Every finding on record at Port Orange Nursing and Rehab Center

Based on observations, interviews, record review, and facility policy and procedure review, the facility failed to ensure that two (Resident #3 and Resident #113) of three residents reviewed for limited range of motion (ROM) received appropriate treatment and services to increase range of motion, and/or to prevent further decrease in range of motion, in a total survey sample of 36 residents. The findings include:1. During the initial tour on 3/29/26 at 1:51 PM, Resident #3 was observed in bed. Her right arm was contracted to the elbow, and her left-hand fingers were also contracted. She did not have any splints on her elbow or hand. When she was asked if she had any concerns, she stated she wanted to have more range of motion. She explained that there was an aide that conducted range of motion (ROM) with her, however, there is no consistency with the care because she keeps being taken away to work on the floor. When there is no consistency, I feel too much pain when they try to do it.Review of the medical record for Resident #3 revealed she was admitted to the facility on [DATE], with a re- entry on 3/15/25. Her diagnoses included atherosclerosis of native arteries of right leg with ulceration of heel and midfoot, quadriplegia, and peripheral vascular diseases. Review of the modified quarterly minimum date set (MDS) with an assessment reference date (ARD) of 1/29/26 indicated the resident had a brief interview for mental status (BIMS) score of 15 out of 15, indicating she was cognitively intact. She exhibited no behaviors and was dependent on staff with bed mobility, transfer and hygiene/grooming.Review of the physician's orders dated 3/30/26, revealed an order for Therapy/Splinting: [NAME] bilateral C-bar splints and right soft elbow splint in the morning after breakfast and doff prior to lunch as tolerated. May be removed for skin integrity checks, hand hygiene, and/or cleaning of splint. (Copy obtained)Additional physician orders included: Apixaban 2.5 mg (milligrams) by mouth two times a day for Prophylaxis 1/20/26. Clopidogrel Bisulfate Tablet 75 mg, give one tablet by mouth one time a day for blood clot prevention 3/16/25. Hydrocodone-Acetaminophen 5-325 mg, give one tablet by mouth every 8 hours for pain hold for sedation 7/7/25.During another observation on 3/30/26 at 10:00 AM, Resident #3 was observed in bed. She did not have any splints on her elbow or hand.Review of the resident's care plan, revised on 2/5/26 indicated that the resident required a Splint/Brace with nursing restorative program to right and left hand. Interventions included bilateral comfy hand splints as ordered/tolerated as she allows and gentle ROM prior to splint application. The care plan also indicated that the resident has an activity of daily living (ADL) self-care performance deficit related impaired functional mobility, limits to ROM to bilateral upper extremities (BUE) and bilateral lower extremities (BLE), age and commodities. She makes the choice not to get out of bed. Interventions included right elbow freedom adjustable splint and bilateral resting hand splints per orders/instructions. 2. On 3/30/26 at 11:24 AM, Resident #113 was observed in her room seated in a wheelchair. Her left wrist was contracted, and she could not open her palm. Her bilateral lower [NAME] appeared swollen, and she did not have compression stocking. When she was asked if the facility assisted with splinting, she nodded yes. When she was asked if she had any brace, she nodded no. Her mom (roommate) spoke up and said that she used to have braces but does not know what happened to them. Review of the medical Clinical record for Resident #113 revealed she was admitted to the facility on [DATE]. Her diagnoses included cerebral palsy, severe intellectual disability, anxiety disorder and major depressive disorder. Review of the quarterly MDS with an ARD of 2/3/26 noted that the resident has a BIMS score of 8 out of 15, indicating moderate cognitive impairment. She required substantial to maximum assistance with upper body dressing and dependent with putting on/taking off footwear.Review of physician's order, dated 1/30/26, read, add compression to BLE due for edema - On in the morning and remove at bedtime for Compression to BLE. Another order dated 3/30/26 revealed therapy/splinting: [NAME] left palm guard in the morning after breakfast and doff prior to lunch or as tolerated. May be removed for skin integrity checks, hand hygiene, and/or cleaning of splint- 3/30/26.During another observation on 3/31/26 at 10:17 AM, Resident #113 was observed in her room fully dressed seated in her wheelchair. She was not wearing any braces or leg compression stockings. Review of the resident's care plan revised 2/24/26 indicated she has impaired cognitive function/impaired thought process r/t severe intellectual disabilities. Resident will be offered to go down to therapy to be with the mom due to behaviors when her mom is not with her. She will be encouraged to participate in diversional activities. Further review of the care plan Revised 6/23/25 indicated that the resident required a passive range of motion with nursing restorative program. Passive ROM - Approach/Precautions and encourage compliance to be completed daily (QD), 7 days a week before and after splinting as she allows. Resident has an ADL self-care performance deficit related to: Cerebral palsy, severe intellectual disabilities, depression and anemia. Intervention included compression (TED) hose per order. Left palm guard per order as she allows.In an interview on 3/31/26 at 11:00 AM, the Regional Clinical Director (RCD) stated that she was informed that the facility did not have restorative nursing program, instead it offered a national maintenance program (FMP) through skilled therapy. She mentioned that the Director of Rehab (DOR) would be providing the list of residents on FMP.On 3/31/26 at 11:15 AM, the RCD provided a list of residents on FMP for ST, PT and OT. There was no indication of the services these residents were receiving under each discipline. When asked if she was aware what services they were receiving. She stated that she would inform the DOR to come and explain. Residents #3 and #113 were not in the list. During a joint interview on 3/31/26 at 12:26 PM, with the DOR and the Regional Rehab Manager, they mentioned that when residents are picked up for part B services the rehab department determined if they need FMP. They added that therapy also does quarterly screens to determine resident's needs and most of the skills are conducted by skilled therapy as the facility did not have restorative nursing program. They explained that some services are added to the Certified Nursing Assistants (CNAs) Kardex for the CNAs to provide care. They confirmed that both Residents #3 and #13 were not on FMP programs.During an interview on 3/31/26 at 2:22 PM, with CNA E/Restorative aide, she reviewed the computer point of care system and printed a list of on restorative nursing program. When asked about Residents #3 and #113, she confirmed that they were on the restorative nursing program. However, she acknowledged that she had not been providing restorative services for the last 7 weeks because she kept being pulled to work on the floor due to lack of staffing coverage.On 3/31/26 at 3:30 PM, CNA E was asked to go to Resident #3 and Resident #113's room. After observing Resident #3, CNA E confirmed the resident did not have any splints on and retrieved them from the resident's drawer. (Photographic evidence obtained) When CNA E observed Resident #113, she confirmed the resident did not have any splints or compression stockings on. CNA E retrieved the splints from the resident's drawer. (Photographic evidence obtained) She confirmed that she had not placed the splints on because today was her first day back as restorative aide and she was tasked to obtain monthly weights. A review of the facility's policy and procedure titled Restorative Nursing program revised 8/2023 revealed the following:PURPOSE: It is the policy of the center to assist each Resident to attain and or maintain their individual highest most practicable functional level of independence and well-being, in accordance to State and Federal Regulations FUNDAMENTAL INFORMATION: It is recognized that there are occasions when residents may have unavoidable declines which may not be reversible which might not be under the control of the center. Furthermore, it is recognized that some residents may not wish to participate in restorative care programming will be respected as election of choice and documented accordingly. PROCEDURE: 1. Each resident will be screened and or evaluated by the Nurse designated to oversee the restorative nursing process for inclusion into the appropriate center restorative nursing programs) when it has been identified by 1 interdisciplinary team that the resident is in need or may benefit from such programs). 2. The screening will include the resident or their representative's input, choices, and expectations related to participating in the restorative nursing program. 3. The center restorative nursing program will include but not be limited to the following programs:Hygiene -bathing, dressing, grooming, and oral care,Mobility-transfer and ambulation, including walking, prosthetic and or splint application with or without active and or passive range of motion, bed mobility, Elimination-toileting, bowel and bladder,Dining-eating, including meals and snacks,Communication, including: i. Speech, ii. Language, iii. Other functional communication systems. 4. The above programs will be documented on the center designated restorative care forms/tools in the res electronic medical record.5. Based on clinical evaluation and ongoing consideration residents may be placed in one or more of the above programs at one time. 6. The designated nurse will be responsible for the following:Obtaining orders for the resident's restorative program,Documentation on a monthly basis (at a minimum), andInitiation and updating restorative care plans. 7. Once in an appropriate restorative nursing program, the designated nurse will continue to monitor the reside progress. 8. The designated nurse will evaluate the restorative documentation monthly to determine if there are any changes needed to the existing program and make a monthly progress note, in the resident's electronic medical record related to this evaluation. 9. For active programs, the resident would normally be expected to reflect progress within a four-week period.10. For maintenance programs, the resident would normally be expected to have already reached their highest level of potential and the therefore be supported to maintain their level and if clinically possible [NAME] off further decline. 11. In the event that it is clinically contraindicated for a resident to participate in a restorative care program, the designated nurse will discuss with the physician or extender and if that is medically determined, the physician or extender will provide an order to direct the staff accordingly.

Based on observations, interviews, and record review, the facility failed to ensure that two (Resident #28 and Resident #43) of three residents, who were reviewed for inability to carry out activities of daily living (ADLs), from a total of 36 residents in the sample, received necessary assistance to maintain good grooming and personal hygiene. The findings include: 1. Review of Resident #28's clinical record revealed she was admitted to the facility on [DATE] with diagnoses that included type 1 diabetes mellitus with diabetic chronic kidney disease, acquired absence of left leg above knee, occlusion and stenosis of bilateral carotid arteries, and major depressive disorder. Review of the Quarterly minimum data Set (MDS) with an assessment reference date (ARD) of 1/24/25, revealed the resident had a brief interview for mental status score (BIMS) of 11 out of 15, indicating moderate cognitive impairment. She required substantial to max assistance for showers. An observation and interview of Resident #28 was conducted on 3/30/26 at 10:57 AM. While lying in her bed, she said her body was itching all over and it had been going on for over a week. She explained that she notified the nurse and was hoping to get some Benadryl or something for itch relief. When asked about the last time she had a shower, she stated that she could not recall. Review of Resident #28's current physician orders revealed the following: Nystatin External Cream 100000 UNIT/GM (Topical)- Apply to Peri area topically every shift for Candidiasis of skin and vagina for 14 Days -3/18/26- 4/1/26. Triamcinolone Acetonide External Cream 0.5 % (Topical)- Apply to left thigh topically every morning and at bedtime for rash 3/30/26. Hydrocortisone External Cream 2.5 % (Hydrocortisone (Topical) Apply to affected areas topically every day and evening shift for rash for 14 Days including R posterior hip, R mid-low back, posterior R leg 12/10/25. Ammonium Lactate External Cream 12 % (Lactic Acid (Ammonium Lactate)-Apply to affected areas topically every day and evening shift for dermatitis for 14 Days including Right posterior hip, right mid-low back, R upper leg 12/10/25. Review of the Advanced Registered Nurse Practitioner (ARNP) notes dated 3/30/26, indicated that the resident was seen sitting up in her bed, alert and oriented to baseline, in no acute distress. She was complaining of left thigh pruritus. Upon examination, scratches were noted on her left thigh from scratching. Triamcinolone 0.1% ointment was initiated to the left thigh every morning and at bedtime for symptomatic relief. Review of the care plan for Resident #28 revised on 8/15/25 revealed that the resident has an Activities of Daily living (ADLs) Self-Care Performance deficit related to impaired functional mobility, history of fracture right femur post-surgical, Left above Knee Amputation (AKA). She Requires Partial/Moderate assistance of one for personal hygiene. (Copy obtained). Review of the CNA task 30 days look back from 3/31/26 for Resident #28- indicated that the bathing task did not occur (Copy obtained). On 3/31/26 at 1:58 pm, an interview was conducted with Certified Nursing Assistant (CNA) F who was assigned to Resident #28. When asked how she identified residents' needs, she explained that she reviewed the Kardex, ask the CNA during report, ask nurses and/or therapist. When asked how often residents received a shower. She said, Twice a week, there is shower books at the nurses' station. The showers are splits in two shift days and evening shift. She added that the shower list is sometimes added to the assignment board at the nurse's station. When asked if the showers are documented when provided, she said, Yes, Once the shower is provided it's documented in the computer and the shower sheet that's provided to the nurse. When asked to describe Resident #28, she said she was alert and oriented, and able to make needs known. The resident needed assistance with ADLs and does not refuse care. She confirmed that the resident had a rash mid lower back. When asked if the resident had a recent shower, she stated that she had to review the Kardex because her showers were scheduled in the afternoon. On 3/31/26 at 3:44 PM, an interview was conducted with Licensed Practical Nurse (LPN) G/Unit Manager who was familiar with Resident #28. She stated that the residents received showers at least 2 times a week and if they refuse, they should be offered at a different time or day. She confirmed that showers should be documented in the shower sheet and on the electronic point of care documentation. If the resident refuses a shower the CNAs should also notify the nurse. The Nurse would then attempt to offer a different bath like bed bath, of sponge bath. When asked about Resident #28's care needs, she stated that the resident required moderate assistance with transfer. She can roll in bed, self- propel in wheelchair. She is incontinent of [NAME] and bladder. She explained that the resident was treated for rash recently. She reviewed the ARNP notes dated 3/30/26 and stated that resident had pruritus to thighs and ordered triamcinolone. When asked about the resident's showers days, she confirmed that her shower days were on Wednesday and Saturday in the evening shift. When asked if the resident received the showers, she checked the list for Resident #28 but could not find any documented showers. She checked the paper shower sheets, but she could only find 2 documented showers and one refused shower for the month of March 2026. 2. Review of Resident #43's clinical record revealed she was an [AGE] year old female admitted to the facility on [DATE] with diagnoses that included fracture of unspecified part of neck of left femur, pain in left hip, unspecified abnormalities of gait and mobility, pressure-induced deep tissue damage of sacral region, Alzheimer's disease, and unspecified and muscle weakness (generalized). Review of the Admission/Medicare 5-day MDS dated [DATE] noted the resident had a (BIMS) score of 1 of 15, indicating severe cognitive impairment. The resident's functional status assessment noted a lower extremity impairment on one side, required supervision or touching assistance for personal hygiene, and shower/bathe self-required substantial/maximum assistance. An observation and interview of Resident #43 was conducted on 3/27/26 at 11:25 AM. While lying in her bed, she was observed with coarse facial hair in the chin, jawline, and upper lip area. When asked about the facial hair, she stated, The long facial hair makes her itchy and staff have not offered to help trim or shave her facial hair. On 3/31/26 at 2:16 PM, an interview was conducted with CNA B who was assigned to Resident #43. When asked about Resident #43's facial hair, she stated that she was not aware that the resident had long facial hair. She said that she received training for activities of daily living (ADL) care during orientation and knows how to provide ADL care from her many years as a CNA. She further explained that if she noticed a female resident with facial hair on the chin, jawline or upper lip area, she would ask the resident if they would like her to clean up the facial hair. She explained that CNAs are expected to notice long facial hair, they must document it on the resident's shower's shower sheet and in the resident's electronic record in Point Click Care (PCC). On 3/31/26 at 2:24 PM, CNA B observed Resident #43 in her room. After looking at the resident, she said, The resident's facial hair is too long. Review of Resident #43's care plan revealed a focus of ADL self-care performance deficit, with a goal noting attempts for the resident to improve current level of function will be provided through the review date. Interventions included: bathing with substantial assistance and personal hygiene with touch or supervision assistance. There was no documented evidence that the resident refused ADL care. Review of the shower schedule for Resident #43 revealed that the resident was to receive showers on Tuesdays and Fridays during the 3-11 shift. Review of shower sheets for the previous three weeks lacked a shower sheet for Resident #43. Review of the resident's electronic medical record revealed the resident received a shower on the following dates and times: 3/17/26 at 22:31, 3/18/26 at 18:18; 3/20/26 at 17:31 and 3/31/26 at 19:15. Review of the facility's document titled Procedural Guidelines, SHCEDU0001.10B, Updated: 09/2023 and Effective: 01/2023 documented: Purpose: To facilitate residents' overall comfort, cleanliness, grooming, and well-being. Documentation Guidance: In care plan document interventions and approaches, and the amount of assistance the resident needs.

