Every finding on record at Pierz Villa Inc

Based on interview and document review the facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect facility acquired pressure ulcers for 1 of 1 resident (R3) reviewed with a pressure ulcer.Findings include:R3's Face Sheet indicated she admitted to the facility 6/11/26. R3'ds diagnoses included contact dermatitis, pressure ulcers of buttocks right and left, and pressure ulcer of sacral region.R3's hospital Progress Notes dated 6/5/26, identified pressure injuries to right and left heels.R3's Head to Toe Skin assessment dated [DATE], identified blanchable redness to R3's buttocks. The assessment indicated R3 did not have a pressure ulcer.R3's care plan dated 6/11/26, identified a risk for pressure ulcers. The care plan was updated 6/15/26, and indicated multiple stage II (partial-thickness of skin loss, presents as a shallow open ulcer or serum-filled blister) pressure ulcers.R3's Wound Management Detail Reports dated 6/15/26, identified stage II pressure ulcer on the coccyx, stage II pressure ulcer on the gluteal fold, and stage II pressure ulcer on left buttock. Date identified indicated 6/15/26.R3's Wound Management Detail Report dated 6/23/26, identified a stage II pressure ulcer to the right buttock. Date identified indicated 6/23/26.R3's Progress note dated 6/11/26, indicated R3 was admitted with blanchable redness to buttocks. The Progress Note was edited on 6/15 and indicated multiple pressure ulcers to coccyx and left and right buttocks.R3's Progress Note dated 6/14/26, indicated nurse completed buttock care and noted an open area.R3's admission MDS dated [DATE], indicated she was not at risk for developing pressure ulcers and indicated she had one or more unhealed pressure ulcers. The MDS identified three stage II pressure ulcers present on admission to the facility.R3's Wound Management Detail Report dated 6/23/26, identified a stage II pressure ulcer on the right buttock.R3's discharge MDS dated [DATE], identified Five stage II pressure ulcers present on admission.During interview on 7/23/26 at 11:29 a.m., registered nurse (RN)-A stated when completing the MDS, she reviewed the wound care notes and if there were questions, she would have interviewed staff. RN-A stated the wound documentation indicated R3's pressure ulcers were present on admit. RN-A stated the pressure ulcers noted on R3's hospital notes must have healed in the hospital.During interview on 7/23/26 at 11:29 a.m., the director of nursing (DON) stated when coding the MDS, RN-A should have reviewed the admission assessment.

Based on observation, interview and document review, the facility failed to ensure 1 of 2 ice dispensers for resident use were maintained in a clean and sanitary manner. This had the potential to affect all residents residing at the facility. Findings include: During the initial kitchen tour on 1/26/26 at 12:02 p.m., the following was observed and confirmed by the facility Dietary Director (DD). An ice machine located in the kitchen was noted to be approximately half full of ice. The mechanism inside the machine where ice cubes were formed was noted to have a slimy brownish green substance coating the tray. The interior motor mechanism was noted to have a slimy brownish black substance on the pump and the wall immediately adjacent to the pump. During observation and interview on 1/26/26 at 1:30 p.m., DD was observed in front of the empty ice machine and stated she threw out all the ice and was doing a deep clean of the unit. She went on to state the cleaning and maintenance of the ice machines was the duty of the maintenance department and she could not identify when the ice machine had last been cleaned or serviced. During interview on 1/26/26 at 2:22 p.m., maintenance director (MD) stated he cleaned and serviced the ice machine, however, it was not on a routine schedule. MD stated he was unsure how often the ice machine needed to be deep cleaned/sanitized. A document with a handwritten title of ICE MACHINE PM indicated the ice machine had been cleaned 1/30/25, 5/6/25, 9/2/25, and 12/16/25. In the right margin was a handwritten note by each date that said, filter change. Facility policy for ice machine cleaning and maintenance was requested and was not received.

Based on interview and document review, the facility failed to ensure resident trust account statements were provided on at least a quarterly basis for 1 of 1 residents (R34) reviewed for personal fund accounts. Findings include: R34's Face Sheet printed 1/29/26 indicated he was his own person and could make his own financial and medical decisions. During interview on 1/26/26 at 7:04 p.m., R34 stated he had a personal funds account at the facility, however, did not receive any statements for this account. R34 stated he made his own financial decisions and was his own responsible party. R34 stated he could get money from his personal funds account but had 'no idea' how much money he had available as he did not receive a statement reflecting that information. During interview on 01/28/2026 at 11:04 a.m. administrative assistant (AA) stated she was aware there had previously been a tracking system in place to ensure statements were sent however she was unable to locate any system that could identify statements were being sent to residents or their representatives. (AA) went on to state she was unsure of the last time statements were sent to residents or their representatives. During interview on 1/28/26 at 11:13 a.m. facility Administrator stated there had been a delay in the system and it had been a few months since statements were sent to residents or their representatives. Admin stated she became aware of the situation in July but acknowledged statements were not sent until September 2025. Admin stated R34 requested and was given a statement in December 2025 when he requested money from his personal funds account. Admin stated she was unaware of any document that reflected dates and times of statements being sent to residents or their representatives. She went on to say she expected statements to be sent out at least every quarter and when requested by residents. Admin stated it is important to provide residents with these statements to residents so they can manage their financial status and maintain their highest level of independence. A facility policy titled Resident Personal Funds with a last review date of 11/2025 indicated resident personal funds would be deposited into a separate account at the facilities financial institution and would be managed by the facility business office. A monthly statement will be mailed to the party responsible (resident/resident representative).

Based on observation, interview, and document review, the facility failed to ensure a self administration of medications (SAM) assessment was completed for 1 of 1 resident (R45) who had a physician order for a nebulizer.Findings include:R45 was admitted on 1/2726. R45's diagnosis included sepsis syndrome, congestive heart failure, respiratory failure, influenza A, and pneumonia. R45's physician orders indicated an order for Ipratropium-albuterol (combination medication used to treat bronchospasm associated with chronic obstructive pulmonary disease (COPD)) 0.5-2.5 mg (milligram) 3ml (milliliters) inhalation four times a day.An observation on 1/28/26 at 7:56 a.m., trained medication assistant (TMA)-A set up R45's physician ordered medications. TMA-A brought R45's medications to the room. TMA-A gave R45 the oral medications. TMA-A set up R45's nebulizer, put the Ipratropium-albuterol nebulizer solution in the medication cup and screwed it onto the face mask which was put on R45's face. TMA-A turned on the nebulizer machine and left R45 in the room alone. TMA-A went to dispense another resident's medications. At 8:40 a.m. TMA-A stated I check on the resident when the nebulizer is running. TMA-A stated the nebulizer took about ten minutes. TMA-A stated sometimes I sit in the room with the resident until the nebulizer is done. An observation on 1/28/26 at 8:50 a.m., TMA-A went back to R45's room and made sure all the medication was dispensed out of the medication cup. TMA-A turned off the nebulizer machine, took the face mask off of R45. TMA-A had R45 rinse her mouth out and spit into a cup. TMA-A rinsed off the mask and medication cup and let air dry in R45's room.An interview on 1/29/26 at 10:45 a.m. with the case manager (CM)-A stated a SAM was done upon admission if required. CM-A stated I do not always do them but if it is a nebulizer that was ordered I would do an assessment. CM-A stated there was no SAM completed for R45. CM-A stated the registered nurse (RN) that admitted R45 on 1/27/26, must have missed it. CM-A stated the SAM should have been completed before the TMA left R45 alone with the nebulizer running. CM-A stated the TMA should have stayed in the room when the nebulizer was running to make sure all of the medication was given. An interview on 1/29/26 at 12:41 p.m., with the director of nursing (DON) stated a SAM assessment was done with a nebulizer and inhaler physician order. DON stated the nurse should do this assessment upon admit, before they gave the medications, and staff should stay in the room with the resident until the medication was done and until the SAM was completed. The DON stated it was the residents right to be able to administer the medication by themselves and they did not want to take away their rights. The DON stated R45 did not have a SAM, and it would be corrected.The facility policy Self-Administration of Medications and Nebulizers dated 12/25, indicated each resident had the right to self-administer mediation unless the practice was determined unsafe. On admission to the facility, the residents would be informed of the right to self-administer medication. The interdisciplinary team will assess the resident's cognitive, physical and visual ability to carry out this responsibility. Nursing would get an order from the physician for self-administration of medications. Documentation of the ability to self-administer mediations would appear on the resident's care plan and on the electronic medication administration record.

