Every finding on record at Place at Martinez, The

Based on document review and staff interviews, the facility failed to ensure that the arbitration agreement signed by all facility residents, with a current census of 79 residents, provided for the selection of a venue that was convenient to both parties. Specifically, the facility failed to ensure that a neutral venue available to both parties was documented within the arbitration agreement. This exclusion places facility residents and families at an unknown disadvantage in potential future disputes.Findings include: Review of the facility provided admissions pack revealed under I. Dispute Resolution Procedure: that it failed to include a clause to allow for any arbitration to be conducted at a site which was convenient to both parties signing the form. No statement or clause identified the process of determining a venue for a dispute to ensure a neutral location. During an interview on 11/18/25 at 10:38 AM, the Administrator stated that the facility's arbitration agreement was within the facility's admission contract. The Nursing Home Administrator stated that all facility residents had signed the arbitration agreement form. During an additional interview on 11/21/25 at 2:30 PM, the Administrator stated that she had been the staff member discussing the facility's admission packet with new residents and families while the admission staff member was not available. She confirmed that the arbitration agreement was signed by all the residents in the facility, and that it was not designated separately from the admission agreement. The Administrator was not aware that the requirement for a venue location agreed on by both parties was not included in the arbitration contract.

Based on document review and staff interviews, the facility failed to ensure that the arbitration agreement provided to all facility residents, with a current census of 79 residents, was not required to sign an arbitration agreement as a condition of admission to, or as a requirement to continue to, receive care at the facility. Specifically, the facility failed to ensure the arbitration agreement was not mandatory for all residents admitted to the facility. Findings include: Review of the facility provided admissions pack revealed under I. Dispute Resolution Procedure: that 3. Arbitration: This arbitration provision (Provision) is executed in conjunction with an agreement for admission and for the provision of nursing facility services (the admission Agreement) by the Center to (the Patient and/or Guarantor). The parties to the admission Agreement acknowledge that this Provision is part of the admission Agreement. This Provision is binding on and benefits the Center and Patient and their successors, heirs, executors, administrators, or assigns, and survives the lives or existence of the parties hereto. During an interview on 11/18/25 at 10:38 AM, the Administrator stated that the facility's arbitration agreement was within the facility's admission contract. The Administrator stated that all facility residents had signed the arbitration agreement form. During an additional interview on 11/21/25 at 2:30 PM, the Administrator stated that she had been the staff member discussing the facility's admission packet with new residents and families while the admission staff member was not available. She stated that she would answer questions to the residents and families. She said that she was not aware that the arbitration contract within the admission packet stated that the acceptance of the arbitration agreement was contingent on admissions. She stated that she did not believe that was the intent. She confirmed that the arbitration agreement was signed by all the residents in the facility, and that it was not designated separately from the admission agreement.

