Every finding on record at PruittHealth- Orangeburg

Based on interviews and record review, the facility failed to ensure that physician orders were transcribed and implemented for Resident (R)30, one of three residents reviewed for hospitalizations. On 06/28/26, after R30 reported chest pain, the nurse did not transcribe the physician's orders to monitor vital signs every six hours and to report any abnormal findings or recurrence of chest pain. R30 was admitted to the hospital on [DATE] for congestive heart failure exacerbation. Findings include: Review of R30's Face Sheet revealed R30 was admitted to the facility on [DATE] with diagnoses including but not limited to unspecified heart failure, atherosclerotic heart disease of native coronary artery without angina pectoris, unspecified chronic atrial fibrillation, chest pain, type 2 diabetes without complications, and dementia with agitation. Review of R30's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/17/26 revealed that R30 has the Brief Interview of Mental Status (BIMS) score of 08 out of 15 which indicates that he has a moderate cognitive impairment. Review of R30's Progress Notes dated 06/28/26 at 2:44 PM revealed Resident complaints of chest pain stating, I feel like I am having a heart attack. No shortness of breath noted and no other pain voiced, vital signs blood pressure 156/70, heart rate 73, oxygen (O2) 98%, Nurse Practitioner (NP) notified, NP order vital signs every six hours and to report back if vital signs are abnormal or chest pain returns, Resident Representative (RR) called voicemail left. Review of R30's Physician Orders did not reveal the order related to monitoring R30's vital signs on the order listing. Review of R30's Blood Pressure Vital Sign Documentation from 06/28/26 - 07/04/36 revealed the following: 06/28/26 - no documentation of blood pressure vital signs06/29/26 - no documentation of blood pressure vital signs06/30/26 - no documentation of blood pressure vital signs 07/01/26 - no documentation of blood pressure vital signs 07/02/26 at 5:27 PM 155/72 measured in millimeters of mercury (mmHg) 07/03/26 at 6:42 PM 149/38 mmHg07/03/26 at 9:08 PM 133/60 mmHg 07/04/26 at 5:47 PM 162/66 mmHg07/04/26 at 8:13 PM 171/67 mmHg Review of a Progress Note dated 07/03/26 at 6:45 PM revealed Resident presented with chest pains today. Denies having pain in arms, neck, or face. NP called and new orders were given to order an Electrocardiogram (EKG) and given tums two tablets as needed every six hours. New orders for vitas to be taken each shift for 48 hours. RR called three times with no answer, unable to leave voicemail because answering service states it has not been set up. Resident is currently in bed resting comfortably, no complaints of chest pain has been voice again. Review of late entry Progress not recorded on 07/05/26 at 10:09 AM and dated for 07/04/26 at 9:51 AM revealed Resident had an ECG done related to chest pain. ECG was abnormal, on call NP called and gave new order to send the resident to emergency room (ER) for evaluation related to chest pain and abnormal ECG. Emergency Medical Services (EMS) called, arrived, and transported R30 out via stretcher with two attendants, on call NP/provider notified, along with the Director of Health Services, Nursing Supervisor, and Resident Representative. On coming nurse made aware of R30 status. Review of R30's Hospital Discharge Summary with an admission date of 07/04/26 and discharge date of 07/08/26 revealed admission condition: serious, discharge condition: good, indication for admission, congestive heart failure exacerbation. Hospital course included, R30 is an [AGE] year-old male with past medical history of chronic afibrillation, hypertension, type 2 diabetes mellitus, and hyperlipidemia who was sent from a Skilled Nursing Facility (SNF) for evaluation of chest pain and shortness of breath. Per SNF report, R30 experienced left chest pain beginning the day prior to presentation, and an EKG reportedly demonstrated abnormalities; however no additional evaluation was completed at that time. Due to persistent concern, he was sent to the ER for further assessment. Treatments included intravenous (IV) Lasix Diuresis, O2/oxygen, and medical management of cardiac disease. Review of R30's Care Plan last revised 07/22/26 revealed R30 is at risk for decreased cardiac output related to hypertension, hyperlipidemia, coronary artery disease, and atrial fibrillation, R30 receives daily Digoxin related to atrial fibrillation which has the potential for toxicity. R30 had a hospital admission on [DATE] related to chronic congestive heart failure. Interventions include, monitor for changes in activity tolerance, monitor for shortness of breath, monitor weight as ordered, Cardiologist appointments as scheduled, labs as ordered, medications as ordered, monitor and report to Medical Doctor (MD) any signs or symptoms of cardiac distress, observe for syncope/dizziness/palpitations/or feeling of weakness associated with an irregular heart rhythm. Monitor for increased edema/dyspnea/or chest pain. Serve diet as ordered, and vital signs per protocol. An observation and interview on 07/27/26 at 10:34 AM with R30 revealed that he recently had to discharge from the facility and admit to the hospital (07/04/26 - 07/08/26) after experiencing significant chest pains. R30 stated that I had a lot of fluid around my lungs, and it made it hard for me to breathe at that time. An interview on 07/28/26 at 4:04 PM with Licensed Practical Nurse (LPN)4 revealed that when a nurse receives an order from the physician/provider that they should input the order into the Electronic Medical Record (EMR). LPN4 further stated that nursing staff are responsible for completing vitals for residents and inputting the findings into the EMR. LPN4 finally stated that they were unable to locate the updated order that was requested by the provider on 06/28/26 related to vital signs every six hours for the resident. An interview on 07/29/2026 at 10:42 AM with LPN3 (R30 assigned nurse on 06/28/26) revealed that they received the order from the provider and put a Progress Note into the EMR but did not update the order into the EMR under the resident's Physician Orders. LPN3 further stated that it was at the end of the shift and they gave the report of the new order to LPN5 verbally. LPN3 verified/confirmed that the order related to additional vital signs for R30 was not input into the EMR as a Physician's Order. An interview on 07/29/26 at 11:23 AM with the Director of Nursing (DON) revealed that staff did not meet professional standards of practice related to R30's updated Physician' Orders for additional monitoring. The DON further stated that the facility does not have a policy/procedure related to Physician Orders but follow federal guidelines/regulations related to Quality of Care. An interview on 07/29/26 at 2:20 PM with LPN5 revealed that they were not resident's assigned night nurse on 06/28/26 and that they received report LPN3 related to additional vital signs for R30 due to chest pain. LPN5 stated that she was unaware that the order was not revised into the EMR. An interview on 07/29/26 at 2:23 PM with LPN6 stated that nurses are responsible for inputting orders into the EMR when they are received from providers.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure residents received alternative measures prior to the installation of side rails, and assessments were completed for the risk of entrapment for one of two residents (Resident (R) 235) reviewed for side rails of 26 sample residents. The lack of alternate side rail measures and proper assessment/consent could lead to potential restraint or side rail entrapment. Findings include: Review of the facility's policy titled, Bed Rails, revised 08/08/24, revealed that when it has been determined by the admitting nurse and/or interdisciplinary team (IDT) that bed rails are medically necessary for a patient's care (or are requested by a patient or the patient's representative), the following procedures should be followed prior to their use. The nursing and maintenance staff should regularly inspect the mattress and bed rails for areas of possible entrapment. Review of R235's undated Face Sheet located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE]. Diagnoses included unsteadiness on feet, lack of coordination, and muscle weakness. Review of R235's Care Plan, initiated 05/06/24, located under the Care Plan tab of the EMR, revealed resident was at risk for Falls and intervention in place was 1/4 side rails for enabling increased movement. Review of R235's Order Summary Report located under the Orders tab of the EMR, revealed an order, dated 04/16/25, for 1/4 side rails for turning and repositioning. Review of R235's EMR revealed no documented evidence of any alternative measures prior to installation, and no documented evidence of assessing risk for entrapment. During an interview on 05/08/25 at 9:17 AM, Licensed Practical Nurse (LPN)1 stated all residents had a bedrail observation form completed on admission. She stated 99% of the time, residents got bedrails. She stated staff did not explore alternatives prior to using bedrails because residents got them the day they were admitted . She stated she had never been aware of alternatives being explored prior to bedrail use. During an interview on 05/08/25 at 12:58 PM, the Maintenance Director (MD) stated he completed a monthly audit of bedrails. He stated he checked the functionality of them to ensure they stayed up and locked, ensured the mattress was the correct size, and that the call light worked. He stated he did a visual assessment to ensure it did not appear to have a gap greater than two inches, but he did not assess the risk for entrapment. He stated he did not have a device to check for the risk for entrapment. During an interview on 05/08/25 at 3:24 PM, the Director of Nursing (DON) stated she expected staff to complete bedrail assessments. She stated that alternatives were explored on a patient-by-patient basis, and it would depend on them. She stated she was unaware that any alternatives had to be explored for any residents prior to bedrail use and that staff should assess and monitor that risk of entrapment.