Based on record review and interviews, the facility failed to ensure the skilled nursing facility Advanced Beneficiary Notice (SNFABN-10055) was provided to 1 or 3 residents (R59) reviewed for Beneficiary notifications.Findings include:R59's Perspective payment system Part A Discharge Minimum Data Set (MDS) dated [DATE], indicated R59 was admitted on [DATE] and Medicare Part A discharge date of 8/13/25.R59's Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN), informed R59 services would end on 8/14/25. However, this notice was given outside of the 48 hours prior to services ending requirement and was provided on 9/22/25.On 1/22/26 at 1:14 p.m., the MDS Coordinator (MDSC) stated the facility had struggled to identify the correct payer source for the resident and once they did they had R59 sign an SNFABN, however they were unable to locate form and had R59 sign a new SNFABN on 9/22/25. The MDSC confirmed it was outside the required 48 hours prior to the end of services.On 1/22/25 at 10:18 a.m. the administrator stated their expectation was for the beneficiary notices to be provided to the residents 48 hours prior to the end of their services, and they were important to provide so the residents are aware of their payment changes and they may be responsible for payment.The facility policy was requested and was provided an undated document titled Beneficiary Notice Guidelines which indicated R59 should have received an SNFABN.

Based on interview and document review the facility failed to comprehensively assess or re-assess and, if needed, develop interventions to promote safety and reduce the risk of injury or impairments for 1 of 2 residents (R40) reviewed for assessments. Findings include: Significant change of status minimum data set (MDS) dated [DATE], indicated R40 was admitted to the facility on [DATE], was cognitively intact, displayed no behaviors, and had the following diagnoses: pulmonary embolism (a life-threatening condition that occurs when a blood clot blocks an artery in the lungs), generalized weakness and restless leg syndrome (a neurological disorder that causes uncomfortable feelings in the legs). Additionally, the MDS indicated R40 was dependent on staff for toileting, mobility, transfers, and required substantial assistance for bathing, upper, and lower body dressing. Nursing progress notes indicated R40 had a syncopal episode (a brief loss of consciousness caused by a sudden drop in blood flow to the brain) on 7/5/24, 8/9/24, 9/5/24, and 9/13/24, while being transferred with an e-z stand lift (a device used to assist a person from a sitting to a standing position). R40's medical record lacked evidence of an assessment after each episode, vital signs taken, or re-assessment for transfer status. Further, the care plan lacked interventions to guide staff with safe transfers in the event of a syncopal episode. During interview on 12/11/24 at 10:01 a.m., registered nurse (RN)A stated any resident who had a syncopal episode would immediately be evaluated by staff, have vital signs taken and if the episode happened during a transfer, the resident would be re-assessed for transfer safety. RN-A went on to say it was important to obtain vital signs and assess after a syncopal episode to identify any concerns and determine if a resident needed to be evaluated in an emergency room . RN-A stated if a resident had a history of syncopal episodes, it would be indicated on the care plan and interventions would be in place to ensure staff followed appropriate interventions for the resident. During interview on 12/11/24, at 12:31 p.m. director of nursing (DON) stated she was aware R40 had multiple syncopal episodes. DON stated she expected staff to do an assessment, including vital signs, after any syncopal episode. Furthermore, she expected R40's care plan and the staff pocket care plans to include R40's history of syncopal episodes and include guidelines to direct staff care. DON confirmed R40's medical record lacked evidence of any assessments or vital signs being taken after each syncopal episode. Further, R40's care plan lacked specific staff guidance on syncopal episodes. DON stated it was important to obtain vital signs immediately after a syncopal episode to assist in identifying any significant changes and assess if R40 needed to be transferred to a higher level of care for evaluation. A policy on assessments was requested but not provided. 49657

Based on document review and interview, the facility failed to submit complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data, during 1 of 1 quarter reviewed (Quarter 1), to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. Findings include: Review of the Payroll Based Journal (PBJ) [NAME] Report 1705D identified the following dates triggered for review: 10/21/23, 10/22/23, 10/29/23, and 11/11/23 for failure to have licensed nurse coverage 24 hours per day. Review of applicable nursing staff's timecards on the above-mentioned dates identified licensed nursing staff had worked 24 hours each day, therefore the data submitted in the PBJ to CMS was inaccurate. Interview with the Executive Director (ED) on 3/19/24 identified due to nursing schedules of 12 hour shifts with a half hour break automatically removed from the employee shift it appeared the nurse only was working 11.5 hours, therefore data submitted through PBJ specifications established by CMS was inaccurate.

Based on interview and document review, the facility failed to ensure 4 of 5 residents (R20, R25, R29, R34) were appropriately vaccinated against pneumococcal disease upon admission and/or offer updated vaccination per Centers for Disease Control (CDC) vaccination recommendations. This had the ability to affect all 43 residents. Findings include: Review of the current CDC pneumococcal vaccine guidelines located at https://www.cdc.gov/vaccines/vpd/pneumo/hcp/pneumo-vaccine-timing.html, identified for: Adults [AGE] years of age or older, staff were to offer and/or provide based off previous vaccination status as shown below: a) If NO history of vaccination, offer and/or provide: aa) the PCV-20 OR bb) PCV-15 followed by PPSV-23 at least 1 year later. b) For PPSV-23 vaccine ONLY (at any age): aa) PCV-20 at least 1 year after prior PPSV-23 OR bb) PCV-15 at least 1 year after prior PPSV-23 c) For PCV-13 vaccine ONLY (at any age): aa) PCV-20 at least 1 year after prior PCV13 OR bb) PPSV-23 at least 1 year after prior PCV13 d) For PCV-13 vaccine (at any age) AND PPSV-23 BEFORE [AGE] years: aa) PCV-20 at least 5 years after last pneumococcal vaccine dose OR bb) PPSV-23 at least 5 years after last pneumococcal vaccine dose Review of 4 sampled residents for vaccinations identified: 1) R20 was admitted [DATE]. R20 received the PCV-13 on 08/13/2020 and the PCV-23 on 09/04/2019 (age 82). There was no documentation to support R20 had been offered the PCV-15 or PCV-20 to ensure being updated with current CDC guidance for vaccines. 2) R25 was admitted [DATE]. R25 received the PCV-13 on 02/12/2015 and the PCV-23 on 09/03/2002 (age 65). There was no documentation to support R25 had been offered the PCV-15 or PCV-20 to ensure being updated with current CDC guidance for vaccines. 3) R29 was admitted [DATE]. R29 received the PCV-13 on 10/16/2018 and the PCV-23 on 04/11/2017 (age 74). There was no documentation to support R29 had been offered the PCV-15 or PCV-20 to ensure being updated with current CDC guidance for vaccines. 4) R34 was admitted [DATE]. R34 received the PCV-13 on 11/19/2023 and the PCV-23 on 09/29/2011 (age 88). There was no documentation to support R34 had been offered the PCV-15 or PCV-20 to ensure being updated with current CDC guidance for vaccines. When interviewed on 3/19/24 at 9:42 a.m., registered nurse (RN)-A stated she normally relied on Walmart or Thrifty [NAME] Pharmacies to help determine eligibility for vaccines and had not initiated education, obtaining consent or declination or administered the pneumovax 20 for R20, R25, R29 or R34. The facility policy Pneumonia vaccinations dated 4/2023, identified pneumonia vaccinations will be offered to all residents per Centers for Disease control (CDC) recommendations.

