Every finding on record at Ridgecrest Health and Rehabilitation

Based on observations, interviews, and record reviews it was determined that the facility failed to not administer medications that were pulled by another nurse for 1 (Resident #3) of 3 (Resident # 1, Resident #3, and Resident #4) sampled resident. The findings are: The quarterly Minimum data Set (MDS), dated [DATE], revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 09, which indicated the resident had moderate cognitive impairment. Review of Resident #3's Care Plan revised on 05/09/2023, revealed the resident received pain medication. Interventions included administering analgesic medications as ordered by physician. On 10/29/24 at 11:10 AM Licensed Practical Nurse (LPN) 1 was observed pulling medications for Resident #3. On 10/29/24 at 11:19 AM, LPN #1 had medications in a medication cup on top of the medication cart. The Medicare Manager walked up to the medication cart and asked LPN #1 who the medications in the cup belonged to. LPN #1 informed the Medicare Manager that the medications were for Resident #3. The Medicare Nurse picked up the cup of medications and a cup of water and walked over to Resident #3 and administered Resident #3 the medications. On 10/29/24 at 11:20 AM, the Medicare Manager indicated that she knew the correct medications were in the cup for Resident #3 because LPN #1 informed her that they were correct. On 10/29/24 at 11:54 AM, Resident #3 indicated that he thinks he just got his evening meds, but he didn't know. A review of a narcotic log for pain medication indicated a Norco 5/325mg (milligram) was signed out for Resident #3 at 11:20 AM by LPN #1. A review of Resident #3's Medication audit report dated 10/29/2024 indicated that Resident #3 received his 8:00 AM medications at 11:14 AM, and 11:19 AM. On 10/29/24 at 1:26 PM, LPN #1 indicated that other staff occasionally help with passing medications. She indicated that it's important for the residents to receive the right medication. She indicated that the nurse that's pulling the medications should be the one giving the medication to ensure the resident receives the correct medications. On 10/29/24 at 2:13 PM, the Director of Nurse (DON) indicated the 8:00 AM medications should be given between 7:00 AM and 9:00 AM. She indicated that the nurse that pulls the medications should be the nurse that administers the medication to the resident. A policy titled Administering Oral Medication indicated that the purpose of the procedure for medication guidelines is for the safe administration of oral medications.

Based on observations, interviews, and record reviews, it was determined the facility failed to administer medications within the recommended time frame for 1 (Resident #3) of 3 (Resident # 1, Resident #3, and Resident #4) sampled residents. The findings are: The quarterly Minimum data Set (MDS), dated [DATE], revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 09, which indicated the resident had moderate cognitive impairment. Review of Resident #3's Care Plan revised on 05/09/2023, revealed the resident received pain medication. Interventions included administering analgesic medications as ordered by physicians. On 10/29/24 at 9:27 AM Licensed Practical Nurse (LPN) #1 indicated she was passing morning medications late because she's had 17,000 things happen. She indicated the medications should have been passed by 9:00 AM. On 10/29/24 at 11:10 AM, LPN #1 was observed pulling medications for Resident #3. On 10/29/24 at 11:19 AM, LPN #1 had medications in a medication cup on top of the medication cart. The Medicare Manager walked up to the medication cart and asked LPN #1 who the medications in the cup belonged to. LPN #1 informed the Medicare Manager the medications were for Resident #3. The Medicare Nurse picked up the cup of medications and a cup of water and walked over to Resident #3 and administered Resident #3 the medications. On 10/29/24 at 1:26 PM, LPN #1 indicated that other staff occasionally help with passing medications. She indicated that it's important for the residents to receive the right medication. She indicated that the nurse that's pulling the medication should be the one giving the medication to ensure the resident receives the correct medications. A review of Resident #3's Medication Audit Report dated 10/29/2024 indicated Resident #3 received his 8:00 AM medications at 11:14 AM and 11:19 AM. On 10/29/24 at 2:13 PM, the Director of Nurse (DON) indicated that the 8:00 AM medications should be given between 7:00 AM and 9:00 AM. She indicated the nurse that pulls the medications should be the nurse that administers the medication to the resident. A policy titled Administering Oral Medication indicated that the purpose of the procedure for medication guidelines is for the safe administration of oral medications.

