Every finding on record at Pinewood Healthcare Center

Based on observation, staff interview, record review, and review of the facility's policy titled Date Marking for Food Safety, the facility failed to ensure that food items were properly dated, labeled, and discarded in the refrigerator, freezers, and dry storage. These deficient practices had the potential to place the 47 residents who received meals from the kitchen at risk of foodborne illness. Findings include:Review of the facility's policy titled Date Marking for Food Safety, with a review date of 01/01/2026, indicated that the facility adheres to a date-marking system to ensure the safety of ready-to-eat, time/temperature control for safety foods. The Policy Explanation and Compliance Guidelines for Staffing section included, . 2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. 3. The individual opening or preparing a food item shall be responsible for date marking the food at the time the food is opened or prepared. 4. The marking system shall consist of a color-coded label, the day/date of opening, and the day/date the item must be consumed or discarded. 6. The Head Cook, or designee, shall check the refrigerator daily for food items that are expiring and discard accordingly. 7. The Dietary Kitchen Manager (DKM), or designee, shall spot-check refrigerators weekly for compliance.Observation during the initial kitchen inspection on 03/09/2026 from 10:00 AM to 11:00 AM revealed the following:Observation of food stored in the kitchen's residential refrigerator revealed: Two bags of cucumbers containing numerous cucumbers with visible signs of spoilage, including black discoloration. One bag of lettuce containing a head of lettuce with visible black discoloration. Additional food items observed in the refrigerator, without an expiration or discard-by date, included bags of bacon, sandwich meat, ground beef, cheese, lettuce, two bags of cucumbers, two cartons of eggs, and six bags of tomatoes.Observation of food stored in two two-door reach-in freezers located in the dining room area revealed the following food items without an expiration or discard-by date: Three clear bags of ground beef Four containers of barbecue meat Seven bags of pepperoni Two bags of beef patties Three bags of chicken patties One-third bag of chicken nuggets Three bags of sweet corn nuggets Two bags of breaded vegetables Two bags of hash browns Four bags of tater tots One blue bag containing two rutabagas One bag of pepperoni Four bags of chopped rutabagasFurther observation revealed: Six bags of pepper and onion mix with sell-by dates of 11/24/2025. Frozen vegetables (broccoli) with a sell-by date of 12/27/2025.Observation of the kitchen pantry revealed: Eleven bags of tortilla chips with a use-by date of 01/27/2026. One bag of cornmeal with a use-by date of 01/27/2026. One bag of cornmeal with a use-by date of 01/27/2026. Five jars of maraschino cherries without an expiration date and with a date of 05/16/2024 in black marker on the top of the lids.During an interview on 03/10/2026 at 1:25 PM, the Dietary Kitchen Manager (DKM) confirmed the above food storage concerns identified during the kitchen inspection. The DKM stated that staff should discard food with signs of spoilage or expiration dates. The DKM further stated that she was unaware that the perishable food items were not labeled or dated, and that they should be.

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled, Self-Administration of Medications by Patients/Residents, the facility failed to ensure one of 29 Residents (R) (R31) did not have unauthorized, unsecured medications at bedside. This deficient practice had the potential to allow unauthorized access of medications to other residents and visitors in the facility.Findings include:Review of the facility's policy titled Resident Self-Administration of Medication dated 1/1/2026 under the section titled Policy revealed, It is the policy of this facility to support each resident's right to self -administer medication. A resident may only self-administer medications after the facility 's interdisciplinary team has determined which medications may be self-administering safely.Review of clinical records for R31 revealed the following diagnoses that included but were not limited to personal history of other disease related to nonexudative age-related macular degeneration, bilateral, stage unspecified, visual loss, hypertension, and unspecified atrial fibrillation. Review of the admission Minimum Data Set (MDS) Assessment for R31 dated 2/12/2026 revealed, Section C (Cognitive Patterns), a Brief Interview for Mental Status Score (BIMS) score of 15 which indicated little to no cognitive impairment Review of clinical records for R31 revealed, there was no physician order or completed assessment to determine whether or not the resident was capable of self-administration of medications.Observation on 3/9/2026 at 2:09 PM of R31's room revealed prescription medications [a bottle of nasal spray, muscle cramp spray, eye drop, and (Name of anti-inflammatory) pain lotion] lying on the bedside stand. At the time of observation, R31 revealed that the medication was her very own personal medications and that she took the medications daily without the supervision of the nurses. R31 revealed that the nurses allowed her to take medications.During an observation and interview on 3/10/2026 at 12:36 PM of R31's room with Licensed Practical Nurse (LPN) KK confirmed the medications at the resident's bedside. LPN KK also confirmed that R31 had not been assessed to self-administer medications independently. She reported being unsure of how the medications was left in the resident possession. She reported that in the past, R31's friend was known to bring medications into the facility to the resident. LPN KK then proceeded to remove the medications from the room.During an interview on 3/10/2026 at 12:44 PM with the Director of Nursing (DON) and Assistant Director of Nursing (ADON), both staff confirmed R31 was not assessed to self-administer medications. The DON and ADON reported that since admission, R31 had a history of having unauthorized medications brought into the facility. The ADON reported that R31 and her friend had been educated before about medication being left in the resident room. The DON revealed that her expectation was for staff to monitor the resident medications.

Based on resident and staff interviews, record review, and review of the facility's policy titled Abuse, Neglect, and Exploitation, the facility failed to report to the State Survey Agency (SSA) within the required two-hour time frame a fall with major injury for one of two Residents (R) (R2) reviewed for falls.Findings include:Record review of the facility's policy titled Abuse, Neglect, and Exploitation revised 1/1/2026 revealed, VII. Reporting/Response. A. The facility will have written procedures that include:1.Reporting of all alleged violations to the Administrator, state agency , adult protective services and to all other required agencies (e.g. was enforcement when applicable ) within specified time frames (a). Immediately, but not later than 2 hours after the allegation is made, if the event that cause the allegation involve abuse, or results in serious bodily injury or (b). Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.Record review of R2's electronic health record (EHR) revealed a diagnosis of T12 fracture with the onset date of 6/25/2025.Record review of R2 's EHR progress note dated 6/25/2025 at 11:31AM revealed, R2 had an unwitnessed fall and was found on the floor.Review of R2's Quarterly Minimum Data Set (MDS) dated [DATE] for Section C (Cognitive Patterns), Brief Interview for Mental Status Score (BIMS) of 14 which indicated intact cognition; Section GG (Functional Abilities and Goal) revealed, impairment on one side for upper extremities and impairment on both sides for lower extremities, independent with bed mobility and dependent for transfer requiring two-person assistance.Review of the incident report form, dated 6/25/2025, revealed the facility began the investigation involving an unwitnessed fall from bed. R2 turned on light and Certified Nursing Assistant (CNA) went in and noticed the resident on the floor. R2 was assessed for injuries with no injuries and no pain documented at the time. Further review of the incident report revealed, the box checked for None in the Predisposing Environmental Factors and Predisposing Situation Factors.A review of a progress note for R2, dated 6/27/2025, at 9:59 AM, revealed Physician (Name) notified of resident complaining of back and stump pain and request to go to ER (Emergency Room) with order given to go to ER for evaluation. [sic]A record review of the hospital radiology report (x-ray) for R2, dated 06/27/2025, documented Findings: 3 views of the lumbar spine. Vertebral body: There is compression fracture at T12. Clinical impression: Stable T12 burst fracture.Record review of the Facility's Self Reportable (FRIs) for the past year revealed there was no FRI submitted for R2.During an interview on 3/12/2026 at 4:26 PM with the Director of Nursing (DON) verified the facility failed to submit a State Reportable to the State Office within the two-hour time frame because she was unaware that R2 had a T12 fracture. She confirmed R2 injury was brought to her attention during the survey by the Survey Team. The DON reported failing to review the resident discharge hospital record and resident progress note after the resident returned from the hospital. She reported that Licensed Practical Nurse (LPN) KK was aware of the fracture and admitted to not informing her of the fracture.

Based on observations and staff interviews, the facility failed to ensure that aerosol containers and cleaning chemicals were not stored in three of 47 resident rooms (room [ROOM NUMBER], 40, and 42). This deficient practice increased the risk for accidents. Findings include:Observations on 3/9/2026 at 12:40 PM, 3/10/2026 at 12:18 PM, and 3/11/2026 at 1:50 PM, in room [ROOM NUMBER], revealed an aerosol can (deodorant spray) sitting on the bedside table.Observation on 3/9/2026 at 12:52 PM, 3/10/2026 at 12:19 PM, and 3/11/2026 at 1:54 PM in room [ROOM NUMBER] revealed an aerosol can on the bedside table.Observations on 3/9/2026, 3/10/2026 at 12:19 PM, and at 1:01 PM, and 03/11/2026 at 1:58 PM in room [ROOM NUMBER] revealed a container of bleach disinfectant wipes stored on a portable cubby in the resident's room.During an interview on 3/11/2026 at 2:05 PM, Certified Nursing Assistant (CNA) GG verified that the aerosol containers and disinfectant wipes were present in rooms [ROOM NUMBER]. CAN GG stated that these items should not be in residents' rooms, particularly due to residents who wander, and indicated the facility has a policy restricting aerosol and disinfectant products from resident care areas.During an interview on 3/11/2026 at 2:08 PM, the Director of Nursing (DON) confirmed that the aerosol containers and bleach disinfectant wipes were present in the identified resident rooms and stated they should not be in resident rooms. The DON immediately removed the bleach disinfectant wipes from room [ROOM NUMBER] and stated staff would need to speak with the resident in room [ROOM NUMBER] before removing the aerosol container to avoid causing distress.

Based on observations, interviews, record reviews, and review of Bylaws of the Board of Trustees, the facility's Governing Body failed to ensure that supply vendors were paid in a timely manner, so that there was not a disruption in supplies for resident care needs. This failure resulted in the deinstallation of linens by the facility's linen supply company on 6/11/2025. Findings include: Review of the Bylaws of the Board of Trustees, approved and adopted on 1/26/2021 by [name of hospital], revealed that the Board of Trustees is recognized as the governing body of the hospital. The bylaws included a definition of Chief Executive Officer (CEO). The CEO means the individual appointed by the Governing Body to act in its behalf in the overall management of the hospital. During an interview on 6/24/2025 at 2:51 pm, the Administrator stated that the [name of hospital] Board of Trustees is also the nursing home's Governing Body. During an interview on 7/2/2025 at 1:57 pm, the hospital CEO stated that [name of hospital] manages the nursing home. 1. During an interview on 6/24/2025 at 1:00 pm the Administrator stated that the facility's linen supplier was in-house and no longer outsourced and that the hospital had bought all new linens (for the nursing home). When questioned about the change in the process of obtaining linens, the Administrator indicated it was a decision made by the hospital. Review of email correspondence dated 6/9/2025, between the facility's previous linen supply company and hospital accounting staff and nursing home medical records staff, revealed that the linen supply company notified the facilities (hospital and nursing home) that a de-installation of linens, supplied by the company, would take place on 6/11/2025 at 9:30 am at the nursing home. The email indicated that the de-installation was in response to the outstanding unpaid balance on the account. During an interview on 6/24/2025 at 3:00 pm with the Medical Records Staff AA and the Administrator, Medical Records Staff AA (who also ordered facility supplies) stated that the linen supply company would email her and the hospital, and any emails she received from them, she sent to the hospital also. When questioned about the nursing home's response to the 6/9/2025 email notification of the pending de-installation of linens scheduled on 6/11/2025, the Administrator stated she was not made aware of the email, but that they get threatening letters and emails from vendors/suppliers all the time. Medical Records Staff AA agreed and stated that when she gets emails (such as the 6/9/2025 email from the linen supply company), she sends them to the hospital and they take care of it, and nothing ever happens, nothing comes of it. When she received the email on 6/9/2025, she sent it over as usual, and she thought the hospital would take care of it. Review of 6/26/2025 1:02 pm email correspondence from the linen supply company's Accounts Receivable Manager, revealed that the facility's outstanding balance was $20,876.62 for supply invoices dated 1/5/2025 through 5/25/2025. The email also included that the hospital had issued a check to the linen company for over $11,000 ( in May 2025) and the check bounced. The email further documented that the linen service had been suspended six times over the past year and a half due to nonpayment of invoices, and the hospital accounting group had been unresponsive and offered no solution for the insufficient funds issued in May (2025). During an interview on 6/26/2025 at 2:33 pm, the linen company's Accounts Receivable Manager stated that the linen company had supplied the facility with bed sheets, under pads, towels, washcloths, cleaning cloths and laundry bins. She confirmed she had not received any response from the hospital regarding the outstanding balance on the account. During an interview on 7/2/2025 at 1:26 pm, the linen company's Regional Sales Manager confirmed he was onsite at the nursing home on 6/11/2025 for the linen de-installation. The Regional Sales Manager indicated they worked with the facility staff and did not remove linens from any beds with residents in them, and they did not take any linens that were covering residents. They returned the next day for those remaining items. The Regional Sales Manager state the process was quick, and they were there for about an hour. He also stated that while he was still at the facility, someone from the nursing home went to the hospital and returned with a cart of linens and had it before his company staff left the building. 2. Review of email correspondence dated 6/26/2025, between the facility's pharmacy vendor and facility staff, revealed that the outstanding balance was $10,807.06. The last payment made to the pharmacy vendor was on 4/9/2025. The pharmacy vendor was requesting payment. During an interview on 7/3/2025 at 11:28 am, the pharmacy vendor's [NAME] Manager confirmed that no additional payment had been made on the account. The last payment received on 4/9/2025 was for $12,877.79 and was for November and December 2024. The facility still owed for all of 2025. The [NAME] Manager stated that her next email would be to notify the facility they would be put on a Cash on Delivery (COD) status. The [NAME] Manager stated that the last time she sent out a COD notice, the hospital Chief Financial Officer (CFO) called her and a check was sent to them (pharmacy vendor) and that was the April payment. 3. During initial observations of the facility on 6/23/2025 from 1:00 pm to 1:54 pm, with the Housekeeping Supervisor, the storage area for adult briefs was observed. The Housekeeping supervisor pointed to an empty top shelf and stated they were currently out of size 3XL adult briefs and had one pack of size XL briefs in the storage area. He confirmed they had residents who used 3XL and XL sized adult briefs and stated there may be some in the residents' rooms.