Based on observation, interview and document review, the facility failed to ensure resident' room walls were maintained in a clean, sanitary manner for 2 of 2 residents (R1, R4) who resided on different wings and whose walls were in disrepair. Findings include: On 4/17/23, at 1:12 p.m. R1 was seated in a recliner chair in his room. R1's back of recliner was against the wall which contained numerous scraped areas, dents and blackened marks extending along a large portion of the room' back wall approximately three to four feet in length. R1 stated the wall had been like that since he moved into the facility and staff were aware of the wall. On 4/17/23, at 3:40 p.m. R4 was seated in a recliner chair in her room. The wall behind R4's recliner chair was scraped and tattered causing the wall to have exposed sheetrock which extended several centimeters (cm) into the wall. The area of damage was approximately three feet in length. R4 stated the wall had been like that for several years and that staff were aware of it. On 4/20/23, at 4:41 p.m. the administrator was interviewed and stated she was not aware several resident rooms had walls which needed repair. Administrator stated staff reported maintenance concerns by either leaving a note at the nurse's desk, sliding a post it note under administrator's door or calling maintenance's extension and leaving a message. Administrator stated facility did not have any maintenance logs or tracking forms. Administrator stated if she hears about a maintenance issue/concern more than twice then she knows that it was not completed. A facility policy on building repair was not provided.

Based on interview and document review, the facility failed to thoroughly investigate alleged violations for 2 of 2 residents (R17, R139) involved in two separate allegations of neglect. Findings include: R17 R17's quarterly Minimum Data Set (MDS) dated [DATE], indicated R17 had moderate cognitive impairment, used a wheelchair independently for mobility, and diagnoses included stroke, hemiplegia (paralysis) affecting right dominant side, and depression. On 11/2/22, an allegation of neglect related to elopement was reported to the state agency (SA), and the subsequent investigation summary was submitted to the SA on 11/7/22. The facility investigation documentation for the 11/2/22 allegation consisted of a copy of the 11/2/22 SA report and the 11/7/22 SA report. However, the facility investigation documentation lacked evidence of a thorough investigation. The investigation lacked evidence the facility: -conducted observation of the alleged victim, including the location where the alleged situation occurred, physical/mental condition of the alleged victim, and interactions between the staff and alleged victim. -conducted observations and interviews to determine a timeline of the alleged situation. -conducted an interview with the alleged victim. -conducted interviews with witnesses. -conducted interviews with facility personnel. -conducted record review for pertinent information related to the alleged victim, as appropriate, such as progress notes, incident reports, plan of care, assessments, lab reports, and video/photographic evidence. R139 R139's quarterly MDS dated [DATE], indicated R139 had severe cognitive impairment, and required extensive staff assist with activities of daily living (ADLs). R139's resident face sheet, undated, indicated diagnoses included Alzheimer's disease, chronic obstructive pulmonary disease (COPD), and long-term (current) use of anticoagulants (prevents blood clots). On 3/12/23, an allegation of neglect related to falls was reported to the state agency (SA), and the subsequent investigation summary was submitted to the SA on 3/15/23. The facility investigation documentation for the 3/12/23 allegation consisted of a copy of the 11/2/22 SA report and the 11/7/22 report, fall incident report, and toileting log. However, the facility investigation documentation lacked evidence of a thorough investigation. The investigation lacked evidence the facility: -conducted observation of the alleged victim, including the location were the alleged situation occurred, physical/mental condition of the alleged victim, and interactions between the staff and alleged victim. -conducted observations and interviews to determine a timeline of the alleged situation. -conducted an interview with the alleged victim. -conducted interviews with witnesses. -conducted interviews with facility personnel. -conducted record review for pertinent information related to the alleged victim, as appropriate, such as progress notes, call light reports, assessments, hospital records, physician orders, plan of care, and video/photographic evidence. On 4/19/23, at 2:37 p.m. the administrator stated there were no additional investigation documents for the allegations related to R17 and R139. On 4/20/23, at 1:46 p.m. the social worker (SW) stated the facility did not document and retain the individual observations, interviews, and record reviews that were completed during an investigation. All of the observations, interviews, and record review information was summarized and documented in the investigation summary submitted to the SA. On 4/20/23, at 4:24 p.m. the administrator stated when she and the SW conducted an investigation, they took notebooks and do not take a lot of notes. They document their investigation in real time in the investigation summary report, and we basically all got in a room and shared 'this is what she said', and do not have notes from the interviews. The administrator acknowledged the facility policy specifically indicated the need for interviews, record review, and retention of all documentation. The administrator stated it was important to conduct a complete investigation of all allegations. The facility Vulnerable Adult Abuse/Neglect Policy and Procedures, last reviewed 12/22/22, indicated the facility investigation would gather, document, and keep evidence related to the allegation, including documented evidence of observations, interviews, and record reviews.

Based on interview and document review, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) to 3 of 3 residents (R1, R7, R24) reviewed whose Medicare A coverage ended and then remained in the facility. Findings include: R1 R1's Centers for Medicare and Medicaid Services (CMS)-10123 signed as received on 2/2/23, identified a last covered day (LCD) of 2/7/23. R1's undated Census Records listing identified on 4/18/23, R1's payer source changed from Medicare Part A to Private Pay, and remained in the facility. R1's medical record was reviewed and lacked any evidence a SNFABN had been provided to explain the estimated cost per day or provide rationale or explanation of the extended care services or items to be furnished, reduced, or terminated. R7 R7's CMS-10123 signed as received on 3/6/23, identified a last covered day (LCD) of 3/7/23. R7's undated Census Records listing identified on 4/18/23, R7's payer source changed from Medicare Part A to Private Pay, and remained in the facility. R7's medical record was reviewed and lacked any evidence a SNFABN had been provided to explain the estimated cost per day or provide rationale or explanation of the extended care services or items to be furnished, reduced, or terminated. R24 R24's CMS-10123 signed as received on 1/2/23, identified an LCD of 1/2/23. R24's undated Census Records listing identified on 4/18/23, R24's payer source changed from Medicare Part A to Private Pay, and remained in the facility. R24's medical record was reviewed and lacked any evidence a SNFABN had been provided to explain the estimated cost per day or provide rationale or explanation of the extended care services or items to be furnished, reduced, or terminated. During an interview on 4/19/23, at 10:45 a.m. social worker (SW) verified he was responsible to provide the Medicare non-coverage notices within the nursing home (NOMNC CMS10123). SW stated he utilized the form (NOMNC CMS10123) as that was the form that was provided to him and he does not complete the form (CMS-10055) in any situation. SW acknowledged the medical record lacked any evidence a SNFABN had been provided, offered, or refused by residents. During interview on 4/20/23 at 2:50 p.m. administrator stated Discharges/Beneficiary notices were discussed and reviewed at the daily IDT meeting. Administrator stated nurses, therapists, administration, and social worker talk about discharges and what date the beneficiary notice needed to be given. Administrator stated there was a book in the social worker's office to help dictate what form the residents were given. Administrator stated the SW was responsible to get the forms ready. Administrator stated it was important for resident's/families to know what was going on and if they don't understand the forms and costs, it could financially harm them. Administrator was not aware of the SNFABN (CMS-10055) form existed. A Beneficiary Notice policy was requested but was not provided.