Based on record review and interview, the facility failed to ensure that a discharge Minimum Data Set (MDS) assessment was completed timely for one of 26 sample residents (Resident (R) 37) reviewed for MDS assessments. The failure to submit the discharge MDS did not allow for the closure of the residents' MDS cycle. Findings include: Review of R37's Admission Record located in the Profile tab of the electronic medical record (EMR) revealed admission to the facility on [DATE]. Further review revealed R37 was discharged to the hospital on 03/30/25. Review of R37's quarterly MDS under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 03/05/25 revealed a Brief Interview for Mental Status (BIMS) assessment could not be completed. Further review revealed there was no discharge MDS assessment completed for R37. During an interview on 05/08/25 at 12:48 PM, the MDS Coordinator stated she reviewed the daily census activity report for any discharges, and they were discussed in morning meeting. She said the discharge assessment was simply missed. She said she did not complete the discharge MDS, but she should have. During an interview on 05/08/25 at 3:24 PM, the Director of Nursing (DON) stated she expected the necessary MDS assessment to have been completed.

Based on observations, interviews, and facility policy review, the facility failed to label and date foods, discard expired foods and failed to maintain a clean ice machine, in 1 of 1 main kitchen. Findings include: Review of the facility policy titled Food Ordering, Receiving and Storage revised [DATE] revealed, Policy Statement: It is the policy of PruittHealth that food will be routinely ordered and received from approved corporate vendors who obtain food from regulated and reputable sources to ensure food safety. The corporate office maintains a list of approved vendors. Storage and Rotation Guidelines: Date all items with delivery date. Review of the facility policy titled Ice Machines (Handling/Scoops) revised [DATE] Policy Statement: It is the policy of PruittHealth to maintain safe and sanitary conditions when serving ice to prevent cross contamination and the spread of bacteria. Procedure: it is the responsibility of the dietary partners to clean and sanitize the ice machine designated for dietary purposes at least monthly using the following process: Turn ice machine off. Completely empty ice bin. Clean inside of ice machine removing all build-up/debris. Sanitize entire ice machine with an approved sanitizing solution per manufacturer's recommendations. During the initial tour of the kitchen on [DATE] at 11:02 AM, revealed the following: cheese in refrigerator with no label or date, coleslaw expired on [DATE], ice machine dirty with pink and brown watery substance around the rim and the underside, jar of grape jelly opened with no open date/label, jar of red substance not dated/labeled. During an interview on [DATE] at 9:02 AM, the Dietary Manager (DM) stated, when the food truck comes in, they label the food with the date they received it. The DM further stated anytime a food item is opened, pulled for use, or thawed, it is supposed to be labeled with the date and time. The DM stated when food was leftover and will be used again, it should be labeled with what the item is, the date, the time, and use by date. The DM concluded maintenance/servicing of the ice machine was done monthly by maintenance personnel and that last cleaned on [DATE].

Based on observations and interviews, the facility failed to serve food at the appropriate/preferred temperature in 1 of 1 main kitchen. Findings include: The facility did not provide a policy on proper cooking, reheating temperatures, or proper holding temperatures. During an observation on 12/11/23 at 11:24 PM, of Cook 2 taking food temperatures on the steam table revealed the following: Onion rings - 140 degrees Fahrenheit (F) Fish fillets- 130 degrees F Steamed Cabbage- 110 degrees F Purred Cabbage-150 degrees F Purred fish- 130 degrees F During an interview on 12/11/23 at 11:30 AM, Cook 2 stated she only went by what the thermometer told her and the thermometers do not work properly. During an interview on 12/13/23 at 9:03 AM, the Dietary Manager (DM) stated the cooks know the proper food temperature ranges, but there were no proper temperature postings in the kitchen. The DM furthered stated that about two or three months ago thermometers were purchased and replaced.

Based on review of facility policy, observations and interviews, the facility failed to ensure expired medications, and insulin pens were labeled and stored according to manufacturers recommendations in 2 of 4 medication carts and 1 of 2 treatment carts. Findings include: Review of the undated facility policy titled, Medication Storage in the Healthcare Centers states, Policy Statement: Medications and biological's are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. 3. Nurses are required to check all medications for deterioration and expiration before administration. Nurses are also required to inspect medications storage facilities, including medication carts, routinely. 11. Multi-dose containers, injectable's, ophthalmic and optic preparations and inhalers are to be dated when opened. 12. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction, and reordered from the pharmacy, if a current order exists. During an observation on 12/10/23 at 11:20 AM of the URS Medication Cart revealed: Atropine 1% eye drops, Lot #AP230414, RX #632971 was opened on 10/27/23 and expired on 11/25/23. Levemir Flex Pen, Lot #NZF7NOL, in use with no open date and an expiration date of 11/27/23. Levemir Flex Pen, Lot #NP5H734, in use with no open date and no expiration date. Insulin Aspartane Flex Pen, Lot #HZF7K85, in use with no open date and no expiration date. Novolog Flex Pen, Lot #HZF7V86, in use, with an open date of 11/08/23 and no expiration date. During an observation on 12/10/23 at 11:50 AM of the URS Middle Medication Cart revealed: One bottle of Even Care Blood Glucose Test Strips, Lot #16823033009, Expiration date 12/14/24. There was no open date and no expiration date. Levemir Flex Pen, Lot #NP54707 in use with no open date and no expiration date. During an interview on 12/10/23 at 12:24 PM, Licensed Practical Nurse (LPN)1 confirmed the eye drops, Insulin pens and Blood Glucose Strips did not have an opened date and an expiration date. LPN1 removed the items from the medication carts. During an observation on 12/12/23 at 9:40 AM of the URS Treatment Cart revealed: One bottle of Sterile Saline 100 milliliters (mls) (3.4 ounces) with approximately 30 mls left in the opened bottle, Manufactured by Medline with Lot #22114283, stored on the treatment cart with other medications in use, and no longer sterile. One bottle of Iodoform Packing Strips, Manufactured by Sterite Curad with Lot #02270, sterile and opened and partially used, and placed back on the treatment cart and no longer sterile. Registered Nurse (RN)1 confirmed and removed the items from the treatment cart.