Based on staff interviews and record review, the facility Administration failed to ensure oversight of the kitchen to ensure proper sanitation of pots, pans, dishes, utensils and countertop surfaces. This was evidenced by the Administration not being aware the dish machine and three-compartment sink did not have proper sanitation; and was not aware that the thermostat on the dish machine was inoperable. Also, the Dietary Manager did not have a Certified Dietary Manager (CDM) certification or equivalent. The deficient practice had the potential to affect 53 out of 56 residents that received an oral diet from the kitchen. Findings include: Review of Administrator's job description, Copyright 2023 from The [Name], LLC, revealed, Major Duties and Responsibilities - Plans, develops, organizes, implements, evaluates and directs the overall operation of the facility as well as its programs and activities, in accordance with the current state and federal laws and regulations . Evaluates key performance indicator outcomes with department heads to determine the need for action from leadership and/or management such as re-education or revisions related facility's outcomes, regulatory compliance and/or customer satisfaction. Review of Dietary Manager's job description, Copyright 2023 from The [Name], LLC, revealed, Required Qualifications .Certification as a dietary manger. Certification as a food service manager .Major Duties and Responsibilities - Oversees the budget and purchasing of food and supplies, and food preparation, services, and storage .Dietary Manager Assigned Tasks . Ensures proper sanitation and safety practices of staff. During an interview on 3/6/2025 at 3:01 p.m., the Dietary Manager stated she did not have her Certified Dietary Manager certification (or equivalent) and did not enroll in an online class until January 25. The Dietary Manager stated they did not review the sanitation or temperature logs. She also stated she did not appoint anyone to review or monitor the logs. During an interview on 3/6/2025 at 4:45 p.m. with the Administrator, she stated she did not make sure sanitation test strips and sanitizing chemicals were ordered right away once she was informed the sanitation test strips and did not know the hot water to the dish machine was not working properly. The administrator stated that she did not monitor the Dietary Manager nor ensure oversight of the kitchen. The Administrator stated she started working at the facility 11/2024. The Administrator stated that she knew the Dietary Manager was not certified and did not hire her for the position. The Administrator stated her expectations was the Dietary Manager was monitoring sanitizing logs. During an interview on 3/11/2025 at 11:21 a.m., the Administrator stated they had arranged for a Dietitian to work every day with the Dietary Manager until she was certified. The Administrator stated they also will have the Dietary Manager enroll in an education program to help with the education of the dietary staff. Cross Reference F812

Based on observations, staff interviews, record review, and review of the facility's policies titled Manual Warewashing-3 Compartment Sink and Dishwasher Temperature, the facility failed to ensure all dishes, pots, pans and cooking utensils were properly sanitized to decrease the risk of spread of infection and cross contamination. This was evidenced by the facility staff not having the proper method to check the sanitizer solution concentration levels for the dish machine and three compartment sink. The deficient practice had the potential to affect 53 out of 56 residents that received an oral diet from the kitchen. Findings include: Review of the facility's policy titled, Manual Warewashing-3 Compartment Sink dated [DATE] revealed, Policy: To prevent the spread of bacteria that may cause food borne illness, this facility washes, rinses, and sanitizes pots, pans, and other utensils using a 3 compartment sink in accordance with current standards for food safety .Policy and Compliance Guidelines: . 7. Sanitizing solutions shall be tested by a test kit or other device that accurately measures the concentration in MG/L (milligram/liter). Testing will occur periodically but not limited to: a. When sink is initially filled, b. At least once per shift, c. With extended use, and d. As needed. Review of the facility's policy titled, Dishwasher Temperature dated [DATE] revealed, Policy: It is policy of this facility to ensure dishes and utensils are cleaned under sanitary conditions through adequate dishwasher temperatures. Policy Explanation and Compliance Guidelines: .3. For high temperature dishwashers (heat sanitization): a. The wash temperature shall be ,d+[DATE] F (degrees Fahrenheit):. i. For a stationary rack, single temperature machine: 165 F. ii. For stationary rack, dual temperature machine: 150 F. iii. For a single tank, conveyor, dual temperature machine: 160 F . iv. For a multi-tank, conveyor, multi-temperature machine:150 F. b. The final rinse temperature shall be 180 F or above but not exceed 194 F (165 F for stationary rack, single temperature machine). Corrective actions shall be taken for final temperatures below the required rinse temperatures. 4. For low temperature dishwashers (chemical sanitization): a. The wash temperature shall be 120 F. b. The sanitizing solution shall be 50ppm (parts per million) hypochlorite (chlorine) on dish surface in final rinse. 5. Chemical solutions shall be maintained at the correct concentration, based on periodic testing, at least once per shift, and for the effective contact time according to manufacturer's guidelines. Results of concentration checks shall be recorded. 6. Water temperatures shall be measured and recorded prior to each meal and/or after the dishwasher has been emptied or re-filled for cleaning purposes. Review of facility's temperature and sanitizer log dated ,d+[DATE], ,d+[DATE] and ,d+[DATE] with recorded temperatures and sanitizing results reading showing no discrepancies with temperature or test strip results. Review of the [Name] test strip bottle revealed the color-coded levels associated with the parts per million (ppm) concentration levels of the solutions to be tested . The proper range for the dish machine was ,d+[DATE] ppm (green) and for the three-compartment sink 400- 500 ppm (green). During an observation on [DATE] at 8:48 a.m. the Dietary Manager completed a test of the sanitizer solution using a test strip for the dish machine and the three-compartment sink. The test strip reading was around 150 ppm (parts per million) (yellow-ish brown) using [Name] test strips for the dish machine and Quaternary (QAC) strips registered 0 ppm (light olive green) for the three-compartment sink. The color of the test strips were yellow-ish brown and not green, as it should have been for the appropriate concentration level of ,d+[DATE] ppm. During an observation on [DATE] at 8:49 a.m. the Dietary Manager completed a test strip for the dishwasher and three compartment sinks. Test strip reading was around 150 ppm (yellow-ish brown) using [Name] lab strips and Quaternary (QAC) strips 0 ppm (light olive green). During an observation on [DATE] at 8:57 a.m. the Dietary Manager completed a test strip for the dishwasher and three compartment sinks. Test strip reading was around 150 ppm (yellow-ish brown) using [Name] lab strips and Quaternary (QAC) strips 0 ppm (light olive green). During an observation on [DATE] at 9:01 a.m. the Dietary Manager completed a test strip for the dishwasher and three compartment sinks. Test strip reading was around 150 ppm (yellow-ish brown) using [Name] lab strips and Quaternary (QAC) strips 0 ppm (light olive green). During an observation on [DATE] at 2:58 p.m., Dietary Aide JJ completed a test of the sanitizer concentration level using a test strip for the dish machine. The test strip reading was around 150 ppm (yellow-ish brown) using [Name] lab strips, which was at a lower level than it should have been. During an observation on [DATE] at 3:01 p.m., the Dietary Manager completed a test of the sanitizer concentration level using [Name] lab strips and Quaternary (QAC) strips for three-compartment sink. The test strip reading was around 150 ppm, which was yellow-ish brown in color, using [Name] lab strips and the Quaternary (QAC) strips, which read 0 ppm was light olive green color. During an interview on [DATE] at 3:01 p.m., the Dietary Manager stated she did not know if the dish machine was serviced, nor could she explain who checked the sanitization log. During an interview on [DATE] at 3:08 p.m., Dietary Aide JJ stated the test strips did not measure at a proper concentration level for the sanitizing solution. Dietary Aide JJ stated they informed the night nurse but was unsure of whom and when this happened. Dietary Aide JJ, when asked how and by whom the sanitizing logs were completed with the information verifying no discrepancies, Dietary Aide JJ hunched their shoulders up and down and said, I don't know. Dietary Aide JJ stated she started working at facility three months ago. During an interview on [DATE] at 3:09 p.m. with Dietary Aide II stated they had worked at the facility for three years. Dietary Aide II stated the dish machine, and sanitizing solutions were checked by [Name], but they were unsure of when [Name] had last serviced the machine or solutions. Dietary Aide II stated that logs were completed to show correct temperature and chemical reading, although things were not working. Dietary Aide II stated they couldn't remember if they told anyone about the solutions or test strips not reading at the proper levels. During an interview on [DATE] at 3:11 p.m., with Dietary Aide HH stated she ran the dish machine four wash cycles, and the temperature was 84 F (degrees Fahrenheit), 101 F, 119 F and 121 F. Dietary Aide HH stated the machine did not reach 145 F or hotter until the machine ran two to four wash cycles in a row. Dietary Aide HH stated the log might be incorrect due to the machine's temperature gauge not working correctly. During an interview on [DATE] at 3:13 p.m., the Dietary Manager stated they had 12 containers of [Name] test strips that expired [DATE], [DATE], [DATE], [DATE] and [DATE]. The Dietary Manager stated the test strips were used to ensure the proper concentration for sanitization was reached for three compartments sink and dishwashing machine. The Dietary Manager stated she had not ordered any new strips after she realized they had expired. The Dietary Manager stated she was aware for a while that the dish machine did not get hot right away and staff would have to run the machine at least three to four cycles before the temperature was reached. The Dietary Manager stated they did not make arrangement to have the machine serviced. During an interview on [DATE] at 4:45 p.m., the Administrator stated there was a previous contract with a company that serviced the dish machine and provided sanitation solutions. The Administrator stated she did not know if the facility had been getting serviced by [Name] and was unsure of the prior contract. The Administrator stated she had not been informed they did not have a vendor to supply sanitizing solutions. During an interview on [DATE] at 4:51 p.m., the Housekeeping Supervisor stated the contract with the previous vendor had ended two years ago. The facility had been using the sanitizing chemicals that were left over from two years ago. The machine had not been serviced since the other company left in the summer of 2023. During an interview on [DATE] at 4:41 p.m., the [Name] Technician stated they received a service call on [DATE] to test the chemical sanitizer solutions. The [Name] Technician stated the three-compartment sink sanitizer solutions were expired; the QT test strips were expired, and the dish machine's sanitizing chemical solution was empty. The [Name] Technician stated they did not have any supplies on hand and placed an order for restocking. The [Name] Technician stated the last time they serviced the three-compartment sink and dish machine for chemicals was ,d+[DATE] and it was fine then. The Ecolab Technician further stated they trained the staff today on how to use the test strips and check chemical sanitizing solution. During an interview on [DATE] at 4:43 p.m., the Dietary Manager stated she did not know the dish machine sanitizing chemicals were empty nor was she aware the sanitizing chemicals were expired. The Dietary Manager stated that staff should not have run the dish machine if no chemical solution was available. The Dietary Manager stated that staff were trained by [Name] Technician on [DATE] how to the use of Ecolab test strips to determine sanitation level and also on how to check the sanitizer solution levels for the dishwashing machine. During an interview on [DATE] at 4:45 p.m., the Administrator stated they were actively working with [Name] to get the appropriate test strips and sanitizer solutions. The Administrator stated they were aware of the concern on [DATE], but did not call [Name] until [DATE] because they had to get the account information. During an interview on [DATE] at 11:21 a.m., the Administrator stated they started using paper plates and plasticware over the weekend. The Administrator stated that they had supplies and sanitation solutions arriving either [DATE] or [DATE]. The Administrator stated they also had a plumber come on [DATE] to check the thermostat on the dish machine. The Administrator stated the plumber will return [DATE] to add a new thermostat and install a recirculation line. The Administrator stated she expected the Dietary Manager to review temperature and sanitizer logs. The Administrator stated that all of kitchen staff had received a written warning on [DATE] for falsifying temperature lot information. Cross Reference F835