Based on interview and document review, the facility failed to thoroughly investigate 2 of 3 residents (R1, R2) reviewed for allegations of verbal abuse. Findings include: R1's quarterly Minimum Data Set (MDS), dated [DATE], indicated R1 was cognitively intact, hearing and vision were adequate, able to make himself understood, understands others, and required physical assistance from staff for bed mobility, transfers, dressing, and toilet use. R2's quarterly MDS, dated [DATE], indicated R2 was cognitively intact, able to make herself understood, understands others, and independent with all activities of daily living (ADLs). During interview on 12/9/21, at 1:20 p.m. R1 stated that not too long ago, there were two aides, a man and a woman, that helped me to go to the bathroom, and she told me to shut up and she told my wife to shut up as well. Additionally, R1 stated, there was another lady that came in and asked me about it and I told her about it. On 12/9/21, at 2:23 p.m. the assistant administrator stated nursing assistant (NA)-A was interviewed on 11/8/21, and when asked about the allegation, NA-A staetd, Well, I guess I can't say anything. and did not admit or deny the allegation. Assistant administrator stated, residents would only be interviewed if they had potentially witnessed the incident. Since there were no witnesses additional residents were not interviewed about NA-A treatment. On 12/9/21, at 3:40 p.m. the administrator stated the investigation should have included interviews with other residents. She confirmed it was important to interview other residents who received care from NA-A to determine if there was a pattern of abuse. The facility's investigation interview notes, dated 11/8/21, indicated R1 and R2 alleged that on 11/8/21, at 11:15 a.m. NA-A told R1 to shut up during cares, and then told R2 to shut up when she tried to intervene and speak up for R1. However, there was no documentation of interviews with other residents who also received care by NA-A. The facility policy Vulnerable Adult Abuse/Neglect Policy and Procedures, revised October 2020, was reviewed, it however lacked a process for investigating allegations of abuse.

Based on observation, interview, and document review, the facility failed to ensure insulin was given per manufacturer's instructions for 1 of 5 residents (R2), reviewed for medication storage. Findings include: R2's Face Sheet with a print date of [DATE], included [DIAGNOSES REDACTED]. R2's annual Care Area Assessment (CAA) dated [DATE], indicated R2 was dependent with activities of daily living (ADLs) including bed mobility, transfers, toileting, bathing, and dressing. R2's physician's orders [REDACTED]. During interview on [DATE], at 2:50 p.m. licensed practical nurse (LPN)-A was reading insulin vials and pens on the south medication cart to verify they matched the orders for each resident receiving insulin. LPN-A grabbed R2's [MEDICATION NAME] and read the open date and expiration date that was hand written on the insulin pen and verified that the handwritten open date was [DATE], and expiration date was [DATE], indicating the [MEDICATION NAME] had expired three days prior. R2's Insulin Administration History record from [DATE] to [DATE] indicated R2 received two units of [MEDICATION NAME] on [DATE] and [DATE] during the 12:00 p.m. medication pass. During phone interview on [DATE], at 1:53 p.m. LPN-A indicated she disposed of the expired insulin after discovery. LPN-A confirmed that she gave R2 the two units of insulin on [DATE] and [DATE] from the [MEDICATION NAME]pen with the expiration date of [DATE]. Further, LPN-A stated It gets extremely busy and it's easy to miss. During interview on [DATE], at 2:35 p.m. director of nursing (DON) confirmed she was informed of medication error on [DATE] after the discovery of expired insulin. DON stated that her expectation is the nurses administering medication should be checking the open and expiration dates on the vial before administering insulin. DON stated that the trained medication assistants (TMAs) go through each medication cart and look at the expiration dates and give to the licensed nurse to dispose of them. Further, the DON indicated that there is no policy specifically for insulin administration but expects the nurse to follow the Medication Administration policy. Review of the Medications with Shortened Expiration Dates chart, at the south nursing station, indicated [MEDICATION NAME] expired 28 days after first use. Review of the Medication Administration policy, dated ,[DATE], directed staff to administer medications to the resident in accordance with the Five Rights, however it did not direct staff on how to administer insulin according to manufacture's instructions. In addition, the policy did not address shortened expiration dates for insulin.