Based on observations, interviews, record reviews, and facility policy and procedure review, the facility failed to ensure that one (Resident #131) of two residents reviewed for oxygen therapy, received the correct number of liters of oxygen ordered by the physician, in a total sample of 36 residents. This could result in the resident not receiving appropriate care and/or clinical complications. The findings include:On 3/29/26 at 11:13 AM, Resident #131 was observed lying in bed with oxygen (O2) via nasal canula (NC). An observation of her oxygen concentrator revealed the oxygen flow was set at 1.5 liters per minute (LPM). (Photographic evidence obtained) When the resident was asked if she adjusted the flow of the oxygen concentrator, she replied, No, I don't touch it. Review of the medical record for Resident #131, revealed she is an [AGE] year-old female admitted to the facility on [DATE], with diagnoses including congestive heart failure, dependence on supplemental oxygen, unspecified asthma, uncomplicated, acute respiratory failure with hypoxia, and shortness of breath. A review of the physician's order written on 3/22/26 revealed, O2 via NC at 2 LPM. Review of Resident #131's admission /Medicare - five-day minimum data set (MDS) assessment, dated 03/27/26, revealed the resident had a brief interview for mental status (BIMS) score of 11 out of 15, indicating moderate cognitive impairment. The resident receives oxygen therapy.On 3/31/26 at 10:00 AM, Resident #131 was observed lying in bed with oxygen via NC. An observation of her O2 concentrator revealed the oxygen flow rate was set at 1.5 LPM. (Photographic evidence obtained)Review of Resident #131's care plan created on 03/22/2026, noted she has O2 therapy related to congestive heart failure. The goal indicated a risk of signs and symptoms of poor oxygen absorption will be minimized through the review date. No interventions were documented. On 3/31/26 at 1:53 PM, Licensed Practical Nurse (LPN) D entered Resident #131's room. She bent down to eye level of the O2 concentrator flow rate and confirmed the flow rate was set at 1.5 LPM. On 3/31/26 at 1:56 PM, LPN D reviewed Resident #131's medical record in Point Click Care (PCC) and reported the resident's O2 order is written for 2 LPM. She reviewed the medication administration record (MAR) and stated that she documented 2 LPM for the resident at 10:19 AM this morning. LPN D was asked to explain her process to ensure residents on O2 therapy receive the correct amount. She stated that she reviews O2 orders and then checks concentrator flow rates to ensure they match. She explained that she checks O2 concentrator rates throughout her shift. Review off the facility's Oxygen Administration policy, Revised: 08/2023, disclosed .Procedure 1. Check physician's order.11. Turn the unit on to the desired flow rate and assess equipment for proper functioning.

Based on interviews and record review, the facility failed implement sufficient safeguards and supervision to prevent one (Resident #1) of four residents reviewed for Activities of Daily Living (ADL) care from an avoidable fall with a subsequent right hip fracture. The facility failed to ensure that staff implemented care plan interventions specifying two-person assistance with ADLs for Resident #1. On January 10, 2026, Resident #1's ADL care was provided by one Certified Nursing Assistant (CNA) rather than by two CNAs as indicated in the resident's care plan. The resident fell out of bed during ADL care and sustained a right hip fracture.Any resident requiring two-person staff assistance was at risk. There were 20 residents who required two-person assistance with ADL care at the time of the survey.The facility's failure created a situation that caused a serious injury to Resident #1 and resulted in the determination of Immediate Jeopardy on February 6, 2026. The Immediate Jeopardy was determined to have been corrected as of January 16, 2026.The findings include: Cross reference F600 A review of Resident #1's medical record revealed an admission date of 09/01/22 with a re-entry on 04/19/23 and subsequent discharge on [DATE]. The resident's diagnoses included cerebrovascular disease (condition that impairs blood flow to the brain, restricting necessary oxygen and nutrients), stage IV sacral pressure ulcer (a severe wound that exposes muscle, tendon or bone), malignant neoplasm of the breast (cancer), palliative care (specialized care for people living with a serious illness, focused on relieving symptoms, pain, and stress), chronic pain syndrome, and atrial fibrillation (AFIB – rapid, irregular heartbeat). A review of Resident #1's Situation, Background, Assessment and Recommendation (SBAR) summary note, dated 01/10/26 at 8:41 AM, revealed that the resident had a fall. Recommendations included: STAT (immediately) right hip x-ray and continue with neurology status check. A progress note dated 01/10/26 at 9:35 AM indicated that the writer spoke with Resident #1 in her room about being transferred to the emergency room (ER) for an evaluation per her son's request. The resident was noted as initially upset about being transferred out of facility, but after a discussion, she agreed to go. Her X-rays were not completed in the facility due to her being transferred to the ER. A review of the 01/10/26 radiology report revealed, mildly displaced right femoral neck fracture with femoral shaft impaction. A nursing progress note dated 1/10/26 at 1:45 PM, revealed that the writer was notified by the ER nurse that the resident had a positive hip fracture. A review of the 01/10/26 hospital emergency department note revealed, While being transferred, patient was dropped by staff as per EMS (emergency medical services). Patient did land on her right hip. Patient does take Eliquis for atrial fibrillation, no known head injury. She is complaining or 4-10 pain to the right hip. Conclusion: Mildly displaced and angulated acute sub-capital fracture of the right femoral neck. A review of Resident #1's active care plan, revised on 10/16/25, revealed that the resident had an ADL Self-Care Performance Deficit related to atrial fibrillation (AFIB – rapid, irregular heartbeat), hypertension (HTN – high blood pressure), overactive bladder, a history of breast cancer, dementia, anemia, and end-stage disease process. The care plan noted that the resident required assistance as follows: Bed Mobility: Substantial/maximal assistance of two. Transfers: Dependent/Total Mechanical Lift/two-person/medium pad. The care plan indicated that the resident was at risk for a fall or a fall-related injury due to impaired mobility and decreased safety awareness. Interventions included: Bariatric mattress, bed in lowest position, bolsters to bed, left side mobility bar, and cue for safety awareness. A review of the CNA task list from 12/10/25 through 01/10/26 revealed that the resident received one-person ADL assistance on 21 of the 31 days reviewed. A review of Resident #1's annual Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 01/06/26, revealed that Resident #1 had a brief interview for mental status (BIMS) score of 14 out 15 possible points, indicating intact cognition. She was noted as dependent with toileting hygiene, bed mobility and transfers. A telephone interview was conducted with CNA B on 02/05/26 at 1:52 PM. She stated 01/10/26 was her first day of work and she was being coached by CNA A that day. When she and CNA A entered Resident #1's room to provide care at approximately 5:15 AM, CNA A asked her to care for resident in bed B while CNA A cared Resident #1. CNA B pulled the privacy curtain in order to provide care to the resident in bed B. As she was providing care, she stated she heard a thud and then CNA A yelled, Oh shit, she is on the floor. When CNA B looked out from behind the curtain, she saw CNA A running toward Resident #1's bed from the doorway of the room. Resident #1 was on her back kind of toward her right side with her head toward the top of the bed. The bed was in the high position. Resident #1 was complaining of right hip pain. CNA A called for the nurse and the nurse came to evaluate Resident #1. CNA A stated she had gone to get the nurse to perform wound care to the resident because her dressing was soiled and she left the resident propped on her side in the bed. When asked if they had reviewed the Kardex prior to entering the room, CNA B stated, no. She added that she was not aware of how to access the Kardex either since this was her first day. She said that after the incident she received training. She further stated the resident was obese and required two people for transfers and bed mobility. A telephone interview was conducted on 02/05/26 at 2:41 PM with Licensed Practical Nurse (LPN) C, who stated she had been employed by the facility for about four years. She further stated she had a permanent assignment unless there was a call out. She confirmed that she was familiar with Resident #1 as she was regularly part of her assignment. She described her as alert and oriented with episodes of confusion. The resident was totally dependent for care by two staff members. LPN C stated she was assigned to Resident #1 on 01/10/26, the date of Resident #1's fall with subsequent hip fracture. She stated at approximately 5:30 AM, CNA A peeked her head out of the resident's door and asked LPN C to get a wound dressing because the resident's current dressing was soiled. As LPN C was getting the dressing, she heard CNA A yell that the resident was on the floor. She immediately ran to the room; the bed was raised. Resident #1 was lying on the floor between the beds. She was on her right side then rolled to her back. Her head was close to the wall, and her hands were on her head. She complained of head pain and stated she hit her head. LPN C assessed the resident (no injuries noted) and assisted her back in bed with the help of three staff and a mechanical lift (Hoyer). Shortly after getting back in bed, the resident complained of pain in her right hip at 10/10 (worst possible pain). The physician and hospice were notified. Review of the facility's policy and procedure titled Comprehensive Person-Centered Care Plan (revised 8/2023), revealed: The center will develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following: 1. The services that are to be provided to attain or maintain the resident's highest practicable physical mental, and psychosocial well-being as required are provided to the resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The facility's immediate actions to remove the Immediate Jeopardy included: The CNA involved with the incident was suspended on 01/10/26 and terminated on 01/12/26. The CNA was reported to the board of nursing on 01/13/26. An ad hoc QAPI (Quality Assurance and Performance Improvement) committee meeting was held on 01/10/26 with the Administrator, Director of Nursing (DON), and Medical Director to review the incident and plan to be implemented. On 01/10/26, Neglect education was initiated and completed verbally by the Staff Development Coordinator (SDC) and Unit Managers (UMs) for licensed nurses and certified nursing assistants related to proper positioning of residents in bed when providing routine care, wound care and repositioning of residents in bed with an emphasis on abuse and neglect. 100% of signatures were obtained prior to the staff's first shift on 01/16/26. Assessments were completed by 01/14/26 by the DON, UMs, MDS (Minimum Data Set) Coordinator, SDC, IPCO (Infection Preventionist), and Rehabilitation Director of residents to determine which residents required assistance with ADL care while in bed, proper positioning during care and the number of people required to assist during care while in bed. A comparison was completed by 01/14/26 by the DON, Ums, MDS Coordinator, SDC, IPCO, and Rehabilitation Director to ensure all residents' care plans and Kardex's accurately reflected the residents' bed mobility needs and the number of staff required to assist the resident. Competencies were initiated on 01/10/26 by the DON, UMs, IPCO and SDC of licensed nurses and certified nursing assistants in providing ADL care and repositioning of residents during ADL care while in bed. Competed 100% by 01/16/26. A second ad hoc QAPI meeting was conducted on 01/12/26 with root cause analysis and discussion. It was determined that no other residents were affected by the deficient practice. The root cause analysis was completed on 01/12/26. The root cause was identified as CNA A's failure to follow Resident #1's plan of care. A third ad hoc QAPI meeting was conducted on 01/15/26 to ensure all components of the QAA(Quality Assessment and Assurance)/QAPI of this incident were addressed and were in substantial compliance as of 01/16/26. The monitoring procedure to ensure that the removal plan was effective and remained corrected/in compliance with the regulatory requirements included: To remain in compliance and under the direction of the Administrator, beginning 01/16/26: Initiated monitoring on 01/16/26 by the NHA (Nursing Home Administrator), DON, UMs, IPCO, SDC, 3-11 Supervisor, and Weekend Supervisor for CNA documentation to ensure it matched the Kardex, that the appropriate number of staff were visualized providing care, and interviews were conducted with the residents, if possible, to ascertain the appropriate number of staff was used to provide care. All newly hired licensed staff and certified nursing assistants to receive education on the process of reviewing the Kardex prior to providing care and using the appropriate number of staff for bed mobility. Verification of the facility's removal plan was completed by the survey team on 02/05/26 and 02/06/26. Interviews were conducted with twelve clinical staff members, who worked across all shifts, as well as facility management, including the Administrator, Director of Nursing, Unit Managers, MDS Coordinators and Rehabilitation Director. Interviews revealed that staff were able to state they had been trained and were knowledgeable about facility policies and procedures regarding care plans, use of the Kardex, required supervision of residents and the required number of staff to care for individual residents. Tours of the facility indicated that safe resident transfers and bed mobility assistance, using appropriate equipment and number of staff to assist, were in place. A review of in-service documentation revealed that 100% of staff had acknowledged education and training related to resident supervision, resident assistance needs and following care plans/Kardex's. Based on verification of the facility's Immediate Jeopardy removal plan, the immediate jeopardy was determined to have been corrected as of 01/16/26.