Based on review of facility policy, observations, and interviews, the facility failed to follow a procedure during Foley catheter care to decrease the likelihood of infection for Resident (R)70, for 1 of 1 residents observed for Foley catheter care. Findings include: Review of the facility policy titled Procedure: Catheter Care states, Procedure: 3. Explain procedure to resident. 4. Perform hand hygiene according to facility policy/protocol. 5. Don personal protective equipment as appropriate for procedure. 6. Explain reason for the procedure to the resident. Female Resident. 1. Wet washcloth and sparingly apply soap or perineal cleanser. 2. Separate inner labia with nondominant hand. Wash down the center, wiping downward from front to back and stopping at the base of the labia. Continue washing, wiping from front to back, alternating from side to side and moving outward to the thighs. Turn the washcloth or use a new washcloth for each area. 3. Rinse and dry the urethral and perineal area, working in the same direction until entire area is clean, soap free, and dry. 4. Hold catheter tubing to one side and support against leg to avoid traction or unnecessary movement of the catheter while washing perineum. Keep drainage bag below level of bladder. 5. When washing, rinsing, and drying the urethral area: a. Gently wash, rinse and dry around the juncture of the catheter and meatus. b. Wash the catheter from the meatus down the tube about 3 inches. 11. Position the bed linen and the resident. 12. Perform hand hygiene according to facility policy/protocol. 13. Document procedure per facility policy/protocol. 14. Take appropriate actions for abnormal findings or observations. Review of R70's Face Sheet revealed the facility admitted R70 with diagnoses including, but not limited to: urinary retention with an indwelling Foley Catheter and muscle spasms. During an observation and interview of Foley catheter care on 12/12/23 at 10:40 AM, revealed the following: Certified Nursing Assistant (CNA)1 knocked on R70's door, and the resident asked us in. CNA1 explained the procedure to the resident and this surveyor asked permission to observe. R70 stated that it would be ok. CNA1 provided privacy and both CNAs washed their hands and both applied gloves. CNA1 opened wipes, and lowered the head of the bed. CNA2 removed the bed covers and pulled up R70's gown. Both CNAs unfastened the resident's brief, R70 had a bowel movement, so the brief was pushed down toward the bed between the resident's leg. The CNAs did not stop catheter care and clean the resident. CNA2 lifted the left leg of R70 and moved it over to the left side of the bed and the right leg followed. CNA1 took a wipe and wiped down the left side of the groin area. Then CNA1 took another wipe in hand and cleaned the catheter tubing from the outer skin down the tubing. CNA1 then removed her gloves, washed her hands, applied gloves and wiped down the right groin area with a wipe. CNA1 then cleaned down the tubing again, removed her gloves and washed her hands. Then CNA1 stated they were going to clean the resident due to the bowel movement, and then stated before she would do that she would remove her gloves and wash her hands. CNA1 stated she was finished with catheter care. So this surveyor thanked R70 and CNA 1 was retrieving a clean brief from the resident's closet. Then CNA 1 and CNA 2 proceeded to change R70's soiled brief. CNA 1 had not cleaned the insertion site of the Foley catheter. During an interview on 12/12/2023 at 11:00 AM with CNA 1, I informed CNA1 my observation of catheter care and she stated that she cleaned the catheter insertion site after I left R70's room and both CNAs cleaned up R70.

Based on observations, interviews, record review, and review of facility policy, the facility failed to provide Resident (R)14 with treatment to prevent further decrease in range of motion (ROM) for 1 of 1 residents reviewed for range of motion. Findings include: Review of facility policy titled, Restorative Nursing Program revised on 11/04/21 revealed, It is the policy of this healthcare center to provide restorative nursing which actively focuses on achieving and maintain optimal physical, mental, and psychological functioning and wellbeing of the patient/resident. Restorative nursing program is under the supervision of a Registered Nurse (RN) or a Licensed Practical Nurse (LPN) and restorative nursing services are provided by Restorative Nursing Assistant (RNAs), Certified Nursing Assistants (CNAs), and other qualified staff. 2. Determine appropriate restorative services based on the screening. Documentation. 1. Restorative nursing care will be documented in the Electronic Health Record (EHR) or paper form. Review of R14's Face Sheet revealed R14 was admitted to the facility on [DATE] with a diagnoses including but not limited to: dysarthria following cerebral infarction, cognitive communication deficit, cerebral infarction, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, contracture, left shoulder, contracture, left wrist, contracture left hand, and contracture, left elbow. Review of R14's Physician Orders revealed, Resident required carrot to left hand daily, 7 days per week, and may remove during activities of daily living (ADLs). Review of R14's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/14/23, revealed R14 had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated the resident had severe cognitive impairment. Further review of the MDS revealed R14 was dependent for personal hygiene, showering, and toileting. R14 had functional limitation in range of motion on both sides to the upper and lower extremity. Review of R14's Care Plan dated 12/02/23 revealed, [R14] required carrot to Left hand daily 7 days per week. Interventions included to, don carrot to Left hand daily and may remove during morning ADLs. Patient to use carrot as can tolerate. Review of 14's Point of Care Restorative Nursing Category Report (MDS 3.0) dated 11/12/23 - 12/12/23 revealed, no splint or brace assistance on 11/06/23, 11/08/23, 11/11/23, 11/12/23, 11/13/23, 11/18/23, 11/19/23, 11/2323, 11/24/23, 11/25/23, 11/26/23, 12/01/23, 12/02/23, 12/03/23, 12/06/23, 12/09/23, and 12/10/23. Further review of the report revealed, R14 only received 5 hours of splint or brace assistance on 11/07/23, 11/09/23, 11/10/23, 11/14/23, 11/15/23, 11/16/23, 11/17/23, 11/20/23, 11/21/23, 11/22/23, 11/27/23, 11/28/23, 11/29/23, 11/30/23, 12/04/23, 12/05/23, 12/07/23, 12/08/23, and 12/11/23. During an observation on 12/10/23 at 12:01 PM, R14 was lying in bed with no assistive device on left hand contracture. During an observation on 12/11/23 at 9:30 AM R14 was lying in bed with no assistive device on left hand contracture. During an observation on 12/12/23 9:13 AM R14 was lying in bed with no assistive device on left hand contracture. During an interview on 12/12/23 at 9:34 AM, Restorative Certified Nursing Assistant (RCNA)4 revealed RCNA4 applied the carrot to R14's hand for 5 hours per day. RCNA4 stated she puts the carrot in R14's hand around 10:00 AM and takes it off around 4:00 PM every weekday. RCNA4 further stated R14 did not refuse care and on the weekends the carrot was washed. RCNA4 stated the weekend CNAs should place a washcloth in the resident's hand. RCNA4 applied R14's carrot on 12/11/23 at 10:30 AM until 4:00 PM. RCNA4 concluded that Licensed Practical Nurse (LPN)7 provided instruction on how long the device was left in place. During an interview on 12/12/23 at 9:51 AM, the Director of Rehab revealed that the therapy recommendation was for R14 to wear the carrot 8 hours per day. The CNAs and the nurses can both put the device in the resident's hand. During an interview on 12/12/23 at 9:58 AM, CNA5 revealed that the restorative CNA or the restorative nurse applied the carrot to R14's hand. CNA5 stated that on 12/11/23, the carrot was applied to R14's hand at 11:00 AM. CNA5 stated she is unsure if the restorative CNA took the carrot out of R14 hand. CNA5 did not know how long the resident was required to wear the carrot each day. During an interview on 12/12/23 at 10:18 AM, RCNA4 revealed the majority of the residents wore their splints for 5 hours per day and thought that it was the same order for the R14. RCNA4 stated that the facility trained staff to look at care plans and orders for application of the splint. RCNA4 stated R14's medical record was not read properly and the expectation is for R14 to receive devices to prevent further reduction in range of motion as the physician ordered. During an interview on 12/12/23 at 2:41 PM, CNA3 revealed, they were not familiar with R14's restorative orders. CNA3 stated she was not sure who was responsible for the application and removal of the restorative device. During an an interview on 12/12/23 at 3:10 PM, Licensed Practical Nurse (LPN)7 revealed that RCNA4 was responsible for restorative nursing during the week. LPN7 stated that CNAs and nursing staff were responsible any other time. LPN7 stated that RCNA4 put the carrot in R14's hand upon arrival to work and took it off before the end of shift. LPN7 further stated R14's carrot is in place about 4-6 hours per day. LPN7 confirmed that R14's order was for 7 days a week and may be removed with ADL care only. LPN7 further stated that she was just recently put in the position about 2 weeks ago and only looked at the documentation sporadically and that RCNA4 is periodically pulled to the floor as a CNA. LPN7 expected residents to receive assistive devices per physician order to prevent further decline in ROM. During an interview on 12/12/23 at 3:31 PM, the Director of Nursing (DON) revealed that R14's physician order for the assistive device was for it to be applied 7 days per week/24 hours a day. The DON stated that the nursing staff was responsible for monitoring the device placement. The DON further stated that LPN7 monitored the application and documentation of restorative care. The DON continued that RCNA4 completed the restorative care during the week, and the nurses were responsible for applying assistive devices on the weekend. The DON stated that RCNA4 was under the impression that the assistive device was only to be placed for a few hours a day. The DON indicated she did not review restorative documentation, but indicated after looking at R14 restorative documentation, the resident did not receive the service as ordered. The DON concluded the expectation was that R14 receive range of motion services per physician order to prevent further decline.