Based on observation, interview, and document review, the facility failed to secure 1 of 1 residents (R21) with a safety belt while in the tub chair. This resulted in actual harm when R21 fell from the bath chair and sustained a nasal fracture and laceration to the bridge of his nose and required five stitches. Prior to this survey the facility had implemented corrective action on 3/17/20. The deficient practice is being issued as past non-compliance. Findings include: R21's quarterly Minimum Data Set ((MDS) dated [DATE], identified R21 had severe cognitive impairment and had [DIAGNOSES REDACTED]. The MDS indicated R21 was dependent with transfers and bathing tasks, and required extensive assistance with all other activities of daily living (ADLs). The MDS identified R21 had no falls since the prior assessment and identified R21's transfer balance was not steady and only able to stabilize with human assistance. R21's annual Care Area Assessment (CAA) dated 12/24/19, identified R21 had cognitive loss due to [MEDICAL CONDITION] and required assist of two with bed mobility, transfers, toileting, and dressing. The CAA indicated R21 required assist of one with locomotion, personal hygiene and bathing. R21's care plan, revised 7/9/20, identified R21 had cognitive loss related to [MEDICAL CONDITION] and required assist of two with a Hoyer (mechanical lift used to transfer immobile residents) to transfer. The care plan instructed staff to use two staff to transfer R21 to the tub chair and to use the safety belt on R21 when in the tub chair. The care plan identified R21 was at risk for falls due to limited mobility secondary to [MEDICAL CONDITION]. Review of R21's event report dated 3/12/20, indicated R21 fell face first out of the tub lift chair in his room due to staff not applying the safety belt. R21 developed a triangular shaped cut across his nose and a cut between his eyes. R21 was noted to be face down in a large pool of blood and staff turned him to his back due to the bleeding and R21 being unable to breathe properly. Staff applied pressure to stop the bleeding and called 911. R21 was transferred to the local hospital for treatment. The post fall summary of the event report identified R21 fell out of the chair due to staff not applying the safety belt. Education was immediately provided to the staff involved, signs posted and the rest of the staff were educated on the importance of using the safety belt. Review of R21's progress notes from 3/12/20, to 8/19/20, revealed the following: - 3/12/20, at 8:11 a.m. staff reported they needed assistance as R21 was bleeding everywhere. R21 had a large pool of blood next to him and staff were noted to be applying pressure to R21's nose to stop the bleeding from the V-shaped laceration present on R21's bridge of his nose. Additionally, R21 had a small laceration between his brows. R21's right cheek and eye swelled up and pupils were noted to be sluggish. R21 was assisted off the floor to the ambulance cot with the Hoyer lift and assistance of four staff. - 3/12/20, at 8:55 a.m. R21 fell face first out of the tub chair and landed on his face and had a triangular shaped cut across his nose, a laceration between his eyes and a large pool of blood underneath his face. Two NA's were present in the room at the time of the fall. Staff held R21's neck and turned R21 onto his back due to the bleeding and inability for R21 to breathe properly. Staff applied pressure and a NA called the ambulance. Staff noted bruising starting to form to R21's knees. R21 was transferred via ambulance to the local hospital. - 3/12/20, at 12:49 p.m. R21 returned from the hospital with orders of [MEDICATION NAME] (an antibiotic) 100 mg. (milligrams) twice daily and a nasal spray two to three sprays twice daily for three days. - 3/12/20, at 10:10 p.m. R21 had bruising and swelling under his left eye, his nose and on his forehead. The stitches present on R21's nose remained clean dry and intact. R21 remained in bed all shift, appeared weaker than usual and refused to eat supper. - 3/13/20, at 1:43 a.m. R21 continued to have bruising and swelling under his left eye and stitches were noted to be clean dry and intact. - 3/13/20, at 12:07 p.m. R21 was seen by medical doctor (MD) for follow-up after the fall. - 3/13/20, at 6:43 p.m. bruising and swelling noted under R21's left eye and bruising noted to R21's forehead. - 3/14/20, at 12:02 p.m. swelling continued to be noted under both R21's eyes and nose. Dark purple bruising under R21's left eye remained and the stitches to R21's nose laceration were clean dry and intact. - 3/15/20, at 1:20 a.m. slight bruising noted under R21's eyes and swelling remained to R21's bridge of his nose and under his eyes. - 3/15/20, at 10:19 p.m. stitches remained intact and bruising remained under R21's right eye. - 3/17/20, R21 had appointment with ear nose and throat (ENT) MD (medical doctor) and sutures were removed from R21's laceration and the nasal fracture was noted to be in good position with no surgery required. Review of MD progress notes from 3/12/20, to 3/17/20, revealed the following: - 3/12/20- emergency department (ED) progress notes indicated R21 presented to the ED after a fall. R21 was noted to have [MEDICAL CONDITION], was on [MEDICATION NAME] (a blood thinner) and occasionally had falls. R21 fell face first, hit his nose and had significant blood noted from his nose. CT (computerized tomography) scan was completed of the head, facial bones and neck and revealed a comminuted fracture (A comminuted fracture is a break or splinter of the bone into more than two fragments. Since considerable force and energy is required to fragment bone, fractures of this degree occur after high-impact trauma) of the nasal bone with deviation to the right. R21 received five sutures to the laceration to the nose he obtained from the fall. R21 was sent back to the facility on antibiotics and a nasal spray with plans to follow-up with the ENT MD sometime in the next week. - 3/13/20, family medicine progress note indicated R21 was seen for a follow-up ED (emergency department) visit. On 3/12/20, R21 fell and hit his face on the floor and sustained a displaced [MEDICAL CONDITION] bone and a laceration to his nose. Plan to continue antibiotics, follow-up with ENT and to have sutures removed in five to seven days. - 3/17/20, ENT progress note indicated R21's sutures were removed from the nasal laceration and the nasal fracture was in good position. Review of the CT of the head results on 3/12/20, revealed a comminuted [MEDICAL CONDITION] bone with mild deviation to the right. Review of R21's MD current orders revealed R21 was on [MEDICATION NAME] 5 mg five days a week and received [MEDICATION NAME] 7.5 mg. two days a week. During observation on 8/19/20, at 9:07 a.m. R21 was seated in his wheelchair while nursing assistant (NA)-A and NA-B applied the loops from the lift sling to the Hoyer lift. NA-A operated the Hoyer lift to lift R21 up out of wheelchair while NA-B guided R21 to the bed. NA-A lowered R21 down in the bed and with NA-B's assistance removed the sling from underneath R21 while rolling him back and forth in bed. NA-B removed R21's incontinence brief, provided peri cares and applied a fresh brief. NA-A removed R21's shoes, covered R21 with a blanket and clipped his call light to his bed within his reach. NA-A and NA-B removed their gloves and completed hand hygiene. R21 had non-skid strips next to his bed and in his bathroom. On 8/19/20, at 9:14 a.m. NA-B stated R21 required total assistance with all cares and a Hoyer lift was used for transfers. NA-B stated R21 received a tub bath twice a week, indicated two staff transferred R21 onto the tub chair and stated staff were expected to apply the safety belt around R21's waist when he was in the chair to prevent falls. NA-B stated R21 did have a fall from the tub chair a few months ago and R21 required stitches to his nose. On 8/19/20, at 10:41 a.m. NA-C stated she worked five days a week as the bath aid for the facility. NA-C stated R21 received a tub bath two days a week on Mondays and Thursdays and indicated he was totally dependent on staff for transfers onto the tub chair and for bathing tasks. NA-C stated it was an expectation the staff apply the safety belt to R21 when he was in the tub chair. NA-C stated she was aware R21 had a fall from the tub chair a few months back after staff had not applied the safety strap and he required a trip to the hospital as a result of the fall. On 8/19/20, at 10:49 a.m. registered nurse case manager (RN)-A confirmed R21 had a fall from the tub chair a few months ago when staff had not applied the safety belt and broke his nose. RN-A confirmed R21 was not able to hold himself up in the tub chair due to [MEDICAL CONDITION] and indicated the safety belt should have been applied at all times. RN-A reviewed R21's electronic health record (EHR) and stated on 3/12/20, R21 had a nasal fracture and had stitches to the bridge of his nose as a result of the fall from the tub chair. RN-A stated all staff received education and signs were posted to remind staff to apply the safety belt when R21 and other residents were in the tub chair. On 8/19/20, at 11:27 a.m. NA-D stated R21 required total assistance from staff with most ADLs and he tended to lean forward when up in the tub chair. NA-D stated on 3/12/20, she was wheeling R21 in the tub chair to the doorway of his room to bring him to the tub room for his bath when R21 fell forward from the tub chair, landed on his face and started to bleed. NA-D confirmed staff had not applied the safety belt to R21 prior to his fall. NA-D stated the nurse was notified, provided first aid to R21 and R21 was sent to the hospital for treatment. NA-D stated R21 received a cut from the fall and indicated she received immediate education on the use of the safety belt when R21 and other residents were up in the tub chair. On 8/19/20, at 11:35 a.m. director of nursing (DON) stated it was expected staff applied the safety belt for all tub chair transfers. DON confirmed R21 had a fall on 3/12/20, from the tub chair due to staff not applying the safety belt to R21. DON confirmed R21 was sent to the ED and was diagnosed with [REDACTED]. DON stated immediate education occurred to the staff involved in the incident and reminder signs were placed in both tub rooms of the need to use the safety belt. DON stated all nursing staff were educated on the use of the safety belt beginning that same morning and was completed by the time the incident report was closed on 3/17/20. DON stated R21's care plan was updated on 3/17/20, to instruct staff to apply the safety belt as soon as R21 was up in the tub chair. DON stated audits of the use of safety belts had been completed and no further issues were identified. Review of the manufacturer's instructions titled System Preparation (Before Transferring of Lifting), undated, instructed staff to route the belt through the belt loops of the chair frame prior to placing the resident into the chair. After the resident is transferred to the chair, staff were instructed to bring the seat belt around the resident to be connected. Review of facility policy, Baths, dated 7/01, instructed staff to assist resident into the tub chair and secure the safety straps. Review of the employee files revealed both NA's that assisted R21 on the day of the fall had been trained in the use of the safety belt for tub baths upon hire. The past non-compliance that began on 3/12/20, was verified during the 8/20/20, onsite visit and was corrected by the facility on 3/17/20. The verification of corrective action was confirmed by interview with a variety of nursing staff, residents and observation of residents who received tub baths, in addition to documentation of education provided to the nursing staff. On 3/12/20, immediate education was provided to the staff involved. R21's care plan was revised and education was completed for the majority of the remaining nursing staff by 3/17/20. Additionally, reminder signs were posted in both of the tub rooms in the facility and audits were completed to ensure staff compliance with the use of the safety belt.