Based on interviews and record review, the facility failed to ensure the residents' right to be free from neglect by failing to implement sufficient safeguards and supervision to prevent one (Resident #1) of four residents reviewed for Activities of Daily Living (ADL) care from an avoidable fall with a subsequent right hip fracture. The facility failed to ensure that staff implemented care plan interventions specifying two-person assistance with ADLs for Resident #1. On January 10, 2026, Resident #1's ADL care was provided by one Certified Nursing Assistant (CNA) rather than by two CNAs as indicated in the resident's care plan. The resident fell out of bed during ADL care and sustained a right hip fracture.Any resident requiring two-person staff assistance was at risk. There were 20 residents who required two-person assistance with ADL care at the time of the survey.The facility's failure created a situation that caused a serious injury to Resident #1 and resulted in the determination of Immediate Jeopardy on February 6, 2026. The findings of Immediate Jeopardy were determined to have been corrected as of January 16, 2026.The findings include: Cross reference F0689 A review of Resident #1's Situation, Background, Assessment and Recommendation (SBAR) summary note, dated 01/10/26 at 8:41 AM, revealed that the resident had a fall. Recommendations included: STAT (immediately) right hip x-ray and continue with neurology status check. A review of the 01/10/26 radiology report revealed, mildly displaced right femoral neck fracture with femoral shaft impaction. A review of the 01/10/26 hospital emergency department note revealed, While being transferred, patient was dropped by staff as per EMS (emergency medical services). Patient did land on her right hip. Patient does take Eliquis for atrial fibrillation, no known head injury. She is complaining or 4-10 pain to the right hip. Conclusion: Mildly displaced and angulated acute sub-capital fracture of the right femoral neck. A review of Resident #1's active care plan, revised on 10/16/25, revealed that the resident had an ADL Self-Care Performance Deficit related to atrial fibrillation (AFIB – rapid, irregular heartbeat), hypertension (HTN – high blood pressure), overactive bladder, a history of breast cancer, dementia, anemia, and end-stage disease process. The care plan noted that the resident required assistance as follows: Bed Mobility: Substantial/maximal assistance of two. Transfers: Dependent/Total Mechanical Lift/two-person/medium pad. The care plan indicated that the resident was at risk for a fall or a fall-related injury due to impaired mobility and decreased safety awareness. Interventions included: Bariatric mattress, bed in lowest position, bolsters to bed, left side mobility bar, and cue for safety awareness. A review of the CNA task list from 12/10/25 through 01/10/26 revealed that the resident received one-person ADL assistance on 21 of the 31 days reviewed. A telephone interview was conducted with CNA B on 02/05/26 at 1:52 PM. She stated 01/10/26 was her first day of work and she was being coached by CNA A that day. When she and CNA A entered Resident #1's room to provide care at approximately 5:15 AM, CNA A asked her to care for resident in bed B while CNA A cared Resident #1. CNA B pulled the privacy curtain in order to provide care to the resident in bed B. As she was providing care, she stated she heard a thud and then CNA A yelled, Oh shit, she is on the floor. When CNA B looked out from behind the curtain, she saw CNA A running toward Resident #1's bed from the doorway of the room. Resident #1 was on her back kind of toward her right side with her head toward the top of the bed. The bed was in the high position. Resident #1 was complaining of right hip pain. CNA A called for the nurse and the nurse came to evaluate Resident #1. CNA A stated she had gone to get the nurse to perform wound care to the resident because her dressing was soiled and she left the resident propped on her side in the bed. When asked if they had reviewed the Kardex prior to entering the room, CNA B stated, no. She added that she was not aware of how to access the Kardex either since this was her first day. She said that after the incident she received training. She further stated the resident was obese and required two people for transfers and bed mobility. In a joint interview with the Director of Nursing (DON) and the Administrator on 02/05/26 at 4:20 PM, the DON stated the staff were expected to review the residents' Care Plans and Kardex's (summary form used by clinical staff to reference crucial resident information at a glance) prior to providing care. She further stated staff should also conduct change-of-shift rounds to communicate with one another about residents' care needs. Once the care was provided, it should be documented electronically in the residents' records. When the DON was asked about Resident #1's fall on 01/10/26, the DON explained that she received a call from the unit manager indicating that she had been notified by the assigned nurse that the resident had a fall from bed and was complaining of head and leg pain. The unit manager stated the CNA was providing care by herself. The DON was informed that Hospice and the attending physician had already been notified and a new order was obtained for a STAT (immediate) x-ray and neuro checks. The resident's son had also been notified. At approximately 9:17 AM on 01/10/26, the resident's son called the facility and asked that Resident #1 be sent to the hospital for an evaluation. In the afternoon the same day, the hospital nurse confirmed that the resident had a right hip fracture. The resident's family elected not to move forward with surgery as the resident was on palliative care. She passed away a week later. The DON and the Administrator initiated an investigation. The DON stated she interviewed CNA A over the phone. CNA A confirmed that she provided care for Resident #1 by herself. She also confirmed that she had not reviewed the Care Plan/Kardex before providing care. She was suspended pending the outcome of the investigation. On 01/12/26 around 7:30 AM, the DON asked CNA A to come to the facility. The CNA conducted a reenactment of how the incident occurred, revealing that Resident #1 was on her right side holding the mobility bar. The resident's bed was waist high. CNA A walked to the door to ask the assigned nurse to conduct a dressing change because the resident's dressing was soiled. CNA A left the bed waist high with Resident #1 positioned on her side. As CNA A was walking back to the resident from the doorway, the resident's left leg was bending, and the weight of it pulled the resident over the side of the bed to the floor. She landed on her back and rolled to her left side. The resident complained of hitting her head and CNA A yelled for help. During their investigation, the DON and the Administrator stated they identified a systemic issue; CNAs were not documenting the care provided per the care plan. After the 01/10/26 incident, the facility initiated a performance improvement Plan (PIP) on proper positioning during care, wound care and repositioning residents. One of the systemic changes was to conduct a random audit three times a week to ensure residents who required two-person assistance with ADLs received care per the care plan and documentation was completed accordingly. A review of the CNA Job Description revealed essential duties and responsibilities including: Provides personal care and services such as: a) Assisting with activities of daily living (turning and positioning, toileting and elimination, assistive devices, safety and cleanliness, bathing and grooming, feeding, maintaining mobility, nutrition and hydration, reporting abnormal signs and symptoms, data gathering, patient socialization and reality orientation, end-of-life care cardiopulmonary resuscitation and emergency care, postmortem care, residents' rights, documentation of nursing-assistant services. and other tasks that a CNA may perform.) b) Obtains and records vital signs and weight as assigned. c) Accurately documents all care as required by company policy and in compliance with state and federal regulations. Contributes to the resident assessment and care plan. Makes routine rounds on each assigned resident and patient in accordance with established procedures. A review of the facility's policy and procedure titled Abuse and Neglect Prohibition (revised 8/2023), revealed: Policy: Resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, exploitation and misappropriation of property. Definition: Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. The facility's immediate actions to remove the Immediate Jeopardy included: The CNA involved with the incident was suspended on 01/10/26 and terminated on 01/12/26. The CNA was reported to the board of nursing on 01/13/26. An ad hoc QAPI (Quality Assurance and Performance Improvement) committee meeting was held on 01/10/26 with the Administrator, Director of Nursing (DON), and Medical Director to review the incident and plan to be implemented. On 01/10/26, Neglect education was initiated and completed verbally by the Staff Development Coordinator (SDC) and Unit Managers (UMs) for licensed nurses and certified nursing assistants related to proper positioning of residents in bed when providing routine care, wound care and repositioning of residents in bed with an emphasis on abuse and neglect. 100% of signatures were obtained prior to the staff's first shift on 01/16/26. Assessments were completed by 01/14/26 by the DON, UMs, MDS (Minimum Data Set) Coordinator, SDC, IPCO (Infection Preventionist), and Rehabilitation Director of residents to determine which residents required assistance with ADL care while in bed, proper positioning during care and the number of persons required to assist during care while in bed. Competencies were initiated on 01/10/26 by the DON, UMs, IPCO and SDC of licensed nurses and certified nursing assistants in providing ADL care and repositioning of residents during ADL care while in bed. Competed 100% by 01/16/26. A second ad hoc QAPI meeting was conducted on 01/12/26 with root cause analysis and discussion. It was determined that no other residents were affected by the deficient practice. The root cause analysis was completed on 01/12/26. The root cause was identified as CNA A's failure to follow Resident #1's plan of care. A third ad hoc QAPI meeting was conducted on 01/15/26 to ensure all components of the QAA(Quality Assessment and Assurance)/QAPI of this incident were addressed and were in substantial compliance as of 01/16/26. The monitoring procedure to ensure that the removal plan was effective and remained corrected/in compliance with the regulatory requirements included: To remain in compliance and under the direction of the Administrator, beginning 01/16/26: Initiated monitoring on 01/16/26 by the NHA (Nursing Home Administrator), DON, UMs, IPCO, SDC, 3-11 Supervisor, and Weekend Supervisor for CNA documentation to ensure it matched the Kardex, that the appropriate number of staff were visualized providing care, and interviews were conducted with the residents, if possible, to ascertain the appropriate number of staff was used to provide care. All newly hired licensed staff and certified nursing assistants to receive education on the process of reviewing the Kardex prior to providing care and using the appropriate number of staff for bed mobility. Verification of the facility's removal plan was completed by the survey team on 02/05/26 and 02/06/26. Interviews were conducted with twelve clinical staff members, who worked across all shifts, as well as facility management, including the Administrator, Director of Nursing, Unit Managers, MDS Coordinators and Rehabilitation Director. Interviews revealed that staff were able to state they had been trained and were knowledgeable about facility policies and procedures regarding care plans, use of the Kardex, the definition of neglect, and the required number of staff to care for individual residents. Tours of the facility indicated that safe resident transfers and bed mobility assistance, using appropriate equipment and number of staff to assist, were in place. A review of in-service documentation revealed that 100% of staff had acknowledged education and training related to neglect, resident supervision, resident assistance needs and following care plans/Kardex's. Based on verification of the facility's Immediate Jeopardy removal plan, the immediate jeopardy was determined to have been corrected as of 01/16/26.

Based on observation and interview, the facility failed to store and distribute food and beverages in a safe and sanitary manner to prevent foodborne illness, by failing to maintain a proper cold holding temperature of milk on the tray line to be supplied to residents and food held in a reach-in refrigerator. The facility also failed to maintain one (East Wing Nourishment Room) of three ice machines used for residents in a safe and sanitary manner. The findings include: 1. During an observation of the kitchen on 12/1/2020 at 11:30 AM, the cook was observed taking the temperatures on the tray line. During the tray line observation, the cook was asked to take the temperature of a small container of milk located in a grey plastic container in front of the tray line. The Assistant Food Service Manager took the half-pint carton of milk and used the facility thermometer to test the temperature of the milk. The temperature was 50 degrees Fahrenheit (F). She obtained a second half pint of milk from the plastic container and tested the milk at 45 degrees F. She obtained a third carton of milk and tested it at 47 degrees F. She was asked to check the calibration of the facility's digital thermometer. She put the thermometer in a cup of ice with a small amount of water and pulled the thermometer out when it reached 32.5 degrees. She retested the temperature of the three cartons of milk and they were at 50 degrees F, 45.2 degrees F and 46 degrees F. During an interview with the Assistant Food Service Manager on 12/1/2020 at 11:45 AM, she confirmed the findings. She stated they normally put the milk and juice in the plastic container and poured ice over it. She stated she did not know what happened today. During another observation of the kitchen on 12/3/2020 at 11:50 AM, the Assistant Food Service Manager was asked to take the temperature of a cold item in the reach-in refrigerator. She took out a package of sliced deli ham dated 12/3/2020, that was wrapped in clear plastic wrap in a plastic bag. She tested the temperature of the ham using a facility digital thermometer. The ham tested at 50.3 degrees F. The Assistant Food Service Manager was asked if the ham was heated prior to being placed in the refrigerator. She stated it was a package of deli ham that was taken out of the refrigerator and sliced for use for lunch today. She stated the ham placed back in the refrigerator was not heated. She stated it had been back in the refrigerator for 30-45 minutes. She did not know how long it was out of the refrigerator. She was asked to check the calibration of the thermometer. The Kitchen Manager was in the area and tested the thermometer in ice/water and it registered at 32 degrees. 2. During an observation of the East Wing nourishment room on 12/03/2020 at 9:17 AM, an observation was made of the inside of the ice machine. There was a black substance observed across the evaporator (white plastic bar) that ran across the back of the inside of the ice bin. There was water condensation dripping from the bar onto the ice. (Photographic evidence obtained) During an interview with the East Wing Unit Manager on 12/03/20 at 9:20 AM, she was asked who maintained the ice machine in the nourishment room. She stated the responsibility was shared between housekeeping and maintenance. She was asked to observe the inside of the ice machine. The East wing Unit Manager went into the nourishment room on 12/3/2020 at 9:21 AM and looked inside the ice machine. She confirmed the findings. A paper towel was then run across the white bar in the back of the ice machine and some of the black substance transferred to the paper towel. The Maintenance Manager joined the observation and stated he would clean the ice machine.