Based on record review, staff interviews, document review, policy review, and review of McGeer's criteria, the facility failed to have an Antibiotic Stewardship Program that followed current standards of practice for prescribing an antibiotic for five of five residents (Resident (R) 25, R62, R63, R46, and R50) reviewed for antibiotic stewardship out of total sample of 27 residents. This failure had the potential for residents to be prescribed unnecessary antibiotics.Findings include: Review of the undated facility's policy titled, The Place Antibiotic Stewardship Program indicated, The program includes antibiotic use protocols and a system to monitor antibiotic use. The facility uses the (CDC [Centers for Disease Control] NHSN [National Healthcare Safety Network] Surveillance Definitions, updated McGeer's criteria, or other surveillance tool) to define infections. Review of McGeer's Criteria dated 11/05/24 revealed, . Table 2. Urinary Tract Infection (UTI) Surveillance Definitions Syndrome: UTI without indwelling catheter Criteria: 1. At least one of the following sign or symptom: Acute dysuria or pain, swelling, ., Fever or leukocytosis, and one or more of the following: acute costovertebral angle pain or tenderness, suprapubic pain, gross hematuria, new or marked increase in incontinence, new or marked increase in urgency, new or marked increase in frequency. If no fever or leukocytosis, then greater than 2 of the following: suprapubic pain, gross hematuria, new or marked increase in incontinence, new or marked increase in urgency, new or marked increase in frequency 2. At least one of the following microbiologic criteria greater than or equal to 100,000 Colony Forming Units (CFU) per milliliter (mL) of no more than 2 species of organisms in a voided urine sample greater than or equal to 100 of any organism(s) in a specimen collected by an in-and-out catheter . 1. Review of R25's undated Face Sheet, located under the Profile tab in the electronic medical record (EMR), indicated R25 was admitted to the facility on [DATE] with the diagnosis of renal insufficiency and diabetes mellitus. Review of R25's Physician Orders, located in the hard copy of R25's medical record, indicated an order dated 01/19/25 to obtain UA [urinalysis] C&S [culture and sensitivity]. Review of the Nursing Progress Notes, located under the Progress Note tab in the EMR, revealed there was no documentation to indicate R25 signs and symptoms to warrant a UA and C&S to be ordered. During an interview on 11/21/25 at 2:15 PM, the Infection Preventionist/Wound Care Nurse (IP/WCN) reviewed the Infection Control Report for R25. In this report, the IP/WCN confirmed there was no documentation to indicate any signs and symptoms R25 was experiencing at the time the UA C&S was ordered. This report also indicated that the Nurse Practitioner ordered Omnicef (an antibiotic) 300 mg (milligrams) by mouth two times a day for 10 days on 01/21/25 for R25. The C&S report was reviewed by the IP/WCN, and she confirmed the results of 10,000 – 49,000 CFU/ml (colony-forming units per milliliter) Proteus mirabilis. The IP/WCN confirmed this result did not meet McGeer's criteria of At least 100,000 cfu/ml or no more than 2 organisms or microorganisms in a voided urine sample, even though the IP/WCN documented on the Infection Control Report the infection did meet criteria for a UTI (Urinary Tract Infection). Copies of the physician's orders for the antibiotic and nursing documentation to reflect the signs and symptoms that R25 was experiencing prior to the order of the UA C&S on 01/19/25 were requested. No further documentation was received prior to the exit conference on 11/21/25. 2. Review of R62's Face Sheet, located under the Profile tab in the EMR, indicated R62 was admitted to the facility on [DATE] with the diagnosis of coronary artery disease and renal insufficiency. Review of R62's Physician Orders, provided by the facility, indicated an order dated 08/19/25 for Doxycycline Hyclate (antibiotic) 100 mg by mouth two times a day for 10 days for infection. Review of R62's Progress Note, provided by the facility, revealed the Nurse Practitioner documented, Chief Complaint: cough. Patient [R62] states that her cough today seems worse. She [R62] denies fever, sore throat, runny nose, body aches/chills. chest pain, shortness of breath. Today Oxygen [sic] saturations noted to be 95% on room air. Vital signs noted to be stable. Review of R62's Chest X-Ray Results dated 08/19/25 and provided by the facility indicated No pleural effusion. No acute cardiopulmonary process. During an interview on 11/21/25 at 2:25 PM, the IP/WCN reviewed the Infection Control Report for R62 and confirmed that this did not meet McGeer's criteria due to R62 not having a fever, and the x-ray results on 08/19/25 did not reveal pleural effusion or any acute cardiopulmonary processes, and R62's oxygen saturations were 95% on room air. 3. Review of R63's Face Sheet, located under the Profile tab in the EMR, indicated R63 was originally admitted to the facility on [DATE] with the diagnosis of Alzheimer's Disease and traumatic brain injury. Review of R63's Physician Orders, provided by the facility and dated 04/23/25, indicated Zithromax Z-Pak [antibiotic] 250 mg [milligram] po [by mouth] give 500 mg on day 1 [sic], then 250 mg po on day 2-5 [sic] then stop for cough/congestion. During an interview on 11/21/25 at 2:35 PM, the IP/WCN confirmed that R63 did not meet McGeer's criteria for the diagnosis of congestion. The IP/WCN confirmed the Infection Control Report was not filled out completely to reflect any signs and symptoms the resident was experiencing at the time the antibiotic was ordered on 04/22/25. Nursing progress notes for R63 were requested regarding what signs and symptoms R63 was experiencing prior to the order of the Azithromycin on 04/22/25. No further information was provided by the IP/WCN prior to the exit conference on 11/21/25. During an interview on 11/21/25 at 4:55 PM, the Director of Nursing (DON) stated, [IP/WCN] went over this. We review it together. [IP/WCN] fills out the form, then we bring it to a clinical meeting to discuss with the team. Our NP [nurse practitioner] is also involved in this process. Our biggest thing is to make sure we follow and meet McGeer's criteria for antibiotic use. 4. Review of R46's admission Record, located under the Profile tab of the EMR, revealed she was admitted to the facility on [DATE]. Review of R46's Acute Care Note, dated 11/05/25 and located under the Progress Notes tab of the EMR, revealed, Staff states that resident is noted with some increased confusion . Assessment/Plan: R41.0 - Disorientation, unspecified - New order: UA/CS [urine analysis with culture and sensitivity]. Review of R46's Order Note, dated 11/05/25 and located under the Progress Notes tab of the EMR, documented that a new order was received for a UA/CS due to confusion. Review of R46's EMR under the Orders tab revealed a physician's order, dated 11/10/25, for Macrobid (an antibiotic), 100 milligrams (mg) twice daily for 10 days for a urinary tract infection (UTI). Review of R46's Lab Report, dated 11/06/25 and located under the Miscellaneous tab of the EMR, revealed a result of 40,000 - 50,000 colony-forming units per milliliter (cfu/mL) of Enterococcus faecalis was reported, which was susceptible to Macrobid. Review of R46's paper Infection Report Form, dated 11/11/25 and provided by the IP/WCN, revealed that none of the criteria listed to determine if a UTI was present were checked, but confusion was written in. The form instructed that acute dysuria, fever or leukocytosis, and/or symptoms of suprapubic pain, hematuria, new or increased incontinence, urgency, or frequency must be noted along with at least 1,000,000 cfu/mL of microorganisms detected. The form documenting R46's symptoms did not meet the criteria of a UTI. The form also documented that Macrobid was prescribed. Review of R46's Acute Care Note, dated 11/12/25 and located under the Progress Notes tab of the EMR, revealed, Patient seen today due to being place [sic] on ABT [antibiotic] r/t [related to] UTI. Patient placed on Macrobid 100mg po [orally] BID [twice a day] x10 days. She is tolerating well with no adverse reactions noted. Vital signs [were] noted to be stable. She remains afebrile. She denies chest pain, shortness of breath, headaches, lightheadedness, nausea, vomiting and dizziness. Patient denies urgency, back pain, frequency, and dysuria. 11/5 UA: 40,000 - 50,000 enterococcus faecalis, susceptible nitrofurantoin [Macrobid]. Review of R46's EMR and hard chart did not reveal any documentation that the physician was notified that the infection did not meet criteria for antibiotic use. There was no documented rationale for the continuation of the antibiotic without meeting criteria for a UTI. During an interview on 11/21/25 at 1:29 PM, the IP/WCN stated that if a resident's symptoms and lab values did not meet the criteria of a true infection, she would speak to the physician and try to get the antibiotic discontinued, as it was not necessary. The IP/WCN was unable to provide evidence that the physician was contacted to discuss the findings and the appropriate course of treatment. During an interview on 11/20/25 at 6:31 PM, the Medical Director stated his expectation was to determine whether symptoms and lab values met the criteria of an actual infection prior to treatment with antibiotics or for the discontinuation of an antibiotic if already started when the lab results were received, and the facility determined the criteria were not met. The Medical Director stated there should be a discussion with the physician to determine the proper course of treatment. 5. Review of R50's admission Record, located under the Profile tab of the EMR, revealed she was admitted to the facility on [DATE]. Review of R50's Order Note, dated 10/13/25 and located under the Progress Notes tab of the EMR, revealed, Macrobid Oral Capsule, Give 100 mg by mouth two times a day for dysuria [pain on urination] for 10 days. Review of R50's EMR did not reveal any documentation prior to the above Order Note regarding dysuria or any other symptoms. Review of R50's 10/14/25 Infection Note, dated 10/14/25 and located under the Progress Notes tab of the EMR, revealed, Resident remains on abt [antibiotic] Macrobid. Resident remains afebrile. Review of R50's EMR and hard chart revealed no order for a UA/CS or lab results related to administration of Macrobid. Review of R50's Infection Report Form, provided on paper by the IP/WCN, revealed that none of the criteria listed to determine if a UTI was present were checked. The form instructed that acute dysuria must be accompanied by at least 1,000,000 cfu/mL of microorganisms detected. The form documenting R50's symptoms did not meet the criteria of a UTI. The form also documented that Macrobid was prescribed. Review of R50's EMR and hard chart did not reveal any documentation that the physician was notified that there was no criteria documented for antibiotic use. There was no documented rationale for the continuation of the antibiotic without meeting criteria for a UTI. During an interview on 11/20/25 at 6:19 PM, the IP/WCN stated that to determine whether a UTI met criteria for treatment, there must be a UA/CS performed. She stated R50 did not have a UA/CS ordered or performed because she was on hospice, and the hospice physician initiated the Macrobid order as a prophylactic. The IP/WCN stated, Hospice does that a lot. The IP/WCN was unsure if she provided any education to the hospice physician regarding antibiotic stewardship and the criteria to meet before initiation of antibiotic treatment. The IP/WCN stated the Medical Director was aware of this issue, but the Hospice had its own Medical Director who took care of all the residents in hospice. She stated she did not know if the facility's Medical Director provided any education to the hospice staff. During an interview on 11/20/25 at 6:31 PM, the Medical Director stated the hospice physician managed care for residents on hospice. He stated the hospice takes the patients as their own, they do what they want to do. The Medical Director stated the hospice did not allow a facility physician to oversee medical care for the residents on hospice. The Medical Director stated his expectation was to typically perform a UA/CS, even for his patients on hospice, prior to treatment with antibiotics. He stated there could be instances where it was impossible to get a urine sample, and treatment would be initiated without a UA/CS; however, this was rare. The Medical Director stated the hospice physician typically treated residents on hospice with antibiotics without first ordering a UA/CS. The Medical Director stated this was the way the hospice physician practiced, but he did not practice that way, and it was not the way it should be done.

Based on observations, staff interviews, and document review, the facility failed to ensure that eight of the eight residents who received pureed diets out of a total of 85 residents received the foods as called for in the menus. These failures placed the eight residents at risk for weight loss, malnutrition, or dissatisfaction with their meals.Findings include: Review of a handwritten, undated document titled Texture Count, provided by the Dietary Manager (DM), revealed the facility had eight residents who received a pureed diet. 1. During interview and concurrent observation of breakfast service in the kitchen on 11/20/25 at 7:34 AM, Dietary Aide (DA) 2 stated she prepared pureed eggs, pureed waffles, and cream of wheat for the pureed meals. She was observed serving pureed meals consisting of pureed eggs, waffles, and cream of wheat. Review of the Diet Extensions: Thursday, Week 1, Menu, provided on paper by the Dietary Manager (DM), revealed that the pureed breakfast meal should have consisted of pureed oatmeal, pureed banana, pureed sausage patty, and pureed waffle. During an interview on 11/21/25 at 1:47 PM, the DM stated she had never prepared pureed oatmeal before and had never heard of it being done. She stated she did not know the menu called for pureed oatmeal. The DM stated she did not know why pureed eggs were served instead of pureed sausage or why cream of wheat was served instead of pureed oatmeal. The DM stated she did not know why the pureed banana was not served. The DM stated DA2 probably overlooked it on the menu. The DM placed a call to DA2 for an interview; however, there was no response prior to survey exit. The DM stated she expected staff to serve food as called for on the menu. 2. During interview and concurrent observation of breakfast service in the kitchen on 11/21/25 at 7:35 AM, DA1 stated she had prepared pureed eggs, cream of wheat, and pureed oatmeal for the pureed meals. She was observed serving pureed meals consisting of pureed eggs, cream of wheat, and pureed oatmeal. Review of the Diet Extensions: Friday, Week 1, Menu, provided on paper by the DM, revealed the pureed breakfast meal should have consisted of pureed banana, pureed eggs, pureed diced potatoes, and pureed wheat bread. During an interview on 11/21/25 at 1:47 PM, the DM stated she was unaware that the menu was not followed at breakfast. She stated she did not know why pureed banana was not served, or why pureed oatmeal was served in place of pureed diced potatoes. During an interview on 11/21/25 at 1:50 PM, DA1 stated she did not puree potatoes as the shipment had not come in. She confirmed she did not serve pureed banana.

