Every finding on record at PruittHealth - Lakeside, LLC

Based on observations, staff interviews, and a review of the facility's policy titled Labeling, Dating, and Storage, the facility failed to ensure food items in the walk-in refrigerator, freezer, emergency water/food supply, and dry storage were properly dated and expired foods were disposed of. The deficient practices had the potential to place 53 of 55 residents(R) who receive food from the kitchen at risk of contracting a foodborne illness.Findings Include:Review of the facility's policy titled Label, Dating, and Storage, reviewed and dated 11/11/2022, documented in Procedure 1: Food and beverage items will have an identifying label as well as a received date and opened date, as applicable; for items prepared onsite, a use by date will also be indicated.During the initial tour on 04/14/2026 at 8:42 AM, with the Assistant Kitchen Manager (AKM) and Kitchen Manager(KM), it was revealed the freezer contained opened items such as a bag of squash, a box of red velvet layer cake, and a bag of sliced salami, boxes of ground beef, vanilla ice cream, and orange juice were open with no received date or open date. Also, single bag items of squash and salami were not dated.The dry food pantry was observed; a box of animal crackers with 150 bags was found with an expiration date of 04/11/2026.The rack used for the storage of bread revealed five loaves of hot dog buns, with each loaf containing 12 buns in each bag, and three loaves of sliced white bread that contained 24 slices, had expired on 04/11/2026, which the AKM and KM acknowledged were expired.Interview on 04/16/2026 at 03:00 PM with the KM confirmed that she and the AKM are responsible for ensuring that the freezer, refrigerator, and pantries are checked and within the appropriate temperature range and correctly labeled and stored with the received, use-by, and expiration dates, and acknowledged the animal crackers were expired. She also stated that her expectation is that all food items are properly labeled and expired items are disposed of. The KM stated that a negative outcome could cause cross-contamination and residents could get sick.Interview on 04/16/2026 at 03:10 PM with AKM confirmed that the bread and animal crackers were expired and food items were not properly labeled. She stated that the negative outcome could cause foodborne illness.

Based on record review and staff interviews, the facility failed to ensure the need for a Level II Preadmission Screening/Resident Review (PASARR) for evaluation and determination for specialized services were offered to meet resident needs for one of 10 sampled residents (R) (R9) for PASARR Level II.Findings include:Review of Electronic Health Record (EHR) revealed R9 had diagnoses of but not limited to unspecified intellectual disabilities, schizoaffective disorder, degenerative disease of nervous system. Further review revealed R9 had a diagnosis of schizoaffective disorder upon admission on [DATE].Review of the Annual Minimum Data Set (MDS) dated [DATE] for R9 revealed she was admitted to the facility on [DATE]. Section A revealed R9 had not been evaluated for Level II PASARR.Review of Care Plan dated 04/15/2026 revealed R9 Problem: Resident is resistive of care from staff. Resident may swing at staff during care provided. Approach: Explain the care staff wants to provide to the resident. Behavior monitoring as ordered. Med review and med changes. Further review of the care plan for R9 revealed Problem: Psychotropic Drug Use. Approach: Contact Hospice prior to psych consultation. Psych consultation. Assess and implement non-drug interventions such as activities. Pharmacist to review medications. Monitor for side effects.Review of the Level I PASARR dated 03/09/2023 revealed R9 was not triggered for the diagnosis of schizophrenia.Interview on 04/16/2026 at 04:35 PM with Social Services Director (SSD) revealed she has been employed with the facility for four months. It was revealed that R9 is diagnosed with anxiety and schizophrenia. SSD revealed a PASARR Level I was sent for R9 upon admission on [DATE]. It was confirmed that R9 was not triggered to have a diagnosis of schizophrenia on Level I PASARR. It was confirmed that a Level II PASARR referral was not triggered for R9 due to the Level I PASARR not triggering for schizophrenia. SSD confirmed a Level II PASARR referral should be sent for R9 based on her diagnosis of schizophrenia. SSD stated she would not confirm nor deny that R9 was admitted into the facility with a diagnosis of schizophrenia. SSD stated she would not confirm nor deny that the Level I PASARR should have triggered that R9 had a diagnosis of schizophrenia upon admission.Interview on 04/16/2026 at 05:10 PM with the Director of Nursing (DON) revealed she has been employed with the facility for four years. It was confirmed R9 is diagnosed with intellectual disabilities and schizophrenia. It was revealed that R9 was admitted into the facility on [DATE]. DON revealed a Level I PASARR was signed for R9 upon admission on [DATE]. It was confirmed that R9 was not triggered to have a diagnosis of schizophrenia on the Level I PASARR. It was confirmed the Level I PASARR was incorrect due to the diagnosis of schizophrenia not being triggered. It was confirmed a Level II PASARR referral was not triggered for R9 due to the Level I PASARR not accurately triggering the diagnosis of schizophrenia. DON confirmed R9 was admitted into the facility with a diagnosis of schizophrenia. DON confirmed the Level I PASARR should have triggered that R9 had a diagnosis of schizophrenia upon admission. It was confirmed that when residents are admitted into the facility, the Social Services Director is responsible for ensuring the Level I PASARR has the correct diagnoses triggered. DON revealed her expectation is for the Social Services Director to verify that the Level I PASARR diagnoses are correct based on the diagnoses the residents have upon admission. DON revealed the SSD must verify the accuracy of the Level I PASARR so that the Level II PASARR services can be provided to residents as needed.

Based on staff interview and record review, the facility failed to ensure the timely submission of the Minimum Data Set (MDS) assessment for one of five residents (R) (R49). The deficient practice had the potential to increase the probability for R49 not to receive care according to their care needs. Findings include: Record review for R49 revealed resident was admitted to the facility with the diagnoses of but not limited to chronic kidney disease stage 5, type 2 diabetes, chronic obstructive pulmonary disease, right upper quadrant abdominal mass, essential hypertension, syncope and collapse, hyperlipidemia, bradycardia, and generalized anxiety disorder. Resident medication review revealed a physicians order for the following, atorvastatin 40 mg (milligram), Breo Ellipta 100-25, buspirone 10 mg, clopidogrel 75 mg, gabapentin 300 mg, hydroxyzine 25 mg, pantoprazole 20 mg, paricalcitol 1 mcg (microgram), and paroxetine Hcl (hydrochloride) 40 mg. Review of R49's Quarterly Minimum Data Set (MDS) assessments revealed the last completed assessment was dated 10/10/2024. Continued review revealed a Quarterly MDS dated [DATE] indicated that it was still in progress. Interview on 3/1/2025 at 1:29 pm with the MDS Coordinator revealed that she was the only staff member in the facility that completed the assessments. Each resident will have a quarterly assessment completed every ninety-two days, annual assessment yearly, and a significant change assessment will be completed if the resident meets the criteria of having two areas of decline or improvement, starts hospice services, or receives a fracture during a fall. Once the assessment is completed it is sent to the Director of Health Services (DHS) for her signature and review and the assessment is placed in a file and is saved in a folder with the facility name on it, someone from the corporate office then submits the assessment into the system for processing. The staff member did not know who in corporate submitted the assessment. Continued interview also revealed that R49's Quarterly assessment was completed on 1/24/2025 and was rejected on 2/3/2025 due to missing information in Section O (therapy). The assessment was currently being corrected and there were some issues with inputting the information due to the transition into a new system. Staff member confirmed that the assessment for R49 was late. Interview on 3/02/2025 at 10:27 am with the DHS confirmed that the Quarterly MDS assessment for R49 was not completed within the allotted timeframe. Continued interview also revealed that her expectation was that the MDS assessments were to be completed and processed timely. If there was a concern with the transmission or completion of the assessment, the MDS Coordinator was expected to reach out to the DHS or the corporate liaison for assistance to ensure that the assessments were completed.