Based on observations, interviews, record review, and review of facility policy, the facility failed to ensure reasonable accommodations were provided to meet the needs and functional ability for 1 of 1 residents reviewed for accommodations of needs. Specifically, Resident (R)73's call light was observed out of reach and not accessible if the resident needed assistance. Findings include: A review of the facility's undated policy titled, Procedure Call Light, revealed, Ensure that all residents (even those who are confused) have access to the call signal at all times and know how to use it. A review of R73's Face Sheet revealed the facility admitted R73 on 09/05/23 with diagnoses including but not limited to: dysphagia following cerebral infarction, dysphagia, oropharyngeal phase, cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of R73's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/05/23 revealed R73 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated that the resident had moderate cognitive impairment. Further review of the MDS revealed R73 required substantial to maximal assistance with eating and was dependent on staff for toileting, hygiene and showers. Review of R73's Care Plan with a revised date of 12/07/23, revealed R73 required extensive to total assistance with activities of daily living (ADL's) due to left hemiparesis related to (r/t) cerebral vascular accident (CVA). Interventions included, to keep call light within reach at all times when in room. During an observation on 12/10/23 at 12:11 PM, R73 was in bed. R73's call light was on the floor, approximately three feet from the resident. During an observation on 12/11/23 at 9:33 AM, R73 was in bed and the call light was on the floor, approximately three feet from the resident. During an interview on 12/11/23 at 9:36 AM, Licensed Practical Nurse (LPN)5 revealed that it was the responsibility of all staff members to ensure that the call light was within the resident's reach. LPN5 acknowledged the call light was not within R73's reach. LPN5 concluded that it was everyone's responsibility to monitor the placement of residents' call lights. During an interview on 12/13/23 at 9:51 AM, Certified Nursing Assistant (CNA)6 revealed, the call light should be in the resident's reach. CNA6 stated she was not aware how often the call light placement should be checked. CNA6 further stated she only checked R73's call light placement in the morning and after lunch because R73 went to activities. During an interview on 12/13/23 at 10:06 AM, the Director of Nursing (DON) revealed the call light should always be functioning and within the reach of the resident. All staff members were responsible for ensuring the residents' call light was within their reach. Call light placement should be checked on all residents every hour.

Based on observations, interviews, record review, and review of facility policy, the facility failed to provide services to Resident (R)14, who was unable to carry out activities of daily living (ADL), necessary to maintain good grooming and personal hygiene for 1 of 3 residents reviewed for ADL care. Findings include: Review of R14's Face Sheet revealed R14 was admitted to the facility on [DATE] with diagnoses including but not limited to: dysarthria following cerebral infarction, cognitive communication deficit, cerebral infarction, and hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side. Review of R14's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/14/23, revealed R14 had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated R14 had severe cognitive impairment. Further review of the MDS revealed R14 was dependent on staff for personal hygiene, showering, and toileting. Review of R14's Care Plan with a revised date of 12/02/12 revealed, R14 required staff to anticipate and provide all ADL's. Interventions included to provide daily grooming, oral hair and skin care, nail care/shampoo as needed, and anticipate all ADL needs. During an observation on 12/10/23 at 11:58 AM, R14 was lying in bed with white facial hair on the chin and cheeks approximately a quarter of an inch long. During an observation on 12/11/23 at 9:30 AM, R14 was lying in bed with white facial hair on chin and cheeks approximately a quarter of an inch long. During an observation on 12/12/23 at 9:12 AM, R14 was lying in bed with white facial hair on chin and cheeks approximately a quarter of an inch long. During an interview on 12/12/23 at 9:18 AM, Certified Nursing Assistant (CNA)1, revealed that she assisted with providing care to R14. CNA1 stated that grooming was a part of personal care and should be done daily. During an interview on 12/12/23 at 9:58 AM, CNA6 revealed that residents are to receive personal hygiene and grooming daily. CNA6 stated that R14 was not shaved yesterday because, I did not get around to getting it done. During an interview on 12/12/23 at 12:30 PM, the Director of Nursing (DON) stated that personal hygiene and grooming should be performed daily and as needed. The DON further stated, any nursing staff could shave a resident when needed and it is expected that a dependent resident to be provided grooming and personal hygiene daily. During an interview on 12/12/2023 at 2:41 PM, CNA3 revealed that personal hygiene consists of changing, bathing, grooming, and shaving and was completed as needed. CNA6 stated that hair on R14's face was not noticed when care was provided to the resident on 12/10/23.

Based on observation, interview and review of the facility policy, the facility failed to ensure expired food items were removed from the walk-in refrigerator and dented cans were removed from the dry storage for 1 of 1 main kitchen. The findings included: On [DATE] at 03:32 PM, a brief initial tour of the kitchen with the second shift Head Cook, observation of the kitchen walk-in refrigerator revealed two (2) Sara [NAME] Sweet Hawaiian Rolls with an out of date [DATE] and two (2) Sara [NAME] Honey Wheat Bread with an out of date [DATE]. Observation of dry storage room revealed two (2) canned goods, 6lb 10oz Gehls Mild Cheddar Cheese sauce, which have been compromised or punctured. The 2nd shift Head Cook stated he/she would move the cans to the dented cans area. During an interview with the second shift Head Cook on [DATE], the head cook was asked what is the process for identifying and removing expiring food products and dented cans? The head cook stated, A staff member from the second shift usually checks for expired, out-of-date foods, and dented cans. I don't know how they missed these. We get a truck every Tuesday and we go through the bread and all the cans to make sure they don't have any dents or punctures. I guess he overlooked them. During an interview with the Certified Dietary Manager on [DATE], the CDM inquired about the findings of the inspection. The surveyor informed the CDM that during the walkthrough tour on [DATE], there were four (4) packs of bread in the walk-in refrigerator that were out-of-date and two (2) dented cans in the dry storage room. Review of the facility policy titled Food Ordering, Receiving, and Storage, stated 3. Prepared food and/or beverage items will be discarded according to the USDA Quick Reference Shelf-Life List. 9. Dented cans should be kept in a separate designated area, with a dented can sign, and away from regular stock. Vendor should be informed of damages upon delivery and should issue a credit according to their policy.