Based on observations, staff interviews, and policy review, the facility failed to maintain a safe, functional, and sanitary environment in the main dining room where 14 out of a total of 85 residents ate their meals. This failure had the potential to lead to the spread of infection or feelings of discomfort and dissatisfaction among residents. Findings include: Review of the undated policy titled, The Place Facilities Safe and Homelike Environment, revealed, Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment. During initial observations of the main dining room on 11/18/25 at 9:11 AM, four of five observed ceiling vents were covered with fuzzy dust and dirt. These vents were located above residents' dining tables. The wall below the pass-through window to the kitchen had spilled liquid or food debris running down the length of the wall and onto the floor below. During observation of lunch in the main dining room on 11/18/25 beginning at 12:07 PM, 14 residents were seated at the tables eating lunch. The ceiling vents above the residents were observed with caked-on fuzzy dust and dirt. The wall and floor below the pass-through window continued to have the same liquid spills and food debris. During a concurrent observation and interview on 11/21/25 at 9:50 AM, the Director of Maintenance (DOM), who also served as the Director of Housekeeping, observed the ceiling vents caked with dust and dirt and stated they were dirty and needed to be cleaned. The DOM stated the dust was a concern because it was directly above where residents ate. The DOM stated the housekeeping department was responsible for cleaning the ceiling vents and stated they should be cleaned about every two weeks, but did not have documentation of the cleaning. He stated the vents needed to be cleaned immediately. The DOM also observed the wall and floor under the pass-through window to the kitchen and agreed it was soiled with food or liquid spills. The DOM stated the housekeeping staff cleaned the floor in that area, but he felt the kitchen staff should be responsible for cleaning the wall under the pass-through window. The DOM stated the wall needed to be cleaned.

Based on observation, resident and staff interviews, record review, and review of the facility assessment, the facility failed to ensure one of 27 sampled residents (Resident (R) 107) had the needed adaptive equipment for meals. This deficient practice had the potential to place the resident at risk for an undignified existence. Findings include: Review of [The Facility Name] Facility Assessment, last updated 02/28/24 and provided by the facility, revealed .Services and Care We Offer Based on our Residents' Needs.These are the services we offer our residents.Nutrition-Individualized dietary requirements.assistive devices. Review of R107's undated admission Record, located in the resident's electronic medical record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic inflammatory demyelinating polyneuritis (CIDP). Review of R107's admission Minimum Data Set (MDS), with an assessment reference date (ARD) of 11/13/25 and located in the resident's EMR under the MDS tab, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was fully cognitively intact. The MDS also revealed that the facility assessed the resident to need setup or clean-up assistance for eating. The MDS revealed the facility assessed the resident did not have any upper extremity (shoulder, elbow, wrist, hand) range of motion (ROM) impairment. Review of R107's Diet Order & Communication form dated 11/06/25 and provided by the facility revealed the resident was ordered a regular textured diet with no added salt. The adaptive equipment section was not completed. Review of R107's Nutrition/Dietary Note, dated 11/10/25 and located in the resident's EMR under the Progress Notes tab revealed Note Text: RD [Registered Dietitian] review re: new admit to facility for respite care.visited resident, able to make needs known.resident requested built up utensils as she used at home, will notify nursing of resident request. Review of R107's Health Status Note, dated 11/20/25 and located in the resident's EMR under the Progress Notes tab revealed Resident requesting special utensils from home, residents [sic] daughter notified and stated will be bringing them up to the facility at 11 AM. During an interview on 11/18/25 at 12:00 PM, R107 stated she used built-up utensils when she was at home and while she was admitted to the prior nursing facility; however, the staff have not asked her any questions about adaptive equipment, nor have they observed her eating. During an observation and interview on 11/20/25 at 8:40 AM, R107 was eating her cereal using regular dining utensils. The resident appeared to be having difficulty holding the spoon. The resident stated she told a staff member this morning, and he stated he would ask about it. During an interview on 11/20/25 at 10:03 AM, the Director of Therapy (DOT) stated R107 was admitted to the facility for a respite stay and received a therapy screening; however, she would not receive any type of therapy services. The DOT stated she completed the occupational therapy screening, which included asking the resident to raise and lower her upper extremities. When asked if the screening included assessing if the resident needed any adaptive mealtime equipment, such as built-up utensils, the DOT stated that it would be a nursing recommendation. The DOT stated she did not ask the resident about needing adaptive equipment, and the resident did not bring it up to her. The DOT stated that therapies would not observe R107 eating a meal unless it was just by coincidence at the time of the screening. During an observation and interview on 11/20/25 at 10:42 AM, Licensed Practical Nurse (LPN) 4, who was the Unit Manager, observed the resident who now had a built-up spoon and a built-up fork. The LPN stated the facility got the resident some to use until her family brought the resident's in from home. When asked if therapy had evaluated the resident for the use of the adaptive equipment that was loaned to the resident to ensure it was the most appropriate, LPN4 stated since R107 was there on respite, therapy was not allowed to evaluate nor make recommendations. During an interview on 11/21/25 at 5:00 PM, the Director of Nursing (DON) stated it was her expectation that R107's family would have brought the resident's adaptive equipment to the facility if the resident needed it. During an interview on 11/21/25 at 5:54 PM, the Administrator stated it was her expectation that when the DOT completed the screening on R107, she would have operated within the parameters of her discipline and observed the resident eating a meal as part of the screening.