Based on observation, staff interviews, record review, and review of facility's policies titled Hand Hygiene, and Enhanced Barrier Precautions, the facility failed to perform hand hygiene between residents for six out of 21 residents observed during meal service, to prevent the spread of infection and communicable diseases. In addition, the facility failed to don gown prior to administering medications to one of three Residents (R) R53 with a gastrostomy (G-tube). Findings include: Review of the facility policy titled, Hand Hygiene, dated 1/1/2025 read, Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table . Hand Hygiene Table: Condition: Between resident contacts. Either Soap and Water or Alcohol Based Hand Rub (ABHR is preferred). A review of the facility policy titled, Enhanced Barrier Precautions dated 2025, stated, It is the policy of this facility to implement enhanced barrier precautions [EBP] for the prevention of transmission of multidrug-resistant organisms. Definitions: Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown, and gloves use during high contact resident care activities . 2. Initiation of Enhanced Barrier Precautions . b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. indwelling medical devices (e.g. feeding tubes .) even if the resident is not known to be infected or colonized with a MDRO [multidrug-resistant organism] . 3. Implementation of Enhanced Barrier Precautions: a. Make gowns and gloves available immediately near or outside of the resident ' s room .4. High-contact resident care activities include .g. Device care or use .feeding tubes . 1. During a meal service observation in the main dining room on 3/4/2025 at 11:33 a.m., Registered Nurse (RN) AA, without performing hand hygiene, walked over to a resident seated at the dining room table, and started cutting up their food on their plate for them. Without performing hand hygiene, RN AA went to another table and assisted a resident with cutting up her pork chops. Then RN AA went over to the kitchen door and retrieved a sandwich, wrapped in a clear bag, from the kitchen staff and delivered the sandwich to the resident, seated at another table. RN AA went to another table, sat down beside a resident and, without performing hand hygiene, started feeding the resident with a spoonful of food. The RN continued to feed the resident until the resident finished eating. RN AA got up from the chair after feeding the resident and went over to another table and sat down across from another resident. RN AA picked up the resident ' s spoon and fed the resident a bite of her food. After the RN finished feeding the resident, RN AA got up and walked to the doorway of the kitchen. The RN was handed another sandwich wrapped in clear plastic wrap. RN AA, without performing hand hygiene, brought the sandwich over to another resident seated in the dining room, removed the sandwich from the package and set it on the resident ' s plate in front of her. During an interview on 3/5/2025 at 12:40 p.m., RN AA stated, I didn ' t wash my hands between helping each resident during lunch. I probably should have. During an interview on 3/5/2025 at 1:59 p.m., the Director of Nursing stated, I expect that when staff are helping a resident in the dining room, they wash their hands between each resident, and especially when feeding them. [RN AA] does our in-services for infection prevention and hand hygiene. She also does our hand hygiene audits. 42991 2. A review of the document titled, Diagnosis Report revealed R53 had the following diagnoses: acute respiratory failure with hypoxia, dysphagia, and encounter for attention to Gastrostomy (G-tube). In a review of the Admission Minimum Data Set (MDS), dated [DATE] revealed the facility admitted R53 on 12/10/2024. Continued review of the MDS revealed Section C (Cognitive Patterns), the resident had both short-term and long-term memory loss, and Section K (Swallowing/Nutritional Status), the resident had a feeding tube. In review of R53's care plan, no date, stated, Focus - Prevent Spread of Multidrug resistant organism: G-tube. Goal - Staff will implement EBP daily to decrease the risk of spreading MDROs in facility. Interventions - Follow EBP as designed by the facility. Will be followed during .devices care or use .feeding tube. [sic] Observation of Licensed Practical Nurse (LPN) BB, on 3/5/2025 at 2:00 p.m., during medication administration to R53 revealed the LPN administered quetiapine fumarate 150 milligrams (mg) and valproic acid oral solution 250 mg via the resident's G-tube. Continued observation revealed the LPN had donned gloves but had failed to don a gown. An interview with DON on 3/7/2025 at 9:30 a.m., revealed R53 should have been on EBP because the resident had received medications through a GT and the staff should have donned a gown. The DON stated some staff may not have been trained on EBP. A review of the document titled, Inservice Sign-In Sheet, Enhanced Barrier Precautions dated 4/2/2024 revealed LPN BB had not received training on EBP. A telephonic interview with LPN BB on 3/72025 at 9:38 a.m., revealed he/she could not recall if he/she had or had not received training on EBP and he/she had not been aware R53 was on EBP. The LPN stated in the past, the DON, or the ADON would post signage on the resident's door, as well as provide a (Personal Protective Equipment) PPE cart. Interview with the Assistant Director of Nursing (ADON) on 3/7/2025 at 10:14 a.m., revealed R53 had changed rooms recently; however, the signage and PPE cart had not been transferred along with the resident during the move.

Based on observations, staff interviews, record review and review of facility's policy titled Abuse, Neglect and Exploitation, the facility failed to report an injury of unknown source for one out of one Resident (R) R5 reviewed for abuse. Findings include: Review of the facility's policy titled Abuse, Neglect and Exploitation dated 10/1/2018 revealed under the The Components of the facility abuse prohibition plan are discussed herein section revealed, II. Employee Training .C. Training topics will include: .4. Reporting process for abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources; Under the section labeled IV. Identification of Abuse, Neglect and Exploitation it was noted B. Possible indicators of abuse include, but are not limited to: 1. Resident, staff or family report of abuse 2. Physical marks such as bruises or patterned appearances such as a hand print, belt or ring mark on a resident's body 3. Physical injury of a resident, of unknown source Continued review of the policy revealed VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Review of R5's clinical record revealed admitting diagnoses that included but not limited to, Parkinson's Disease, orthostatic hypotension, arthritis, Non-Alzheimer's Dementia, and depression. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed, Section C (Cognitive Pattern), a Brief Interview of Mental Status score of 4, which indicated R5 was severely cognitively impaired and Section GG (Functional Abilities and Goals), indicated R5 required substantial to total assistance with activities of daily living (ADLs). In an observation during the initial tour on 3/42025 at 11:55 a.m. revealed, R5 was in his room in the bed and was having a mobile x-ray conducted of his right foot. Accompanied by Licensed Practical Nurse (LPN) EE, during a follow-up observation on 3/6/2025 at 9:45 a.m., LPN EE removed R5's right sock and presented that the resident's right foot was swollen with a circular red bruise to the top of the foot. The bruise measured approximately 1.5 to 2 inches in diameter. LPN EE stated that she heard the resident may have had foot injured in the shower or when being transferred by staff. LPN EE confirmed the resident had an x-ray of his right foot, and the results of the assessment indicated there was no fracture to the foot. A follow-up interview on 3/6/2025 at 2:45 p.m. with LPN EE revealed that on Monday, 3/3/2025, Certified Nursing Aide (CNA) FF called her into the shower room and showed her a bruise on the top of the resident's foot. When asked about the protocol for reporting an injury of unknown origin, the nurse said injuries of unknown origin were to be reported to the Director of Nursing (DON). LPN EE did not report the injury of unknown origin to the DON. In an interview with the facility's DON on 3/6/2025 at 5:30 p.m., the DON said that injuries of unknown sources were reported to the Administrator immediately and an investigation was started immediately. The DON confirmed this did not happen for R5's injury of unknown origin that required a mobile x-ray on the morning of 3/4/2025 and said that the injury should have been reported at that time. When asked if an investigation had started, the nurse said that she had started an investigation; however, nothing had been documented yet. An interview with CNA FF on 3/6/2025 at 5:45 p.m. revealed that on the morning of Monday, 3/3/2025, he notified the charge nurse, LPN EE, and the wound nurse, LPN GG about R5's bruise on top of his foot. In an interview with the wound nurse, LPN GG on 3/7/2025 at 9:18 a.m., LPN GG said that CNA FF reported that he discovered a bruise on top of R5's foot and wanted her to look at it. LPN GG said that the bruise was about the size of a quarter on 3/3/2025, and when she saw it again on the morning of 3/4/2025, the resident's foot was swollen, and the bruise had spread and become much larger. She notified the physician, and an x-ray of the foot was ordered. She reported the injury of unknown origin to the charge nurse and to the DON. In an interview on 3/7/2025 at 9:46 a.m., the facility's Administrator said that the protocol in addressing injuries of unknown origin was to ensure an incident report was completed, and if the origin of the injury was unknown, then follow-up was required, and it was a reportable event to the state. The Administrator said that the chain of command for reporting injuries of unknown origin was for the aide to report to the charge nurse; the charge nurse reported to the DON; and then the DON reported to the Administrator. If it was not determined how an injury happened, then an investigation was initiated, and an investigation report was completed. The Administrator confirmed R5's injury of unknown origin was not reported to her on 3/4/2025, as it should have been, and confirmed that an investigation was not initiated regarding the resident's injury of unknown origin.

Based on staff interviews, record review, and review of the facility's policy titled Resident Assessment-Coordination with PASARR (Preadmission Screening and Resident Review), the facility failed to refer one out of two sampled Residents (R) R1 with a serious mental disorder for a Level II PASARR. Findings include: A review of the facility's undated policy titled Resident Assessment-Coordination with PASARR, under the Policy section revealed, This facility coordinates assessments with the PASARR program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Under the Policy Explanation and Compliance Guidelines: 1 . b. PASARR Level II - a comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the facility) that determines whether the individual has mental disorder (MD), intellectual disability, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs . 6. The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority. 7. Recommendations, such as any specialized services, from a PASRR level II determination and/or PASARR evaluation report will be incorporated into the resident's assessment, care planning, and transitions of care . 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability or a related condition will be referred promptly to the state mental health or intellectual disability authority for a Level II resident review. A review of R1's History and Physical dated 3/13/2016 revealed the facility had admitted the resident on 3/8/2016 with the following diagnoses: paranoid schizophrenia, osteoarthritis (OA), and dementia. A review of the Annual Minimum Data Set (MDS) dated [DATE] for R1 revealed, Section C (Cognitive Pattern), a Brief Interview Mental Status (BIMS) score of three which indicated severe cognitive impairment and not able to complete the interview. A review of the document dated 2/3/2011 and titled, Georgia Department of Community Health stated Attention: Medicaid Prior Approval/Utilization Review (UR) Department revealed On the basis of available clinical information, it is determined that [R1] has met the criteria for Level I PASARR approval. Continued review of the clinical record did not reveal the facility had referred the resident to the appropriate state designated authority for a PASARR II screening despite the resident having a diagnosis of Schizophrenia. An interview, on 3/6/2025 at 12:21 p.m. and on 3/7/2025 at 8:54 a.m. with the Social Worker (SW) revealed the resident did have a PASARR I completed prior to admission but the resident was not diagnosed with schizophrenia until 2016, so PASARR II had not been completed. The SW stated she was not aware a PASARR II had not been completed, and normally the Admissions Department would complete PASARR II. In an interview with the Medical Records (MR) staff, it was revealed she would complete a PASARR I upon admission if needed, however, he/she did not know who would normally complete a PASARR II. An interview with the Administrator on 3/7/2025 at 9:41 a.m., revealed that a psychiatrist should take the lead role on whether or not a PASARR should be completed on a resident. She stated it was his/her expectation that the facility's policies and procedures be followed in regard to PASARR II.