Based on interview and document review, the facility failed to ensure complete and comprehensive Minimum Data Set (MDS) were completed for 2 of 6 residents (R14, R22) reviewed for assessment accuracy. Findings include: The Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, dated 10/2017, identified the MDS as an assessment tool which facilities are required to use. The manual directed comprehensive assessments, include the completion of both the MDS and the CAA (care area assessment) process, as well as care planning. Further, the manual provided instructions to ensure accurate and complete coding for each section of the assessment as follows: Section M1030 Skin wounds and [MEDICAL CONDITION] affect quality of life for residents because they may limit activity, may be painful, and may require time-consuming treatments and dressing changes . Steps for Assessment: 1. review the medical record, including skin care flow sheet or other skin tracking form. 2. Speak with direct care staff and the treatment nurse to confirm conclusions from the medical record review. 3. Examine the resident and determine whether any venous or arterial ulcers are present. Section M1040 Skin wounds and [MEDICAL CONDITION] affect quality of life for residents because they may limit activity, may be painful, and may require time-consuming treatments and dressing changes . Steps for Assessment: 1. review the medical record, including skin care flow sheet or other skin tracking form. 2. Speak with direct care staff and the treatment nurse to confirm conclusions from the medical record review. 3. Examine the resident and determine whether any ulcers, wounds, or skin problems are present. R14's Admission comprehensive assessment dated [DATE], had a check mark in the box to indicate the presence of a rash on R14's left leg, which per family's report, had been there 30+ years. R14's admission MDS, dated [DATE], section M1030 had a 0 in the box to enter the total number of venous and arterial ulcers present. Further, M1040 had an X in the box for none of the above as the answer to other ulcers, wounds, and skin problems, During an observation on 8/17/20, at 1:24 p.m. R14 revealed a wound on the left shin area about the size of a quarter with a whitish scab and a drainage spot the size of a pin head on the sock. R14 stated nursing did not do any cares for the wound because it had been there for 30+ years and had not changed. During an interview on 8/20/20, at 9:35 a.m. RN-B confirmed that she had completed R14's initial skin assessment and recalled a rash on the left shin. During an interview on 8/20/20, at 11:07 a.m. MDS coordinator (RN-C) stated information to complete the MDS was gathered through the electronic health record, nurses notes, and wound documentation. RN-C confirmed documentation upon admission of a rash on R14's left shin and that there were no wound assessments completed for R14 since admission, until the day prior. R22's admission MDS, dated [DATE], identified R22 was cognitively intact. The MDS further identified R22 was at risk for pressure ulcers/injuries. However, the MDS indicated R22 did not have any unhealed pressure ulcers. During interview on 8/20/20, at 8:42 a.m. RN-A stated R22's skin was not intact and that R22 had wounds on his left great toe since admission. During interview on 8/20/20, at 9:27 a.m. RN-B confirmed R22 had four wounds on his left great toe. RN-B further confirmed each of these areas were likely caused by pressure. During interview on 8/20/20, at 12:31 p.m. RN-C verified R22's admission MDS did not indicate pressure ulcers. RN-C stated she was not aware of the wounds because they were not noted in the progress notes or admission assessments. During interview on 8/20/20, at 12:37 p.m. DON confirmed R22's admission MDS failed to identify R22 had any pressure ulcers. Review of the facility's policy, MDS-Minimum Data Set for Nursing Facility Residents' Assessment and Care Planning, dated 7/97, included input and assistance with completing the form shall be obtained from direct-care staff.

Based on observation, interview, and document review, the facility failed to provide services in a dignified manner for 1 of 2 residents (R22), reviewed for dignity. Findings include: R22's admission Minimum Data Set (MDS), dated [DATE], identified R22 was able to make himself understood and his speech was clear. The MDS further identified R22 had [DIAGNOSES REDACTED]. During observation and interview on 8/17/20, at 5:20 p.m. R22's oxygen nasal cannula was noted taped to his face using clear plastic tape. R22 stated he taped the cannula to his face, because, It won't stay in my nose, so I tape it. R22 further stated he talked with a facility staff member on 8/16/20, about getting a mask to use instead. R22 reported he was told, 'maybe a mask will work,' but a mask was not brought in for R22 to try. During observation on 8/18/20, at 1:52 p.m. R22 was outside at an activity. Nasal cannula was secured to his nose with clear plastic, medical tape. During observation and interview on 8/18/20, at 2:17 p.m. R22 was in his room. The nasal cannula was taped to his face with clear plastic medical tape. Tape was placed under his nose and reached to each cheek, under his eyes. R22 stated, I have to go to [MEDICAL CONDITION] with this tape on my face. I'm not happy about that. I think a mask would look a lot nicer. This tape looks ridiculous. During observation and interview on 8/19/20, at 7:12 a.m. R22 was resting in bed with the nasal cannula in his nose, taped to the bridge of his nose, as well as under his nose to both lower cheeks, with clear, plastic medical tape. R22 stated he was given the tape by one of the nurses. R22 further stated he again talked with one of the facility staff, in the evening on 8/18/20, about trying an oxygen mask. R22 did not recall the name of the staff he talked with. R22 stated, They brought in a mask for the nebulizer but not for the oxygen. R22 stated the response to his request was, 'I don't know if we have any.' R22 stated I think a mask would look a lot nicer, but I have to keep this in my nose so I need to do something. During observation on 8/19/20, at 9:18 a.m. R22's nasal cannula remained taped across the bridge and under his nose, and across both cheeks, with clear plastic medical tape. R22 was brought out of his room and to the entrance of the facility to leave for an appointment. R22 left the facility with nasal cannula taped to his face. During observation on 8/20/20, at 8:27 a.m. R22's nasal cannula tubing was around his ears with gray foam protectors. The oxygen tubing was under R22's nose, with white paper tape securing it over the bridge of his nose, and the edges of the tape were loose and peeling up. Clear, plastic medical tape was observed across the bottom of his nose to above both cheek bones, the edges of the tape were loose. During interview on 8/20/20, at 8:42 a.m. registered nurse (RN)-A stated R22 taped the nasal cannula himself, because, He thinks it stays in there better. RN-A stated she talked with R22 about a face mask on 8/19/20, and stated, I explained he could do the facemask, but he said he would want to take it off to eat. RN-A further stated R22 had not asked RN-A about a mask before that conversation. RN-A confirmed the tape does not look good and does not look dignified and stated, I wouldn't want to look like that. During interview on 8/20/20, at 10:11 a.m. director of nursing (DON) stated, He is the one that requests to put it there because his nasal cannula won't stay in. DON confirmed the tape makes him feel undignified. Facility policy for dignity requested but was not provided.