Based on staff interviews, record review, and review of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, text revision (DSM-5-TR), the facility failed to ensure one of five residents (Resident (R) 107) reviewed for unnecessary medications had an adequate indication for its use out of 27 sampled residents. This failure had the potential to place the resident at risk of receiving unnecessary medications.Findings include: Review of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, text revision (DSM-5-TR) revealed .Cultural Concepts of Distress. Relevance for Diagnostic Assessment. The term cultural concepts of distress refers to ways that individuals experience, understand, and communicate suffering, behavioral problems, or troubling thoughts and emotions. Three main types of cultural concepts of distress may be distinguished. Cultural idioms of distress are ways of expressing distress that may not involve specific symptoms or syndromes, but that provide collective, shared ways of experiencing and talking about personal or social concerns. For example, everyday talk about 'nerves' .may refer to widely varying forms of suffering withoutmapping onto a discrete set of symptoms, syndrome, or disorder. Cultural explanations or perceived causes are labels, attributions, or features of an explanatory model that indicate culturally recognized meaning or etiology for symptoms, illness, or distress.Examples of Cultural Concepts of Distress.Nervios ('nerves') is a common cultural idiom of distress and causal explanation in Latinx cultural contexts in the United States and Latin America. Nervios refers to a general state of vulnerability to stressful life experiences and to difficult life circumstances. The term nervios includes a wide range of symptoms of emotional distress, somatic disturbance, and inability to function. Nervios is a broad cultural idiom of distress that spans the range of severity from cases with no mental disorder to presentations resembling adjustment, anxiety, depressive, dissociative, somatic symptom, or psychotic disorders. Review of the DSM-5-TR revealed nerves is a symptom associated with many different mental health diagnoses and not a diagnosis. Review of R107's undated admission Record, located in the resident's electronic medical record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included post-traumatic stress disorder (PTSD) and bipolar disorder. There were no anxiety-related disorders identified. Review of R107's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/13/25 and located in the resident's EMR under the MDS tab revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was fully cognitively intact. The Active Diagnoses section of the MDS did not identify the resident to have an active anxiety disorder diagnosis. Review of R107's physician Order Summary Report, located in the resident's EMR under the Orders tab, revealed an order dated 04/06/25 for buspirone Oral Table 15 mg [milligram] give 1 tablet by mouth two times a day for nerves. The Order Summary Report listed the facility's Medical Director as the ordering physician. During an interview on 11/21/25 at 5:00 PM, the Director of Nursing (DON) verified R107's order for buspirone, documented for nerves as the indication for use. The DON stated the resident's Veterans Administration (VA) hospital discharge orders reflected nerves for the diagnosis. The DON stated it was her expectation that the nurse who reconciled the medications would enter the order as it was shown on the discharge orders received. The DON stated the facility's physician(s) did not have any involvement with respite residents' medications, as they brought the medications from home with the indication of use.

Based on record review, staff interviews, policy review, and the review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer or provide documentation of consent or refusal for pneumonia vaccines for two of five residents (Residents (R)25 and R63) and/or their resident representatives (RR) out of 27 sampled residents. This failure had the potential to put these residents at increased risk of developing pneumonia.Findings include: Review of the CDC website page titled Pneumococcal Vaccine Timing for Adults, dated March 2025 and located at https://www.cdc.gov/pneumococcal/downloads/Vaccine-Timing-Adults-JobAid.pdf, revealed the CDC recommended pneumococcal vaccination for all adults [AGE] years of age or older. A PCV20 or PCV21 (types of pneumonia vaccines) should be administered greater to or equal to one year after PPSV23 given at any age. 1. Review of R25's Face Sheet, located under the Profile tab in the electronic medical record (EMR) indicated R25 was admitted to the facility on [DATE] with the diagnosis of diabetes mellitus and was [AGE] years old upon admission. Review of R25's Immunizations, located under the Immunization tab in the EMR, indicated R25 received Pneumovax 23 on 05/21/22. There was no documentation of R25 receiving or refusing any pneumococcal vaccinations that were recommended a year after the initial Pneumovax vaccine was given to R25. 2. Review of R63's Face Sheet, located under the Profile tab in the EMR, indicated R63 was originally admitted to the facility on [DATE] and was currently [AGE] years old. Review of R63's Immunizations, located under the Immunization tab in the EMR, indicated no documentation to reflect that R63 was offered or refused the Pneumovax vaccination. During an interview on 11/21/25 at 2:15 PM, the IP/WCN stated she did not keep up with vaccinations and that they were being completed by Licensed Practical Nurse (LPN4). During an interview on 11/21/25 at 4:15 PM, LPN4 was notified of the missing documentation for R25 regarding being offered or refusing the Pneumovax vaccination. R63 had missing documentation to reflect being offered or refusing the Pneumovax vaccinations. LPN4 stated she would gather this information and bring it to the surveyor. During an interview on 11/21/25 at 4:45 PM, the Director of Nursing (DON) stated, Upon admission, we review with the resident their immunizations. Our expectation is to check and see if the resident is in the GRITS system [Georgia Registry of Immunization Transactions Services]. We started consents for flu vaccines in September, and we also revisited the residents' Pneumovax vaccines. No further information was provided to the survey team prior to the exit conference.

Based on record review, review of the RAI (Resident Assessment Instrument) Version 3.0 Manual and staff interviews, the facility failed to transmit Minimum Data Set (MDS) Assessments timely for three residents (R) (#1, #2, and #3) of 29 sampled residents. Findings include: Review of the RAI Version 3.0 Manual dated (MONTH) (YEAR) documented under Chapter 5: Submission and Correction of the MDS Assessments, Transmitting Data - Assessment Transmission: comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date. All other MDS assessments must be submitted within 14 days of the MDS Completion date. R#1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The discharge MDS for this resident had an Assessment Reference Date (ARD) of 3/18/19. This discharge MDS was not transmitted until 8/28/19 making this assessment 138 days overdue. R#2 was admitted on [DATE] with [DIAGNOSES REDACTED]. The ARD for the discharge MDS for this was 3/31/19. This discharge MDS was not transmitted until 8/28/19 making this assessment 132 days overdue. R#3 was admitted on [DATE] with [DIAGNOSES REDACTED]. The ARD for the Annual MDS assessment was 7/30/19. This annual MDS was not transmitted until 8/28/19 making this assessment one day overdue. During an interview on 8/28/19 at 1:23 P.M., MDS Coordinator AA stated that R#1 and R#2's MDS assessments were not completed therefore did not go into her batch list to be transmitted. She also stated that R#3's MDS was transmitted late by one day. She stated that she transmits MDS's once or twice per week and then runs a validation report to compare those assessments transmitted to her schedule of MDS's due to ensure they were all accepted. She indicated these MDS assessments fell between the cracks. During an interview with the Director of Nursing (DON) on 8/29/19 at 9:00 a.m., she stated that she expects for the MDS staff to complete the MDS assessments by the transmission due date indicated per the system and the RAI Manual.

Based on observation and record review, the facility failed to follow the care plan related to the use of an abdominal binder to secure a gastrostomy tube (GT) for one (1) resident (#17). The sample size was twenty-nine (29) residents. Findings include: Review of a Physician Visit Report dated 05/01/16 noted that resident #17 had dysphagia (difficulty swallowing), and had a PEG (percutaneous endoscopic gastrostomy) tube. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] documented the resident had a feeding tube. Review of the care plans revealed an alteration in nutrition due to a weight gain care plan; a potential for aspiration due to use of a feeding tube care plan; and a potential for dehydration due to the use of a feeding tube care plan revealed that they were all updated on 10/24/15 and each included an intervention for an abdominal binder at all times. Review of the Nurse's Notes dated 01/09/16 at 10:00 p.m. revealed that resident #17's GT was observed out of place with the inflated bulb resting on his/her abdomen. Further review of this Nurse's Note revealed that two staff members were providing care at that time, and that the abdominal binder was in place but had been unfastened to allow for care. Further review of this Nurse's Note revealed that the two staff members told the nurse that they went to turn and reposition the resident, to clean her sacral area, and the GT popped out. During an observation of care by Certified Nursing Assistants AA and BB on 05/04/16 at 3:00 p.m., a wide abdominal binder was noted in place securing resident #17's GT. Cross-refer to F 322.