Based on interview and record review, the facility failed to make prompt efforts to resolve a grievance related to lost items and reported to staff for one (Resident #70) of 30 sampled residents. The findings include: During an interview with Resident #70 on 11/30/2020 at 12:30 PM, she stated she had several dark clothing items that did not come back from laundry and that she really needed the items since it would be getting cold. She stated her name was written inside the items, but they were dark blue items so maybe her name was not seen. The three items were a navy pair of pants with a peach tribal design, a navy shirt with palm trees and a pair of navy flannel pants with stripes. She stated one of the staff members she told about the missing items was a certified nursing assistant (CNA), Employee C, who worked at night. She stated the items had been gone for at least a couple of weeks. A review of Resident #70's clinical record revealed she was admitted to the facility on [DATE]. A review of her admission minimum data set (MDS) assessment revealed she had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points, indicating no cognitive impairment. A review of the grievance log for November 2020 found no grievances for Resident #7 and no grievances about missing clothing for the most recent three months. During an interview with Resident #70's nurse (Employee A) on 12/2/2020 at 8:24 AM, she was asked about the process for missing items. She stated for missing clothes, first they would get a description of the item. Then they would go to the laundry and look for it. If the item was not located, they would notify the Unit Manager or Social Services. Employee A was asked how long after not finding the item in the laundry she would wait to tell the Unit Manager or Social Services. She stated it would be the same day, within hours. She was asked if she was aware of whether Resident #70 was missing any items. She stated she was not. During an interview on 12/02/20 at 8:47 AM with the West Wing Unit Manager, she was asked if she was aware that Resident #70 had missing clothing. She stated she was not aware. During an interview on 12/02/2020 at 8:53 AM with Resident #70's CNA (Employee B) he stated he was not aware the resident was missing clothing. During an interview on 12/02/2020 at 9:39 AM with the Social Service Director (SSD), she stated she was informed on 12/2/2020 that Resident #70 had missing clothing. She stated she spoke with Resident #70 and reviewed her inventory sheet. The items the resident mentioned were not on it. She stated she checked the laundry and the items were not found. She stated they would probably be reimbursing the resident and she would speak with Employee C about reporting missing items. During further interview with the SSD on 12/02/20 11:44 AM, she stated she spoke with the CNA (Employee C) and the CNA informed her that Resident #70 told her she had missing clothing. The SSD stated the CNA told her that Resident #70 informed her three things were missing and all, but two came back from laundry. The SSD stated the CNA informed Resident #70 she would go to the laundry to look for the item and she did not. The SSD confirmed the CNA (Employee C) did not tell anyone about the missing items.

Based on observation, staff interviews and record review, the facility failed to ensure leftover food saved in the facility's refrigerator to be served to residents later was cooled in a safe and sanitary manner. The facility also failed to ensure the emergency food supply did not contain expired food items. These failures could result in foodborne illness for the 111 residents that were residing in the facility. The findings include: 1. During an interview with the Kitchen Manager/Certified Dietary Manager on [DATE] at 9:50 AM, he was asked if the facility kept leftover food. He stated the facility kept some leftovers, and may keep them up to three days. He was asked if he had logs for staff or procedures for staff to follow in order to ensure that hot items were cooled to a safe temperature. He stated he did not have anything posted and would find something to provide to the staff. He was asked to take the temperature of a hot item that was a leftover from the previous day and stored in the refrigerator. He pulled out chicken noodle soup that was in a frosted plastic container approximately ,[DATE] inches in diameter and height. Observation of the container found it was full of noodles and a yellow very thick broth. The Kitchen Manager took the temperature of the soup using a digital thermometer. The temperature flashed 42.4, 42.5 and 43.4 degrees as he moved it around the container. The Kitchen Manager obtained a second thermometer and tested the temperature. The temperature this time was at 43.2 degrees. The Kitchen Manager took the container and asked a staff member to dispose of it. During an interview on [DATE] at 10:20 AM with a dietary staff member and cook (Employee J), she was asked to explain how she would cool hot foods from the tray line that the facility was going to keep as leftovers. She stated she would remove the item from the tray line. She would put the item in one of the containers and pointed to the shelf where there were plastic and metal containers. She stated she would place the container on the counter and wait for it to cool before putting it in the refrigerator. She was asked if she would test the temperature and she stated 'yes'. She was asked at what temperature she would consider it safe to put the food in the refrigerator and she stated 150°. She was asked what temperature she wanted the food to be at to be safe in the refrigerator, and she stated 140 degrees. She was asked several times and she continued to state 140 degrees. The interview was witnessed by the Kitchen Manager, and he stated he would train the staff. The temperature taking and the interview was observed by the Registered Dietician (RD), Employee H. On [DATE] at 12:23 PM, the RD (Employee H) provided a policy for cooling and reheating foods. A review of the procedures under '1' found the following under Cooling Foods: Rapidly cool all potentially hazardous food requiring refrigeration after preparation to an internal temperature of 41 degrees Fahrenheit or below within six hours or less. The total cooling time may not exceed 6 hours. The procedure instructed staff to place food in 2 inch deep pans, chill from 140 degrees to 70 degrees in the first two hours, and chill from 70 degrees to 41 degrees or below in the next four hours. Take and record temperatures every 30 minutes to assure temperatures are decreasing according to the above schedule. 2. During an observation of the facility's emergency food supply with the Kitchen Manager and the Registered Dietician (RD) on [DATE] at 10:30 AM, several large boxes were observed with evaporated milk. The boxes were marked with a date received in (YEAR). The boxes were opened to determine when the evaporated milk would expire. The milk had a code on each can with the following information (6 310 5332 10 and ,[DATE] 09:25) The RD and the Kitchen Manager were both asked if they knew when the milk would expire. They did not. The RD stated she would contact the manufacturer. During a second interview with the RD on [DATE] at 12:23 PM, she stated she called the manufacturer and read off the information and was told the milk expired the end of November. She was asked if she obtained any information the facility could use to determine when items with a code versus an expiration date would expire and she stated, No.

Based on observations, record reviews and interviews, the facility failed to follow standard precautions to prevent the spread of infections by not changing a pressure ulcer dressing appropriately for one (Resident #36) of 10 residents with a pressure ulcer out of 35 sampled residents. The findings include: A clinical record review was conducted for Resident #36, which revealed an admission date of [DATE] and the following Diagnoses: [REDACTED]. Resident #36 was admitted to Hospice for end-stage cerebral [MEDICAL CONDITION] on 10/25/18. A review of the Minimum Data Set (MDS) assessment, a Significant Change dated 10/31/18, revealed that in Section M, the resident was recorded as having a Stage IV pressure ulcer that was acquired while in the facility. A review of the physician's orders [REDACTED]. The physician's 11/28/18 wound care notes were reviewed, and noted a Stage IV to the left ischium for 957 days. A review of a History and Physical, dated 3/6/18, noted a chronic sacral wound. An observation was made of Resident #36 on 12/17/18 at 12:17 PM. The resident was observed lying on an air mattress and was positioned with pillows. An observation of a dressing change was conducted at 2:29 PM on 12/18/18 with Employee F, Registered Nurse (RN). RN F reported that Resident #36 received pain medication at 2:00 PM. The RN cleaned the bedside table with a bleach wipe, placed supplies wrapped in aluminum foil on the bedside table, and washed her hands. She donned gloves, removed the old dressing, and cleaned the open wound with normal saline. She removed her gloves, washed her hands, donned new gloves, applied Santyl, Calcium Alginate, and a dry dressing that was dated and initialed. An interview was conducted with RN F at 2:50 PM on 12/18/18. She was asked about removing the soiled dressing and cleaning the wound with normal saline at the same time without washing her hands or donning new gloves. She confirmed she did clean the wound with normal saline at the same time the old dressing was removed without changing her gloves or washing her hands first. The RN stated, I take the dirty out before the clean dressing is applied, and reported this is what she usually did. A policy and procedure for dressing changes was requested from the Director of Nursing ( DON) on 12/18/18 at 2:55 PM. A review of the policy and procedure for Clean Dressing Change, revised 11/28/17, reported under Procedure 19-23: Remove used dressing and place in trashcan, remove gloves, hand hygiene, don gloves, cleanse wound as ordered with single outward [MEDICAL CONDITION] and using separate gauze for each cleansing wipe. An interview was conducted with the DON on 12/20/18 at 3:13 PM concerning the observation of the dressing change for Resident #36. The DON stated that education was provided to the RN and the policy and procedure was reviewed. The resident's physician and the wound care physician were notified.

Based on observation, interviews and record review, the facility failed to ensure it provided restorative services for one (Resident #22) of one residents sampled for restorative care provided, out of a total sample of 35 residents. This placed resident #22 at risk for functional decline. The findings include: During an initial tour of the facility on 12/17/18 at 10:58 AM, Resident #22 was observed in a wheelchair in the center of his room. An interview was conducted with the resident at this time. He was alert and oriented, and was observed with a weak (flaccid) left upper and lower extremity. He reported that he kept getting kicked off of the physical therapy (PT) rehabilitation program. During the interview, Resident #22 expressed concerns with staff not assisting him to ambulate. An observation was made on 12/19/18 at 9:52 AM of Resident #22 in his room, sitting in a wheelchair. He was leaning back with his eyes closed. The television was on. An interview was conducted with Employee A, Rehabilitation Program Manager, on 12/19/18 at 2:45 PM. She stated Resident #22 was admitted on [DATE], and this was when he was first seen in rehab. She confirmed that Resident #22 had previously suffered a stroke and required rehabilitation services. The resident was on rehab until 1/11/2015. The rehab discharge summary was reviewed. The base line was Maximum Assist. The resident completed the therapy and was a minimum assist, which documented improvement. Resident #22 required 90% verbal cuing at the beginning of therapy, also identified as the Baseline. At the end of the first therapy on 1/11/2015, Resident #22 required only 20% verbal cuing with minimum assist from supine to sit. Transfers at baseline was documented as totally dependent on 10/04/2014, and Resident #22 required 90% verbal cueing while moving from a sitting to a standing position. At the end of the treatment on 1/11/2015, Resident #22 progressed to stand-by assist with 5% cueing. Ambulating at baseline was documented as could not walk at all. At baseline, Resident #22 could walk zero feet. At the end of treatment, Resident #22 was ambulating 60 feet with 20% verbal cueing and contact guard assist with a hemi walker. The rehab manager confirmed that Resident #22 was last in physical therapy from 9/07/2018 through 10/05/2018. Employee A was interviewed again on 12/19/18 at 3:05 PM, and confirmed that Resident #22 was referred to restorative nursing to Ambulate in hallway with Hemi)/walker x 2 person assist on 10/06/2018. Employee A confirmed that Resident #22 was discharged from rehab services on 10/05/2018 with a documented baseline sit to stand, transfer and pivot transfer decline identified. Ambulation; Baseline maximum assist stand pivot transfer 50% verbal cueing; upon completion minimum assist with 25% verbal cueing. Then on ambulation, 10 feet with 50% verbal cueing and maximum assist with Hemi Walker. When therapy was completed, Resident #22 was walking 30 feet with 25% verbal cueing and minimum assist using the hemi-walker. Employee A confirmed that Resident #22 was supposed to complete therapy with restorative staff. The last documented PT treatment for [REDACTED]. An interview was conducted with Employee D, Nurse Manager, on 12/19/18 at 3:58 PM. Employee D reported she was the nurse leader over the restorative nursing program, but that Employee C, Certified Nursing Assistant (CNA) ran the restorative program, caring for the residents and had an nursing assistant aide. Employee D stated that Resident #22 was in two programs, including ambulation with the Hemi-walker, and she confirmed that he had splinting. An interview was conducted with Resident #22 on 12/20/18 at 9:25 AM. He reported he did not walk this week with restorative. The Hemi-walker was observed in the room near the wall. The resident pointed to it and stated that was what the restorative aide used to work with him. Employee C, Restorative CNA, was observed and interviewed on 12/20/18 at 9:31 AM. She reported she was at the facility for the survey on Tuesday, Wednesday and Thursday. She reported she did put the splint on the resident on Tuesday and Thursday, but not on Wednesday. Yesterday, she was called to cover a resident group for 30 minutes. She also covered wound care rounds with the wound care doctor and wound care nurse and depending on admissions, she did the admission weights. Employee C reported that Resident #22 required a 2-person assist. Resident #22 must ambulate, required help and took time to ambulate. She reported Resident #22 had not ambulated at any time this week with restorative. She stated she was the only restorative aide, and she did not have any help. She stated she had to use the wheelchair and needed 1 - 2 people to stand-by for safety and assistance. She reported that there was no ambulation last week either for the same reasons. Since the resident had been on restorative in (MONTH) (YEAR), Resident #22 had not been ambulated. She further stated she alerted the Director of Nursing and Unit Manager that Resident #22 required two staff members to participate in the program, and reminded them at scheduled meetings that she had with Employee D and the Director of Nursing. She stated she had documented evidence supporting the report of her concerns, however she was told that she could not provide that information for review. Another interview was conducted with Resident #22 on 12/20/18 at 10:03 AM. He confirmed it had been over a month since he had ambulated with facility staff. He confirmed that he wanted to ambulate. An interview was conducted with the DON on 12/20/18 at 10:19 AM. She was asked about her knowledge of the restorative program. She confirmed Employee D oversaw the program and reported that she tried not to move staff from their responsibilities with restorative, but it could happen. She stated that Employee C did not address specific concerns and had been instructed that if the restorative nurse aides could not work with a resident, they were to contact the resident's nurse aide for help. The DON was asked to provide the note Employee D signed confirming that Employee C stated she needed assistance with Resident #22 specifically. This documentation was never provided. An interview with Employee C was conducted on 12/20/2018 at 10:45 AM, and she reported that she was instructed not to provide the note for review. She stated, They are my boss and you are the surveyor. An interview was conducted with Employee D on 12/20/2018 at 10:49 AM while reviewing the printed 20-page care plan for Resident #22. Employee D confirmed the restorative program care plan indicated it was to be carried out three times a week as tolerated. She reported that the last time she saw Resident #22 walk was a month ago. Employee D stated Resident #22 should be ambulating three times a week. She further stated that restorative was offered at least three times a week, and no refusals had been documented. She met with the restorative aide weekly, and Employee D signed off on the notes weekly. The weekly notes were reviewed for the months of (MONTH) and (MONTH) (YEAR). There was no documentation of concerns, refusals or treatment not being provided to Resident #22. Employee D, Unit Manager, was interviewed again on 12/20/18 11:55 AM. She confirmed that the review of the restorative activity, dated (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR), for Resident #22 included instructions to ambulate in the hallway with a hemi-walker as tolerated. She also confirmed that it was documented it did not occur for all dates and/or was not documented, except for one of the days reviewed, on Friday (MONTH) 12, (YEAR). Employee D stated she should have been reviewing and questioning the first month that this activity was not performed in (MONTH) (YEAR). She stated the activity was not being done, the activity was documented as not having occurred, and that was unacceptable. An interview was conducted with Resident #22 on 12/20/18 at 3:09 PM. He confirmed that it was the first time in a long time that they got me up and walked with me using the walker. He stated it had been about a month. He stated he walked in physical therapy, but had only walked one time since physical therapy ended. A review of resident #22's care plan (Pages 1-20) revealed it was initiated on 10/08/2018: Self Care deficit related to (r/t) acute ischemic [MEDICAL CONDITIONS] with left (L) sided [MEDICAL CONDITION]. Left sided neglect. The documentation included Left Ankle Foot Orthosis as needed during gait training with restorative nurse program (RNP) Certified Nurse Aide (CNA). There was no specific care plan provided to address the physical therapy discharge recommendations dated 10/08/2018 at 3:47 PM to Facilitate patient maintaining current level of performance in order to prevent decline, development of and instruction in the following Restorative Nursing Program (RNP) has been completed with the Interdisciplinary Team (IDT): Ambulation. The care plan only included a documented Focus Area of Increased tone and decreased AROM (active range of motion) in LUE (left upper extremity), initiated on 10/10/2018. A review of the Restorative Nursing Program, dated 10/05/2018, for Resident #22 documented the resident's problem was Decreased safety with Transfers and Ambulation. Goals were documented as Ambulated with a hemi-walker and left Ankle Foot Orthosis (AFO) with minimum of two people x 40 feet or longer. Program note documented, Ambulate in hallway with hemi-walker as tolerated. Frequency/Duration was documented as Daily as tolerated. Additional comments entered Patient (Pt.) would like to be able to ambulate from bedroom to the end of the hall. A review of the Restorative program list provided for the weeks of 12/06/2018 and 12/13/2018, included Resident #22's name with the documented restorative intervention: Ambulate with hemi-walker X 2 person 10/06/2018. Also documented by Employee D on 10/09/2018, Add tasks required to resident's Plan of Care, edit care plan interventions to include items in Kardex, and complete progress notes monitoring program. A review of the task documentation was conducted for Resident #22. It was documented for task, Ambulate in hallway with hemi-walker as tolerated with a look back of 14 days from 12/07/2018 to 12/19/2018 and did not occur. A review of the Documentation Survey Report v2 for Resident #22 including October, (MONTH) and (MONTH) of (YEAR), revealed that Resident #22 under the Ambulate in hallway with a hemi-walker as tolerated was documented for code '8' for all dates beginning (MONTH) 09, (YEAR) through (MONTH) 19, (YEAR), except for (MONTH) 25, (YEAR) (left blank) (MONTH) 02, (YEAR), (MONTH) 09, (YEAR), (MONTH) 12, (YEAR), (MONTH) 19, (YEAR), and (MONTH) 04, (YEAR) (which were left blank). An interview with Employee C and Employee D confirmed that the resident did not receive the restorative intervention as intended. A review of the staffing assignments from (MONTH) 14, (YEAR) to through (MONTH) 19, (YEAR), with dates missing 11/05/2018, 11/12/2018, 11/15/2018, 11/19/2018 and 12/04/2018, did not support consistent restorative nursing aide coverage through all dates reviewed, or the restorative care that was supposed to be provided/offered to Resident #22 was not provided/offered.