Based on observation, interview, and facility policy review, the facility failed to ensure dietary staff practiced good hand washing to prevent potential cross contamination for the residents who received meal trays from 1 of 1 kitchen. These failed practices had the potential to affect 103 residents who received meals from the kitchen (Total Census: 105), as documented on a list provided by the Dietary Manager on 7/31/2024. The findings are: 1. On 07/30/24 at 3:15 PM, Dietary aide (DA) #5 picked up tray cards and packets of condiments and placed them in the trays, contaminating her hands. Without washing her hands, she picked up clean glasses by their rims and placed them on the trays to be used in serving lunch beverages to the residents. At 4:28 PM, the surveyor asked DA #5 what he should you have done after touching dirty. objects and before handling clean equipment. He stated, Washed my hands. 2. On 07/30/24 at 3:44 PM, DA #5 turned on the hand washing sink faucet and washed her hands. After washing her hands, she pulled out tissue papers and dried her hands. After drying her hands, she turned off the sink faucet with the same tissue, contaminating her hands. She then picked up clean glasses by their rims and placed them on the trays to be used in serving lunch beverages to the residents. 3. On 07/30/24 at 3:46 PM, DA #6 turned on the hand washing sink faucet and washed her hands. After washing she dried her hands with tissue paper, then used the same tissue to turn off the faucet, which contaminated her hands. Afterward, she lifted the trash can lid and threw the tissue away. Without washing her hands, she picked up clean plates, and placed them in the plate warmer to be used in portioning food items to be served to the residents for lunch with her fingers inside the plates. The Surveyor asked DA #6 what she should have done after touching dirty objects and before handling clean equipment. She stated, I should have washed my hands. 4. On 07/30/24 at 4:12 PM, DA#6 walked into the kitchen from the dining room. Without washing her hands, she walked straight to the clean side of the dish washing machine and picked up a bowl with her fingers inside the bowl and placed it on the tray, then picked up a plate with her fingers inside the plate and placed it on the plate warmer to be used in portioning food items to be served to the residents for lunch. The Surveyor immediately asked DA #2 what she should have done after touching dirty objects and before handling clean equipment. She stated, I should have washed my hands. 6. On 07/30/24 at 5:24 PM DC #5, opened the freezer and took out a tub that contained cartons of ice cream and placed it on the counter. She pushed the food preparation counter that had trays with glasses of beverages towards the steam table. placed it on the counter pushed a cart that contained two trays with glasses of ice towards the counter attached to the steam table, contaminating her hands. She picked up cartons of milk, cartons of supplements, and cartons of ice cream and placed them on the trays. Without washing her hands, she picked up glasses from the trays by the rims and placed them on the trays to be served to the residents for lunch. 7. On 07/31/24 at 7:34 AM Dietary [NAME] (DC) #7 pushed a plate warmer towards the steam table. Without washing her hands, she picked up clean plates from the plate warmer and placed them on the steam table bar to be used in portioning food items to be served to the residents for lunch with his fingers inside the plates. At 8:19 AM, the Surveyor asked DC #7 What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands. 8. A facility policy titled preventing foodborne illness- employee hygiene and sanitary practices under employees must wash their hands, whenever entering or re-entering the kitchen. Before coming in contact with any food surfaces. During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks and or after engaging in other activities that contaminate the hands.

50923 Based on observation, interviews, and record review, it was determined that the facility failed to ensure dignity was maintained while performing Activities of Daily Living (ADL) care for 2 (Resident # 22 and # 66) of two residents receiving personal care. Specifically, the facility failed to ensure curtains were pulled to provide privacy, and that soiled items were not passed over a resident's face during incontinence care. Finding included: 1. Review of a facility policy titled Dignity, dated February 2021, indicated, Residents are to be treated with dignity and respect at all times .Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures .Demeaning practices and standards of care that compromise dignity are [is] prohibited. Review of an Admission Record indicated Resident # 22 was admitted on [DATE] with a diagnosis of acute and chronic respiratory failure and chronic obstructive pulmonary disease with exacerbation. