication was documented as administered when the Resident's blood pressure was 132/88 in the morning. However, a review of the Medication Administration progress note dated March 20, 2026, revealed per document, the medication was held due to the blood pressure of 132/88 being above the blood pressure parameter, but in the MAR, the documentation revealed that the medication was administered. Despite a physician's order instruction to hold the administration of Midrodrine Hydrochloride 5 MG give 2 tablets by mouth three times a day for Hypotension for a systolic blood pressure greater than 120, the March 2026 MAR revealed that on March 5, 6, 7, 8, 11, 16, and 20, 2026, the medication was administered when the Resident's systolic blood pressure was above 120. The physician's order instruction, to hold the medication for a systolic blood pressure greater than 120, was not followed. An interview was conducted on March 20, 2026, at 1:12 PM, with a Licensed Practical Nurse (LPN/Staff #191). The LPN stated that a check mark placed in the MAR means that the medication was given to the resident, and she said that if a medication was not administered to the resident, she would document in the notes the reason why the medication was not given. For instance, if the medication was not given due to the vital signs were outside the ordered parameter, she said that she has to read the physician's orders carefully and pay attention to the orders. Another interview was conducted on March 20, 2026, at 1:43 PM, with another LPN (Staff #151). Staff #151 stated that during a medication administration, when a medication was not administered to the Resident, a message would display on the computer screen during administration, and the message on the screen would ask for a reason why the medication was not being given. She said that she would type the reason using the codes provided in the MAR. She said that code number 1 meant that the resident refuse; code number 2 meant to hold the medication and check the nurses progress note, and to document a reason why the medication was being held; and when the medication was administered, it goes directly to the electronic MAR. Further, Staff #151 stated that regarding following physician's orders, it is important to follow the order for her resident's safety, and that her residents are getting the right medications for their health and for the diagnosis that they have. She stated that if a physician ordered a medication such as Midrodrine, which is given to treat a low blood pressure, she stated that she would expect her resident's blood pressure to go up. She also stated that if a Midrodrine order has an instruction to hold if the systolic blood pressure is greater than 120, she would check the resident's blood pressure first, and if the resident's blood pressure was outside the ordered parameter, she would hold the medication. She said that if the medication was given outside the ordered blood pressure parameter, she would notify the doctor, monitor the resident, and then follow whatever orders are given to her by the physician. She said that, monitoring the resident would include watching for the Resident's complaint of headaches because sometimes a headache can be a sign for a high blood pressure. She also stated that if Midrodrine was ordered 3 times a day with a blood pressure parameter order, she would check the resident's blood pressure three times a day prior to administering the medication. The Director of Nursing (Staff #101) was interviewed on March 20, 2026, at 2:03 PM. Regarding medication administration, the DON stated that she expects her staff to clean their hands, match the medication with what they have, verify ordered blood pressure parameters, and that the medication ordered was appropriate to give. Further, the DON stated that during medication administration, there has to be a physician order for the medication, and the staff to follow the right dose, right time, right route, and for the right resident. The DON stated that during medication administration, if the medication was administered, the electronic record would show it as given. She said that if the medication was refused, the staff nurse would document it as refused. She also said that if the medication was held, which was coded as number 2, she expects her staff nurse to document the reason why the medication was held. Regarding the medication Midodrine, the DON stated that the medication was ordered for low blood pressure. She said that if Midrodrine has an ordered blood pressure parameter, such as to hold if the systolic blood pressure was greater than 120, she expects her staff to verify that the medication would be okay to give; she expects her staff to give the medication to the resident unless it is not within the parameter ordered or was instructed by the doctor to hold the medication. The DON stated that Resident #160's Midodrine medication order include to hold if systolic blood pressure was greater than 120. She said that on March 6, 2026, the Resident's blood pressure was 139/85 and 128/78 and that the medication was given. She said that her staff did not follow the doctor's order and did not follow the ordered blood pressure parameters. Further, the DON looked at March 6, 2026, and stated that there was no progress note to clarify the medication administration, and the DON said that the check mark in the MAR would appear to indicate that the medication was given. Furthermore, the DON looked at the March 11, 2026, documented blood pressure of 148/86 in the MAR, and she said that Midodrine was given outside the blood pressure parameter, and there were no progress notes to clarify why it was given. The DON also looked at the March 16, 2026, blood pressure of 133/82 documented in the MAR, and she said that it appears that Midodrine was given, but there was a progress note which documented that it was not given. The DON stated that the process and expectation regarding documentation is that if her staff held a medication, she expects her staff to mark it as held in the MAR, and document in the progress notes that the medication was held or not. She said that if there was no documentation that the staff held the medication, then the medication was given outside the doctor's order for the blood pressure parameter. After the DON's interview on March 20, 2026, at 3:21 PM, regarding the administration of Midrodrine outside the ordered blood pressure parameter for Resident #160, the DON provided additional documents to the surveyor. The document was a Quality Team Tracking Form identifying a problem area for blood pressure medication given with hypotension. The document was dated February 1, 2026. The problem identified was antihypertensive medications administered outside of the blood pressure and heart rate hold parameters. The document included two residents with their January 2026 MARs, one resident with his February 2026 MAR, and Resident #160 with his March 1 through 13, 2026 MAR. A review of the facility policy titled Medication Administration-Oral reviewed on May 2025, revealed that the facility's policy is to accurately prepare, administer and document oral medications.

Based on observation, interview, review of clinical record, and review of facility policy and procedure, the facility failed to ensure medications were administered and stored according to policy for one resident (Resident #16) out of 33 sampled. The universe was 168. The deficient practice could increase the likelihood of medication overdose and residents having unrestricted access to medications.Findings include: Resident #16 was re-admitted to facility on January 14, 2026 with diagnoses that included displaced supracondylar fracture with intracondylar extension of lower end of left femur, initial encounter for closed fracture, chronic obstructive pulmonary disease (COPD), unspecified, and a need for assistance with personal care. Review of the quarterly minimum data set (MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 15, indicating the resident was cognitively intact with no rejection of care noted. Review of the MDS revealed the resident required oxygen therapy. Review of the comprehensive care plan revealed no evidence that Resident #16 was able to self-administer medications. Review of a physician order with a start date of October 11, 2025 for Fluticasone Propionate Nasal Suspension 50 micrograms per actuation (MCG/ACT), indicated two sprays in both nostrils one time a day for allergies. However, there was no evidence that this medication was authorized for self-administration. Review of a physician order with a start date of October 11, 2025, for Albuterol Sulfate HFA (hydrofluoroalkane) Inhalation Aerosol Solution 108 (90 Base) MCG/ACT, which indicated 1 inhalation orally every four hours as needed for shortness of breath/wheezing. However, there was no evidence that this medication was authorized for self-administration. There was no evidence of a self-administration assessment within the clinical record. An observation was conducted on March 17, 2026 at 9:41 in the resident's room of one red albuterol inhaler with a grey cap and one over-the-counter allergy nasal spray on the resident's bedside table both containing the room number and resident name. An interview was conducted on March 17, 2026 at 9:41 a.m. with Resident #16. Resident #16 stated the nurses will often come into her room and hand her the inhaler and nasal spray for her to self-administer and come back at a later time to pick them back up. Resident #16 stated she knows staff are not supposed to do that but further stated that she does not want to cause trouble.An observation was conducted of Resident #16's bedside table on March 17, 2026 at 9:51 a.m. with licensed practical nurse (Staff #138/LPN). At the time of the observation Staff #138 noted there were two medications on Resident #16's bedside table, she identified one as being an over-the-counter allergy nasal spray and the other being an inhaler used for shortness of breath related to COPD. An interview was conducted on March 17, 2026 at 9:51 a.m. with Staff #138. Staff #138 stated she did not currently have any residents with self-administration orders. Staff #138 stated if there was an order for self-administration she would hand the medication to the resident and wait for them to take it and then bring it back to the cart, further stating the resident should not be left alone with the medication. Staff #138 stated the risks of leaving medications at the bedside included incorrect dosing, medication abuse, and potential harm for other residents. Staff #138 stated the medications left on Resident #16's bedside should not be there and that she would remove them, further stating that this does not meet facility expectations. An interview was conducted on March 19, 2026 at 8:36 a.m. with a LPN (Staff #109). Staff #109 stated that if a resident wanted to self-administer the medications she would discuss it with the charge nurse and the provider in order to see if it would be appropriate. Staff #109 stated the resident would be assessed based on their cognitive level, the likelihood of error, and how accurately the resident could follow instructions. Staff #109 stated that all medications including over-the-counter medications require an order and if she saw any medications at the bedside she would confiscate them and educate the family or resident. Staff #109 stated the risks could be the clinical staff would not know if the resident is taking the correct medication or dosage. An interview was conducted on March 19, 2026 at 10:06 a.m. with the Director of Nursing (DON/Staff #101). Staff #101 stated all medications including over-the-counter medications must have a physician order because the physician has to decide if it is safe for the resident to be taking. Staff #101 stated that if a resident expresses a wish to self-administer medication the staff will complete an evaluation to determine if self-administration is appropriate. Staff #101 stated that there must be an order from the provider before a resident can begin self-administration of medications. Staff #101 stated that at the time of the observation there was no order or assessment completed for self-administration for the medications located on Resident #16's bedside table. She stated the risks could include overdose, missed medications, and potential harm to the resident. Review of the Self Administration of Medications policy last reviewed in August 2025 revealed the purpose is to determine the ability of alert residents to participate in self-administration while maintaining the safety and accuracy of medication administration. Further review of the policy revealed if a resident is a good candidate for self-administration, this would be documented within the care plan.