Based on observation, staff interviews, record review, and review of the facility's policy titled Comprehensive Care Plans, the facility failed to implement a comprehensive person-centered care plan for one out of 21 sampled Residents (R) R53. Specifically, R53's care plan was not followed by staff in regard to Enhanced Barrier Precautions (EBP). Findings include: A review of the policy titled Comprehensive Care Plans dated 2025 stated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality .Policy Explanation and Compliance Guidelines: .8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. A review of the document titled, Diagnosis Report no date, revealed R53 had the following diagnoses: acute respiratory failure with hypoxia, dysphagia, and encounter for attention to gastrostomy tube - (G-tube]. In a review of the Admission Minimum Data Set (MDS), dated [DATE] revealed the facility admitted R53 on 12/10/2024. Continued review of the MDS revealed Section C (Cognitive Patterns), the resident had both short-term and long-term memory loss, and Section K (Swallowing/Nutritional Status), the resident had a feeding tube. In a review of R53's care plan dated 12/10/2024 revealed, Focus - Prevent Spread of Multidrug resistant organism: G-tube. Goal - Staff will implement Enhanced Barrier Precautions (EBP) daily to decrease the risk of spreading multi-drug-resistant organisms (MDROs) in facility. Interventions - Follow EBP as designed by the facility. Will be followed during .devices care or use .feeding tube. [sic] Observation of Licensed Practical Nurse (LPN) BB, on 3/5/2025 at 2:00 p.m., during medication administration to R53 revealed the LPN administered quetiapine fumarate 150 milligrams (mg) and valproic acid oral solution 250 mg via the resident's G-tube. Continued observation revealed the LPN had donned gloves but had failed to don a gown. In an interview with the Director of Nursing (DON) on 3/7/2025 at 9:30 a.m., it was revealed it was her expectation that staff follow each resident's care plan, mostly, in order to protect and care for each resident. An interview with LPN CC, on 3/7/2025 at 9:36 a.m., revealed care plans were developed by the MDS Nurse, but any nurse could update the care plans as needed. She revealed the purpose of a care plan was so staff would be aware of how to care for each resident. He/She continued to state if staff did not follow the care plan, the residents would not be properly cared for. An interview with the Administrator on 3/7/2025 at 9:41 a.m., revealed it was his/her expectation that staff follow all the facility's policies and procedures related to EHB.

Based on interviews, record review, review of the Work Attendance policy and review of the Licensed Practical Nurse (LPN) job description, the facility failed to ensure that services being provided by an LPN met professional standards of quality including: leaving the facility while on duty and without notice, being unable to be located by other on-duty nursing staff, and leaving 32 of the 58 residents of the facility without their assigned licensed nurse. Findings include: The facility had a Work Attendance policy with revision date of 2017. The policy documented that all employees must fulfill their individual work schedule commitments in order to meet the organization's staffing needs, avoid the unnecessary costs of excessive absenteeism, and promote operational efficiency. The policy emphasized the importance of being at work on time and when scheduled. Under the policy's Unscheduled Absences section, failure to work any portion of an assigned shift, including leaving work early for reasons other than being asked to leave by the supervisor was considered an unscheduled absence. The facility had a Job Title-Licensed Practical Nurse job description. The job description documented a general description of an LPN which included, but was not limited to, someone who, under the supervision of a Registered Nurse (RN), provides direct care for the adult and geriatric age groups as assigned, directs care provided by the Certified Nursing Assistant (CNA's) during scheduled shifts, assumes responsibility for professional duties as determined by qualifications and training, and may assume charge in the absence of the RN. The job qualification section of the job description also included that the LPN must have an acute sense of responsibility. Review of the 6/22/23 Midnight Census Report revealed that the facility had a total census of 58 residents. There were 32 residents on the front and middle halls (rooms 1 through 25) and 26 residents on the back hall (rooms 26-51). Review of the 6/22/23 PPD Form daily staffing sheet also revealed a census of 58 residents. The staffing sheet documented for the 11:00 p.m. to 7:00 a.m. shift (6/22/23 11:00 p.m. to 6/23/23 7:00 a.m.) there was one RN, two LPNs, and four CNAs assigned to the facility. Review of the facility's time reports revealed that the assigned staff were RN GG, LPN BB, LPN HH, CNA CC, CNA DD, CNA EE, and CNA FF. LPN HH was assigned to the back hall. LPN BB was assigned to the front and middle halls. RN GG completed other duties. During an interview on 7/18/23 at 11:56 a.m., a family member of Resident (R) D stated that RD (who resided on the front hall) had called him, so he and another family member decided to go to the facility on [DATE] (during the early morning hours). RD's family member stated that when they arrived at the facility, the nurse (LPN BB) was off the premises. LPN BB returned to the facility while RD's family was still there. Law enforcement was notified. Review of the [NAME] Office Miscellaneous Incident Report revealed an incident date and time of 6/23/23 at 4:00 a.m. The report narrative documented that LPN BB stated she left the facility from 2:00 a.m. to 4:00 p.m. [sic] and the other staff were present the rest of the night. While LPN BB was absent from the facility on 6/23/23 between 2:00 a.m. and 4:00 a.m., there were two other nurses (LPN HH and RN GG) and four CNA's (CNA CC, CNA DD, CNA EE, and CNA FF) present. However, there was no evidence that LPN BB made anyone aware that she was leaving. During an interview on 7/18/23 at 11:08 a.m., CNA FF confirmed LPN BB was her assigned nurse supervisor on the 6/22/23 11:00 p.m. to 6/23/23 7:00 a.m. shift. She stated that she was not aware LPN BB left the facility. During an interview on 7/18/23 at 12:44 p.m., CNA CC confirmed she was assigned to RD on the 6/22/23 night shift. She stated that she was unable to find LPN BB when RD's family members came to the facility. During an interview on 7/24/23 at 11:28 a.m., CNA EE confirmed that she was not aware that LPN BB had left the facility. She stated that LPN BB came back in about 20 to 30 minutes after RD's family came in. During an interview on 7/19/23 at 12:57 p.m. LPN HH confirmed that she was assigned to the back hall of the facility from 6/22/23 7:00 p.m. to 6/23/23 7:00 a.m. She stated that she was not aware that LPN BB had left the facility and was unable to locate her when RD's family member arrived and was walking around looking for her. LPN HH stated that LPN BB returned to the facility about 45 minutes after RD's first family member arrived. During an interview on 7/19/23 at 3:42 p.m., RN GG stated that she was already at the facility caring for a family member. She came on duty at 11:00 p.m. on 6/22/23. RN GG indicated that when she came on duty on the night shift, she usually completed tasks such as answering call lights, changing dressings or reapplying dressings during her shift. She confirmed that on 6/23/23, she did not know that LPN BB had left the facility. During an interview on 7/11/23 at 10:40 a.m., the Administrator confirmed that LPN BB left the facility without permission and was terminated. Review of the Separation Notice revealed that LPN BB was terminated from employment on 6/23/23.

Based on interviews and record review, the facility failed to ensure that one resident (R#3) of 13 sampled residents resident's rights was not violated when being made to go to bed when he was not ready. Findings include: Record review revealed that Resident (R)#3 was admitted to the facility on [DATE] and had diagnoses that included, but were not limited to, Alzheimer's disease, dementia, diabetes, arthritis, paranoid schizophrenia, and paranoid personality disorder. A 6/21/23 Quarterly Minimum Data Set (MDS) assessment documented that R#3 had impaired cognition, with a Brief Interview for Mental Status (BIMS) score of 5 out of 10. R#3 was also documented as being provided with staff assistance for Activities of Daily Living (ADL's), including extensive assistance for transfers. Review of personnel records revealed that TNA AA had been an employee at the facility from 6/10/19 through 4/27/23. He obtained a TNA certificate on 5/26/20. Review of the care plan for R#3 revealed the following focus area: I have the potential for alteration in skin integrity. I have fragile skin and I bruise easily. I am prone to skin tears. I am at risk for infection. I am at risk for pressure ulcers related to decreased mobility. Interventions included being gentle with resident when providing ADL needs and to inform resident of which tasks are about to be performed. A review of facility reported incidents revealed a Facility Incident Report Form, dated 4/21/23, that documented a bruise of unknown origin to the arm. The form included that the bruise and two small skin tears were identified on 4/21/23 at 6:28 a.m. on R#3. Treatment was applied to the skin tears and the physician and responsible party were notified. A review of the accompanying investigation that included staff and resident statements, nurse's notes, and a follow-up summary conclusion revealed that facility staff were able to identify the cause of the bruising and skin tears. The injuries were determined to have been caused on 4/19/23, when TNA AA forced R#3 to go to bed against his will, at which time R#3 hit TNA AA, resulting in bruising and skin tears to R#3's right arm. The MDS Coordinator and Assistant Director of Nursing (ADON) documented in a 4/21/23 statement that they interviewed R#3 and he reported that the other night he wasn't ready for bed and that he was grabbed by the arm while being put in the bed. R#3's roommate (RA) is documented in the written statement as stating that the incident occurred on a Wednesday (4/19/23) on the evening shift. During an interview on 7/24/23 at 11:46 a.m., RA confirmed the occurrence between R#3 and a male nursing staff. He stated that R#3 did not want to go to bed but he was put in the bed. RA stated he did not see what happened, but he heard it. The ADON and Administrator documented in a statement that they interviewed TNA AA on 4/21/23 via phone. The statement documents that TNA AA stated he told R#3 that it was time to go to bed and R#3 did not want to go to bed. TNA AA told R#3 again that it was time to go to bed and R#3 agreed. When TNA AA got R#3's arm and held on to the back of his pants to assist R#3 to bed. R#3 started swinging his arms and hitting TNA AA in the face. TNA AA placed R#3 in the bed against his will. Further review of TNA AA's personnel record confirmed he was terminated from the facility.

Based on interview, record review and review of the Transfer and Discharge (including AMA) policy, the facility failed to complete a discharge summary that included a recapitulation of the resident's stay, medication reconciliation, and a post discharge plan of care for one resident (#1) from a total sample of 13 residents. Findings include: The facility had a Transfer and Discharge (including AMA) policy, dated 9/28/22. The policy defined resident-initiated transfer or discharge to mean that a resident or resident representative had provided verbal or written notice of intent to leave the facility. The policy's Anticipated Transfers or Discharges section included that the nurse caring for the resident at the time of discharge was responsible for ensuring the Discharge Summary was completed and included, but was not limited to the following information: 1. A recap of the resident's stay 2. A final summary of the resident's status 3. Reconciliation of all pre-discharge medications with the post-discharge medications 4. A post discharge plan of care that is developed with the resident and the resident's representative which will assist the resident to adjust to the new living environment Review of the clinical record revealed that Resident (R)#1 was admitted to the facility on [DATE] and had diagnoses that included, but were not limited to, diabetes, chronic constipation, hypermagnesemia, adult failure to thrive, severe protein-calorie malnutrition, and hypokalemia. An 11/15/22 Admission Minimum Data Set (MDS) assessment assessed R#1 has having some cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 9 out of 15. Review of the Admission Discharge Form Plan of Care form revealed that R#1's initial discharge plan was to remain in the facility. Further review of the clinical record revealed a 12/15/22 nurse's note that documented R#1 stated that she wanted to go home and that she was only here for a short time to get stronger. The physician was notified of R#1's wishes with approval given. Further nurse's notes on 12/15/22 documented that R#1's family was notified of her desire to go home. The family stated that they would make arrangements for the resident to go home. A 12/19/22 social progress note documented that R#1 stated she was ready to go home and that her family was getting ready to take her home at the end of the month. On 12/28/22 R#1 was discharged from the facility. A 12/28/22 3:00 p.m. nurse's note documented that R#1 discharged home with family. The note included that R#1 was alert and oriented and in stable condition. Medications were sent with R#1. The physician was notified that R#1 was discharged to home with family. Further review of the closed clinical record revealed no further discharge summary information. There was no evidence that staff completed a recapitulation of the resident's stay, reconciliation of all pre-discharge medications with the post-discharge medications, or a post discharge plan of care. During an interview on 7/19/23 at 11:30 a.m. the Administrator stated that she could not find any additional discharge summary information for R#1.

Based on interviews, record review, and review of the facility policy titled, Comprehensive Care Plan the facility failed to accurately revise Advance Directive care plan and include measurable objectives and timeframes for one resident ((R#33) of 24 sampled residents. Findings include: Review of the facility policy titled Care Plan Policy revised date 10/7/22 revealed the facility will develop and implement a person-centered care plan for each resident consistent with resident's rights that includes measurable objectives and timeframes to meet a resident's medical and psychosocial needs that are identified in the resident's assessment reference date. Review of medical record revealed R#33 admitted [DATE] and readmitted on [DATE]. Review of Minimum Data Set (MDS) dated [DATE] revealed R#33 had a Brief Interview of Mental Status (BIMS) score of 13 and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of medical record for R#33 revealed no documented Advance Directives and a POLST dated 5/6/2020 with choice Allow Natural Death and Do Not Attempt Resuscitation with an Authorized Person signature dated 5/6/20, Physician Signature dated 3/5/20 and Concurring Physician Signature dated 5/16/20 but there was no documentation the Subsequent Review of the POLST Form had been completed or updated for when he readmitted on [DATE]. Further review of Physician Orders dated 10/1/22-10/31/22 revealed no code status orders. Review of Care Plans dated 5/19/20 revealed DNR status related to DNR request with Goal and Target date indicated DNR status will be honored through next review date 8/26/21 with Achieved date 6/30/22. The care plan was revised (date unknown) and indicated Resident is a Full Code with no measurable goal and timeframe. During an interview on 10/27/22 at 8:30 a.m. with Case Management revealed that she is responsible for Advance Directive Care plans. She revealed only the DNR Advance Directive Status had been added to residents' care plans and Full Code Advance Directives were not included in resident's care plan. She confirmed she updated the R#33 care plan to Full code with no revision date, measurable goal, timeframe, or interventions included. During an interview on 10/27/22 at 8:45 a.m. with R# 33 revealed he wanted to remain a DNR and was asked by Medical Records when he readmitted on [DATE]. During an interview on 10/27/22 at 10:00 a.m. the Director of Nursing (DON) reported that staff should ensure an accurate Advance Directive Care plan with accurate code status in place.

