Every finding on record at Rehabilitation Center of The Palm Beaches, The

Based on observation, record review and interviews, the facility failed to honor the resident representative's request to ensure, 1 of 3 sampled residents reviewed for Choices, Resident #71, received a shower on the scheduled shower days. The findings included: Record review documented Resident #71 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment done on 12/27/24 documented Resident #71 had a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment and the resident is dependent for all care needs. During an observation in the room of Resident # 71, there was a white sheet of paper posted on the bulletin board with the following handwritten message: please see that she (Resident #71) get a shower on her shower days. Review of the orders shows the resident's shower schedule is every Monday and Thursday on the 3 PM - 11 PM shift. Review of the documentation on the Certified Nursing Assistant (CNA) task list from 02/27/25 to 03/24/25 showed Resident #71 received 4 bed baths and 3 tub baths on the scheduled shower days. An interview was conducted on 03/26/25 at 4:39 PM, Staff C, CNA, who stated she provided a bed bath to Resident #71. An interview and observation were conducted with Staff D, Licensed Practical Nurse (LPN) in the room of Resident # 71. The LPN stated that the note on the bulletin board was written by the resident's sister who is involved in her care. A side-by-side review of the record and interview on 03/27/25 at 10:54 AM with the Director Of Nursing (DON), who confirmed the lack of shower documentation on the task list for Resident #71. She also confirmed the facility does not have a tub.

Based on interview and record review, the facility failed to accurately document the discharge status of 1 of 3 sampled residents reviewed as closed records, Resident #100. The findings included: Record review documented Resident #100 was admitted to the facility on [DATE] and discharged home on 01/24/25. Resident #100's diagnoses upon admission included: Anemia, Hypertension, Hip fracture, Spondylopathy in lumbar region, Muscle wasting and atrophy, Abnormalities of gait and mobility, Obesity, and Chronic pain syndrome. Review of Resident #100's care plan for discharge, dated 01/14/25, documented, The resident wishes / or Responsible Party wishes to: return home. The goal of the care plan was documented as, Safely discharge to a lower level of care (Home, Home with Home Health Aide, Assisted Living Facility, Independent Living Facility, other) when rehab goals are met. Reivew of a progress note, dated 01/24/25, documented, Resident discharge from [name of facility] to home at 300 pm, VIA PRIVATE CAR accompanied, 2-persons food / medication administered as ordered before leaving the facility one of the staff accompanied resident to the lobby skin warm / intact / dry, lung sound clear no SOB [shortness of breath] or distress noted, vs WNL [vital signs within normal limits]. Discharge instruction reviewed with resident voice understood the explanation; med list / medication provided, follow-up with MD [medical doctor] within 3-5 days post discharge. Review of a Social Services progress note, dated 01/24/25, documented, Discharge Summary note. Res [resident] is A&Ox3 [alert and oriented times three], independent with decision making, requested to speak with this writer yesterday as she would like to d/c [discharge] home today. Res informed this writer yesterday that the hospital was planning to d/c her spouse home today thus she wanted to be at home, plus res feels she can manage safely at home and prefers being at home. DME [durable medical equipment] ordered thru [through] [name of company] DME yesterday. Review of Resident #100's discharge Minimum Data Set (MDS) assessment, dated 01/24/25, documented Resident #100's discharge status as 'Short-Term General Hospital. An interview was conducted on 03/26/25 at 9:59 AM with the MDS Coordinator, who when asked about Resident #1's discharge status, confirmed that the resident was discharged home. The MDS Coordinator stated that she would update and resubmit the assessment.

Based on observation, record review, and interview, the facility failed to follow physician orders for 2 of 6 sampled residents, as evidenced by the topical cream for Resident #5 was not applied as ordered, and the blood pressure medication was not given as needed for Resident #58; and failed to follow physician orders to obtain a urology consultation as ordered for 1 of 2 sampled residents reviewed for catheters, Resident #63. The findings included: 1. Record review revealed Resident #5 was readmitted to the facility on [DATE]. Review of the current Minimum Data Sheet (MDS) assessment dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 05, on a 0 to 15 scale, indicating severe cognitive impairment. Review of a physician order dated [DATE] instructed the staff to apply an antifungal cream to the areas affected with a rash (skin condition) on the day (7 AM to 3 PM) and evening (3 PM-11 PM) shifts. Review of the care plan dated [DATE], documented Resident #5 was at risk for potential or actual impairment of the skin related to itching, rash with a goal that the resident's skin impairment will be healed with an intervention that the nurse will administer medication as ordered. An observation on [DATE] at 10:08 AM revealed Resident #5 was scratching her arms and shoulders profusely. Further observation revealed Resident#5 had scattered bumpy and reddened areas on her arms, shoulders and chest. An observation on [DATE] at 3:23 PM in Resident #5's room revealed Resident #5 had her eyes closed, scratching her arms and shoulders. During an interview on [DATE] at 10:08 AM, when asked how she was doing, Resident #5 stated, I have all these bites. When asked how long she has had the rash, Resident #5 stated, I just came from the hospital, but I had the rash before. When Resident #5 was asked if the nurse was aware of the rash, she stated I think so, I will let them know. When asked if any cream had been applied to the rash, Resident #5 stated, No. During an Interview on [DATE] at 3:25PM, when asked if any treatment was provided to Resident #5, Staff D, Licensed Practical Nurse (LPN), reviewed Resident #5's orders in the computer and stated Triamcinolone (corticosteroid ointment for the skin). Staff D went into the clean utility room, where the treatment cart was stored. Staff D looked throughout the treatment cart and did not find the triamcinolone ointment. Staff D stated, I used the last of the cream this morning on the resident and I threw the tube away. I will have to order a new one. She was in the hospital, and she came back. When asked if that was the only treatment that was to be provided to Resident #5, Staff D stated Yes. During an interview on [DATE] at 9:15AM, when asked if an antifungal cream was ordered for a resident what medication is used, the Unit Manager stated, It's a stock medication that comes in a tube. When asked to show the antifungal cream that was ordered for Resident #5, the Unit Manager looked in the treatment cart and she picked up a jar of triamcinolone ointment and stated, This is for that resident. When asked if the triamcinolone ointment is the medication that would be used if the order was for an antifungal cream the Unit Manager stated, No. Sometimes the antifungal cream comes in small packets. I will go get some from the supply room. During an interview on [DATE] at 9:40 AM, when asked if there was any antifungal cream in stock, Staff F, Central Supply staff, stated, We are out of it. I'm in the process of ordering it now. When asked how long they had been out of the antifungal cream, Staff F stated, We've been out since Tuesday. When asked if she meant yesterday on Tuesday, Staff F stated, No, last week I had two tubes of the cream on the shelf that were expired on Friday, so I threw them out, but I forgot to reorder it at that time. If I order it today, it will come tomorrow. During an interview on [DATE] at 10:06 AM, the Unit Manger stated, I'm trying to figure out which nurse used the last of the antifungal cream for the resident and did not reorder it. I called central supply to see if there was any cream and she said the ones she had were thrown out on Friday because they were expired. During an interview on [DATE] at 10:50 AM, when asked how long Resident #5 had the rash, Staff D, LPN) stated, She has a rash off and on. She has seen a dermatologist in the past. I think a few months ago. During an interview on [DATE] at 10:56 AM, when ask how Resident #5's skin looked when she provided care, Staff G, Certified Nursing Assistant, stated, She has a rash that she has had for a while. Review of [DATE] Treatment Administration Record (TAR) for Resident #5 documented that the nurses had signed off on the order for the administration of the antifungal cream, but the medication had not been available. 25404 2. Record review revealed Resident #58 was admitted to the facility on [DATE] with diagnoses to include essential primary Hypertension (high blood pressure). Review of the current MDS assessment dated [DATE] documented Resident #58 had a BIMS score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. This MDS also documented a current diagnosis of Hypertension. Review of the current care plan initiated on [DATE] documented the resident had hypertension and staff were to administer medications as ordered and monitor vital signs as ordered. Review of the current orders revealed Resident #58 was receiving three routine blood pressure medications. These medications included Metoprolol which was originally ordered at 50 milligrams (mg) daily and increased to 100 mg twice daily on [DATE], Hydralazine 10 mg three times daily, and Amlodipine 5 mg twice daily was added to the regimen as of [DATE]. The orders also included for staff to administer Catapres 0.1 mg every eight hours as needed for a systolic blood pressure reading greater than 150. This order did not include any time frame in which staff were to measure the resident's blood pressure. The only active order for the monitoring of vital signs was to complete a set once during the night shift (11 PM to 7 AM). There was one discontinued order to monitor vital signs every shift for three days only upon return from a brief hospitalization . During an interview on [DATE] at 9:56 AM, Resident #58 stated his only concern was that his blood pressure was running high. Review of the [DATE] Medication Administration Record (MAR) for Resident #58 revealed the following high blood pressures with no 'as needed' Catapres administered: a) On [DATE] on the night shift, the resident's blood pressure was ,d+[DATE]. b) On [DATE] on the night shift, the resident's blood pressure was ,d+[DATE]. c) On [DATE] on the night shift, the resident's blood pressure was ,d+[DATE]. Further review of the record revealed staff were not documenting the blood pressure for Resident #58 every eight hours, or with each shift, in order to know when the 'as needed' Catapres was needed. Review of the blood pressure readings from [DATE] through [DATE] revealed a lack of three daily blood pressure readings every day except on [DATE], [DATE], [DATE], [DATE], and [DATE]. During an interview on [DATE] at 3:32 PM, when asked the process for blood pressure monitoring, Staff A, Licensed Practical Nurse (LPN), stated she takes the blood pressure of her residents on blood pressure medications every morning upon arrival and documents them in the electronic medical record (EMR) at the end of her shift. The LPN provided a handwritten paper with documented blood pressures for several residents and stated she was getting ready to document the readings from this morning at the time of the interview. Further review of the [DATE] MAR and blood pressure readings for Resident #58 on [DATE], revealed Staff A, LPN had cared for the resident on [DATE], [DATE], [DATE], [DATE], and [DATE], but only documented his blood pressure on [DATE] and [DATE]. During an interview on [DATE] at approximately 4:15 PM, when asked the process for blood pressure monitoring, Staff B, Registered Nurse (RN), stated she takes the blood pressure for her residents who are on blood pressure medications at the beginning of the shift. When asked about documentation, the RN stated she might document them in the vital sign section of the EMR, or she may just document, OK to give in the electronic MAR. When asked specifically about Resident #58, the RN stated she had just taken his blood pressure, and it was ,d+[DATE]. The RN volunteered, I told him to hang loose for a bit and I'd bring back his meds. Further review of the [DATE] MAR and blood pressure readings lacked any documented blood pressure reading of ,d+[DATE] for Resident #58 on [DATE]. During an interview on [DATE] at 9:51 AM, when asked the process for blood pressure monitoring for Resident #58 who had an 'as needed' order for Catapres, the Director of Nursing (DON) stated she would expect staff to check the resident's blood pressure at least once a shift and document the reading. During a side-by-side review of the record, the DON agreed with the concern of the lack of blood pressure monitoring and provision of Catapres for Resident #58. The DON confirmed the physician recently increased his routine blood pressure medications. 36734 3. Record review documented Resident #63 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had mild cognitive impairment and was dependent on staff for activities of daily living (ADLs). The assessment further documented the resident had an indwelling catheter (urinary catheter). Resident #63 was readmitted to the facility on [DATE] after a hospitalization . Resident #63's had care plan for using a urinary catheter with a documented risk for an infection and/or complications. Review of Resident #63's physician orders revealed an order dated [DATE] to follow up with urology for hemorrhagic cystitis (an inflammation of the bladder lining that leads to bleeding). Further record review revealed the resident had not followed up with urology, and there was no documentation of the resident refusing follow up with urology. An interview was conducted with the Director of Nursing (DON) on [DATE] at 10:00 AM, who acknowledged the above finding.

Based on observation, record review and interviews, the facility failed to provide adequate hydration for 1 of 1 sampled resident, as evidenced by not ensuring that Resident #16 was able to have the fluids she was allowed. The findings included: Record review revealed Resident #16 was admitted to the facility on [DATE]. Review of current Minimum Data Sheet (MDS) assessment dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 05, on a 0 to 15 scale, indicating severe cognitive impairment. Review of the physician order dated 02/27/25 instructed the staff that Resident #16 was on a 1200 milliliters per day fluid restriction with 900 milliliters to be given by dietary daily and 300 milliliters to be given by nursing daily. During an interview on 03/24/25 at 10:42 AM, Resident #16 stated, I was put on liquid restriction. I get 2 juices, 4 ounces at lunch and dinner. I leave it on my table to sip on it throughout the day and the aides always take it away. They have been asked not to, but they still dump it. When asked if she had fluids this morning, Resident #16 stated, Yes, but they dumped it. They aren't supposed to just take my food. It's so depressing to me, because I like to sip on it. My lips are so dry. An observation on 03/26/25 at 10:44 AM in the hallway, revealed Resident #16 was in the hallway complaining to the MDS coordinator about her juice being taken away from her room. She stated [Name], Licensed Practical Nurse (LPN) poured one 4 ounce cup of juice in my ice and they took it away. I did not even have coffee. My mouth is so dry. Why do they keep doing this. Staff D stated, I will go get you another 4-ounces of juice since they took it away. Resident #16 asked Why can't we put up a sign or something, so they know not to take it. Staff D stated, I will just inform the aides not to take your juice.