Based on record review and staff interviews, the facility failed to ensure that Minimum Data Set (MDS) assessments was accurate for one resident (R) (R15) related to inaccurate coding of the preadmission screening and resident review (PASARR) level II. The sample size was 27. Findings include: A review of the Minimum Data Set (MDS) OBRA (Omnibus Budget Reconciliation Act) Annual Assessment, Section A-Identification A, dated 12/19/24, revealed R15 was not assessed for PASARR level II. A review of the medical record revealed R15 had a PASARR level II assessment, with a start date of 8/25/23 and end date of 12/31/2299. During an interview with the MDS Coordinator on 3/1/2025 at 3:25 pm, she acknowledged the MDS OBRA Annual Assessment, Section A-Identification Information, dated 12/19/24, indicated R15 had not been screened for a PASARR II. The MDS Coordinator confirmed that R15 was issued a PASARR II on 8/5/2023, and the MDS was not accurately coded. The MDS Coordinator said the Social Worker (SW) put the information in section A, but she said it was the MDS Coordinator's responsibility to ensure the MDS was coded accurately. An interview with the Director of Nursing (DON) on 3/1/2025 at 3:27 pm revealed it was her expectation for the MDS Coordinator to ensure the MDS was coded accurately. During an interview with the DON on 3/1/2025 at 4:20 pm, she stated there was no facility policy for the accuracy of the MDS. The MDS Coordinator used the resident assistant instrument (RAI) for MDS guidance.

Based on staff interviews, record reviews, and a review of the facility policy titled, Legionella Water Management, the facility failed to develop an updated water management program plan for the prevention of Legionella for 52 of 52 residents in the building. The deficient practice had the potential to promote growth of Legionella and other opportunistic waterborne pathogens in the building water systems. Findings included: A review of the facility policy titled, Legionella Water Management, revised 2017, revealed 3. The purposes of water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. 4. The water management program used by our facility is based on the Centers for Disease Control and Prevention and ASHRAE recommendations for developing water management program. e. Specific measures used to control the introduction of and/or spread of legionella (e.g., temperature, disinfectants); f. The control limits or parameters that are acceptable and that are monitored; g. A diagram of where control measures are applied; h. A system to monitor limits and the effectiveness of control measures; i. A plan for when control limits are not met and/or control measures are not effective; and j. Documentation of the program; The facility does not have updated measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in building water systems that are based on nationally accepted standards (e.g., ASHRAE, CDC, U.S. Environmental Protection Agency, or EPA). Interview on 11/5/2023 at 9:45 am with the Maintenance Director revealed he was not aware of any changes to the water management plan. The facility was checking water temperatures daily but did not have an assessment of the building's water system. The Maintenance Director stated the facility is not currently flushing monthly to clear the lines. An interview on 11/5/2023 at 11:00 am with the Administrator revealed she was not made aware of the updates regarding water management as of today. The Administrator stated she would carry out any directives related to updates to the water management program upon receipt. The Administrator further revealed it was her responsibility to maintain and ensure the water is safe for residents and staff in the building in relation to water temperatures. Interview on 11/5/2023 at 10:30 am with the Chief Clinical Officer stated that the Infection Control Preventionist (ICP) and Maintenance Director would collaborate to devise a plan for the updated water management plan.

Based on observations and staff interviews the facility failed to ensure that it was maintained in a clean, comfortable, and homelike environment in four of 16 resident rooms (A111, A112, A113, and A115) on A hall and two of 16 resident rooms (B202 and B204) on B hall (two of three halls) that included dust and grime buildup on packaged terminal air conditioners (PTAC) vents and rooms A109/A111 and A110/A112 shared bathroom air vents with dust buildup. The facility census was 50. Findings revealed: The facility does not have a maintenance or housekeeping policy. Observations made during initial rounds on 11/03/2023 between 8:00 AM and10:00 AM revealed: Room A9/A11 and A10/A12 shared bathroom vent to have dust buildup. Rooms A11, A12, A13, A15, B2 and B4 PTAC units had dirt and dust buildup on the vents and front grate area. Observations made during initial rounds on 11/04/2023 at 9:00 AM revealed: Room A9/A11 and A10/A12 shared bathroom vent to have dust buildup. Rooms A11, A12, A13, A15, B2 and B4 PTAC units had dirt and dust buildup on the vents and front grate area. Interview and observations on 11/05/2023 at 8:28 AM with the facility Maintenance Director and the contracted Housekeeping Manager revealed housekeepers are responsible for cleaning the PTAC unit covers and bathroom air vents during daily cleaning. The PTAC unit filters are cleaned during deep cleaning. The housekeepers deep clean two rooms per day. They both verified concerns identified. The Maintenance Director indicated the PTAC units have dustier due to the construction going on. Interview on 11/05/2023 at 8:39 AM with the Administrator revealed she would expect the facility to be clean at all times. Requested policies on maintenance, housekeeping and accidents/hazards.