Based on observation, interview, review of clinical records, and review of facility policies and procedures, the facility failed to ensure that infection control practices were followed regarding a nephrostomy bag and tubing for one resident (Resident #212) out of 33 sampled residents. The universe was 168. The deficient practice could result in potential infections. Findings include: Resident #212 was admitted to the facility on [DATE] with diagnoses that included displacement of nephrostomy, subsequent encounter, need for assistance with personal care, difficulty in walking, not elsewhere classified, and other artificial openings of urinary tract status. Review of the entry minimum data set (MDS) dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 13, indicating moderately impaired cognitive status. Review of the MDS revealed the resident was dependent on staff for toileting hygiene. Review of the baseline care plan initiated on January 19, 2026, revealed a focus indicating that Resident #212 had bilateral nephrostomy tubes, with a preference to have the nephrostomy bag secured on his left side. Interventions included positioning the nephrostomy bag and tubing below bladder level and away from the entrance door. There was no evidence in the care plan of the resident's preference for a privacy cover or placement of the tubing. There was no evidence within the progress notes that indicated Resident #212 had specified placement of the nephrostomy bag tubing. An observation was made on March 17, 2026 at 8:32 a.m. of Resident #212 sleeping in bed with a nephrostomy bag attached to the right side of the bed, facing the door, no privacy cover was visible, and the nephrostomy tubing was lying on the floor. An observation was made on March 17, 2026 at 8:44 a.m. of Resident #212's room with the assistant director of nursing (ADON/Floor Nurse/Staff #261). Resident #212's nephrostomy bag was facing the door without a privacy cover, and the nephrostomy tubing was twisted and lying on the floor. An interview was conducted on March 17, 2026 at 8:44 a.m. with Staff #261. Staff #261 stated enhanced barrier precautions (EBP) are used with nephrostomies/catheters to lessen the risk of infection. Staff #261 stated that nephrostomy bags and tubing should be secured lower than the bladder and out of view from the hallway to preserve the residents' privacy. Staff #261 stated that the nephrostomy tubing and bag should not touch the floor, as there are bacteria everywhere, which could lead to unnecessary infections. During the observation, Staff #261 stated she was unsure how to secure the tubing without it touching the floor and further stated there is no risk for infection. An observation was made on March 17, 2026 at 10:18 a.m. of Resident #212's room with a second ADON (Staff #129). Resident #212's nephrostomy bag was secured on the right side of the bed and twisted so the urine was not visible from the hallway. The nephrostomy tubing was twisted and lying on the ground. An interview was conducted on March 17, 2026 at 10:18 a.m. with Staff #129. Staff #129 stated that infection control practices for residents with nephrostomies include EBP. Staff #129 stated nephrostomy bags are usually secured on the bed, but indicated some staff prefer to have the nephrostomy bags secured on the trash cans. Staff #129 stated that nephrostomy tubing and bags should not touch the floor as there is a risk for infection. Staff #129 stated Resident #212 had a nephrostomy and not an indwelling catheter and further stated it is difficult to ensure the bag and tubing is off the floor due to the design of the tubing. An observation was made on March 17, 2026 at 11:37 a.m. of Resident #212. Resident #212 was observed to be in bed sleeping with the covers drawn and the lights off. At the time of the observation, Resident #212's nephrostomy bag was secured on the right side of the bed and was twisted away from the door so that the urine would not show with the nephrostomy tubing lying on the ground. An interview was conducted on March 18, 2026 at 2:51 p.m. with a certified nursing assistant (CNA/Staff #19). Staff #19 stated that during nephrostomy care EBP is used. Staff #19 stated the nephrostomy bag should never face the door as that is a privacy violation. Staff #19 stated that a nephrostomy bag and tubing should not touch the ground . Staff #19 further stated if she noticed a nephrostomy bag and tubing on the ground she would immediately inform the nurse and change the whole nephrostomy system due to the potential contamination. An interview was conducted on March 18, 2026 at 3:04 p.m. with a registered nurse (RN/Staff #219). Staff #219 stated a nephrostomy is a surgical procedure where tubing is placed directly into the kidney to drain the urine into a nephrostomy bag, while a catheter is inserted through the urethra. Staff #219 stated that EBP precautions are used to protect the resident, staff, and other residents within the building from potential infections. Staff #219 stated most nephrostomies have as-needed (PRN) orders to change, and further stated that if the tubing or bag was touching the floor that would be considered soiled. Staff #219 further stated that the nephrostomy tubing or bag touching the floor could lead to infections due to bacteria traveling up the tubing. An interview was conducted on March 19, 2026 at 9:50 a.m. with the Director of Nursing (DON/Staff #101). Staff #101 stated that nephrostomy bags should be placed away from the door to ensure privacy and ensure the tubing is not kinked to reduce the risk of infection. Staff #101 stated everyone is responsible for ensuring the nephrostomy tubing and bag are not touching the floor and education is provided to the resident if they express a wish to have the tubing remain on the floor. Staff #101 stated the expectation for staff is to clean the site and tubing according to their policy and ensure infection control practices. Staff #101 stated there is a risk for infection if the catheter/nephrostomy tubing and bag are touching the floor. Staff #101 stated Resident #212 is very particular regarding his nephrostomy and expressed that he wants his nephrostomy tubing on the ground to ensure a visual of his nephrostomy. Staff #101 further stated that staff must respect the resident's wishes regardless of a risk for infections. There was no evidence of a policy specific to nephrostomies or nephrostomy care. Review of the Catheter Care, Indwelling policy last revised November 2024 revealed the purpose is to promote hygiene and comfort in order to decrease risk of infection for catheterized residents. Review of the Infection Prevention and Control Program policy last revised April 2025 revealed the goals of the program include to recognize infection control practices while providing care and identify and correct problems relating to infection control.

The facility failed to ensure that one medication cart was secured when left unattended. The deficient practice could result in residents, visitors, and/or staff members having unrestricted access to medications. Findings include: An observation of a medication cart was conducted on September 11, 2025, at 12:07 p.m., with 2 surveyors present, who observed that a cart was left unattended and unlocked. An interview was conducted on September 11, 2025, at 12:09 p.m. with Registered Nurse, Staff #41, who confirmed that the cart was unlocked in the hallway. The RN Staff #41 stated that if the cart is left unlocked and unattended, people could get into the cart and get into the medications. An interview was conducted on September 11, 2025 09:00 a.m. with the Director of Nursing (DON), Staff #67, who stated that her expectations were that if a staff member was not present, medication carts should be locked and secured. The risks that present themselves are that residents have access to medications. The facility policy reviewed in November 2024, titled, Pharmacy Services Drug Storage, revealed that drugs and/or biologicals should not be left unsecured/unattended. The policy further stated that medication and treatment carts will be kept locked when unattended.

Based on clinical record review, observations, interviews, facility documentation, and policies, the facility failed to ensure medications were not left unsupervised at the bedside for one resident (# 3). This deficient practice could result accidental ingestion, incorrect administration, or unauthorized access of medications. The sample size was 3.Resident # 3 was admitted to the facility on [DATE] with diagnoses of dependence on renal dialysis, Type 2 Diabetes Mellitus, chronic pain, and legal blindness. The quarterly Minimum Data Set (MDS) dated [DATE], included a Brief Interview for Mental Status (BIMS) score of 12, indicating the resident was cognitively intact.The clinical record failed to reflect a physician's order or an interdisciplinary care team review, allowing medications to be left at the resident's bedside. The Counseling/Disciplinary Notice dated June 24, 2025, provided a written warning to the administering Registered Nurse (RN/Staff # 17). The corrective action of the disciplinary notice provided education with the nurse on the five rights of medication administration, however the facility policy identified seven rights of medication administration. The list of medications left behind by the RN was attached to the notice, and included:-Aspirin 81 mg- Cinacalcet 30 mg x 2 tablets-Famotidine 20 mg 1/2 tab-Fexofenadine 180 mg 1 tablet-Glycolax Powder 17 gram-Minoxidil 2.5mg 1 tablet-Renal Vitamin 0.8 mg 1 tablet- Sertraline 100 mg 1.5 tablets-Vitamin C 500 mg 1 tablet-Zinc 50 mg 1 tablet-Clonidine 0.1 mg 2 tablets-Docusate sodium 100 mg 1 tablet- Lantus insulin- Oyster shell 500 mg 1 tablet- Sevelamer Carbonate 800 mg 3 tabletsThe facility provided documentation that the clinical educator (Staff # 10) provided education entitled Learning Medication at Bedside in-service for licensed nursing staff for day and night shift on June 24, 2025. An observation of a Lantus Solar star insulin pen, and a medicine cup of medications were observed on top of the side dresser during an interview with the resident on June 24, 2025 at 10:45 a.m. At 10:51 a.m. on June 24, 2025, Staff # 17 was observed retrieving the cup of medications and insulin pen from the top of side dresser, and then administering the cup of pills with a cup of water after the resident's identification was confirmed. After the resident swallowed the pills, the RN was observed administering the Lantus Solostar into resident's abdomen according to professional standards. The observation failed to reflect the oral medications were identified to the resident prior to administration.During an interview with the resident at 10:45 a.m. on June 24,2025 the resident revealed that he does not self-administer medications, but the nurse will come back in to give it to him. After the RN left the room, the interview with the resident resumed. The resident revealed that he was visually impaired, and did not know exactly what he was receiving but stated he was pretty sure his phosphorus binders were in there. An interview with Staff # 17 was conducted on June 24, 2025 at approximately 10:56 a.m. The nurse revealed that it was unusual for her to have left the medications by bedside. She recalled that the resident refused the pills without the filtered water, so she left the pills in the room to fulfill the resident's request. The nurse confirmed the resident did not have an order to self-administer medications. The nurse reflected that the correct process was to, take the medications with me, and if he refused the medications, it should have been discarded. An interview conducted with a Certified Nursing Assistant (CNA/Staff # 34) was conducted on June 24, 2025 at 12:20 p.m. Staff #34 revealed that if a CNA found medications by the bedside, they are to alert the nurse, so the medications can be disposed of properly.An interview was conducted on June 24, 2025 with a Licensed Practical Nurse (LPN/Staff #27) at 12:27 p.m., revealed that meds left at the bedside are dangerous because someone can take it and not know what it is. During an interview with LPN/Staff # 45, on June 24, 2025 at 12:45 revealed that when medications are given, the nurse is expected to wait until the resident swallows the pills to ensure that the medications are taken. The LPN advised against leaving medications unattended in the room because someone else could take the medications accidentally. If medications were found by the bedside, the LPN revealed that the medications are supposed to be discarded in the trash.The facility's policy Flex Administration of Drug Policy, reviewed January 2025, revealed the seven rights of medication administration are followed to ensure safety and accuracy of administration.