Based on observations, interviews and a review of the policy and procedure, the facility failed to provide nail care for one (Resident #36) of 35 sampled residents. This resident had a contracture of the left hand causing the long nails to press into her palm, placing her at risk for pain, impaired skin integrity and infection. The findings include: A medical record review was conducted for Resident #36 which reported an admission date of [DATE], and the following Diagnoses: [REDACTED]. The resident was admitted to Hospice for end-stage cerebral [MEDICAL CONDITION] on 10/25/18. A review of the Minimum Data Set (MDS) assessment, a Significant Change assessment dated [DATE], revealed under Section G that the resident required extensive assistance with bed mobility and eating, and total assistance with transfers, toileting, and bathing. Under Section C of the MDS, the resident was checked as having moderately impaired cogntion. A review of the physician orders [REDACTED]. On 12/20/18 at 8:30 AM, Resident #36 was observed in bed with the head of the bed elevated. She was being fed breakfast by a Certified Nursing Assistant (CNA). The resident's nails were observed over one inch long, bending inward on the right hand. The left hand was under the covers. An interview was conducted with the resident at 9:00 AM on 12/20/18. She was asked about her long fingernails, and she reported she did not like them. She wished someone would cut them. The resident was asked to pull her left hand out from under the covers for observation. It was contracted and was observed with three of the middle fingers bending inward and pressing into the palm of her hand. Redness and indentations were observed underneath of the fingers in the palm of her hand. An interview was conducted with Employee G (CNA) at 10:00 AM on 12/20/18 in the resident's room. The CNA was starting to provide activities of daily living (ADL) care. She was asked about the resident's long nails (over 1 inch long), and reported that the nurses cut the residents' nails. The CNAs were not permitted to cut fingernails, but could file them. CNA G confirmed the resident's nails were long and stated she would notify the nurse. An interview was conducted with Employee C, Restorative CNA, on 12/20/18 at 10:28 AM. Employee C reported that she applied the splint to the resident's left hand due to a contracture. She confirmed she was aware of the long fingernails, and that they were pressing into the palm of the left hand. She reported she was not permitted to cut fingernails. CNA C stated the nurses were notified over the last two weeks that the resident's nails were very long and were pressing into the palm of her left hand. CNA C could not remember which nurses she told. An observation was made of the resident sitting in the wheelchair in her room on 12/20/18 at 10:30 AM. Employee F, Registered Nurse (RN), was in the room and confirmed the long fingernails on both hands. She further confirmed the left hand fingernails were pressing into the resident's palm. The palm was red with indentations where the fingernails were pressed into the palm of the hand. The resident was alert and requested that staff cut her nails. On 12/20/18 at 11:00 AM , Employee F, RN, was observed propelling the wheelchair for Resident #36 and taking the resident out of her room. Her fingernails had been cut. The policy and procedure for 'Resident AM and PM care', revised 2/20/18, was reviewed and revealed the purpose was to facilitate resident's overall comfort, cleanliness, grooming and well being. The policy and procedure for Resident Care, Fingernail Care, was reviewed and revealed the care of the fingernails promoted circulation to the hands and helped prevent small tears around the nails that could lead to infections.

Based on observation, interview and record review, the facility failed to ensure care was provided in a dignified manner for two (Residents #88 and #100) of four residents reviewed for dignity in a sample of 35 residents. The findings include: 1. On 12/17/2018 at 9:15 AM, Resident #88 was observed being pushed in a wheelchair out of his room by Employee I, Certified Nursing Assistant (CNA). CNA I was asked where she was taking Resident #88. She stated she was taking him to the therapy gym. Resident #88 was heard saying, I don't want to go. He stated several times that he did not want to go. He lifted his shirt to show his pants were wet, and he continued to hold the shirt up so it would not touch his pants. Observation of the resident's pants found they appeared wet, as the area in the front appeared darker than the rest of the pants. CNA I was asked why she was taking Resident #88 to therapy when his pants were wet. She stated she could not leave him alone in the room; she would need to go to the laundry room to get clean pants. CNA I was asked whether she could ask the nurse, who was standing a few feet away at the medication cart, to supervise Resident #88 until she returned. She asked the nurse and left the resident to go to the laundry room to get a pair of pants. Resident #88 continued to hold his shirt up until CNA I returned. A review of Resident #88's clinical record revealed an admission date of [DATE]. The 14-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #88 had short- and long-term memory problems. The resident needed extensive one-person assistance for bed mobility, transfers, dressing, and toilet use. During an interview with Resident #88's nurse (Employee E), on 12/19/18 at 9:47 AM, she stated she recalled CNA I asking on 12/17/2018 if she would watch Resident #88 while CNA I went to get him clean pants. She stated she was not aware the CNA was going to take Resident #88 to the therapy gym with wet pants. She further stated had she known that, she would have told her to go to the laundry room herself. You should never take a resident anywhere with wet pants. During an interview with the West Wing Unit Manager on 12/19/18 at 11:18 AM, he stated he and the Director of Nursing (DON) called CNA I. He stated the CNA confirmed Resident #88 was wet. She did not want to leave the resident alone, so she was taking the resident to therapy. He stated CNA I was educated. She was told that she should have gotten someone to stay with the resident. Pushing him out of his room with wet pants was a dignity issue. CNA I agreed. 2. An observation of Resident #100 was made on 12/17/18 at 9:06 AM. The resident was sitting at the threshold of the doorway, just inside his room. A clear urinary catheter tube was observed emerging from the bottom of one of his pajama-style long pants. The tube looped at the resident's ankles and ran up the other pants leg. The tubing was filled with yellow urine, and was visible to anyone walking the hallway. Resident #100 was observed again on 12/19/18 at 9:19 AM in his room. He was seated in a wheelchair at the door and was wearing a shirt, but had a disposable yellow gown draped across his thighs and knees. The catheter tube was observed running down the length of his bare left leg and dragging on the ground underneath of the wheelchair. A urine collection bag could be observed underneath the wheelchair. There was no dignity cover concealing the urine collection bag. Anyone walking in the hallway could have easily seen the exposed and dragging tubing, as well as the uncovered bag. An interview was conducted with Employee K, Certified Nursing Assistant (CNA), on 12/19/18 at 10:07 AM. When asked about Resident #100's urinary catheter, she stated she performed peri-care, and emptied the urine collection bag for Resident #100. She stated there was a green tab that hooked the catheter tubing to the chair and then into the dignity bag. She further stated she had put it on this morning. Resident #100 was observed on 12/20/18 at 9:40 AM, sitting at the threshold of the door to his room. He was observed in shorts, with the catheter tubing emerging from the shorts down the left leg. The tubing ran down between his legs and under the chair to the uncovered catheter bag. The resident was asked about the observations of the exposed and dragging tubing and uncovered urine collection bag. He stated he wished the staff would clip the bag further back under the chair so nobody could see the tubing and bag. The resident said he hated that, and that it was embarrassing. There used to be a cover for the bag, but it got a hole in it and they threw it away. Resident #100 asked whether this writer could get him another cover and ask the staff to conceal the bag better. A record review for Resident #100 revealed a 14-day Minimum Data Set (MDS) assessment, with an assessment reference date of 12/11/18. Resident #100 had a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15 points, indicating intact cognitive skills. The resident's inattention fluctuated, and he required extensive assistance of one staff member with dressing and hygiene. Resident #100 had an indwelling urinary catheter, and was frequently incontinent of bowel. [DIAGNOSES REDACTED]. Resident #100 was care planned on 11/27/18, with a revision made on 12/4/18 for [MEDICAL CONDITION] with urethral stricture and urinary outlet obstruction. The goal was to be free from signs and symptoms of urinary tract infections and other complications related to the catheter. Approaches included to change the catheter monthly and as needed for blockage or dislodgement, ensure proper positioning of the drainage tube at all times, and keep the drainage bag below his waist. Attach a leg bag when out of bed per resident preference, and keep the bag covered at all times. Position/secure the tubing to prevent traumatic removal. Resident #100 had a physician's orders [REDACTED]. An interview was conducted with Employee L, Licensed Practical Nurse, on 12/20/18 at 10:02 AM. She stated Resident #100 had a suprapubic catheter. She stated the tubing should be secured by a leg strap, and when out of the room, the resident should have a strap securing the tubing to his leg. She did not know why the resident did not have a cover in place for the urine collection bag, but he was supposed to if he was out of his room, or used the leg bag. She acknowledged the tubing was dragging on floor and the bag was visible to all who passed by in the hallway. She was told Resident #100 expressed that he was embarrassed. LPN L stated she would look into the bag cover. She was not sure why one was not in use. An interview with Employee M, Unit Manager, on 12/20/18 at 12:27 PM, revealed Resident #100 had a suprapubic catheter and a closed system. The resident had a leg urine collection bag for use. The catheter tubing should be clipped out of the way. Dignity covers were available for urine collection bags. Employee M was not aware Resident #100's tubing had been dragging on the floor during the observation on 12/19/18 at 9:19 AM. He confirmed that was an infection control concern. He acknowledged the tubing and bag were visible to all in the hallway, because Resident #100 was positioning himself in the doorway frequently throughout the day. Employee M stated he would look into a cover for the dignity concern.

Based on observations and interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary and clean environment for six (6) (rooms 167, 168, 162, 120, 117 and 115) out of 10 bathrooms observed. The findings include: On 7/25/18 at 9:17 a.m., a tour of the facility commenced and revealed the following concerns: room [ROOM NUMBER] had a brown substance (resembling soil/grime) in the corners in the bathroom doorway. The toilet seat riser that was placed over the toilet was noted to have visible rust on the leg. The paint on the bathroom doorjamb was peeling off. The bottom of the bathroom door was soiled and had peeling paint. In room [ROOM NUMBER], there was a soiled plunger in the corner of the bathroom. The plunger was not bagged or covered. The paint on the doorjamb was peeling off. In room [ROOM NUMBER], the paint on the doorjamb was peeling off. The closet door was noted with build up along the bottom of it (resembling soil/grime). The bathroom door was soiled and was missing pieces of the wood veneer. room [ROOM NUMBER] had a brown substance on the wall (resembling fecal matter). In room [ROOM NUMBER], the scald guard was lying on the floor under the sink, an unbagged and unlabeled bed pan was resting on the handrail behind the toilet, and a brown substance (resembling fecal matter) was observed on the wall. In room [ROOM NUMBER], an unbagged and unlabeled bed pan was resting on the handrail behind the toilet, and a brown substance was observed on the wall (resembling fecal matter). The paint on the bathroom doorjamb was peeling off. Photographic evidence was obtained for all concerns identified above. On 7/25/18 at 3:44 PM, an interview was conducted with the Maintenance Director, and he walked from room to room confirming all of the above-mentioned concerns. He stated that the housekeeping department was contracted in, and that he would walk around first thing in the morning with the Housekeeping Supervisor and Administrator and get all of the concerns addressed in all of the rooms. He was then asked about the plunger in room [ROOM NUMBER], and he stated that someone used it over the weekend and just forgot to put it back in the soiled utility room.