Based on resident interviews, staff interviews, and the review of the facility policy titled, Resident Trust Policy and a document titled Patient Trust Fund Authorization/Agreement the facility failed to provide resident trust fund account quarterly statements for three of four resident (R) (R#24, R#30, and R#39) reviewed. Forty-four (44) resident trust fund accounts are managed by the facility. Findings: Review of the undated policy titled, Resident Trust Policy revealed: Upon written authorization of a resident, Eastview Nursing Center must safeguard, manage, and account for the personal funds of the resident deposited in their account. 6. The resident shall have reasonable access, upon request, to a record of all transactions made to his/her account. Quarterly statements will be provided in writing to the resident or to the resident's responsible party. Review of the document titled, Patient Trust Fund Authorization/Agreement updated 5/19/2018 indicated: I acknowledge that I have been advised of my rights to manage my personal financial affairs and that I am not required to deposit personal funds with the facility. I DO authorize the facility to hold, safeguard, manage and account for monies I may deposit with the facility in a Resident Trust Fund (RTF). I have reviewed the facility policies on the Management of Personal Funds in the facility Welcome Packet. I understand that I will receive quarterly statements bearing all transactions on the resident account. 1. Review of R#24 annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was assessed as fifteen which indicated cognitively intact. An interview on 11/3/2023 at 9:50 am with R#24 stated she has a trust fund account with the facility. The resident stated she does not receive a quarterly statement for the trust fund account that the facility manages. The resident stated the person in the front office will give the balance in the account if she ask. Review of the document titled Patient Trust Fund Authorization/Agreement signed by R#24 on 9/20/2022. There are no other signatures for the Person responsible for the Account or the Resident Representative. 2. Review of R#30 quarterly MDS dated [DATE] revealed a BIMS was assessed as six which indicated severe cognitive impairment. Review of the document titled Patient Trust Fund Authorization/Agreement signed by R#30 on 11/8/2022. There are no other signatures for the Person responsible for the Account or the Resident Representative. An interview on 11/3/2023 at 11:22 am with R#30 was alert and was able to correctly answer the surveyor screening questions. The resident stated he has a trust fund account with the facility. He stated he does not receive a quarterly statement for the trust fund account that the facility manages. 3. Review of R#39 quarterly MDS dated [DATE] revealed a BIMS was assessed as fifteen which indicated cognitively intact. Review of the document titled Patient Trust Fund Authorization/Agreement signed by R#39 on 11/9/2022. There are no other signatures for the Person for the Account or the Resident Representative. An interview on 11/3/2023 at 11:23 am with R#39 The resident stated she has a trust fund account that the facility manages and does not receive her quarterly statement. The resident stated she would love to know how much money she has in her trust fund account. An interview on 11/5/2023 at 8:15 am with R#39 stated she did not verbally or in writing give the facility permission to give anyone her (R#39) quarterly statements. An interview and observation on 11/4/2023 at 11:04 am with the previous Office Manager who was responsible for providing the residents with their quarterly statements. The Office Manager stated she does not provide R#30 and R#39 with a copy of their quarterly statement. She stated the statements are given to a family member who is the responsible Party for R#30 and R#39. The Office Manager stated R#24 does not have any family. She stated R#24 is provided with her quarterly statement. The office Manager and surveyor spoke with the resident and R#24 agreed to allow the office manager to look in her personal belongings for a copy of a quarterly statement. No statements were located. An interview on 11/5/2023 at 8:34 am with the Administrator stated she was not aware that residents were not receiving their quarterly statements. She stated the residents should receive the statements quarterly.

Based on observations, record review, staff interview, and the review of the facility policy titled, Restorative Nursing Services, the facility failed to ensure one (Resident (R) 8 reviewed for range of motion (ROM) received a splint/brace as needed to address her limited range of motion in her right hand. The deficient practice had the potential for further reduction of ROM. The sample size was 19 residents. Findings include: Review of the facility policy titled, Restorative Nursing Services revised July 2017 revealed residents will receive restorative nursing care as needed to help promote optimal safety and independence. Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services. Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care. Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care. Review of R8's Admission Record, revealed she was admitted to the facility with diagnoses that included hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness) following nontraumatic subarachnoid hemorrhage affecting right dominant side. Review of R8's Quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 10/3/2023 and located in the MDS tab of the Electronic Medical Record (EMR), revealed she scored five out of 15 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. R8 did not exhibit any behavioral symptoms, including rejection of care. She had impaired functional range of motion on one side in both the upper and lower extremities. Review of R8's Orders tab of the EMR revealed there was no order for use of hand splint/brace to right hand, passive range of motion (PROM), or restorative services. Review of R8's Care Plan revealed, R8 participates in the restorative nursing program daily to maintain current level passive range of motion. The goal was for resident to tolerate range of motion and splint use as evidenced by no complaints of pain or increased tone. Restorative Nursing program was listed as an intervention. Review of the record revealed the following care under the TASK tab on the Kardex: NURSING REHAB: Assistance with Splint/Brace (Don & Doff w/proper hand hygiene) to Rt. Hand as tolerated x 6d/wk. NURSING REHAB: PROM to Rt. Hand before & after Splint/Brace x 15 min/day x 6d/wk. Record review revealed under the Task section of the electronic record Task: Nursing Rehab: Assistance with Splint/Brace (Don & Doff with proper hand hygiene) to right hand as tolerated x 6 days per week. Look back over the last 30 days revealed the hand splint was documented as applied for only 10 of the 30 scheduled days. Verified by DON Record review revealed under the Task section of the electronic record Task: Nursing Rehab: Passive Range of Motion (PROM) to Right hand before and after Splint/Brace x 15 minutes x 6 days per week. Look back over the last 30 days revealed the exercises were documented as performed 18 of the 30 scheduled days, 2 days documented as resident refused. Verified by DON. Observation 11/3/2023 at 9:27 am and 1:18 pm revealed R8 with right clinched closed and without anything in her hands to reduce the progression of contracture. During subsequent observations, R8 was again observed without any orthotic device on her right hand, which remained contracted into a fist: -On 11/4/2023 at 8:47 am, R8 was observed sitting in wheelchair in front of nurses station with both eyes closed without any device on her right hand. Further observation revealed a blue hand splint lying on residents bedside dresser. -On 11/4/2023 at 12:26 pm, R8 was observed seated in her wheelchair in the dining room without any device on her right hand. Resident observed self-feeding with the use of her left hand. -On 11/4/2023 at 2:00 pm, R8 was observed seated in her wheelchair in front of the nurses station without any device on her right hand. In an interview on11/4/2023 at 2:17 pm with Certified Nurse Aide (CNA) AA, she stated she was assigned to R8 today, but she did not perform passive range of motion exercises, nor did she apply the splint the residents right hand because she though the Activity Director/CNA was responsible to do that. CNA also stated that she had been trained by therapist to do range of motion and apply splints. In an interview on 11/4/2023 at 2:22 pm, Licensed Practical Nurse (LPN) BB stated she was not aware R8 had a hand splint or needed to have one on because there were not any orders related to a splint. In an interview on 9/7/2023 at 3:34 pm, the Director of Nursing (DON) stated if there was a physician's order for the palm guard, it would show up on the CNAs' documentation and they would chart its use. She stated she was unaware there was no order for or documentation of the palm guard. During an interview on 11/04/2023 at 2:25 pm with MDS/Care Plan Coordinator revealed that she oversees the Restorative Program. She stated that currently there is only 1 resident actually on the restorative program and 9 or 10 residents on the Maintenance Program for range of motion and splinting. She further stated that the CNAs on the floor were all trained by the therapist on how to safely perform the range of motion exercises and apply splints/braces. She stated that her role is to enter the program into the electronic record. The Activities Director, who is also a CNA, monitors the residents to make sure the CNAs on the hall are actually performing the exercises and applying the splints. She stated the CNAs assigned to resident documents the range of motion exercises and the donning and doffing of the splints in the electronic record. During an interview on 11/04/2023 at 2:34 pm with Activity Director/CNA revealed that the CNAs assigned to the resident is responsible for the exercises and applying the splints. She stated that she checks to make sure they are applying the splints. She further stated that she does not have a list of residents with splints, she just remembers who they are. She stated that she is aware that resident is supposed to wear a splint to her right hand for 4-6 hours 6 days a week. She further stated that if the CNAs do not apply the splints, then she will apply them. AD further stated that she had not seen resident with the splint on today. During an interview on 11/04/2023 at 2:46 pm with DON revealed that the resident is currently on the Maintenance Restorative Nursing Program for range of motion and splinting. She further stated that all CNAs were trained by the therapist on range of motion and donning and doffing splints. She further stated that the CNA assigned to the resident is responsible for the plan of care and the Activity Director/CNA is responsible to check behind the CNAs to ensure that the treatment was done. DON further stated that it is her expectation that the restorative plan of care be followed for all residents.