Based on observation. record review, and resident and staff interviews, the facility failed to provide an individualized activities program to meet the needs for one resident ((R#66) of 69 residents. Findings include: During observation and interview on 10/25/22 at 9:45a.m. R#66 was observed sitting in her wheelchair in doorway of her room. R#66 stated she was not happy with the activities at this facility. She stated there are not enough activities provided. R#66 stated she would love to do some crafts as she used to own a craft shop. She stated she also likes to knit. 10/25/22 at 1:35 p.m. observed R#66 propelling self-down hallway near her room. 10/26/22 at 8:45 a.m. observed R#66 sitting in wheelchair in doorway of her room. 10/27/22 at 10:00 a.m. observed R#66 sitting in wheelchair down hall. During an interview with the Director of Nursing (DON) on 10/26/22 at 9:52 a.m. she stated that she does not remember who did R#66 activities screening on admission. She stated they try to do everything as a group effort. DON stated when R#66 was admitted she was a little confused from a recent hospital stay. She stated R#66 is more alert and oriented now. DON stated they have not done a reassessment with her for activity preference. DON also stated that R#66 normally comes out and likes to smoke. She stated R#66 comes to front lobby and talk to other residents. Interview with the Administrator on 10/26/22 at 10:00 a.m. revealed the Activity Director has been out since sometime in August. Administrator also stated that when she started three weeks ago, the Dietary Manager had been filling in, but everyone was pitching in and helping with activities. Interview with Dietary Manager (DM) on 10/26/22 at 10:09 a.m. revealed she goes around to residents and ask them what their hobbies were before admission. She stated R#66 likes BINGO crossword puzzles, smoking, and visits with other residents. She stated she does not know if R#66 likes to do craft or knit. DM stated she took R#66 a word search book. When asked what activities are provided to residents who do not come down for the church services, DM stated that the other residents sit in their rooms and watch tv if their tv is on. The facility did not have a current activity policy in place at the time of the survey. Also, there was no evidence of one-on-one activities being documented for residents.

Based on record review and staff interview, the facility failed to notify the responsible party of a change in condition for one resident ((R) R#73) of six residents sampled. Findings include: Review of the electronic medical record (EMR) revealed that R#73 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of progress note dated 7/31/2022 at 11:30 a.m., revealed R# 73 was alert and oriented with clear speech. Further review of the note revealed that R# 73's J-tube was clogged internally, and facility staff were unable to unclog the tube. Staff notified the Physician, and a new order was written to send R# 73 to the emergency room (ER). There was no evidence in the progress notes that R#73's responsible party was notified of the need to go to the ER due on 7/31/2022. During an interview conducted on 10/27/22 at 3:16 p.m. with the Director of Nursing (DON) she verified no documentation to support that the responsible party was notified. The DON also revealed that it is her expectation that the responsible party be notified when a resident has a change in status or will be transferred out of the facility. DON further expressed that the responsible party should have been notified of this event.

Based on record review, resident and staff interviews, the facility failed to obtain a Physician's signature on the Physician Orders for Life Sustaining Treatment (POLST) for an Attempt Resuscitation Cardiopulmonary Resuscitation (CPR) consent for one Resident (R) (R#40) and failed to complete a subsequent review of the POLST for one Resident (R) (R#33). The sample size was 24 residents 1. Review of POLST: Guidance for completing the POLST form revealed: If the patient has decision making capacity, that patient chooses whether to complete and sign the POLST with his or her physician. Review of Minimum Data Set (MDS) dated [DATE] revealed R#40 had a Brief Interview of Mental Status (BIMS) score of 15. Review of medical record for R#40 revealed no documented Advance Directives and a POLST with a choice to attempt resuscitation (CPR) but there was no Physician's signature. Further review of Physician Orders dated [DATE]-[DATE] revealed there were no Advance Directive orders. During an interview on [DATE] at 10:20 a.m. R#40 revealed she had requested staff perform cardiopulmonary resuscitation (CPR) on her should she stop breathing. She reported she is responsible and able to make decisions for herself. During an interview on [DATE] at 10:00 a.m. the Director of Nursing (DON) she expressed that her expectations were for staff to complete Advance Directives on admission, send to the Physician(s) for signature(s), and for Nurses to ensure an accurate Advance Directive Care plan is place. She confirmed R#40 did not have a physician's signature on POLST or a Physician's order for code status. During an interview on [DATE] at 2:00 p.m. with Medical Records revealed she was instructed by the facilities Medical Director that a Physician's signature is not needed on POLST when a resident has the decision-making capacity to be a Full Code therefore, she stopped sending them over for him to sign. She verified R# 40 POLST did not have a signature. During an interview on [DATE] at 2:27 p.m. with DON reported it is her understanding that when a resident has the mental or decision capacity to be a Full code that at least one physician signature is needed on the POLST for it to be valid. DON reported that she expected staff to obtain Physician's signature(s) for POLST as needed. 2. Review of Physician Orders for Life Sustaining Treatment (POLST): Subsequent Review of the POLST form revealed: This form should be reviewed when (i) the patient is transferred from one care setting or care level to another (ii) released to return home (iii) there is substantial change in the patient's health status, or (iv) the patient's treatment's treatment preferences change. Review of medical record revealed R#33 admitted on [DATE] and readmitted on [DATE]. Review of Minimum Data Set (MDS) dated [DATE] revealed R#33 had a BIMS score of 13. Review of medical record for R#33 revealed no documented Advance Directives and a POLST dated [DATE] with choice Allow Natural Death and Do Not Attempt Resuscitation with an Authorized Person signature dated [DATE], Physician Signature dated [DATE] and Concurring Physician Signature dated [DATE] but there was no documentation the Subsequent Review of the POLST Form had been completed or updated for when he readmitted on [DATE]. Further review of Physician Orders dated [DATE]-[DATE] revealed no code status orders. Review of the Facility DNR Front Hall and DNR Back Hall list did not reveal R# 33's name. During an Interview on [DATE] at 8:20 a.m. with Medical Records who revealed she is responsible for completing advanced directives for residents. She reported that advanced directives are discussed and completed on admission and readmission. It was further reported that two physician signatures are required on all DNR orders. Medical Records reported that the DNR list is updated every time there is a new DNR. Medical Records explained that an orange dot on the outside of chart indicated that a resident has a DNR status. Medical records reported she discussed with R# 33 if he wished to remain a DNR when he readmitted on [DATE] and he wanted to remain a DNR. She verified that the POLST had not been updated since [DATE] and acknowledged she forgot to update the POLST to reflect Resident # 33 decision on [DATE] but had done so on the Advance Directives Checklist. Medical Records confirmed R#33 name was not on the facility's DNR list. She revealed the DNR list provided to Surveyor was in error and provided an updated copy with R# 33 name included on list. During an interview on [DATE] at 8:45 a.m. with R# 33 revealed he wanted to remain a DNR and was asked by Medical Records when he readmitted on [DATE]. During an interview on [DATE] at 8:50 a.m. with CNA AA revealed residents who have a DNR status are identified by the red stickers on their charts, beds, DNR list and Care Plan Book behind the Nurse's station. During an interview on [DATE] at 10:00 a.m. DON confirmed the POLST Form had not been updated when R#33 readmitted on [DATE] and there was no physician's order for a code status.

Based on record review and staff interview, the facility failed to maintain a surety bond sufficient to cover the current total funds in the resident trust account. The deficient practice had the potential to affect 69 residents with trust fund accounts managed by the facility. Findings include: Review of the Resident Fund Management Services (RFMS) Trial Balance Report dated 4/30/22 revealed a balance of $93,444.05. Review of the Resident Fund Management Services (RFMS) Trial Balance Report dated 5/31/22 revealed a balance of $95,737.93. Review of the Resident Fund Management Services (RFMS) Trial Balance Report dated 6/30/22 revealed a balance of $98,543.48. Review of the Resident Fund Management Services (RFMS) Trial Balance Report dated 7/31/22 revealed a balance of $97,165.73. Review of the Resident Fund Management Services (RFMS) Trial Balance Report dated 8/31/22 revealed a balance of $105,099.41. Review of the Resident Fund Management Services (RFMS) Trial Balance Report dated 9/30/22 revealed a balance of $109,704.18. Review of the State of Georgia Department of Community Health Long Term Care Facility Residents' Fund Bond with effective date of 6/17/20, revealed a bond rider increase bond from $55,000.00 to $95,000.00 Interview on 10/26/22 at 10:24 a.m. with the Administrator confirmed the surety bond amount was $95,000.00. She confirmed the current bond of $95,000.00 was not enough to cover the resident trust fund. Administrator stated that she had not addressed this issue because she had only been the Administrator at this facility for three weeks. She further expressed that the facility does not have a policy on resident trust fund account, but she would contact the corporate office to have the bond amount raised.

Based on observations and staff interviews the facility failed to maintain two clean and sanitize ice machines which is used for resident hydration and for meal service. The deficient practice had the potential to affect 60 of 64 residents that utilized the ice from both operating ice machines. Findings include: Review of facility policy entitled Ice dated 9/2017 revealed under procedures number two (2) The Dinning Service Director will coordinate with the Maintenance Director to ensure that the ice machine will be disconnected, cleaned and sanitized quarterly and as needed, or according to manufacturer guidelines. Number three (3) The exterior of the ice machine will be cleaned weekly, number four (4) ice bins will be cleaned monthly and as needed. Observation on 4/27/21 at 8:10 a.m. of ice machines revealed there were two ice machines stored in a locked room on the back hall. Observation of the ice machine one facing the door revealed the outside of the machine had calcium build up in the door hinges on the left and right side, also noted was calcium build up on the left side along black striping from the front of the machine to the back side was also noted as well. Inside of machine one along the lip of the white plastic cover that guides the ice to the base of the machine has dirt and grime build up which was brown in color. The top of ice machine one also has a sheet of pollen resting on it from the open window directly behind it, there was also calcium build up noted to base of the machine as well all the way around from front to back. Observation of ice machine two that was to the right of machine one revealed that the front of the machine on the outside under the lip is rusted with streaks of calcium build up as well as brown streaks streaming down to the front of the machine, the right side of the machine has calcium build up which was streaming down from the top of the machine to the bottom as well. Inside of ice machine two had noted black substance on the inner wall on the right side as well as the left side. The top of ice machine two was covered in yellow powdered like substance that appeared to be pollen coming in from the opened window as well. Interview with Dietary Manger on 4/27/2021 at 8:10 a.m. revealed that the ice machines are wiped down daily and that it was the responsibility of the Maintenance Director to ensure that the inside of the machines were cleaned and disinfected. Further interview revealed that staff member was unable to disclose the last time the ice machines were cleaned. Dietary Manager confirmed all observations of ice machine one and two and acknowledged that both machines were in need of cleaning. Interview on 4/27/21 at 8:15 a.m. with the Administrator revealed that the ice machine is cleaned by the dietary manager daily. The administrator also confirmed all of the grime and build up that was observed in both ice machines. Interview on 4/28/21 at 3:40 p.m. with the Maintenance Director revealed that the ice machine is cleaned by the kitchen staff and if there is a problem with the machine then he would fix the issue and the kitchen staff is to clean it. Continued interview also revealed that there is no policy that he goes by for cleaning the machine nor is there a log of when the machine is cleaned.