Based on record reviews, interviews, and observations, the facility failed to provide an accurate comprehensive assessment for one resident reviewed for vision and hearing services (Resident #69), and for one resident reviewed for Hospice services (Resident #61). The findings include: 1. Resident #69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident #69 had adequate vision with no corrective lenses and adequate hearing with no assistive devices. A review of the MDS assessment dated [DATE], revealed adequate vision with no corrective lenses and adequate hearing with no assistive devices. A review of the Care Plans dated October 18, 2017, revealed no plan of care for impaired vision, even though Resident #69 had a [DIAGNOSES REDACTED]. There was no plan of care for impaired hearing. A review of the progress notes revealed no information related to the resident's vision or hearing abilities/deficits. A review of the assessments revealed no information related to inadequate vision or hearing. A review of the physician's orders [REDACTED]. On December 4, 2017 at 1:07 PM, an interview with Resident #69 revealed the resident was blind and had a hard time hearing. The resident instructed the surveyor to speak into the left ear. On December 7, 2017 at 11:49 AM, an interview with Employee C, Resident Care Specialist, revealed it was her responsibility to ensure the MDS was coded correctly to meet the needs of the resident. She stated the MDS should be coded correctly upon admission. If a mistake was made, it could be corrected when the error was found. She also stated that the care plan was generated from the data entered in the MDS, and when an error was found, the care plan was also corrected. She stated that the facility attempted to catch errors as quickly as possible. She also stated therapy would sometimes make notes and put into place any devices to assist the resident. She also confirmed the MDS indicated the resident had adequate vision with no corrective lenses, and there was no plan of care in place for vision or hearing. She also confirmed therapy did not put into place assistive devices for inadequate vision or the resident's impaired hearing. On December 7, 2017 at 12:11 PM, an interview with Employee E, Certified Nursing Assistant (CNA), revealed the resident had an issue concerning eyesight and when handing the resident items, one needed to tell the resident where it was. She stated the resident did not have assistive devices to help with vision other than her corrective lenses. The resident wore glasses that helped keep the eyes from straining and from pain. She stated the resident told her she needed to speak into the left ear because of difficulty hearing. On December 7, 2017 at 12:17 PM, an interview with Employee F, Licensed Practical Nurse (LPN), revealed the resident had a hard time focusing and wore corrective lenses. She also stated the resident was hard of hearing, and staff needed to speak into the left ear. She stated other than glasses, there were no assistive devices to assist with vision and that the resident did not have assistive devices to help with hearing. 2. A record review for Resident #61 revealed the resident began receiving Hospice services on 10/27/2017. A significant change Minimum Data Set (MDS) assessment was completed on 11/9/2017. It was not coded to indicate that the resident was receiving Hospice services. Employee C, an MDS nurse, was interviewed on 12/6/2017 at 12:13 PM. She confirmed that the resident was receiving Hospice services during the look back period of the 11/9/2017 significant change MDS assessment, and that the assessment was not coded correctly.

Based on observations, record review, and staff interviews, the facility failed to ensure that residents were free from accident hazards for 1 (Resident #22) of 4 sampled residents. The findings include: On 12/5/2017 at 3:34 p.m., Resident #22 was observed in a shower room being assisted by Employee A, a Certified Nursing Assistant (CNA). The resident was in the furthest shower stall (by the window) and was wearing a gown. The resident had a sling around the back and underarms, and was slightly lifted from the shower chair using a mechanical lift. The resident's toes were barely touching the floor. Employee A stated she just finished showering the resident and was transferring back to the wheelchair. Employee A left the resident's side and walked to the door of the room, opened it, and called out, I need a spotter. The resident was approximately 15 feet from the door and could not be seen due to the privacy curtain partially pulled. Two other staff members arrived momentarily and staff finished transferring the resident. Employee A was interviewed on 12/5/2017 at 3:45 p.m. She stated she was transferring the resident alone and she should not have been doing it by herself. She needed a spotter. The facility's Resident Transfer: Mechanical Lift Policy (reviewed 5/24/2016 revised 8/23/11) was reviewed. Manufacturer's instructions and recommendations should always be followed, including the number of staff needed for a safe transfer. Mechanical lifts requires at least a 2-person assist. Resident #22's last quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident required extensive, 2 + person assistance with transfers. The resident's care plan also revealed a 2-person transfer was required. On 12/7/2017 at 1:40 p.m., the Director of Nurses stated that aides in the shower room should use the call bell in the room to ask for help, and should not leave residents by themselves. On 12/7/2017 at 3:30 p.m., the MDS Nurse, Employee G, confirmed Resident #22 did need at least two persons for transfers.

Based on record reviews and staff interviews, the facility failed to notify the physician, the responsible party, and/or an interested family member of a significant change in status for 1 of 4 sampled residents (Resident #1). The findings include: 1. Review of a 12/27/16 progress note signed by the MDS (Minimum Data Set) Coordinator at 9:39 a.m., revealed that on 12/23/16, Resident #1 was observed on the floor on the right side of her dresser. Resident #1 was voicing complaints of pain in her back and neck. The ARNP (Advanced Registered Nurse Practitioner) was in to see Resident #1, and an order was given to send her to the emergency room for evaluation. Magnetic resonance imaging done at the hospital was negative. There was a laceration at the temple with no sutures. Resident #1 was seen by a physician over the weekend and followed up with the ARNP today. A progress note dated 12/25/16 at 3:07 p.m. and signed by a Licensed Practical Nurse (LPN), stated that 'Early this a.m. Resident #1 was out of bed and propelling self down hallway. At lunch, Resident #1 became sleepy and had to be fed, and was only taking small sips of fluids. Resident #1 awakens when her name is called. The supervisor was notified, and a new order for urinalysis was obtained to be completed in the a.m.' A progress note dated 12/24/16 at 2:32 p.m. signed by a Licensed Practical Nurse stated that 'Upon awakening this a.m., Resident #1 was lethargic; her speech was slurred, but her vital signs were stable. Resident #1 was trying to use the telephone upside down. Able to follow simple commands. Supervisor notified and physician here and examined resident. Staff washes and dresses. Transferred out of bed to wheelchair. More awake and alert. Answers appropriately. Offered extra fluids and pudding. Physician informed of condition this a.m. Continue to monitor. No new orders. At this time is sitting up, and answers when name is called.' During an interview with Employee A, Registered Nurse (RN), on 12/28/16 at 2:26 p.m., she was asked about family having been notified for Resident #1 related to the changes in health status noted on 12/24, 12/25, and 12/27/16. She stated, We always notify family, and it is supposed to be documented in the chart, but you are seeing what I am seeing in the chart. She confirmed there was no documentation in the resident's chart to indicate that the family or responsible party had been notified. No further documentation was provided by the facility during the survey to indicate that the family or responsible party had been notified.

Based on record review and staff interviews, the facility failed to obtain a urinalysis for 1 of 4 sampled Resident's (Resident #1). The findings include: Resident #1 had a physicians order on 12/10/2016 to collect a urinalysis with culture and sensitivity. Upon review of the lab results in the electronic medical system on 12/28/2016, the results were not available. On 12/28/16 at 3:30 p.m., Employees A and B were asked whether they could help this surveyor locate the results for the urinalysis completed on 12/10/16. Both employees looked in the computer, but were unable to find the results. Employee B stated, I will check on that and see if I can locate them. On 12/28/16 at 5:30 p.m., Employee B stated, I was not able to locate the results. I called the lab, and they do not have the results either. When Employee B was asked whether the urine sample had been collected and sent to the lab, he was not sure, and said he would have to check with the lab to see if the urine was sent. Upon further investigation, it was determined by Employee B that the urinalysis was never completed as ordered.

Based on record review and staff interviews, the facility failed to maintain the clinical records within acceptable standards of practice for 2 of 4 sampled residents (Residents #1 and #4). Resident records must be complete, accurate, and easily accessible. The findings include: 1. Resident #1 had a physicians order on 12/10/2016 to collect a urinalysis with culture and sensitivity. Upon review of the lab results in the electronic medical system on 12/28/2016, the results were not available. On 12/28/16 at 3:30 p.m., Employees A and B were asked whether they could help this surveyor locate the results for the urinalysis completed on 12/10/16. Both employees looked in the computer, but were unable to find the results. Employee B stated, I will check on that and see if I can locate them. On 12/28/16 at 5:30 p.m., Employee B stated, I was not able to locate the results. I called the lab, and they do not have the results either. When Employee B was asked whether the urine sample had been collected and sent to the lab, he was not sure, and said he would have to check with the lab to see if the urine was sent. Upon further investigation, it was determined by Employee B that the urinalysis was never completed as ordered. 2. A review of Resident #4's Medication Administration Record [REDACTED]. Take with [MEDICATION NAME] 25 mg to equal 75 mg twice a day. Upon review of the MAR, Resident #4 did not have a blood pressure documented prior to administering the [MEDICATION NAME] on 12/8/16 at 9:00 AM, on 12/9/16 at 9:00 AM, on 12/12/16 at 9:00 AM, on 12/13/16 at 9:00 AM, on 12/14/16 at 9:00 AM, on 12/15/16 at 9:00 AM, on 12/17/16 at 9:00 AM, on 12/18/16 at 9:00 AM, on 12/20/16 at 9:00 AM, on 12/21/16 at 9:00 AM, on 12/22/16 at 9:00 AM, on 12/23/16 at 9:00 AM, on 12/24/16 at 5:00 PM, on 12/26/16 at 9:00 AM, on 12/27/16 at 9:00 AM, and on 12/28/16 at 9:00 AM. On 12/28/2016 2:08 PM, an interview was conducted with Employee G, Licensed Practical Nurse (LPN), regarding nursing staff obtaining a blood pressure for Resident #4 prior to administering hypertensive medications. Employee G reviewed the December 2016 Medication Administration Record [REDACTED]. Employee G stated, I'm sure I had them. The CNA (Certified Nursing Assistant) will get our blood pressures, and give them to us on little sheets of paper. When asked if she had the blood pressures in front of her during the time of medication administration, why she didn't enter them in the computer, she replied, It gets to be too much. Sometimes it (the computer) will ask you five different times for the blood pressures, and it gets to be too much to enter them all. when asked why she didn't enter them for Resident #4, she replied, I don't know. When asked if Resident #4's blood pressure was obtained just prior to the administration of the hypertensive medication, she stated, I don't know, I'm not sure. Employee B, LPN, who was present during this interview, confirmed that the blood pressures should have been taken and entered as ordered.