Based on clinical record reviews, staff interviews, review of policy and procedures, the CMS (Centers for Medicare and Medicaid Services) guidance, the facility failed to ensure two sampled residents (#365 and # 18) were placed on enhanced barrier precautions (EBP). The deficient practice could result in the transmission of multi-drug resistant organisms. Findings include: -Resident (#365) was admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD) with acute exacerbation, acute kidney failure with tubular necrosis, dependence on renal dialysis. The care plan dated March 13, 2024 included that the resident had an indwelling catheter for neurogenic bladder. Goal was that the resident will show no signs/symptoms of urinary infection. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 indicating resident had mild cognitive impairment. The assessment also included that the resident had diagnoses of renal insufficiency, renal failure, end stage renal disease (ESRD), neurogenic bladder, pneumonia and septicemia; and that, the resident had an Indwelling catheter (including suprapubic catheter and nephrostomy tube). The ADL (activities of daily living) care plan dated March 13, 2024 included that resident had ADL self-performance deficit related to ESRD (end stage renal failure), sepsis and urinary retention. The progress note dated March 31, 2024 revealed the resident was alert and oriented x4; and that the resident had an indwelling catheter and was receiving hemodialysis The physician order dated April 3, 2024 revealed an order for EBP. The ADL care plan was revised on April 3, 2024 to include an intervention of EBP. Review of the Treatment Administration Record (TAR) for March 2024 and April 2024 revealed catheter care was provided as ordered. However, there was no evidence found in the clinical record that the resident was placed on EBP from April 1 through April 2, 2024. -Resident (#18) was admitted on [DATE] with diagnoses of dependence on renal dialysis, ESRD and presence of urogenital implants. Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 indicating the resident had intact cognition. The MDS also included that the resident had an indwelling catheter. Review of the current care plan included that the resident had infection in the urine, MDRO (multidrug resistant organism and) CRE (carbapenem-resistant Enterobacteriaceae). Intervention included enhanced precautions when providing resident care. The physician order dated April 3, 2024 included an order for EBP. Review of the TAR for March and April 2024 revealed resident was provided with catheter care. During the initial screening process conducted on April 1, 2024, there were no signs posted related to EBP for residents #18 and #365; and, there was infection control cart that contained personal protective equipment (PPE) available to use. Despite the physician order for EBP, an observation conducted on April 3, 2024 at 1:55 p.m., there were no EBP signs posted and no PPE cart found outside of the rooms for residents #18 and #365. An interview was conducted with a certified nurse assistant (CNA/staff #145) April 5, 2024 at 10:29 a.m. The CNA stated that the facility protocol for EBP was the use of gloves and gowns when in contact with the resident or when providing personal care. The CNA said that when a resident's status was changed to EBP, staff receive notification from the charge nurse or report from other staff. The CNA also said that there would be signs are posted outside the resident's door and signs on which bed was on EBP. The CNA further stated that there was a new policy for contact precautions for catheters that started on April 4, 2024. An interview with a housekeeping staff (#194) was conducted on April 5, 2024 at 10:09 a.m., Staff #194 said that resident rooms that were on transmission-based precautions (TBP) or EBP were cleaned with a special cleanser and using proper PPE. She further stated that she becomes aware of the resident rooms that were designated as EBP or TBP by seeing the signs posted and the PPE carts located outside the resident rooms. An interview was conducted on 04/05/24 10:48 AM with the Director of Nursing (DON) who stated that the facility had been working on EBP and TBP and had the precautions on the trach and vent units. She stated that the facility had rolled out the new CMS guidance on EBP the week prior; and that, the new guidance from CMS was very confusing. The DON stated that she had a late conversation on April 4, 2024 with the county health department who told her who needed to be placed on EBP; and that, this would include all residents with indwelling catheters. The DON said that education was provided to staff who will use EBP when doing wound care, tracheotomy care, incontinence care, changing of linens and dressing changes. Review of the facility policy titled Infection Prevention and Control Program with revision date of October 2023 included that the infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performances improvement program. Goal was to ensure compliance with state and federal regulations related to infection control. The CMS QSO memo dated March 20, 204 included that recommendation of the use of EBP for residents with chronic wounds, infection or colonization with CDC-targeted MDRO when contact precautions do not otherwise apply or indwelling medical devices during high contact resident care activities regardless of their MDRO status, in addition to residents who have an infection or colonization with a CDC (Centers for Disease Control and Prevention)-targeted or other epidemiologically important MDRO when contact precautions do not apply. For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use and wound care. The memo included that the effective date for this guidance is April 1, 2024.

Based on clinical record review, interviews, and policies, the facility failed to ensure medications were administered as ordered for one resident (#14). The deficient practice could result in residents not receiving their medications as ordered. Findings include: Resident #14 was admitted to the facility on [DATE] with diagnoses that included paraplegia, Diabetes Mellitus (DM) type 2, and Multiple Sclerosis (MS). Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored a 15 on the Brief Interview for Mental Status (BIMS) indicating she was cognitively intact. Review of the resident's behavior care plan, initiated November 8, 2022, revealed that the resident had a potential for a behavior problem related to calling on the call light frequently when care has been provided. Interventions included to administer medications as ordered and to monitor and document for side effects of medications. Review of the December 2022 recapitulation of physician's orders revealed the following orders: -Citalopram 10 milligrams (mg), give 3 tablets by mouth every day for depression. -Debrox solution instill 2 drops in left ear every night shift for wax buildup. -Glimepiride give one tablet by mouth one time a day for DM type 2. -Potassium Chloride packet, give one packet by mouth every day for supplement. Reviw of the December 2022 Medication Administration Record (MAR) revealed that there were several medications that were not administered as ordered. These included the potassium chloride on December 1, Debrox solution on December 2, Citalopram on December 11, and glimepiride on December 15. The nursing notes for December 2022 indicated that multiple medications were not administered due to them being on order. No further documentation was noted regarding the administration of these medications. There was no evidence that the physician was made aware of the situation. During an interview with the resident at 9:18 a.m. on December 14, 2022, the resident stated that the facility does run out her medications sometimes. She said it can take 3-4 days to get the medications in. An interview was conducted with a Licensed Practical Nurse (LPN/staff #138) at 9:33 a.m. on December 14, 2022. She stated that they do not run out of medications very often. She said she orders medications several days ahead and that they usually come the same day they are ordered if they are ordered early enough. She said otherwise, they come in the next day. She said that there is a machine in the medication room that can be used to pull medications that are not available otherwise. During an interview with a LPN (staff #192) at 11:17 a.m. on December 15, 2022, she said that she was aware that the resident was missing/had no supply of one medication, glimepiride, and so she told the resident that it had to be ordered. She said that she ordered it from pharmacy and documented this in a nursing note. She said she has not yet notified the physician, but that notification to the physician is the protocol in the facility. She further said that the medication was not available in the emergency medication supply. She said the risk of the resident not getting that medication is that it can have adverse effects on the resident's blood sugar. An interview was conducted with the Assistant Director of Nursing (ADON/staff #193) at 1:10 p.m. on December 15, 2022. She said that her expectation is that nursing staff will maintain the medication supplies for each resident. She said that when the supply gets low, staff should order more. She said that in general, she wants the staff to maintain a 7 day supply and to order when there are 7 days remaining. She said this gives pharmacy time to process and deliver the medication. She said that medications should not be omitted/not administered related to the supply. She said that if this does happen, the nurse should notify the physician and document this. She said that running out of medications could cause adverse effects to the resident. She said the resident not getting her medications does not meet her expectations. Review of the facility's professional standards policy, revised November 2007, revealed the policy of the facility is to provide services that meet professional standards of quality and are provided by qualified persons in accordance with each resident's care plan. The facility's medication administration policy, revised January 2022, revealed a policy that medications are to be administered as prescribed by the attending physician. The policy included that medications must be administered in accordance with the written orders of the physician. All drugs and dosage schedules must be recorded on the MAR. If a medication is withheld, refused, or given other than at the scheduled time, the documentation will be reflected in the clinical record. The facility's physician's orders policy, dated August 2022, revealed a policy that the facility that drugs shall be administered only upon the written order of a person duly licensed and authorized to prescribe such drugs. The policy included that the facility must accurately implement orders. Further, drugs and biological that are required to be refilled must be reordered from the issuing pharmacy prior to the last dosage being administered to ensure refills are on hand.

Based on observation, staff interviews, and policy review, the facility failed to ensure food was properly sealed and labeled, and had an expiration date in accordance to food safety standards. Failure to store food properly could result in poor food quality and/or foodborne illness. Findings include: During an initial kitchen observation conducted on 10/25/21 at 11:34 AM, a plastic container of food was observed on a shelf in the freezer with the top partially open to air. In addition, the food item was not labeled or dated. The kitchen manager stated that the container was filled with beef stew. An interview was conducted with the kitchen manager (staff #218) on 10/27/21 at 12:19 AM. The kitchen manager stated that she believes the stew was made during the weekend, even though it was not on the menu. Staff #218 stated the cook forgot to label and date the container of stew. She stated that the container lid was not sealed properly and must have popped open. The kitchen manager stated that the container of stew should have been sealed, labeled and dated. Staff #218 stated that she checks the freezer every Monday to ensure food is stored in compliance with food storage standards. She included that she had not yet checked the freezer that morning. In an interview conducted with the Director of Nursing (DON/staff #39) on 10/28/21 at 11:01 AM, the DON stated that she did speak with the kitchen manager who admitted the lid on the stew container was not sealed and the stew was not labeled. The DON stated that it is her expectation that food stored in the refrigerator and freezer be labeled, dated and sealed to ensure safety of the residents from potential foodborne illnesses. Review of the facility policy titled Food Storage - Policy and Procedure (2014) stated frozen perishable food and products are to be covered, labeled and dated to assure nutritive value and food quality if not for immediate use. All foods in the freezer are to be checked periodically and undated foods are to be discarded.

Based on observations, facility documentation, staff interviews, review of the Center for Disease Control (CDC) recommendations and policies and procedures, the facility failed to ensure that infection control standards were maintained. The deficient practice could result in the spread of infection, including COVID-19 to residents and staff. Findings include: Upon entering the facility on August 12, 2020 at 8:00 a.m., the Community Liaison (staff #69) asked the screening questions, and took the surveyors temperatures. Staff #69 did not instruct the surveyors to wash their hands. He did not provide education on hand hygiene, to limit interactions with others in the facility and surfaces touched, PPE, or COVID-19. After staff #69 left, the receptionist (staff #143) handed the surveyors a N95 mask. When the Director of Nursing (DON/staff #76) came out to meet the surveyors, she instructed them to go down the hall to the bathroom located to the left and wash their hands. An interview was conducted on August 12, 2020 at 8:50 a.m. with staff #143, who stated that she is the one who normally screens people entering through the front entrance of the building. She stated she had received training on the screening process. Staff #143 said that she asks the screening questions and if a person answers yes to one or more of the questions, she contacts the DON. She said that if a person has a temperature of 99.2 degrees Fahrenheit (F) or higher, the person cannot enter the facility. She stated she did not have any information/education to provide to visitors and that she was not told to provide information/education to visitors during her training. An interview was conducted on August 12, 2020 at 10:59 a.m. with staff #69, who stated that he had received training on the screening process. He said that if a person answers yes to one or more of the questions or has a temperature of 99.5 degrees F or higher, he must contact the DON and the person cannot enter the building. He said that they must provide an N95 mask and goggles to anyone entering the facility. Staff #69 also stated that they must tell the person to wash his or her hands, and let the person know there is COVID-19 in the building. He acknowledged that he did not offer a N95 mask or goggles to the surveyors, ask them to wash their hands, or educate them about COVID-19. He said that he should have finished the screening process before going to get the DON. In an interview conducted with the DON on August 12, 2020 at 11:35 a.m., she said that she expects staff to ask the screening questions, provide a N95 mask and goggles if needed, and tell the person if there was COVID-19 in the facility. The DON stated that if the person has a temperature of 100 degrees F or higher, the staff would not allow the person to enter the building and if the person answered yes to one or more of the questions, staff are to contact her. Review of the facility's In-service training documentation regarding the screening process did not include educating visitors. The facility's Infection Control and Prevention policy revised May 4, 2020, states staff, other health care workers, family, visitors and government officials entering the building must be screened for symptoms of COVID-19. The policy also included establishing procedures for monitoring, managing, and training visitors to include wearing of facemask continuously while in the building, use of other PPE as appropriate, frequent hand hygiene, movement restricted to the patient's room or area designated by the facility, and limit surfaces touched. Review of the facility's [MEDICATION NAME] Visits - During COVID-19 Pandemic policy revealed the DON will meet the visitor at the front entrance, provide education on cough, hand hygiene, and COVID-19 transmission precautions. The DON will in-service on any additional precautions during the visit, such as touching face masks or goggles, hand hygiene, hand washing, etc. Review of the CDC Preparing for COVID-19 in Nursing Homes guidance updated June 25, 2020 revealed residents, healthcare personnel and visitors are to be educated about COVID-19, current precautions being taken in the facility, and actions they should take to protect themselves, emphasizing the importance of hand hygiene and source control. Screen visitors for fever of 100.0 degrees F or higher, symptoms consistent with COVID-19, or known exposure to someone with COVID-19. They should also be reminded to frequently perform hand hygiene. The CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) dated July 15, 2020 states that patients, visitors, and healthcare personnel should be educated about the importance of performing hand hygiene immediately before and after contact with their facemask or cloth face covering. Facilities should provide instruction, before visitors enter patients' rooms, on hand hygiene, limiting surfaces touched, and use of PPE according to current facility policy while in the patient's room. Visitor should be instructed to only visit the patient room.