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/10/2023 revealed Resident # 22 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated Resident #22 was moderately cognitively impaired. On 07/29/2024 at 9:00 AM observed Certified Nursing Assistants #3 and #4 performing incontinent care on Resident #22 without pulling the privacy curtain. During the care, CNA #3 placed soiled linen into a bag and passed it across the resident's face and handed it to bag to CNA#4. On 07/29/24 at 9:50 AM, Certified Nursing Assistant (CNA) #3 was asked if the bag of soiled items should have been passed across Resident #22's face and if the privacy curtain should have been pulled completely. He stated the curtain should have been pulled and the bag of soiled items should not have been passed across the resident's face. On 7/29/24 at 9:50 AM, CNA #4 was asked if the bag of soiled items should have been passed across the Resident #22's face and if the privacy curtain should have been pulled completely. She stated the curtain should have been pulled and the bag of soiled items should not have been passed across the resident's face. On 7/29/2024 Resident #22 was interviewed and asked if it bothered him when the soiled bag was passed across his face and when the curtain was not pulled. Resident #22 replied that he was not a baby, and they should not embarrass him. Review of Resident #22's Care Plan showed, The resident has an ADL self-care performance deficit related to impaired mobility, morbid obesity, dementia. Date Initiated: 12/22/2021 The care plan included interventions TOILET USE: The resident requires assistance by 2 staff for toileting with Revision date of 7/25/2024. 2. A review of an Admission Record for Resident #66 indicated he was admitted on [DATE] with diagnosis of cerebral infarction and dysphagia following nonromantic subarachnoid hemorrhage. The annual MDS with an ARD of 8/17/23 revealed Resident #66 had a BIMS score of 6 which indicated Resident #66 was severely cognitively impaired. On 7/29/2024 at 7:10 AM, CNA #1 and CNA #2 entered the room of Resident #66 and provided incontinent care and did not pull the curtain to provide privacy between residents. On 7/29/2024 at 7:30 AM, CNA #1 was interviewed and asked should the privacy curtain have been pulled to provide privacy. CNA #1 stated it should be pulled, but they didn't pull it. On 7/29/2024 at 7:30 AM, CNA #2 was interviewed and asked should the privacy curtain have been pulled to provide privacy. CNA #12 stated it should be pulled, but that they didn't pull it. During an interview on 7/30/2024 at 11:00 AM, the Director of Nursing (DON) was asked if the bag of soiled items containing feces should have been passed across Resident #22's face and if the privacy curtain should have been pulled completely. She stated the curtain should have been pulled and that the bag of soiled items should not have been passed across the resident's face. The DON was asked if the privacy curtain should have been pulled while the CNAs were providing incontinent care for Resident #66. She stated that it should have been.

50923 Based on observation, record review and interview, it was determined that the facility failed to complete an accurate Minimum Data Set (MDS) for two (Resident #36 and #103) sample mix residents. The findings are: 1. On 08/01/24 at 3:35 PM, MDS Nurse #20 was asked to confirm if Resident #36 was receiving an antipsychotic. MDS Nurse #20 reviewed the record and identified an order for Olanzapine, and confirmed this medication was an antipsychotic. When asked to review the latest MDS, MDS Coordinator #20 reported that they probably overlooked the medication or simply miscoded the document. When asked if an antipsychotic should be coded on the MDS, MDS Nurse #20 affirmed that the medication should have been identified. 2. Review of Resident #103's Admission Record, dated 05/23/2024, revealed a diagnosis of sleep apnea. a. On 07/29/24 at 10:29 AM, the Surveyor observed a Continuous Positive Airway Pressure (CPAP) mask at Resident #103's bedside with CPAP mask sitting on bedside table not in a bag. Resident #103 stated, I have sleep apnea. b. Review of Resident #103's Order Summary Report active as of 07/29/24 did not document CPAP usage. c. On 08/01/24 at 8:26 AM, the Surveyor observed Resident 103's CPAP mask at the bedside not in a storage bag. No storage bag was present. d. Review of Resident #103's Care Plan did not reveal a CPAP was in use. e. Review of resident #103's the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/30/2024 revealed Section O0110. Special Treatments, Procedures, and Programs documented the resident does not use a CPAP. f. On 08/01/24 at 3:45 PM, the Assistant Director of Nursing (ADON) #16 confirmed Resident #103's CPAP mask was not bagged, and confirmed CPAP usage should be on the MDS because, It's a treatment. Any respiratory therapy should be and it's an intervention. g. On 08/01/24 at 3:51 PM, the Director of Nursing (DON) confirmed Resident #103's CPAP usage should be on their MDS because it's part of their plan of care. h. On 08/02/24 at 2:31 PM, MDS Nurse #20 confirmed a resident using a CPAP machine should be on the MDS to make sure it's being put on the resident, staff awareness, and care of the resident.