Based on observation, staff interview, and review of facility documents titled, Safety Data Sheets and Material Safety Data Sheets, the facility failed to store chemicals so that they were inaccessible to residents and visitors in one unoccupied resident room under renovation, on one of three halls. The facility census was 52. Findings include: Review of the Safety Data Sheet for ARDEX Feather Finish dated December 13,2020 revealed under Section 11- Toxicological Information: Routes of expose skin and eyes (yes), ingestion (yes). Skin corrosion or irritation causes skin irritation. Prolonged exposure to wet product may cause skin burns. Serious eye damage/eye irritation: Causes eye burns. May cause blindness. Specific Target Organ Toxicity, Single exposure: May cause respiratory irritation. Review of the Material Safety Data Sheet issue date August 1, 2013, revealed under Section 2- Hazards Identification: Hazard Statements: This product may cause slight irritation to the eye. May cause slight irritation to skin. Wear suitable gloves, eye/face protection, and respiratory protection. Keep put of reach of children. Observation on 11/03/2023 at 9:39 AM of an unoccupied resident room, A118, revealed room under renovation. The room door was open and did not have a lock on the inside or the outside. Inside of the room were noted: Two bottles of odorless mineral spirits with a label that indicated Danger harmful or fatal if swallowed, eye and skin irritant, combustible. A bucket of carpet tile pressure-sensitive adhesive with a label that indicated Warning: This product is considered not hazardous under age 29, may cause slight irritation to the eyes, wear gloves and eye/face protection. Keep out of reach of children. A bucket of restorative flooring adhesive. According to the Safety Data Sheet it can cause slight irritation to the eyes and slight irritation to the skin. Keep out of reach of children. Three cans of wall paint. According to the Safety Data Sheet it can cause skin irritation, serious eye damage, may cause cancer by inhalation, and can cause damage to lungs through prolonged or repeated inhalation. Interview on 11/03/2023 at 9:46 AM with the Administrator revealed she would expect the door to be kept closed and locked when workers are not in the room. She indicated the workers are contracted to redo the floors and paint the walls. She indicated they were in the building early this morning but left when surveyors arrived. She did indicate the door should have a lockable doorknob. She verified the chemicals and paint were accessible by the residents. Interview on 11/03/2023 at 9:50 AM with the Maintenance Director revealed the contractors were in the room earlier but left when surveyors arrived. He indicated the door should be locked. The contractors usually remove all the paint and chemicals when they leave. He had a new doorknob that was lockable from the outside and put it on the door and locked it.

Based on observations, record review, staff interviews, and review of the facility policy titled, Prevention of Infection Oxygen Use, the facility failed to provide respiratory care consistent with professional standards of practice for one of four residents (R) (R17) receiving oxygen therapy related to ensuring oxygen filter were cleaned and oxygen nasal cannula were routinely changed. This deficient practice had the potential to cause respiratory associated infections and or illnesses. Findings include: Review of facility's undated policy titled, Prevention of Infection Oxygen Use under; Infection control Considerations Related to Oxygen Administration - 1. Obtain equipment (i.e., oxygen tubing, and prefilled humidifier). 2. [NAME] bottle with date and initials upon opening and discard when empty. 3. Check water level of any pre-filled reservoir. 4. Change pre-filled humidifier when empty. 5. Change the oxygen cannula and tubing every seven (7) days, or as needed. 6. Keep the oxygen cannula and tubing used PRN in a plastic bag when not in use. 7. Wash filters from oxygen concentrators every seven days with soap and water. Rinse and squeeze dry. 8. Wash hands after manipulation. A review of the clinical record for R17 revealed she was admitted to the facility with diagnoses including but not limited to chronic obstructive pulmonary disease. A review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed R17 had a Brief Interview for Mental Status (BIMS) of 10, which indicated moderately impaired cognition. Section O (Special Treatments and Programs) revealed resident received oxygen therapy. A review of a care plan revealed R17 had a diagnosis of COPD and was at risk for acute infection. A review of the Medication Administration Record for October 2023 through 11/3/2023 revealed documentation verifying resident was receiving oxygen therapy. Observation on 11/3/2023 at 9:14 am, during initial screening and at 1:17 p.m. revealed resident observed lying in bed, oxygen nasal cannula intact. The oxygen concentrator is on with the settings at 2 liters. The filter on the oxygen concentrator has a white/light grey fuzzy substance over the entire filter, the humidifier bottle is empty, and the nasal cannula tubing is dated 10/13/2023. Observation on 11/4/2023 at 8:56 am revealed the oxygen nasal cannula tubing is now dated 11/3/2023, the humidifier bottle remains empty, and the concentrator's oxygen filter continues to have a white/light grey fuzzy substance on the entire filter. During an interview 11/4/2023 at 10:02 am with Certified Nurse Aide (CNA) DD revealed that he does not do anything with the oxygen but ensures the oxygen is on and if the water bottle is low, he informs the nurse. During an interview 11/4/2023at 10:17 am with Licensed Practical Nurse (LPN) BB revealed that she ensures residents receiving oxygen had the nasal cannula intact and the concentrator is set at the correct setting. She further stated that she does not focus on the humidification bottles or the dating of the tubing because the shift before her is responsible for that. LPN BB further stated that she did not notice the humidification bottle was empty today. LPN BB also stated she had not looked at the filter and she does not know anything about the concentrator filter. During an interview 11/4/2023 at 10:30 a.m. with the Assistant Director of Nursing (ADON) revealed that the RN Supervisor is responsible for changing the oxygen tubing and humidifier on Sunday, but anyone can change the tubing if it is not dated or needs changing. ADON further stated that the Infection Control Preventionist (ICP) make rounds weekly and ensure that the tubing and bottles were changed and dated. She stated that the humidification bottle usually does not last that long, so they need to be checked and changed every couple of days. During walking rounds, ADON verified the filter needed to be cleaned and the humidification bottle was empty. ADON further stated that the dirty filter could potentially contribute to respiratory illnesses for the resident. During an interview 11/4/2023 at 10:36 a.m. with the ICP revealed that she had worked at the facility for 3 months and is still in training. She stated that she was informed by the DON that it was her responsibility to check the concentrators to make sure the Registered Nurse (RN) Supervisor changed the tubing, water bottles and cleaned the filters. She further stated that the water bottles are changed when they are almost out. She further stated that if it was not done, she had the responsibility of changing it out and dating the respiratory supplies. She stated that she is responsible for checking these weekly and thought she had checked R17's concentrator Thursday (11/02/2023). ICP looked at the filter on R17's oxygen concentrator and verified it had not been cleaned as required and the humidifier prefilled water was empty. During an interview 11/4/2023 at 10:48 am with the Director of Nursing (DON) revealed the weekend RN supervisor changes and dates the respiratory supplies weekly on Sunday. DON further stated the ICP is responsible for checking to ensure everything was clean, changed and dated to include the filter. DON stated that nursing department is responsible for ensuring that the oxygen is in compliance.