Based on record review and interview, the facility failed to ensure physician visits in a timely manner for 1 of 2 sampled residents reviewed for catheters, Resident #63. The findings included: Record review revealed Resident #63 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had mild cognitive impairment and was dependent on staff for activities of daily living (ADLs). The record revealed Resident #63 was hospitalized on [DATE], and readmitted to the facility on [DATE]. Review of Resident #63's physician progress notes revealed a progress note dated 11/07/24. There was no further evidence the resident was seen or evaluated by a physician between 08/24/24 through 11/07/24. An interview was conducted with the Director of Nursing (DON) on 03/27/25 at 10:00 AM, who acknowledged the above finding.

Based on observations, interviews and record reviews, the facility failed to provide notification to the residents' representative after a change in condition for 2 of 23 sampled residents, Residents #31 and #3. The findings included: Review of the facility policy, titled, Fall and Injury Reduction Policy, effective March 2023, documented, in part, Notify the resident representative of the fall, new intervention, and/or care given, or location transferred. The facility's policy titles, Notification of Resident/Patient Change in Condition, effective October 2021, documented, in part: Policy: Nurses will notify the resident / resident representative, if there is a crucial / significant change in the resident condition. If the change int eh resident's condition is not crucial or significant, the resident's Physician, resident representative or legal representative will be notified at the earliest convenient time during regular business hours. Procedure: 1. Notify the Physician resident/resident representative, and case management when indicated, if there is a significant change in condition, regardless of the time of day. 2. Document the Nurse's Notes, the time notification was made and the names of the person(s) to whom you spoke. 1. Record review documented Resident #31 was admitted to the facility on [DATE]. According to an Admission Minimum Data Set (MDS), dated [DATE], Resident #31 had a Brief Interview for Mental Status (BIMS) score of 04, indicating severe cognitive impairment. The MDS documented the resident required 'Substantial / maximal assistance' for toileting and transferring and was 'occasionally incontinent' of urine and bowel. Resident #31's diagnoses at the time of the assessment included: Anemia, Hypertension, Urinary Tract Infection (UTI) (on admission), Hyponatremia, Non-Alzheimer's Dementia, Encephalopathy, difficulty walking, Cognitive communication deficit, Muscle weakness, and Urinary incontinence. Review of the facility's grievance log showed that the resident had an unwitnessed fall on 11/07/23. An 'Event Note' documented an unsuccessful attempt at notification on 11/07/23 at 23:00 (11:00 PM). Review of the Progress note, dated 11/07/23 at 23:43 (11:43 PM), documented by Staff A, Licensed Practical Nurse (LPN), Note Text: Resident was observed on the floor by the bathroom door around 2100 (9:00 AM). Resident states that he was going to the bathroom. Resident was observed on his side with his head up. Resident is very weak; he couldn't get himself back the bed. Transfer resident back to bed with Hoyer lift. Safety precaution maintained, call light within reach, bed at lowest position. No injuries noted; No complaint of pain. Resident is resting comfortably. Resident #31 was unable provide details of the incident /event and was not interviewable. During an interview, on 11/28/23 at 10:11 AM, with Resident #31's daughter, when asked about the details of the resident's fall, the resident's daughter stated, I haven't noticed any changes in him. They didn't tell me about it. During an interview, on 11/30/23 at 7:48 AM, with Staff B, Registered Nurse (RN) on Suites unit since 2020, when asked about the incident, Staff B replied, I wasn't in that day, when I came in the next day, they told me they found him sitting on the floor in his room. Staff A was the nurse on the floor that day, she would have been responsible to call the family and the doctor. 11-7 [11 PM - 7 AM] didn't do the follow up and did not inform me. When they have the morning meeting, they see everything on the 24-hour report. Staff B reviewed the progress note and stated, there is nothing that says that she called the daughter (referring to Staff A). During an interview, on 11/30/23 at 7:56 AM, with Staff C RN/UM (Unit Manager) on Suites unit, when asked about notifying Resident #31's daughter about the fall, Staff C replied, I would have been coming in and going over the reports and we would go over the 24-hour report in the morning meetings. It would have been reviewed during the morning meeting. If she notified the daughter, she should have put it in the nurse's notes. Staff C confirmed that there was no progress note regarding notifying the resident's family. During an interview, on 11/30/23 at 9:02 AM, with Staff A, when asked about Resident #31's fall on 11/07/23, Staff A replied, I don't know. I was working and I found him on the floor and I asked for help. When asked about notifying Resident #31's representative about the fall, Staff A replied, there was no answer, you have to let the family know. I put the note of what happened, it is protocol to notify the family I leave a note and the facility will follow up. During an interview with the Director of Nursing (DON) on 11/30/23 at approximately 11:00 AM, the DON stated that Resident #31's daughter was in the facility regularly. 41837 2. Record review for Resident #3 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Fracture of Unspecified Part of Neck of Left Femur Subsequent Encounter for Closed Fracture with Routine Healing, Pressure-Induced Deep Tissue Damage of Sacral Region, and Unspecified Dementia. The Minimum Data Set (MDS) assessment for Resident #3 dated 10/24/23 revealed in Section C, a Brief Interview of Mental Status Score of 7, indicating severe cognitive impairment. In Section H it was documented that the resident had an indwelling catheter. Review of the Physician's orders for Resident #3 revealed an order entered on 11/29/23 with an effective date of 11/27/23 to D/C (Discontinue) Foley cath (catheter). Photographic Evidence Obtained. Review of the Nursing Progress Note for Resident #3 dated 11/27/23 included: Resident son made aware of above mention. [linked]. Review of the Nursing Progress Note for Resident #3 dated 11/27/23 included: Called place to hospice requesting for admission to come to facility for resident. Per Nurse [name], she will send message to admission department. MD [physician] made aware, new order received to D/C F/C [Discontinue Foley / Catheter], monitor for voiding. An interview was conducted on 11/28/23 at 2:45 PM with Staff E, Registered Nurse Unit Manager (RNUM) who stated she has worked at the facility for about 16 months always as the Unit Manager. When asked about the indwelling urinary catheter (Foley) for Resident #3, she stated the resident's Foley was taken out yesterday. When asked by whom, she stated she did it after talking to the doctor (Primary) who gave her the order, and notifying Resident #3's son. During a telephone interview conducted on 11/29/23 at 12:56 PM with the son of Resident #3 who was asked if the resident had an indwelling urinary catheter in place when he was admitted to the facility, he said yes. When asked if any physician or staff member of the facility informed him of the removal of the indwelling urinary catheter, he said 'no, one told him about that, someone called the other day to talk to him about hospice for his father'.

Based on interviews, record review and policy review, the facility failed to provide necessary treatment and services to prevent worsening of a pressure ulcer for 1 of 2 sampled residents sampled for pressure ulcers (Resident #254). The findings included: The Policy and Procedure, titlesd, Treatment Protocols for Stage III and Stage IV Pressure Area or Full Thickness Wounds with No Drainage (Shallow or Deep), effective October 2021, documented, Review support surface guideline to ensure the Resident / Patient receives the benefit of a therapeutic bed surface when clinically necessary. Review of the record revealed Resident #254 was initially admitted to the facility on [DATE]. The resident had multiple hospitalization s during her residence at the nursing home and was transferred to the hospital on 04/30/23 and did not return to the facility. Review of the quarterly Minimum Data Set (MDS) with an assessment reference date of 04/01/23 documented a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. The resident had diagnoses that included Acute Kidney Failure, Unspecified Dementia, and Diabetes Mellitus. Review of the care plan for Activities of Daily Living (ADLs), initiated on 02/06/23 and revised 04/24/23, documented the resident needed the assistance of one staff member for turning and repositioning, a glide sheet for bed mobility with the assistance of two staff members, and a mechanical lift to transfer the resident to a chair. On 12/21/22, the resident was admitted from another nursing facility. Review of the resident's record revealed she was treated for a stage 2 sacral pressure wound at the previous facility and the wound had resolved prior to being admitted to this facility. Review of the resident's Electronic Health Record (EHR), from 12/21/22 through a readmission from the hospital on 03/30/23, revealed the resident did not have a sacral wound but had treatment of skin cream to the buttocks. Review of the readmission data collection evaluation dated 03/20/23 revealed a skin evaluation of coccyx pressure. An admission summary note dated 03/30/23 noted sacral redness to coccyx and a dry dressing applied. On 03/31/23, a wound note revealed a sacral wound with a length of 7.5 centimeters (cm), width of 4.5 cm and a depth of 0.2 cm. The wound note revealed the daughter was notified of the wound. On 04/04/23, a skin and wound evaluation revealed the resident had a stage 3 pressure wound located on her sacrum. The wound measurements were 3.4 centimeters (cm) in length, 0.9 cm in width and 0.3 cm in depth. The resident was seen by a wound care specialist on 04/04/23. The wound was debrided (necrotic tissue removed by a scalpel) and the primary dressing was calcium alginate. On 04/11/23, the wound physician evaluated the sacral wound. The wound measured at 1.4 cm in length, 0.7 cm in width and 0.3 cm in depth. The physician noted the importance of repositioning every 2 hours or as needed and consistent use of offloading devices. On 04/18/23, the wound physician evaluated the sacral wound. The wound measured at 6 cm in length, 2.2 cm in width and 0.3 cm in depth. The clinical stage of the wound continued at a stage 3. The physician noted that the wound was not improved and had increased in volume. The wound was again debrided and the treatment was changed to calcium alginate with silver and repositioning often. On 04/21/23, the resident was transferred to the hospital and returned to the facility on [DATE]. On 04/25/23, the wound physician evaluated the resident. The sacral wound now had a length of 8.2 cm, a width of 4.3 cm and a depth of 0.6 cm estimate. The wound was now an unstageable pressure injury per physician notes. The wound was debrided. Per physician note, the staff was educated on the importance of offloading the area and consistent use of offloading devices. Continued treatment of calcium alginate with silver. On 04/30/23, the resident was transferred to the hospital and did not return to the facility. Review of the nursing notes and record lacked any documentation of the resident being turned or repositioned. Interview with Certified Nursing Assistants (CNAs) during the 4-day survey revealed they could not recall the specifics related to turning and repositioning this resident. On 11/29/23 at 12:54 PM, an interview was conducted with Staff E, Registered Nurse and Unit Manager (RN/UM). Staff E was asked what a pressure reducing device to the chair and bed was. Staff E replied they have gel cushions for the chair and special mattresses for the bed if the sacral wound is stage 3 or above or if the family asks for a special mattress. In a phone interview with the family member of the resident, she revealed that on 04/14/23, she asked for an air mattress and was told the resident did not qualify for it. An interview was conducted with the Director of Nurses (DON) on 11/30/23 at 10:56 AM. She stated the resident was assessed at a stage 3 on 03/31/23. When asked about the mattress that was on Resident # 254's bed, she replied that all the residents have a special mattress for pressure reduction. A review of the mattress description provided by the Administrator revealed the mattresses in the facility are support mattresses that are pressure reduction and help decrease skin problems in moderate to high risk residents. In a subsequent interview with the DON on 11/30/23 at 12:36 PM, she stated the facility does not have a policy for when a resident has a stage 3 sacral wound that they (the residents) are put on an alternating pressure relief mattress but that is what they do. The DON stated they rent those mattresses. She stated that they did not rent an alternating pressure relief mattress for Resident #254 but the resident should have had an alternating pressure relief mattress. The offloading that was planned by the wound care physician was not provided.