Based on observations, interviews, and the review of the facility's policy titled Infection Prevention and Control Policies and Procedures, the facility failed to ensure employees, vendors, and contractors were COVID-19 screened before entering the facility. The facility also failed to ensure staff practiced proper hand-washing prior to meal administration, for 2 of 2 meals observed. Findings Include: A review of the facility's s policy titled, Infection Prevention and Control Policies and Procedures under Procedure says the following: The facility will complete a Prevent COVID-19 Screening Checklist and/or COVID-19 Prevent Worksheet prior to entering facility, which includes vaccination history for employees, contracted staff, and consultant only. The facility will follow the screening process for signs and symptoms of COVID-19 and will restrict entry if concerns are identified. On 10/17/21 at 3:00 PM, COVID-19 screening, hand sanitizer, and available face masks were observed at the front entrance of the facility. At approximately 3:15 PM on 10/17/21, an observation revealed two transport services staff members entering the building, with a stretcher, without being screened for COVID-19. At approximately 4:20 PM on 10/17/21, transport services staff entered into the building without being screened for COVID-19. At 5:05 PM on 10/17/21, an observation revealed two nursing staff entering in through a side door of the nurses' station on Unit 1 and the door at the back of the hall in Unit 1 was propped open with a white towel. The Charge Nurse removed the towel allowing the door to close after confirming it was propped open. At approximately 6:00 PM on 10/17/21, three visitors came into the building through the side door of the nurses' station on Unit 1. The Charge Nurse, asked the visitors to go outside and re-enter the facility through the main entrance. On 10/20/21 at approximately 12:40 PM, a visitor came in the front door of the facility and walked straight down the hall to Resident #58's room without being screened for COVID-19. In an interview with the Infection Control Coordinator on 10/20/21 at 2:45 PM, s/he stated that all persons, including employees, contractors, and vendors, entering the facility must be COVID-19 screened at the front entrance of the facility. The findings included: An observation on 10/17/21 at approximately 6:23 PM of the meal service in rooms 36 through 54 revealed staff entering resident rooms, touching the over the bed table, touching the bed remote and then setting up the meal trays for residents without cleaning their hands before setting up the meal trays. An additional observation on 10/20/21 at approximately 12:45 PM meal trays were being delivered to resident on the middle hall and the rehab hall. Staff were entering rooms and touching the residents, the over the bed table, the bed covers and then not cleaning their hands before setting up the meal trays. An interview on 10/20/21 at approximately 1:00 PM with Certified Nursing Assistants #1 and #2 verified that they were entering resident rooms with meal trays and touching objects in the room and not cleaning their hands before setting up the meal trays. Review on 10/20/21 at approximately 1:30 PM of the facility's policy, Hand Washing, states under Policy Statement, Cleaning your hands reduces the spread of germs and decreases the spread of infections. Under, When to Perform Hand Hygiene, Before and after any direct patient skin contact, after any contact with objects/medical equipment on the vicinity of the patient.

Amended 1/10/2022 Based on interviews and review of the daily postings for staffing, the facility failed to ensure a Registered Nurse was in the facility for 8 consecutive hours daily for multiple days from 9/17/2021 through 10/17/2021. The facility further failed to ensure the Director of Nursing did not serve as the charge nurse for 1 of 5 days of the survey. The facility had a census of 68 residents. The findings included: An observation on 10/17/2021 at approximately 3:00 PM revealed the Director of Nursing serving as the charge nurse in the facility with a census of 68 residents. No other Registered Nurses were working in the facility on this date. Further review of the staffing posted for licensed and non licensed nursing staff from 9/17/2021 through 10/20/2021 revealed no documentation on the postings to ensure any Registered Nurses were in the facility serving as the charge nurse on the following days: No Registered Nurse on the daily posting of staff worked for 10/17/21, 10/10/21, 10/9/21, 10/8/21, 10/6/21, 10/4/21, 10/3/21, 10/2/21, 9/30/21, 9/29/21, 9/27/21, 9/26/21, 9/25/21, 9/23/21, 9/22/21, 9/21/21, 9/19/21. An interview on 10/17/2021 at approximately 4:00 PM with the Director of Nursing confirmed that s/he was the Supervisor because no other Registered Nurse have reported to work. An interview on 10/18/2021 at approximately 9:30 AM with the Administrator confirmed the findings.

Based on observations, interview, and review of the facility policy titled, Medication Administration: General Guidelines, the facility failed to ensure a medication administration error rate of less than 5 percent during 2 out of 26 opportunities for error observed during medication administration. The findings included: An observation on 10/19/21 at approximately 8:31 AM during medication administration, Resident (R) 56 received [MEDICATION(S)] Extended Release 10 milligrams by mouth. The Licensed Practical Nurse (LPN) administering the medications for R56 crushed the medications and stated the resident could not swallow the medications whole. R56 also received [MEDICATION(S)] 500 milligrams, 1 tablet by mouth daily and LPN1 also crushed this medication. During medication reconciliation on 10/19/21 at approximately 10:00 AM, the medications, [MEDICATION(S)] Extended Release and the [MEDICATION(S)] were marked as,DO NOT CRUSH. During an interview on 10/19/21 at approximately 2:00 PM with LPN 1, s/he confirmed the [MEDICATION(S)] Extended Release tablet and [MEDICATION(S)] should not have been crushed. Review on 10/19/21 at approximately 3:00 PM of the facility policy titled, Medications Administration: General Guidelines, states under Policy Statement: Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Number 22 states, Long-acting or [MEDICATION(S)] coated dosage forms should generally not be crushed and require a physician's specific order to do so. The physician must record in the medical record that the benefit of crushing the dosage form outweighs the potential risk.

Based on record reviews, interviews, and review of the facility policy titled, Weight Monitoring, the facility failed to provide interventions for Resident (R) 44 to promote weight maintenance or to decrease weight loss for 1 of 4 residents reviewed for Nutrition. The findings included: The facility admitted R44 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 10/20/21 at approximately 3:29 PM of the medical record for R44 revealed the following weights: 7/1/2021 200.4 lbs. 7/20/21 196.6 lbs. 8/10/21 181.0 lbs. 9/9/21 180.4 lbs. 10/8/21 175.1 lbs. These weights reflected a 25 pound weight loss in 3 months. Further review on 10/20/21 at approximately 3:40 PM of the medical record for R44 revealed the following Dietary notes from the Registered Dietician: 8/17/2021 at 10:32 PM Weight review: CBW 181 pounds on 8/10/21 and 196.6 pounds on 7/20/21. Resident is followed for behaviors. Will recommend supplementation due to weight loss and ask the interdisciplinary team to follow with weekly weights also at this review. No weekly weights could be found in the medical record for Resident #44 to ensure the weights were being monitored. An additional dietary noted from the Registered Dietician: 10/15/21 at 4:04 PM Weight review: CBW is 175 pounds, a slight decrease this month, significant decrease x 180 days or less. Will recommend to increase the Standard 2.0 to three times daily at this time. The Standard 2.0 was discontinued on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 10/21/21 at approximately 9:00 AM with the Certified Dietary Manager (CDM) concerning the weekly weights, the CDM stated that s/he had identified the weight loss on 9/2/21, after the resident had lost 20 pounds and stated that s/he had wanted to start R44 on Magic Cup but s/he is not allowed to make recommendations for weight loss. During an interview on 10/21/2021 at approximately 9:23 AM with the Registered Dietician, s/he stated s/he was not concerned about the weight loss due to the fact that R44 had behaviors. S/he stated the Standard 2.0 three times a day would give the resident 540 calories. The Dietician is not concerned that the facility does not do weekly weights when a significant weight loss is identified. S/he then rewrote the order for the Standard 2.0 to be given three times a day, since it was not increased to three times daily previously. Review on 10/21/2021 at approximately 10:00 AM of the facility's policy titled, Weight Management Program, revealed the Procedure,Patients/residents will be placed on a Weight Monitoring Program, unless the weight loss is anticipated and/or planned. Patients/residents will be placed on a weight monitoring program and will be weighed weekly. Under Weight Frequency: number 6 states, Re-weighs must be obtained on all weights (daily, weekly, or monthly) that shows a weight loss/gain of three pounds or more for weekly weights and 5 pounds or more for monthly weights. Reweighs must be obtained and documented within 24 hours of prior weight, Under Weight Team, number 3 states, The Weight Team Responsibilities include evaluating weights for significant changes; recommending appropriate interventions, reviewing patient/resident meal, supplement, and snack intakes; revision interventions; if necessary.