Based on observation, interview and record review, the facility failed to provide meaningful activities for 1 of 1 residents (R5), dependent on staff for activities. Findings include: R5's [DIAGNOSES REDACTED]. R5's Care Area Assessment (CAA) dated 5/18/20, indicated a potential problem for cognitive loss/dementia related to [DIAGNOSES REDACTED]. R5's Activity assessment dated [DATE], indicated participation strengths were social skills. Leisure interests were cards/other games, exercise/sports, music, reading/writing, watching TV, and talking or conversing. Focusing of programming indicated 1:1 activities, independent activities, outdoor activities, relaxation activities, social interaction activities, and other- ride in the country and bingo. Activity progress note indicated R5 was starting to play hallway bingo, one to one visits two times per week, and was given the daily newsletter along with the weekly Morrison County Record. R5's interests included reading the news and visiting with others. The Activity Assessment progress note further indicated to provide R5 with daily newsletter and to encourage activities of interest. R5's care plan, dated 8/17/20, indicated R5 had a variety of interests that included country music, cards, dice, bingo, outdoor activities and visiting with others. Goals for R5 included, R5 would participate in activities of his interest including playing cards, outdoor activity, dice, and bingo two to three times per week in the next three months. Interventions included adapt programs (bingo)/ provide in hallways, encourage resident to take part in activities of his interest, and provide one to one visits. R5's care plan also indicated he had an altered mood state related to [DIAGNOSES REDACTED]. Goals for R5 included to involve in activities of interest. R5's Activity Participation Record from May through August of 2020 lacked evidence that R5 was offered activities of interest as indicated on R5's plan of care. Further, in May, R5 was offered bingo 11 days out of 31, June, was offered 13 days out of 30, July and August lacked evidence that R5 was offered bingo on any day. Resident Bingo list that was posted on bulletin boards of both south wings lacked evidence of R5 being invited to bingo on all seven days of the week evidenced by R5's name not being included on the list. During observations on 8/18/20, at 12:55 p.m. through 1:46 p.m. R5 was sitting in his room, in his recliner, with TV off. Activity calendar indicated Bingo at 1:30 p.m. During observations on 8/18/20, at 1:46 p.m. staff offered R5 to go outside and husk corn, but did not offer the choice between attending bingo or outdoor activity. During observations on 8/18/20, at 2:20 p.m. through 4:30 p.m. R5 was sitting in his room, in his recliner, light off, and TV off. Activity calendar indicated dice/horse race at 4:15 p.m. Further, activity staff started activity at 4:12 p.m. and staff did not offer resident to participate in dice/horse race activity. During interviews on 8/19/20, at 11:57 p.m. activity coordinator (AC) stated R5 enjoyed outdoor activities, cards, and Bingo. Further, AC stated R5 had been more quiet and had daily pop- in visits. AC confirmed R5 has not been getting daily newsletter due to her copier being broken and further stated she could use a different copier. AC confirmed R5 was not on Bingo invite list and stated she will assure R5 gets invited and involved more. Further, AC confirmed R5's activity logs were blank for Bingo in 8/20 and there were no marks of any refusals. AC stated that Bingo was offered in resident rooms everyday, but just recently started with group activities again. AC stated her expectation would be for staff to ask R5 if he would like to participate in the activities, especially those of R5's interests listed. During interviews on 8/19/20, at 12:35 p.m. DON stated her expectation of staff would be to offer R5 his favorite activities based off his preferences and staff should be following his care plan. Review of the facility Activity policy, dated 3/02, indicated the activity coordinator plans and organizes a program of activities for residents on a group level and for individuals. Residents shall be encouraged, but not forced, to participate in activities. Further, ambulatory resident may walk to and from activities or be assisted as needed. Non ambulatory residents will be encouraged to attend activities independently or will be assisted as needed.

Based on observation, interview and document review, the facility failed to appropriately assess, monitor, implement interventions, and document skin conditions for a pressure ulcer for 1 of 2 residents (R22). Findings include: R22's admission Minimum Data Set ((MDS) dated [DATE], identified R22 was able to make himself understood and his speech was clear. The MDS further identified R22 had [DIAGNOSES REDACTED]. R22's admission MDS failed to identify that R22 had a pressure ulcer/injury (bed sore). The MDS indicated a formal assessment instrument/tool was completed and used to complete the MDS and that R22 was at risk for pressure ulcer/injury. R22's admission skin assessment, dated 6/19/20 failed to indicate a wound was noted by the assessing nurse upon admission. R22's skin assessment upon hospital return, dated 7/20/20, identified, necrotic (dead tissue) area on Lt (left) grt (great) toe. R22's progress notes, dated 6/19/20-8/20/20, failed to identify the wound on R22's left toe, and failed to identify if R22's primary physician or if a nurse practitioner had been updated regarding the wound on R22's left great toe. R22's weekly skin checks failed to identify new or worsening skin concerns, including the area on R22's left great toe. R22's care plan, dated 6/22/20, and revised 8/3/20, indicated R22 was at low risk for pressure ulcers as evidenced by Braden Scale (used to determine risk for pressure ulcer/injury). Interventions included daily skin inspections by nursing assistants (NA), float heels off of bed, and turn and reposition every two hours. R22's treatment order, dated 7/20/20, included, clean left great toe with NS (normal saline) pat dry, then swab with [MEDICATION NAME] daily and allow to dry. Keep clean dry and intact. During interview on 8/17/20, at 5:09 p.m. R22 reported a black spot on the top of his left big toe. R22 reported the black spot was present when he admitted to this facility, I don't know when it happened. I think it was before I came here. R22 further stated the areas were treated by facility staff on a daily basis. During observation on 8/19/20, at 7:23 a.m. registered nurse (RN)-A completed treatment on R22's left great toe as ordered by his physician. Observation of the left great toe, revealed the following: four areas of eschar (area of dead tissue), one above toenail at top of toe that was smaller than a dime; one area to the right of toenail; one to the left of the toenail and one on the underside of the toe. There was no swelling or redness. R22 offered complaints of pain when area was touched and when swabbed with iodine, and reported pain as, Not too bad, but I can feel it. During interview on 8/20/20, at 8:42 a.m. RN-A stated the process at admission included a skin assessment by a registered nurse. If concerns with skin were found, then a nursing treatment was put in the computer for the area to be monitored. If size, shape, color needed to be documented in wound rounds, then it would be. RN-A stated, (R22) skin is not intact, not his toe. He's had the black spot on his left toe since he admitted to this facility, and indicated not being sure what caused the area on his left great toe. RN-A further stated, R22 received a weekly skin check that was completed by a nurse. RN-A confirmed weekly skin checks failed to identify the wound on R22's left great toe. RN-A further confirmed there were no measurements of the wound on R22's left great toe, in the skin assessments or skin checks. RN-A stated she was not able to determine if the wound on R22's left great toe had improved or worsened since admission due the lack of documentation, including measurements. RN-A stated she had been monitoring the wound since admission and thought it looked the same as it did when R22 admitted to the facility. During interview on 8/20/20, at 9:10 a.m. RN-B stated the process for treatments performed on wounds that are not pressure related, are completed by either licensed practical nurse (LPN) or RN. If the nurse who completed the treatment had questions or concerns regarding the wound, they would talk with RN-B or update a nurse practitioner. RN-B reported the RN who completed the admission assessment would determine if the resident had a pressure ulcer and wound rounds were completed weekly for residents identified to have a pressure ulcer. RN-B stated she was one of the nurses assigned to complete wound rounds and stated she was not aware of the wound on R22's left great toe. RN-B further confirmed R22's medical record, including progress notes and assessments failed to identify a pressure ulcer. During observation and interview on 8/20/20, at 9:27 a.m. RN-B assessed R22's left great toe. RN-B reported her findings as: necrotic area on tip of toe and on side. No redness. No signs or symptoms of infection. Areas around wounds were blanchable (when skin becomes white or pale when slight pressure is applied). RN-B measured two of the wounds and stated the following measurements: tip of toe-1.4 centimeters (cm) x 1.5 cm, no measurable depth, no drainage; underside of toe- 0.6 cm x 0.7 cm, no measurable depth, no drainage. RN-B stated the other two necrotic areas are similar in size to the second area she measured. RN-B assessed wound to be pressure related and unstageable (severity cannot be determined). R22 stated he had pain in the toe when it was touched, however, declined to see a physician when offered by RN-B. RN-B confirmed presence of pressure ulcer on R22's left great toe and indicated the wound should have been identified upon admission. RN-B stated R22's left great toe should have been monitored on weekly wound rounds, starting at time of admission. During interview on 8/20/20, at 10:11 a.m. director of nursing (DON) stated skin assessments were completed on the day of admission by the RN Case Manager and included a full head-to-toe skin assessment, and the nurse manager determined if noted skin concerns were related to pressure. DON stated weekly skin checks were completed by LPN's on the residents' bath day. The nurse manager completed weekly wound rounds for pressure ulcers. Documentation of pressure ulcers included measurements, length, width, and depth, presence of drainage, appearance of wound, including wound bed and staging (stage I-IV, depending on severity of wound). DON verified there was no documentation of R22's left great toe wound on his admission skin assessment. The facility's pressure ulcer policy was requested but not received.