Based on record review and staff interview, the facility failed to provide the Ombudsman with notification of transfer for one resident (R) (R#40). The deficient practice had the potential to affect five residents that were transferred or discharged from the facility in the last three months. Findings include: Record review for R#40 revealed resident was admitted to facility on 5/16/2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident was sent to acute care hospital on 3/31/2022 for respiratory distress and shortness of breath. There was no notification of resident transfer provided to the Ombudsman Office after resident was transferred. Interview with facility owner on 4/3/22 at 8:56 a.m. revealed the Ombudsman is notified only of involuntary discharges per their request, and the Administrator or Business office manager are responsible for this notification. Interview with Business Office Manager on 4/3/22 at 9:30 a.m. revealed that the Ombudsman is notified of residents that are involuntarily discharged on ly per the Ombudsman request. Before the involuntary discharge the documents are faxed to the Ombudsman office and mailed to the resident's family members informing them of the pending discharge and the reason. Further interview also revealed that a copy of the notification was kept at the facility in a file. Post survey interview with facility Ombudsman Representative on 4/6/2022 at 10:30 a.m. revealed facility staff had not reported any discharges or transfers of any kind from the facility in the past year. Further interview also revealed that facility staff was directed to notify the Ombudsman's Office of any facility discharges or transfer monthly. Continued interview also revealed that no staff member of the facility was ever directed to only inform Ombudsman office of involuntary discharges from the facility.

Based on observation, review of the facility policy titled Wound Management Program, and staff interviews, the facility failed to wash/sanitize hands and change gloves during wound treatment for one resident (R) (#29). The sample size was 18 residents. Findings include: Observation of wound care for R#29 on 4/3/22 at 9:30 a.m. revealed Licensed Practical Nurse (LPN) AA placed a red biohazard bag on R#29's bed. LPN AA washed her hands, donned gloves, and removed the old dressing from sacrum. LPN AA changed gloves but did not wash or sanitize hands. She cleaned the wound with a normal saline soaked gauze and patted dry with a clean gauze. She then applied silver alginate rope to wound base and covered with an [MEDICATION(S)] (dressing). LPN AA did not wash/sanitize hands or change gloves after cleaning the wound and before applying the medication. Observation of wound care for R#29 on 4/3/22 at 9:40 a.m. revealed LPN AA washed her hands, donned gloves, and removed the old dressing from right trochanter. LPN AA changed gloves but did not wash or sanitize hands. She cleaned the wound with a normal saline soaked gauze and patted dry with a clean gauze. She then removed gloves and donned gloves. LPN AA did not wash/sanitize hands after removing gloves. LPN AA then applied silver alginate to wound base and covered with an [MEDICATION(S)]. LPN AA did not wash/sanitize hands after cleaning the wound and before applying the medication. Further observation of wound care for R#29 on 4/3/22 at 9:48 a.m. revealed LPN AA washed her hands, donned gloves, and removed the old dressing from right ischium. LPN AA changed gloves but did not wash or sanitize hands. She cleaned the wound with a normal saline soaked gauze and patted dry with a clean gauze. She then removed gloves and donned gloves. LPN AA did not wash/sanitize hands after removing gloves. LPN AA then applied silver alginate rope to wound base and covered with an [MEDICATION(S)]. LPN AA did not wash/sanitize hands after cleaning the wound and before applying the medication. Interview with the Director of Nursing (DON) on 4/3/22 at 10:20 a.m. revealed that LPN AA has been in-serviced on infection control related to wound care. DON stated LPN AA has been checked off on handwashing. DON provided the most recent In-service for LPN AA. Skills Check-Off sheet revealed LPN AA checked off on hand washing last on 2/28/22. Further interview with the DON on 4/3/22 at 12:00 p.m. revealed that she expects the nurses to wash hands and apply clean gloves after removing the dressing and after cleaning the wound. During an interview on 4/3/22 at 10:00 a.m., LPN AA had no response when asked why she did not sanitize her hands throughout wound care dressing changes. Interview on 4/3/22 at 2:45 p.m. with the Owner revealed that she expects the nurses to follow proper wound care and infection control measures. She stated LPN AA works at another building and comes in to help this facility out. Owner further stated she would make sure LPN AA receives more in-services and training on hand hygiene, wound care, and infection control.

Based on interviews and record review, the facility failed to ensure stored clinical information was stored in a way in which it was not accessible to non-essential staff which could impact all current and discharged residents with a census of 68. Findings include: On 4/10/19 at 2:40 p.m. when entering the door for the basement with the Dietary Manager, the basement door was noted to be unlocked with a chair sitting in front of the door to keep it closed. Upon entry of the basement revealed boxes marked financial and other boxes with resident information was identified. An interview on 4/11/19 at 2:20 p.m. with the Medical Records staff, who reported that some resident records are kept in basement but others are kept in medical record office. An interview on 4/11/19 at 2:23 p.m. with the Director of Nursing (DON) who reported that the facility does not have a policy on storage of medical records. She further reporting that the Medical Records Consultant is new and has not worked with Medical Records staff at the facility related to storage of medical records. Tour of medical record storage in basement on 4/11/19 at 2:28 p.m. with Maintenance Manager and Medical Records revealed: 1. Upon entering the basement there is a room, to the right, in which the medical records are stored. The door where records are stored is opened and not locked. 2. In the basement in the open area there were multiple boxes with resident medical information inside of the boxes. Interview with the Maintenance Manager on 4/11/19 at 4:30 p.m. who reported that he has a key and there is a second key in the front office for entrance into the basement. The Maintenance Manager reported that the door to the medical records room in the basement typically stays locked but he may not have locked it when he checked the dehumidifier a few days ago. It was also reported that dietary staff has access to the basement for their emergency water supply but they only come with him in attendance. Interiew with the Maintenance Manager and the Administrator conducted on 4/11/19 at 3:38 p.m. The Maintenance Manager reported that the basement door was unlocked yesterday because the lock had to be cut and replaced. It was further reported that he replaced the lock on the door on yesterday after surveyor and dietary left the area. The Administrator reported that the next project was to clean out the basement, although there is no written plan in place for this. The Administrator reported that the Owner notified her upon hire (three weeks ago) that the basement needed to be cleaned out. The Administrator confirmed there is no policy for the storage of medical records.