Based on observation, record review and staff interview, the facility failed to ensure that a gastrostomy tube (GT) was kept secured to prevent accidental dislodgement for one (1) resident (#17). The sample size was twenty-nine (29) residents. Findings include: Review of a Physician Visit Report dated 03/03/16 noted resident #17 was in a vegetative state with a history of a [MEDICAL CONDITIONS]. Review of a Physician Visit Report dated 05/01/16 noted that resident #17 had dysphagia (difficulty swallowing), and had a PEG (percutaneous endoscopic gastrostomy) tube. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] noted the resident had short- and long-term memory problems, with severely-impaired decision making; was totally dependent on staff for activities of daily living (ADL's); and had a feeding tube. Review of resident #17 ' s care plans revealed the following: an alteration in nutrition due to a weight gain care plan; a potential for aspiration due to the use of a feeding tube care plan; and a potential for dehydration due to the use of a feeding tube care plan each revealed that they were all updated on 10/24/15 each care plan included an intervention for an abdominal binder to be worn at all times. Review of the physician's orders [REDACTED]. Review of the Nurse's Notes dated 06/04/15 at 10:15 p.m. revealed that the GT kept popping out, and needed to be replaced. Further review of the Nurse's Notes revealed that resident #17 was sent to the emergency room (ER) at 1:00 p.m. on 06/08/15 for a GT replacement. Review of the Nurse's Notes dated 09/18/15 at 11:00 a.m. revealed that the resident's GT was accidentally pulled out by staff during bath time, and he/she was sent to the ER for replacement of the tube. Review of the Nurse's Notes dated 10/23/15 at 2:45 p.m. revealed that the GT was out with the bulb inflated, and the resident was sent to the ER at 3:25 p.m. for tube replacement. Review of the ER Discharge Instructions dated 10/23/15 noted the feeding tube had been replaced, and to consider use of a band/Velcro to hold the PEG tube in place. Review of Nurse's Notes dated 01/09/16 at 10:00 p.m. revealed that the GT was observed out of place with the inflated bulb resting on the resident's abdomen. Further review of this Nurse's Note revealed that two staff members were providing care at that time, and that the abdominal binder was in place, but had been unfastened to allow for care. Further review of this Nurse's Note revealed that the two staff members told the nurse that they went to turn and reposition the resident in order to clean her sacral area, and the GT popped out. This Nurse's Note further documented that the resident was sent to the ER for replacement of the GT. Review of all of these Nurse's Notes revealed that there was no documentation of any bleeding from the PEG tube site, nor any signs of discomfort. During the following observations on 05/02/16 at 2:05 p.m. and 3:58 p.m.; 05/04/16 at 7:52 a.m. and 11:42 a.m.; and 05/05/16 at 8:25 a.m., resident #17 was noted in bed with a wide elastic binder around his/her waist. Further observations revealed that the resident had no spontaneous movements, and no attempts to pull on her GT were noted. During an observation of ADL care provided by the Certified Nursing Assistants (CNA) AA and BB on 05/04/16 at 3:00 p.m., the CNA's were noted to turn the resident on her side, and an abdominal binder was noted around the resident's waist. During interview with CNA AA at this time, she stated that she was aware of the resident's GT coming out one time, but did not know how it happened, and that the binder was used to keep the tube in place. Upon further interview, she stated she had never known the resident to pull on her GT in the year she had known and worked with her. During interview with the Director of Nursing (DON) on 05/05/16 at 1:31 p.m., she stated that any resident with a GT was supposed to have an abdominal binder in place, and that the staff had been informed and had received in-service training on this. During further interview, the DON stated that the binder had to be released for showers and during care as needed, but that the staff needed to make sure the GT was on the abdomen and not under the arm or somewhere where it could be pulled on. During further interview at this time, the DON stated that he/she did not know why a binder was not initiated until after the GT had come out in October. The DON further stated that the CNA ' s had an assignment sheet that told them the residents' care needs. Review of resident #17 ' s CNA Assignment Sheet at this time revealed that it did not have a notation for the use of an abdominal binder on it, and the DON stated that this should have been included.

Based on observation, record review and staff interview, the facility failed to ensure that ventilation fans used in food serving and dishwashing areas were kept clean; failed to ensure that chemical concentration in two (2) of two (2) red buckets was sufficient to ensure sanitization of surfaces; and failed to ensure that foods were labeled, dated and maintained at the proper temperature in two (2) of two (2) nourishment room refrigerators. There was a total of seventy-nine (79) residents that consumed an oral diet. Findings include: 1. During initial tour of the kitchen on 02/02/15 at 9:52 a.m., a large commercial-type fan mounted on the wall was noted to have a moderate coating of dust on it. On further observation, this fan was blowing directly towards the dish machine, which was in use with cleaned dishes and utensils being pulled out of the machine towards the fan. During interview with the Dietary Manager (DM) at this time, she stated that she had already placed a work order to have the fan cleaned. Upon further observation, there was another commercial-type fan mounted on the wall, and it was blowing directly across the 3-compartment sink. Upon further observation, this fan had a light coating of dust on it, and a dietary employee was using the sink to wash cooking equipment and utensils. During observations on 02/04/15 at 12:25 p.m., the dish machine and 3-compartment sink were noted to be in use, and there were lunch food items on the steam table. One of the dusty ventilation fans was noted to be on and pointed toward the cleaned dishes coming out of the dish machine, and also pointed indirectly toward the steam table. The other dusty ventilation fan was on and blowing across the 3-compartment sink, including on dishes on the drainboard. The Dietary Manager stated that she had placed a work order when she came in on 02/02/15 to have the fans cleaned, and that Maintenance had to clean them as they had to be taken down off the wall mounts. During interview with the DM on 02/04/15 at 4:46 p.m., she stated that she did not have a set cleaning schedule for the ventilation fans, but that she placed a work order to clean them as needed. Upon further interview she stated that she didn't remember the last time the fans were cleaned. Review of the DM's work orders revealed that the last time an order had been placed to clean the fans was on 06/02/14. Further interview with the DM, she thought that the fans may have also been cleaned in August, but had no documentation of this. 2. On 02/04/15 at 4:46 p.m., the DM was asked to check the concentration of the quaternary (quat) solution in the two red buckets used to wipe off food prep areas. The bucket under the table between the steam table and ovens registered 100 parts per million (ppm), and the bucket by the dish machine did not register any quat at all; this was verified by the DM. Upon interview, the DM stated that the acceptable concentration was 200 ppm, and that the bucket by the steam table had recently been filled because the water was still warm. During observation on 02/05/15 at 12:45 p.m., the DM checked the sanitizer level in the red bucket by the steam table, which had very little reaction on the test strip. The DM stated this had been filled less than an hour ago as the water was still warm. Upon further observations, the bucket by the dish machine registered no sanitizer at all, and the water in the bucket was steaming hot. During interview with the DM on 02/05/15 at 1:41 p.m., she stated that she had recently learned at a workshop that non- disposable dish cloths may affect the sanitizer level in the red buckets, and that it was best to use disposable cloths, but that she had not gotten a shipment of the disposable cloths yet. 3. During observation in the B-hall Nourishment Room on 02/05/15 at 8:08 a.m., the following was noted and verified by the Nursing Home Administrator (NHA): The refrigerator was labeled: "For resident use only, not for use by staff." The thermometer inside registered 50 degrees Fahrenheit (F). Contents of this refrigerator included: -Three plastic Tupperware-type containers, one with peaches and two with corn. They were not labeled or dated. -One Dairy Queen-type ice cream dessert half eaten, that was totally melted, and unlabeled and undated. -Seven cups of ice cream, the contents of which were very soft to touch on the outside of the container. -Four (half) sandwiches wrapped in plastic wrap with no date. Review of the Refrigerator Temperature Log noted that the temps recorded for February were: 02/01/15: 44 degrees F. The form had a "Yes" notation that staff notified Maintenance with a work order. 02/02/15: 50 degrees F. 02/03/15: 46 degrees F. 02/04/15: 39 degrees F. The Log noted that the temp should be between 36-46 degrees, and that if it was not registering in that range please fill out a request form for Maintenance. During interview with the NHA at this time, she stated that ice cream should not be stored in this refrigerator as there was no freezer compartment. During observation in the A-hall Nourishment Room on 02/05/15 at 8:23 a.m., the following contents in the refrigerator were verified by the NHA: -One small clear plastic container with an unknown white substance which was unlabeled and undated. -One open package of Lunchables inside a grocery bag labeled "Fannie" that was undated. During interview with the NHA at this time, she stated that there was no resident by the name of Fannie. Upon further interview, she stated that Housekeeping was responsible for ensuring that the nourishment refrigerators were clean, and that the refrigerator was for resident food only. Review of the B-hall Refrigerator Temperature Logs revealed the following: January 2015: The temp was recorded as 46 degrees on 01/02/15. December 2014: The temp was recorded as 46 degrees two times; 48 degrees two times; and 50 degrees once. This was verified by the NHA. Review of the December 2014 A-hall Refrigerator Temperature Log revealed that the temperature was 42 degrees F. five times, and 44 degrees once. During interview with the Maintenance Director on 02/05/15 at 8:43 a.m., he stated that he reviewed his work orders since November, and saw nothing to check the nourishment refrigerator on the B-hall. During interview with the DM on 02/05/15 at 12:30 p.m., she stated that nourishment refrigerators should be kept at 41 degrees or below, and that ice cream should be stored in a freezer at 0 degrees. Review of the facility's policy and procedure for Storage in Refrigerators noted: -Fruits, vegetables, dairy products, meat and poultry should be stored between 33-40 degrees F. -Ice cream and frozen foods should be stored between -10 and 0 degrees F. -Food must be covered, labeled and dated when stored.

