Every finding on record at Promedica Skilled Nursing And Reh- Greenville West

Based on review of the facility policy, record review, and interview, the facility failed to report to the State Survey Agency an allegation of abuse that occurred on 03/21/26. Specifically, Resident (R)1 alleged she was physically abused and neglected by a staff member on 03/21/26, for 1 of 3 residents reviewed for abuse.Findings include:Review of the facility policy titled Abuse and Neglect - Clinical Protocol with a revision date of March 2018, states: Treatment/Management 2. The management and staff, with physician support, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations. Review of the facility's March 2026 Grievance Log revealed a grievance filed by R1 on 03/22/26, stating, Nurse grabbed her arm and hurt her. During an interview with the Director of Nursing (DON) on 07/01/26 at 10:40 AM, the DON stated she has been in her position for approximately 3 years. The DON revealed that there was no reportable created for the incident because the resident did not have any bruises. The DON stated that when an allegation is made, she creates a soft file and if she doesn't report the incident she gives her information to social services and that she does not keep any information she doesn't report. During a follow up interview with the DON and the Acting Administrator on 07/01/2026 at 1:30 PM, the DON stated that when there is an allegation of abuse made she has two (2) hours to investigate the allegation to determine if it is reportable. The DON continues to explain that allegations are reported if during her investigation she sees that there is an issue, and the allegation is not reported if she doesn't find the allegation to be an issue. The Acting Administrator reiterated that if within two hours the allegation is determined not to be substantiated it is not reported.

Based on facility policy review, observation, and interview, the facility failed to ensure medications were stored securely in their original packaging. Specifically, 8 pills and 2 capsules were found loose in 1 of 6 medication carts reviewed. Additionally, the facility failed to discard expired medications for Resident (R)123, in 1 of 4 medication storage rooms reviewed. Findings include: Review of the facility policy titled Storage of Medications with a last revision date of November 2020 revealed, Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. The policy heading also reveals, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. During an observation on 12/17/25 at 11:08 PM of the Hall 200 Medication Cart 2 during a medication pass, in the presence of Licensed Practical Nurse (LPN)1 and the Director of Nursing (DON), revealed eight loose pills and two loose capsules were located in the medication cart. The medications were not stored in their original containers at the time of observation. During an observation on 12/18/25 at 2:48 PM of the Hall 300 Medication Room, in the presence of the DON, revealed two medication packets of Sucralfate 1-gram tablets, totalling 58 individual tablets, labelled for R123. The medication packaging indicated an expiration date of 10/31/25. At the time of observation, the expired medication remained stored in the medication room. During an interview on 12/17/25 with the DON and LPN1 revealed that medication carts are to be checked every shift to ensure medications are adequately stored based on facility guidelines. The DON and LPN1 acknowledged the eight loose pills and two loose capsules and agreed they are not supposed to be stored outside the original container. During an interview on 12/18/25 at 2:48 PM, the DON acknowledged the expired medication cards for R123. The DON stated medication cards should not have been stored in the medication storage room and should have been disposed of. During an interview on 12/18/25 at 3:18 PM, the Administrator stated that nursing staff are responsible for ensuring medication carts and medication rooms are free of loose pills and expired medications. The Administrator explained that due to a full census and the high volume of medications, medication carts were overfilled, and during medication administration, medications may have inadvertently fallen out of packets as nurses removed and returned medication cards. The Administrator acknowledged loose pills found on the Hall 200 medication cart and expired medication packets found in the Hall 100 medication storage room and stated that an overflow bin system was implemented, with excess medications placed in designated overflow bins stored in locked medication rooms to alleviate cart overcrowding and prevent recurrence.

Based on observations, interviews, and facility policy review, the facility failed to ensure foods that were are stored in the freezer, refrigerators, and dry food storage were appropriately sealed, labeled, dated with a use by date, and/or discarded after the manufacturer's expiration date in 1 of 1 kitchen, and 1 of 3 nourishment rooms. This had the potential to affect all residents who received food from the kitchen. Findings include: Review of the facility's policy dated 05/28/15, titled Food Safety Requirements documented, . all food, non-food items, and supplies used in food preparation shall be stored in such a manner as to maintain safety and sanitation of the food or supply for human consumption as set forth in the Federal Drug Administration Food Code, state regulations and city/county health codes. Labeling and rotating food supply: 1. For food products that are opened and not completely used or prepared at facility and stored, the product should be labeled as to its contents and use-by dates. During an initial observation of the kitchen on 10/21/24 at 11:02 AM, revealed the following in the dry storage: 1 - 5 pound (lb) bag of yellow cake mix with a dead bug on top of the bag. 7 - 4 lb boxes of Iodized Salt contents hard, boxes stained with an unknown liquid. 1 - Box of 12 - 5 once (oz) packages of chocolate instant pudding, stained with black substance on all individual packages. 1 - 10 lb box of pasta open and not dated, not labeled, and not sealed properly. 1 - 8 oz bottle Ensure best by date of 10 [DATE]. 9 - 8 oz bottles of Nepro shakes covered with an unknown tan colored substance. Freezer revealed the following: 2 - 10 lb bags of pepperoni with no open date. 3 - Bags of frozen biscuits, open, with no open date. 2 - Bags of dinner rolls, open, with no open date. 1 - 3 lb box Cibatta breadsticks, open, with no open date. 1 - Package of hash browns, open, with no open date. 1 - 13.5 lb box of frozen cooked french toast, open, with no open date, the contents inside the box were all open, with no open date. 1 - Bag of yeast rolls, open, no date, not labeled. 1 - Bag of dumplings, open, no date, not labeled. 1 - 5 lb bag of chicken wings, open, no date, not labeled. 1 - 64 oz bag of vegetable blend, open, no date, not labeled. 1 - Bag of carrots, open, no date, not labeled. 1 - 20 lb bag of vegetable stew blend, open, no date, not labeled. 1 - Box of funnel cake, open, no open date. 4 - Bags of hash browns, open, no date, not labeled. 1 - Bag of frozen chicken, open, no date, not labeled. During an interview on 10/21/24 at 11:15 AM, the Dietary Manager (DM), who was present during the initial kitchen tour, observed the dead bug on bag of cake mix and revealed that when they find insects in the area of the dry food storage they would discard all the items in the area and have the area fogged. The DM stated that for items that are opened they should be labeled with the date it was opened. During an observation of the Unit 1 Nourishment Room on 10/23/24 at 12:05 PM revealed the following: 1 - 33.8 Fl oz. TwoCal HN with a use by date of 1 [DATE]. During an interview on 10/23/24 at 12:05 PM, the DM revealed the nurses are responsible for checking the dates on the supplies once they are on the floor. The DM further reveals that they, including kitchen staff, checked the dates on the snacks before they bring snacks to the floor but they do not check the dates on the items already in the drawers of nourishment rooms. During an interview on 10/24/24 at approximately 10:30 AM, the Operations Manager (OM) revealed that there is a management team including themselves that are constantly in the kitchen completing audits to ensure that food is properly stored. The OM states that labels may sometimes come off in the freezer but it's their expectations that food items that are open are properly dated and labeled.

Based on observations, record reviews, interviews, review of facility policy and review of manufacturer labeling, the facility failed to ensure that medications were properly stored in 2 of 3 medication rooms and 5 of 10 medication carts. Findings include: Review of the facility's policy titled Storage of Medications revised on [DATE], documented, Drugs and biologicals used in the facility are stored in locked compartments . and Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. During an observation on [DATE] at approximately 11:10 AM, of the 200 Hall medication room and an open storage area behind the nursing station revealed the following: -One bottle Sterile 0.9% (percent) Normal Saline, USP (United States Pharmacopeia) by Medline 100 ml (milliliter) opened, approximately one-half full and dated by facility [DATE], manufacturer label stated: Contents sterile unless container is opened or damaged. Do not reuse. -One tube of Skintegrity Hydrogel 4 oz. (ounce) by Medline opened, approximately ,d+[DATE] full with manufacturer expiration date ,d+[DATE]. -One unopened package of Lubricating Jelly by Medline 0.09 oz. with manufacturer expiration date [DATE]. On [DATE] at approximately 11:25 AM, these finding were confirmed by Licensed Practical Nurse (LPN)1. During an observation on [DATE] at approximately 11:31 AM, of the 300 Hall Medication Room revealed the following: -One bottle of Ready Prep PVP 4 oz. ,d+[DATE] full, with expiration date of ,d+[DATE]. -One tube of Sting Free Liquid Skin Prep and Shield by Dermalite 2 oz. ,d+[DATE] full with manufacturer expiration date [DATE]. -One package of Curad Xerofoam Dressing 4 x 4 (inch) with manufacturer expiration [DATE]. On [DATE] at approximately 11:40 AM, these findings were confirmed by LPN2. During an observation on [DATE] at approximately 10:17 AM, of the 300 Hall medication cart 2, 300 Hall revealed the following: -One opened, not dated, in use container of Breyna 80 mcg (microgram)/4.5 mcg. -One opened, not dated, in use container of Spiriva Respimat 2XXX,d+[DATE].5 mcg. -One opened, not dated, in use container of Symbicort 80 mcg/4.5 mcg. -One opened, not dated, in use container of Arnuity Ellipta 100 mcg. On [DATE] at approximately 10:20 AM, these findings were confirmed by LPN3. During an observation on [DATE] at approximately 10:25 AM, of the 300 Hall Treatment cart revealed: -Eleven packages of Sani-Cloth Large wipe, expired ,d+[DATE]. On [DATE] at approximately 10:31 AM, this finding was confirmed by LPN2. During an observation on [DATE] at approximately 10:35 AM, of the 200 Hall Treatment cart revealed the following: -Two tubes of Skintegrity Hydrogel 4 oz. (ounce) expired ,d+[DATE]. -One bottle Sterile 0.9% Normal Saline 100ml, ,d+[DATE] full dated as opened [DATE], labeled Sterile until opened, single use only. On [DATE] at approximately 10:39 AM, these finding was confirmed by LPN1. During an observation on [DATE] at approximately 10:41 AM, of the Hall 100 Treatment cart revealed the following: -One single use packet Hibiclens 15ml expired ,d+[DATE]. -One package Aplicare Alcohol Swabsticks 3's expired ,d+[DATE]. On [DATE] at approximately 10:50 AM, these finding was confirmed by RN2. During an observation on [DATE] at approximately 10:44 AM, of the house wide treatment cart stored on Hall 100, revealed the following: -One unopened bottle [NAME] Sterile Water by Coviden, 100 ml expired [DATE]. On [DATE] at approximately 10:52 AM, this finding was confirmed RN3. Review of the Consultant Pharmacist QI Summary dated April - [DATE], revealed expired and undated meds identified and reported to facility for further action.