Based on observations records review and interview the facility failed to provide the necessary care and services to ensure that R4 maintained activity of daily living (ADLs) abilities or received appropriate assistance with activities of daily living when needed for one of one sampled resident reviewed for ADLs. Findings: The facility admitted R41 on 1/01/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 10/17/2021 at 5:07 PM, R41 was noted to be lying in his/her bed. S/he appeared disheveled, with their face, clothing, and fingernails uncleaned. There was a strong, offensive odor in the room. There were no sheets on the bed and clothes and food on the floor, including his/her closet floor. Observation revealed feces on and around the toilet and the toilet seat was cracked. There was a large brown/golden stain on the wall behind the handwashing sink and the entire floor of the room felt sticky. On 10/18/2021 at 1:45 PM, R41 was observed to be in his/her wheelchair at the nurse's station. S/he was dressed in an old, long sleeve collared shirt and ripped pajama bottoms with part of his/her upper thigh exposed. R41 was observed eating lunch in his/her room, unsupervised, throughout the dates of October 18-20, 2021. At each time, food was observed on the floor. R41's care plan indicated that s/he requires supervision to limited assistance with ADLs. It also noted that R41 is highly involved with all adls and is self-motivated. In a re-visit to R41's room with the Maintenance Manager on 10/20/21 at approximately 3:00 PM, s/he verified the above findings. In addition, the Maintenance Manager confirmed there was dried-up food debris on the closet floor.

Based on observations, records review, and interviews, the facility failed to determine and complete a significant change in functional status assessment for Resident (R) 41. R41 had a significant decline in activities of daily living (ADLs). Findings: The facility admitted R41 on 1/01/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 10/17/2021 at 5:07 PM, R41 was noted to be lying in his/her bed. S/he appeared disheveled, with their face, clothing, and fingernails uncleaned. There was a strong, offensive odor in the room. There were no sheets on the bed and clothes and food on the floor, including his/her closet floor. Observation revealed feces on and around the toilet and the toilet seat was cracked. There was a large brown/golden stain on the wall behind the handwashing sink and the entire floor of the room felt sticky. On 10/18/2021 at 1:45 PM, R41 was observed to be in his/her wheelchair at the nurse's station. S/he was dressed in an old, long sleeve collared shirt and ripped pajama bottoms with part of his/her upper thigh exposed. The Minimum Data Set (MDS) assessments reviewed on 10/19/2021 at 2:15 PM revealed the following: Annual MDS dated [DATE] revealed R41 with a Brief Interview of Mental Status (BIMS) score of 5 (impaired cognitive status). ADLs were coded as bed mobility, dressing, personal hygiene, and toilet use;R41 needs supervision. For ADLs including transfer, eating, and bathing; R41 is independent. Quarterly MDS dated [DATE] revealed a BIMS score of 7, indicating impaired cognitive status. ADLs were coded as bed mobility, transfer, eating, and personal hygiene;R41 needs supervision. For ADLs including dressing and toilet use; R41 needs extensive assistance. For bathing, R41 needs physical assistance. R41 went from independent with transfers, eating, and bathing to needs supervision and from supervision with dressing and toilet use to needs extensive assistance. R41 was observed eating lunch in his/her room, unsupervised, throughout the dates of October 18-20, 2021. At each time, food was observed on the floor. R41's care plan indicated that s/he requires supervision to limited assistance with ADLs. It also noted that R41 is highly involved with all adls and is self-motivated. In an interview with the MDS Coordinator on 10/20/21 at 10:40 AM, s/he expressed the computer system did not alert him/her of resident's significant change, therefore it was not completed.

Based on record review and interviews, the facility failed to notify the Ombudsman when one (1) of one (1) resident discharged to the hospital. (Resident #36) Findings include: Interview with the Assistant Director of Nursing (ADON) on 10/20/21 at 01:29 PM revealed the Business Office provided the Bed Hold Policy when the residents were transferred to the hospital. S/he stated, We don't contact the Ombudsman until the end of the month. There is a list that is sent to the Ombudsman every month of the ones who were discharged from the facility. The Business Office Manager can get you a copy of the list. The only ones who are notified when the resident is discharged is the Administrator, the DON, and ADON. Interview with the Business Office Manager on 10/20/21 at approximately 1:45 PM revealed there was a Bed Hold form that nursing sent with the resident when the resident was transferred to the hospital on 08/18/21, but there was no documentation to show when the Ombudsman was notified. Review of Resident #36's clinical record revealed an admitted [DATE] and the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #36's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) Score of 07 out of 15, indicating intact severely impaired cognition. Review of the clinical record revealed Resident #36 was transferred to the hospital on 08/17/21 and returned on 08/23/21. Resident returned to the facility from hospital. No acute distress noted. Treatment nurse performed body audit. Medications reviewed and verified. Physician notified of resident's return. Further review of the clinical record revealed the facility provided the resident and/or family a copy of the Bed Hold Policy on 08/18/21. Further review of the clinical record lacked documentation the facility provided the Ombudsman notification of the resident's discharge to the hospital. The facility failed to provide a policy indicating notice to a representative of the Office of the State Long-Term Care Ombudsman.

Based on observations, interviews and review of the facility guidance titled, Regulate Temperature in Nursing Homes, the facility failed to ensure the temperature in the resident room and hallways was maintained at 71 degrees Fahrenheit and not less on 3 of 3 units. The findings included: An observation on 10/18/2021 at approximately 9:30 AM of the thermostat reading on the unit including the middle hall and the rehab unit revealed the thermostat was set on 70 degrees Fahrenheit and the temperature was maintained at 70 degrees. Residents were observed on the unit, in sweaters, jackets and hoodies with the hood utilized. Residents were also asking for additional blankets. An additional observation on 10/20/2021 at approximately 10:05 AM revealed the thermostat set on 68 degrees and the temperature was maintained at 68 degrees Fahrenheit, residents were still dressed in sweaters, jackets, and hoodies. An interview on 10/20/2021 at approximately 10:50 AM with the maintenance directors, confirmed the findings and then stated, the staff will lower the temperatures at night. I have a difficult time keeping the temperature over 68 or 70 degrees because the staff keep turning the temperature down when they get hot. The thermostats do not have have the locked covers to prevent anyone from changing the temperature. Review on 10/20/21 at approximately 1:40 PM of a facility form titled, Regulate Temperature in Nursing Homes, states, all nursing homes maintain a temperature of not less than 71 degrees Fahrenheit .