Based on observation, record review, resident interview, staff interview, physician interview, facility Pressure Ulcer Documentation Guide review, facility Weekly Skin Assessment Schedule and Responsibility Policy review, facility Braden Scale Schedule and Responsible Policy review, and hospital History and Physical review, the facility failed to ensure that residents at risk for pressure sore development were provided skin assessment, per facility policy, to ensure the timely discovery of pressure sores, and the timely provision of care to promote healing, for three (3) residents (#3, #73, and "B"), of seven (7) residents at risk for pressure sore development, from a survey sample of twenty-nine (29) residents. The facility failed to promptly identify the development of pressure sores, and ensure timely treatment, prior to the sores being assessed as unstageable with yellow slough, thus resulting in harm for Resident #73. The facility also failed to promptly identify the development of a pressure sore, and ensure timely treatment, for Resident #3 prior to the wound becoming an open gluteal wound having eschar and surrounding [DIAGNOSES REDACTED], thus resulting in harm for this resident. Findings include: According to the facility's Pressure Ulcer Documentation Guide, utilized for the documentation of resident pressure sores, a Stage I pressure ulcer was any persistent skin redness; a Stage II pressure ulcer was a partial loss of skin layers; a Stage III pressure ulcer was the presence of deep craters in the skin; and a Stage IV pressure ulcer was a break in the skin exposing muscle or bone. A pressure ulcer having necrotic tissue (eschar or slough), was defined as being unstageable. This Guide indicated, for pressure ulcer documentation, for staff to document the stage and measurement of a pressure ulcer, and also to document the presence of exudate (none, light, moderate, heavy) and the predominant tissue ([MEDICATION NAME], granulation, slough, necrotic). According to the facility's Weekly Skin Assessment Schedule and Responsibility Policy, weekly skin assessments would be done on all residents at high or severe risk (per Adjusted Braden Risk) for development of pressure ulcers and residents who had pressure ulcers. 1. Record review for Resident #73 revealed an Admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date of 06/08/2013, which documented an admission date of [DATE]. Section I-Active [DIAGNOSES REDACTED]. Section M - Skin Conditions documented that the resident was at risk of pressure-ulcer development, but had no unhealed pressure sores at the time of assessment. An admission Nurse's Notes entry of 05/24/2013 at 10:30 a.m. documented Resident #73's admission to the facility. This Nurse's Notes entry documented that at the time of admission, Resident #73 did have scarred areas to the sacrum. This Nurse's Notes entry also documented, as had the Assessment MDS referenced above, that the resident had no open areas at that time. Review of the Braden Scale For Predicting Pressure Sore Risk Form for Resident #73 revealed that on 05/24/2013, the resident had been assessed as having a score of 12, thus indicating that the resident was at high risk for pressure sore development. Subsequent Braden Scale For Predicting Pressure Sore Risk assessments completed on 05/30/2013, 06/06/2013, and 06/13/2013 also assessed the resident to have a high-risk score of 12 as well. Review of physician's orders [REDACTED]. A laboratory report for Resident #73, completed the next day on 05/30/2013, revealed that the resident had a low hemoglobin level of 8.5 grams per deciliter (g/dL) (normal range, 14 to 17.5 g/dL), and a low [MEDICATION NAME] level of 2.7 g/dL (normal range, 3.5 to 5 g/dL). On a 06/11/2013 nutritional assessment for Resident #73, completed subsequent to the 05/30/2013 laboratory report referenced above, the Registered Dietician (RD) noted that the resident had severe [MEDICAL CONDITION], moderate [MEDICATION NAME] depletion, and poor appetite. The RD also noted that the resident's current weight of 138 pounds was 86 percent of the ideal body weight, and noted the resident's use of [MEDICATION NAME] and Ensure Plus. However, even though Resident #73 had been assessed as being at high risk for pressure sore development and as having a nutritional risk, and even though the facility's Weekly Skin Assessment Schedule and Responsibility Policy specified weekly skin assessments for residents who were at high risk for pressure sore development, further record review revealed no evidence of weekly skin assessments, or any skin assessments, having been completed after the resident's 05/24/2013 facility admission until a 06/14/2013 Nurse's Notes entry. This 06/14/2013, 3:10 p.m. Nurse's Notes entry documented that Resident #73 was noted to have open areas with yellow slough to center (2 centimeters) where the previous scarred areas had been, and documented that the physician was notified. Orders were received for staff to clean the wounds with one-quarter strength Dakins Solution and to apply Dakins-soaked 4-by-4 gauze and a dry dressing to the wound every day. Record review revealed no evidence to indicate that these pressure sores had been identified prior to having slough on 06/14/2013. Additionally, based on the initial pressure sore assessment as documented in the 06/14/2013 Nurse's Notes for Resident #73 referenced above, the assessing nurse assessed and documented the presence of slough and a wound measurement. However, there was no evidence to indicate that the nurse assessed and documented, per facility policy, the stage of the wound (or that it was not stageable) and the presence or absence of exudate. During an interview conducted on 09/25/2013 at 3:30 p.m., the Treatment Nurse acknowledged that weekly head-to-toe skin assessments had not been done for the resident. On 06/19/2013, the Treatment Nurse documented on the Wound Assessment Form that Resident #73's pressure sores were unstageable with light purulent drainage, slight odor and yellow-gray slough. A later Nurse's Notes entry of 06/19/2013, timed at 4:00 p.m., documented that the physician had issued new treatment orders. Staff were to apply [MEDICATION NAME] II ointment to the pressure ulcers with dry dressing twice a day and were to administer [MEDICATION NAME] DS twice a day for ten (10) days. A subsequent 06/21/2013, 7:10 a.m. Nurse's Notes entry documented that Resident #73's physician had been notified of the resident having a temperature of 102 degrees Fahrenheit, low blood pressure, and lethargy, and documented that an order was received to send the resident to the hospital. A Nurse's Notes entry of 06/21/2013 at 7:30 a.m. documented that Resident #73 had been transported to the hospital. Review of Resident #73's hospital History and Physical of 06/21/2013 revealed that the hospital physician assessed the resident as having a urinary tract infection [MEDICAL CONDITION], with [MEDICAL CONDITION]ly from the UTI. The hospital physician also noted a Stage III sacral pressure ulcer. Further review of Resident #73's facility clinical record revealed a Nurse's Notes entry of 06/25/2013 at 2:30 p.m. which documented that Resident #73 had been transferred from the hospital of initial transfer to another hospital for admission, and a 3:00 p.m. Nurse's Notes entry documented the resident's discharge from the facility. During a 09/26/2013, 4:55 p.m. interview with the Administrator, the Administrator stated that certified nursing assistants examined residents' skin daily during care. The Administrator stated that she thought weekly head-to-toe skin assessments had been done, per facility policy, by licensed nursing staff. However, the Administrator related no specific nursing staff member who was designated as being responsible for performing weekly skin assessments for residents who were at risk for pressure-sore development. She also stated that she had not been aware that weekly resident head-to-toe skin assessments were not being done. Based on the above, despite the fact that Resident #73 had been assessed to be at high risk for pressure sore development, had a documented history of pressure sores, had a poor appetite, was below the ideal body weight, and had low hemoglobin and [MEDICATION NAME] levels, and despite facility policy specifying that residents at high risk for pressure sore development receive weekly skin assessments, the facility failed to assess Resident #73's skin, per the policy, from the resident's 05/24/2013 admission until 06/14/2013. The facility thus failed to provide ongoing skin monitoring and assessment of this resident, per policy, for a period of three weeks, and on 06/14/2013, the resident was then found to have unstageable open pressure areas to the sacrum, with yellow slough. 2. Record review for Resident #3 revealed an Admission MDS having an Assessment Reference Date of 06/20/2013 which documented the resident's 06/20/2013 facility admission. Section G - Functional Status of this MDS documented that the resident had impaired range of motion on both sides for both the upper and lower extremities, and that the resident was totally dependent for bed mobility. Section H - Bladder and Bowel of this MDS documented that the resident was incontinent of both the bowel and bladder, and Section I - Active [DIAGNOSES REDACTED]. Section M - Skin condition documented that the resident did not have a current pressure sore at that time, but was at risk of developing pressure sores. The current physician's orders [REDACTED]. Review of the monthly weights for Resident #3 revealed that the resident had experienced a weight loss from a June 2013 weight of 184.5 pounds to a July 2013 weight of 175 pounds. This represented a significant weight loss of 5.2% in one month. On 07/23/2013, a Nutritional Assessment signed by the Registered Dietician noted the resident's weight loss, and added [MEDICATION NAME] Protein Powder. However, even though Resident #3 had been assessed as being at risk for pressure sore development, had [DIAGNOSES REDACTED]. A Nurse's Notes entry of 08/01/2013 at 10:30 a.m. for Resident #3 documented an open area to the resident's right lower gluteal fold, with thin scabbing and redness around the site. This Notes entry documented that the physician was notified. A physician's note, also of 08/01/2013, documented that the physician had seen the resident and had described the gluteal wound as measuring approximately 2 by 4 centimeters, having eschar and minimal surrounding [DIAGNOSES REDACTED]. The physician subsequently issued an 08/07/2013 order for the resident to be evaluated at the Wound Clinic. During an interview conducted on 09/25/2013 at 09:30 a.m., the Treatment Nurse acknowledged that there had been no routine monitoring of the resident's skin. During an interview conducted on 09/27/2013 at 12:30 p.m., Resident #3's physician stated that if regular skin assessments had been done, the development of the resident's wound could possibly have been detected earlier. Further record review for Resident #3 revealed a Significant Change MDS with an Assessment Reference Date of 08/08 2013 which documented in Section M - Skin Conditions that the resident had developed a pressure sore. The facility's Braden Scale Schedule and Responsibility Policy specified that a new Braden Scale Assessment would be done whenever a resident experienced a change in condition in order to predict pressure sore risk. Further record review revealed that a Braden Scale Assessment had been completed for Resident #3 on 07/18/2013, prior to the resident's significant change in condition, but there was no evidence to indicate that a new Braden Scale Assessment had been completed, per facility policy, upon the resident's change of status as reflected on the Significant Change MDS of 08/08/2013. Based on the above, despite Resident #3 having been assessed as being at risk of pressure sore development, having multiple risk factors which included [MEDICAL CONDITION], Profound Mental [MEDICAL CONDITION], and impaired range of motion in the upper and lower extremities, and having experienced significant weight loss, the facility failed to provide routine weekly skin assessments, in conformance with facility policy, throughout the month of July 2013. The resident was then found on 08/01/2013 to have developed an open gluteal wound which had eschar and surrounding [DIAGNOSES REDACTED]. The facility also failed to conduct a new Braden Scale Assessment, per policy, upon this change is the resident's status. 3. Record review for Resident "B" revealed a Quarterly MDS assessment having an Assessment Reference Date of 06/20/2013 which documented, in Section C - Cognitive Patterns, that the resident's Brief Interview for Mental Status score was 11, indicating that the resident had only moderate cognitive impairment. Section I - Active [DIAGNOSES REDACTED]. Review of Resident "B"'s September 2013 Treatment Record revealed receipt of a 09/16/2013 order for Santyl ointment to be applied with a clean bandage to the right knee daily until a wound was healed. This Treatment Record documented this right knee treatment was initiated on 09/16/2013 and continued daily. However, review of the resident's record revealed no evidence of any assessment or description of this wound. During an interview with Resident "B" conducted on 09/24/2013 at 10:45 a.m., the resident stated that he/she thought the knee wound was from his/her pressing down on the over-bed table that he/she liked to keep over the bed. During an interview with the Treatment Nurse conducted on 09/24/2013 at 10:55 a.m., this nurse initially stated that she thought the wound to Resident "B"'s right knee was vascular, but then stated that it had been caused from the over-bed table pressing on the resident's right knee. During an interview conducted on 09/25/2013 at 5:00 p.m., the physician confirmed that the wound to Resident "B"'s right knee was a pressure ulcer. During further interview at 5:25 p.m. that afternoon, the physician stated he would have expected staff to have assessed the pressure ulcer when it was identified on 09/16/2013. Observation of Resident "B"'s right knee pressure sore on 09/25/2013 at 5:10 p.m. revealed an open circular pressure sore with a red wound bed and surrounding pink tissue. Further record review for Resident "B" revealed a 09/25/2013 physician's progress note in which the physician documented that the pressure ulcer presently measure 1 centimeter (cm) by 2 cms by 0.5 cms. Based on the above, despite identifying the cause of Resident "B"'s right knee wound discovered on 09/16/2013 to be a pressure sore caused from the over-bed table, staff failed to assess and document a description of the pressure ulcer in the resident's clinical record, per the facility's wound policy, until after surveyor inquiry.