Based on observations, interviews, and record review, the facility failed to maintain accuracy of records for 3 of 23 sampled residents, Residents #3 #79, and #95. The findings included: Review of the facility's policy, titled, Late Entry, Addendum, Corrections and Clarification, with an effective date of June 2022, included: The facility will utilize the following procedures when documentation problems or mistakes occur, and changes or clarifications are necessary. Late Entry: At times it will be necessary to make an entry that is late (out of sequence) to provide additional documentation to supplement entries previously written. When a pertinent entry was missed or not written in a timely manner, a late entry will be used to record the information in the medical record. Guidelines Late Entry 1. Document the late entry as soon as possible timeframe. 2. Record the late entry on the next available chronological line of the applicable form. 3. State Late Entry at the beginning of the documentation. 4. Enter the current date and time. 5. Identify date and time (if known), for which the late entry is written. 6. Document the late entry. 7. Draw a line from the end of your entry to your signature. 8. Sign your name and title at the end of the line. 1. Record review for Resident #3 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Fracture of Unspecified Part of Neck of Left Femur Subsequent Encounter for Closed Fracture with Routine Healing, Pressure-Induced Deep Tissue Damage of Sacral Region, and Unspecified Dementia. The Minimum Data Set assessment (MDS) for Resident #3 dated 10/24/23 revealed in Section C a Brief Interview of Mental Status Score of 7, indicating severe cognitive impairment. In Section H, it was documented that the resident had an indwelling catheter. Review of the Physician's orders for Resident #3 revealed an order dated 10/22/23 for Urinary Catheter: Urinary catheter care daily and as needed every day shift for Preventative Measure and as needed for preventative measure with a discontinued date of 11/28/23. Review of the Physician's orders for Resident #3 revealed an order dated 10/22/23 for Urinary Catheter: Drain urinary catheter bag every shift and prn [as needed] every shift and as needed with a discontinued date of 11/28/23. Review of the Physician's orders for Resident #3 revealed an order dated 11/28/23 as S/P (Status / Post) Foley catheter removal, monitor for voiding if not voiding in 6-8 hours, reinsert Foley and notify MD [physician] every shift for 2 days. (The actual verbal order was received on 11/27/23). Review of the Physician's orders for Resident #3 revealed an order entered on 11/29/23 with an effective date of 11/27/23 to D/C (Discontinue) Foley cath. Photographic Evidence Obtained. Review of the Treatment Administration Record (TAR) for Resident #3 included an order as S/P Foley catheter removal, monitor for voiding if not voiding in 6-8 hours, reinsert Foley and notify MD every shift for 2 Days revealed documentation as being completed from 11/28/23 starting with the evening shift (3:00 PM to 11:00 PM) until night shift (11:00 PM to 7:00 AM) on 11/29/23. Review of the TAR for Resident #3 printed on 11/29/23 at 2:11 PM did not reveal an order to remove / discontinue indwelling urinary catheter (Foley). Review of the TAR for Resident #3 printed on 11/30/23 at 11:05 AM revealed the order dated 11/27/23 to D/C foley cath was documented as signed off by Staff E RNUM on 11/27/23. Review of the time stamped TAR for Resident #3 revealed the order to D/C foley cath was actually entered on 11/29/23 at 7:25 AM and signed off on 11/29/23 at 7:27 AM by Staff E RN/UM. On 11/27/23 at 10:49 AM, an observation was made of Resident #3 lying in bed with no catheter drainage bag seen. On 11/27/23 12:50 PM, a second observation was made of Resident # 3 lying in bed with no catheter drainage bag seen. During an interview conducted on 11/27/23 at 10:49 AM, Resident #3, who was asked if he has a urinary catheter, said I don't know what you are talking about. During an interview conducted on 11/28/23 at 2:22 PM with Staff D, Registered Nurse, who stated she has worked at the facility for about 5 years. When asked if Resident #3 had an indwelling urinary catheter she stated no, it was removed today or yesterday by the Unit Manager. When asked was it was documented that the indwelling urinary catheter was removed, she said it should be documented in the nurse's notes by the nurse who removed it. During an interview conducted on 11/28/23 at 2:45 PM with Staff E, Registered Nurse / Unit Manager (RNUM), who stated she has worked at the facility for about 16 months always as the Unit Manager. When asked about the indwelling urinary catheter (Foley) for Resident #3, she stated the resident's Foley was taken out yesterday (11/27/23). When asked by whom, she stated she did it after talking to the doctor (Primary) who gave her the order. When asked if she documented in the resident's chart that she removed the indwelling urinary catheter, she said she was not sure if she put a note in. When asked when she removed the indwelling urinary catheter, she said it was in the late afternoon yesterday but could not remember what the time was. When asked if she communicated this to the day shift (7:00 AM-3:00 PM) nurse, she said no, she told the evening shift nurse (3:00 PM-11:00 PM). She acknowledged she did not document the Foley being taken out until today (11/28/23). She stated she put in a late entry into the resident's electronic chart to document the Foley being removed. When asked if she had put in an order to remove the indwelling urinary catheter, she said she forgot to do that as well and was informed by the day nurse today that there was no order to remove the Foley. She put the order in the resident's chart today (11/28/23) to remove the Foley. When the RN/UM showed this surveyor the order she put into the chart to remove the Foley, it also included to monitor for voiding if not voiding in 6-8 hours, reinsert Foley and notify MD. The RN/UM then acknowledged there was no documentation of the resident voiding. The RN/UM stated that she was told by the night shift (11:00 PM-7:00 AM) nurse that the resident had voided. An interview was conducted on 11/28/23 at 3:30 PM with Staff F, Registered Nurse (RN), who stated she has worked at the facility since March of 2023. When asked if a resident has an indwelling urinary catheter (Foley) where do they document the care, the RN stated it would come up as an alert in the Treatment Administration Record (TAR) to document. When asked where and who would document any urine output for a resident, she stated it would be the nurse and it would depend on how the order is written, they would document under order for urinary catheter drainage or the actual amount voided if the order is written like that, both ways would be documented in the TAR. When asked if the resident had an order for an indwelling urinary catheter and if the indwelling urinary catheter was removed but the order was not discontinued, the RN stated the Unit Manager is responsible for discontinuing the orders. When asked about Resident #3 and if he had an indwelling urinary catheter, she said he did not have a Foley when she worked yesterday (11/27/23 on the Evening Shift 3:00 PM to 11:00 PM). The Unit Manager informed her the Foley had been removed and the resident had already voided. When asked why she documented on the TAR for Resident #3 that he had an indwelling urinary catheter and a leg strap in place for the urinary catheter, she said it was probably because the order was not discontinued, and it alerted her it needed to be addressed. When asked if it may have been better to indicate in the TAR under urinary catheter a code indicating see nurses note and make a note that the resident did not have an indwelling urinary catheter, she said that probably should have been what she should have done. During a telephone interview conducted on 11/29/23 at 1:15 PM with Resident #3's Primary Physician, he was asked if he had seen the resident, and he said yes. When asked about the indwelling urinary catheter for Resident #3, he asked what room he was in, and it was provided to the physician. The Primary Physician then stated that he gave an order to discontinue the Foley catheter verbally over the phone and the staff informed him that the resident refused to have the Foley removed. When asked what the current status of the Foley catheter for Resident is #3, he said he still has it (Foley) in. 39026 2. Resident #79 was admitted to the facility on [DATE] with diagnoses that included Hydrocephalus, Personal history of other malignant neoplasm of the skin and Atrial Fibrillation. Resident #79 had a Brief Interview of Mental Status (BIMS) score of 9 according to the quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/24/23, indicating the resident had moderate cognitive impairment. On 11/27/23 at 12:17 PM, an observation was made of the resident sitting in his room. The resident had a IV (intravenous) site on his left upper arm covered with a clear occlusive dressing which was covered with a gauze wrap. The resident was unable to verbalize if he was currently on an antibiotic or not. Review of a physician order, dated 11/22/23, revealed an order to Change IV Dressing on right arm every 7 days as well as PRN (as needed) for soiling and/or dislodgement. There was no IV in the resident's right arm, only the left arm. An interview was conducted with the Director of Nurses (DON) on 11/27/23 at 3:30 PM, who stated the resident pulled out the IV on his right arm and on 11/23/23, it had to be replaced and was put in the left arm. When asked about the order that stated the IV was still on the right arm, she stated that it was never changed when the IV site was changed. 3. Resident #95 was admitted to the facility on [DATE], hospitalized on [DATE], then readmitted on [DATE]. Resident #95 diagnoses included Osteomyelitis of vertebra, cervical region, Type 2 Diabetes Mellitus, and Pressure ulcer of sacral region stage 4. The resident's BIMS score was 15, according to the 5-day MDS with an ARD of 11/14/23, indicating the resident was cognitively intact. Review of the Electronic Health Record (EHR) revealed the resident had a physician order dated 11/11/23 for wound care for the coccyx wound. The order was to clean the wound with Dakins 0.5%, pat dry, apply calcium alginate and collagen powder to wound bed and cover with foam dressing every evening shift for wound to buttock. The Treatment Administration Record (TAR) was signed by a nurse as completed from 11/11/23 to 11/27/23. The EHR also revealed an order for negative pressure wound therapy to coccyx. Negative pressure wound therapy dressing was to be completed on Tuesday and Friday. The order was dated 11/13/23 and discontinued on 11/29/23. It was marked as completed on the TAR on 11/14/23, 11/17/23, 11/21/23, 11/24/23 and 11/28/23. On 11/28/23 at 4:01 PM, an interview was conducted with Registered Nurse / Unit manager, Staff C. Staff C stated when she came in this morning the wound vac was not responding and was malfunctioning. She stated Resident #95 said the nurse came in and had to reset it from about 3:00 AM through the rest of the night. Staff C stated that she tried to fix it when she came in at 6:00 AM but could not. She called the physician around 8:30 AM and received an order for a wet to dry dressing so the resident could go to a doctor visit. When asked about the order for the calcium alginate dressing, Staff C stated that she was unaware of that order and maybe she should have used that order. Staff C could not determine why the resident had 2 orders for the same wound and stated that it might have been a backup order for the wound vac or a dressing that is put under the wound vac. The observation for the wound vac therapy dressing was conducted on 11/29/23 at 5:45 PM. On 11/29/23, the order for wet to dry dressing was discontinued. The wound vac was discontinued. A new order was received to revert back to: cleansing the wound with normal saline, apply collagen powder, to wound bed, pack with alginate dressing cover with island or foam dressing. On 11/29/23, the DON was made aware the resident had 2 orders for the sacral wound and verbalized understanding that there should not have been 2 orders for the same wound.

Based on observation, interview, record review and policy review, the facility failed to accurately assess and reassess the efficacy of interventions for skin rash for 1 of 1 sampled resident, reviewed (Resident #92); and failed to provide post-op surgical care for 1 of 1 sampled resident, reviewed (Resident #82). The findings included: 1. During the initial screening of residents on 08/01/22 at 1:50 PM, Resident #92 was observed to have a reddened raised rash on both his arms, as well as linear scratches in the same areas. Record review on 08/02/22 revealed Resident #92 was admitted on [DATE] with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Known allergies to [MEDICATION(S)], penicillin and sulfa were also noted. The admission summary, dated 07/01/22 at 11:54 PM, noted a general body rash and multiple dry scabs to both legs. On 07/18/22 at 2:55 PM, a progress note read: Torso and upper back covered in hives, with associated itching, presenting as an allergic response to something. Legs clean, no hives, Communicated with Attending physician, awaiting feedback regarding treatment plan. Evening nurse to follow. (Written by Staff C, a Registered Nurse). No follow up documentation or new orders were found. Review of the resident's physician orders showed a previous order for an 'as-needed' antihistamine from 07/01/22 to 07/15/22. The [MEDICATION(S)] cream 2% was originally ordered on 07/05/22 to apply to groin/peri area every day and evening shift. A different order, dated 07/02/22, read: 'cleanse generalized area with normal saline and dry area. Apply antifungal cream to affected area. Reapply twice a day, treat rash for 14 consecutive days even if rash has improved, every day and evening shift for wound healing for 14 days. If no improvement in 14 days, consider treatment change.' The treatment began on 07/05/22 and continued until it was discontinued on 08/02/22 after surveyor intervention. No documentation reassessing the efficacy of the treatment at any time over the 28 days was found in the medical record. Review of the resident's care plan revealed a focus area of RASH: The resident has Rash to groin/peri/generalized body, (not initiated until 07/26/2022) with the following interventions: 1) The resident's rash will heal by review date; 2) Administer medication as ordered by MD. Monitor/document side effects and effectiveness; 3) Avoid scratching and keep hands and body parts from excessive moisture and 4) Monitor skin rashes for increased spread or signs of infection. On 08/02/22 at 3:15 PM during an interview, Resident #92 was asked if the visible rash itched. He responded, Boy, does it ever! The resident lifted his clothing to expose his torso which was also covered in the same reddened and raised rash. He said the worst is on his back, he has some rash on his legs, and he sweats a lot. He believed it started in the previous facility as an allergic reaction to antibiotics. He then demonstrated how he relieves the itching by rubbing skin to skin with his hands or rubbing his clothing on the abdomen and added that sometimes it [CONDITION(S)]. He said the cream they (nurses) put on doesn't really work, so I guess I'll just have to suffer. Immediately following the interview, at 3:25 PM, the Director of Nursing (DON) was brought to the room to observe the rash and the resident verbalized to her that he was itching all over. The DON then reported she spoke to the physician and received an order to discontinue the [MEDICATION(S)] because it was not effective and to start [MEDICATION(S)] 10mg every 8 hours as needed for paraneoplastic rash. On 08/03/22 at 09:15 AM, during an interview with Staff B, Licensed Practical Nurse (LPN), assigned to care for Resident #92, she said he had received one dose of the antihistamine earlier in the day (7:31 AM) and he had reported less itching. This was verified with the resident at 11:45 AM. Record review revealed the resident had not received any doses of the antihistamine between 08/02/22 at 3:35 PM when it became available and the dose given the next morning on 08/03/22 at 7:31 AM, further delaying relief. The DON was made aware and contacted the physician to report improvement of the itching. The order of [MEDICATION(S)] was changed from as needed to routine three times daily. On 08/04/22 at 9:50 AM, during an interview with Staff C, RN, she reported the resident's itching had diminished. On 08/04/22 at 2:20 PM, during an interview with Resident #92, he was asked whether he had reported the itching or asked for treatment from the staff on any previous occasions. He said he believed the cream they were using was cortisone and that nothing more could be done. He stated, I am grateful for whatever I can get. 2. Facility Policy, titled, [CONDITION(S)] Management dated October 2021, documented, The facility will coordinate care and services for hemodialysis residents. Daily assessment and documentation of shunt or access site for bleeding, signs and symptoms of infection, redness/pain. Notify physician of abnormal findings. Facility Policy, titled, admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review the transfer orders. Obtain further orders as appropriate. [CONDITION(S)] is a treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The blood is removed from the body and filtered through an artificial kidney. The filtered blood is then returned to the body with the help of a [CONDITION(S)] machine. Arteriovenous graft (AV graft) is a type of access used for hemodialysis. An AV graft is the connection of a vein and an artery that utilizes a hollow synthetic tube under the skin. This allows needles to be placed into the graft providing high enough blood flow for hemodialysis. Central Venous Catheter (CVC) is a type of [CONDITION(S)] access used in which a long tube is threaded through the skin into a central vein in the chest. A CVC is typically intended as a temporary access until an AV graft or fistula is placed. Some of the possible disadvantages of a CVC are damage to the central vein from prolonged use, possible increased length of [CONDITION(S)] treatment from lower blood flow and increased risk of infection. On 08/03/22 at 10:00 AM, Resident #82 was observed to have a right CVC and a left antecubital incision with five black sutures. Resident #82 stated that they only use the catheter in her chest for [CONDITION(S)]. She said that they are not using her AV graft for [CONDITION(S)] because she still has her sutures from surgery. She stated that she had her surgery two months ago and has never gone back for follow-up or to have her sutures removed and does not know why. Record review on 08/03/22 for Resident #82 documented an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) assessment, dated 07/07/22, documented Resident #82 as being cognitively intact and requiring extensive assistance for all activities of daily living except eating which requires limited assistance. No physician orders for AV graft follow up care, surgical incision care or suture care were noted. The Baseline care plan, dated 06/17/22, documented a left antecubital surgical incision. Surgical notes, reviewed from an acute care hospital, documented placement of an AV Graft left arm on 06/01/22 with nylon suture used for skin closure. On 08/03/22 at 10:10 AM, the Director of Nurses (DON) was questioned by the surveyor regarding follow up care for Resident #82's AV Graft incision. The DON stated she was unable to find any orders for care or follow-up for the surgical AV graft site. On 08/03/22 at 10:20 AM, the Regional Nurse Consultant stated that she was unable to locate notes for Resident #82's AV Graft care or orders for follow up. She said the sutures and incision were documented on admission and on a skin assessment on 06/20/22. On 08/04/22 at 9:08 AM, Staff A stated she felt bad because she missed that Resident #82 had sutures all this time. She said she did not see them because they are not to take blood pressure readings in that arm. On 08/04/22 at 12:00 PM, the DON stated they are looking at their admission process to ensure something else like this does not happen again. She stated they should have followed up on Resident #82's surgical incision, sutures, and post op care. On 08/04/22 at 12:36 PM, the Nurse Manager of the [CONDITION(S)] Center stated that the nursing home facility handles the post op care and management of appointments. The [CONDITION(S)] center provides the [CONDITION(S)]. He stated that they do not use graft sites that still have sutures.