Based on observation, record review, and interview the facility failed to ensure that base line care planning completed with interventions upon admission for pressure ulcers, enhanced barrier precautions, and Peripherally Inserted Central Catheter (PICC) lines for 4 residents out of the sample residents (Resident #363, #366, #367, and #371). A review of the Order Summary reveals that Resident #363 had diagnosis of malnutrition, and pressure ulcer at an unspecified site and an unspecified stage. A review of the Order Summary reveals that Resident #363 had an order for Treatment to unstageable pressure injury to coccyx: cleanse with wound cleanser or sterile water. Apply thin layer of [named brand of burn gel] cover with calcium alginate. Cover with 6 X 6 border foam daily and PRN until resolved. Every day shift for wound treatment may substitute as necessary. Reassess in 14 days. Start Date 7/23/2024 A review of the Order Summary reveals that Resident #363 had an order entered for Enhanced Barrier Precautions related to wound care on 07/29/2024 at 01:26 PM. A review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 07/20/2024 reveals that Resident #363 scored a 13 (cognitively intact) on the Brief Interview for Mental Status. A review of the Care Plan reveals that Resident #363 Focus: Resident requires Enhanced Barrier Precautions related to Wounds added on 07/29/2024 by MDS Nurse #19. On 07/29/2024 at 6:32 AM, Surveyor observed staff leaving Resident #363's room with bags. Surveyor observed no enhanced barrier precautions signage posted on the door, and that no personal protective equipment was set up nearby. On 07/30/2024 at 10:00 AM, Surveyor observed enhanced barrier precautions were set up with enhanced barrier precautions signage on the door frame and a small plastic bin for supplies next to the door. On 08/01/2024 at 11:15 AM, during an interview the MDS Nurse #19 stated that they input the orders while working on the care plans to add enhanced barrier precautions, for Resident #363 it was put in on 07/29/2024 at 1:27 PM. The resident was admitted on [DATE]. A review of the Order Summary revealed Resident #366 had diagnoses of paralytic syndrome affecting right side with a stroke, anxiety disorder and major depressive disorder. A review of the Order Summary revealed Resident #366 had an order for Treatment to moisture associated skin damage (MASD) to coccyx: cleanse with wound cleanser or sterile water. Apply coloplast. Cover with 4 X 4 on Monday, Wednesday, Friday, and PRN (as needed) until resolved. Start Date 07/24/2024. A review of the Order Summary revealed Resident#366 had an order entered for Enhanced Barrier Precautions related to wound care on 07/29/2024 at 1:06 PM. A review of the Care Plan revealed Resident #366 does not have pressure ulcers implemented in the baseline care plan. A review of the Care Plan revealed Resident #366 Focus: Resident requires enhanced barrier precautions related to wounds put in on 07/29/2024 MDS Nurse #19. On 07/29/2024 at 6:35 AM, Surveyor observed staff entering Resident #366's room to get Resident #366 ready for breakfast. There was no enhanced barrier precaution signage posted on the door, and no personal protective equipment was set up nearby. On 07/30/2024 at 10:00 AM, Surveyor observed that enhanced barrier precautions had been set up with enhanced barrier precaution signage on the door and a small bin for supplies set up next to the door. On 08/01/2024 at 11:15 AM, during an interview MDS Nurse #19 stated they updated the care plan while inputting the orders for enhanced barrier precautions, for Resident #366 this occurred on 07/29/2024 at 1:06 PM. MDS Nurse #19 confirmed that Resident #366 was admitted to the facility with pressure ulcers. MDS Nurse #19 stated that resident was admitted to the facility on [DATE]. A review of the Order Summary reveals Resident #367 had diagnoses of type 2 diabetes mellitus, and traumatic partial amputation of right foot. A review of the Order Summary reveals Resident #367 had an order for Enhanced Barrier Precautions related to wounds on 07/29/2024 at 1:36 PM. A review of the Order Summary reveals Resident #367 had an order for Wound care orders: present on admission right mid foot amputation site: wound vac change Monday, Wednesday, Friday and PRN (as needed). Continuous high suction at 125 MMHG with foam. Clean wound bed with wound cleanser prior to wound vac placement. If wound vac leaks or malfunctions, attempt to fix with (named dressing) or tape. If unsuccessful, remove all pieces of foam and pack with saline, damp to dry dressing. Contact APRN. A review of the Care Plan reveals Resident #367 Focus: Resident requires enhanced barrier precautions related to wounds put in on 07/29/2024 by MDS Nurse #19. On 07/29/2024 at 7:35 AM, Surveyor observed a wound vac sitting on a table on the left side of the bed. Surveyor observed no enhanced barrier signage was posted on the door and no personal protective equipment was set up nearby. On 07/30/2024 at 10:00 AM, Surveyor observed enhanced barrier precautions had been set up with enhanced barrier precaution signage on the door and a small bin for supplies set up next to the door. On 