Based on review of facility policy, record review, observation and interview, the facility failed to develop and implement Resident (R)71's Comprehensive Care Plan, to include the usage of a Continuous Positive Airway Pressure (CPAP) machine for treatment of obstructive sleep apnea. Findings include: Review of the facility policy titled Care Planning with a revised date of 03/2022, states, 1. Resident care plans are developed according to the timeframes and criteria established by 483.21. The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at S 483.10(c)(2) and S 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team. Review of R71's Face Sheet revealed R71 was admitted to the facility on [DATE], with diagnoses including, but not limited to: obstructive sleep apnea, hypertension, iron deficiency, neoplasm rectum, neoplasm of prostate, morbid obesity, pulmonary nodule, tobacco use (smoker), and type 2 diabetes mellitus without complications. Review of R71's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/07/24, revealed R71 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R71 was cognitively intact. Further review of the MDS revealed R71 did not exhibit signs of rejecting care. Review of R71's Physician Orders revealed R71 had no order for Continuous Positive Airway Pressure (CPAP) treatment. Review of R71's Care Plan revealed no care plan to instruct staff how to provide effective and person-centered care of the resident, regarding CPAP treatment. During an observation and interview on 10/21/24 at 1:04 PM, revealed R71 had a CPAP machine on the nightstand with a gallon of distilled water next to the CPAP machine. R71 stated he used the CPAP machine last night. During an observation and interview on 10/22/24 at 9:05 AM, revealed R71 had a CPAP machine on the nightstand, with the CPAP mask behind the nightstand. R71 stated he used the machine until 4:30 AM, because it ran out of distilled water. During an interview on 10/23/24 at 9:10 AM, the Unit Manager revealed that R71's CPAP machine showed up to the facility and she had no orders. The Unit Manager stated the resident will be care planned to reflect the treatment. During an interview on 10/24/24 at 9:22 AM, the Director of Nursing (DON) revealed that she spoke about R71's CPAP machine being at the facility with no instructions for two days. R71 went to the physician and there were no orders for the CPAP machine. The DON further stated, The patient had went to the front and got the device himself, I'm assuming. The distilled water came from the nurses. The DON concluded, I expect my nurses to follow physician orders. The CPAP machine should not have been in his room until we got the order. The proper orders would have been in, and the equipment would have been stored properly and proper documentation. We review orders in the morning with MDS, treatments are expected to be care planned. During an interview on 10/24/24 at 10:21 AM, the Operations Manager revealed that staff are to follow process and procedures to ensure that it has an order and appropriately care planned.

Based on review of facility policy, observations, record review, and interviews, the facility failed to ensure Resident (R)56 was not served food based on allergies/preference, for 1 of 24 residents reviewed. Findings include: Review of the facility's policy titled Nutrition assessment dated 2001, revealed, Policy Statement: As part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident. Policy Interpretation and Implementation: 1. The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframes) and as indicated by a change in condition that places the resident at risk for impaired nutrition. 3. (a. 11) Food restrictions, including food allergies and cultural or religious practices affecting food choices; and . Review of R56's Face Sheet revealed R56 was admitted to the facility on [DATE], with diagnoses including but not limited to: end stage renal disease, type two (2) diabetes mellitus with diabetic chronic kidney disease, dependence on renal dialysis, peripheral vascular disease unspecified, and acquired absence of left leg below knee. Review of R56's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/21/24, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R56's cognition is intact. Review of R56's Meal Ticket for 10/22/24, revealed Allergies: Eggs and Notes: NO EGGS. Review of R56's Care Plan with a start date of 09/18/24, documented, Problem, Allergy: Risk for allergic reaction due to Ibuprofen, Onion, Bactrim, Egg-derived Products. Documented goal, Will remain free from signs or symptoms of allergic reaction. Documented approach, Monitor for signs/symptoms of allergic reaction such as rash, hives, itching and notify physician promptly if reaction occurs. During an interview on 10/21/24 at 2:24 PM, R56 stated in reference to the food served at the facility, It's ok, no flavor in potatoes. R56 further stated that the facility will bring things that is on the dislikes lists and gave him an egg salad sandwich once, on the day of dialysis, although eggs were on the dislike list. However, R56 stated there are alternatives. During an observation and interview on 10/22/24 at 8:30 AM, R56 finished his breakfast and the tray was observed without a meal ticket. R56 stated the Admissions Director had spoken to him and took the meal ticket because a correction was made. R56 stated they served him eggs and had to get it fixed. During an interview on 10/22/24 at 8:51 AM, the Admissions Director stated there were eggs on R56's tray. The Admissions Director further stated dietary was notified of the allergy to eggs and the meal ticket was left with dietary. A request was made for the meal ticket. During an interview and record review on 10/22/24 at 9:00 AM, the Director of Nursing (DON) presented the meal ticket from 10/22/24 and documented on the meal ticket was eggs as an allergy highlighted in red and in the notes it stated, NO EGGS. During an interview on 10/22/24 at 9:01 AM, the Dietitian stated the Admissions Director came to report that R56 had eggs on their breakfast tray and the resident had an allergy to eggs. The Dietitian stated R56 was given bacon, a cinnamon roll, and Rice Krispies. The Dietitian further stated that an apology was given to R56 for the incident. In addition, the [NAME] was made aware of the incident and reported to the Dietitian that they did not see the allergy on the meal ticket. The Dietitian also made the Dietary Manager aware of the incident. During an interview on 10/22/24 at 9:07 AM, the Admissions Director stated they knew it was a liability to leave the eggs in the room so they removed the eggs from the plate and left the cinnamon roll on the plate for R56 to eat while they went to dietary to make the correction. During an interview on 10/24/24 at 9:31 AM, the Dietary Manager reported that their role was to check allergies on meal ticket. Normally they will handwrite an alternative provided if allergens are being served for that meal.