Based on observation, record review, facility and [MEDICAL TREATMENT] provider staff interview, the facility failed to follow the care plan related to monitoring the [MEDICAL TREATMENT] for patency for one (1) resident (#83). The sample size was thirty-six (36) residents. Findings include: During an observation on 02/03/15 at 10:30 a.m., resident #83 was noted with a gauze dressing to her left upper arm, and no external tubings were noted. Review of her clinical record revealed [DIAGNOSES REDACTED]. Further review of the clinical record revealed that she had a left upper extremity arteriovenous (AV) fistula. Review of the [MEDICAL TREATMENT] care plan revealed an approach to monitor the shunt for patency. During interview with Licensed Practical Nurse (LPN) "DD" on 02/05/15 at 9:10 a.m., she stated that she checked the resident's [MEDICAL TREATMENT] when she came back from [MEDICAL TREATMENT], and once a day on the non-[MEDICAL TREATMENT] days. Review of the resident's clinical record revealed that there was no documentation that the [MEDICAL TREATMENT] was being checked for patency. During interview with LPN's "EE" and "FF" on 02/06/15 at 8:47 a.m., they stated that resident #83 had a left arm external tubing that was used for [MEDICAL TREATMENT]. Upon further interview, LPN "EE" stated that she monitored for pain, swelling and bleeding at the [MEDICAL TREATMENT]. During interview with the Nephrology Centers of America [MEDICAL TREATMENT] employee "GG" on 02/06/15 at 12:09 p.m., she stated that resident #83 had a left upper arm AV fistula with no external [MEDICAL TREATMENT] access device, and that the AV fistula should be checked for thrill and bruit (to ensure proper functioning of the fistula).

Based on observation, record review, facility and [MEDICAL TREATMENT] provider staff interview, the facility failed to monitor the [MEDICAL TREATMENT] for patency for one (1) resident (#83). The sample size was thirty-six (36) residents. Findings include: During an observation on 02/03/15 at 10:30 a.m., resident #83 was noted with a gauze dressing to her left upper arm, and no external tubings were noted. Review of her clinical record revealed [DIAGNOSES REDACTED]. Further review of the clinical record revealed that she had a left upper extremity arteriovenous (AV) fistula. During interview with Licensed Practical Nurse (LPN) "DD" on 02/05/15 at 9:10 a.m., she stated that she checked resident #83's [MEDICAL TREATMENT] when she came back from [MEDICAL TREATMENT], and once a day on the non-[MEDICAL TREATMENT] days. Review of the resident's clinical record revealed that there was no documentation that the [MEDICAL TREATMENT] was being checked for patency. During interview with LPN's "EE" and "FF" on 02/06/15 at 8:47 a.m., they stated that resident #83 had a left arm external tubing that was used for [MEDICAL TREATMENT]. Upon further interview, LPN "EE" stated that she monitored for pain, swelling and bleeding at the [MEDICAL TREATMENT]. During further interview, neither LPN was able to locate the name or phone number of the resident's [MEDICAL TREATMENT] provider in the clinical record. During interview with Nephrology Centers of America (where the resident was sent for [MEDICAL TREATMENT]) employee "GG" on 02/06/15 at 12:09 p.m., she stated that resident #83 had a left upper arm AV fistula with no external [MEDICAL TREATMENT] access device, and that the AV fistula should be checked for thrill and bruit at the nursing home (to ensure proper functioning of the fistula). Review of the [MEDICAL TREATMENT] Communication Records revealed that the facility staff documented seventeen of nineteen times that resident #83's [MEDICAL TREATMENT] access ports were capped and clamped. During further review of these same forms, the [MEDICAL TREATMENT] staff never documented that the ports were capped and clamped, and on the 12/22/14 Record the [MEDICAL TREATMENT] staff made the notation of (Not Applicable) "N/A"on this line. Review of the facility's policy and procedure for [MEDICAL TREATMENT] Catheters noted the nurse should document in the resident's medical record every shift as follows: location of catheter; condition of dressing; if [MEDICAL TREATMENT] was done during shift; and observations post-[MEDICAL TREATMENT]. During interview with the Assistant Director of Nursing on 02/06/15 at 1:54 p.m., she verified that resident #83 had an internal [MEDICAL TREATMENT] without any external tubing, and verified that the facility [MEDICAL TREATMENT] policy and procedure did not apply to the type of [MEDICAL TREATMENT] access that resident #83 had. During interview with LPN "EE" on 02/06/15 at 2:42 p.m., she stated that resident #83 had just returned from [MEDICAL TREATMENT], and that the resident had a thrill and bruit, but was not sure which was which, and where she was supposed to feel and listen for it. Upon further interview LPN "EE" stated that she didn't know anything about [MEDICAL TREATMENT], and wished she knew more about it. Observation of resident #83's left upper arm on 02/06/15 at 2:53 p.m. revealed that she had an AV fistula with no external [MEDICAL TREATMENT].