08/01/2024 at 11:15 AM, during an interview the MDS Nurse #19 stated they updated the care plan while inputting the orders for enhanced barrier precautions, for Resident #367 this happened on 07/29/2024 at 1:36 PM. The resident was admitted on [DATE]. A review of the Order Summary reveals that Resident #371 had diagnoses of endocarditis, and type 2 diabetes mellitus. A review of the Order Summary reveals that Resident #371 had an order for Cefazolin Sodium Intravenous Solution Reconstituted 2 GM Use 2 gram intravenously every 8 hours for endocarditis until 07/31/2024 at 11:59 PM. Start date 06/28/2024 A review of the Order Summary reveals Resident #371 had an order for Treatment to stage 2 to coccyx: cleanse with wound cleanser or sterile water, pat dry with 4 X 4 gauze. Apply thin layer of hydrocolloid to wound bed. Cover with 4 X 4 border foam on Monday, Wednesday, Friday, and PRN (as needed) until resolved. Start Date 06/28/2024 A review of the Order Summary shows an order for Enhanced Barrier Precautions related to PICC line entered on 07/31/2024 at 8:32 AM. No Enhanced Barrier Precaution Orders for Wound Care. A review of the Care Plan reveals Resident #371 did not have their pressure ulcers or PICC line in care plan. A review of the Care Plan reveals Resident #371 Focus: Resident requires enhanced barrier precautions related to PICC line. On 07/31/2024 at 1:40 PM, Surveyor observed enhanced barrier precautions had been set up with enhanced barrier precaution signage on the door and a small bin for supplies set up next to the door. On 08/01/2024 at 11:15 AM, during an interview the MDS Nurse #19 they updated the care plan while inputting the orders for enhanced barrier precautions for Resident #371 this occurred on 07/31/2024 at 8:32 AM, MDS Nurse #19 stated Resident #371 was admitted on [DATE]. MDS Nurse #19 confirmed that they were not aware that Resident #371 had wounds and did not set up enhanced barrier precautions for it. MDS Nurse #19 stated It is very important to care plan accurately, and it is hard to care plan when you don't know. I have been on the floor a lot the last several weeks and we are trying to keep up. What do you do when you want the residents taken care of on the floor and at the same time you are behind on care plans and MDS. Both of us MDS Nurses are working six days a week up to 120 hours in a two-week period. A lot of systems are broken, our previous treatment nurses stepped down without notice. The two new treatment nurses started yesterday, and they are working on a baseline for the wounds in the building. We have hired 16 people to try and start filling the gaps. On 08/01/2024 at 11:50 AM, during an interview the Director of Nursing stated it is important to accurately code MDS and care plans to give the best care for the residents. Enhanced barrier precautions are important to protect the resident and the staff from any outside infections. On 8/02/24 at 2:31 PM, during an interview the MDS Nurse #20 confirmed pressure ulcers should be on the care plan. To let the staff know what's going on, so we can do proper assessments, preventative care to prevent worsening and so treatment orders can be put in and noted on the care plan are ongoing. MDS Nurse #20 confirmed a PICC line should be on the care plan. MDS Nurse #20 stated it should be For infection control so we can have proper barrier in place such as EBP. If getting antibiotics through the PICC line, we put on the care plan what we're treating so we know were working with. A review of the facility policy Care Plans, Comprehensive Person-Centered states A comprehensive person-centered care plan that include measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident.

50682 Based on observation, record review, and interview, the facility failed to ensure residents who required assistance with activities of daily living were regularly provided with the necessary assistance to maintain good hygiene and grooming, as evidenced by failure to ensure fingernails were kept clean and trimmed for one out of one sampled resident. (Resident #71); to ensure proper Activities of Daily Living (ADLs) was provided for 1 (Resident #22) of 1 sampled resident who were dependent on staff for ADLs. The findings are: 1. A review of the Order Summary revealed that Resident #71 had diagnoses of Type II diabetes mellitus, kidney failure, and a need for assistance with personal care. A review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/13/2024 reveals that Resident #71 had a Brief Interview for Mental Status (BIMS) score of 03 (severe cognitive impairment). A review of section GG reveals that Resident #71 is coded as independent for eating, substantial/maximal assistance toileting hygiene, shower/bathe self, lower body dressing, and partial/moderate assistance upper body dressing, and personal hygiene. A review of the Care Plan for Resident #71 revealed, Focus: The resident has an ADL self-care performance deficit r/t decreased mobility, generalized weakness, cognitive communication deficit; Interventions/Tasks: Bathing/Showering: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. On 07/29/2024 at 8:12 AM Resident #71 lifted their hands and