Based on record review and interview, the facility failed to document the location of pain for 1 of 1 sampled resident reviewed as a closed record (Resident #96); and failed to document a change in condition for 1 of 5 sampled residents reviewed for Covid-19 (Resident #21). The findings included: 1. Resident #96 was admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #96 was care planned for pain or a potential for pain related to a history of fall with a fractured femur. An intervention included to observe and report signs and symptoms of pain and worsening of pain. Report changes in pain location, type, frequency, and intensity. A review of Resident #96's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #29's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated [DATE], documented to apply a [MEDICATION(S)] to the resident's right hip daily for pain. A physician order, dated [DATE], documented for [MEDICATION(S)] 5 milligrams every 6 hours as needed for pain. A review of Resident #29's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident #29's record did not reveal the location of the resident's pain, intensity, or effectiveness of pain medication. Resident #29 expired on [DATE]. 2. An observation of room [ROOM NUMBER], on [DATE] at 1:00 PM, revealed isolation signage on the door, with a personal protective equipment cart outside of the room door. It was noted 2 resident's were located in the room. An observation of room [ROOM NUMBER] was observed on [DATE] at 10:00 AM, with the same isolation signage on the door. It was noted only one resident remained in the room [ROOM NUMBER] A, Resident #21. An interview was conducted with Staff A, Licensed Practical Nurse (LPN), on [DATE] at 10:15 AM. Staff A stated Resident #21 exhibited signs and symptoms of Covid-19, coughing, therefore the roommate was moved. A review of Resident #21's record did not reveal any documentation of any signs and symptoms. An interview was conducted with the Infection Control Preventionist (ICP) on [DATE] at 10:00 AM. The ICP stated she was not aware of Resident #21 having any signs or symptoms of Covid-19. The ICP acknowledged there was no supporting documentation in the resident's chart. There was no documentation that the physician or family member had been notified of possible exposure to Covid-19. The ICP stated all residents were tested for Covid-19 on [DATE] for recent outbreak. The ICP acknowledged the non-existing documentation of Resident #21's condition.

Based on observation and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety that could potentially affect 96 of the facility's 106 residents. The findings included: During the initial kitchen / food service observation tour conducted in the on 06/28/21 at approximately 8:30 AM, accompanied with the Food Service Director (CDM), the following were noted: 1. Observation of the ceiling vent located directly above the food preparation area noted to have a heavy build-up of condensation which was also noted to be dripping. It was discussed with the CDM that the condensation could drip directly into foods, onto staff, and onto food preparation surface resulting in food contamination. The surveyor requested that the issue be addressed immediately and the vent wiped down periodically. Interview with the Director of Maintenace during the observation revealed that the issues began approximately 1 week ago and an outside refrigeration vendor was contracted to repair the issue. The director further stated that it would be approximately another 7 - 14 days until repairs would be made. 2. Observation of the dish machine noted that the internal separation curtains (3) were heavily worn and required replacement. The curtains were also noted to be covered in the thick food matter paste. The interior of the machine was also covered with dried food matter. It was discussed with the CDM during the observation that the curtains required replacement, and the the machine was not being cleaned properly after each meal. It was also discussed that the company servicing the machine is not performing deliming of the interior and exterior surfaces on a regular basis. 3. Observation of the bench mounted commercial can opener noted a build-up of metal shaving around the blade area. It was discussed with the CDM the metal shaving could be the result of a dull opener blade and they should be monitored daily and replaced as needed. 4. During the observation of the walk-in freezer, it was noted the there was a heavy build-up of dripping condensation on the exterior and a build up of ice on the interior walls. It was discussed with the CDM at the time of the observation that the build-up of condensation and ice is indicative that there is a problem with the unit and that a commercial refrigeration company should assess the issue. 5. Observation of the clean pot and pan storage area noted that all 4 shelves were soiled with dust and were also dust laden. The CDM informed the surveyor that the shelving had recently been re-painted with regular spray paint by the maintenance department. The surveyor informed the CDM that only specialized paint required from the manufacturer be used and that the shelving be replaced. 6. Numerous steam table pans (6) and skillets (3) were noted to have a heavy build-up of carbon on their surfaces. The surveyor discussed with the CDM that the pans should be replaced. 7. Observation of the convection oven noted a heavy build-up of carbon on the interior of the unit and it also had a liquid layer of carbon on the bottom interior. It was discussed with the CDM that the carbon build-up can result in dangerous gases being released on the foods and that the unit wasn't being cleaned properly on a regular basis. 8. During a subsequent tour of the food pantry in the Step Done Unit on 06/30/21 at 12:30 PM, it was noted that opened staff-drinking bottles (1) were being stored in the resident's refrigerator. It was also noted that a open case of disposable spoons was located in the food storage cabinet. It was also noted in the cabinet that there was evidence of roach droppings. It was discussed with the CDM at the time of the observations that no opened / used drinking containers can be stored in the resident's refrigerator. It was also discussed that that all cases / containers of disposable silverware should be properly covered and should not be left opened to air. The need for pest control was discussed. Following the initial 06/28/21 and 06/30/21 tours, the findings were reviewed and acknowledged by the administrator.

Based on interview, record review, and policy review, the facility failed to ensure residents were not unnecessarily confined to their rooms for 2 of 2 sampled residents with the potential to affect 23 residents on transmission based precautions in the Suites Unit, Residents #83 and #253; and failed to follow the smoking schedule for 1 of 1 sampled resident reviewed for smoking, Resident #7. The findings included: Review of the policy Cohorting of New Admissions and Readmissions revealed, Residents that are being admitted that are fully vaccinated and have not had prolonged contact with someone with [CONDITION(S)]-CoV-2 infection in the prior 14 days no longer require quarantine. Resident may go to the well unit and implement enhanced monitoring . Negative Test from hospital within 48 hours of discharge. If the COVID-19 test is a Point-of-Care (POC) test from the hospital > may place in room with another resident admitted within 5 days to remain for observation x 14 days > may to to the well unit is no s/s (signs or symptoms) of COVID-19 on day 15. Review of the record revealed Resident #83 was admitted to the facility on [DATE] from an acute care hospital, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A brief interview for mental status (BIMS) score that was conducted on the 5-day Minimum Data Set (MDS) assessment revealed to be 12, which indicates mild cognitive impairment. Record review revealed the resident had a negative COVID test in the hospital prior to admission and had not received the COVID vaccine. On 06/28/21 at 11:03 AM, during the initial pool selection process in the Suites, an interview was conducted with Resident #83. Resident #83 pointed to the signs on the door of her room that indicate droplet precautions and stated I don't know why I am in my room - is there something wrong with me? Observation of the resident on 06/28/21 at 1:00 PM revealed the resident to be sitting alone in her room with the television on. Observation of the resident on 06/29/21 at 9:00 AM, 1:00 PM and 3:30 PM revealed the resident to be sitting alone in her room with the television on. Observation of the resident on 06/30/21 at 12:25 PM revealed the resident sitting in her chair in her room with her lunch uncovered on a tray in front of her. Interview conducted with Resident #83 at this time as to why she was not eating her lunch. The resident answered that she needs help to eat and she is waiting for someone to come back to help her. On 06/30/21 at 4:00 PM, this surveyor went to visit Resident #83 and she was no longer in her room. Record review revealed that resident was moved to the 300 unit which is the well unit on 06/30/21 at 2:00 PM. Resident #83 was in the Suites isolation unit from 06/10/21 through 6/30/21, a total of 21 days. On 06/30/21 at 10:05 AM, an interview was conducted with the Director of Nursing (DON) regarding Resident #83 who had been admitted on [DATE] and was still in isolation. She stated that they try to admit to the 'well unit' if they have had the vaccine but they don't know the vaccine status until they are admitted . Discussed that the resident is in isolation with no group activities, not able to eat in the dining room and should not be on isolation anymore. The DON stated that they try to move the resident to the well unit on day 15 but they don't have room now. 2. Review of the medical record for Resdient #253 revealed the resident was admitted to the facility on [DATE] from an acute care hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was transferred from the hospital for rehabilitation. Resident #253 is alert and oriented and did not have a Brief Interview for Mental Status done yet. Resident #253 completed 2 doses of the COVID vaccine in March, 2021. During the initial pool process on 06/28/21 at 10:53 AM, Resident #253 stated that she wishes she could be in activities, but she is stuck in her room due to isolation. Resident #253 stated I saw the activities schedule and there are a few I really wanted to go to but I feel like I am in prison in this room. I want to go to the dining room, but I can't, I'm stuck here. On 06/28/21 at 11:30 AM, an interview was conducted with the Staff Development Coordinator who was in charge on the Suites, regarding Resident #253. Discussed the resident being on a isolation unit when she has already received 2 doses of the COVID vaccine. The Staff Development Coordinator stated that there are no rooms available on the well unit so she has to stay here until a room becomes available. 3. During the initial observation tour conducted on 06/28/21, the facility identified 3 residents which were currently cigarettes smokers, and that included Residents' #7, #101, and #90. During the initial screening process, Resident #101 stated issues with the facility smoking times but requested not to state his specific issues. Resident #90 was noted to be sleeping during numerous attempts to interview. During an observation of Resident #7 on 06/29/21 at 11:15 AM, it was noted that the resident was seated in her wheelchair while at the nurses station. The resident stated to the surveyor that once again it is time for designated smoking time of 11:15 AM, but there is not staff here to assist me. The resident further stated that this occurs all the time. The surveyor and the resident waited at then nurses station from 11:15 AM through 11:30 PM. A Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] . With the assistance of the Risk Manager, Staff A was performing an activity which was located in the Activity Room on 06/28/21 at 11:15 AM. At the request of the surveyor, Staff A was interviewed and it was noted to state that she was unaware of her smoking room assignment and forgot all about it. Resident #7 once again stated that this occurs all the time. Review of the clinical record of Resident #7 on 06/29/21 noted that the resident signed the Resident Smoking Safety Education & Acknowledgement on 04/07/21. Guidelines included that all lighter / matches and any other paraphernalia may not be kept on their person or in the rooms. Staff members are assigned to the smoking area. A follow-up interview conducted with Resident #7 on 07/01/21 revealed that since the smoking time issues were brought to the attention of the facility administrator by the surveyor that the smoking times are now being followed. The resident further stated that the assigned staff comes directly to her room for all smoking times to verify that the resident wishes to be brought to the smoking patio.