Based on facility documentation, staff interviews, review of the Centers for Disease Control (CDC) guidelines and policy review, the facility failed to ensure that multiple staff were thoroughly and accurately screened, prior to their shift. The deficient practice could result in symptomatic staff caring for residents, while exhibiting symptoms of COVID-19. Findings include: On July 7, 2020 at 9:10 a.m., an entrance conference was conducted with the facility's Administrator (staff #30), the Director of Nursing (DON/staff #5), and a Resource Nurse (staff #24). The Administrator stated the facility census was 106, and that there were currently no COVID positive residents. He stated that approximately one month ago, there was one resident who tested positive for COVID-19 and was transferred to a COVID positive facility, within a couple of hours after receiving the positive test result. He stated that two staff members had serology results that were positive for COVID-19 antibodies (approximately one month ago). An interview was conducted on July 7, 2020 at 12:19 p.m., with the DON. She stated that all staff have been educated regarding the screening process and that all staff screen themselves. Review of the Employee Entrance Process which was posted at the staff entrance revealed that each employee is responsible to answer the questions on the screening log. If they answer yes to any questions, or if their temperature is greater than 100 degrees F, they are to call their immediate supervisor and will be sent home. The posted information also included that if the employee meets requirements they will clock in, and that a nursing supervisor will review the log daily. A review of the staff screening logs dated June 15, 2020 through July 1, 2020 was conducted on July 7, 2020 and included alterations or missing information as follows: June 15: The answers were completely missing for two staff, and were partially missing for two other staff. June 16: Two staff had marked lines through both the yes and no answers for multiple screening questions. June 16: Three staff had not answered all of the questions and one staff had scribbled through both the yes and no answers for two questions. June 17: One staff member failed to write down her temperature at the start of her shift. June 18: Seven staff members did not answer all of the screening questions. One staff member answered both yes and no to three questions. June 19: Three staff did not answer all of the questions on the questionnaire. June 20: Two staff members did not answer all of the questions on the questionnaire, and two staff marked lines through both the yes and no answers for multiple screening questions. June 21: one staff member had a missing answer to a screening question and answered yes to having multiple symptoms. June 22: Three staff members marked lines through both the yes and no answers for multiple questions. Two staff members did not answer all of the screening questions. June 23: One staff member did not answer all of the screening questions. June 25: One staff member did not answer any screening questions (staff #3), one staff member had marked lines through both the yes and no answers for multiple screening questions, and one staff member did not answer one of the screening questions. June 26: Two staff had marked lines through both the yes and no answers for multiple screening questions. June 27: Two staff members had marked lines through both the yes and no answers for multiple screening questions. June 29: Two staff marked both yes and no for several screening questions. One staff member (#97) marked lines through both the yes and no answers. June 30: Two staff members marked lines through both the yes and no answers for multiple screening questions, and two staff did not write down their temperatures, when leaving their shifts. July 1: One staff member did not answer all of the screening questions. An interview was conducted with a member of the housekeeping staff (staff #17) on July 7, 2020 at 12:38 p.m. She stated that she thought she had completely filled out the screening log. She stated that she has not received any inservice education regarding how to fill them out. On July 7, 2020 at 12:47 p.m., an interview was conducted with the DON. The DON said that she talks to staff every two weeks regarding screening and goes over the process each time. She stated that her expectation is for staff to be truthful and honest, and that they understand everything that the screening log is asking. She said that staff are not to be fearful of answering that they do have symptoms. She stated that all staff have listened to a presentation on how to fill out the screening log, and that they they talk about the signs and symptoms in huddle constantly. The DON reviewed the staff screening logs and stated that they did not meet her expectation at all. An interview was conducted on July 7, 2020 at 1:40 p.m., with a member of the dietary staff (staff #3). She stated that she has attended three in-services that went over all of the steps to complete the screening form. She stated that on June 25, she must have been in a hurry and forgot to answer all of the questions. On July 7, 2020 at 2:00 p.m., an interview was conducted with a Certified Nursing Assistant (CNA/staff #97). She reviewed the process for screening in at the beginning of her shift and stated that she had attended an inservice. She stated that she had not realized that she had marked through both the yes and no answers on the screening form. Another interview was conducted on July 7, 2020 at 2:21 p.m., with the DON. She stated that she tries to look at the screening logs throughout the day, and reviews them on a weekly basis. She said if she notices something missing or concerning, she would go back and ask the staff member follow-up questions. She stated that she did not see these omissions. The DON said that she has educated her staff and they have no problem telling her or other administrative staff if they are symptomatic. The DON said her process is to provide education during huddle with the staff, and that her expectation is for the screening logs to be filled out completely. According to the DON, the Employee Entrance Process (which is posted at the staff entrance) is their screening policy. The Entrance Process stated that all employees come in through one entrance which is the back entrance. Employees are to wash/sanitize their hands. Employees are to put a mask on. Each employee is responsible to answer questions on the screening log. If they answer yes to any questions or if their temperature is greater than 100 degrees F, they are instructed to call their supervisor and they will be sent home. Employee is to sign in on employee log, and if employee meets requirements, then the employee will clock in. The process included that a nursing supervisor will review the log daily. Review of the Infection Control and Prevention policy revealed to include preparatory plans and actions to respond to the threat of COVID-19, including but not limited to infection prevention and control practices in order to prevent transmission. The policy included to ensure that policies and practices are in place to minimize exposures to respiratory pathogens, including [MEDICAL CONDITION] that causes COVID-19. It is particularly important to protect individuals at increased risk for adverse outcomes from COVID-19 (e.g. older individuals with comorbid conditions), including healthcare personnel who are in a recognized risk category. Review of the CDC guidance titled, Preparing for COVID-19 in Nursing Homes revealed that as part of a routine practice, screen all Healthcare Personnel (HCP) at the beginning of their shift for fever and symptoms of COVID-19. Actively take their temperature and document absence of symptoms consistent with COVID-19. If they are ill, have them keep their cloth face covering or facemask on and leave the workplace. Fever is either measured as a temperature greater than 100.0 degrees F or subjective fever.

Based on staff interviews, record review and review of policies and procedures, the facility failed to ensure that one resident's (#2) representative was informed that resident #2 had developed DTI's (Deep Tissue Injuries) on both heels and the right lateral foot, and failed to notify the resident's family and the physician when there was a worsening of the DTI on the right heel. The deficient practice could result in a delay in resident representatives being notified when a resident experiences a significant change in condition. Findings include: Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the clinical record revealed an Admission Record/Face Sheet that included contact information for the resident's wife and son. An Initial Admission Record dated April 21, 2020 included that the resident had been admitted for [MEDICAL CONDITION] femur, was alert and oriented at times and able to follow simple directions. The assessment included that the resident had normal skin and heels intact. An Admission MDS (Minimum Data Set) assessment dated [DATE] included that resident #2 had a BIMS (Brief Interview for Mental Status) score of 7, which indicated that he was severely cognitively impaired, required extensive physical assistance from two or more persons for bed mobility and had functional impairment in range of motion in his lower extremity on one side. The assessment included that resident #2 had no unhealed pressure ulcers. A nursing note dated May 1, 2020 at 9:54 a.m. included that resident #2 had reported pain to bilateral heels while in therapy and had suspected DTI's to both heels which were dark purple in color, painful and non-blanchable. The note included that resident #2 also had a suspected DTI to the right lateral foot. The note included that the wound nurse was aware of the suspected DTI's, the physician was notified and there were new (physician's) orders for skin prep every shift, an air mattress and a wedge cushion. physician's orders [REDACTED]. The nursing note dated May 1, 2020 at 9:54 a.m. did not include any additional information that a resident's family member had been notified of the suspected DTI's to both heels and the right lateral foot. A Weekly Pressure Ulcer Review dated May 1, 2020 included an assessment of the following SDTI's (Suspected Deep Tissue Injury) that were present on that date, and had not been present upon admission: -The left heel had a SDTI that measured 2.0 cm. (Centimeters) x 2.0 cm. with defined margins and peripheral tissue [MEDICAL CONDITION] and was treated with skin prep daily. -The right heel had a SDTI that measured 6.0 cm. x 4.0 cm. with defined margins, peripheral tissue [MEDICAL CONDITION] and was treated with skin prep daily. -The right lateral foot had a SDTI that measured 2.5 cm. x 3.0 cm. with defined margins and peripheral tissue [MEDICAL CONDITION] and was treated with skin prep daily. Review of the clinical record revealed the following eMAR (electronic Medication Administration Record) change of condition notes: -An eMAR note dated May 3, 2020 at 12:28 p.m. included that there had been a change in condition for suspected DTI to bilateral heels and the right lateral foot. The note included that the resident had darkened areas to bilateral heels. -An eMAR note dated May 3, 2020 at 4:28 p.m. included that there had been a change in condition for suspected DTI to bilateral heels and the right lateral foot. -An eMAR note dated May 4, 2020 at 8:56 p.m. included that the resident there had been a change in condition for suspected DTI to bilateral heels and the right lateral foot, and that the wound(s) had not opened. The change of condition notes dated May 3, and 4, 2020 did not include any additional information that a resident's family member had been notified of the DTI's to both heels and the right lateral foot. A Change in Condition note dated May 7, 2020 at 8:08 p.m. included that that resident had a change in condition which was a cough, and that the physician and the resident's family had been notified, and that a phone message had been left for the family member at 12:00 a.m. The Change in Condition note did not include any additional information that the resident's family had also been notified of the DTI's on bilateral heels and the right lateral foot. A Weekly Pressure Ulcer Review dated May 8, 2020 included the following: -The left heel DTI measured 2.0 cm. x 2.0 cm. with defined margins and peripheral tissue [MEDICAL CONDITION]. -The right heel had a DTI that now measured 7.0 cm. x 4.0 cm. with defined margins and peripheral tissue [MEDICAL CONDITION]. -The right lateral foot had a DTI that measured 2.5 cm. x 3.0 cm. with defined margins and peripheral tissue [MEDICAL CONDITION]. The review included that the DTI's continued to be treated with skin prep daily. Physicians orders dated May 8, 2020 included an order for [REDACTED]. Review of the clinical record did not include any additional information that a resident's family member had been notified that the resident had DTI's on both heels and the right lateral foot, or that the DTI on the resident's right heel had enlarged or worsened on May 8, 2020. A Daily Skilled Note dated May 11, 2020 at 11:26 p.m. included that the right heel had a pressure ulcer that was 7 cm. in diameter, with no pain, and was black in color, and that the skin condition was a new onset. The clinical record did not include any additional information that the physician and the resident's family had been notified of the worsened right heel wound which previously had been assessed as a DTI that measured 6.0 cm. x 4 cm. and had worsened to a pressure ulcer that was 7.0 cm. in circumference, and was black and non-painful or that additional treatments or interventions had been obtained for the resident's right heel after the nurse had assessed the wound. A nursing note dated May 17, 2020 at 10:00 a.m. included that resident #2 had been found unresponsive and was transferred to the hospital. During an interview conducted on June 17, 2020 at 1:35 p.m. with the DON (Director of Nursing/staff #146) the DON stated that there was a wound meeting with the wound nurse, the dietitian, and the ADON (Assistant Director of Nursing) and there was a discussion whether or not the resident's pressure wounds were avoidable. The DON stated she did not remember any additional specific details regarding the meeting, and she did not remember if they had discussed the resident's pressure ulcers with his family. During an interview conducted on June 24, 2020 at 10:40 a.m. with the DON, she stated that there had been a change in condition note written on May 7, 2020 and that the nurse had been unable to reach the family. The DON stated that if the nurse had been able to reach the family they would have explained everything that was going on with the resident. The DON stated that she recognized at the time that there was a problem with change in condition notifications being done and that a new form was put into place. The DON was unable to provide any additional documentation that the family had been notified that resident #2 had developed DTI's on bilateral heels and the right lateral foot when the DTI's were assessed on May 1, 2020, or when the right heel DTI was assessed to have enlarged on May 8, 2020, or when the DTI on the right heel became blackened and non-painful and again enlarged on May 11, 2020. A policy and procedure titled Change of Condition Reporting/Monitoring included that it is the policy of the facility that all changes in resident condition will be communicated to the physician and resident representative, and that monitoring residents for changes of condition occurs with each resident observation and if changes are noted, further assessment and notifications. The policy included that any sudden or serious change in a resident condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a request for physician visit promptly and/or acute care evaluation, and the responsible party will be notified that there has been a change in the resident's condition and what steps are being taken. The policy included that all attempts to reach the physician and responsible party will be documented in the nursing progress notes and that documentation will incude time and response.