stated they would like their nails trimmed and cleaned. The surveyor observed that the nails were long, jagged, and had a dark gritty substance underneath them. On 07/29/2024 at 1:00 PM, Surveyor observed nails have not been trimmed or cleaned. On 07/30/2024 at 1:00 PM, Surveyor observed nails have not been trimmed or cleaned. On 07/31/2024 at 1:10 PM, Licensed Practical Nurse #14 (LPN) stated Resident #71's nails were about 2 centimeter long, and it is easier for stuff to collect underneath, such as food. LPN #14 confirmed they do need trimmed and cleaned, stated that they are diabetic. LPN #14 stated the resident could ingest bacteria and pathogens. On 07/31/2024 at 1:27 PM, Certified Nursing Assistant #13 (CNA) stated the residents' nails are usually long, and they try to keep them clean. CNA #13 stated they should be cleaned on bath days and as needed, and confirmed nails need trimming and cleaning. CNA #13 stated they must report it to the nurse to trim nails as they are diabetic. CNA #13 stated there is gunk stuck underneath the nails and if they scratch themselves, it could cause infections or sores. On 08/01/2024 at 11:55 AM, the Director of Nursing (DON) stated nail care should be performed when it is needed, and that nail care is important, so they do not harm themselves with long fingernails. A review of the facility policy Activities of Daily Living (ADLS), Supporting states Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal hygiene, and oral hygiene; 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming and oral care). 2. A review of an Admission Record indicated Resident # 22 was admitted on [DATE] with a diagnosis of Acute and Chronic Respiratory Failure and Chronic Obstructive Pulmonary Disease with exacerbation and Type 2 Diabetes Mellitus with foot ulcer. The annual Minimum Data Set (MDS) with an assessment Reference Date (ARD) of 11/10/2023 revealed Resident # 22 had a Brief Interview for Mental Status (BIMS) score of 11 which indicated Resident #22 was moderately impaired. Review of Resident #22's Care Plan, initiated 12/22/2021, revealed that resident had an ADL self-care performance deficit related to impaired mobility, morbid obesity, dementia, and was dependent on staff for ADL care. On 7/30/24 at 10:30 AM, Resident #22 was observed during personal care being provided by Certified Nursing Assistant (CNA)#3. CNA#3 was asked if she provided foot/toenail care for Resident #22, and she stated she did not because Resident #22 was a diabetic. CNA #3 was asked to describe Resident #22's toenails. CNA #3 described the toenails as long and dirty. On 7/30/2024 at 10:40 AM, Assistant Director of Nursing (ADON) #16 was interviewed and asked to observe and describe Resident #22's toenails. ADON #16 described the toenails as dirty, thick, long and yellow. ADON #16 was asked who should provide nail care for Resident #22 and she said a nurse would because resident was a diabetic. On 7/30/2024 at 2:30 PM, the Director of Nursing (DON) was asked who should provide nail care for a diabetic resident. She said a nurse should.

Based on record review, and interview, the facility failed to set up wound assessment upon admission to ensure healing and improvement of wounds for 4 out of the sample residents (Resident #363, #366, #367, and #371); failed to follow physician orders for a scheduled wound care treatment for 1 (Resident #367) of 1 resident reviewed for wound care treatment. The findings are: 1. A review of a facility policy titled, Negative Pressure Wound Therapy, dated February, indicated, Clean wound according to facility protocol, or as ordered. A review of the Admission Record, indicated the facility admitted Resident #367 with diagnoses that included partial traumatic amputation of right foot. A review of Order Summary Report, revealed Resident #367 had an order for wound vac change every Monday, Wednesday, and Friday and as needed. Continuous high suction at 125 millimeters of mercury with foam. During an observation on 07/31/2024 at 1:41 PM, Surveyor observed Licensed Practical Nurse (LPN) #14 prepare a cup of 4 x 4 gauze and wet it with Dankins Solution half strength. LPN # 14 placed with other wound care supplies in the resident's room. During an observation on 07/31/2024 at 1:48 PM, the previous dressing was removed by LPN #14. LPN #14 used moistened gauze to pat the wound bed. Then, placed a clean moistened gauze sponge over the wound before redressing the wound with the pre-packaged wound care supplies. During an interview on 08/01/2024 at 5:50 PM, LPN #14 stated she used Dankins Half Strength Solution to clean the wound. Also, confirmed she did not have an order for any solution to clean it with. During an interview on 08/01/2024 at 6:27 PM, Assistant Director of Nursing (ADON) #16 stated there was no order for a cleaning agent with the dressing change. ADON #16 confirmed that Dankins Half Strength Solution should not have been used during the wound care. During an interview on 08/02/2024 at 11:47 AM, the Director of Nursing (DON) stated there was not an order for a cleaning agent with the wound care order, then reached out to the facility Advance Practice Registered Nurse (APRN) who clarified