40417 This deficient practice has two Deficient Practice Statements A. Based on observations, record reviews, interviews, and policy review, the facility failed to ensure that 2 of 2 residents (Residents (R) 14 and R32) reviewed for tracheostomy (trach) care in the sample of 23 residents had the necessary supplies at the bedside in the event of a life-threatening emergency, and failed to train staff on appropriate emergency tracheostomy care in the event that a resident's airway was compromised, which placed residents with a tracheostomy at increased likelihood of serious harm or death. On [DATE] at 9:05 PM, the Administrator and the Regional Director of Operations were informed of an Immediate Jeopardy (IJ) at F695-J: Respiratory/Tracheostomy Care and Suctioning. The Immediate Jeopardy began on [DATE] when the survey team identified the concerns related to the facility not having readily available emergency tracheostomy supplies and the facility failed to train staff on what to do in the event the resident's trach was dislodges from the airways for R14 and R32. The facility provided an acceptable removal plan on [DATE] at 1:15 PM. On [DATE] at 05:20 PM, the Administrator was notified that the IJ was removed but the deficient practice existed at F695-D. Findings include: Review of the facility's policy titled, Skills and Techniques Evaluation revised ,d+[DATE] revealed .The Skills and Techniques Evaluation is completed during job-specific orientation revalidated annually .documents skill validation and or return demonstration of skills and techniques identified as necessary to care for patient' needs . Reviewed of an untitled binder provided by the Administrator for clinical staff competencies for ,d+[DATE] revealed there were no training or return demonstrations of emergency tracheostomy care in the event the tracheostomy tube was dislodged provided by the facility. Review of the facility's policy titled, Tracheostomy tube cannula and stoma care dated [DATE] revealed, .To prevent infection, perform tracheostomy care using sterile technique .unintentional decannulation Be prepared for emergency replacement by keeping at the bedside a new tracheostomy tube with obturator that is the same size as originally placed tube and a new tracheostomy tube with an obturator that's one size smaller . replace the tube .follow .steps .start with the same size tracheostomy tube .If you encounter problems with reinserting switch to a tube that is one size smaller .using sterile technique . Review of the facility's policy titled, Laryngectomy stoma and tube care dated ,d+[DATE] revealed, .It is important to know what type of laryngectomy, particularly if the resident requires emergency care or an airway intervention. Patients who have undergone total laryngectomy require bag-mask ventilation over the stoma .because there is no communication between the trachea and upper airway . surgeon .bringing the trachea to the opening created in the neck .When the stoma heals, the patient can use a baseplate or laryngectomy tube .Coughing up or clearing mucous must occur through the stoma . Proper laryngectomy stoma care is crucial to maintain stoma patency and prevent complications, such as fistula, stomal stenosis, peristomal skin irritation, stomal crusting, and airway obstruction . Inspect all equipment and supplies. If a product is expired is defective, or has compromised integrity, remove it from patient use, label it as expired or defective, and report the expiration or defect as directed by your facility . verify the practitioner's order . 1. Review of R14's undated Admission Record Report, located in the hard chart, revealed R14 was admitted to the facility on [DATE] with a trach and a diagnosis of brain damage. Review of R14's annual Minimum Data Set (MDS), located in the EMR, under the MDS tab, with an Assessment Reference Date (ARD) of [DATE], revealed the Brief Interview for Mental Status (BIMS) was incomplete. The MDS revealed R14 had a trach. Review of R14's comprehensive Care Plan, under the Care Plan tab located in the EMR and revised on [DATE], revealed .Has/At risk for respiratory impairment related to tracheostomy . Further review of the care plan revealed no information for emergency management of tracheostomy, no style, size, or cuff or uncuffed tracheostomy information, and no intervention related to emergency management of R14's tracheostomy. Review of R14's Order Summary Report, dated [DATE], located in the EMR under the Orders revealed the following: .Change trach collar weekly and as needed . dated [DATE]. .Change Trach Inner Canula . dated [DATE] without specific information about the inner cannula [it should be noted that there can be significant differences between the different manufacturer's tubes]. Suction PRN or ___ (frequency) every day shift for Maintain patent airway . .Trach care daily and PRN [as needed]: For disposable: remove and dispose of inner cannula. Replace with new inner cannula. every day shift for Reduce risk of infection . dated [DATE] and without specific information about the inner cannula [it should be noted that there can be significant differences between the different manufacturer's tubes]. Further review of the physician orders in the EMR under the Orders tab revealed no order for an emergency tracheostomy kit at the bedside. The orders did not include patient specific tracheostomy details (brand, style, cuffed or uncuffed). Review of R14's Treatment Administration Record (TAR), located in the EMR under the Orders tab and dated ,d+[DATE], revealed: .Suction PRN or ___ (frequency) every day shift for Maintain patent airway . staff's initials documented the procedure was performed from [DATE] through [DATE]. .Trach care daily and PRN: For disposable: remove and dispose of inner cannula. Replace with new inner cannula . with no specific direction for cleaning the skin around the stoma and assessing for complications. Review of the TAR revealed staff initials documented for [DATE] through [DATE] indicating care was provided. During an interview on [DATE] at 8:05 PM, Licensed Practical Nurse (LPN)1 verified R14's physician orders did not include patient specific tracheostomy details. During an observation on [DATE] at 12:20 PM, R14 was lying in bed with a suction machine at her bedside. Emergency tracheostomy supplies were not visible at her bedside. R14 did not have an ambu bag or replacement tracheostomy tube at her bedside. During an observation on [DATE] at 1:53 PM, R14 did not have an ambu bag, a visible spare tracheostomy or an emergency kit at her bedside. R14 had a suction catheter machine at her bedside. During an interview on [DATE] at 3:40 PM, Certified Nurse Aide (CNA)1 stated that she assisted with R14's care. She stated the facility had not provided training for trach or any emergency trach management training. CNA1 stated if R14's trach came out it was her responsibility to notify the charge nurse. During an observation and interview on [DATE] at 3:47 PM, LPN1 verified R14 did not have an ambu bag or emergency trach kit at R14's bedside. LPN1 pointed at R14's supply of inner cannulas and identified them as R14's replacement tracheostomy tube. She said her responsibility was to replace the trach if it came out. LPN1 stated that she was not sure what size trach R14 required or had in her stoma. LPN1 looked at R14's trach and stated she could not see the brand, type or size. She stated R14 had an order to receive suction as needed. She stated the facility had not provided training for trach or any emergency trach management training and had not been asked to show skills or knowledge with emergency management of a trach or any trach care. During an observation and interview on [DATE] at 4:03 PM, the MDS Coordinator verified R14 did not have an ambu bag at her bedside and stated she did not understand what an emergency trach care kit included. The MDS Coordinator stated it was her responsibility to put R14's trach back in if it came out. The MDS Coordinator identified R14's supply of inner cannulas as R14's replacement tracheostomy tube. She said she was not sure what size trach R14 required or had in her stoma. The MDS Coordinator looked at R14's trach and stated she could not see the brand, type or size. She stated R14 had an order to receive suction as needed. She stated the facility had not provided training for trach or any emergency trach management training. During an observation and interview on [DATE] at 4:11 PM, Registered Nurse (RN)1 verified R14 did not have an ambu bag, replacement trach or emergency trach kit at her bedside. RN1 identified a bag that read manual emergency resuscitator she verified the bag was empty and stated an ambu bag should be in that bag. RN1 stated it was the nurses' responsibility to replace R14's trach immediately if it came out. She said the trach should be replaced with the same size trach or one smaller. RN1 stated replacement trachs were kept in the storage room on 300. During an observation of the 300-hall storage room on [DATE] at 4:30 PM, RN1 verified there were no replacement tracheostomy tubes in the storage room. RN1 stated she had not received training regarding trach care or emergency management of a tracheostomy. Review of Basic Crash Cart Checklist located on the 100 hallway (provided by LPN1) and 200 hallway (provided by RN2) revealed no tracheostomy supplies listed. During an interview on [DATE] at 8:00 PM with LPN1 and on [DATE] at 8:05 PM with RN2, both stated trach supplies were not on the crash cart. During an observation and interview on [DATE] at 4:21 PM, the Unit Manager-RN (UM-RN) stated if R14's trach came out the nurse would attempt to reinsert it. The UM-RN identified R14's supply of inner cannulas as R14's spare trach. She said the ambu bag was down the hallway on the crash cart. The UM-RN stated she thought R14's trach tube was an uncuffed Shiley brand but did not know the size. The UM-RN verified trach sizes were specific to each resident. The UM-RN stated R14's trach dislodging would be an emergency. The UM-RN stated she had not received training regarding emergency trach care and had not been required to demonstrate trach competencies. During an interview on [DATE] at 6:03 PM, the Medical Director stated she expected nurses to be trained, be able to identify emergency situations and have equipment to address emergency situations at the bedside of a resident with a trach. She stated she expected the facility should follow their policy regarding emergency supplies needed at the bedside. 2. Review of R32's undated Admission Record located in the EMR revealed R32 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses to include malignant neoplasm of larynx and, chronic obstructive pulmonary disease. Review of R32's admission MDS with an ARD of [DATE] revealed a BIMS score of 14 out of 15 indicating she was cognitively intact. The MDS indicated that R32 was not provided tracheostomy care or suctioning. Review of R32's Physician's Orders under Orders tab located in the EMR revealed .Laryngeal [Laryngectomy stomas are formed following excision of the larynx, usually for the treatment of an underlying malignancy. This is a permanent stoma in which the trachea is separated from the esophagus and brought to an opening in the neck] tube care BID [twice a day] Cleanse with soap and water pat dry . dated [DATE]. There was no order for emergency management of laryngeal tube (trach stoma), no suctioning information and no specific information for brand, type, or size of laryngeal tube. Review of R32's TAR dated ,d+[DATE] revealed .Laryngeal tube care BID Cleanse with soap and water pat dry . [DATE]. There was no order for emergency management of laryngeal tube (trach stoma), no suctioning information and no specific information for brand, type, or size of laryngeal tube. Review of R32's comprehensive Care Plan revealed .Maintain and use artificial larynx .Maintain patent airway Date Initiated: [DATE] . Maintain replacement laryngeal tube and Ambu [A bag valve mask (BVM), sometimes referred to as an Ambu bag, is a handheld tool that is used to deliver positive pressure ventilation to any subject with insufficient or ineffective breaths. It consists of a self-inflating bag, one-way valve, mask, and an oxygen reservoir] bag at bedside Date Initiated: [DATE] . The Care Plan did not indicated emergency management of trach/laryngeal tube, no suctioning intervention, and no patient specific information of laryngeal tube replacement (brand, type or size). During an observation on [DATE] at 12:36 PM, R32 was sitting on the bed and did not have an emergency kit, laryngeal replacement tube or ambu bag at her bedside. During an observation on [DATE] at 2:03 PM, R32 still had no emergency trach kit, no laryngeal replacement tube, and no ambu bag was at her bedside. During an observation and interview on [DATE] at 4:32 PM, R32 was in her room with UM1. The UM1 stated R32 had a [NAME] [laryngeal] tube and it was rubber material and was clean. The UM1 stated R32 had facial paralysis and the [NAME] tube maintained her airway. The UM1 stated R32 did not have a spare laryngeal tube at her bedside and should have. UM1 stated she expected the nurses to replace R32's laryngeal tube. UM1 stated R32 did not have an emergency kit at her bedside or an Ambu bag. UM1 stated she could not remember when the last training for tracheostomies was provided by the facility, but knew it was over a year ago. During an observation and interview on [DATE] at 4:34 PM, R32 was in her room with RN2 who stated he provided care for R32, and she had a [NAME] tube. RN2 stated R32's [NAME] tube was used for breathing. RN2 stated he did not provide a demonstration of his competency skills or knowledge of how to care for a resident with a [NAME] tube to the facility. RN2 stated R32 did not have an ambu bag or emergency kit trach tube, replacement laryngeal tube, or sterile kit for suctioning at her bedside. RN2 stated if R32's laryngeal tube came out it was an immediate life situation for R32. RN2 stated he would put R32's laryngeal tube in with whatever supplies that were readily available even the used one that was dislodged. RN2 stated he would clean it up and put it back in. RN2 stated if R32's same size laryngeal tube would not go back in her stoma, he would attempt to reinsert a smaller size. RN2 stated residents with a trach or laryngeal tube required two replacement trachs, one the same size and one smaller at the bedside. RN2 stated he didn't know where the facility stored the replacement trachs or laryngeal supplies. During an interview on [DATE] at 4:44 PM, CNA3 stated if a resident's decannulated or dislodged tracheostomy/laryngeal tube occurred was to get the nurse. CNA3 stated a resident's trach/laryngeal tube dislodgement was an emergency. CNA3 stated she was not provided training for trach/laryngeal tube emergency management by the facility. During an interview on [DATE] at 4:54 PM, CNA6 stated she was not responsible for trach care. CNA6 stated she doesn't remember if the facility had provided her with training for trach care. CNA6 stated she was not sure what to do for a resident with a trach/laryngeal tube while providing the resident with a shower. CNA6 stated the facility should have provided her trach/laryngeal tube training. During an interview on [DATE] at 5:22 PM, LPN2 stated the facility had not provided any training for suctioning, trach care, replacing a trach, or any emergency trach care. LPN2 stated if a resident's trach came out, she would use sterile technique to reinsert it. LPN2 stated it would be considered an emergency if a resident's trach came out. During an interview on [DATE] at 6:01 PM, the Administrator confirmed the facility used Lippincott hospital procedures for their resource for policies and procedures. The Administrator confirmed the DON was responsible for ensuring the clinical staff were competent with trach care. During an interview on [DATE] at 6:32 PM, the Administrator stated it was leadership's (Administrator and the DON) responsibility to ensure the facility central supply clerk and unit managers ordered and provided resident's medical supplies at the facility. During an interview on [DATE] at 6:21 PM, the DON verified R32 did not have a physician's order to suction her laryngeal tube and should have had an order. The removal plan included physician order revisions, placing tracheostomy supplies at the bedside in each resident's room, in-servicing nursing staff regarding tracheostomy care, revising residents' care plans and physician order revisions, placement of emergency supplies in the supply room. Following interviews with facility staff, observation of tracheostomy supplies, clinical record review of revised care plans and physician orders, and review of staff in-services for emergent trach care, the survey team verified implementation of the Removal Plan and removed the IJ on [DATE] at 5:18 PM. B. Based on observation, record review, interview and policy review, the facility failed to ensure oxygen concentrators currently used by residents, had clean filters for 2 of 2 Residents (R17 and R49) reviewed for oxygen use. Findings include: Review of the facility's policy, Oxygen Administration dated ,d+[DATE] indicated, .Preparation of Equipment .2. For oxygen concentrator . If using concentrator: Clean filter weekly: Remove filter from back or sides of concentrator Rinse filter with water Shake off excess water. Air dry. Replace filter . 1. Review of the EMR revealed R17 was admitted to the facility on [DATE] with diagnoses which included congestive heart failure, heart disease and pulmonary hypertension Review of R17's EMR under the Orders tab revealed a Physician's order dated [DATE], which indicated, Oxygen via nasal cannula 2 LM [Liters per minute] every shift for hypoxia to keep O2 [oxygen] over 90%. During an observation on [DATE] at 12:20 PM, R17 was in her bed wearing a nasal cannula attached to the oxygen concentrator. The filter on the side of the machine was coated with an off-white layer of dust. Review of the EMR under Face Sheet, revealed R49 was admitted to the facility on [DATE] with diagnoses which included congestive heart failure, chronic and obstructive pulmonary disease, 2. Review of R49's EMR under the Orders tab revealed a Physician's order dated [DATE], which indicated, Oxygen 3 LM via nasal cannula to keep O2 sat greater than 92%. During an observation on [DATE] at 1:05 PM, R49 was in her bed wearing a nasal cannula attached to the oxygen concentrator. The filter on the back of the machine was coated with a thick layer of off-white dust. During an interview on [DATE] at 12:50 PM, the Administrator was shown R17 and R49's oxygen concentrator filters. The Administrator agreed the filters were dirty and the expectation was to have a clean filter. The Administrator stated the filters should be cleaned weekly by the nursing staff. During an interview on [DATE] at 3:30 PM, LPN1 stated she thought maintenance was responsible for cleaning the oxygen concentrator filters. During an interview on [DATE] at 3:33 PM, LPN4 stated she thought maintenance was responsible for cleaning the oxygen concentrator filters. During an interview on [DATE] at 3:55 PM with Maintenance Director (MD), he stated he has never been asked to clean the oxygen concentrator filters. MD said he thought cleaning the oxygen concentrator filters was a nursing staff responsibility.