Based on observation, interview, and record review, the facility failed to ensure appropriate care and services were provided to maintain or improve safe eating and swallowing skills, for 1 of 6 sampled residents, Resident #74, reviewed for nutrition. The findings included: Resident #74 has an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current MDS, dated [DATE], noted: Sec C - BIMs=5; Sec G - Limited assistance Sec K - no swallowing issues; height-69 inches wt (weight)-163 lbs, No Known weight loss Sec M - no issues WTs (weights) 06/05/21, 159.5lbs; on 04/06/21, 163.2lbs The Current MD orders of 05/17/21 included NAS Diet, Pureed, Nectar Consistency; Puree texture, Nectar consistency, for dysphagia magic cup with lunch and dinner, angled utensils. During the initial dining observation conducted of the lunch meal on 06/28/21 at 12:15 PM, it was noted that Resident #74 was seated in the main dining room. Further observation noted the resident to be alert with some cognitive deficit. The resident was noted to be eating the dessert (ice cream) prior to eating the main meal without staff intervention. It was also noted the resident required thickened liquids. Observation conducted over the next 30 minutes noted the Speech Therapist (SLP)(Staff A) to be working extensively with the resident. Specifically, Staff A had to constantly remind the resident of specific safe swallowing strategies to avoid potential chocking. Staff A had to remind Resident #74 to eat small bites of food, double swallows after foods, hard swallow between foods and alternate liquids and bites of foods. The resident was notably having difficulty swallowing and required the SLP to be present during the meal. Observations on 06/29/21 at 9:15 AM revealed Resident #74 in his room sitting in a wheelchair eating breakfast with no assistance or supervision and the call bell was not within reach. Additional observation on 06/30/21 at 9:30 AM revealed Resident #74 in his room eating breakfast with no assistance or supervision. The following was observed: The milk was in a carton, not in cup; Two curved spoons was noted on tray; and No adaptive fork was present as indicated on the menu. Resident #74 was observed scooping large amounts of food onto his spoon, with an estimated amount the size of a golf ball. Resident #74 proceeded to place the entire heaping spoon into his mouth. The resident was unable to swallow all the food and displaced some into his cheek (pocketing) then attempted to swallow again. He then repeated the process again rapidly until all the food was gone off his plate. There was no fluid intake between bites was noted; and no pauses, chin tucks or hard swallows were noted. Residual food was noted on his face and chest. The call bell was not noted within reach. Additional observation on 07/01/21 at 9:28 AM revealed Resident #74 in his room eating breakfast with assistance and supervision by Speech Therapist, Staff A. The call bell was within reach. The resident was noted using an adapted spoon and observed consuming large bites of foods. Interview with Speech Therapist, Staff B on 06/29/21 at 1:49 PM, and reviewing of the observation of the resident eating lunch yesterday was made. The resident was having difficulty with swallowing and having to be prompted using strategies of how to swallow that included chin tucks, hard swallows, clearing of throat, small bites, and alternating solids and liquids frequently, all the things he needed to do not to aspirate (aspiration occurs when food or fluids is breathed into the lungs instead of being swallowed which can possibly lead to pneumonia, choking and death). She stated that was correct. The Care Plan for Resident #74 was reviewed with Staff B, which stated the resident needs to be observed for signs and symptoms of aspiration while eating. When asked how he can be observed for aspiration if he is alone, she stated, you make a good point, there is a potential for aspiration, he needs supervision. Record review on 07/01/21 revealed the following: Physician diet order, dated 05/17/21 for: No added salt diet, Pureed texture, Nectar Consistency, for dysphagia magic cup with angled utensils. The Care Plan, completed 06/10/21 for ASPIRATION RISK documented: 'The Resident is at risk for aspiration related to difficulty swallowing because of: diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Allow extra time to eat; provide additional assistance patient to have nectar thick liquids. Ensure resident sitting in upright position, is alert and ready to consume PO (oral) intake. Provide modified diet as ordered. Observe for signs & symptoms of aspiration, coughing, tearing, runny nose, wet vocal tone, difficulty breathing, and pocketing of food.' The Speech Therapy Plan of Care Note, dated 06/30/21, by Speech Therapist Staff A documented: Patient assessed on puree consistencies, to increase safety of the swallow, patient returned demonstration of previously trained therapeutic swallowing strategies of effortful swallow, double swallow, and clear / re-swallow to achieve dry vocal quality given min-mod verbal cues required 50% of the time. Patient noted with coughing spell x 1 at end of meal with dry vocal quality indicated post cough. Review of the established comprehensive assessment for a resident documented the facility must provide the necessary care to ensure the resident maintains their highest level of functional wellbeing. There was no evidence that the assessed needs for Resident #74 were provided that ensured the safe swallowing function during eating as evidenced by lack of specialized dining utensils, lack of consistent monitoring for all meals with coaching strategies and prompting to maintain safe swallowing in addition to the lack of maintaining a call bell within reach during eating. This impacted one out of six residents reviewed for nutrition.

Based on observation, interview, and record review, the facility failed to provide an ongoing activity program for 2 of 3 sampled residents reviewed for activities, Resident #83 and #253. The findings included: 1. On 06/28/21 at 11:03 AM during the initial pool selection process on the Suites, an interview was conducted with Resident #83. Resident #83 pointed to the signs on the door of her room that indicate droplet precautions and stated I don't know why I am in my room-is there something wrong with me? Resident also stated that she does not leave her room and there is nothing for her to do. The resident was admitted to the facility on [DATE] from an acute care hospital. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A brief interview for mental status (BIMS) that was conducted on the 5-day Minimum Data Set (MDS) assessment revealed to be 12 which indicates mild cognitive impairment. Record review reveals the resident had a negative COVID test in the hospital prior to admission and had not received the COVID vaccine. Observation of the resident on 06/28/21 at 1:00 PM revealed the resident to be sitting alone in her room with the television on. Observation of the resident on 06/29/21 at 9:00 AM, 1:00 PM and 3:30 PM revealed the resident to be sitting alone in her room with the television on. Observation of the resident on 06/30/21 at 12:25 PM revealed the resident sitting in her chair in her room with her lunch uncovered on a tray in front of her. On 06/30/21 at 9:26 AM, an interview was conducted with the Director of Activities. The Director of Activities stated that in the activity department, there is her and an assistant. They work alternate weekends so there are 4 days a week that there is only one person in the activities department. Since residents in the Suites can't come out of their rooms to group activities, they use an activities cart and will walk around and go to each room. On the cart is a portable radio, magazines, books and sensory objects. The residents in Suites can have compassionate care visits also. We try to get there 3-4 times a week. Review of documentation for individual activity for Resident #83 revealed the resident was admitted on [DATE]. She had a total of 2 visits from activities on 06/16/21 and 06/27/21. A review of the activities care plan for Resident #83 revealed the resident required staff assistance with involvement of activities related to cognitive deficits and would benefit from in room and small group activities; and to Explain and encourage the importance of social interaction, leisure activity time and participation. 2. During the initial pool process on the Suites on 06/28/21 at 10:53 AM, Resident #253 stated that she wishes she could be in activities, but she is stuck in her room due to isolation. Resident #253 stated I see the activities schedule and there are a few I really wanted to go to but I feel like I am in prison in this room. I want to go to the dining room, but I can't, I'm stuck here. Review of the medical record revealed the resident was admitted to the facility on [DATE] from an acute care hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was transferred from the hospital for rehabilitation. Resident #253 is alert and oriented and did not have a Brief Interview for Mental Status done yet. Resident #253 had completed 2 doses of the COVID vaccine in March, 2021. A review of the psychosocial care plan, created on 06/25/21, revealed, The resident is at risk for alteration in Psychosocial well being related to restriction on visitation, Activity outings and/or group activities secondary to COVID-19. Interventions included: Encourage alternative activities that can be done in room and monitor for psychosocial changes. A review of a skilled evaluation nursing note, dated 06/26/21 revealed the resident's mood and behavior to be anxious. A review of the documentation for the individual activity report for Resident #283 revealed she had one visit from activities on 06/27/21.

Based on interview, record review, and policy review, the facility failed to ensure the completion of a Social Service Assessment/Discharge Evaluation for 3 of 3 sampled residents reviewed for the provision of Advanced Directives (Residents #29, #41, and #253). Without this assessment, the facility lacked documented evidence of the resident's Advanced Directives, discharge planning, and other potential social service needs. The findings included: Review of the policy Admissions effective February 2021 documented, Policy: On admission, Social Services will obtain and document relevant historical data about the resident/patient, family, and others as necessary. Procedure: . 10. Complete the Social Service Assessment/discharge Evaluation according to the resident/patient's Level of Care. Initiate on admission and complete within 3 days of admission. 1. Review of the record revealed Resident #29 was admitted to the facility on [DATE]. Further review of the record lacked any evidence the facility had inquired about the resident's Advanced Directives (except for the resident's code status), and the record lacked any documented social service assessment. The record also lacked any social services progress notes. Review of the current care plan initiated on 04/27/21 documented, ADVANCE DIRECTIVES: Resident Advance Directives is as follows: Resident / authorized responsible party request FULL CODE wish to be honored. Interventions on this care plan included to discuss Advance Directives with the resident and/or appointed health care representative. During an interview on 07/01/21 at 9:44 AM, the Social Services Director (SSD) was asked how the facility obtains Advanced Directive information for their residents. The SSD stated the initial information is obtained from the Admission's Department, and if the resident had any Advanced Directives he would follow up with the resident. When asked where in the record this would be documented, the SSD stated on the Psychosocial History and Assessment form in PCC (Point Click Care / Electronic Medical Record). During a side-by-side review of PCC with the Social Service Director, the social services assessment was not located for Resident #29. The SSD volunteered he had spoken with the son of Resident #29 who stated he was the resident's decision maker. When asked if this was documented in the medical record, the SSD was unable to locate any progress notes or documentation. During this continued interview, the SSD explained PCC should trigger or alert him as to who needs to have the Psychosocial History and Assessment form completed and confirmed he should do one with each new admission. When asked if he tracks the new resident admissions, the SSD stated that he does. When asked why he had not completed the assessment for Resident #29, the SSD again stated, Because PCC did not trigger it. The SSD confirmed the Psychosocial History and Assessment / social services assessment would include information related to Advanced Directives, discharge planning, and other potential needs. During an interview on 07/01/21 at 10:23 AM, the Administrator (NHA) was made aware of the lack of Social Service assessments and was asked to locate and provide the facility's policy and procedure related to the assessment. During an interview on 07/01/21 at 10:56 AM, the Admissions Director was asked about her role in obtaining Advanced Directive information for a resident. The Admissions Director stated she just informs the resident and or family they have a right to execute Advanced Directives. When asked if she asks the resident and or family what Advanced Directives they have, the Admissions Director stated she does not. 2. During an interview on 06/28/21 at 11:38 AM, Resident #41 stated about two weeks ago she had spoken with the Social Services Director about having Home Health services upon discharge and that she had not heard back from him. The resident also voiced that she should be discharged soon, wants to ensure she has home health assistance, but has not been told a discharge date . During a subsequent interview on 06/29/21 at 4:16 PM, Resident #41 was asked if anyone at the facility had asked her about Advanced Directives, and stated, they never asked me. Resident #41 also stated that no one had spoken to her about her discharge since our conversation the previous day. Review of the record revealed Resident #41 was admitted to the facility on [DATE]. Further review of the record lacked any evidence the facility had inquired about the resident's Advanced Directives (except for the resident's code status), and the record lacked any documented social service assessment. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #41 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was alert and oriented. Review of the current care plans documented as of 05/25/21 Resident #41 requested to be a full code and as of 05/04/21 the resident wished to be discharged to a lower level of care. Both care plans had the intervention to discuss with the resident. During an interview on 07/01/21 at 9:50 AM, the SSD was asked about the discharge plans for Resident #41. The SSD stated the resident was planning on returning to home and stated her discharge date was 07/09/21. The SSD was asked if the resident had been made aware of this and if it was documented in the medical record. The SSD stated they last spoke maybe yesterday and also last week. The SSD stated there would be a note in the record. A side-by-side review of the record lacked any evidence of any notes related to discharge and lacked the social services assessment. Final review of the record lacked any documented evidence of informing Resident #41 of her discharge date but did reveal a Psychosocial History and Assessment completed on 07/01/21 at 11:52 AM after surveyor intervention. 3. Review of the medical record for Resident #253 revealed the resident was admitted to the facility on [DATE] from an acute care hospital with diagnoses that included shortness of breath and pedal [CONDITION(S)]. She was transferred from the hospital for rehabilitation. Resident #253 is alert and oriented and did not have a Brief Interview for Mental Status done yet. On 06/29/21 at 10:23 AM, Resident #253 was asked if she had an advance directive. She stated that she just completed the Advance Directive last fall with her family. She does not remember being asked when she was admitted if she had an Advance Directive. An interview that was conducted with the Social Service Director on 06/29/21 at 10:15AM revealed the admission director will ask if the resident has an advance directive and he will follow up after that and is discussed at care plan meetings. The facility should determine on admission if the resident has an advance directive or not. An interview was conducted with the Admissions Director on 06/29/21 at 10:45 AM which revealed that she asks the resident upon admission if they have an advanced directive but on this resident's admission intake, that page was blank. She remembers the resident being very anxious on admission and she wanted to do the admission quickly. She stated that she usually asks if they have one and then social service will follow up and it is discussed at care plan meetings. Interview with Social Service Director(SSD) on 07/01/21 at 12:20 PM revealed he spoke with the resident yesterday. This surveyor stated that there is no documentation of this conversation in the resident's progress notes and the record also lacked a social service assessment. The SSD stated that he will be putting the information in PCC (Point Click Care/Electronic Health Record).