Based on observations, record review and staff interviews the facility failed to provide care and services to promote the prevention of pressure sore development for two (2) residents (#102, #99) identified as moderate risk for development of pressure ulcers and dependent on staff for all care. Findings include: Review of the clinical records revealed that resident #102 was admitted on [DATE] and acquired a pressure ulcer in the facility which was identified on 1/22/15 as an unstageable with no documentation of the early development of the wound. Further review revealed that there was no documentation of any pressure reducing devices to prevent the wound from occurring. Review of the Minimum Data Set ( MDS) assessment dated [DATE] revealed that he was totally dependent on staff for all activities of daily living, including bed mobility and transferring. His [DIAGNOSES REDACTED]. He had a Braden score of 14 (moderate risk for pressure ulcer development). Record review of the admission assessment dated [DATE] revealed that all skin was intact with no breakdown or redness observed upon admission to the facility. Review of the bath skin assessment reported by the Certified Nursing Assistant (CNA) revealed that on 12/24/14, 12/31/14, 1/7/15, 1/9/15, 1/12/15, 1/16/15, 1/21/15, and 1/23/15 that there were no concerns for skin tears, bruises, discoloration, toe nails, scalp irritation, rash, eyes reddened or drainage. On 1/26/15 it was noted that the resident had a dressing intact to the right outer foot. Review of the Nurse's Weekly Skin Assessments dated 12/18/14 through 1/15/15 revealed that the resident had no opened areas to the skin until 1/22/15 when an open area to the right outer heel with drainage was noted. Further review of the clinical record revealed that a Care Plan was developed on 12/17/14 for potential for skin breakdown with an intervention to report any reddened or excoriated areas. The Care Plan developed on 1/22/15 for a Right outer heel unstageable wound which measured 3.0 x 3.0 x UTD (unable to determine) with contributing factors listed as limited mobility, dependent for positioning, incontinence, dry flaky skin, and diabetes. The interventions included to assist to turn and reposition, positioning devices, pressure device to bed, encourage and assist with food and fluid , provide wound care as ordered with xeroform and santyl daily. Review of the Nurses Wound Notes dated 1/22/15 revealed that the resident was noted with an area of concern to the right heel area. The right heel was described as an unstageable wound to the right outer heel which was noted to be dark, semi hard, with eschar and slough present. It was noted that where the eschar was detaching there was scant serosangeous drainage noted with a slight odor present. Further review of the Nurse Wound Notes dated 1/29/15 revealed that the unstageable wound to the right heel measured 3.0 x 3.0 x UTD. Interview with Licensed Practical Nurse (LPN) "AA" on 2/2/15 at 2:40 p.m. revealed that resident #102 had a pressure ulcer of the right outer heel that was unstageable and measured 3.5 x 3.0 x 0 cm. LPN "AA" further revealed that she could not remember if the resident had any heel pads prior to his wound but recalled that he was very anxious in bed. Interview with the LPN Wound Care nurse on 2/4/15 at 9:45 a.m., revealed that resident #102 acquired his wound in the facility and once it was identified they implemented and monitored the resident with pressure relieving devices. The Wound Care nurse further revealed that the Certified Nursing Assistant (CNA's) complete a daily bath sheet and skin assessment for each resident and the nurses complete a weekly skin assessment for each resident. Continued interview revealed that she was surprised that the wound was not identified in its early stages by staff, and had not been discovered until it had black eschar, drainage and odor. The Wound Care nurse revealed that the resident likes to kick his leg to the side so it may be due to constant friction to the area. She further revealed that she would expect the staff to notify her of any signs of pre-ulceration. Observation on 2/5/15 at 11:05 a.m. revealed resident #102 sitting in his wheelchair in the hallway with bilateral heel boots noted to be falling off his feet. Interview with the LPN Wound Care nurse on 2/6/15 at 9:14 a.m., revealed that she was informed by LPN "AA" that the resident had a wound. When she saw the wound it already had eschar that was detaching it was then identified as an unstageable pressure ulcer. Continued interview revealed that she felt the wound should have been identified before she saw it. The Wound Care nurse revealed that even though a recent Doppler test revealed the resident had mild [MEDICAL CONDITION] his wound was due to a pressure ulcer. Interview with CNA "CC" on 2/6/15 at 12:35 p.m. with revealed that she works often with Resident #102 and has given him showers before and after he acquired the wound. "CC" further revealed that she cannot recall when he began wearing his protective heel boots. She does however recall he had a soft spot on his heel prior to the resident developing a wound but does not remember reporting it to the nurse. Review of the facility policy for the Prevention of Pressure ulcers (revision 2005) - (2) The most important site of a pressure ulcer is where the bone is near the surface of the body including the back of the head , ears , elbow knees heels ankles and toes. (3). If pressure ulcers are not treated when discovered, they quickly get larger, become very painful for the resident and often times become infected. (6) The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family and addressed. Factors that indicate residents at risk: impaired mobility/decreased mobility and functional ability. Cognitive impairment. Review of resident #99's clinical record revealed that he was admitted to the facility on [DATE] after a hospitalization , and [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] noted that except for eating, he was totally dependent on staff for all activities of daily living, including bed mobility. Upon further review of the MDS, it noted that the resident was at risk for pressure ulcer development, with no current pressure ulcers. Review of the Braden Scale dated 08/29/14 noted a score of 14 (moderate risk for pressure ulcer development). Review of the care plan for potential for skin breakdown, developed 09/04/14, noted that he was at risk due to a bed mobility problem, bowel incontinence, and Braden score. Review of the approaches for this care plan revealed no mention of any actual skin compromise. Review of protein labs revealed that on 09/05/14 resident #99's [MEDICATION NAME] level was 3.3 (normal 3.5-5.0), and his pre-[MEDICATION NAME] level on 09/24/14 was 12.6 (normal 20.0-40.0). Review of the resident's weights revealed a ten-pound weight loss from admission to 09/15/14, at which time an order for [REDACTED]. Review of the admission Nurse's Notes dated 08/29/14 revealed that both of resident #99's heels were soft, intact, and slightly red. Review of the clinical record revealed that there was no documentation that any preventive measures were put in place to address the resident's soft and red heels, other than in the Nurse's Notes dated 09/09/14 at 10:30 p.m. that there were protective boots on both feet, and on 09/12/14 at 10:10 p.m. that the resident was turned and repositioned every two hours by staff. Further review of the Nurse's Notes revealed that the only other time that heel protectors were documented as applied was on 09/16/14 at 3:00 p.m. Review of Nurses Notes-Wounds noted that on 09/16/14, resident #99 was noted with a Stage 2 pressure ulcer to the left heel, a serosanguinous-filled intact blister measuring 1.7 centimeters (cm) length by 2.5 cm width by undetermined depth. Upon further review of the Wound notes revealed that the resident was often noted to scoot in bed, and that skin prep daily to the heels were ordered. During interview with the Licensed Practical Nurse (LPN) Wound Care nurse on 02/06/15 at 9:17 a.m., she verified that the admission Nurse's Notes dated 08/29/14 noted that resident #99's heels were soft and red, and that she was not notified and would have expected that the staff let her know. Upon further interview, she verified that there was no notation if the heels were blanchable on admission, and if they weren't skin prep to the heels would have been appropriate. The Wound Care LPN further stated that the heels should have been floated and/or heel protectors applied from admission, and saw no documentation that this had been done until the left heel pressure ulcer was identified. Review of the facility's Wound Care Protocol noted for a Stage 1 pressure ulcer, to apply protective spray to the affected areas daily and as needed, to leave it uncovered, and if friction was a concern to use a thin [MEDICATION NAME] dressing every three days and as needed. Further review of the Wound Care Protocol revealed that for a Stage 2 intact blister, to apply protective spray to affected area, keep heels elevated off mattress, apply heel boots/pressure relieving devices, and start Vitamin C, a multivitamin, and zinc supplements daily. Review of the Physician's orders revealed that these supplements had not been ordered from the discovery of the pressure ulcer on 09/16/14 until the resident was discharged to the hospital on 09/20/14. This was verified during interview with the Wound Care LPN on 02/06/15 at 10:54 a.m. At this time, the LPN provided the facility's Prevention of Pressure Ulcers policy and procedure, which noted that when in bed, every attempt should be made to float the resident's heels.