Based on observations, interviews, record review and review of the facility policy, the facility failed to ensure 1 Resident ((R) 56) of 2 sampled residents' urinary catheter collection bag was positioned above the level of R56's bladder. The facility's deficient practice increased R56's risk of urinary tract infections. Findings include: Review of the facility's undated policy titled, Catheter Care: Indwelling Cather-Resident Services revealed, .catheter care hygiene for residents with indwelling catheter .check that tubing is not looped, kinked, clamped or positioned above the level of the bladder . Review of R56's undated Admission Record located on the Electronic Medical Record (EMR) revealed admitted to the facility on [DATE] with diagnosis acute kidney failure. Review of R56's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/01/23 and located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating she was cognitively intact. The MDS indicated R56 had an indwelling catheter with renal insufficiency with urinary tract infection in the last 30 days and no neurogenic bladder diagnosis. Review of R56's Physician's Orders dated 02/13/23 under Orders tab located on the EMR revealed .Maintain Foley catheter .for urinary retention every shift . Review of R56's Treatment Administration Record (TAR) dated 02/23 under the Orders tab located on her EMR revealed .Maintain Foley catheter . Review of R56's comprehensive Care Plan under Care Plan tab located on the EMR revealed .Use of indwelling urinary catheter needed due to urinary retention . Maintain drainage bag below bladder level Date Initiated: 01/28/2023 . During an observation on 02/14/23 at 11:46 AM, two facility staff members (Speech Therapist (ST) and the Rehab Director (RBD)) escorted R56 to her room in her wheelchair. R56's urinary collection bag was attached to the left side of the wheelchair, near her arm rest and above the level of her bladder. RBD and ST stated at the time of the observation, the facility did not provide them with catheter care training. RBD confirmed R56's indwelling catheter collection bag was above the level of her bladder and should not be positioned there. Cloudy yellow urine was observed in the tubing and the urinary catheter collection bag. During an interview on 02/14/23 at 2:53 PM, the Nurse Practitioner (NP) stated R56 had an indwelling urinary catheter and that the urinary catheter collection bag should be positioned below the level of the bladder due to assistance with drainage and prevent back flow into the bladder. NP stated it was not best practice to transport R56 to her room with the collection bag above the level of her bladder. During an interview on 02/14/23 at 5:37 PM, the Director of Nursing (DON) stated the indwelling catheter collection bag should remain below the level of the bladder for infection control practices. DON stated resident's urinary catheter collection bag should not be attached to the arm of their wheelchair during transport. The DON stated urine back flow into the bladder could cause infections.

This requirement is not met as evidenced by: Based on record reviews, interviews and observations the facility failed to ensure one of two residents (Resident #3) investigated for feeding tubes had their feeding tubes aspirated for gastric volume prior to medication administration placing the resident at risk for blockage of tubing or inadequate delivery of medication. The findings include: Resident #3: Record Review of MDS on 8/5/2020 at 2 pm, revealed Resident # 3 admitted to facility 11/26/2010 with [DIAGNOSES REDACTED]. No significant weight change. Medications ordered via feeding tube. No accidental gtube removals in past five months. Review of Feeding Tube policy 8/5/2020 at 7 pm revealed the facility process for checking gtube placement prior to medication administration stated .for continuous and intermittent feedings, aspiration of gastric volume must be done prior to medication administration. Interview with sister of Resident #3 on 8/6/2020 at 10:30 AM, revealed the family has no complaints or concerns with the care the resident is receiving at the facility. She stated the resident is always clean and neat. She stated the resident had an issue with having her gtube accidentally pulled out when the staff used only one person to move her, but there has not been an issue since before March. Observation:8/5/2020 at 12:15 AM, Resident #3in bed, HOB elevated approximately 30 degrees, non-verbal, [MEDICAL CONDITION] intact, gtube dressing clean and dated, feeding infusing, respirations unlabored. LPN #3, entered resident's room, identified him/herself and paused the feeding infusion. S/he placed the syringe for medication administration into gtube. The gtube was not aspirated for gastric contents. It was flushed by gravity with 30 cc warm water, medications administered x 2 with 5 cc water flush between medications. It was then flushed by gravity with 30cc warm water, feeding reconnected, feeding pump checked for correct flow rate. LPN #3 performed hand hygiene prior to and after care. Resident appeared quiet throughout procedure no signs of respiratory distress. Resident #8: August 6, 2020 at 11 AM, review of Resident #8 MDS revealed resident admitted to facility 5/29/2020 with [DIAGNOSES REDACTED]. No significant weight change. Medication ordered by physician to be administered via feeding tube. Feeding Tube policy stated .for continuous and intermittent feedings, aspiration of gastric volume must be done prior to medication administration. Interview: Unable to contact family after several attempts. LPN #5 interviewed and stated Resident #8 has had no problems with gtube blockage or leaking. Resident also has no history of residuals when checked prior to medication administration or every shift for proper placement. When questioned about how often the gtubes are flushed she stated gtubes are flushed via the feeding pump and checked each shift for residuals and patency as well as prior to any medication administration. Observation of Resident #8 on 8/6/2020 at 11:10 am resident in bed, HOB elevated approximately 30 degrees, non-verbal, [MEDICAL CONDITION] intact, gtube dressing clean and dated, feeding infusing, respirations unlabored. LPN #5 entered the resident's room, paused the feeding infusion, auscultated for correct gtube placement, then placed syringe for medication administration onto gtube and aspirated for residual feeding. The gtube was flushed by gravity with 30 cc warm water, the medication was administered and the gtube was flushed with another 30cc of warm water. The feeding was reconnected, feeding pump checked for correct flow rate. LPN #5 performed hand hygiene prior to and after care. Resident appeared quiet throughout procedure.