Based on observation, interview, and document review, the facility failed to ensure a treatment was provided for a non-pressure skin wound, for 1 of 1 residents (R14), reviewed for non-pressure skin concerns. Findings include: R14's quarterly Minimum Data Set (MDS), dated [DATE], indicated cognitive impairment, and R14 required extensive assistance with bed mobility, dressing, toileting, and personal hygiene. R14 had [DIAGNOSES REDACTED]. R14's care plan, last revised 6/5/20, indicated R14 was no longer able to care for self at home and had low to no risk for pressure ulcers. Interventions included assist of one staff for dressing, daily skin inspection by nursing assistants, to apply compression stockings each morning and off at bedtime, and assistance for baths or shower on Friday. During an observation on 8/17/20, at 1:24 p.m. R14 revealed a wound on the left shin area, approximately the size of a quarter, with a whitish scab and a drainage spot the size of a pin head on the sock. Further, R14 stated nursing did not do any cares for the wound because it had been there for 30+ years and had not changed. During an interview on 8/19/20, at 7:13 a.m. trained medication aid (TMA)-C stated R14 was an early riser, mostly independent, and usually had her compression socks on prior to TMA entering R14's room. TMA-C stated she became aware of R14's wound a couple weeks prior and had reported it to registered nurse (RN)-A. During an interview on 8/19/20, at 12:33 p.m. RN-A stated awareness of a scabbed area on R14's left shin and stated there were no current orders for a dressing change or monitoring for the wound, other than a full skin assessment that was completed on bath days. During an interview on 8/19/20, at 12:57 p.m. director of nursing (DON) confirmed the R14's clinical record lacked evidence that R14 had a wound on her left shin, however, at 1:06 p.m. DON confirmed the presence of a wound on R14's left shin. DON stated it was her expectation that staff should have noted R14's wound during the weekly skin checks and would at least be doing a dressing change and monitoring. During an interview on 8/20/20, at 9:35 a.m. RN-B confirmed she had completed R14's initial skin assessment and recalled a rash on the left shin. RN-B stated she was unaware of any current skin issues. During an interview on 8/20/20, at 11:07 a.m. MDS coordinator (RN-C) confirmed documentation upon admission of a rash on R14's left shin and that there were no wound assessments completed for R14 since admission, until the day prior. During an interview on 8/20/20 at 12:27 p.m. licensed practical nurse (LPN)-A stated she completed skin checks when residents were in the bathtub, but the bath aid would indicate if there were any concerns, and wounds were charted. LPN-A did not know if R14 had any wounds. Review of the facility policy, Wound Rounds, revised 1/15, stated resident wounds should be measured to show progress on a weekly basis to assure it continues to heal and to promote quality of life.

Based on observation, interview, and document review, the facility failed to ensure proper placement and storage of catheter drainage bag was provided, in a manner to prevent potential for infections for 1 of 1 resident (R24), reviewed for catheter care. Findings include: R24's admission Minimum Data Set (MDS), dated [DATE], identified R24 had moderate cognitive impairment and required assistance from one staff for bed mobility, transfers, ambulation, dressing, personal hygiene, bathing, and toilet use. In addition, R24's MDS identified [DIAGNOSES REDACTED]. R24's care plan, dated 7/2/20, directed catheter cares twice daily and as needed, to change the catheter as ordered by the physician and according to Centers for Disease Control recommendations, to change the drainage bag weekly, to cover the urinary collection bag, and to keep the drainage bag below the level of the bladder. Review of R24's progress notes did not indicate R24 was non-compliant with placement of catheter collection/drainage bag. During observation and interview on 8/17/20, at 4:47 p.m. R24 was seated in his wheelchair in his room. The urine collection bag was covered inside another bag and was hung from R24's wheelchair, on the left side, on the frame located above the large side wheel. The collection bag was noted at the same level as R24's thigh. R24 stated, They were looking at my chair to find a place to hang it under the chair but they didn't find anything that would work, and stated the collection bag was always hanging where it was noted at time of this observation. During observation on 8/18/20, at 12:49 p.m. R24 was seated in his wheelchair in his room. The urine collection bag was hung from R24's wheelchair, on the left side, on the frame located above the large side wheel. The collection bag was noted at the same level as R24's thigh. The collection bag was covered by a bandana tied to the wheelchair. During observation on 8/18/20, at 12:55 p.m. nursing assistant (NA)-E emptied R24's urine collection bag. After the bag was emptied, NA-E placed the collection bag so it hung from R24's wheelchair, on the left side, on the frame located above the large side wheel. The collection bag was noted at the same level as R24's thigh. NA-E covered the collection bag with the bandana. During observation on 8/19/20, at 7:52 a.m. R24 was seated in his wheelchair in the dining room. The urine collection bag hung from R24's wheelchair, on the left side, on the frame located above the large side wheel. The collection bag was noted at the same level as R24's thigh and was covered with a bandana. The catheter tubing was noted to come out of bottom of R24's pant leg then extend up to the top of the urine collection bag. During observation on 8/19/20, at 8:59 a.m. R24 was ambulating in the hallway with staff. Urine collection bag was stored in a bag attached to the cross bars under R24's wheelchair. During interview on 8/19/20, at 9:09 a.m. R24 stated he didn't know why the urine collection bag was hanging under his chair. They said they moved it because they don't like to see it on the side of the chair. During observation on 8/19/20, at 11:39 a.m. R24 was seated in his wheelchair in his room. The urine collection bag was hung from R24's wheelchair, on the left side, on the frame located above the large side wheel. The collection bag was noted at the same level as R24's thigh and was not covered. During interview on 8/19/20, at 11:42 a.m. NA-B stated she wasn't sure how the urine collection bag got placed on the side of his wheelchair. It's supposed to be under his chair. During interview on 8/19/20, at 11:47 a.m. NA-D stated R24 was mostly independent with cares, except catheter care, perineal care (cleaning the private areas), and cleaning R24's underarms. NA-D further stated she was just in R24's room and put the urine collection bag in the storage bag hanging from the cross bars under the wheelchair. It is supposed to be under his chair. During interview on 8/20/20, at 9:57 a.m. registered nurse (RN)-A stated, I try to encourage him to keep it (urine collection bag) below his wheelchair. He always puts it back up on the armrest because it is where he likes it. I try to explain it drains better. RN-A further stated, staff would be putting it back under R24's wheelchair or educating R24 when they notice it is on the side of R24's wheelchair or they should tell her about it and she would take care of it. RN-A confirmed, if the urine collection bag is not stored below the level of the bladder, the urine will not drain and may result in urinary tract infections. RN-A confirmed further that staff should be making attempts to put the urine drainage bag under R24's wheelchair so it can drain properly. During interview on 8/20/20 at 10:03 a.m. director of nursing (DON) stated the expectation is that the urine collection bag is hung from the bed frame, below the level of bladder, when R24 is in bed and below the seat of the wheelchair, in a bag, to ensure it is below the level of the bladder, for gravity flow. DON confirmed, if the urine collection bag is not kept below the level of the bladder, it may cause the urine to back flow into the bladder which could cause an infection. DON stated further, It (urine collection bag) should be under the chair. Staff should follow the care plan. DON confirmed, R24's care plan stated to keep drainage bag below level of bladder. DON stated she would expect staff to educate R24 with reason for urine collection bag to go under the wheelchair when it noted to be on the side of the wheelchair. Review of the facility policy, Catheter. Care of Indwelling. Suprapubic, dated 12/95 indicated, Observe drainage bag position; must never touch the floor and always kept below the level of the bladder.