Based on record review, staff interview, resident interview, and physician's Clinic Visit note review, the facility failed to ensure ongoing monitoring and the provision of timely care for one (1) resident ("C"), related to a [MEDICAL CONDITION] rash, and failed to monitor the [MEDICAL TREATMENT] of one (1) resident ("A") for potential complications, on the standard survey sample of twenty nine (29) residents. This resulted in a delay in treatment and harm for Resident "C", who complained of pain and itching and was subsequently treated for [REDACTED]. Findings include: 1. Record review for Resident "C" revealed the April 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A Nurse's Notes entry of 05/04/2013 at 11:00 a.m. documented that Resident "C" complained of not feeling well, and a Nurse's Notes entry of later in the day of 05/04/2013 at 2:45 p.m. documented that the resident had been transferred to the hospital. A Nurse's Notes entry of 05/07/2013 at 2:20 p.m. documented that Resident "C" had returned to the nursing facility, and that upon return, the resident was noted to have a rash to the forehead, abdomen, and right lower extremity. This Nurse's Notes entry documented that the physician was notified of the resident's return, but there was no evidence to indicate that the physician was notified of the resident's status, to include the presence of the rash to the forehead, abdomen, and right lower extremity, at that time. There was also no evidence of any treatment to the rash at that time. A Progress Notes entry for Resident "C" of 05/07/2013, also documented, as a wound care note, that the resident had returned from the hospital with a rash to the forehead, abdomen and legs. This Progress Notes entry further documented that Resident "C" was scratching at the areas, and that the resident stated the bottom of the foot itched. But, as indicated above, there was no evidence of treatment of [REDACTED]. A Nurse's Note entry of 05/08/2013 at 9:50 a.m. documented that Resident "C"'s skin color and turgor were within normal limits, but made no reference to the rash of the forehead, abdomen, and right lower extremity which had been documented as being present the prior day, in the 05/07/2013 Nurse's Notes entry referenced above. A Nurse's Notes entry of 05/13/2013 at 11:00 a.m. for Resident "C" documented that a call had been made to notify the physician of itching of a rash behind the resident's right knee, and a subsequent Nurse's Notes entry of 05/13/2013 at 11:25 a.m. documented that the physician had called with new orders. A physician's orders [REDACTED]. However, even though the 05/13/2013, 11:00 a.m. Nurse's Notes entry for Resident "C" referenced above indicated the resident had a rash with itching, there was no evidence in this Nurse's Notes entry, or elsewhere in the medical record, to indicate that nursing staff actually assessed the rash or the resident's skin at that time. Additionally, prior to this 05/13/2013 Nurse's Notes entry, there was no evidence to indicate that nursing staff had monitored the status of Resident "C"'s skin at all since the 05/08/2013, 9:50 a.m. Nurse's Notes entry referenced above (which did not note any rash), even though the readmission Nurse's Notes entry of 05/07/2013 had noted the resident to have rashes of the forehead, abdomen, and right lower extremity. Record review for Resident "C" revealed no evidence to indicate that nursing staff conducted any skin assessment for Resident "C" on 05/14/2013, even though the resident had experienced itching and a rash behind the right knee the previous day, and had been ordered to receive treatment for [REDACTED]. A subsequent Nurse's Notes entry of 05/15/2013 at 11:45 a.m. for Resident "C" documented that the resident then complained of right foot pain/burning, documented that the foot was warm to touch with redness noted, and documented that the physician was notified. A subsequent Nurse's Notes entry of later in the day on 05/15/2013 at 4:30 p.m. documented that the physician's office had called and an order had been received for Resident "C" to be seen in the physician's office on 05/16/2013. A Nurse's Notes entry of 05/16/2013 at 6:00 a.m. for Resident "C" documented that the resident had complained of itching throughout the night, and that the resident stated the ointment being utilized for the rash did not work. However, further record review revealed no evidence to indicate that Resident "C" had received routine skin monitoring, or assessment of the areas of skin rash, since the 05/07/2013 return to the facility with documented rashes of the forehead, abdomen and legs. There was also no evidence to indicate that nursing staff had encouraged Resident "C" not to scratch the rash, as specified by the Care Plan, since the resident's facility admission. A Nurse's Notes entry of 05/16/2013 at 9:30 a.m. documented that Resident "C" had been sent out for the physician's appointment for right foot pain/burning, and an 11:00 a.m., 05/15/2013 Nurse's Notes entry documented that Resident "C" had returned to the facility with a [DIAGNOSES REDACTED]. The physician's Clinic Visit note of 05/16/2013 for Resident "C" documented the resident's physician's clinic visit on that date. On this note, the physician documented that Resident "C" had presented with a rash from the right upper buttock on the right side all the way down to the lateral calf that was composed of open vesicles ranging in size from one (1) millimeter to one (1) centimeter, most pronounced in the buttock area, with yellowish exudate covering the base of the [MEDICAL CONDITION]. The physician documented that Resident "C" stated that he/she had been scratching these [MEDICAL CONDITION], and had popped blisters while continuing to scratch. The physician further documented that some of the [MEDICAL CONDITION] appeared to be secondarily infected, while others were consistent with primary shingles. This Clinic note documented an Impression of [MEDICAL CONDITION] with sciatic distribution and with secondary infection due to scratching. physician's orders [REDACTED]. During an interview with Resident "C" conducted on 09/26/2013 at 10:05 a.m., Resident "C" stated that when he/she returned to the nursing facility from the hospital on [DATE] there was a rash to his/her lower back, buttocks, and all the way down his/her right leg that itched "like crazy." The resident acknowledged that the facility had obtained a cream from the doctor, but stated that it had not worked, further stating "I had shingles and nobody knew it 'til I went out to the doctor." During an interview with the Assistant Administrator conducted on 09/25/2013 at 4:00 p.m., she stated that nursing staff thought Resident "C"'s rash had possibly been a reaction to medication the resident had in the hospital. However, no evidence was presented regarding timely assessment related to the origin or extent of the rash, or of timely effective treatment for [REDACTED]. Based on the above, for Resident "C", the facility failed to ensure the necessary assessment, monitoring, and timely provision of effective treatment for [REDACTED]. Rather, effective treatment was obtained only after a physician's clinic visit of 05/16/2013, nine (9) days after the initial discovery of the rash. There was also no evidence to indicate that nursing staff had counseled Resident "C" regarding scratching the rash, as had been specified by the Care Plan. 2. Review of the clinical record for Resident "A" revealed that the resident received [MEDICAL TREATMENT] three times weekly. The Care Plan for Resident "A" identified that the resident received [MEDICAL TREATMENT], and referenced as one of the Approaches for staff to monitor the resident's [MEDICAL TREATMENT] catheter for signs and symptoms of infection, and for the physician to be notified when needed. However, further review of Resident "A"'s medical record revealed no evidence of routine monitoring of the resident's [MEDICAL TREATMENT] catheter. During an interview with Resident "A" conducted on 09/25/2013 at 8:45 a.m., the resident stated that the nurses did not check his/her [MEDICAL TREATMENT], but rather only removed the dressing at bedtime and checked for bleeding when he/she returned from [MEDICAL TREATMENT]. During an interview with Licensed Practical Nurse (LPN) "AA" conducted on 09/25/2013 at 11:15 a.m., this nurse acknowledged that she did not check the resident's [MEDICAL TREATMENT] catheter access site for signs and symptoms of infection. She stated that she only looked at the site when the dressing was removed at bedtime after [MEDICAL TREATMENT]. During an interview with LPN "FF" conducted on 09/24/2013 at 2:15 p.m., this nurse stated she monitored the resident's access site when he/she returned from the [MEDICAL TREATMENT] clinic, but could provide no evidence of this monitoring.

Based on observation, record review, staff interview, Weekly Skin Assessment Schedule and Responsibility Policy review, facility Policy and Procedure for Urinary Catheter Care review, and physician's Clinic Visit note review, the facility failed to provide care in accordance with the Care Plan for two (2) residents (#3 and "C") regarding skin assessment, for one (1) resident (#95) regarding urinary catheter care, for one (1) resident (#30) regarding medication administration, and for one (1) resident ("A") regarding monitoring of the resident's [MEDICAL TREATMENT] catheter, from a survey sample of twenty-nine (29) residents. Findings include: 1. Record review for Resident #3 revealed an Admission Minimum Data Set (MDS) assessment with an Assessment Reference Date of 06/20/2013 which documented, in Section I - Active Diagnoses, [DIAGNOSES REDACTED]. Section M - Skin condition documented that the resident was at risk of developing pressure sores. The Care Plan of Resident #3 referenced a Problem Need, dated 06/20/2013, which identified that the resident had the potential for skin breakdown, and identified as one of the Approaches that nursing staff would monitor the resident's skin condition. The facility's Weekly Skin Assessment Schedule and Responsibility Policy specifically required weekly skin assessments for all residents at high or severe risk for development of pressure ulcers and for residents who had pressure ulcers. However, further record review for Resident #3 revealed no evidence of weekly monitoring of the resident's skin, as required by the Care Plan and the facility's policy, for the month of July 2013. A Nurse's Notes entry of 08/01/2013 at 10:30 a.m. for Resident #3 documented an open area to the resident's right lower gluteal fold, with thin scabbing and redness around the site. During an interview conducted on 09/25/2013 at 09:30 a.m., the Treatment Nurse acknowledged that there had been no routine monitoring of the resident's skin. Based on the above, the facility failed to provide routine skin assessment, as required by the resident's Care Plan, related to the resident's risk of pressure sore development. The resident subsequently developed an open gluteal pressure sore which had eschar and surrounding [DIAGNOSES REDACTED]. Cross refer to F314, example 2, for more information regarding Resident #3. 2. Record review for Resident "C" revealed a Nurse's Notes entry of 05/07/2013 at 2:20 p.m. which documented Resident "C"'s readmission to the facility, and documented a rash to the resident's forehead, abdomen, and right lower extremity. The Care Plan for Resident "C" documented an entry referencing the resident's Activities of Daily Living status. An entry, dated 05/07/2013, to this Care Plan documented the rash to Resident "C"'s abdomen, forehead, and legs, noted that the resident was scratching at the areas, and specified for staff to encourage the resident not to scratch vigorously. However, even though a 05/13/2013, 11:00 a.m. Nurse's Notes entry for Resident "C" documented that the resident continued to have a rash with itching, there was no evidence in this Nurse's Notes entry, or elsewhere in the medical record, to indicate that nursing staff had encouraged the resident not to scratch the rash, as specified by the Care Plan. A Nurse's Notes entry of 05/16/2013 at 6:00 a.m. documented that the resident had complained of itching throughout the night. However, there was still no evidence to indicate that nursing staff had encouraged the resident not to scratch the rash, as specified by the Care Plan. A physician's Clinic Visit note of 05/16/2013 for Resident "C" documented a physician's clinic visit, and documented a rash from the right upper buttock on the right side down to the lateral calf composed of open vesicles. The physician documented that Resident "C" stated that he/she had been scratching these [MEDICAL CONDITION] and had popped blisters while continuing to scratch. The physician also documented that some of the [MEDICAL CONDITION] appeared to be secondarily infected. Based on the above, for Resident "C", the facility failed to ensure the necessary counseling and encouragement regarding not scratching a rash, as specified by the Care Plan. Resident "C", who was subsequently diagnosed with [REDACTED]. Cross refer to F309, example 1, for more information regarding Resident "C". 3. Record review for Resident #95 revealed a Care Plan which identified the resident's use of an indwelling urinary catheter, and which specified as an Approach, originally dated 04/22/2013, to provide urinary catheter care per protocol. The facility's Policy and Procedure for Urinary Catheter Care for a female specified to use a washcloth to cleanse the labia, using only one section of the cloth for each downward stroke, and then to cleanse around the urethral meatus with a different part of the washcloth. Using a new section of the washcloth, staff was to secure and cleanse the catheter. However, during an observation of indwelling catheter care for female Resident #95 on 09/25/2013 at 12:30 p.m., Certified Nursing Assistant "BB" failed to cleanse the labia. The CNA also wiped the tubing without folding the cloth with each stroke, and failed to anchor the tubing while wiping. Based on the above, the CNA failed to provide urinary catheter care for Resident #95, in accordance with facility Policy and Procedure, as specified by the Care Plan. Cross refer to F315 for more information regarding Resident #95. 4. Record review for Resident "A" revealed an 08/29/2013 Care Plan entry which identified that the resident received [MEDICAL TREATMENT] three (3) times weekly for [MEDICAL CONDITION]. Approaches related to the resident's receipt of [MEDICAL TREATMENT] care included for staff to monitor the resident's [MEDICAL TREATMENT] catheter for signs and symptoms of infection, and for the physician to be notified when needed. However, further review of Resident "A"'s medical record revealed no evidence of routine [MEDICAL TREATMENT] catheter monitoring. During a 09/25/2013, 11:15 a.m. interview with Licensed Practical Nurse "AA", this nurse acknowledged that she did not check the catheter site for signs and symptoms of infection. Based on the above, the facility failed to provide routine [MEDICAL TREATMENT] catheter monitoring for Resident "A", as specified by the Care Plan, to ensure the prompt identification of signs and symptoms of infection, and to ensure prompt physician consultation when needed. Cross refer to F309, example 2, for more information regarding Resident "A". 5. Record review for Resident #30 revealed a Care Plan entry, originally dating from 03/18/2013, which specified as an Approach for licensed nursing staff to administer medications as ordered. A Nurse's Notes entry of 04/18/2013 at 6:00 p.m. documented a physician's orders [REDACTED]. daily. However, review of the April 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. and [MEDICATION NAME] 5 mgs. were administered daily from 04/19/2013 through 04/22/2013, even though the resident's Care Plan indicated to administer medications as ordered. Cross refer to F333 for more information regarding Resident #30.