Based on observations, record reviews and interviews the facility failed to ensure 2 of 3 residents (Resident #2 and Resident #6) were free of potential pressure wound contamination, placing the residents at risk for infection. The findings include: During wound care observation of Resident #2 on 8/5/2020 , Resident #2 lying in bed, tv on, eyes closed, non-verbal, dressed in hospital gown, pillows under both legs and behind back to position slightly left side up. RN #1 knocked, announced him/herself, entered room with wound care supplies after gowning and gloving per protocol. S/he performed hand hygiene prior to beginning the dressing change. S/he removed a pair of scissors from his/her pocket, used them to cut the xeroform gauze and placed them back in his/her pocket. S/he did not clean the scissors before or after using them. The resident was repositioned left side up with the assistance of CNA #1, and the resident's incontince brief was removed to access the pressure ulcer site. The resident had loose stool in the brief which was partially cleaned by RN #1 prior to removing the pressure ulcer dressings. S/he removed the two sacral dressings, cleaned the remaining stool, then used the same wipe to clean around the two sacral pressure ulcer sites. S/he changed gloves, performing hand hygiene prior to regloving. S/he cleaned the pressure ulcer, applied Santyl with clean gauze, placed new adhesive dressing,dated and initialed it with a sharpie marker s/he had dropped on the floor and did not clean off. S/he again changed gloves and performed hand hygiene prior to regloving. S/he cleaned the second sacral pressure ulcer site, applied Santyl and the adhesive dressing. S/he did not change gloves, then removed the dressing from the residents left leg, applied new xeroform gauze and a new dressing, dated and initialed the dressing. S/he collected the trash, removed his/her gown and gloves and performed hand hygiene prior to leaving the room. Record Review: 8/5/2020 at 1 PM revealed Resident #1 was admitted to facility 6/1/2020 with [DIAGNOSES REDACTED]. Wound care treatments documented as completed daily. 8/6/2020 at 2:30 pm, Review of skin policy revealed policy stated in part .resident care to provide measures to prevent infection and cross-contamination. Review of hand hygiene policy revealed staff to do hand hygiene before and after dressing changes and when moving from contaminated to clean body site. Interview: 8/5/2020 Interview with RN #1 confirmed hand hygiene is perfomed prior to procedure, when gloves are changed and when finished with the procedure. S/he confirmed items used to clean contaminated areas are not to be used on other areas for cleaning. When asked how often residents are repositioned if they are unable to reposition themselves, s/he replied resident's who are unable to reposition themselves are repositioned every two hours and the incontinence brief is changed if needed. 8/5/2020 Interview with CNA #1 verified residents are repositioned after morning care and morning meals, and every 2 hours thoughout the day. S/he stated when s/he observes the residents, if they are in the same position for several hours s/he repositions them. Resident #6 Observation: 8/5/2020 at approximately 2:30 pm, LPN #3 obtained supplies from treatment cart. A styrofoam cup filled with liquid, covered with top and a straw sticking out of the top noted on top of treatment cart near room [ROOM NUMBER]. LPN #3 knocked on the door of Resident #6, announced his/herself, perfomed hand hygiene and set up his/her dressing change area. S/he removed scissors from his/her pocket and cut a package of xeroform gauze and placed the scissors back in his/her pocket. The scissors were not cleaned prior to or after use. S/he performed hand hygiene, gloved and removed the sacral dressing. S/he removed the gloves, performed hand hygiene, regloved then cleaned and redressed the sacral pressure ulcer, dated and initialed the dressing. S/he removed the gloves, performed hand hygiene, regloved and removed the left knee dressing. S/he removed the gloves, perfomed hand hygiene, regloved, cleaned and dressed the wound, dated and initialed the dressing. S/he collected her trash, removed the gloves and perfomed hand hygiene prior to leaving the resident's room. Record Review:8 /5/2020 at 4 pm revealed resident admitted to facility 6/14/19 with [DIAGNOSES REDACTED]. Wound care treatments documented as completed daily. 8/6/2020 at 2:30 pm, Review of skin policy revealed policy stated in part .resident care to provide measures to prevent infection and cross-contamination. Review of hand hygiene policy revealed staff to do hand hygiene before and after dressing changes and when moving from contaminated to clean body site. Interview: 8/5/2020 approximately 2 pm LPN #3 interviewed, when asked what training s/he received to be able to perform dressing changes, s/he stated the nursing staff have yearly pressure ulcer care competencies they must complete, as well as hand hygiene competencies. 8/5/2020 approximately 11:30 am Interview with RN #1 confirmed hand hygiene is perfomed prior to procedure, when gloves are changed and when finished with the procedure. S/he confirmed items used to clean contaminated areas are not to be used on other areas for cleaning.

Based on observations and interviews, the facility failed to provide residents with dignity by not knocking on the resident door before entering their rooms. Staff was observed entering residents' rooms without knocking on 2 of 3 Units observed (100 and 200). The findings included: During the initial tour on 6/17/19 at approximately 9:53 AM a Certified Nursing Aide (CNA) was observed entering a resident room [ROOM NUMBER] without knocking. At approximately 9:55 AM on 6/17/19 at 9:55 AM a CNA and nurse were observed entering resident room [ROOM NUMBER] without knocking. During an interview on 6/17/19 at approximately 9:57 AM with Registered Nurse (RN) #1 s/he confirmed the observations. RN #1 stated s/he does not knock on a resident's door if the door was opened. RN #1 then added s/he does not knock if the door was opened and the call light was on. A random meal observation on 6/17/19 at approximately 12:54 PM revealed some staff members were knocking on resident room prior to entering and some were not. Staff generally was observed knocking on resident's doors when the room door was closed. During a random observation on 6/17/19 at approximately 10:16 AM revealed Certified Nursing Assistant (CNA) #1 entering room [ROOM NUMBER] without knocking. Interview with the CNA confirmed s/he had failed to knock before entering.

Based on observation and interview, the facility failed to maintain a clean, homelike environment on 1 of 3 units observed during the survey. The base boards in 3 shared bathrooms were observed to be unclean. The findings included: During an observation of the shared bathroom for rooms [ROOM NUMBERS], on 6/17/19 at 10:45 AM, the base boards appeared unclean, with a heavy buildup of stains and splatter marks. During an observation of the shared bathroom for rooms [ROOM NUMBERS], on 6/17/19 at 2:20 PM, the base boards appeared unclean, with a heavy buildup of stains and splatter marks. During an observation of the shared bathroom for rooms [ROOM NUMBERS], on 6/19/19 at 9:04 AM, the base boards appeared unclean, with a heavy buildup of stains and splatter marks. During an interview on 6/17/19 at 10:45 AM, Resident #10 stated s/he had reported to staff some time ago that the bathroom needed additional cleaning. The resident stated s/he was told they would get to it. The resident couldn't recall exactly when or to whom s/he reported this. During observations and interviews with the Maintenance Director and Nursing Home Administrator (NHA) on 6/19/19 at 9:40 AM, both confirmed the heavy buildup of stains and splatter marks to the base boards. During an interview with the NHA on 6/19/19 at 10:30 AM, the NHA agreed that the base boards appeared to have not been cleaned on regular basis.

Based on interview and record review, the facility failed to respond to pharmacy recommendations for 1 of 5 residents reviewed for unnecessary medications. The pharmacist recommended that Resident #10 be given a trial discharge of [MEDICATION NAME] 5 mg (milligrams), and the physician did not address the recommendation. The findings included: Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. [MEDICAL CONDITION]. Review of Resident #10's orders on 6/19/19 at approximately 11:03 AM revealed the resident received [MEDICATION NAME] ([MEDICATION NAME]) 5 mg qd (everyday). Review of Medication Regimen Reviews for Resident #10 on 6/19/19 at approximately 11:45 AM revealed a 3/8/19 recommendation that the resident be given a trial discharge of [MEDICATION NAME] 5 mg. The physician response to the recommendation could not be found in the chart. During an interview with Director of Nursing (DON) on 6/19/19 at approximately 1:15 PM s/he confirmed there was no documentation that the physician responded to the pharmacist's recommendation.