Based on observations, interviews and review of the facility's policy titled, Resident's Bill of Rights, the facility failed to ensure staff knocked on resident room doors and waited for permission to enter during the lunch and dinner meal service in rooms 36 through 54 and on the middle hall and the rehab hall for 2 of 2 meal services observed. The facility further failed to ensure the privacy, respect, and dignity of Resident (R)18 as evidenced by staff addressing his/her incontinence in the presence of other residents for 1 of 5 residents reviewed for unnecessary medications. The findings included: An observation on 10/17/2021 at approximately 6:23 PM of the meal service in rooms 36 through 54 revealed staff were entering resident rooms with meal trays, without knocking on the doors and waiting for permission to enter. Staff was observed yelling, knock, knock, and then entered the rooms. An additional observation on 10/20/2021 at approximately 12:45 PM revealed meal trays were being delivered to residents on the middle hall and the rehab hall. Staff were entering rooms without first knocking and waiting for permission to enter. An interview on 10/20/2021 at approximately 1:00 PM with Certified Nursing Assistant (CNA)1 and CNA2 verified that they were entering resident rooms with meal trays and not first knocking on the doors and waiting for permission to enter. Review on 10/20/2021 at approximately 1:30 PM of the facility's policy, Resident's Bill of Rights, states under, Personal Treatment,A resident of this facility, has the right to be treated with respect and dignity. Findings: The facility admitted R18 on 02/18/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a meal observation on 10/20/21 at 1:05 PM, R18 approached a surveyor and said she wants to go to the bathroom. The surveyor passed the information on to a group of three CNAs that were close by. The CNAs kept talking among themselves and ignored the R18 request. At 1:08 PM, R18 repeated her request to go to the bathroom. CNA5 was asked if R18 has been taken to the bathroom and added she keep on saying she wants to go to the bathroom, perhaps she needs to be changed. CNA5 said in a loud voice in the hall, She is also incontinent then said to the resident (First name of the resident), go to your room. CNA4 started pushing R18 to her room and the other two, CNA 3 and CNA5 followed her. The three CNAs stayed in R18's room for a brief moment with the door closed. The CNAs came out of the room. CNA4 proceeded to start passing meals. CNA3 went into a residents's room without knocking or addressing the resident appropriately. Once inside the room s/he said, What's up, big head? CNA5 went into a resident's room without knocking, greeting, or asking for permission to come in or greeting the resident. She went into the room and put the meal tray on the bedside table and left the room. During an interview with CNA3, CNA4 and CNA5 on 10/20/2021 at approximately 1:20 PM, they confirmed the findings.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistance to prevent accidents as evidenced by the elopement of Resident #1 for 1 of 3 residents reviewed for elopement. The findings include; Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility submitted a reportable to the State Agency on 5/7/2020 indicating Resident #1 had walked out of the facility, fell , scraped face and lip and was sent to the emergency room for evaluation. Review of the hospital's discharge paperwork on 5/13/2020 indicated Resident #1 had a discharge [DIAGNOSES REDACTED]. S/he was discharged back to the facility with prescriptions for Nasal Spray and [MEDICATION NAME] ointment. On 5/13/2020 at approximately 12:30 PM, during an interview with the Director of Nursing, s/he showed the area where the resident had exited the building and stated that due to the resident being a new admit, they were placed on a quarantined unit because of the recent COVID-19 outbreak. The DON agreed that the alarm did sound, but due to the plastic enclosing the hall, the staff were unable to hear the alarm. Review of the Resident's Minimum Data Set (MDS) from Admission indicated a Brief Interview of Mental Status (BIMS) score of 12 indicating minimal cognitive deficiencies. Review of the Fall Risk assessment completed on 4/28/2020 indicated the Resident scored a 14 and a high risk for falls due to unsteady gait. Review of the Baseline Care Plan dated 4/29/2020 showed Resident #1 was care planned for falls related to weakness requiring interventions to include; education on call light use, assisting with toileting and transfers as needed, and keeping the environment safe. Observations of the Resident on 5/13/2020 showed minor healing injuries to the face, pleasant manner and mood and placement at the nurse's station with a mask on.