Based on record reviews and staff interviews, the facility failed to provide the necessary care and services to attain or maintain residents' highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care related to medication administration for 15 (Residents #216, #91, #199, #68, #265, #43, #11, #116, #4, #87, #94, #75, #319, #166, and #158) of 36 sampled residents; for failure to obtain physician ordered lab work for 1 (Resident #110) of 5 residents reviewed for unnecessary medications, and failure to provide required and physician-ordered oxygen for two residents (Residents #107 and #60) sampled for oxygen administration of a sample of 36 residents. The findings include: 1. Resident #216 had an order for [REDACTED]. Resident #216 also had an order for [REDACTED]. Resident # 91 had an order for [REDACTED]. On 9/27/16 the dose scheduled before lunch at 11:30 AM was not administered until 1:36 PM, and on 9/28/16, it was not administered until 1:13 PM. Resident #91 had orders for [MEDICATION NAME], and [MEDICATION NAME] XR scheduled everyday at 9:00 AM, and they were not documented as being administered until 2:11 PM on 10/1/16. Resident #199 had an order for [REDACTED].#199 also had orders for [MEDICATION NAME], Tamsulosin, [MEDICATION NAME] ER, and [MEDICATION NAME] every day at 9:00 AM, but they were not documented as having been administered until 12:31 PM on 10/1/16. Resident #68 had an order for [REDACTED]. Resident #265 had an order for [REDACTED]. On 10/1/16 the 8:00 AM scheduled dose was not documented as having been administered until 12:54 PM, and on 10/2/16, not until 12:51 PM. Resident #265 had an order for [REDACTED]. Resident #43 had an order for [REDACTED].>400 call MD (physician). Blood sugars were scheduled to be taken before meals and at bedtime. On 10/1/16 the 11:30 AM, Resident #43's blood sugar was documented as having been measured at 2:59 PM. On 10/2/16, the 11:30 AM blood sugar was documented as having been measured at 3:15 PM. Resident #43 had an order for [REDACTED]. According to the facility's meal schedule, the scheduled breakfast times in the building were from 7:45 AM until 8:35 AM. Resident #43 resided on the East wing, and the meal time for that wing was 7:45 AM. The resident ate breakfast in her room. [MEDICATION NAME] was documented as having been administered on 9/21/16 (at 10:49 AM), 9/23/16 (at 10:47 AM), 9/24/16 (at 10:02 AM), 9/26/16 (at 10:31 AM), and 9/27/16 (at 11:13 AM). Resident #43 had an order for [REDACTED]. Resident #11 had an order for [REDACTED].< 60, and a heart rate < 60. Upon review of the resident's Medication Administration Record [REDACTED]. An interview was conducted with Employee D regarding the blood pressure for Resident #11; she looked in the computer and was unable to locate it. She stated The computer does not cue you to enter them. Employee D was also unable to locate the blood pressures for Residents #116 and #4 who were also administered blood pressure medications with parameters to hold if the systolic reading was <110 and the diastolic reading was <60. Resident #87 had an order for [REDACTED].< 60. The nurse failed to obtain the blood pressure before administering the medication on 10/12/16. An interview was completed with Employee C on 10/12/16 at 11:09 AM, and she stated, I must have missed it. Employee C then reviewed the electronic medical record and determined that the blood pressures had not been being taken. Resident # 94 had an order for [REDACTED].< 60. On 10/11/16 at 10:42 AM, Employee B was observed by this surveyor passing Resident #94 her AM medications. Employee B was asked which medications she had just administered to Resident #94, and she replied, I just gave her a pain pill for a pain level of 7, [MEDICATION NAME], Aspirin, [MEDICATION NAME], and eye drops. Employee B was then asked about the resident's [MEDICATION NAME], and she stated, Yes, I just gave that, and did not take a blood pressure. Employee B pulled up the resident's [MEDICATION NAME] order on her computer screen and stated, Yeah, I see the parameters, but we haven't been taking any blood pressures. Employee B was then asked how many more residents she had left to pass medications to, and she listed seven (7) resident's names; then said maybe more. Employee B was asked if she had an emergency or something else this morning that would have delayed her residents' medication pass. She stated, No, I am a supervisor and I am not used to passing meds. I volunteered to come in today. These people get a lot of meds. On 10/11/16 at 10:51 AM, this surveyor asked Resident #94 if the nurse usually took her blood pressure before giving her medications to her in the mornings, and Resident #94 shook her head no. Residents #75, #319, #166, #158, #87, #116, and #4 all had their medications administered late on several different days. On 10/11/16 at 12:32 PM, an interview was conducted with the Director of Nursing (DON) and the West Wing Unit Manager (UM) regarding residents receiving their medications late. The DON stated that they were aware of residents receiving their medications late, and they were working on it. The UM stated that they were trying to get medications discontinued so the nurses would have fewer medications to pass. The DON confirmed that this had been an ongoing problem, and that they were working on it. The DON was then asked for a list of late medication administrations for the previous two weeks. On 10/11/16 at 4:27 PM, the DON brought this surveyor two reports of late medication administration. The first, from 9/19/16 through 9/30/16 was 176 pages long with 57 residents listed, and a second, from 10/1/16 thru 10/3/16 was 64 pages long and had 54 residents listed. 2. A record review for Resident #110 found current physician's orders [REDACTED]. Complete Blood Count (CBC), Basic Metabolic Panel (BMP), Magnesium, Vitamin B12, Vitamin D, [MEDICAL CONDITION] Stimulating Hormone (TSH), and T4 every 3 months one time a day starting on the second ( 5/2/2016). The Director of Nursing and Unit Manager of the West Wing were asked on 10/11/2016 at 3:00 PM for evidence of when the lab work for Resident #110 was last obtained. The West Wing Supervisor provided evidence that the Basic Metabolic Panel (BMP) was completed on 8/11/2016, and the Magnesium, Vitamin B12, and Vitamin D were completed on 8/2/2016. The Unit Manager of the West Wing was asked on 10/12/2016 at 10:52 AM for the results of the remainder of the ordered lab work. She confirmed the CBC, TSH, and T4 that should have been completed on 8/2/2016 were not completed. She stated the resident's physician was contacted on 10/11/2016, and STAT (immediate) orders were obtained for the CBC, TSH, and T4. 3. On 10/3/16 at 12:15 PM, Resident #107 was sitting in the dining room with her O2 (oxygen) tank on the back of her wheelchair, and upon reviewing the regulator on the O2 tank, it was noted to be empty. Employee J verified that the tank was empty and obtained a SpO2 (estimate of arterial oxygen saturation) reading of 76%, then over 3-4 minutes, the SpO2 went up to 88%. Per the website amperodirect.com, For a regular healthy person, the normal blood oxygen saturation level (SpO2) should be around 94% to 99%. For patients with mild respiratory diseases, the SpO2 should be 90% or above. Supplementary oxygen should be used if SpO2 level falls below 90%, which is unacceptable for a prolonged period of time. Per The Mayo Clinic at mayoclinic.org, Normal arterial oxygen is approximately 75 to 100 millimeters of mercury (mm Hg). Values under 60 mm Hg usually indicate the need for supplemental oxygen. Normal pulse oximeter readings usually range from 95 to 100 percent. Values under 90 percent are considered low. Employee J was interviewed on 10/3/16 at 12:20 PM, and stated that the facility did not have a system for monitoring O2 tanks, they just eyeball them. Resident #107 had a physician's orders [REDACTED]. No SpO2 checks were ordered, and the last SpO2 taken was on 12/24/15. An interview was conducted with the East Wing Unit Manager on 10/3/16 at 12:32 PM regarding oxygen administration. When asked who usually changed the O2 concentrators, she replied that the aides did, or the nurse, if the nurse was available. The Unit Manager was asked for a copy of the facility's policy and procedure for oxygen administration. On 10/3/16 at approximately 2:12 PM, the policy and procedure for oxygen administration was provided to the survey team. Oxygen Administration SHC RC2 0005.02, dated 11/12/11, revealed, PURPOSE: A resident will need oxygen therapy when hypoxemia (low oxygen in blood) occurs. Arterial blood gas (ABG) analysis, pulse oximetry monitoring, and clinical examinations determine the adequacy of oxygen therapy. The resident's disease, physical condition, and age will help determine the most appropriate method of administration. A licensed Nurse or a Respiratory Care Practitioner performs this procedure. An interview was conducted with Employee K (Certified Nursing Assistant (CNA) on 10/3/16 at 3:37 PM. When asked who changed the portable oxygen tanks when they were low, she stated the CNAs or the nurse. She was asked where the oxygen was kept, and she stated that it was kept in the clean utility room. Empty canisters were placed in the soiled utility room. She demonstrated to this surveyor how the tank was changed. An interview was conducted with Employee H on 10/3/16 at 4:05 PM. It revealed she was responsible as a CNA to check and change out portable oxygen canisters when they were low. On 10/3/16 at 4:10 PM, an interview conducted with Employee I revealed it was part of the CNAs' responsibility to check and change out oxygen canisters for residents when required. On 10/03/16 4:30 PM, an interview was conducted with Resident # 60. She revealed that she wore oxygen all the time using a concentrator in the room, and had an oxygen tank on the back of her wheelchair for use when she was out of her room. When asked how often her tank was changed, she replied, Every other day and it is ridiculous. When it is empty, I have to go find someone to change the tank and I shouldn't have to.

Based on record reviews and staff interviews, the facility failed to provide services to meet professional standards of quality related to medication administration for 15 (Residents #216, #91, #199, #68, #265, #43, #11, #116, #4, #87, #94, #75, #319, #166, and #158) of 36 sampled residents, and failed to obtain physician ordered lab work for 1 (Resident #110) of 5 residents reviewed for unnecessary medications. The Florida Nurse Practice Act, Chapter 464.003 defines the practice of professional nursing as the performance of those acts requiring substantial specialized knowledge, judgment and nursing skill based upon applied principles of psychological, biological, physical and social sciences which shall include, but not limited to: The administration of medications and treatments as prescribed by a duly licensed practitioner practice of practical nursing as the performance of selected acts, including the administration of treatments and medications in the care of the ill, injured or infirmed and the promotion of wellness, maintenance of health and prevention of illness of others, under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician of a licensed dentist. The findings include: 1. Resident #216 had an order for [REDACTED]. Resident #216 also had an order for [REDACTED]. Resident # 91 had an order for [REDACTED]. On 9/27/16 the dose scheduled before lunch at 11:30 AM was not administered until 1:36 PM, and on 9/28/16, it was not administered until 1:13 PM. Resident #91 had orders for [MEDICATION NAME], and [MEDICATION NAME] XR scheduled everyday at 9:00 AM, and they were not documented as being administered until 2:11 PM on 10/1/16. Resident #199 had an order for [REDACTED].#199 also had orders for [MEDICATION NAME], Tamsulosin, [MEDICATION NAME] ER, and [MEDICATION NAME] every day at 9:00 AM, but they were not documented as having been administered until 12:31 PM on 10/1/16. Resident #68 had an order for [REDACTED]. Resident #265 had an order for [REDACTED]. On 10/1/16 the 8:00 AM scheduled dose was not documented as having been administered until 12:54 PM, and on 10/2/16, not until 12:51 PM. Resident #265 had an order for [REDACTED]. Resident #43 had an order for [REDACTED].>400 call MD (physician). Blood sugars were scheduled to be taken before meals and at bedtime. On 10/1/16 the 11:30 AM, Resident #43's blood sugar was documented as having been measured at 2:59 PM. On 10/2/16, the 11:30 AM blood sugar was documented as having been measured at 3:15 PM. Resident #43 had an order for [REDACTED]. According to the facility's meal schedule, the scheduled breakfast times in the building were from 7:45 AM until 8:35 AM. Resident #43 resided on the East wing, and the meal time for that wing was 7:45 AM. The resident ate breakfast in her room. [MEDICATION NAME] was documented as having been administered on 9/21/16 (at 10:49 AM), 9/23/16 (at 10:47 AM), 9/24/16 (at 10:02 AM), 9/26/16 (at 10:31 AM), and 9/27/16 (at 11:13 AM). Resident #43 had an order for [REDACTED]. Resident #11 had an order for [REDACTED].< 60, and a heart rate < 60. Upon review of the resident's Medication Administration Record [REDACTED]. An interview was conducted with Employee D regarding the blood pressure for Resident #11; she looked in the computer and was unable to locate it. She stated The computer does not cue you to enter them. Employee D was also unable to locate the blood pressures for Residents #116 and #4 who were also administered blood pressure medications with parameters to hold if the systolic reading was <110 and the diastolic reading was <60. Resident #87 had an order for [REDACTED].< 60. The nurse failed to obtain the blood pressure before administering the medication on 10/12/16. An interview was completed with Employee C on 10/12/16 at 11:09 AM, and she stated, I must have missed it. Employee C then reviewed the electronic medical record and determined that the blood pressures had not been being taken. Resident # 94 had an order for [REDACTED].< 60. On 10/11/16 at 10:42 AM, Employee B was observed by this surveyor passing Resident #94 her AM medications. Employee B was asked which medications she had just administered to Resident #94, and she replied, I just gave her a pain pill for a pain level of 7, [MEDICATION NAME], Aspirin, [MEDICATION NAME], and eye drops. Employee B was then asked about the resident's [MEDICATION NAME], and she stated, Yes, I just gave that, and did not take a blood pressure. Employee B pulled up the resident's [MEDICATION NAME] order on her computer screen and stated, Yeah, I see the parameters, but we haven't been taking any blood pressures. Employee B was then asked how many more residents she had left to pass medications to, and she listed seven (7) resident's names; then said maybe more. Employee B was asked if she had an emergency or something else this morning that would have delayed her residents' medication pass. She stated, No, I am a supervisor and I am not used to passing meds. I volunteered to come in today. These people get a lot of meds. On 10/11/16 at 10:51 AM, this surveyor asked Resident #94 if the nurse usually took her blood pressure before giving her medications to her in the mornings, and Resident #94 shook her head no. Residents #75, #319, #166, #158, #87, #116, and #4 all had their medications administered late on several different days. On 10/11/16 at 12:32 PM, an interview was conducted with the Director of Nursing (DON) and the West Wing Unit Manager (UM) regarding residents receiving their medications late. The DON stated that they were aware of residents receiving their medications late, and they were working on it. The UM stated that they were trying to get medications discontinued so the nurses would have fewer medications to pass. The DON confirmed that this had been an ongoing problem, and that they were working on it. The DON was then asked for a list of late medication administrations for the previous two weeks. On 10/11/16 at 4:27 PM, the DON brought this surveyor two reports of late medication administration. The first, from 9/19/16 through 9/30/16 was 176 pages long with 57 residents listed, and a second, from 10/1/16 thru 10/3/16 was 64 pages long and had 54 residents listed. 2. A record review for Resident #110 found current physician's orders [REDACTED]. Complete Blood Count (CBC), Basic Metabolic Panel (BMP), Magnesium, Vitamin B12, Vitamin D, [MEDICAL CONDITION] Stimulating Hormone (TSH), and T4 every 3 months one time a day starting on the second ( 5/2/2016). The Director of Nursing and Unit Manager of the West Wing were asked on 10/11/2016 at 3:00 PM for evidence of when the lab work for Resident #110 was last obtained. The West Wing Supervisor provided evidence that the Basic Metabolic Panel (BMP) was completed on 8/11/2016, and the Magnesium, Vitamin B12, and Vitamin D were completed on 8/2/2016. The Unit Manager of the West Wing was asked on 10/12/2016 at 10:52 AM for the results of the remainder of the ordered lab work. She confirmed the CBC, TSH, and T4 that should have been completed on 8/2/2016 were not completed. She stated the resident's physician was contacted on 10/11/2016, and STAT (immediate) orders were obtained for the CBC, TSH, and T4.