Based on observation, interview, review of facility policy and manufacturer's instructions, the facility failed to provide sanitary insulin administration during 1 of 1 injection observed during the survey. The nurse failed to clean the Humalog Kwikpen prior to insulin administration for Resident #28. The findings included: The facility admitted Resident #28 with [DIAGNOSES REDACTED]. On 6/18/19 at 11:55 AM, Licensed Practical Nurse (LPN) #1 was observed preparing to administer Insulin for Resident #28. At the medication cart, LPN #1 removed the Humalog Kwikpen, pen needle and alcohol swab from the cart. LPN #1 removed the pen cap and went to Resident #28's room. LPN #1 then used the alcohol swab to cleanse the administration site on Resident #28. LPN #1 attached the pen needle to the rubber seal of the Kwikpen and administered the medication to the resident. LPN #1 did not clean the rubber seal with alcohol prior to giving the injection. During an interview with LPN #1 on 6/18/19 at 12:10 PM, LPN #1 confirmed s/he did not clean the rubber seal with an alcohol swab prior to giving the injection. LPN #1 stated s/he always cleans the rubber seal prior to giving insulin. LPN #1 stated s/he must have forgotten to do this due to nerves. Review of the facility's Medication Administration: Injections policy revealed prior to insulin administration Remove the pen cap and clean the top with alcohol prior to attaching the pen needle. Review of the Humalog Kwikpen manufacturer's instructions revealed, prior to attaching the pen needle Step 1: Pull the Pen cap straight off. Wipe the Rubber Seal with an alcohol swab.

Based on record review and interviews, the facility failed to review and revise a care plan for 1 of 1 sampled resident reviewed for activities. Resident #47's care plan was not updated to address the resident's needs for one to one activities being provided based on documentation that the resident's refusal of group activities that were documented as being offered repeatedly. The findings included: The facility admitted Resident #47 on 3/14/14 with [DIAGNOSES REDACTED]. A further review of the medical record on 3/15/18 at approximately 10 AM revealed a Quarterly Minimum Data Set ((MDS) dated [DATE] and an Annual MDS that indicated that Resident #47 had a Brief Interview of Mental Status (BIMS) score of 2 (not interview-able). A review of a care plan indicated the resident prefers in room activities such as watching television, talk shows and listening to gospel music. A review of the most recent Recreation/Activity Evaluation in the electronic record dated 1/26/17 revealed the resident had interest in pets/animals, card/games, gospel music, movies, television programs. The 1/26/17 Activity Evaluation had a section related to the resident's interest, parties/socials was left blank and the resident had no interest in outdoor activities. The resident was not observed engaged in activities on 3/15/18 from 9 AM to 11:30 AM or 2 PM to 4 PM on the 300 Unit. There were no family members observed visiting during the survey which were included as part of the resident's structure program of activities. A review of the care plan initiated 11/28/17 and revised 5/03/18 indicated under the focus area the resident prefers in room activities such as watching television and visits with family. The care plan under interventions indicated allow resident to choose seating placement, encourage participation in activities, provide assistance to activities, provide brief in-room visits and provide light weight fitting garments for outdoor activities. Per the 1/26/17 Recreation/Activity Evaluation, under enjoys/participation in outdoor leisure activities was coded no. The care plan did not address the resident interest in pet visits per the activity evaluation. An interview on 5/15/18 at approximately 2:27 PM with the Activity Director (AD) revealed the sensory stimulation activity took place during ADL care when the Certified Nursing Aides (CNAs) put lotion on the resident. They confirmed the resident's interest in pet visits and confirmed he/she had no documentation of pet visits being offered/provided to the resident. The AD stated the resident had access to the birds on the unit on (MONTH) 9th when the bird cage was cleaned. The AD confirmed the resident's family was part of the activity program and further stated the family visits the resident 2 to 3 times a month. The surveyor informed the AD that the resident was not observed activities during the survey and the AD confirmed the observation. The AD stated he/she had thought about one to one activities for resident and that he/she had planned on addressing the concern of one to one activities in (MONTH) (YEAR). An interview on 5/16/18 at approximately 12:30 PM with Registered Nurse (RN) #2 confirmed the care plan did not address one to one activities being provided for the resident.

Based on observations, record review and interviews, the facility failed to ensure that 1 of 1 sampled resident reviewed for activities was provided a structured program of activities. Resident #47 was not observed being provided structured activities during the survey. The resident remained in room in bed with no structured activities in progress. The findings included: The facility admitted Resident #47 on 3/14/14 with [DIAGNOSES REDACTED]. During random observations on 5/14/18 during the initial pool process from 10:10 AM to 12:30 PM and 2 PM to 4 PM while Unit 300, Resident #47 was in room in bed. Staff was observed going in room to provide activities of daily living (ADL) care and medications. An observation on 5/14/18 at approximately 10:13 AM revealed a live musical activity in progress. Resident #47 was not observed in the activity provided. An interview on 3/14/18 at approximately 11:38 AM with Registered Nurse (RN) #1 revealed the resident's family members visit two (2) to three (3) times a month. A further review of the medical record on 3/15/18 at approximately 10 AM revealed a Quarterly Minimum Data Set ((MDS) dated [DATE] and an Annual MDS that indicated that Resident #47 had a Brief Interview of Mental Status (BIMS) score of 2 (not interview-able). A review of a care plan indicated the resident prefers in room activities such as watching television, talk shows and listening to gospel music. A review of the most recent Recreation/Activity Evaluation in the electronic record dated 1/26/17 revealed the resident had interest in pets/animals, card/games, gospel music, movies, television programs. The 1/26/17 Activity Evaluation had a section related to the resident's interest parties/socials was left blank and the resident had no interest in outdoor activities. The resident was not observed engaged in activities on 3/15/18 from 9 AM to 11:30 AM or 2 PM to 4 PM on the 300 Unit. There were no family members observed visiting during the survey which were included as part of the resident's structure program of activities. A review of a quarterly activity note dated 7/27/17 indicated the resident was awake on/off during the day and while in geri chair for safety and comfort when out of bed. The resident received assistance with activities of daily living (ADLs). The resident refuses invitations to group activities and resident enjoys resting, watching television and socializing. The note indicated the activity staff will encourage group participation. The resident's family visits for added stimulation and are supportive of care. A review of a quarterly activity note dated 10/12/17 indicated the resident was awake on/off during the day and while in geri chair for safety and comfort when out of bed. The resident received assistance with activities of daily living (ADLs). The resident refuses invitations to group activities and resident enjoys resting, watching television and socializing. The note indicated the activity staff will encourage group participation. The resident's family visits for added stimulation and are supportive of care. A review of a quarterly activity note dated 12/21/17 indicated the resident was awake on/off during the day and while in geri chair for safety and comfort when out of bed. The resident received assistance with activities of daily living (ADLs). The resident refuses invitations to group activities and resident enjoys resting, watching television and socializing. The note indicated the activity staff will encourage group participation. The resident's family visits for added stimulation and are supportive of care. A review of a quarterly activity note dated 3/26/18 indicated the resident was awake on/off during the day and while in geri chair for safety and comfort when out of bed. The resident received assistance with activities of daily living (ADLs). The resident refuses invitations to group activities and resident enjoys resting, watching television and socializing. The note indicated the activity staff will encourage group participation. The resident's family visits for added stimulation and are supportive of care. A review of the Daily Recreation/Activity Participation Documentation for the months of (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) revealed the resident refused activities such as Arts/Crafts, Beauty/Barber Shop, Bingo, Card/Games, Creative/Expressive Activities, Current Events, Educational, Exercise, Gender-Based Program, Physical Activities, Newspaper and Spiritual/Religious Activities. The section on activity participation related to the resident's interest in pet visits were left blank. Further review of the activity participation documentation revealed the resident independent activities were movies, music/singing and television. The participation record indicated the resident was an active participate in socializing and sensory stimulation. Further review of the documented activity program revealed the program was individualized to the resident's cognitive impairment. There was no documentation to indicate the resident's response to activities and the duration of the activities for a cognitively impaired resident. An interview on 5/15/18 at approximately 2:27 PM with the Activity Director (AD) revealed the sensory stimulation activity took place during ADL care when the Certified Nursing Aides (CNAs) put lotion on the resident. The confirmed the resident interest in pet visits and confirmed he/she had no documentation of pet visits being offered/provided to the resident. The AD stated the resident had access to the birds on the unit on (MONTH) 9th when the bird cage was cleaned. The AD confirmed the resident's family was part of the activity program and further stated the family visits the resident 2 to 3 times a month. The surveyor informed the AD that the resident was not observed activities during the survey and the AD confirmed the observation. The AD stated he/she had thought about one to one activities for resident and that he/she had planned on addressing the concern of one to one activities in (MONTH) (YEAR).