Based on observation, record review, interview and policy review, the facility failed to ensure nurses completed administration of seven medications for 1 of 1 sampled residents, resulting in the failure to appropriately store medications (Resident #63). The findings included: During an observation and interview on 06/28/21 at 9:54 AM, Resident #63 was sitting on the edge of her bed and stated she was not feeling good. When asked why, the resident voiced a long explanation that they (the nurses) were trying to give her medications for [CONDITION(S)] but she is just depressed. The resident went on to state she gets an allergic reaction to the medications. When asked what kind of reaction, Resident #63 stated she has nose bleeds and gets dizzy or light headed. The resident stated she would show the surveyor the pills and started opening a large clear plastic bag. The large bag was tied up in a knot, and the resident proceeded to open up three additional tied up bags, each one inside the other. The resident obtained a small medication cup, poured the medications out on the bed, and counted out eight pills. The cup had three small round brown pills, four white round pills, and one oval pill. When asked, the resident stated she just does not take them. Resident #63 then stated she tells the nurses she does not want them but they make her take them. The resident stated the eight pills were from different days. At this time, the Director of Nursing (DON) was called into room and shown the pills. The DON observed the pills and took them from the resident. When questioned by the DON, Resident #63 again stated she does not take these pills because she has reactions to them, stating she gets light headed / dizzy and gets nose bleeds. (Photographic evidence obtained on 06/28/21 at 10:10 AM in the accompaniment of the DON in the conference room. It was later noted the photograph only had seven pills and the DON was informed the resident and surveyor had counted out eight pills, so one may still be on the bed or in the room). The DON was asked to identify the medications. The DON agreed the nurses had not ensured Resident #63 took her medications and agreed that medications should not be left unattended or in a resident's room. On 06/28/21 at 12:25 PM, the DON identified the medications as [MEDICATION(S)] (an antidepressant/the three white pills), [MEDICATION(S)] (an antipsychotic/the three brown pills), and [MEDICATION(S)] (an antidepressant/the oval pill). The DON stated she had spoken with the primary care physician (PCP) and did a medication review over the phone. The PCP ordered some laboratory work and asked that psych services be informed. The DON notified the psych services and they stated they would be in later in the week. The DON stated they started in-services with all nursing staff to ensure they observe the residents take all of their medications and did a facility wide sweep of the residents' rooms and found no additional medications at the bedside. Review of the record revealed Resident #63 was originally admitted to the facility on [DATE], and readmitted on [DATE]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #63 had a Brief Interview for Mental Status (BIMS) score of 13 on a scale of 0 to 15, indicating the resident had minimal cognitive issues. This MDS also documented the resident had been administered both antipsychotic and antidepressant medications. The Admission Data Collection nursing assessment documented Resident #63 did not want to self-administer medications. The current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 02/07/20, [MEDICATION(S)] [MEDICATION(S)] Tablet Disintegrating 15 MG (milligrams); give 1 tablet by mouth at bedtime for depression. 06/03/21, [MEDICATION(S)] Tablet; give 20 mg by mouth at bedtime for Depression. 06/28/21, [MEDICATION(S)] Tablet; give 0.5 mg by mouth one time a day for [CONDITION(S)] (disorder). 06/28/21, [MEDICATION(S)] Tablet 0.5 MG; give 2 tablet by mouth at bedtime for [CONDITION(S)] (disorder). Review of the record lacked any documented evidence of Resident #63 hoarding medications prior to surveyor identification. The record did reveal Resident #63 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the policy Medication Administration, dated 09/18, (September 2018) documented, Procedure . 20. The resident is always observed after administration to ensure that the dose was completely ingested. Review of the policy Medication Storage, dated 09/18, documented, Bedside Medication Storage. Policy: Bedside medication storage is permitted for residents who are able to self-administer medications, upon the written order of the prescriber and when it is deemed appropriate in the judgment of the nursing care center's interdisciplinary resident assessment team.

Based on observation, interview, and record review, it was determined that entrees designated on the approved menu to be prepared by scratch/fresh methods were substituted by canned entree that lacked flavor, appearance and nutritive value for 95 of the 106 residents, which included interviews conducted with Resident's #1, #74, and #127. The findings included: During the observation of the lunch meal in the main kitchen on 06/30/21 at 11:45 AM, it was noted that the lunch entree of Beef Stew lacked appearance and attractiveness that included poor color and watered down / soupy appearance. When plated, it was noted that the beef stew mixture would spread out like a puddle across the entire surface of the plate, and also mixed into the vegetable (Peas & Carrots), which were also on the entree plate. Interview with the Dietary Manager at the time of the observation revealed that the Beef Stew entree was a canned product. When asked why the Beef Stew is not freshly prepared, it was noted that canned has always been utilized. A review of the standardized recipe for the beef Stew entree also noted to utilized canned Beef Stew. A review of the approved menu for the lunch meal of 06/30/21 noted documentation that the Beef Stew entree was to be made freshly prepared from scratch. The Dietary Manager stated that she was not aware that the menu documented freshly prepared from scratch. Interviews conducted with 3 residents, Residents' #1, #74, and #127, during the lunch meal observation of 06/30/21. It was noted that all 3 residents, whose cognition were intact, refused to eat the meal and complained to the surveyors about the Beef Stew entree's appearance.

Based on observation, interview and record review, it was determined that 1 of 6 sampled residents, Resident #14, selected for nutritional review, failed to be proved with physician ordered adaptive eating devices and utensils. The findings included: During the observation of the lunch meal on 06/28/21 at 12:30 PM, it was noted the meal tray was served to the room of Resident #14. A review of the diet meal card on the tray documented: CCHO (consistent or controlled carbohydrate diet), Mechanical Soft diet, Divided Plate, Weighted Utensils and Cup with Lid. Further observation of the resident's meal noted that only one 2-handled cup with Sippy lid was included, and only one weighted fork and spoon were included. It was noted that the resident had 3 beverages on the lunch tray (milk, juice, water) of which the juice was poured into. The resident had to attempt to drink the milk from the carton and water from a regular cup. It was noted that the resident was spilling the beverages when attempting to drink from the carton and cup. It was also noted that Resident #14 could benefit from the use of a weighted knife. A second meal observation conducted of Resident #14 on 06/29/21 at 9:20 AM again noted that only 1 adaptive drinking cup was provided for 3 tray beverages and no weighted knife was provided. A third meal observation of Resident #14 conducted on 06/30/21 at 9:20 AM again noted the breakfast meal to include only one 2-handles cup with Sippy lid and only one weighted fork and spoon. The resident was again to drink from cup and carton resulting in spillage of the beverages. At the request of the surveyor, the Food Service Director (FSD) was requested to come to the room of Resident #14 and review the adaptive equipment being supplied on the meal trays. She confirmed the documentation of the meal tray card and stated that a 2-handled cup with Sippy lid should be served with for all tray beverages and also stated that a weighted knife should also be provided with meals. Review of the clinical record of Resident #14 on 06/30/21 noted a physician's order, dated 06/17/21, for CCHO Diet, Mechanical Soft, Divided Plate, -Weighted Utensils, and Cup with Lid. Review of current Nutritional Care Plan originally developed on 04/07/21 documented to include: adaptive weighted utensils, divided plate, and cup with lid.

Based on observation, interview and record review, the facility failed to provide nutritional care and services consistent with the resident's comprehensive assessment and plan of care, for 1 of 3 residents reviewed for weight loss (Resident #1). The findings included: During an interview on 03/09/20 at 1:10 PM, a family member stated that Resident #1 was losing weight and that he had been telling the staff for approximately a month and he felt like the staff was not listening to him. Review of Resident #1's record on 03/09/20 revealed that Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1's Minimum Data Set (MDS), an admission assessment, of 01/27/20 revealed a Brief Interview for Mental Status (BIMS) of 10 out of a possible 15, which indicates moderate cognitive impairment. Resident #1's Comprehensive Nutrition Assessment of 01/28/20 revealed a note from the Registered Dietitian 'Visited with the resident at bedside-lunch tray left untouched as per observation. Resident at nutritional risk for inadequate po intake'. Resident #1's record revealed a weight on 1/23/20 of 136.5 pounds. On 02/01/20, Resident #1 weighed 137.0 pounds. Resident #1 had not been weighed since 02/01/20. Resident #1 was weighed on 03/09/20 during the survey and weighed 127.5 pounds, a 6.93% weight loss in one month. Review of Resident #1's Medication Administration Record [REDACTED]. Review of the MAR from 02/01/20 through 03/08/20 revealed no documented side effects related to [MEDICATION NAME]. Continued review of the MAR indicated [REDACTED]. Review of the MAR from 02/01/20 through 03/08/20 revealed no documented side effects related to [MEDICATION NAME]. Review of Resident #1's plan of care revealed a nutritional focus, initiated 01/28/20, with an intervention that the Registered Dietitian would consult and follow Resident #1 as needed. The nutritional focus plan of care also had an intervention that the Registered Dietitian would obtain, and review lab work as ordered and report results to Resident #1's doctor and follow up as indicated. Review of Resident #1's laboratory test revealed results from 02/25/20 of an [MEDICATION NAME] serum level, as low, at 2.4g/dl. The reference range for a normal value is 3.5 - 5.0 g/dl. Low [MEDICATION NAME] levels in your blood can be due to improper nutrition. On 03/03/20, Resident #1's [MEDICATION NAME] serum was low at 2.3 g/dl. On 03/10/20 at 1:25 PM, the RD was asked if she had reviewed Resident#1's laboratory results from 02/25/20 and 03/03/20. The RD stated that she had not. Review of Resident #1's physician orders [REDACTED]. During the same interview, the RD was asked about the physician order [REDACTED]. The RD stated she was not aware of a physician order [REDACTED]. During an interview on 03/10/20 at 1:25 PM, the Registered Dietitian (RD) stated she assessed Resident #1 to be at risk for weight loss during her admission assessment of 01/28/20. The RD stated that she was aware that the family had voiced concerns about Resident #1 losing weight but could not recall when she was first aware. The RD stated that she participated in a care plan meeting with the family on 02/27/20 and remembered the family being concerned about the resident losing weight. The RD stated that she had not documented any progress notes for Resident #1 related to the family care plan meeting. The RD stated that she did not update Resident #1's plan of care after the 02/27/20 care plan meeting. The RD stated that she had visited with Resident #1 on several occasions and talked to her about her meal consumption and her weight. The RD stated that she could not recall the dates that she had met with Resident #1 and that she did not document any of her interactions with the resident.

Based on observation, record review, and staff interview, the facility failed to follow the mechanical soft menus for residents with a physician ordered mechanical soft diet for residents with chewing and/or swallowing problems. The facility had 13 residents who were prescribed mechanical soft diets. The findings included: According to the facility menu for Wednesday, Week 3, the mechanical soft diet menu indicated that no raw vegetables were to be served at the lunch meal. On 10/09/19, starting at 11:30 AM, the lunch trayline observation was conducted. The Cook was portioning the mechanical soft cold entree on the residents' plates. She put a large tomato slice, measuring about 2-3 inches in diameter and a large iceberg lettuce leaf, about 4 inches in diameter on the entree plate. The Dietary Aide took the mechanical soft entree plates with the tomato and lettuce, put them on the trays and into the meal cart. After the fourth mechanical soft meal tray was put into the cart, the Cook and Dietary Aides were informed by the surveyor that there should not be any raw vegetables on the lunch plates. The tomato slices and lettuce were removed from the lunch plates. An interview was conducted on 10/10/19 at 4:15 PM with the dietitian. She confirmed that the residents prescribed mechanical soft diets should not be receiving raw vegetables with their meals.

Based on record review and interview, the facility failed to inform the physician timely concerning a change in a wound for 1 of 3 sampled residents ( #1). The findings include: Review of Resident #1's clinical record revealed the initial Nursing Assessment on 10/28/2012 identified that the resident had an excoriation on her left buttock, Stage II, no measurement listed. The Braden Pressure Ulcer Assessment on 10/28/2012 documented a score of 14, Moderate risk. Admission Summary 10/28/2013 identified that the resident had a left buttock excoriation 2-3 cm and local redness noted. Wound Care Nurse # 1 assessed the wound on 10/30/2012 and identified the wound as Stage II, measuring 1 cm x 1.9 cm, clear, scant drainage, color of wound bed red, no odor, tissue granulated no tunneling. On 12/4/2012 the wound increased in size to - 2.4 x 1.0. The nurses documented the wound was emitting an odor beginning 12/20/2012. Wound Care Nurse #2 documented on 12/20/2012, "dressing change, foul odor, scant amount of serous drainage " ; 1/4/2013, "wound care, large amount of purulent drainage with mal odor noted on sacrum and upper back; 1/9/2013, Medical Doctor (MD) and wound care MD contacted and informed about resident's condition. MD and Wound care MD agree to order ... ... sacral and back wounds culture and sensitivity for aerobics and anaerobic"; 1/11/2013, "wound care treatment, moderate amount of purulent drainage with mal odor." Although the mal odor was noted on 12/20/12, the physician was not notified of the change until 1/9/13. Wound Culture was completed on 1/10/2013 of the sacral and back wounds culturing Pseudomonas aeruginosa, moderate growth for the sacrum and heavy growth for the back wounds. (See F314 for additional information.)