Based on staff interviews, review of records and review of policies and procedures, the facility failed to ensure that a comprehensive care plan for one resident (#2) was updated to include interventions to prevent the development of DTI's (Deep Tissue Injuries) on bilateral heels and the right lateral foot, and prevent worsening of the DTI on the right heel. The deficient practice could result in care plans not being updated to include pressure ulcer prevention interventions for multiple residents. Findings include: Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. An Initial Admission Record dated April 21, 2020 included that the resident had been admitted for [MEDICAL CONDITION] femur, was alert and oriented at times and able to follow simple directions. The assessment included that the resident had normal skin and heels intact. A Braden Scale assessment for predicting pressure sore risk dated April 21, 2020 included that the resident had a risk score of 16.0, which indicated that resident #2 was at low risk for developing a pressure sore. A care plan dated dated April 22, 2020 included that the resident had potential/actual impairment to skin integrity (which was a surgical incision). The care plan included the following interventions: -Encourage good nutrition and hydration in order to promote healthier skin. -Use caution during transfers and bed mobility to prevent to prevent striking arms, legs and hands against any sharp or hard surface. The care plan did not include any additional interventions that addressed preventing pressure sores in the feet or heels. An Admission MDS (Minimum Data Set) assessment dated [DATE] included that resident #2 had a BIMS (Brief Interview for Mental Status) score of 7, which indicated that he was severely cognitively impaired, required extensive physical assistance from two or more persons for bed mobility and had functional impairment in range of motion in his lower extremity on one side. The assessment included that resident #2 had malnutrition and was at risk for pressure ulcers. The assessment included that resident #2 had no unhealed pressure ulcers. A Braden Scale assessment dated [DATE] included that the resident now had a score of 14.0 which indicated that the resident was now at moderate risk for developing pressure sores. With the change in score, no update to care plan for pressure ulcer prevention was noted. A nursing note dated May 1, 2020 at 9:54 a.m. included that resident #2 had reported pain to bilateral heels while in therapy and had suspected DTI's (Deep Tissue Injuries) to both heels which were dark purple in color, painful and non-blanchable. The note included that resident #2 also had a suspected DTI to the right lateral foot. A Weekly Pressure Ulcer Review dated May 1, 2020 included an assessment of the following SDTI's (Suspected Deep Tissue Injury) that were present on that date, and had not been present upon admission: -The left heel had a SDTI that measured 2.0 cm. (Centimeters) x 2.0 cm. with defined margins and peripheral tissue [MEDICAL CONDITION] and was treated with skin prep daily. -The right heel had a SDTI that measured 6.0 cm. x 4.0 cm. with defined margins, peripheral tissue [MEDICAL CONDITION] and was treated with skin prep daily. -The right lateral foot had a SDTI that measured 2.5 cm. x 3.0 cm. with defined margins and peripheral tissue [MEDICAL CONDITION] and was treated with skin prep daily. Review of clinical record form did not reveal that any additional interventions were added to the care plan on May 1, 2020 that addressed the newly assessed DTI's to the bilateral heels and the lateral right foot. A Weekly Pressure Ulcer Review dated May 8, 2020 included the following: -The left heel DTI measured 2.0 cm. x 2.0 cm. with defined margins and peripheral tissue [MEDICAL CONDITION]. -The right heel had a DTI that now measured 7.0 cm. x 4.0 cm. with defined margins and peripheral tissue [MEDICAL CONDITION]. -The right lateral foot had a DTI that measured 2.5 cm. x 3.0 cm. with defined margins and peripheral tissue [MEDICAL CONDITION]. The review included that the DTI's continued to be treated with skin prep daily. An IDT (Interdisciplinary Team Note) dated May 8 2020 at 10:14 a.m. included that a meeting had been held to discuss the resident's wounds. The note included that resident #2 had dementia, diabetes, muscle wasting and hypertension and that the resident was placed on a low air loss mattress on admission with orders to float heels while in bed. The note included that the resident now presented with bilateral DTI's to heels despite preventive measures in place, and that the wound nurse had placed treatment orders and educated staff on wound healing and the plan of care. Review of the clinical record did not reveal that the care plan for impairment to skin integrity had been updated to include any additional interventions added to the care plan on May 8, 2020 that addressed the DTI on the left heel and the lateral right foot, and the worsening of the DTI on the right heel. A Daily Skilled Note dated May 11, 2020 at 11:26 p.m. included that the right heel had a pressure ulcer that was now 7 cm. in diameter, with no pain, and was black in color, and that the skin condition was a new onset. The note included that a pressure reducing device for the bed and the chair, and turning and repositioning was being used to maintain skin integrity. Review of the clinical record did not reveal that the care plan for impairment to skin integrity had been updated to include any additional interventions added to the care plan on May 11, 2020 that addressed the continued worsening of the DTI on the right heel. A nursing note dated May 17, 2020 at 10:00 a.m. included that resident #2 had been found unresponsive and was transferred to the hospital. During an interview conducted on June 22, 2020 at 10:00 a.m. with a Wound Nurse/staff #37, the nurse stated that when the resident was in the facility in May 2020, the ADON (Assistant Director of Nursing) was writing care plans, and she did not know if the care plan had been updated (to include interventions for the DTI's on the heels and the right foot). During an interview conducted on June 22, 2020 at 2:30 p.m. with the DON (Director of Nursing/staff #146) she stated that care planning is done according to CMS standards with changes in condition and during care plan conferences and 14 days after admission with the Admission MDS Assessment. The DON stated that the wound nurse and the nurse on the floor can update care plans as needed. During an interview conducted on June 23, 2020 at 12:12 p.m. with the DON she stated that there was no explanation for the resident to not have a care plan for wound prevention that included the heels and feet other than that is something they identified and that they were updating their processes for wound care at that time. A policy and procedure titled Comprehensive Person-Centered Care Planning that included it is the policy of the facility that the Interdisciplinary Team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and time frames to meet a resident's medical, nursing, mental and psychosocial needs are identified in the comprehensive assessment. The policy included that the care plan will be revised as needed, and interventions will be implemented, and the plan of care will be reviewed and/or revised by the IDT after each assessment.