Based on record review and interviews, the facility failed to identify and/or diagnose skin wounds for 1 of 4 residents reviewed for pressure sores. Resident #3 was admitted with fungal infection of the skin, developed a cyst right of the sacrum. The resident's skin condition deteriorated and required an incision, drainage and debridement. The facility denied the resident had pressure sores until s/he returned from the hospital. The findings included: Resident #3 was admitted initially to the facility and found on initial assessment was noted with fungal infection on buttocks and posterior upper thigh. No treatment was ordered for the infection until a month after admission. The resident was diagnosed with [REDACTED]. A week later the documented fungal infection was diagnosed as two (2) pressure ulcers (decubiti) by Nurse Practitioner #2. (Treatment was ordered for pressure sores and interventions were put into place.) Nine days later, the treatment was changed for worsening wounds. 11/30/17 the Physician saw the resident and documented resident with multiple decubiti. On 12/6/17 the resident was sent to the hospital for change in condition. The resident returned from the hospital following an I&D, and debridement of wound. S/he had new [DIAGNOSES REDACTED]. The facility admitted resident #3 with [DIAGNOSES REDACTED]. Review of the medical record revealed an Admission Minimum Data Set (MDS) of 10/12/17: The resident was coded to have a Brief Interview for Mental Status (BI[CONDITION]) score of 14 out of 15. The resident required extensive assist of 1-2 with all Activities of Daily Living except s/he required supervision with eating. S/he received intermittent catheterizations, and was occasionally incontinent of bladder and always incontinent of bowel. S/He was 69 inches tall and weighed 166 pounds. S/He was coded to be at risk for pressure sores and had pressure reducing devices to bed and chair. The resident did not have any pressure sores on admission. Review of the care plan revealed the resident had a care plan created on 11/24/17: Resident has pressure ulcer/fungal infection on the sacrum: Interventions included: Daily body audit, friction reducing transfer surface, incontinent management, pressure redistributing support surface. The Resident also had a care plan for skin problem with no explanation of what the skin problem was, initiated 10/6/17, Created on 11/15/17, revised on 11/24/17. Goals included, will heal without complication, will heal within limits of disease process, show no signs of infection. Interventions included: administer treatment per Dr's order, encourage and assist to turn and reposition, follow-up care with physician as ordered, report evidence of infection, specialty mattress on bed, cushion to chair, (initiated 11/15/17). Review of the physician's orders [REDACTED]. 11/14/17: Air mattress, wheelchair cushion, turn every 2 hours, limit wheelchair to 1 hour max each interval, Wound care, change dressing bid, clean with wound cleanser, apply [MED] and cover with gauze on sacrum and right buttocks. Vitamin C one tab po daily. Pre-[MEDICATION NAME] level 11/18/17: BMP (Basic Metabolic Panel) for dehydration/fluid deficit. 11/21/17: Med pass [AGE] cc three times a day. 11/23/17: Cleanse wound to right buttocks and sacrum with Dakins solution, apply [MED] and cover with border gauze, one time a day. 12/5/17: BMP and CBC (Complete Blood Count) with differential today. Weigh pt today. 12/6/17: Skin prep to right heel every day and evening shift, Vitamin C give 500 mg by mouth (po) one time a day for supplement. [MEDICATION NAME] XL extended release 24 hour, 50 mg, give one tablet by mouth one time a day [MEDICAL CONDITION](hypertension). Folic Acid 1 mg by mouth daily for supplement. Limit wheel chair to 1 hour max each interval every shift. Baza antifungal cream 2%, apply to buttocks and peri area every shift for presence of fungal infection. Use for 10 days. Oxygen 2L/M nasal cannula every shift for [MEDICAL CONDITION]. Send to ER for eval and treatment. Admission History and Physical (H&P) completed on 10/5/17 by the facility physician. Resident with inability to care for self at home.No significant [MEDICAL CONDITION] and no decubiti. Progress Notes: 10/31/17: Nurse Practitioner (NP) #1 Cloudy Malodorous urine: Res self-cath due to [MEDICAL CONDITION]. [MED] 240 [MEDICATION NAME] on a daily basis. Resident reports had urinary tract infections in the past, in the past her/his provider would increase her/his [MED] dose. Obtain u/a and increase [MED] to 500 mg twice daily for 7 days. 11/7/17: NP #1: Patient seen due to area on her/his bottom. Staff are placing a thick ointment on her/his bottom to prevent skin breakdown. S/He recently developed small little knot to right of her/his pubic bone. Non-tender, denies pain. S/He has discolorations to her/his bottom. There is no open skin to her/his bottom. There is a small nodule noted to her/his right upper buttock, non-tender non-erthematous, there is no drainage. Candidiasis of skin and nails, Begin Baza cream to sacrum 3 times a day. Cyst near tail bone. 11/14/17: NP #2: Presents today for evaluation of worsening wounds to her/his coccyx and right pubic/upper thigh wound. Review of systems: Skin- Decubitus ulcers x 2. Worsening wounds. Right posterior glottis/upper thigh wound with black eschar surrounded by 100% slough surrounding [DIAGNOSES REDACTED]. Plan: Worsening wounds. Right posterior buttocks upper thigh wound with black eschar surrounded by 100% slough. Surrounding [DIAGNOSES REDACTED]. Coccyx wound unstageable, eschar [AGE]% slough. New dressing change orders twice daily. Clean with wound cleanser, apply [MED], cover with gauze. Air mattress. Turn every 2 hours while in bed. + wheelchair time x (times)1 hour max each interval. Follow-up wound in 2 weeks if not better consult wound center for recommendation and evaluation. Vitamin C po daily. Pre-[MEDICATION NAME] level. 11/21/17: NP #1 Seen for difficulty with catheterization. 11/30/17: Physician: [AGE] day follow-up. Main complaint is chronic back pain. Nursing has asked me to evaluate him/her for possible Hospice. S/He has multiple decubiti. ICD codes: Decubitus ulcer of coccygeal region. Her/his pain and depression both contribute to immobility. 12/5/17: NP #1: Problem, lethargy, worsening wounds. Exam: Poorly responsive. Dressing intact to her/his posterior sacrum and right posterior glottis, upper thigh. Labs reviewed. Due to her/his significant lethargy, I will decrease medication load, discontinue [MEDICATION NAME], discontinue vitamin D, discontinue hydrochlorithiazide, and discontinue [MED]. Decubitus ulcer of coccygeal region, evaluate labs, consider hospice versus wound care clinic. History and Physical 12/21/17 (re-admission): Readmission after hospitalization [MEDICAL CONDITION] and osteo[DIAGNOSES REDACTED]. Decubitus of the sacrum with a negative pressure dressing. S/He is no longer able to answer questions. S/He has a peg tube now. S/He has had severe weight loss. S/He has a right heel decubitus. Summary of Plans: Goals: Comfort Care, Prognosis: Terminal. Review of the Nurses Progress notes revealed a note written on 11/23/17: Resident admitted with fungal [MEDICAL CONDITION] to buttocks and peri area that was treated with antifungal. The resident [MEDICAL CONDITION] have slough and an odor and [MED] is being used. Lab work was completed on the resident, the pre-[MEDICATION NAME] is 9 which is low and the Physician services and the family were notified. Spoke with son regarding [MEDICAL CONDITION] to buttock. Son stated s/he saw them yesterday (11/22/17) and thought the wounds looked better. Son pleased with progress. Also aware of [MEDICATION NAME] level. Daily body audits and weekly skin assessments were requested throughout the survey. No daily body audits or weekly skin assessments were provided before the resident was diagnosed with [REDACTED]. Right heel with a red/blue discoloration. An 8 cm x 6 cm skin tear to sacral area. Resident was transferred to another room. After transfer to new room on 11/15/17, Skin alteration records were provided to the surveyor. The skin alteration records showed the following: 11/15/17 Right buttocks measured 3.5 cm x 2.8 cm area, described as dark pink/red alteration, no drainage, surrounding tissue discolored, blue, purple, yellow. On 11/23/17; the measurements were the same, with serosanguinous drainage, surrounding skin red. On 11/24/17 measurements were the same eschar on upper bottom side. Moderate amount of Serosanguinous drainage with foul odor. Left Buttock, 11/15/17 6.2 cm x 6.8 cm, dark pink/red tissue with surrounding tissue of blue/purple/yellow discoloration. 11/23/17 measurements remain the same with alteration with eschar, surrounding tissue reddened. Undated measurements the same with dark pink/red tissue, eschar, serosanguinous drainage, foul smelling. In an interview with the surveyor on 1/9/18 at 10:20 AM the Director of Nursing (DON) stated, When s/he (resident #3) came in s/he had fungal infection. The doctor said that the resident was on [MED] and felt that would take care of it. We put a barrier cream on and put her/him on a pressure reducing mattress. Those were our interventions when s/he arrived. In November, we asked the physician to take a look, the resident had something we didn't know what it was. The physician thought it was a pilonidal cyst. S/He ordered the antifungal cream in November, November 7th. The wound got worse, day 5 or 6 we asked him/her to recheck it, s/he was seen by Nurse Practitioner #2. The notes of 11/14/17 were by another Nurse Practitioner, (NP #2) we did not know that s/he had diagnosed wounds as pressure sores. Her/his notes are not in our system. S/he writes her/his notes and sends them to us. I don't know (NP #2). The wound started getting worse, it wasn't progressing. We asked the doctor to reassess. The Physician said it was fungal [MEDICAL CONDITION]. The Physician saw her/him on 11/7 and thought it was a cyst too and fungal infection and ordered the Baza cream. There was no stop date for the [MED] because the resident was on it [MEDICATION NAME] on 10/17. I looked at that wound every day. It was strange, I've never seen anything like it. The physician said it was fungal, and had a cyst. There was never any eschar. On 1/9/18 at 1:02 PM: During an interview with the Physician and the Director of Nursing. The hospital nurses notes says the resident had a sore on buttocks. It does not say anything about it being a pressure sore. The hospital opened it up (did an I&D) on December 6th. No wound notes from hospital until after they opened up the cyst. The Physician stated that s/he reviewed the NP notes and saw the ICD code for decubiti and brought it forward to his/her notes. S/He added multiple decubiti to his/her Progress Note of 11/30/17. The Physician stated, I did not examine the resident's skin. I did not look at her/his skin. I reviewed the NP notes and saw the documentation of decubitus. I went by what s/he saw. I did not have anyone to hold him/her over for me to look at her/his bottom. Her/his (NP) notes don't make sense. I have reviewed the documentation and her/his is the only note that describes the resident with pressure sores.