Based on observation, record review, and interviews, the facility failed to ensure 1 of 3 sampled residents reviewed with pressure ulcers received the necessary care and services to promote healing. The facility nursing staff failed to identify and implement wound care for a right lateral ankle unstageable pressure ulcer for Resident #104. Wound center treatment orders for a right heel treatment three times daily were not communicated to the facility physician for clarification. The facility had documented the wound care to the right heel as having been done once daily. The facility failed to document weekly wound measurements/descriptions for the right heel. Documentation was unclear and/or lacking as to how the right heel wound had progressed. The findings included: The facility admitted Resident #104 with [DIAGNOSES REDACTED]. A review on 1/8/15 of a hospital Discharge Summary dated 9/26/14 revealed Resident #104 had been admitted to the hospital on [DATE] with right lower extremity ischemia. A diagnostic workup revealed occlusion of his right superficial femoral artery (SFA) with substantial SFA disease as well. He was taken to the operating room and underwent open common femoral exposure and femoral artery reconstruction which were successful with good revascularization with a good triphasic doppler signal noted in his/her dorsalis pedis as well as posterior tibial vessels. Resident #104 was discharged to the nursing home on 9/26/14. A review on 4/7/15 of the Admission Nursing Observation Form (admission body audit) dated 9/26/14 revealed a scab had been noted to the resident's right lower leg with the right heel described as "dark/red ischemic". The right great toe had been noted as necrotic. A review of wound documentation on 4/7/15 and 4/8/15 revealed the following: A wound note dated 9/26/14 stated, "Resident admitted to facility with incision to R(ight) groin post stent...Ischemic R(ight) foot and great toe. R(ight) great toe with necrotic tissue present. [MEDICATION NAME] and dry dressing daily. Heel protectors on (in) bed". The wound note did not describe the right heel or note a scab to the right lower leg. A review of the September 2014 Physician Telephone orders revealed a 9/26/14 order for [MEDICATION NAME] and a dry dressing daily to the right great toe. There were no orders for a treatment to the right heel or orders noted related to the scab to the right lower leg. A review of weekly wound documentation from 9/26/14 through 10/6/14 revealed documentation for Ischemic areas to the "R(ight) foot/great toe" that described 100% purple ischemic areas. It was unclear from the documentation what parts of the foot had been ischemic and/or if this included the heel. There were no measurements noted. A wound note dated 10/3/14 stated there had been no changes noted, to continue the current treatment. The entry noted a future appointment to see the surgeon on Monday, and noted a pulse had not been detected to the right foot. A note dated 10/6/14 stated the resident went to see the surgeon, with the dressing having been changed. A further review of wound notes revealed Resident #104 had been sent out and admitted to the hospital on [DATE] with [MEDICAL CONDITION] and pneumonia; and readmitted to the nursing facility on 10/21/14. Wound notes dated 10/21/14 through 11/28/14 documented that the right foot remained ischemic with no pulse. The notes included that the [MEDICATION NAME] and dry dressing treatment continued to the right great toe daily; with eschar and necrosis setting in to the great toe. There was no mention of how the right heel looked on re-admission. A re--admission body audit had not been noted in the record. A nurse's note dated 10/21/14 documented that the resident had returned with "...skin dry + intact". A body audit dated 10/27/14 included information that there was "R(ight) foot discoloration". Weekly wound documentation from 10/21/14 through 10/27/14 documented the "Rt foot/Rt great toe had been 100% purple/ischemic. On 10/28/14, the documentation included 100% purple ischemia/eschar (right foot/great toe); and then starting on 11/1/14, the area had been noted as having 100% eschar with no purple/ischemic areas. The documentation was unclear and did not separate out the areas of the right foot and toe. Weekly wound documentation through November 2014 for both the right foot and toe (or for just the right toe) indicated 100% purple ischemia/ eschar to the area. There were no measurements noted or descriptions of the extent of the ischemia/necrosis. A wound note dated 12/4/14 at 2:00 PM documented that the physician had been in the facility and made aware that "eschar to heel is loose + has odor- To see Dr -- (surgeon) next wk (week)". A review of nurse's notes and documentation in the chart revealed nothing to show how this right heel wound had started and/or progressed up to this point. There were no wound orders for a treatment to the right heel and no treatments noted on the Treatment Administration Record for the right heel through December 2014. A note dated 12/11/14 stated the resident had been out of the facility to see the surgeon. According to the note, no surgery was to be done (to the right great toe?), "To self amputate". A note dated 12/16/14- which was a late entry for 12/12/14, documented that the wound to the right foot continued with odor, the doctor was aware, the resident having seen the surgeon this week with no plans for surgical intervention, and to continue with the current treatment. The note was unclear and did not specify whether the wound was to the right great toe or heel. A review of December 2014 wound notes and documentation revealed nothing further noted specifically about the right heel after the 12/4/14 note. The December weekly wound documentation did not include a description or measurement of the area of the heel affected. A physician progress notes [REDACTED]. The Assessment included information that the resident had [MEDICAL CONDITIONS] with wounds noted, that the resident had a reconstruction previously to the right femoral artery; and that the wound nurse was checking to see if there had been studies done for the left foot. According to the note, "These wounds appear to be related to [MEDICAL CONDITION] instead of pressure." A Physician's Telephone Order dated 1/1/15 discontinued the [MEDICATION NAME] treatment to the right toe (along with discontinuing treatments to new areas on the left foot). New treatments to the right foot and left foot were initiated with [MEDICATION NAME] to be done every 3 days and as needed. The orders did not specify which areas of the feet were to be treated and/or if this included the heel. A facility wound note dated 1/3/15 stated the resident had been seen at the wound center clinic with treatment orders changed to [MEDICATION NAME]. According to the note, areas to the right foot remained unchanged. The wound center note for the visit was not located in the record. A wound center note dated 1/13/15 documented that Resident #104 had multiple ischemic lower extremity wounds and had been scheduled to have a right great toe amputation the next week with the surgeon. According to the note, the resident had multiple vascular procedures on the right lower extremity and continued to have drainage from the wounds; with the nursing home having changed the dressings. The wound center documentation indicated Resident #104 had an arterial ulcer to the right great toe, along with a right heel unstageable pressure ulcer that had necrotic tissue. The right heel pressure ulcer measured 4 cm x 10.5 cm x 0.8 cm depth, and had scant yellow drainage with a strong odor. The wound margin was well defined with the wound bed 51-75% dry black eschar, and 1-25% moist yellow slough. According to the note, there was no change noted in the wound progression. The wound center documentation dated 1/13/15 noted a pressure ulcer to the right lateral ankle and described it as unstageable with necrotic tissue; measuring 1 cm x 1 cm x 0.2 cm depth. There was scant yellow drainage with no odor, with the wound bed 76-100% adherent yellow slough. There was no change noted in the wound progression. According to the 1/13/15 wound center note, treatment to the right heel was to continue with [MEDICATION NAME] every 2-3 days and as needed. A review of the January 2015 Treatment Administration Record revealed a treatment to the "right foot" with [MEDICATION NAME] every 3 days that had been continued until 1/27/15. Since the treatment to the right great toe was also for [MEDICATION NAME] every 2-3 days as needed, it was unclear if the Treatment Administration Record (TAR) documentation included both the right heel and the right great toe treatments since there was only one treatment for [REDACTED]. The wound center note indicated the right lateral ankle was to be treated with Santyl daily. There were no orders written and no treatment initiated for Santyl daily to the right lateral ankle. According to an interview with the wound nurse on 4/7/15; s/he was unaware of the resident having a wound to the right lateral ankle. Additional instructions from the wound center included information that the wound(s) were to be cleaned with mild soap and water. During an interview on 4/8/15, the wound nurse stated the wounds had been cleaned with Normal Saline as per policy, and soap and water had not been used. The wound nurse stated s/he did not recall seeing the information on the wound center notes related to a treatment of [REDACTED]. On 1/19/15 a bilateral lower extremity duplex study was completed. According to the study, the right side "revealed essentially normal flow other than in the right anterior tibial artery where the proximal vessel was not seen. There were low velocities also present in the right posterior tibial artery. The right dorsal pedal artery was not imaged. On the left side, there were elevated velocities in the left common femoral artery consistent with stenosis which was moderately severe...". The impression was that the right superficial femoral artery stent was patent with flow into the right popliteal, posterior tibial artery. The right proximal anterior tibial artery was not seen. There was moderately severe stenosis of the left common femoral artery. Resident #104 was sent out of the facility for a right great toe and 2nd toe amputation on 1/27/15. New orders were written for [MEDICATION NAME] to the right foot daily (upon return to the facility), with the [MEDICATION NAME] every 3 days having been discontinued. The January 2015 TAR reflected the new order for the right foot. A 1/29/15 wound note indicated the area to the (right) heel was still necrotic with a foul odor. Weekly facility wound notes revealed on 2/6/15, the ischemic areas to the right and left foot continued to worsen. On 2/13/15, it was noted the ischemic areas to the right and left feet were still worsening with odor noted, with the physician aware and the resident receiving antibiotic therapy. Facility weekly wound documentation revealed that on 2/2/15 the heel had 100% loose eschar (the first notation of weekly wound descriptions for the heel area). On 2/12/15, the right heel (Ischemic) had been documented as having 75% eschar and 25% slough. There were no measurements noted through February and March 2015 to the right heel. A wound center note dated 2/27/15 documented the right great toe had been amputated (on 1/27/15). The note documented the resident still had a right lateral ankle necrotic unstageable pressure ulcer that measured 0.8 cm x 0.8 cm x 0.3 cm, with scant yellow drainage, with 76-100 % adherent yellow slough. The note stated that the wound was deteriorating. There had been no treatment orders initiated and no treatments documented for this area. The facility had no wound documentation that correlated with this area. According to the 2/27/15 wound center documentation, the resident's right heel necrotic unstageable pressure ulcer measured 4 cm x 11 cm x 1 cm; with yellow drainage and a strong odor; with 51%-75% eschar black and 1-25% slough. The documentation indicated this wound was deteriorating. During the 2/27/15 wound center visit, the right heel was debrided. According to the note, bone was exposed at the end of the procedure (stage IV pressure ulcer), with some necrotic tissue (fat) still noted. The wound center treatment orders for the right heel stated that the [MEDICATION NAME] treatment should be done three times daily to the heel. However, a review of the February and March 2015 Treatment Administration Record revealed a treatment of [REDACTED]. There was no indication in the record that this treatment had been discussed with and/or clarified with the physicians involved as to how many times a day the treatment to the heel was to be done. Facility weekly wound notes described the right heel wound as having 90% eschar and 10% slough on 2/28/15 and 3/1/15 (after the debridement). A review of a 3/20/15 wound center note revealed the right heel was a stage IV pressure ulcer that measured 3.7 cm x 8.5 cm x 1.4 cm depth. There was bone exposure noted with a moderate amount of yellow drainage with no odor. The wound bed was 26-50% moist yellow slough, with 26-50% granulation with no eschar, and the local pulse was noted as being weak. The note described a right lateral ankle unstageable pressure ulcer that measured 0.7 cm x 0.4 cm x 0.2 cm, with dry yellow eschar. The wound was noted to be improving. According to the wound center note, the treatment for [REDACTED]. A review of the March 2015 Treatment Administration Record revealed the treatment to the heel had been initialed once daily; and there was no treatment in place for the right lateral ankle wound. During an interview on 4/7/15 at 3:24 PM, the wound nurse and Director of Health Services (DHS) were present. According to the wound nurse, the resident currently had 2 surgical amputations to the toe and an area to the right heel which had been debrided. The wound nurse was unaware of a wound to the right ankle. The surveyor and wound nurse/DHS reviewed the wound documentation information in the clinical record along with the wound center notes. According to the wound nurse, s/he followed the orders sent to her/him by the wound center. The wound nurse stated that all the wounds were cleaned with Normal Saline as per policy, and had been cleaned in this manner. The wound nurse verified there was no specific weekly documentation of a right heel wound until 2/2/15; while the wound notes did indicate a wound was present on 12/4/15. The wound nurse verified there had been no orders initiated for the heel until a "right foot" treatment with [MEDICATION NAME] was noted on 1/27/15. The wound nurse verified the wound center documentation stated the right heel treatment was to be done three times daily instead of once daily. The wound nurse stated s/he was unaware of this and would have clarified this with the Physician had s/he known. The nurses were informed of the surveyor's concern related to the documentation; that the treatments on the TAR had not been separated out to show which areas were affected/treated and that the wound documentation was unclear on the progression of the right heel wound. There was no treatment put into place or documentation by the facility of a right lateral ankle unstageable pressure ulcer noted by the wound center. The wound nurse stated s/he was not aware of an unstageable wound to the right ankle, and if s/he had been aware, would have clarified this documentation and treatment with the physician. The surveyor asked the nurses to go and look at the resident's right lower leg. Observation of the resident's right lateral ankle on 4/7/15 at approximately 4:00 PM with the wound nurse and the Director of Health Services (DHS) revealed what appeared to be a small unstageable wound with slight depth and a white dry substance covering the wound bed.