Based on clinical record reviews, staff interviews and review of policies and procedures, the facility failed to ensure that one of three sampled resident's (#2) was provided the necessary care and services in accordance with professional standards of care to prevent new pressure ulcers from developing and to promote healing. The deficient practice resulted in the development of DTI's (Deep Tissue Injuries) on the resident's bilateral heels, right lateral foot and later worsening of the pressure wound on the resident's right heel. Findings include: Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. An Initial Admission Record dated April 21, 2020 included that the resident had been admitted for [MEDICAL CONDITION] femur, was alert and oriented at times and able to follow simple directions. The assessment included that the resident had normal skin and heels intact. The assessment included that resident #2 had a surgical incision on the right thigh and blanchable redness on the coccyx. physician's orders [REDACTED].#2 to have a weekly Braden Scale assessment weekly for 4 weeks, weekly skin evaluation, and to encourage the resident to offload heels while in bed as tolerated. Only 2 Braden Scales were conducted instead of the ordered four. A Braden Scale assessment for predicting pressure sore risk dated April 21, 2020 included that the resident had no impairment of sensory perception and responds to verbal commands, occasionally moist skin, very limited ability to make changes in body position, adequate nutrition intake, and a potential problem for friction and sheer. The assessment included a risk score of 16.0, which indicated that resident #2 was at low risk for developing a pressure sore. A care plan dated April 22, 2020 included that the resident had potential/actual impairment to skin integrity (surgical incision) and included multiple interventions. There were no additional details in the care plan that addressed preventing pressure sores on the feet or heels by off loading heels in bed as tolerated as ordered by the physician. CNA (Certified Nursing Assistant) task flow sheets dated April 22, to April 26, 2020 included multiple daily entries that were marked M which indicated that the resident had a pressure relieving mattress. No other pressure reducing devices were recorded during this period that included offloading of heels. Review of the TAR (Treatment Administration Record) dated April 22, through April 27, 2020 revealed daily entries each shift which included that the resident was encouraged to offload heels while in bed as tolerated. There was no entry on the TAR that indicated that the resident's heels had been offloaded during this same period. An Admission MDS (Minimum Data Set) assessment dated [DATE] included that resident #2 had a BIMS (Brief Interview for Mental Status) score of 7, which indicated that he was severely cognitively impaired, required extensive physical assistance from two or more persons for bed mobility and had functional impairment in range of motion in his lower extremity on one side. The assessment included that resident #2 had malnutrition and was at risk for pressure ulcers. Regarding pressure relieving device for the bed and turning, Section M1200 of the MDS assessment included the section titled: Pressure relieving device for the bed, and Turning and repositioning program. Section M1200 included None of the above were provided. The assessment included that resident #2 had no unhealed pressure ulcers. The second Braden Scale assessment dated [DATE] included almost the same identified risk factors for predicting pressure sores as the previous Braden Scale assessment. However, this assessment included the risk score was now 14.0, which indicated that the resident was at moderate risk for developing pressure sores. Review of the care plan revealed that the care plan for skin impairment had been updated on April 27 to include a focus that the resident had actual impairment to skin integrity related to a surgical incision on the right thigh and redness to the coccyx. The care plan did not include any additional interventions that addressed pressure ulcer prevention for the feet or heels even though the physician ordered staff to encourage off loading the residents heels. A CNA task flow sheet included one entry dated April 27, 2020 at 8:34 a.m. was marked FH which indicated that the resident's heels were floated. There were no additional pressure reducing interventions at 8:34 a.m Additional entries dated April 27, 2020 were only marked M. A Physical Therapy note dated April 28, 2020 included that resident #2 required maximum assistance for bed mobility and was unable to follow commands. To encourage off loading heels would have been difficult for the resident to perform on his own. CNA task flow sheets entries dated April 28, 29, and 30, 2020 were only marked with M and did not include additional data that any additional pressure relieving devices or floating heels had been provided. Review of the TAR (Treatment Administration Record) dated April 28, through April 30, 2020 revealed daily entries each shift which included that the resident was encouraged to offload heels while in bed as tolerated. Further review of the clinical record did not reveal additional information regarding how resident was able to offload his heels (with encouragement), or the method used to offload his heels to prevent pressure injury due to the resident having a BIMS score of 7, muscle wasting and a fractured right hip, recent joint replacement surgery and needing assistance of two for extensive assistance for movement in bed. A Daily Skilled Note dated April 30, 2020 at 5:55 p.m. included that the resident's overall skin description was within normal range and fragile related to his age. A NP/PA (Nurse Practioner/Physician's Assistant) Progress Note dated May 1, 2020 at 9:54 a.m. included that resident #2 had been admitted with a primary medical history that included dementia, and that his mentation waxes and wanes and that the resident had heel pain and had started on heel prep and off loading. A nursing note dated May 1, 2020 at 9:54 a.m. included that resident #2 had reported pain to bilateral heels while in therapy and had a suspected DTI's (Deep Tissue Injuries) to both heels which were dark purple in color, painful and non-blanchable. The note included that resident #2 also had a suspected DTI to the right lateral foot, but no description of the wound was given. The note included that the wound nurse was aware of the suspected DTI's, the physician was notified and there were new (physician's) orders for skin prep every shift, an air mattress and a wedge cushion. A Weekly Pressure Ulcer Review dated May 1, 2020 included an assessment of the following SDTI's (Suspected Deep Tissue Injury) that were present on that date, and had not been present upon admission: -The left heel had a SDTI that measured 2.0 cm. (Centimeters) x 2.0 cm. with defined margins and peripheral tissue [MEDICAL CONDITION] and was treated with skin prep daily. -The right heel had a SDTI that measured 6.0 cm. x 4.0 cm. with defined margins, peripheral tissue [MEDICAL CONDITION] and was treated with skin prep daily. -The right lateral foot had a SDTI that measured 2.5 cm. x 3.0 cm. with defined margins and peripheral tissue [MEDICAL CONDITION] and was treated with skin prep daily. physician's orders [REDACTED]. The physician's orders [REDACTED]. A Nursing Note dated May 1, 2020 at 10:26 p.m. included that the resident was on close observation for bilateral heels DTI's and a DTI to the right lateral foot. The note included that treatment had been provided as per physician's orders [REDACTED]. The note included air mattress delivery pending. Which indicates prior notations that they were using a special mattress was incorrect. A Daily Skilled Note dated May 1, 2020 at 5:55 p.m. included that the overall skin condition was within normal range and that there were no active symptoms effecting the integumentary system observed. However, the note also included that resident #2 had skin ulcer/injury which was located on both heels and was suspected DTI (Deep Tissue Injury) and that a turning and repositioning program was being used to maintain skin integrity. Again no mention of the right lateral foot ulcer. Review of the clinical record revealed the following eMAR (electronic Medication Administration Record) change of condition notes: -An eMAR note dated May 3, 2020 at 12:28 p.m. included that the resident had darkened areas to bilateral heels, was encouraged to float hells while in bed, and had a pressure mattress on the bed. -An eMAR note dated May 3, 2020 at 4:28 p.m. included that the resident had heels floating while in bed. -An eMAR note dated May 4, 2020 at 8:56 included that the resident had DTI's on bilateral heels and the right lateral foot, and that the wound(s) had not opened. Review of the clinical record revealed the following Daily Skilled Notes: -A Skilled Note dated May 2, 2020 at 7:55 p.m. included that no active symptoms effecting the integumentary system had been observed. -A Skilled Note dated May 3, 2020 at 5:55 p.m. included that resident #2 had open [MEDICAL CONDITION] located on bilateral heels, but no descriptions were given of the wound beds of the heel wounds or surrounding skin. -Skilled Notes dated May 4, 5, and 6, 2020 included identical entries that overall the resident's skin was intact, and that there were no active symptoms effecting the integumentary system. No mention of the wound on the right lateral foot was given on May 3, 4 or 5th. An entry in the TAR for May 6, 2020 included an entry space for the weekly Braden Scale assessment dated [DATE] which had been initialed by the nurse that it had been completed. However, continued review of the clinical record did not reveal evidence that a Braden Scale had been completed on that date. A Weekly Pressure Ulcer Review dated May 8, 2020 included the following: -The left heel DTI measured 2.0 cm. x 2.0 cm. with defined margins and peripheral tissue [MEDICAL CONDITION]. No description of the wound bed was given that was previously mentioned as opened. -The right heel had a DTI that had grown larger and now measured 7.0 cm. x 4.0 cm. with defined margins and peripheral tissue [MEDICAL CONDITION]. Again no description of the wound bed was given. -The right lateral foot had a DTI that measured 2.5 cm. x 3.0 cm. with defined margins and peripheral tissue [MEDICAL CONDITION]. The review included that the DTI's continued to be treated with skin prep daily. Review of the clinical record did not reveal that an additional Weekly Pressure Ulcer Review, or that a wound assessment that included measurements, staging or description of each pressure wound had been recorded after May 8, 2020. The next weekly wound assessments should have been conducted on May 15, 2020, the measurements on May 8th was the last assessment before the resident was sent to the hospital. Physicians orders dated May 8, 2020 included an order for [REDACTED]. An IDT (Interdisciplinary Team Note) dated May 8 2020 at 10:14 a.m. included that a meeting had been held to discuss the resident's wounds. The note included that resident #2 had dementia, diabetes, muscle wasting and hypertension and that the resident was placed on a low air loss mattress on admission with orders to float heels while in bed. The note included that the resident now presented with bilateral DTI's to heels despite preventive measures in place, and that the wound nurse had placed treatment orders and educated staff on wound healing and the plan of care. The air loss mattress was not ordered until May 1st and no orders to offload heels were given only that staff were to encourage off loading of heels. The IDT note dated May 8, 2020 did not include any additional details regarding whether the bilateral DTI's to the resident's heel were unavoidable or not. Review of the clinical record through May 8, 2020 did not reveal that any additional interventions had been added to the resident's care plan regarding wounds on bilateral heels or the lateral right foot. Review of the TAR for May 2020 revealed entries for wedge cushion to offload heels while in bed, and the use of the low air loss mattress which had a start date of May 8, 2020, and there were no documented entries for the low air loss mattress and wedge cushion prior to May 8, 2020. Skilled Notes dated May 8, 9, and 10, 2020 included identical entries that overall the resident's skin was intact, and that there were no active symptoms affecting the integumentary system. A Daily Skilled Note dated May 11, 2020 at 11:26 p.m. included that the right heel had a pressure ulcer that was now 7 cm. in diameter, with no pain, and was black in color, and that the skin condition was a new onset. The note included that a pressure reducing device for the bed and the chair, and turning and repositioning was being used to maintain skin integrity. No indication of the size of the left heel with description of the wound or the right lateral foot wound. No description of those wounds in detail since May 8, 2020. The clinical record did not include any additional information that the physician had been notified of the worsened right heel wound which previously had been assessed as a DTI that measured 6.0 cm. x 4 cm. and had worsened to a pressure ulcer that was 7.0 cm. in circumference, and was black and non-painful or that additional treatments or interventions had been obtained for the resident's right heel after the nurse had assessed the wound. Skilled Notes dated May 12, 13, and 14 2020 included identical entries that overall the resident's skin was intact, and that there were no active symptoms affecting the integumentary system. A nursing note dated May 17, 2020 at 10:00 a.m. documented that resident #2 had been found unresponsive and was transferred to the hospital. During an interview conducted on June 17, 2020 at 1:35 p.m. with the DON (Director of Nursing/staff #146) the DON stated that when a resident is found to have a DTI on the heels, the nurse will assess the DTI every shift and document the assessment's in the Daily Skilled Notes. The DON stated that the nurse will obtain orders to treat the DTI immediately and that the resident's heels will be floated with a wedge cushion or pillows. The DON stated that there was a wound meeting with the wound nurse, the dietitian, and the ADON (Assistant Director of Nursing) and there was a discussion whether or not the resident's pressure wounds were avoidable. The DON stated she did not remember any additional specific details regarding the meeting. During an interview conducted on June 22, 2020 at 10:00 a.m. with a Wound Nurse/staff #37, the nurse stated that resident #2 was brought to her attention by a therapist because he had dark purple discolorations on his feet. The wound nurse stated she was sure that the resident had a low air loss mattress on admission and that his heels were being offloaded by placing pillows under his heels. However, the nurse stated that the resident was not capable of offloading his heels independently and that staff would have had to offload his heels for him. The wound nurse stated that weekly pressure ulcer reviews are to be every 7 days and that she did not remember why she had not done a weekly pressure ulcer review after May 8, 2020. The wound nurse stated that she should have written a note about the resident refusing the assessment. During an interview conducted on June 22, 2020 at 2:30 p.m. with the DON she stated that low air loss mattresses and wedge cushions are ordered from a supply company after the physician verifies the order, and that sometimes there are delays obtaining these items due to COVID-19 issues with supplies. The DON stated that resident care plans can be updated by the wound nurse, or any nurse on the floor and that nurses can update Braden Scale assessments as needed. An E-Mail message received from the DON on June 22, 2020 at 4:24 p.m. included that an unavoidable pressure ulcer injury assessment which had not previously been included in the clinical record, had been attached to the electronic clinical record today. Review of this newly discovered document that was unavailable early in the investigation or mentioned, revealed a document titled 5-15-2020 Unavoidable Pressure Injury. The PDF had been uploaded into the clinical record on June 22, 2020 by the DON. A form titled IDT Review-Unavoidable Pressure Injury(s) & Skin Integrity Risk which had been uploaded on June 22, 2020, by the DON, included a statement that read The resident has and continues to receive all necessary care and services to attain/maintain the highest practicable physical, mental and psychosocial well being in accordance with the individual assessment and plan of care. The resident's medical [DIAGNOSES REDACTED]. Furthermore, the resident is at risk for delayed, poor healing due to the same factors. The Risk form included that the resident's pressure ulcers were unavoidable because of impaired mobility and the following clinical conditions-Severe [MEDICAL CONDITIONS] -Diabetes Mellitus -Continuous Urinary Incontinence (the wounds were on the bilateral feet, hard to believe that urine would cause foot problems it would usually start on the resident's sacral region first and no problems identified) -Chronic Liver and/or [MEDICAL CONDITION] -Muscle Wasting The Risk form included a list of additional risk factors including dementia, hypertension and [MEDICAL CONDITION]. The Risk form also included the following of list of interventions that had been put into place: -Low Air Loss Mattress (not applied until May 3rd according to documentation) -Wedge Cushion (unknown when the cushion was received) -Wheelchair Cushion (protects the sacrum and coccyx areas not the feet) -Supplements -Treatment Order -Elevating Legs (no documentation that this was ever done) -Offloading Heels (only charted once prior to May 8th order to offload) The Risk form was signed on May 15, 2020 by the DON, ADON, Wound Nurse and MDS Nurse, and signed on May 22, 2020 by a Dietitian. During an interview conducted on June 23, 2020 at 10:00 a.m. with the wound nurse/Staff #37, she stated that resident #2 was at risk for developing pressure ulcers because he was unable to move or reposition himself in bed and he wasn't eating well and that because of that the pressure ulcers were unavoidable. During an interview conducted on June 23, 2020 at 12:12 p.m. with the DON she stated that there was no explanation for the resident to not have a care plan for wound prevention that included the heels and feet other than that is something they identified and that they were updating their processes for wound care at that time. A policy and procedure titled Documenting and Charting included that it is the policy of the facility to provide a complete account of the resident's care, treatment, response to the care signs and symptoms etc., as well as the progress of the resident's care. The policy also included that the policy is to provide nursing service personnel with a record of the physical and mental state of the resident and guidance to the physician in prescribing appropriate medications and treatment. A policy and procedure titled Wound Management included that it is the policy of the facility that a resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the individual's clinical condition or other factors demonstrate that a developed pressure ulcer was unavoidable. The policy included that an unavoidable pressure ulcer is one that developed even though the provider evaluated the individual's clinical condition and pressure risk factors; defined and implemented interventions that are consistent with individual needs and goals and recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate.