Based on record review and interviews, the facility failed to provide adequate Physician Services for 1 of 3 residents reviewed for wounds. Resident #3 developed wounds in the facility. The wounds were diagnosed as fungal, cyst, and decubiti. The Physician did not examine the resident's wounds but stated the resident had multiple decubiti. The findings included: Cross refer to F6[AGE], Quality of Care; Wounds The facility admitted resident #3 with [DIAGNOSES REDACTED]. The resident was admitted with fungal infection on buttocks and posterior upper thigh. No treatment was ordered for the infection until a month after admission. The resident was diagnosed with [REDACTED]. A week later the documented fungal infection was diagnosed as two (2) pressure ulcers (decubiti). Treatment was ordered for pressure sores and interventions put into place. Nine days later, the treatment was changed for worsening wounds. Seven days later the Physician saw the resident and documented resident with multiple decubiti. Six days later the resident was sent to the hospital for change in condition. Review of the medical record revealed Physician's Progress Notes (MD Progress Notes). Admission H&P completed on 10/5/17. Resident with inability to care for self at home. Good use of arms but unable to transfer self. No significant [MEDICAL CONDITION] and no decubiti. Resident indicated s/he wishes DNR. 10/31/17: Nurse Practitioner (NP) #1: Cloudy Malodorous urine: Res (resident) self cath due to [MEDICAL CONDITION]. [MED] 240 [MEDICATION NAME] on a daily basis. S/He reports had urinary tract infections in the past, in the past her/his provider would increase her/his [MED] dose. Obtain u/a (urinalysis) and increase [MED] to 500 mg (milligrams) twice daily for 7 days. 11/7/17: (NP #1) Patient seen due to area on his bottom. Staff are placing a thick ointment on her/his bottom to prevent skin breakdown. S/He recently developed small little knot to right of her/his pubic bone. Non-tender, denies pain. S/He has discolorations to her/his bottom. There is no open skin to her/his bottom. There is a small nodule noted to his/her right upper buttock, non-tender non-[DIAGNOSES REDACTED]tous, there is no drainage. Candidiasis of skin and nails, Begin Baza cream to sacrum 3 times a day. Cyst near tail bone. 11/14/17: (NP #2) presents today for evaluation of worsening wounds to her/his coccyx and right pubic/upper thigh wound. Review of systems: Skin- Decubitus ulcers x 2. Worsening wounds. Right posterior glottis/upper thigh wound with black eschar surrounded by 100% slough surrounding [DIAGNOSES REDACTED]. Plan: Worsening wounds. Right posterior buttocks upper thigh wound with black eschar surrounded by 100% slough. Surrounding [DIAGNOSES REDACTED]. Coccyx wound unstageable, eschar [AGE]% slough. New dressing change orders twice daily. Clean with wound cleanser apply [MED] cover with gauze. Air mattress. Turn every 2 hours while in bed. + Wheelchair time x 1 hour max each interval. Follow-up wound in 2 weeks if not better consult wound center for recommendation and evaluation. Vitamin C po daily. Pre-[MEDICATION NAME] level. 11/21/17: (NP #1) Seen for difficulty with catheterization. No mention of skin. 11/30/17: (DR) [AGE] day follow-up. Main complaint is chronic back pain. Nursing has asked me to evaluate her/him for possible Hospice. S/He has multiple decubiti. ICD codes: Decubitus ulcer of coccygeal region. Her/his pain and depression both contribute to immobility. 12/5/17: (NP) Problem, lethargy, worsening wounds. Exam: Poorly responsive. Dressing intact to her/his posterior sacrum and right posterior glottis, upper thigh. Labs reviewed. Due to her/his significant lethargy, I will decrease medication load, discontinue [MEDICATION NAME], discontinue vitamin D, discontinue [MEDICATION NAME], and discontinue [MED]. Decubitus ulcer of coccygeal region, evaluate labs, consider hospice versus wound care clinic. The resident was admitted to the hospital on [DATE]. Upon return from the hospital the Physician performed a History and Physical on 12/21/17 (re-admission): Resident DNR per discussion with physician on 10/5/17. Readmission after hospitalization [MEDICAL CONDITION] and osteo[DIAGNOSES REDACTED]. Decubitus of the sacrum with a negative pressure dressing. S/He is no longer able to answer questions. S/He has a peg tube now. S/He has had severe weight loss. S/He has a right heel decubitus. Summary of Plans: Goals: Comfort Care, Prognosis: Terminal. 1/9/18 at 1:15 PM the resident's physician was interviewed by the surveyor. When I followed ----- (Nurse Practitioner #2) the next week, I did not look at the resident's skin. I reviewed her/him (NP) notes and saw the documentation of decubitus. I went by what s/he saw. I did not have anyone to hold her/him over for me to look at her/his bottom. Her notes don't make sense. I have reviewed the documentation and her/his is the only note that describes the resident with pressure sores. The skin was examined the next day for the weekly skin monitoring and there is nothing there describing what the NP wrote in her/his note. S/he is a brand new Nurse Practitioner. S/he is new to my office. In my judgement her/his documentation was inaccurate. The hospital did an Incision and Drainage (I&D) on the cyst and went to the bone to clean it out. They did not say anything about the resident arriving with a pressure sore. There was nothing in the hospital record regarding there being eschar or slough. I only write in my exam, what I actually examined. Although the Nurse Practitioner was new to the Physician's office and a New Practitioner and the Physician did not agree with the Nurse Practitioner's documentation of the resident's wounds, the Physician did not examine/assess the wounds her/himself. The Physician did not provide supervision for the Nurse Practitioner.

Based on record review and interview, the facility failed to revise care plans for 1 of 5 residents reviewed for care plans. Resident #3 was admitted with an indwelling catheter. Orders were changed to in and out catheterizations. The resident's care plan was not revised to show when the changes occurred. The findings included: The facility admitted resident #3 with [DIAGNOSES REDACTED]. Review of the medical record revealed an Admission Minimum Data Set (MDS) of 10/12/17: The resident was coded to have a Brief Interview for Mental Status (BI[CONDITION]) score of 14 out of 15. The resident required extensive assist of 1-2 with all Activities of Daily Living except s/he required supervision with eating. S/he received intermittent catheterizations, and was occasionally incontinent of bladder and always incontinent of bowel. S/He was coded to be at risk for pressure sores and had pressure reducing devices to bed and chair. The resident did not have any pressure sores on admission. Review of the medical record revealed the resident's plan of care. S/he was care planned for use of indwelling urinary catheter needed due to [MEDICAL CONDITION]- secure cath, report changes in amount and color or odor of urine, administer meds as ordered. Care plan created on 11/24/17: Resident has pressure ulcer/fungal infection on the sacrum: Daily body audit, friction reducing transfer surface, incontinent management, pressure redistributing support surface. Resident had care plan for skin problem with no explanation of skin problem, initiated 10/6/17, created on 11/15/17, revised on 11/24/17. Goals included, will heal without complication, will heal within limits of disease process, show no signs of infection. Interventions included: administer treatment per Dr's order, encourage and assist to turn and reposition, follow- up care with physician as ordered, report evidence of infection, specialty mattress on bed, cushion to chair, (initiated 11/15/17). A care plan for Bowel incontinence related to Physical limitations, [MEDICAL CONDITIONS] bladder, initiated on 10/5/17. An intervention initiated on 10/9/17 of Intermittent catheterization per physician orders [REDACTED]. The resident's care plans did not clearly depict the resident or the resident's needs. The care plans were conflicting as to the type of wounds and care of wounds. During the resident's stay the resident had an indwelling catheter and later on had self-performed in and out caths. The care plan did not resolve or revise one treatment when the other was added. During an interview with the Director of Nurses (DON), the DON was asked about the changes in the resident's catheterizations not addressed in the care plan. The DON stated the in and out caths were addressed on another care plan. Although the in and out caths had been addressed on another care plan, the care plan for the indwelling catheter was not revised or resolved. The resident had both catheterizations care planned during the same time period.

Based on record review and interview, the facility failed to maintain an accurate medical record for 1 of 5 residents reviewed. Resident #3 medical record contained conflicting information regarding wounds and conflicting care plan information. The findings included: Cross refer to F 657, Care Plans and F6[AGE] Quality of Care. The facility admitted resident #3 with [DIAGNOSES REDACTED]. The resident was admitted with fungal infection on buttocks and posterior upper thigh. The resident was diagnosed with [REDACTED]. On 11/14/17 the documented fungal infection was diagnosed as two (2) pressure ulcers (decubiti). On 11/30/17 the physician diagnosed the resident with multiple decubiti. On 1/9/18 The Director of Nursing (DON) and the Physician were interviewed. Both denied the resident had pressure ulcers until after return from the hospital. The Physician stated s/he questioned the Nurse Practitioner's documentation of the pressure ulcers, the resident had no other documentation of eschar or the appearance of the wounds to be pressure sores. However, the Skin Alteration Records of 11/23/17 documented eschar and drainage from the wounds. The medical record did not have Skin alteration records until 11/15/17. The skin alteration records were documented the resident had skin tears then on the same day, new skin alteration records documented the same wounds not as skin tears. The resident's care plan included both indwelling catheter and in and out catheterizations. The resident did not receive in and out catheterizations at the same time the resident had an indwelling catheter. The catheter care plan was not revised to show the change in catheterizations. During the interview with the DON on 1/9/17, the DON stated the in and out catheterizations were included with the bowel incontinence care plan. The catheterizations were included as an intervention. The DON was unable to explain why the care plan for indwelling catheter was not updated to reflect the changes in the urinary elimination, when indwelling was changed to in and out caths. The resident did return from the hospital with an indwelling catheter.