the order should be for wound cleanser to be used on the wound bed. The DON confirmed that Dankins Half Strength Solution should not have been used on the wound bed. 2. A review of the Order Summary revealed Resident #363 had diagnosis of malnutrition, and pressure ulcer at an unspecified site and an unspecified stage. A review of the Order Summary revealed Resident #363 had an order for Treatment to unstageable pressure injury to coccyx: cleanse with wound cleanser or sterile water. Apply thin layer of [named brand cover with calcium alginate. Cover with 6 X 6 border foam daily and PRN (when required) until resolved. Every day shift for wound treatment may substitute as necessary. Reassess in 14 days. Start Date 7/23/2024 A review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 07/20/2024 revealed that Resident #363 scored a 13 (cognitively intact) on the Brief Interview for Mental Status. A review of the Care Plan revealed Resident #363 Focus: The resident has Stage unstageable PU to coccyx, on admission. A review of the Assessments revealed no wound and skin evaluations completed. 4. A review of the Order Summary revealed Resident #366 had diagnoses of paralytic syndrome affecting right side with a stroke, anxiety disorder and major depressive disorder. A review of the Order Summary revealed Resident #366 had an order' for Treatment to moisture associated skin damage (MASD) to coccyx: cleanse with wound cleanser or sterile water. Apply coloplast. Cover with 4 X 4 mepilex on Monday, Wednesday, Friday, and PRN (as needed) until resolved. Start Date 07/24/2024. A review of the Assessments revealed no wound and skin evaluations completed. 5. A review of the Order Summary reveals that Resident #367 had diagnoses of type 2 diabetes mellitus, and traumatic partial amputation of right foot. A review of the Order Summary reveals that Resident #367 had an order for Wound care orders: present on admission right mid foot amputation site: wound vac change Monday, Wednesday, Friday and PRN (as needed). Continuous high suction at 125 MMHG with foam. Clean wound bed with wound cleanser prior to wound vac placement. If wound vac leaks or malfunctions, attempt to fix with Tegaderm or tape. If unsuccessful, remove all pieces of foam and pack with saline, damp to dry dressing. Contact APRN. A review of the Care Plan reveals that Resident #367 Focus: The resident has (specify) pressure ulcer (specify location) or potential for pressure ulcer development. A review of the Assessments revealed no wound and skin evaluations completed. 6. A review of the Order Summary reveals that Resident #371 had diagnoses of endocarditis, and type 2 diabetes mellitus. A review of the Order Summary reveals that Resident #371 had an order for Treatment to stage 2 to coccyx: cleanse with wound cleanser or sterile water, pat dry with 4 X 4 gauze. Apply thin layer of hydrocolloid to wound bed. Cover with 4 X 4 border foam on Monday, Wednesday, Friday, and PRN (as needed) until resolved. Start Date 06/28/2024 A review of the Assessments revealed two incomplete Skin and Wound Evaluations on 07/10/2024. No other skin and wound evaluations have been conducted. On 08/01/2024 at 11:15 AM, during an interview MDS Coordinator #19 stated the importance of the wound assessment is To make sure the wound is not getting worse, and it is healing. MDS Coordinator #19 stated when discussing Resident #367's wound assessments that it is To assess what is need and this resident has a new amputation, measurements, prevent worsening, and ensure healing. Confirmed that wound assessments have not been completed for Resident #363, Resident #366, and Resident #367. Confirmed that a wound assessment has been started on 07/10/2024 for Resident #371 and no others have been done since admission. MDS Coordinator #19 stated Usually the treatment nurses would set up wound and evaluation assessments, set up wound care orders, and set up interventions for pressure ulcers in the baseline care plan .two new treatment nurses were training, as the previous treatment nurses quit without notification MDS Coordinator stated the admission assessments for Resident #367 are five days overdue, they were locked on 07/29/2024 and most of them are social assessments. On 08/01/2024 at 11:44 AM, during an interview the Quality-of-Life Specialist stated they are currently training a new social services employee, they had been working on getting caught up on discharges this week. We were planning on starting training for the admission assessments today, and we have three social service employees usually at a time. At this moment we only have one social service employee in training, with no other staff. Confirmed the admission assessment for Resident #367 were overdue and not done in a timely manner. On 08/01/2024 at 11:50 AM During an interview the Director of Nursing (DON) on wound assessments stated, Assess wounds to determine stage, plan of action, how we need to treat and how to do wound care. A review of the facility policy Wound Care states that Documentation: The following information should be put into the resident's medical record; 6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound.