Based on staff interviews, observation, and review of the facility's policy titled, Food Storage: Cold Food the facility failed to discard expired items, failed to label and date items upon opening, and failed to maintain resident microwave free from rust in one of one resident food pantry. This had the potential to affect 61 of 61 residents receiving an oral diet. Findings include: Tour of resident food pantry on [DATE] at 8:32 a.m. with the Dietary Manager, Director of Nursing (DON), Licensed Practical Nurse (LPN) Unit Manager BB, and Infection control Registered Nurse (RN) revealed the following: 1. In the refrigerator there was on half pint of milk with an expiration date of (MONTH) 24, 2019. 2. There was a Thickened Sweet Tea with a received date of [DATE] and no open date. The instructions included once opened, store at ambient temperatures for up to 8 hours or refrigerate for up to 7 days. 3. There was one microwave with food stains and rusting. Interview with the Housekeeping Supervisor on [DATE] at 8:42 a.m. revealed that housekeeping staff only checks the refrigerator for cleanliness and not expiration of items. Reported that housekeeping staff checks pantry twice daily for cleanliness. However, the rusting of the microwave had not been identified before today. She reported maintenance would be notified. Interview on [DATE] at 8:44 a.m. with LPN Unit Manager BB revealed that the Infection Control RN is responsible for checking the resident refrigerator for expired items. DON reported that she would expect that someone from clinical to check expiration dates when checking for the temperatures at night. Dietary Manager reported that she does not check for resident refrigerator. Interview on the same day at 8:48 a.m. with the Infection Control RN, who reported that the refrigerator was checked on Monday and is checked once weekly. It was further reported that there was no expired milk at that time. Infection Control RN confirmed thickened sweet tea is opened and there is no open date. DON confirmed that once the thickened water was opened the opened date should have been identified. Food Storage: Cold 5. The Food Services Director/Cook(s) insures that all food items are stored properly in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.

Based on record review, staff interviews, and review of policy Do Not Resuscitate Orders the facility failed to obtain a concurring Physician's signature for a Physician order [REDACTED].#2, and R#19). The sample size was 31 residents. Findings include: 1. Review of the medical record for R#2 revealed one Physician's signature on the POLST that was signed by the representative (who was not the Power of Attorney (POAH)) on 3/15/19 and by the Physician on 3/15/19. 2. Review of the medical record for R#19 revealed one Physician's signature on the POLST that was signed by the representative (who was not the Power of Attorney (POAH)) on 1/26/18 and by the Physician on 1/26/18. Interview on 4/9/19 at 12:48 p.m. with the Administrator who revealed that there were no POAH or no Health Care agent (HCA) documentation for R#19. Interview on 4/9/19 at 12:54 p.m. with Social Services/Admissions Director, who reported that two Physician's signatures are needed on a DNR if a resident does not have decision making capacity. Social Services/Admissions Director reported that typically code status is discussed and initially signed during the admission process. However, it was reported that Minimum Data Set (MDS) reviews code status quarterly with residents and will update if needed. Interview on 4/9/19 at 12:57 p.m. with MDS who reported there was a called meeting for R#19 and his wife took the POLST form home and brought back in at a later time after discussing with her children. She reported that the Unit Managers would have been responsible for assuring that the form was signed by the Physician. MDS denied that she reviews POLST forms once signed by the Physician. Interview on 4/9/19 at 1:13 p.m. with Licensed Practical Nurse (LPN) AA, Unit Manager, reported that only one physician signature is needed when a family member signs and two physician signatures are needed when the resident is not able to sign and there is no one else that can sign the POLST form for the resident. LPN Unit Manager AA further reported that social services is responsible for getting the POLST signed during admissions and code status is reviewed during care plan meetings. If there are changes MDS reviews and gets the updates. Once signatures from physician is received social services is responsible for scanning into the system. Interview with the Director of Nursing (DON) on 4/10/19 at 9:09 a.m. revealed that the Social Services Director is responsible for obtaining code status and signatures on admission. It was further reported that code status is reviewed during the 72-hour care plan meeting, changes in condition meeting, quarterly meetings, and any called care plan meetings. MDS and Social are responsible for updating code status documents as needed. DON reported that the DON at the time or Unit Manager should have reviewed POLST for R#2 to assure all required signatures were on the form. DON further reported that she is unsure of how the ball was dropped for this resident. She further reported that if a resident has decision making capacity only one physician's signature is needed. However, if the resident does not have decision making capacity or a health care agent two physician signatures are needed. If a resident does not have decision making capacity but has an healthcare agent only one physician signature is needed. Reviewed POLST for R#2 and confirmed that there is only one physician's signature. Interview with the Administrator on 4/10/19 at 12 p.m. who provided copy of POLST for R#19 and confirmed that daughter signed the form, there was only one physician's signature, and there was no documentation of a healthcare agent or power of attorney for healthcare. Do Not Resuscitate Order (Revised (MONTH) 2001) received from DON on 4/10/19 2. A Do Not Resuscitate Order (DNRO) form must be completed and signed by the attending physician and resident (or resident's legal surrogate, as permitted by State law) and placed in the front of the resident's medical record. (Note: Use only State approved DNR forms. If no State form is required, use facility approved form).

Based on record review and staff interview it was determined that the facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN), Form CMS- to three (3) of three (3) selected residents discharged from Medicare Part A Services. One resident (R) R#268 was discharged to the community, two residents, R#41 and R#48 were discharged from Medicare Part A Services, but chose to remain in the facility. The sample size was 31 residents. Findings include: A review of the clinical record for R#41 indicated the resident started skilled services 2/12/19, last covered day of SNF Medicare Part A services documented as 3/6/19, for skilled speech therapy services. The resident chose to remain in facility. There was no evidence that the facility had issued an SNFABN (Form CMS- ) to R#41 or the beneficiary's representative, providing the opportunity to continue with skilled services, at his cost, if Medicare did not reimburse. A review of the clinical record for R#48 indicated that the resident started skilled services 3/6/19, with the last covered day of SNF Medicare Part A services documented as 3/10/19, for skilled nursing services. The resident chose to remain in the facility. There was no evidence that the facility had issued an SNFABN (Form CMS- ) to R#48 or the beneficiary's representative, providing the opportunity to continue with skilled services, at her cost, if Medicare did not reimburse. A review of the clinical record for R#268 indicated that the resident started skilled services 12/13/18, with the last covered day of SNF Medicare Part A services on 3/6/19, for skilled physical therapy services and occupational therapy services. The last therapy service date is documented as 3/5/19. The resident was discharged to the community 3/7/19. No evidenced was found that the NOMNC (Form CMS- ) was provided to the resident/or beneficiary representative acknowledging the resident/or beneficiary's representative had been provided a copy of the form or an explanation of why the form was not provided. An interview was conducted on 4/10/19 at 10:30 a.m. with the Admissions/SS Director who confirmed that she was a new employee, starting in the month of 2/2019 and wasn't sure that she did the beneficiary notices correctly. When asked if she had given the SNF ABN forms to the selected residents, she referred further questions to the Administrator, that the Administrator was currently reviewing the forms for the sampled residents. On 4/10/19 at 11:20 a. m. an interview was conducted with the Administrator, she confirmed that they were not using the proper Federal forms. The Administrator confirmed that R#268 chose to go home after his follow-up appoint with his Physician, and R#41 and R#48 were residents that chose to remain in the facility when Medicare Part A services were determined to be terminated. She confirmed the sampled residents or the beneficiary's representatives were not provided with a copy of the SNF ABN, Form CMS- or if applicable the NOMNC Form CMS .