Based on record reviews, staff interviews and review of policies and procedures, the facility failed to ensure that a fall with minor injuries for one resident (#3) were promptly reported to the physician and the resident's family member. The deficient practice had the potential for physician's and resident representatives not being informed of falls and changes in condition, which could result in prompt medical intervention for falls not being provided timely. Findings include: Resident #3 was admitted on (MONTH) 2, 2019 and readmitted on (MONTH) 11 2019 with [DIAGNOSES REDACTED]. A careplan for self care performance deficit related to impaired mobility and weakness dated (MONTH) 11, 2019 listed multiple interventions including to monitor/document/report to the physician PRN (as needed) any potential for improvement, reasons for self-care deficit, expected course and declines in function. A Fall Risk Evaluation dated (MONTH) 10, 2019 included that resident #3 was alert and oriented to time, place and person, had a history of [REDACTED]. The evaluation included a fall risk score of 11, which indicated that the resident was at high risk for falling. An X-Ray report dated (MONTH) 19, 2019 at 12:53 p.m. included that X-rays of the right elbow and right knee were negative for fracture or dislocation. A physician's progress note dated (MONTH) 19, 2019 at 9:07 p.m. included that the resident had fallen on the day prior to the note and was complaining of right knee pain. A nursing note dated (MONTH) 20, 2019 included that the physician had been notified of X-Ray results which were negative and that the resident was on change in condition status [REDACTED]. AN IDT (Inter-Disciplinary Team) note dated (MONTH) 20, 2019 at 12:42 p.m. included that the IDT Team had met to review a non-injury fall on (MONTH) 18, 2019 and that the careplan had been updated. A nursing note dated (MONTH) 20, 2019 at 11;35 a.m. included that the resident had been assisted onto the commode by a CNA (Certified Nursing Assistant) and had slipped off of the commode onto the floor. The note included that the resident had not reported pain to two CNA's mentioned in the note and quoted a statement from the resident that she had dropped onto the floor in the bathroom and was then put into a wheelchair. The note included that a skin assessment had been provided and the resident had abrasions to the right knee, right knuckles, right elbow and a laceration to the top right lip. The note included that a physician had been notified for an X-Ray, and that the resident had notified her daughter, when the daughter had visited. Continued review of the clinical record did not reveal any additional documentation regarding details of what had transpired immediately after the fall on (MONTH) 18, 2019 including when the resident's nurse, or when the resident's daughter and the physician had been notified of the fall with injuries. During an interview conducted on (MONTH) 29, 2020 at 11:20 a.m. with a family member of resident #3, she stated that she had been told by her mother that she had fallen in the bathroom and stated that staff had not notified her of the fall. The family member stated that she then asked the nurse about the fall, and that later that afternoon, the Director of Nursing called her and told her about the resident's fall. The family member stated that on past occasions when the resident has fallen, they always notify her that she has fallen. An interview was conducted on (MONTH) 29, 2020 at 11:35 a.m. with an LPN (Licensed Practical Nurse/staff #20) who stated that if a resident falls, the CNA is to report the fall immediately to the nurse, and the nurse assesses the resident for injuries immediately, then notifies the physician and the resident's family of the fall right away. During an interview conducted with the DON (Director of Nurses/#63) on (MONTH) 29, 2020 at 12:35 p.m. who stated that the CNA's did not report the resident's fall in the bathroom to the nurse when the resident fell . The DON reviewed an incident record and stated that the resident fell on (MONTH) 18, 2019 at 2:00 p.m. The DON stated that the resident's daughter called a unit manager the next morning (December 19, 2019) and asked about the resident's fall and that is when they found out that the resident had fallen on (MONTH) 18, 2019. An Incident Report dated (MONTH) 18, 2019 and revised on (MONTH) 20, 2019 was provided upon request. Review of the report revealed that the resident fell on (MONTH) 18, 2019 at 2:00 p.m., resident's family member was notified of the fall on (MONTH) 19, 2019 at 8:46 a.m. and the resident's physician was notified of the fall on (MONTH) 19, 2019 at 10:45 a.m. During an interview conducted on (MONTH) 29, 2020 at 2:52 p.m. with a CNA/staff #35 who stated that after the resident fell on (MONTH) 18, 2019 she did not tell the nurse that the resident had fallen because she thought the other CNA was going to tell the nurse about the fall. The CNA stated We made a mistake. I should have said something. A policy and procedure titled Change of Condition Reporting included a statement that it is the policy that all changes in resident condition will be communicated to the physician. The policy included that unusual signs and symptoms will be communicated to the physician promptly, and that all attempts to reach the physician and responsible party will be documented in the nursing progress notes. A policy and procedure titled Fall Management System included that it is the policy of the facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. The policy included that when a resident sustains a fall, a physical assessment will be completed by a licensed nurse, with results documented in the Nursing Progress Notes. The policy included that the Attending Physician and family/responsible party shall be notified of the fall and the resident's status.

Based on observations, staff interviews, and policy review, the facility failed to ensure their system of medication records enabled accurate reconciliation and accounting for all controlled medications. The deficient practice could result in misappropriation of residents' medications. Findings Include: -During an observation conducted on (MONTH) 24, 2019 at 3:11 p.m. with the Charge Nurse/ Registered Nurse (RN/staff #94) of the medication cart on the 200 odd hall, 12 medication cards for a resident that had expired were observed wrapped in the reconciliation sheets separate from the rest of the controlled medications inside the locked drawer. The wrapped medication cards included a card of 25 [MEDICATION NAME] (opioid) 5 milligram tablets. Following this observation, an interview was conducted with staff #94. Staff #94 stated that the medication cards wrapped in the reconciliation sheets are medications of residents that have been discharged or have had their orders changed. She stated that the discontinued controlled medications stay in the locked drawer in the medication carts until they are destroyed or given to the Director of Nursing (DON). Staff #94 further stated that wrapped medications are not reconciled at shift change with the other controlled medications. She stated that the wrapped medications are counted by two nurses when they are removed from the active medications and put aside for destruction and again at the time of destruction. Staff #94 further stated that the discontinued medications are only in the medication carts for a short time. -An observation was conducted of the medication cart on the 200 even hall on (MONTH) 24, 2019 at 3:20 p.m. with a RN (staff #31). Within the separately locked drawer of the medication cart, 14 medications cards wrapped in the reconciliation sheets were observed separated from the other controlled medications. Following this observation, an interview was conducted with staff #31. Staff #31 stated that the discontinued controlled medications stored in the locked drawer in the medication cart are waiting to be destroyed, are not reconciled at shift change. During an interview conducted with a RN (staff #5) on (MONTH) 24, 2019 at 3:30 p.m., the RN stated that only the active controlled medications are reconciled at shift change. She stated that once controlled medications are discontinued, they are stored in the medication cart until they are removed for destruction. -An observation was conducted of the #2 medication cart on the 400 hall on (MONTH) 24, 2019 at 3:41 p.m. with a RN (staff #147). 10 medication cards wrapped in reconciliation sheets were observed in the separately locked drawer of the medication cart separate from the other controlled medications. Following this observation, an interview was conducted with staff #147. Staff #147 stated that the discontinued controlled medications are not reconciled between shifts while waiting for destruction. An interview was conducted with a Licensed Practical Nurse (LPN/staff #144) on (MONTH) 25, 2019 at 9:32 a.m. The LPN stated that the discontinued controlled medications are picked up a couple of times a week, when the nurse let the designated staff know that there are discontinued narcotics. During another interview conducted with the charge nurse (RN/staff #94) on (MONTH) 25, 2019 at 9:41 a.m., the charge nurse stated that the amount of time a discontinued controlled medication remain in the medication cart depends on how many discontinued controlled medications the nurse has stored in the cart and when the nurse is able to notify the DON that controlled medications need to be removed from the cart. Staff #94 stated that the discontinued controlled medications are removed from the medication carts a couple of times a month. An interview was conducted with the DON (staff #159) on (MONTH) 25, 2019 at 9:50 a.m. She stated that discontinued controlled medications remain in the locked narcotic drawer in the medication carts until they are removed by two nurses and placed under double lock in her office for destruction. The DON stated that there is no set schedule for removal of discontinued controlled medications from the medication carts. The DON also stated the expectation is that all controlled medications, active and discontinued, in the medication carts should be reconciled at shift change according to facility policy. She further stated that by not reconciling the discontinued controlled medications at shift change increases the risk for drug diversion. Review of the facility's policy for Controlled Medications revealed the Director of Nursing Services and the consultant pharmacist will maintain the facility's compliance with federal and state laws and regulations in the handling of controlled medications. The policy also revealed that at each shift change, a physical inventory of all controlled medications is conducted by two licensed nurses and is documented on an audit record.