Based on record review and staff interview, the facility failed to accurately assess and document the resident's wounds for 1 of 3 sampled residents (Resident # 1) of 7 residents identified by the facility as having pressure ulcers. The Minimum Data Set failed to correctly identify a worsening wound and failed to identify a new wound the resident developed. The findings include: Review of the clinical record for Resident # 1 discloses that the resident was admitted to the facility on [DATE] with an excoriation on her left buttock, Stage II. The Wound Care Nurse assessed the wound on 10/30/2012 and identified the wound as Stage II, measuring 1 cm x 1.9 cm, clear, scant drainage, color of wound bed red, no odor, tissue granulated no tunneling. On 12/18/2018, the sacrum wound progressed to measuring 8.5 x 5 x 0.3 estimate. Wound currently with excessive Black, sero-sanguineous drainage, mild drainage, mild [DIAGNOSES REDACTED], unstageable, necrotic tissue of muscle. The resident also developed a second wound on her Right Back Mid Lateral, in-house pressure measuring 8 x 6 x 0.1, 100% Dermis tissue, no granulation or necrotic tissue, serous drainage mild, no odor unstageable, removal of thick adherent necrotic tissue of partial thick. Review of the Minimum Data Set Assessment ((MDS) dated [DATE] failed to provide evidence of the above stated wounds. The first MDS dated [DATE] identified on Section M.Skin Conditions; Current Number of Unhealed Pressure Ulcers at Each Stage; the wounds were indicated as zero (0), there were no dimensions documented for the Unhealed Stage 3 or 4 Pressure Ulcer or Eschar; and the Most Severe Tissue Type for any pressure ulcer and the form indicated 4- Necrotic tissue (Eschar); Worsening in Pressure ulcer status since Prior Assessment indicated zero (0). This MDS does not indicate the initial wound worsened nor does it identify the development of the second wound. Another MDS with a 12/18/2012 date and signed by the MDS Coordinator as accurate on 12/21/2012 documented the resident had (1) Current Number of Unhealed Pressure ulcer F. Unstageable - Slough and/or eschar; Dimensions of Unhealed Stage 3 or 4 pressure documented 5.0 cm (length), 5.5 cm (width). Another MDS (30 day) dated December 30, 2012, documented the resident has 1 unstageable Slough and/or eschar measuring 6.3 x 5.5 Stage 4, Necrotic tissue. There are no other wounds identified on the MDS. An interview was conducted on 3/4/2013 at 4:00 PM with the MDS Coordinator who acknowledged she failed to identify the worsening wound on the 18th but stated there is nothing to indicate an unstageable wound. Furthermore she must not have been aware of the wound on the resident's back. She further stated she again was not privy to the information regarding the wound on her back on the 12/30/2012 MDS because she failed to identify the wound on the MDS. It should be noted that the Wound Care Nurse had identified both wounds and had established Skin Grid for Pressure ulcers. The wound on the resident's back, skid grid was initiated 10/30/2012. The 12/18/2012 skin grid documented unstageable 5 x 5.5 yellow drainage with necrotic black tissue. On 12/26/2013, the wound remained unstageable measuring 6.3 x 5.5, yellow drainage with black necrotic tissue. The nurse also identified on 12/18/2012 a wound on the resident's Right Upper Back, excoriation, blister, measuring 6.5 x 3.4 . There is no wound stage identified. Furthermore on 12/26/2012, the facility failed to identify the wound stage but documented the wound measured 5.5 x 3 with scant reddish colored drainage.

Based on record review and staff interview, the facility failed to ensure that 1 of 3 sampled residents (Resident # 1) who were admitted to the facility with pressure ulcers, of 7 residents identified by the facility as having pressure ulcers, was provided care that meets professional standards of quality as evidenced by failure to follow physician orders [REDACTED]. The Florida Nurse Practice Act, Chapter 464.003(3) includes the administration of treatments and medications as prescribed. The findings include: Review of the clinical record for Resident # 1 revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The initial Nursing Assessment on 10/28/2012 identified that the resident had an excoriation on her left buttock, Stage II, no measurement listed. The Braden Pressure Ulcer Assessment on 10/28/2012 documented a score of 14, Moderate risk. Admission Summary 10/28/2013 identified that the resident had left buttock excoriation 2-3 cm and local redness noted. The admission orders [REDACTED]. The was to be completed on the 11-7 shift every 3rd day. Wound Care Nurse # 1 assessed the wound on 10/30/2012 and identified the wound as Stage II, measuring 1 cm x 1.9 cm, clear, scant drainage, color of wound bed red, no odor, tissue granulated no tunneling. On 11/6/2012, the wound measurement remained unchanged. Initially, the wound care nurse documentation discloses the wound decreased in size each week as follows: 11/13/12- 1.0 x 1.2; 11/20/2012 - 1.0 x 1.0; 11/27/2012-.5 x .4. On 11/27/2012, the wound care orders changed to: Cleanse area with Normal Saline Solution apply a clean dry dressing. The resident's wound then began to increase in size; on 12/4/2012 the wound increased in size to - 2.4 x 1.0. The wound care dressing was again changed to [MEDICATION NAME]/Alginate on 12/4/2012. On 12/11/2012 the wound measured 4.4 x 3.6 and despite the wound increasing in size, the facility did not contact the wound care consultant. Furthermore, a 12/11/2012 Nursing Progress Note documented "dressing to coccyx area with no improvement." The nurses continued to document that there was no improvement to the wound as noted on 12/14/2012 at 8:34 AM, "dressing to coccyx area with no improvement noted"; 12/15/2012 at 3:12 AM, "dressing to coccyx area with no improvement noted. Wound care nurse, DON (director of nursing), nurse manager have been made aware of this." On 12/15/2012 at 8:27 AM, the nurse noted a new area was "found on right mid back, raised red ecchymotic area. Tender to touch, origin unknown." Review of the Treatment Administration Record (TAR) for November and December discloses the initial physician prescription for the left buttock excoriated area was noted as " Cleanse area with normal saline or wound cleanser. Apply skin barrier wipe to periwound area. Apply [MEDICATION NAME]/Alginate or [MEDICATION NAME]/Alginate Bordered dressing. Change every 3 days and as needed for 14 days then reevaluate " . The nurses placed their initials in the appropriate boxes indicating the wound dressing was completed as ordered every three days on nights except on 11/27/2012. On 11/27/2012 at 5:16 PM a new order was instituted to Cleanse coccyx with Normal Saline solution, pat dry, apply CDD (Clean Dry Dressing) daily, one time a day for wound healing. There are no nurses' initials in the appropriate boxes to indicate the dressing was completed on 11/27/2012, 11/28/2012 and 1/3/2013. Furthermore on 12/4/2012, the physician prescribed an order to " Cleanse area with normal saline or wound cleanser, apply skin barrier, wipe to periwound area, apply [MEDICATION NAME]/Alginate or [MEDICATION NAME] alginate Bordered Dressing. Change every 3 days and as needed for 14 days. " Review of the TAR discloses the nurses placed their initials each day that the wound care was performed daily not every 3 days as prescribed from 12/4/2012 to 12/17/2012. Review of the physician order [REDACTED]. However there is no indication the wound care consultant was contacted or provided consult for this 11/7/2012 physician order. An interview was conducted on 3/4/2013 at 2:25 PM with the Director of Nursing, who stated the resident had a managed care insurance source at the time and the wound care consultant the facility utilizes does not accept this insurance source. The facility's plan is the wound care nurse saw the resident weekly, measured the wound and follow the established wound care protocol. The facility would also contact the insurance to obtain prior authorization. Someone from the insurance would be sent out or the insurance would allow the consultant to treat the resident. Any services provided to the resident, the facility would need approval by the insurance. The surveyor requested evidence the facility had contacted the insurance for approval of wound care consult. The facility failed to produce evidence to confirm. A later interview was conducted at 4:00 PM with the MDS (Minimum Data Set) Coordinator and Managed Care Insurance Case Manager who then stated this is untrue. She stated when the patient has managed care insurance and the patient has wounds, the consultant physician is contacted. She further stated she was unaware that the patient had an order for [REDACTED]. The resident changed insurance sources on 12/10/2012 and the wound care consultant saw the resident after this date. On 3/5/2013 in the afternoon a telephone interview was conducted with the DON who stated she now had no explanation to why the resident did not have the wound care consultant involvement for the 11/7/2012 physician order [REDACTED]. Interview with the Wound Care Nurses (WCN) on 3/6/2013 at 2:48 PM reveals the nurse assessed and performed the wound care weekly. WCN # 1 assessed the resident's wound from 10/28/2012 to 11/6/2012. When he assessed the wound it was a Stage II 1 x 2 - he was involved for about 2 weeks. He stated initially the wound was very small and they were performing the [MEDICATION NAME] dressing every 3 days. He stated the initial consult to the Wound Care Consultant was 11/7/2012, but he feels it was for leg wounds. However, the consultant was not involved. WCN #1 is a foreign physician [MEDICATION NAME] as a Registered Nurse. He stated he has had one year of experience in wound care. He was removed from wound care secondary to inaccuracy with measurements of the wounds per the DON. WCN # 2 began providing wound care on 11/6/2012. The nurse is a new graduate who became licensed March 2012. His experience in wound care was during his nursing rotation in nursing school. It was further disclosed that prior to the involvement of the wound care consultant on 12/18/2012, the wound was assessed by the Wound Care Nurse. The WCN #2 and the DON confirmed they are to follow the wound care protocol and they normally consult the wound care consultant when the wound advances to Stage III unless the physician prescribes for the consult. They also stated they were uncertain that the Primary Physician assessed the wound prior to the consultant assessing the wound. Further inquiry of Wound Care Nurse # 2 regarding the change in the wound care dressing on 11/27/2012 to the clean dry dressing revealed him to state that "we were just trying something different to see if something else would work." "We tried everything, then we called the wound care consultant." Additionally the surveyor questioned the nurse because the facility has an established wound care protocol for wound care for Stage I and Stage II wounds. The clean dry dressing is not a part of the established wound care protocol. A 12/18/2012 physician order [REDACTED]. One time only for Wounds for 1 day. On 12/18/2012 the Wound Care Consultant assessed the resident and documented the following to include: 1. "Sacrum wound which was present on admission is now measuring 8.5 x 5 x 0.3 estimate. Wound currently with excessive Black, sero-sanguinous drainage, mild drainage, mild [DIAGNOSES REDACTED], unstageable, necrotic tissue of muscle. The wound was debrided and the physician prescribed for the resident to receive Santyl & [MEDICATION NAME] AG daily; dietary consult for protein supplementation, Vitamin C and Zinc supplementation to promote healing. Have also educated patient and ordered time restriction in wheelchair to no more than 2 hour intervals. Plan to return in one week for re-evaluation." 2. Right Back Mid Lateral, in-house pressure ulcer measuring 8 x 6 x 0.1, 100% Dermis tissue, no granulation or necrotic tissue, serous drainage mild, no odor unstageable, removal of thick adherent necrotic tissue of partial thick, no debridement prescribed for the resident to receive Foam dressing every other day. Additional note - wound to right back mid lateral: Patient noted to have developed a blister of the right lateral back over bony prominences of scoliosis." After obtaining consent, Sharp debridement of necrotic tissue performed to promote healing. Please note, there is no documentation of the resident having skin issues on the right mid lateral back until 12/15/2012. Review of the January TAR revealed the nurses failed to place their initials in the appropriate boxes to indicate the dressing was completed for multiple days in January. Review of the Nursing progress notes failed to provide evidence of an explanation of why the dressing was not completed. The following days failed to document the resident's dressing was completed for the Back and Sacral Wounds " Cleanse with [MEDICATION NAME], insert TAS (GCP) moistened gauze into wounds, cover with dry dressing twice daily and as needed for excessive drainage every 12 hours beginning 1/8/2013 " : 1/11/2013 9 AM; 1/14/2013 and 1/15/2013 9 PM; 1/24/2013 9 PM and 1/31/2013 9 PM. Furthermore, the nurses documented the wound was emitting an odor beginning 12/20/2012 but the facility did not obtain a specimen to culture the odoriferous drainage until 1/10/2013. The nurses documented on 12/20/2012, Wound Care Nurse #2 documented that the "dressing change, foul odor, scant amount of serous drainage; 1/4/2013 "wound care, large amount of purulent drainage with mal odor noted on sacrum and upper back; 1/9/2013 Medical Doctor (MD) and wound care MD was contacted and informed about resident's condition. (See F314 for additional information.)