Based on observations, record review and staff interview, the facility failed to submit applications for Preadmission Screening/Resident Review (PASRR) Level II Assessments to the appropriate state designated mental health authority for evaluation and determination of specialized services for two of four (4) residents (R) (R#23 and #8) reviewed with mental illness [DIAGNOSES REDACTED]. Findings include: 1. Record review for R#23 revealed a Pre-Admission Screening/Resident Review (PASRR) Level I Assessment (Form: DMA-6) with a certification date of 3/17/11 that did not indicate that the resident had a serious mental illness, developmental disability or related condition. Review of the current Admission Record form revealed that the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed that during the resident's stay at the facility she was diagnosed with [REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] and the Quarterly MDS dated [DATE] revealed that the resident had short term and long term memory problems and severely impaired decision making skills. Continued review revealed that her active [DIAGNOSES REDACTED]. Further review of the Quarterly MDS dated [DATE] revealed that the resident had received an anti-anxiety medication for two of the last seven days and an antidepressant daily for the last seven days. review of the resident's medical record revealed [REDACTED].) three times a day as needed for increased anxiety, a physician's orders [REDACTED]. every day for depression and a physician's orders [REDACTED]. every bedtime for major [MEDICAL CONDITION], single episode, unspecified. Review of the resident's care plan dated 3/5/18 revealed that the resident was at risk for alteration in psychosocial well-being related to her medical [DIAGNOSES REDACTED]. Continued review revealed that she has signs of depression and episodes of crying. On 3/20/18 at 8:52 a.m., R#23 was lying in her bed and crying out. A Licensed Practical Nurse (LPN) was observed to assess the resident at that time. On 3/20/18 at 10:05 a.m., R#23 was lying in bed quietly with her eyes closed. The resident was not observed with any other negative behaviors during the survey. Although the resident was admitted to the facility with [DIAGNOSES REDACTED]. 2. Record review for R#8 revealed a Pre-Admission Screening/Resident Review (PASRR) Level I Assessment (Form: DMA-6) with a certification date of 4/11/13 that did not indicate that the resident had a serious mental illness, developmental disability or related condition. Review of the current Admission Record form revealed that the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] and the Quarterly MDS dated [DATE] revealed that her active [DIAGNOSES REDACTED]. Further review of the Quarterly MDS dated [DATE] revealed that the resident had received an anti-psychotic for five of the last seven days and an anti-depressant daily for the last seven days. review of the resident's medical record revealed [REDACTED].) two times a day as needed for mood stabilization, a physician's orders [REDACTED]. every day for psychotic behaviors. Review of the resident's care plan dated 2/8/18 revealed that the resident has the potential for psychosocial wellbeing related to confusion, major [MEDICAL CONDITION], anxiety disorder, unspecified [MEDICAL CONDITION], altered mental status and cognitive communication was at risk for alteration in psychosocial well-being related to her medical [DIAGNOSES REDACTED]. Further review of care plan dated 1/8/18 revealed resident exhibits behaviors related to [MEDICAL CONDITION] and cognition. Continued review revealed that she has signs of depression and episodes of crying. Resident can verbally and physically aggressive at times. Observation on 3/20/18 at 3:30 p.m. revealed that R#8 was lying in her bed. Observation on 3/2/18 at 10:05 a.m. revealed that R#8 was in wheelchair in hall. The resident was not observed with any other negative behaviors during these times. Although the resident was admitted to the facility with [DIAGNOSES REDACTED]. An interview on 3/22/2018 at 12:11 p.m. with the Social Services Director (SSD), who was also responsible for admitting residents to the facility, revealed that she had worked at the facility for approximately one year. Continued interview revealed that any residents who had mental illness [DIAGNOSES REDACTED]. The SSD stated at that time that she was unaware that the facility was responsible for submitting an application for PASRR Level II to the state designated mental health authority for the evaluation and determination of specialized services for any resident who was admitted with a [DIAGNOSES REDACTED].