Based on staff interviews and record reviews the facility failed to use the nursing admission assessment results to develop interim care plans for residents admitted with pressure sores for 2 of 3 sampled residents (#1, #3) to ensure that the residents would receive the needed care and treatment to the pressure areas resulting in harm to Resident #1. Professional Standard of Care is defined in Chapter 766.102 as, "the prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment which, in light of all relevant surrounding circumstances, is recognized as acceptable and appropriate by reasonably prudent similar health care providers." The Florida Nurse Practice Act, Chapter 464.003 defines: the "Practice of Professional Nursing" as, "The performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to, the administrations of medications and treatments as prescribed or authorized by a duly licensed practitioner; and the "Practice of Practical Nursing" as, "The performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirmed and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist." The findings include: 1. A review of the medical record for Resident #1 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was alert and oriented and was ambulating independently at home prior to her recent fall. The discharge plan included for Resident #1 to return home after therapy services. An initial nursing assessment on the Resident Data Set form was performed on February 13, 2011 at 5:30pm, by the LPN (licensed practical nurse) assigned to her care (N1). The initial nursing assessment included a skin assessment. The skin assessment diagram revealed Resident #1 was observed with a reddened area and closed blister to the coccyx, bruises to the hands from IV sites, a surgical wound site to the right hip, scratches to left forearm, and a [MEDICAL TREATMENT] catheter to right upper arm. The Braden scale for predicting pressure sore risk was completed on 2/13/11 at the time of admission and was noted to be a 19 which indicated no risk. On February 14, 2011 a registered nurse (N2) signed the Resident Data Set form and noted under sections completed, "reviewed all". The Daily Skilled Nurses' Note that was completed at the time of admission contained documentation that stated "Has closed blister to coccyx area, red. [MEDICATION NAME] applied." A review of the admission physician orders did not include treatment orders for the area to the coccyx. The admission nursing note dated February 13, 2011 revealed the admitting nurse (N1) applied a [MEDICATION NAME] dressing. Further review of the physician orders found there was no order given for the use of [MEDICATION NAME]. A review of the resident's interim care plan dated February 13, 2011 found there was no care plan regarding the pressure area (blister) or potential for skin breakdown. There was an interim care plan for risk of impaired skin with the location marked as right hip. Interventions included pressure reduction mattress, wheelchair cushion if appropriate, keep clean and dry after each incontinent episode, turn and reposition as needed, meds/treatments as ordered by MD, skin integrity documentation initiated, observe for signs/symptoms of infection. It was also noted that the Braden Scale was marked as a 19, indicating no risk. There was no mention of the blister to the coccyx, or that [MEDICATION NAME] had been applied. On March 2, 2011 at 11:00AM an interview was conducted with the DON. During the interview the DON was asked when treatment was first provided to Resident #1's area on the coccyx. She replied the admitting nurse (N1) made an entry on the initial nursing assessment on February 13, 2011 that Resident #1 was observed with a closed blister to the coccyx and applied a [MEDICATION NAME] dressing. The coccyx wound was not again observed until February 19, 2011. The DON also stated the admitting nurse did not include the skin impairment on the interim care plan initiated on February 13, 2011. A review of the physician progress notes [REDACTED].#1: the area was open and measured 7cm x 8cm x .25cm and contained slough. This was documented by an LPN (N5) . An interim care plan was not developed at that time to include the coccyx wound as well as care and treatment that was ordered by the physician on February 19, 2011 . An initial wound care consult was performed on February 23, 2011 and revealed the following: The coccyx wound is necrotic and probably contaminated, it is in close proximity to anal area, the wound extends from the sacrococcygeal junction to the perianal area, and it is uniformly necrotic and sloughy and has heavy thick serous and purulent exudate. The wound is Stage 3 and measured 5.5cm x 2.8cm x 0.7cm. Wound had 80% yellow slough with 5cm [DIAGNOSES REDACTED] and 2cm maceration. The wound was debrided of tissue down to and including muscle extending to viable tissue. Despite the continued deterioration of the coccyx wound (Stage II on February 19, 2011 to a Stage III on February 23, 2011) which required sharp debridement, the facility failed to develop an interim care plan. A review of the focus meeting notes for Resident #1 dated February 24, 2011 revealed the following: The resident was admitted with a closed blister to the coccyx and was assessed on February 23, 2011 by the wound care physician; a new treatment was ordered and will continue to monitor. A care plan to address the coccyx wound was not initiated until March 1, 2011 when the comprehensive assessment, and minimum data set was completed. 2. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Braden Scale was performed with a score of 16 (15-18 indicates resident at risk for skin breakdown). Resident #3 was refered to the wound care specialist and was seen on February 23, 2011 . The wound care physician note dated February 23, 2011 wrote in the Wound Description area on his consultation form the following: Location - pelvis buttocks right medial; etiology - pressure; stage - unstagable; duration - chronic; size (LxWxD) - 2.0 X 1.4 X 0.5; Undermining - none; exudate - scant; % of yellow slough - 15%; % of black eschar - 80%; % of granulation tissue - 25%. Periwound description - odor- none; [DIAGNOSES REDACTED] - 2cm surrounding; maceration - present. Procedural treatment identified: Anesthesia 20% [MEDICATION NAME] - Excisional debridement of tissue down to & including subcutaneous using curette extending to viable tissue. On February 23, 2011 the wound care physician made the following recommendations: The wound to be irrigated with wound cleanser. Sure prep painted on and around the wound. The prep pad is left in situ and covered by a boardered gauze. Offload Q 2 hours - Use pillows or wedges for positioning. Review of the interim care plan dated February 21, 2011 did not address the pressure sore or the potential for further skin breakdown. On February 23, 2011 Resident #3 underwent debridement of the right buttock wound. The wound care physician gave the staff specific recommendations for care and treatment of [REDACTED]. A care plan to address the pressure sore was not initiated until March 1, 2011 after a full assessment and minimum data set had been completed.

Based on observation, record review and staff interviews, the facility failed to have a system in place to timely identify, assess and treat pressure sores and to have measures in place to promote healing of existing pressure sores for 1 of 3 sampled residents. (Resident #1) This failure resulted in harm to Resident #1 who had a decline in the pressure sore area from a closed blister at the time of admission on February 13, 2011 to a Stage III on February 19, 2011, that the facility was unaware of until a dressing was removed 6 days after application. The findings include: A review of Resident #1's medical record revealed that Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was alert and oriented and the discharge plan was for Resident #1 to return home after therapy services. Review in the medical record of the initial nursing assessment completed on the Resident Data Set form was performed on February 13, 2011 at 5:30pm by the LPN (licensed practical nurse) assigned to her care (N1). The initial assessment included a skin assessment. The skin assessment revealed Resident #1 was observed with a reddened area and closed blister to the coccyx, bruises to hands from IV sites, a surgical site to the right hip, scratches to left forearm, and a [MEDICAL TREATMENT] catheter to right upper arm. The Braden Scale for predicting pressure sore risk was completed on February 13, 2011 at the time of admission and was noted to be a 19 which indicated no risk. Review of the facility wound care protocol for partial thickness wound/stage II pressure ulcer revealed that the protocol for trunk or extremities included to cleanse wound with wound cleanser, pat dry and apply protective barrier wipe to intact skin around wound. The protocol noted for sacral/coccyx wounds; "apply foam with silicone dressing. Change dressing daily" Review of the admission nursing note in the resident's medical record dated February 13, 2011 at 5:30pm revealed the admitting nurse (N1) documented the blister to the coccyx and applied a [MEDICATION NAME] dressing. The facility policy is that an RN is to review and sign the initial nursing assessment when done by an LPN. On February 14, 2011 a registered nurse (N2) signed the Resident Data Set form and noted under sections completed, "reviewed all". The director of nursing (DON) was asked on 3/2/11 at 10am if after the initial assessment was reviewed by the RN was the skin impairment reported to the wound nurse, DON and addressed in the care plan. She stated, "no". A review of the admission physician orders did not include treatment orders for the area to the coccyx. Further review of the physician orders found there was no order given for the use of [MEDICATION NAME]. An interview conducted with the DON on March 2, 2011 at 10:05am verified there was no order obtained. The DON was asked what was the facility policy regarding documenting wounds discovered upon admission or newly acquired wounds in the facility. She stated the wounds should be assessed, measured and reported to the physician for appropriate treatment. Further review of the medical record revealed that the resident's physician saw the resident on February 19, 2011 and documented a Stage II on the coccyx. There was no documentation of the size or appearance of the wound by the physician on this progress note. At the bottom of the page in the area noted as plan, was written Santyl to coccyx, check [MEDICATION NAME]. This was signed and dated by the physician as February 22, 2011 . A review of the Weekly Skin Measurement Tool dated February 19, 2011 noted open area, buttocks/coccyx, length 7cm, width 8cm, depth below (<) .25cm(non-measurable= <.25cm). It also noted slough. under other is noted 1 1/2 cm x 5 cm brownish slough in middle of open area. This was signed by a Licensed Practical Nurse (LPN) (N5). A review of the physician order sheet from the medical record revealed that on February 19, 2011 an order was written by (N5) who had documented the appearance and size of the wound. The order stated cleanse open area on coccyx and buttocks with wound cleanser, apply hydrogel, puracol and boarder gauze. Change daily and PRN (as needed) until resolved. This order was signed by the physician on February 22, 2011. On February 21, 2011 another physician order was written that stated coccyx - change treatment order to clean with wound cleaner, skin prep peri wound apply Santyl and cover with border gauze. Change every other day and as needed. This order was also signed by the physician on February 22, 2011. No order was found to have lab work done for a pre [MEDICATION NAME]. An order had been written February 17, 2011 for the resident to receive Pro-Stat 101 for low [MEDICATION NAME] On March 2, 2011 at 10:05am, the DON explained the nurse is to complete a Weekly Skin Measurement Tool to record the specifics of the wounds. When asked if the nurse had completed the weekly skin measurement tool for Resident #1 at the time of admission she stated "no". The DON was asked if the physician had been notified of Resident #1's skin condition at admission. She stated there was no documentation to indicate the physician had been notified. A review of the resident's interim care plan dated February 13, 2011 found there was no care plan noting the pressure area (blister) or potential for skin breakdown to this area. There was an initial interim care plan for risk of impaired skin with the location marked as right hip. Interventions included pressure reduction mattress, wheelchair cushion if appropriate, keep clean and dry after each incontinent episode, turn and reposition as needed, meds/treatments as ordered by MD, skin integrity documentation initiated, observe for signs/symptoms of infection. It was also noted on this interim care plan, that the Braden Scale used for predicting pressure sore risk was marked as a 19, indicating no risk. A review of the treatment records for February 2011 for Resident #1 revealed that there were no treatment orders for the coccyx area from February 13 through February 19, 2011. The nursing documentation from February 13 through February 19 did not include any further assessment of impaired skin to the coccyx area or that a [MEDICATION NAME] dressing was present. There was no documentation that the [MEDICATION NAME] dressing was removed and the area inspected until February 19, 2011. An interview was conducted with the DON on March 2, 2011 at 10:10am. When asked if the nurses date the [MEDICATION NAME] dressing when applied she stated, "no". When asked how often should the [MEDICATION NAME] be changed she said usually every three days. When asked how the staff would know how long the dressing was in place, she said the treatment record would indicate the last date applied. The DON said there would not be any other way to verify the date the [MEDICATION NAME] was applied. On March 2, 2011 at 11:00 am an interview was conducted with the DON. During the interview the DON was asked when treatment was first provided to Resident #1's pressure area on the coccyx. She replied the admitting nurse (N1) made an entry on the initial nursing assessment on February 13, 2011 that Resident #1 was observed with a closed blister to the coccyx and applied a [MEDICATION NAME] dressing. The coccyx wound was not again observed until February 19, 2011. When asked why the wound had not been assessed for six days she stated the facility was unaware that Resident #1 had skin impairment to the coccyx. She also stated that the admitting nurse (N1) had not informed the supervisor when the resident was admitted and the information was not passed on at report. The DON also said the admitting nurse did not include the skin impairment on the initial interim care plan initiated on February 13, 2011. A review of the nursing note dated February 20, 2011 at 8am revealed that a dressing change had been performed. There was no documentation that a treatment order had been obtained, that the previous [MEDICATION NAME] dressing had been removed or the appearance of the wound at the time of the dressing change. Arrangements were made for the wound care specialist to see Resident #1 on his next visit on February 23, 2011. An interview was conducted with the wound nurse (WN) on March 2, 2011 at 9:30am. During the interview she was asked what her duties were as the wound nurse. She stated she did not perform the treatments; the treatments for all residents were performed by the nurses assigned to those residents. Her duties included: making rounds with the wound care physician every Wednesday and tracking the measurements of the wounds. She prepared the weekly wound report that was used at the weekly Focus meetings. She stated she did not perform the weekly measurements of wounds because that was done by the staff nurses. Also, since she is an LPN she is not allowed to assess wounds; therefore, she does not make wound treatment recommendations. She stated that a recent change in her duties now included reviewing the weekly skin assessment records to ensure they are completed for all residents. When asked when she was first notified of the coccyx wound on Resident #1 she stated February 19, 2011 and that she visualized the wound for the first time on February 23, 2011 when the wound care specialist examined and treated the wound. An initial wound care consult was performed on February 23, 2011 and revealed the following: The coccyx wound is necrotic and probably contaminated, ( it was noted that the resident did have episodes of incontinence), it is in close proximity to anal area, the wound extends from the sacrococcygeal junction to the perianal area, and it is uniformly necrotic and sloughy and has heavy thick serous and purulent exudate. The wound is Stage III and measured 5.5cm x 2.8cm x 0.7cm (approximately 2 inches by one inch and 1/4 inches deep). Wound had 80% yellow slough (dead tissue separating from live tissue) with 5 cm [DIAGNOSES REDACTED] (reddened) and 2 cm maceration (soft tissue). The wound was debrided of tissue down to and including muscle extending to viable tissue. A review of the Focus meeting notes for Resident #1 dated February 24, 2011 revealed the following: the resident was admitted with a closed blister to the coccyx and was assessed on February 23, 2011 by the wound care physician, a new treatment was ordered and will continue to monitor. A care plan to address the coccyx wound was not initiated until March 1, 2011. An interview was conducted with the wound care physician on March 2, 2011 at 2:00pm. When asked about the initial evaluation on February 23, 2011 of Resident #1's coccyx wound he stated, the wound was at a Stage III, necrotic and covered with yellow eschar (scab). When he debrided the wound there was a large amount of purulent drainage, indicating the wound was contaminated. At 2:15pm on March 2, 2011 an observation was made of the wound. The physician examined and measured the wound. He described the wound as a Stage III, there was no evidence of purulent drainage and the surface of the wound contained thick yellow eschar. The wound was debrided, cleansed and a new dressing was applied.