Based on record review and staff interview, the facility failed to ensure that two (2) of three (3) Skilled Nursing Facility Advanced Beneficiary Notices (SNFABN) for residents #54 and #104 were properly completed, and failed to provide one (1) resident (#54) with the SNFABN when they were discharged off Medicare Part A services and remained in the facility. A total of three (3) residents were reviewed for the issuance of the proper liability and appeal notices. The sample size was thirty-six (36) residents. Findings include: 1. Review of the Notice of Medicare Provider Non-Coverage (Generic Notice) for resident #104 revealed that he was discharged from Physical Therapy (PT) and Occupational Therapy (OT) on 11/03/14, and the resident remained in the facility. Review of both this Notice and the SNFABN revealed that the forms were not signed by the responsible party (RP) until 11/04/14. In addition, the section on the SNFABN for the RP to indicate whether or not they wanted the resident to continue to receive skilled services was left blank, so that there was no indication that they knew of and understood their right to do so. 2. Review of the Medicare Notices for resident #44 revealed that she was discharged from PT on 01/01/15, and the Generic Notice and SNFABN were signed by the RP on 01/08/15, seven days after skilled services ended. Further review of the Notices revealed that resident #54 was discharged from OT on 01/12/15. Review of the SNFABN's revealed that the section for the RP to indicate that they were aware of their right to continue the skilled services was blank. Further review of the Notices revealed that the resident was discharged from Speech Therapy (ST) on 01/19/15 and remained in the facility, and the only Notice issued was the Generic Notice. Review of this Generic Notice revealed that it was signed by the RP on 01/22/15, three days after the skilled services ended. During interview with the Social Services Director (SSD) on 02/04/15 at 2:25 p.m., she stated that she recently received training on how to complete the required Notices when a resident was discharged from skilled services, and that it was her understanding that only the Generic Notice had to be provided when services ended and the resident remained in the facility. Upon further interview, she stated that 48 to 72 hours before a resident came off skilled services, she would notify the RP. She further stated that if the RP visited the facility frequently, she did this notification by telephone, and then had the RP sign the form(s) when they visited. Upon further interview, she verified that there was no documentation that she called resident #54 and #104's RP's and explained the purpose of the forms, and their right to appeal the decision. The SSD verified that the SNFABN's had not been completed to indicate if the RP did or did not want to continue the services. During interview with the Administrator on 02/04/15 at 3:20 p.m., she stated that they clarified which Notices had to be provided for a resident that came off skilled services and remained in the facility with benefit days remaining, and were told that both the Generic and SNFABN should be issued.

Based on observation, record review and staff interview, the facility failed to ensure that the kitchen range hood was maintained in operating condition for twenty-seven (27) days. The facility census was eighty-eight (88) residents. Findings include: During initial tour of the facility's kitchen on 02/02/15 at 9:52 a.m., the Dietary Manager (DM) denied any equipment problems in the kitchen. During observation on 02/04/15 at 12:25 p.m., the kitchen range hood was noted not to be functional. This was verified during interview with the DM at this time, who stated that she had placed a work order with Maintenance sometime back in January to have it fixed. During further observation on 02/04/15 at 3:30 p.m., the range hood was noted to be functional. Interview with the DM on 02/04/15 at 4:46 p.m., she stated that she left it in Maintenance's hands to follow-up and ensure the kitchen equipment was repaired once a work order had been placed. Review of the work order that the DM had placed to check the range hood was dated 01/07/15.

Based on observation, record review, post incontinence skill performance, and staff interviews, facility failed to ensure that one (1) resident (#5), received appropriate incontinent care to help prevent possible cross contamination. The total sample was five (5) residents. Findings include: Resident #5 was admitted to the facility in November 2012 with Dementia, anxiety, [MEDICAL CONDITION], hypertension, heart failure, metabolic [MEDICAL CONDITION] and depression. Review of the Bowel and Bladder assessment dated [DATE] revealed that the resident is incontinent of both the bowel and bladder, so he needs to be checked every two (2) hours, requires the use of adult incontinence products, give prompt pericare after any incontinence, encourage fluid intake and report any reddened areas. During incontinent care observation with Certified Nursing Assistant (CNA) "AA" on 10/13/14 at 11:24 a.m., he removed the old adult brief from resident #5, washed resident's perineal area, then washed downwards on the right side, and the left side. Continued observation revealed that he changed the direction of the wash cloth, washed the head of the penis; however, did not wash the shaft of the penis. The CNA changed his gloves and rinsed the resident without any problems. Then he rolled the resident over to his right side toward the Assistant Director of Nursing (ADON) and took two (2) wet wipes and wiped downwards from resident's back toward his bottom with the same same wipe, twice. The wipe was observed to have a dark brown colored stain when the CNA whipped the resident's bottom the first time, downwards and for the second observation, the wipe had a fainted brown stain when the CNA wiped upwards for the second time. Continued observation revealed that the CNA placed a diaper on the resident and rolled the resident on his back in the bed. Interview with the ADON on 10/13/14 at 12:02 p.m., revealed that the CNA should have wiped upwards and never downwards, like he did. Continued interview revealed that they are going to have to complete an in-service. Interview with the Staffing Development Coordinator on 10/13/14 at 12:15 p.m., revealed that the nursing supervisor checks off the staff on the weekends on incontinent care, when she works the weekends; however, she was able to confirm that when performs incontinent care, you would go from front to back and never wipe downwards. Review of the POS [REDACTED].

Based on observation, record review, and staff interview, facility failed to ensure that one (1) resident (#5) from a sample of five (5) residents, received appropriate incontinent care to help prevent possible cross contamination. Findings include: Resident #5 was admitted to the facility in November 2012 with Dementia, anxiety, [MEDICAL CONDITION], hypertension, heart failure, metabolic [MEDICAL CONDITION] and depression. Review of the Bowel and Bladder assessment dated [DATE] revealed that the resident is incontinent of both the bowel and bladder, so he needs to be checked every two (2) hours, requires the use of adult incontinence products, give prompt pericare after any incontinence, encourage fluid intake and report any reddened areas. During incontinent care observation with Certified Nursing Assistant (CNA) "AA" on 10/13/14 at 11:24 a.m., he removed the old adult brief from resident #5, washed resident's perineal area, then washed downwards on the right side, and the left side. Continued observation revealed that he changed the direction of the wash cloth, washed the head of the penis; however, did not wash the shaft of the penis. The CNA changed his gloves and rinsed the resident without any problems. Then he rolled the resident over to his right side toward the Assistant Director of Nursing (ADON) and took two (2) wet wipes and wiped downwards from resident's back toward his bottom with the same same wipe, twice. The wipe was observed to have a dark brown colored stain when the CNA whipped the resident's bottom the first time, downwards and for the second observation, the wipe had a fainted brown stain when the CNA wiped upwards for the second time. Continued observation revealed that the CNA placed a diaper on the resident and rolled the resident on his back in the bed. Interview with the ADON on 10/13/14 at 12:02 p.m., revealed that the CNA should have wiped upwards and never downwards, like he did. Continued interview revealed that they are going to have to complete an in-service.

Based on record review and staff interview, the facility failed to timely consult with the physician, and immediately notify the responsible party, related to the occurrence of blood-tinged urine for one (1) resident (#5), who received [MEDICATION NAME] anticoagulant drug therapy, from a complaint survey sample of six (6) residents. Findings include: Review of the medical record for Resident #5 revealed that the resident had a routine physician's orders [REDACTED]. A Skilled Daily Nurses Note entry of 12/30/2011, with no time noted, documented that there were no new changes noted in the resident's status at that time. However, a Skilled Daily Nurses Note entry of 12/30/2011 at 6:45 a.m. documented that the nurse was called to the room by the speech therapist, further documenting that the resident was noted to be voiding blood-tinged urine into the toilet. A Skilled Daily Nurses Note of 12/30/2011 at 7:00 a.m., labeled as a late entry, documented that the nurse had made two attempts to reach the primary physician and the on-call physician concerning the presence of blood when Resident #5 was voiding. This nurse further documented that she had been unable to contact either physician, and had notified the oncoming nurse of the resident's status and the situation of the inability to contact the physician. There was no documented evidence to indicate that an attempt had been made to notify the resident's family at that time. A Skilled Daily Nurses Note entry of 12/31/2012 at 2:00 p.m. documented that the resident's family had arrived to discharge the resident home. However, further record review revealed no evidence to indicate that any additional attempts had been made to consult with the physician regarding Resident #5's blood-tinged urine since the two attempts to notify the physician, as noted in the Skilled Daily Nurses Note of 12/30/2011 at 7:00 a.m., or that any notification had been provided to the resident's family, either before or at the time of the resident's discharge, as documented in the 12/31/2012, 2:00 p.m. Skilled Daily Nurses Note referenced above. During an interview with Licensed Practical Nurse "EE" (the nurse present at time of the resident's discharge) conducted on 06/19/2012 at 11:00 a.m., she indicated she did not recall notifying the physician of the blood in the resident's urine.