Based on observation, record review, review of the facility's Policy and Procedure: Wound Management Program and staff interview, the facility failed to identify a pressure ulcer timely until it presented as an unstageable pressure ulcer for one resident (R) (R#18) of three residents reviewed for pressure ulcers from a sample of 20 residents. Findings include: Review of the facilty's Policy and Procedure: Wound Management Program revealed all residents will be assessed by the Braden Pressure Ulcer Scale assessment on admission, quarterly and with a significant change in condition if the Braden score is 11-15, moderate pressure ulcer precautions will be implemented moderate pressure ulcer precautions (Braden scale 13-14) include the intervention to visually observe skin daily. R#18 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 9, indicating he had some cognitive impairment. Continued review revealed he was non-ambulatory and required the extensive assistance of two staff for bed mobility and total assistance of two staff for toilet use. Further review revealed he received gastrostomy tube feedings and a mechanically altered diet. He was frequently incontinent of bowel and had a suprapubic urinary catheter. Review of the resident's care plan dated 7/23/2017 revealed that he had a pressure ulcer on his left lower buttock related to his immobility and bowel incontinence with an intervention for staff to monitor/document/report to the physician changes in the resident's skin status as needed. Continued review revealed that staff had implemented pressure relieving devices for his wheelchair and bed. Review of the Braden Scale For Predicting Pressure Sore Risk form dated 8/22/2017 revealed that R#18 scored 13 which indicated that he was at moderate risk for the development of pressure ulcers because his skin was often moist, he was chairfast, he had very limited mobility, he had probable inadequate nutrition and he required frequent repositioning with maximum assistance to prevent friction and shearing. Review of the medical record revealed that R#18 was identified with a Stage II pressure ulcer on his sacrum on 8/24/2017. The physician was notified and treatment initiated timely. Weekly wound assessments were performed. Review of the Multiple Weekly Wound Progress Report dated 11/15/17 revealed that the Stage II sacral pressure ulcer deteriorated to a Stage IV pressure ulcer. Continued review revealed that the resident was also identified with a new 4 centimeter (cm.) by 4.5 cm. unstageable pressure ulcer with eschar on his left heel on 11/15/2017. Although the resident was at moderate risk for the development of pressure ulcers per his Braden Scale dated 8/22/2017, there was no indication that staff had performed a visual skin inspection daily as per facility policy in order to identify the unstageable pressure ulcer on his left heel and obtain treatment timely. Review of the Skin Assessments revealed that the last head to toe skin assessment performed and documented was on 10/22/17, almost one month prior to the identification of the unstageable pressure ulcer on the resident's left heel. Review of the High Risk Indicators for Potential Skin Failure form dated 2/26/2018 revealed that the resident's attending physician documented that the resident's pressure ulcers were unavoidable due to his diagnoses, chronic bowel incontinence and decreased mobility. Observations on 3/19/18 at 10:58 a.m., 3/20/18 at 8:39 a.m. and 2:34 p.m., 3/21/18 at 8:55 a.m. and 3:52 p.m. R#18 was observed lying on a pressure relieving mattress and wearing bilateral heel booties. The resident was clean and without odors. On 3/20/2018 at 10:00 a.m., the Treatment Nurse provided treatments as ordered by the physician for the pressure ulcers on the resident's sacrum and left heel. The Stage IV sacral pressure sore measured 3.5 cms. by 2.5 cms. by 2.3 cms. with 2.0 cm. undermining at 12 o'clock. The unstageable left heel pressure ulcer measured 1.5 cms. by 2 cms. with brown eschar. The Treatment Nurse used appropriate infection control during the treatments. Interview with Certified Nursing Assistant (CNA) AA on 3/21/2018 at 2:10 p.m., revealed that she assessed a resident's skin during incontinence care and showers/baths for any redness or breakdown and would notify the nurse immediately. Interview with the LPN/Unit Manager on 3/22/2018 at 12:30 p.m., revealed that the nurses performed monthly skin assessments for residents who scored low or moderate on the Braden Scale. Continued interview revealed that the Treatment Nurse performed weekly skin assessments for those residents who scored high on the Braden Scale. On 3/22/2018 at 3:10 p.m., the facility Quality Assessment Performance Improvement (QAPI) plan was reviewed with the Administrator, Director of Nursing (DON) and Licensed Practical Nurse (LPN)/Unit Manager (UM). Interview with the Administrator, DON and LPN/UM at that time revealed that the DON had assisted with pressure ulcer treatment for [REDACTED]. Continued interview revealed that an investigation was initiated and administrative staff determined that the previous Treatment Nurse had incorrectly staged pressure ulcers and had not communicated the correct evaluation of wounds during the morning meetings. Further interview revealed that the previous Treatment Nurse was terminated and head to toe skin assessments were performed on all the residents by 11/9/2017. The unstageable pressure ulcer on R#18's left heel was identified at that time. Further interview revealed that all certified and licensed nursing staff were in-serviced on pressure ulcers, skin assessments and documentation on 11/10/2017. Continued interview revealed that the DON observed all pressure ulcers weekly for four weeks and continued to observe every other week with the current Treatment Nurse. Interview with the resident's attending physician, who was also the facility's Medical Director, on 3/22/2018 at 4:56 p.m. revealed that she obtained information from the Treatment Nurse regarding the status of a resident's pressure ulcer as well as assessing the pressure ulcers herself. Continued interview revealed that administrative staff had notified her about the incorrect staging by the previous Treatment Nurse and that she had input into the corrective measures that were placed.

Based on observation and staff interview the facility failed to properly label and date food items in the refrigerator; and failed to have a properly working thermometer in the kitchen for one meal during the survey. There were sixty six (66) residents receiving oral alimentation Findings include: 1. Observation on 08/18/14 at 10:20 a.m. of the two door stand -up refrigerator revealed a clear plastic bag that contained an off white food item which was not labeled or dated. Interview on 08/18/14 at 10:25 a.m. with the Dietary Manager revealed that she expects the kitchen staff to label and date all food items before placing them in the refrigerators or freezers. She confirmed that the clear plastic bag with the off white food product did not have a label or date. 2. On 08/20/14 at 12:35 p.m. lunch tray line steam table temperatures were attempted to be taken using the facilities calibrated thermometer. The kitchen did not have a working thermometer at the time the surveyor was present in the kitchen. Interview on 08/20/14 at 12:35 p.m. with the Dietary Manager revealed that the thermometer the staff used earlier to record lunch steam table in the temperature log had fallen onto the floor and broke. She revealed that the new digital thermometers were not calibrated correctly and giving false temperature readings of the food items on the steam table.

Based on record review and staff interview, it was determined that the facility failed to present a pre-existing medical order for "Do Not Resuscitate (DNR)" to emergency transport staff and/or hospital staff for one resident (#88), a closed record, of three (3) residents with advanced directives from a sample of twenty eight (28) residents. Findings include: Review of the clinical record for Resident #88 revealed that the resident was admitted on [DATE] for respite care and had [DIAGNOSES REDACTED]. Review of the resident's advanced directive, dated [DATE] and signed by a family member, revealed a "Do Not Resuscitate (DNR)" order that no medical treatment would be started or continued if the resident's heart stopped beating or he/she stopped breathing. Further review of the advanced directive revealed that the DNR information was to be given to paramedics, doctors, nurses or other health personnel as necessary to implement the resident's directives. Review of the [DATE] at 8:30 a.m. nurse's note revealed that the resident was found in bed breathing very fast and unresponsive to verbal and tactile stimuli. The resident's family member was at his/her bedside. The resident's pulse was fast at 125 beats per minute (BPM), his/her respirations were 32 (normal range was between 16 and 20), his/her temperature was high at 102.6 degrees Fahrenheit (F) and the resident's oxygen saturation level was low at 78 per cent (%). Further review of the nurse's note revealed that the attending physician was notified and ordered staff to transfer the resident to the hospital. The resident was transported to the hospital by emergency medical personnel with the family member at the resident's side. Review of the hospital Emergency Provider Report dated [DATE] revealed that the resident presented to the emergency room with septic shock and pneumonia and was in guarded condition. Further review of the report revealed that the family member had told the emergency room physician that the resident had a DNR order; however, there was not an official DNR paper available to hospital staff. Review of the [DATE] hospital History and Physical revealed that the resident was placed on a ventilator. The resident expired from [MEDICAL CONDITION] while in the hospital on [DATE]. Interview on [DATE] 2:05 p.m. with Licensed Practical Nurse (LPN) "AA" revealed that DNR forms were kept in the front of the residents' charts. Further interview revealed that if the physician ordered nursing staff to transfer a resident to the hospital, then she/he would send a copy of the DNR form with the resident to the hospital as well as notify hospital emergency room staff via telephone of the resident's DNR status. Interview on [DATE] at 3:00 p.m. with Licensed Practical Nurse (LPN) "BB", the nurse who had assessed the resident's change in condition on [DATE], reveled that she/he had notified the Registered Nurse (RN) weekend supervisor of the resident's condition who notified the physician and copied all the paperwork needed to send with the resident to the hospital. Interview on [DATE] at 12:10 p.m., the Registered Nurse weekend supervisor "CC" stated she/he was helping LPN "BB" care for the resident on [DATE] and that another licensed practical nurse had copied and sent the DNR form with the resident to the hospital. Continued interview revealed that she/he did not check to ensure that the DNR form was sent with the resident. Interview on [DATE] at 1:50 p.m. with the Director of Nursing (DON) revealed that the resident's primary care nurse was responsible for ensuring that all paperwork including the DNR form was sent with the resident to the hospital.