Based on facility documentation review, manufacturer's user's guide, staff interviews and policy review, the facility failed to ensure calibration of glucometer machines on 4 of 6 medication carts was performed daily and/or weekly. The deficient practice could result in blood sugar readings that are not accurate. Findings include: Review of the facility's Blood Glucose Monitoring: Daily Quality Control Records revealed the following: Hall 300: January 2019 record was missing 4 days of testing Hall 400: October (YEAR) record was missing 9 days of testing November (YEAR) was missing 10 days of testing December (YEAR) was missing 11 days of testing January 2019 was missing 16 days of testing February 2019 was missing 21 days of testing, no testing the week of (MONTH) 10-16 March 2019 was missing 4 days of testing April 2019 was missing 7 days of testing May 2019 was missing 12 days of testing June 2019 was missing 12 days of testing July 2019 was missing 5 days of testing Hall 500: October (YEAR) was missing 12 days of testing November (YEAR) was missing 10 days of testing December (YEAR) was missing 10 days of testing January 2019 was missing 16 days of testing, no testing the week of (MONTH) 27-February 2 February 2019 was missing 22 days of testing, no testing the week of (MONTH) 10-16 March 2019 was missing 4 days of testing April 2019 was missing 9 days of testing May 2019 was missing 12 days of testing June 2019 was missing 15 days of testing, no testing the week of (MONTH) 23-29 July 2019 was missing 9 days of testing Hall 600: March 2019 was missing 19 days of testing, no testing the weeks of (MONTH) 3-9 and 10-16 April 2019 was missing 18 days of testing, no testing the week of (MONTH) 21-27 May 2019 was missing 25 days of testing, no testing the week of (MONTH) 26-June 1 June 2019 was missing 18 days of testing July 2019 was missing 7 days of testing An interview was conducted with the Assistant Director of Nursing (ADON/staff #61) on (MONTH) 24, 2019 at 1:49 p.m. The ADON stated that the quality control testing is supposed to be performed daily on the glucometers. She stated that the testing ensures they are getting accurate blood sugar readings and that insulin dependent residents are receiving accurate dosages of insulin. After reviewing the glucose monitoring records for hall 400 and 500, the ADON stated quality control monitoring was not performed daily. An interview was conducted with the Director of Nursing (DON/staff #159) on (MONTH) 25, 2019 at 8:41 am. The DON stated her expectation is that glucometer quality control testing be performed every night on the night shift on every glucometer being used. She stated that the incomplete quality control testing forms did not meet her expectation. The DON stated that not performing the glucometer quality control testing daily could result in blood sugar readings that are not accurate, which would put residents at risk for high/low blood sugars, receiving incorrect dosages of insulin, and hospitalization . Review of the facility's policy on Blood Glucose Monitoring instructed to refer to the Manufacturer's Specific Equipment Instructions for care and use of the blood glucose monitor. Review of the Manufacturer's user's guide for the glucometers revealed the purpose of the control solution testing is to validate that the glucometer is working properly with the test strips. The policy also revealed that control solution testing should be performed when using the meter for the first time, using a new package of blood glucose control strips, and at least once a week to verify that the meter and test strips are working properly together.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure one of five sampled residents (#69) and/or their representative were informed of the risks and benefits of a [MEDICAL CONDITION] medication prior to administration. The deficient practice can result in residents and/or residents' representatives not being aware of the benefits and the risks of taking psychoactive medications. Findings include: Resident #69 was admitted to the facility on (MONTH) 26, 2019, with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A care plan dated (MONTH) 13, 2019 included the resident had an anxiety disorder. The goal was for the resident to show decreased episodes of anxiety through the review date. Interventions included giving antianxiety medication as ordered, monitoring for side effects, monitoring/recording occurrence of target behavior symptoms, and implementing non-pharmacological interventions. The quarterly Minimum Data Set assessment dated (MONTH) 3, 2019 revealed the resident scored a 4 on the Brief Interview for Mental Status, indicating severe cognitive impairment. Review of the (MONTH) and (MONTH) 2019 Medication Administration Records revealed the resident was administered [MEDICATION NAME] 0.5 mg on a regular basis. However, review of the clinical record revealed no documentation that consent was obtained for the [MEDICAL CONDITION] medication in (MONTH) or (MONTH) 2019 from the resident's representative prior to administering, nor was there documentation that the resident's representative was informed of the risks and benefits of receiving an antianxiety medication before being administered. Further review of the clinical record revealed a verbal consent for [MEDICAL CONDITION] medication was obtained on (MONTH) 14, 2019. The documentation included for the administration of [MEDICATION NAME] to decrease anxiety, as evidenced by restlessness. The form included the risks and benefits of the medication. Per the consent, verbal authorization was given by the resident's family member/Power of Attorney. An interview was conducted on (MONTH) 25, 2019 at 9:46 a.m. with a Licensed Practical Nurse (LPN/staff #90). She stated that prior to administration of a [MEDICAL CONDITION] medication; the process is to obtain informed consent. The LPN stated the nurses are able to obtain verbal consent over the phone, but sometimes consents are overlooked, which was possibly the case for resident #69. On (MONTH) 25, 2019 at 10:08 a.m., an interview was conducted with the Director of Nursing (DON/staff #159). The DON stated that her expectation is for the nurses to input the physician's orders [REDACTED]. A facility's policy titled Psychoactive Medication revealed the use of psychoactive medication must first be explained to the resident, family member or legal representative. Consent is to be obtained either from the resident or responsible party if the resident is unable. A verbal consent may be obtained if no responsible person is available. The policy included that the facility must explain in the context of the individual resident's condition and circumstances, the potential risks and benefits of all options under consideration and explain the potential negative outcomes of psychoactive medication.

Based on observations and staff interviews, the facility failed to develop and implement a policy to ensure a notice of employee rights about reporting suspicion of crimes was posted in a conspicuous place. The deficient practice could result in employees not knowing their rights. Findings include: An interview was conducted on (MONTH) 25, 2019 at 9:06 a.m. with a Certified Nursing Assistant (CNA/staff #22). The CNA stated that she has not seen a posting in the facility regarding employees' rights to report suspicion of a crime without fear of retaliation. On (MONTH) 25, 2019 at 9:29 a.m., an interview was conducted with the Administrator (staff #160). The Administrator stated that when employees are hired, they receive information about reporting suspicion of a crime without fear of retaliation in their packets. He stated that he was not aware of this information being posted in the facility. Human Resources (staff #164) joined the interview. Staff #164 stated that she receives notices to post from the Resources department. She stated that the notice of employee rights about reporting a suspicion of a crime should be posted in the hallway where the employees clock in for work. At this time, observations of the employee break room and the hallway where the employees clock in for work were conducted with the Administrator and staff #164. No notice of employee rights about reporting a suspicion of a crime was observed posted. Later that day, staff #164 stated that they do not have a policy about posting a notice of employees' rights regarding reporting a suspicion of a crime in a conspicuous place.

Based on the clinical record review, facility documentation, staff interviews, and policy review, the facility failed to ensure safety measures were in place for one resident (#132) who fell . Findings include: Resident #132 was admitted to the facility on [DATE], with Alzheimer's disease, heart failure and chronic kidney disease. Review of the clinical record revealed the resident was identified to be at risk for falls. A physician's orders [REDACTED]. Review of the significant change MDS (Minimum Data Set) assessment dated [DATE], revealed the resident had severe cognitive impairment and required extensive assistance with bed mobility and ADLs (activities of daily living). A fall Care Plan dated December 17, 2015, identified the resident was at risk for injury from falls, due to weakness and poor balance. Interventions included to keep the bed in the low position with wheels locked, fall mats next to the bed and for a bed alarm. Further review of the clinical record revealed nursing documentation that stated the resident slid from the bed to the floor on February 5, 2016, and complained of right hip and thigh pain. According to the facility's investigative documentation, the resident slipped from her bed on February 5, 2016. The fall was witnessed by a family member of the resident's roommate. He stated the resident was trying to close the curtain between the beds. The report further included that a restorative nursing assistant (RNA/staff #28) was on duty when the resident fell and the resident was laying on the right side between the beds. The RNA reported that at the time of the fall, the resident's bed was elevated to knee high and no bed alarm was in place. A certified nursing assistant (CNA/staff #38) reported that the resident was laying on the floor on the right side of the bed and the bed was elevated app. 3 ft, and there was no bed alarm on the bed. The report also included that the floor mat was only on one side (left side) of the bed. Per the report, the resident sustained [REDACTED]. Clinical record documentation showed that the resident was sent to the hospital on February 5, 2016, as the resident had a fractured hip. An interview was conducted on March 9, 2016 at 9 a.m. with staff #28, who was the first staff to find the resident on the floor on February 5. She stated the bed was not in a low position and that a bed alarm was not in place. An interview was conducted with CNA #38 on March 10, 2016 at 2 p.m. She stated that when she entered the resident's room, the bed was not in the lowest position. An interview was conducted with the DON (staff #2) on March 10, 2016 at 3 p.m. She confirmed that the resident's bed was not in the lowest position, when the resident was found on the floor. Review of the Falls Prevention policy revealed that residents will be evaluated for the potential risk of falling so that reasonable and appropriate measures will be taken for each resident to mitigate those risks in order to promote appropriate clinical and multi-disciplinary assessment of falls and fall risk factors and to coordinate management of acute and recurrent falls. The policy further noted that early identification of risk for falls and reduction of multiple falls, enable residents to maintain the highest level of independence in a safe environment, without significant risk or injury. If residents are at risk for falls, the care plan will reflect this and the approaches that are to be taken.

Based on clinical record review, observations, staff interviews, and review of facility policies, the facility failed to ensure that one resident (#171), who entered the facility without a pressure ulcer, was adequately monitored to prevent a facility acquired pressure ulcer. The sample size was two. Findings include: Resident #171 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's Braden Scale dated April 13, 2012, revealed a score of 12 which is considered high risk for the development of pressure ulcers. The Minimum Data Set (MDS) revealed a quarterly assessment which was completed on April 18, 2012. Section M. of the MDS assessment noted that the resident was at risk of developing pressure ulcers. Review of the care plan for risk of skin breakdown dated April 20, 2012, revealed the following interventions: to check for incontinence, clean and dry skin if wet or soiled, perform complete skin assessment and record weekly, perform nutritional screening, use pillows, pads, or wedges to reduce pressure on heels and pressure points, turn/reposition frequently. Review of the Weekly Skin Integrity assessments from April 16, 2012, to May 28, 2012, showed no documented evidence of a pressure ulcer of the right inner heel. Further review of the Daily Skilled Nurse's Notes dated April 13, 2012 through May 8, 2012, revealed "no abnormalities observed" under skin assessment. A physician's orders [REDACTED]. However, the nursing staff continued to document on the Daily Skilled Nurse's Notes "no abnormalities observed" for the skin assessment even after the physician had written orders for a right inner heel pressure ulcer. Review of the resident's care plan for right inner heel 100 percent eschar dated May 9, 2012, revealed the following interventions: skin prep to heel daily, float heels while in bed, notify nurse practitioner. A review of the Wound Evaluation Flow Sheet dated May 9, 2012, revealed a pressure ulcer to the right inner heel that measured 1.5 centimeters (cm) in length by 1.6 centimeters in width that was 100 percent eschar. A physician's orders [REDACTED]. An observation of wound care provided by the licensed practical nurse (LPN) was done on June 12, 2012. Skin prep was applied to the resident's bilateral heels, and the right inner pressure ulcer was measured to be 1.2 cm X .8 cm, purple and blanchable surrounding tissues. At the time of the wound care it was observed that the resident was not wearing the blue off loading boots. The resident's right heel was elevated on a pillow, and the left heel was resting on the bed. During an interview with the LPN immediately following the observation, she stated that the resident was to have the blue boots on while in bed. Review of the facility's policy on skin assessment and wound prevention revealed "...The purpose of the skin assessment is to observe the condition of the resident's skin on admission and on a routine basis. This process not only provides a system for licensed nurses to regularly assess each resident's skin condition, but also provides a means for the nursing assistants to report residents with skin changes.