Based on record review, staff interview, and review of The U.S. Department of Health and Human Services Clinical Practice Guideline (Number 15), the facility failed to ensure that the services provided met professional standards of quality, as specified by facility policy, for three (3) residents (#3, #73, and "B") who were at risk for pressure sore development, and for one (1) resident (#30) who received [MEDICATION NAME] anticoagulant drug therapy, from a survey sample of twenty-nine (29) residents. The facility's failure to promptly identify the development of open sacral pressure ulcers prior to the sores being assessed as unstageable with yellow slough thus resulted in harm for Resident #73. This failure to provide weekly skin assessments also resulted in harm for Resident #3, who developed an open gluteal pressure sore measuring approximately 2 by 4 centimeters, with eschar and thin scabbing, before the wound was identified by facility staff. Findings include: The U.S. Department of Health and Human Services Clinical Practice Guideline, Number 15: treatment of [REDACTED]. Pressure sores should be reassessed at least weekly in order to monitor the progress or deterioration of the pressure sores. The weekly assessment should include an accurate measurement of the length, width, depth of the ulcer, a description of sinus tracts, tunneling, undermining, necrotic tissue, or exudate and the presence or absence of granulation and [MEDICATION NAME] (page 25). During a 09/26/2013, 4:55 p.m. interview, the Administrator stated that she thought weekly head-to-toe skin assessments were to be done by licensed nursing staff, but related no specific nursing staff member who was designated as being responsible for performing weekly skin assessments for residents at risk for pressure-sore development. 1. Record review for Resident #73 revealed an Admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date of 06/08/2013, which documented the resident's 05/24/2013 admission, and documented in Section I-Active [DIAGNOSES REDACTED]. Section M - Skin Conditions documented the resident's risk of pressure-sore development, but that there were no pressure sores at that time. An admission Nurse's Notes entry of 05/24/2013 at 10:30 a.m. for Resident #73 also documented that the resident had no open areas at that time, but did have scarred areas to the sacrum. Braden Scale For Predicting Pressure Sore Risk Forms for Resident #73 completed on 05/24/2013, and subsequently on 05/30/2013, 06/06/2013, and 06/13/2013, all assessed the resident to have a score of 12, indicating a high risk for pressure sores. However, though Resident #73 was at high risk for pressure sore development and the Weekly Skin Assessment Schedule and Responsibility Policy specified weekly skin assessments, record review revealed no evidence of weekly skin assessments after the resident's 05/24/2013 facility admission until a 06/14/2013, 3:10 p.m. Nurse's Notes entry documented that Resident #73 had open areas with yellow slough to the center in the location of the scarred areas. There was no evidence to indicate that these pressure sores had been identified or treated identified prior to 06/14/2013. There was also no evidence to indicate that the assessing nurse assessed and documented, per the Pressure Ulcer Documentation Guide policy, the stage (or inability to stage) the wound, and the presence or absence of exudate. During an interview conducted on 09/25/2013 at 3:30 p.m., the Treatment Nurse acknowledged that weekly skin assessments had not been done for the resident. Based on the above, for Resident #73, the facility failed to provide weekly skin assessments from the 05/24/2013 admission until 06/14/2013 (a three week period), per the standard of practice as indicated by facility policy, even though the resident was at high risk for pressure sore development. The resident was then found to have unstageable open sacral pressure sores with yellow slough. The facility also failed to ensure a thorough assessment of the pressure sores, per the standard of practice as indicated by the facility's Pressure Ulcer Documentation Guide. Cross refer to F314, example 1, for more information regarding Resident #73. 2. Record review for Resident #3 revealed an Admission MDS, with an Assessment Reference Date of 06/20/2013 which documented a 06/20/2013 facility admission. Section G - Functional Status documented that the resident had impaired range of motion on both sides in the upper and lower extremities. Section I - Active [DIAGNOSES REDACTED]. Section M - Skin condition of the Admission MDS documented that while the resident did not have a current pressure sore, the resident was at risk of developing pressure sores. However, even though Resident #3, who was admitted on [DATE], was at risk for pressure sore development, there was no evidence of weekly skin assessments for the month of July 2013. A Nurse's Notes entry of 08/01/2013 at 10:30 a.m. then documented an open area to the resident's right lower gluteal fold, with thin scabbing and redness around the site. A subsequent 08/01/2013 physician's note described the wound as measuring approximately 2 by 4 centimeters, with eschar and minimal surrounding [DIAGNOSES REDACTED]. During an interview conducted on 09/25/2013 at 09:30 a.m., the Treatment Nurse acknowledged that there had been no routine monitoring of the resident's skin. Based on the above, for Resident #3, even though the resident was at risk of pressure sore development, having multiple risk factors, the facility failed to provide routine, weekly skin assessments throughout the month of July 2013, in conformance with the standard of practice as indicated by facility policy. The resident was then found on 08/01/2013 to have an open gluteal wound which had eschar and surrounding [DIAGNOSES REDACTED]. Cross refer to F314, example 2, for more information regarding Resident #3. 3. Record review for Resident "B" revealed a Quarterly MDS having an Assessment Reference Date of 06/20/2013 which documented, in Section I - Active Diagnoses, [DIAGNOSES REDACTED]. Resident "B"'s September 2013 Treatment Record revealed a 09/16/2013 order for Santyl ointment to be applied to the right knee daily, but further review of the resident's record revealed no evidence of any assessment or description of a right knee wound having been completed on 09/16/2013. A 09/25/2013 physician's progress note documented (after surveyor inquiry) that the sore measured 1 centimeter (cm) by 2 cms by 0.5 cms. During an interview with the Treatment Nurse conducted on 09/24/2013 at 10:55 a.m., this nurse stated that the wound to Resident "B"'s right knee had been caused from the over-bed table pressing on the knee. Based on the above, despite the identification of Resident "B"'s right knee pressure sore on 09/16/2013, the facility failed to assess and document a description of the ulcer in the clinical record, per the standard of practice as indicated by the facility's Pressure Ulcer Documentation Guide policy, until after surveyor inquiry. Cross refer to F314, example #3, for more information regarding Resident "B".

Based on record review, staff interview, and Weekly Skin Assessment Schedule and Responsibility Policy review, the facility failed to ensure the development of comprehensive care plans which identified the need for routine skin monitoring and assessment for two (2) residents (#73 and "B") who were assessed for to be at risk for skin breakdown, of seven (7) residents at risk for pressure sore development, from a survey sample of twenty-nine (29) residents. This resulted in harm for Resident #73, who was discovered to have previously unidentified open areas with yellow slough to the center of the sacrum after nursing staff failed to provide routine skin assessment and monitoring, in accordance with facility policy. Findings include: 1. Resident #73's Admission Minimum Data Set (MDS) of 06/08/2013 documented an admission date of [DATE]. Section I-Active [DIAGNOSES REDACTED]. Section H-Bladder and Bowel documented incontinence of bladder and bowel, and Section M-Skin Conditions documented the resident's risk of pressure-ulcer development. Resident #73's Comprehensive Care Plan noted as a Problem that the resident had the potential for skin breakdown for reasons which included incontinence of bladder and bowel and resistance to turning and repositioning. Approaches to address this resident's risk for skin breakdown included keeping the resident clean and dry, and turning and repositioning every two hours as needed to reduce pressure. However, further review of the Care Plan Approaches to address Resident #73's risk of skin breakdown revealed no reference to the need for staff to monitor the condition of the resident's skin, the need to monitor for actual pressure-sore development, or the frequency by which any monitoring would be accomplished. This was despite the fact that the facility's Weekly Skin Assessment Schedule and Responsibility Policy specified weekly skin assessments for residents who were at high risk for pressure sore development. Further record review for Resident #73 revealed no evidence of the resident receiving routine skin assessment after the 05/24/2013 facility admission. A subsequent Nurse's Notes entry of 06/14/13 at 3:10 p.m. documented that Resident #73 was noted to have open areas with yellow slough to the center of the sacral area, and a 06/19/13 Wound Assessment Form entry documented that Resident #73's pressure sores were unstageable with light purulent drainage, slight odor and yellow-gray slough. During a 09/25/2013, 3:30 p.m. interview, when questioned about the frequency of monitoring Resident #73's skin prior, the Treatment Nurse acknowledged that routine skin assessments had not been done for Resident #73. Based on the above, despite the Comprehensive Care Plan of Resident #73 identifying that the resident was at high risk for pressure-sore development, and despite facility policy specifying that residents at high risk for pressure-sore development receive weekly skin assessments, the facility failed to ensure the development of a Care Plan which referenced the need to monitor the resident's skin, or any frequency of monitoring, to allow for ongoing assessment of the skin condition and the timely identification of pressure-sore development. Staff failed to routinely assess Resident #73's skin, and the resident was then found to have unstageable open pressure areas to the sacrum. Cross refer to F314, example 1, for more information regarding Resident #73. 2. Resident "B"'s Admission MDS assessment of 03/25/2013 documented, in Section I - Active Diagnoses, that the resident had [DIAGNOSES REDACTED]. Review of Resident "B"'s Comprehensive Care Plan revealed a Problem, originally dated 03/25/2013, which identified the resident's risk for skin breakdown, and identified Approaches to address this risk, including to turn and reposition the resident every two hours and the use of heel protectors. However, further review of the resident's Care Plan Approaches revealed that the Care Plan did not reference the need for, or the frequency of, skin monitoring regarding the resident's skin condition or the identification of pressure sores. Resident "B"'s September 2013 Treatment Record then documented a 09/16/2013 physician's orders [REDACTED]. During a 09/24/2013, 10:55 a.m. interview, the Treatment Nurse stated that the sore on the knee had been caused from pressure from the over-bed table. Based on the above, the Comprehensive Care Plan of Resident "B", who was at risk for skin breakdown, failed to address the need for routinely monitoring the resident's skin, or of ulcer assessment. The resident was subsequently found to have a previously undetected pressure sore to the knee, for which nursing staff could not provide evidence of any assessment upon its discovery. Cross refer to F314, example 3, for more information regarding Resident "B".

Based on record review, staff interview, and physician's Clinic Visit note review, the facility failed to ensure timely physician consultation for one (1) resident ("C"), related to a [MEDICAL CONDITION] rash, on the standard survey sample of twenty nine (29) residents. This resulted in harm for Resident "C", who complained of pain and itching, and was subsequently treated for [REDACTED]. Findings include: Record review for Resident "C" revealed a Nurse's Notes entry of 05/07/2013 at 2:20 p.m. which documented that the resident had returned to the facility (from the hospital) and was noted to have a rash to the forehead, abdomen, and right lower extremity. However, further record review, to include review of this Nurse's Notes entry, revealed no evidence to indicate that the physician was consulted regarding the presence of the rash to the forehead, abdomen, and right lower extremity at that time. A Nurse's Notes entry of 05/13/2013 at 11:00 a.m. for Resident "C" documented that a call had been made to notify the physician of a rash with itching behind the right knee, and a physician's orders [REDACTED]. However, this represented a delay in physician consultation of six (6) days since the resident first presented with a rash on 05/07/2013. A 05/15/2013, 4:30 p.m. Nurse's Notes entry documented an order for [REDACTED]." had a rash from the right upper buttock down to the lateral calf composed of open vesicles with yellowish exudate. The physician documented that some [MEDICAL CONDITION] appeared to be infected, documented an Impression of [MEDICAL CONDITION], and ordered [MEDICATION NAME] 500 milligrams, Benadyl spray, and [MEDICATION NAME] 25 milligrams. During an interview with the Assistant Administrator conducted on 09/25/2013 at 4:00 p.m., no evidence was presented to indicate that the physician was consulted about the extent of the resident's rash prior to the 05/16/2013 physician's clinic visit. Cross refer to F309, example 1, for more information regarding Resident "C".

Based on observation and staff interview, it was determined that the facility failed to ensure the provision of pressure sore treatment in a manner to prevent infection for one (1) resident (#8), of two (2) residents with existing pressure ulcers, from a total survey sample of thirteen (13) residents. Findings include: During an observation made on 12/04/2013 at 10:00 a.m., Licensed Practical Nurse (LPN) " EE ", assisted by the Assistant Director of Nursing (ADON), provided pressure sore care to Resident #8. The ADON supported the resident on his/her side while LPN "EE" provided the pressure sore care to the sacral and right gluteal fold sores. During the provision of treatment, LPN "EE" was observed to move a trash can with a gloved right hand, and then to continue to provide pressure sore treatment, without changing the soiled gloves or washing her hands. During interview with LPN "EE" conducted on 12/05/2013 at 8:05 a.m., the LPN stated that during the treatment observation, she was so scared she did not realize what she had done.