Based on record review and staff interview, the facility failed to ensure that a pressure ulcer did not worsen, and failed to ensure a resident did not develop a new pressure ulcer for 1 of 3 sampled residents (Resident # 1) who were admitted to the facility with pressure ulcers, of 7 residents identified by the facility as having pressure ulcers. The facility also failed to contact the wound care consultant in a timely manner to ensure the resident received quality wound care prior to the wound progressing and development of a new unstageable wound; failed to ensure the resident's wounds were accurately assessed by qualified wound care staff; failed to follow the established protocol for wound care; and failed to provide the appropriate antibiotic treatment sensitive to the cultured bacteria for the development of the wound infection. The findings include: Review of the clinical record for Resident # 1 discloses that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Prior to hospitalization , the resident lived alone and was self care. The admitting Physician Referral (3008) from the hospital did not disclose a pressure ulcer but identified the resident's skin condition as skin dry/fragile, and an incision to the right hip. The initial Nursing Assessment on 10/28/2012 identified that the resident had an excoriation on her left buttock, Stage II, no measurement listed. The Braden Pressure Ulcer Assessment on 10/28/2012 documented a score of 14, Moderate risk. Admission Summary 10/28/2013 identified that the resident had left buttock excoriation 2-3 cm and local redness noted. The admission orders [REDACTED]. Apply skin barrier wipe to periwound area. Apply [MEDICATION NAME]/Alginate Border dressing change every 3 days and as needed for 14 days then re-evaluate 11-7 shift every 3rd day. The Wound Care Nurse # 1 assessed the wound on 10/30/2012 and identified the wound as Stage II, measuring 1 cm x 1.9 cm, clear, scant drainage, color of wound bed red, no odor, tissue granulated no tunneling. On 11/6/2012, the wound measurement remained unchanged. Initially, the wound care nurse documentation discloses the wound decreased in size each week (11/13- 1.0 x 1.2; 11/20/2012 - 1.0 x 1.0; 11/27/2012-.5 x .4). On 11/27/2012, the wound care orders changed to Cleanse area with Normal Saline Solution apply a clean dry dressing. The resident's wound then began to increase in size as follows on 12/4/2012 the wound increased in size to - 2.4 x 1.0. The wound care dressing was again changed to [MEDICATION NAME]/Alginate on 12/4/2012. On 12/11/2012 the wound measured 4.4 x 3.6 and despite the wound increasing in size, the facility did not contact the wound care consultant. Furthermore, a 12/11/2012 Nursing Progress Note documented "dressing to coccyx area with no improvement." The nurses continued to document that there was no improvement to the wound as noted on 12/14/2012 at 8:34 AM, "dressing to coccyx area with no improvement noted"; 12/15/2012 at 3:12 AM, "dressing to coccyx area with no improvement noted. Wound care nurse, DON (director of nursing), nurse manager have been made aware of this." Additionally, on 12/15/2012 at 8:27 AM, the nurse noted a new area was "found on right mid back, raised red ecchymotic area. Tender to touch,origin unknown." Review of the Treatment Administration Record (TAR) for November and December discloses the physician prescription for the left buttock excoriated area: Cleanse area with normal saline or wound cleanser. Apply skin barrier wipe to periwound area. Apply [MEDICATION NAME]/Alginate or [MEDICATION NAME]/Alginate Bordered dressing. Change every 3 days and as needed for 14 days then reevaluate. The nurses placed their initials in the appropriate boxes indicating the wound dressing was completed as ordered every three days on nights except on 11/27/2012. On 11/27/2012 at 5:16 PM a new order was instituted to Cleanse coccyx with Normal Saline solution, pat dry, apply CDD (Clean Dry Dressing) daily, one time a day for wound healing. There are no nurses' initials in the appropriate boxes to indicate the dressing was completed on 11/27/2012, 11/28/2012 and 1/3/2013. Furthermore on 12/4/2012 the physician prescribed an order to Cleanse area with normal saline or wound cleanser. Apply skin Barrier, wipe to periwound area. Apply [MEDICATION NAME]/Alginate or [MEDICATION NAME] alginate Bordered Dressing. Change every 3 days and as needed for 14 days. Review of the TAR discloses the nurses placed their initials each day that the wound care was performed daily not every 3 days as prescribed from 12/4/2012 to 12/17/2012. Review of the physician order [REDACTED]. However there is no indication the wound care consultant was contacted or provided consult for this 11/7/2012 physician order. An interview was conducted on 3/4/2013 at 2:25 PM with the Director of Nursing, who stated the resident had a managed care insurance source at the time and the wound care consultant the facility utilizes does not accept this insurance source. The facility's plan is the wound care nurse saw the resident weekly, measured the wound and follow the established wound care protocol. The facility would also contact the insurance to obtain prior authorization. Someone from the insurance would be sent out or the insurance would allow the consultant to treat the resident. Any services provided to the resident, the facility would need approval by the insurance. The surveyor requested evidence the facility had contacted the insurance for approval of wound care consult. The facility failed to produce evidence to confirm. A later interview was conducted at 4:00 PM with the MDS(Minimum Data Set) Coordinator and Managed Care Insurance Case Manager who then stated this is untrue. She stated when the patient has managed care insurance and the patient has wounds, the consultant physician is contacted. She further stated she was unaware that the patient had an order for [REDACTED]. The resident changed insurance sources on 12/1/2012 and the wound care consultant saw the resident after this date. On 3/5/2013 in the afternoon a telephone interview was conducted with the DON who stated she now had no explanation to why the resident did not have the wound care consultant involvement for the 11/7/2012 physician order [REDACTED]. An interview was conducted on 3/6/2013 at 4:15 PM with the resident's Primary Physician until 12/1/2012. The physician was questioned regarding her assessment of the wound because review of her progress notes did not disclose documentation regarding the wound. The physician stated when she assessed the resident's wound, the sacrum area was an excoriation, Stage I. She stated the facility has an established wound care protocol for Stage I and Stage II pressure ulcers and the wound care nurses are to utilize the established protocol. However she will consult the wound care consultant when the wound becomes Stage III or at any stage when the wound is not improving. The surveyor questioned the physician regarding the 11/7/2012 physician order [REDACTED]. The resident also had wounds on her legs however, the podiatrist treated those skin issues. The wound care consultant was not contacted at this time. Interview with the Wound Care Nurses (WCN) on 3/6/2013 at 2:48 PM reveals the nurse assessed and performed the wound care weekly. WCN # 1 assessed the resident's wound from 10/28/2012 to 11/6/2012. When he assessed the wound it was a Stage II 1 x 2 - he was involved for about 2 weeks. He stated initially the wound was very small and they were performing the [MEDICATION NAME] dressing every 3 days. He stated the initial consult to the Wound Care Consultant was 11/7/2012 but he feels it was for leg wounds. However, the consultant were not involved. WCN #1 is a foreign physician [MEDICATION NAME] as a Registered Nurse. He stated he has had one year of experience in wound care. He was removed from wound care secondary to inaccuracy with measurements of the wounds per the DON. WCN # 2 began providing wound care on 11/6/2012. The nurse is a new graduate who became licensed March 2012. His experience in wound care was during his nursing rotation in nursing school. It was further disclosed that prior to the involvement of the wound care consultant on 12/18/2012, the wound was assessed by the Wound Care Nurse. They confirmed they are to follow the wound care protocol and they normally consult the wound care consultant when the wound advances to Stage III unless the physician prescribes for the consult. They also stated they were uncertain that the Primary Physician assessed the wound prior to the consultant assessing the wound. Further inquiry of Wound Care Nurse # 2 regarding the change in the wound care dressing on 11/27/2012 to the clean dry dressing he stated that "we were just trying something different to see if something else would work." "We tried everything, then we called the wound care consultant." Additionally the surveyor questioned the nurse because the facility has an established wound care protocol for wound care for Stage I and Stage II wounds. The clean dry dressing is not apart of the established wound care protocol. A 12/18/2012 physician order [REDACTED]. One time only for Wounds for 1 day. On 12/18/2012 the Wound Care Consultant assessed the resident and documented the following to include: 1. "Sacrum wound which was present on admission is now measuring 8.5 x 5 x 0.3 estimate. Wound currently with excessive Black, sero-sanguinous drainage, mild drainage, mild [DIAGNOSES REDACTED], unstageable, necrotic tissue of muscle. The wound was debrided and the physician prescribed for the resident to receive Santyl & [MEDICATION NAME] AG daily; dietary consult for protein supplementation, Vitamin C and Zinc supplementation to promote healing. Have also educated patient and ordered time restriction in wheelchair to no more than 2 hour intervals. Plan to return in one week for re-evaluation." 2. Right Back Mid Lateral, in-house pressure ulcer measuring 8 x 6 x 0.1, 100% Dermis tissue, no granulation or necrotic tissue, serous drainage mild, no odor unstageable, removal of thick adherent necrotic tissue of partial thick, no debridement prescribed for the resident to receive Foam dressing every other day. Additional note - wound to right back mid lateral: Patient noted to have developed a blister of the right lateral back over bony prominences of scoliosis." After obtaining consent, Sharp debridement of necrotic tissue performed to promote healing. Please note, there is no documentation of the resident having skin issues on the right mid lateral back until 12/15/2012. The Wound Care Physician continues to follow the resident and evaluated the resident on 1/2/2013. The physician documented that both wounds were deteriorating as follows: 1. Sacrum, the wound measures 6.4 x 6 x 2, no dermis or granulation tissue, excessive necrotic tissue that was Black/Yellow in color, sero-Purulent, moderate drainage with a mild odor. Wound now a Stage IV. The wound was again debrided by the physician and prescribed for the resident to receive wound dressing of Santyl/TAS (Triple Antibiotic Solution). 2. Right Back Mid pressure ulcer is measuring 6.5 x 5 x 0.4, no dermis tissue, unhealthy/inadequate granulation Tissue, excessive necrotic tissue which was black in color, mild serous drainage, Stage III. The wound was debrided and the physician changed the order to Santyl. Note: The "wounds have increased in size since last visit. Substantially wider, sharp debridement performed to remove necrotic tissue. The physician changed the treatment." On 1/8/2013, the wound continues to deteriorate since last visit with an increase in volume, necrotic tissue. Sharp debridement was performed to promote healing. Dressing changed to TAS for both wounds twice daily. (Sacrum- 8.5 x 10 x 2; excessive, Black Necrotic tissue with Sero-Purulent Moderate drainage with a moderate odor, necrotic tissue involves muscle, Stage IV; Right Back Mid Lateral measures 8.5 x 9 x 0.4, excessive black necrotic tissue with mild serous drainage, with mild odor, necrotic tissue involve muscle, Stage IV). The Wound Consultant continues to evaluate the resident's wounds each week and the wounds continue to deteriorate, regarding the size, development of excessive Black/Yellow necrotic tissue with Moderate to mild serous drainage. Wounds remain Stage IV. On 1/15/2013, the WCC documented the resident is receiving [MEDICATION NAME] for wound infection for 2 weeks. The WCC continues weekly visits until 1/29/2013 when the wounds measure - sacrum -8.3 x 9.3 x 3 with undermining of 9.3 x 10.5, wound tissue remain unchanged as above; Right Back Mid Lateral measuring 10 x 9.5 x 0.5, no undermining, tissue description remains the same. Resident is now on Hospice and has developed new pressure areas on the Right Hip and Left heel. Review of the January TAR revealed the nurses failed to place their initials in the appropriate boxes to indicate the dressing was completed for multiple days in January. Review of the Nursing progress notes failed to provide evidence of an explanation of why the dressing was not completed. The following days failed to document the resident's dressing was completed for the Back and Sacral Wounds; Cleanse with [MEDICATION NAME], insert TAS (GCP) moistened gauze into wounds, cover with dry dressing twice daily and as needed for excessive drainage every 12 hours beginning 1/8/2013: 1/11/2013 9 AM; 1/14/2013 and 1/15/2013 9 PM; 1/24/2013 9 PM and 1/31/2013 9 PM. Furthermore, the nurses documented the wound was emitting an odor beginning 12/20/2012 but the facility did not obtain a specimen to culture the odoriferous drainage until 1/10/2013. The nurses documented on 12/20/2012, Wound Care Nurse #2 documented that the "dressing change, foul odor, scant amount of serous drainage; 1/4/2013 "wound care, large amount of purulent drainage with mal odor noted on sacrum and upper back; 1/9/2013 Medical Doctor (MD) and wound care MD was contacted and informed about resident's condition. MD and Wound care MD agree to order insert Foley catheter, urinalysis culture and sensitivity, sacral and back wounds culture and sensitivity for aerobics and anaerobic"; 1/11/2013 "wound care treatment, moderate amount of purulent drainage with mal odor." Wound Culture was completed on 1/10/2013 of the sacral and back wounds culturing Pseudomonas aeruginosa, moderate growth for the sacrum and heavy growth for the back wounds. The physician prescribed on 1/14/2013 for the resident to receive [MEDICATION NAME] 1 gm intravenously every 24 hours for 2 weeks. The resident received one dose of the [MEDICATION NAME] on 1/15/2013. There were no further intravenous antibiotics orders to treat the resident's wound infection. It should be noted, in reviewing the physician orders, there was no separate order discontinuing the antibiotic. The discontinuation was noted on the computerized physician order [REDACTED]. No further information was provided. An interview was conducted on 3/7/2013 at approximately 4:30 PM with the Director of Nursing, who reports that the [MEDICATION NAME] was discontinued on a computer order on 1/15/2013 secondary to the resident's increased creatinine level. It was further reported that the resident received by mouth Bactrim and [MEDICATION NAME]. However according to the laboratory results, the bacteria was resistive to these antibiotics (Bactrim and [MEDICATION NAME]). The resident did not receive antibiotic sensitive to the bacteria culture. Review of the physician order [REDACTED]. This was ordered before the wound culture. An interview was conducted on 3/11/2013 in the morning with the wound care physician who reports they became involved with the resident on 12/18/2012. She denied involvement with the resident prior to this date and was not aware of an earlier referral. She reports that they visit the facility weekly but if the facility has issues with a wound, she will either come in or provide treatment orders, if contacted. Because they cover several facilities, she may or may not come in on the same day she is contacted but someone could evaluate the resident quickly. If she or her colleagues are unable to come in, she will give the facility orders to treat the wound until she is able to evaluate the wound. She stated when she documented that the resident was on the [MEDICATION NAME], she read the orders. She stated she was not responsible for the antibiotic orders and though she documented that the resident was on the [MEDICATION NAME] for two weeks. She based this on the resident's current orders. She stated they were treating the wound topically with the wound dressing of Triple Antibiotic Solution (TAS) and would not offer explanation beyond this.