49689 Based on observation, record review, interview and facility document review, it is determined that the facility failed to ensure that nursing staff had the competencies and skills to provide care and respond to individualized needs as identified in baseline care plan, comprehensive care plan and care plan revision, setting up enhance barrier precautions for wound care, Percutaneous Endoscopic Gastrostomy (PEG) tubes, Peripherally Inserted Central Catheter (PICC) lines, contact isolation, wound care assessments, Continuous Positive Airway Pressure (CPAP) and medication administration specifically the facility: 1. Failed to ensure that base line care plan, comprehensive care plan, and revision of care plan was completed with interventions upon admission for pressure ulcers, enhanced barrier precautions, CPAP, Elopement, and PICC line for 7 residents out the sampled residents (Resident #363, #366, #367, #371, #103, #462) 2. Failed to ensure enhanced barrier precautions were utilized upon admission for 4 residents out of the sampled residents (Resident #363, #366, #367, #371) and failed to ensure enhanced barrier precautions were utilized during care for two sampled resident (R#28 and 371) 3. Failed to ensure wound assessment were set up to ensure healing and improvement of wounds, and ensure admission assessments were completed in a timely manner for 4 residents out of the sampled residents (Resident #363, #366, #367, #371) 4. Failed to ensure that medications were ordered timely to ensure residents had physician ordered medications at scheduled times for 2 (Resident #31, #28) of 2 sample mix residents. 5. Failed to ensure that residents on contact isolation did not have a roommate and that staff wore appropriate PPE when entering the room for 1 (Resident #31) of 1 sampled residents. The Findings are: 1. Resident #31's Admission Record dated 4/3/2024 noted a diagnosis of Asthma, Chronic Obstructive Pulmonary Disease (COPD), Emphysema, Wheezing, and Chronic Cough. a. Resident #31's physician orders dated 4/23/2024 documented, Advair HFA Inhalation Aerosol 115-21 mcg/ ACT (Fluticasone-Salmeterol) 2 puff inhale orally two times a day related to Chronic Obstructive Pulmonary Disease. Wait 1 minute between puffs. Rinse and spit after administration. Montelukast Sodium oral tablet 10 mg (Montelukast Sodium) give 10 mg by mouth one time a day for COPD/ Asthma. b. On 7/30/2024 at 08:39 AM, during observation of medication administration for 600 hallway with Registered Nurse (RN) #25, resident #31 did not receive Advair HFA Inhalation Aerosol, and Montelukast Sodium. c. On 7/31/24 8:55 AM, the Surveyor interviewed Registered Nurse (RN) #25 and asked, Should all medications for Resident #31 be available when due? She stated, Yes, yes they should. I did reorder them just now. d. Review of the Medication Administration Record (MAR) documented the resident did not receive Advair HFA Inhalation Aerosol 115-21 mcg/ ACT (Fluticasone-Salmeterol) 2 puff inhale orally two times a day related to Chronic Obstructive Pulmonary Disease. Montelukast Sodium oral tablet 10 mg (Montelukast Sodium) give 10 mg by mouth one time a day for COPD/ Asthma. 2. Resident #28's Admission Record dated 2/11/2020 noted a diagnosis of Dry Eye Syndrome of Bilateral Lacrimal Glands, Blepharitis Eye and Eyelid, and Disorder of Eye and Adnexa, dysphagia, and gastrostomy status. a. Resident #28's physician orders dated 3/2/2022 documented, Refresh Lacri-Lube Ointment (White Petrolatum-Mineral Oil) Instill 1 ribbon in right eye two times a day for lagophthalmos; Enteral feed order every shift Enteral Water Flush; with 60 (cubic centimeter) cc water before and after meds and feedings. Enteral feed order four times a day 300 milliliters (mL) enteral water flush four times a day (QID). a. Review of the MAR documented the resident did not receive Refresh Lacri-Lube Ointment (White Petrolatum-Mineral Oil) Instill 1 ribbon in right eye two times a day for lagophthalmos. b. On 7/31/2024 at 8:53 AM, the Assistant Director of Nursing (ADON) #16 stated, It was last ordered in March. Resident #28 uses a different pharmacy so I can't reorder it on the computer I have to call. b. On 07/31/24 at 8:53 AM, during observation of medication administration for 500 hallway with ADON #16, Resident #28 did not receive Refresh Lacri-Lube Ointment (White Petrolatum-Mineral Oil) Instill 1 ribbon in right eye two times a day for lagophthalmos. Resident #28 received a total of 330 milliliters (mL) water flush. Resident 28 received 40 mL water flush prior to medication administration through PEG tube, then 30 mL after elder tonic administered, then 60 mL after medication administration, then nutritional supplement 250 mL administered followed by 60 mL flush, then 140 mL flush. Total flush given was 330 milk Physician order documented 60 mL prior to medication administration, 60 mL after medication administration and 300 mL of enteral water flush. Resident received a total of 210 free water flush. c. On 7/31/24 at 9:19 AM, the Surveyor interviewed ADON #16 and asked, Should all medications for the resident be available when due? She stated, Yes, of course they should be. I'll have to look later it's obstructing my time limit. d. On 08/01/24 at 1:34 PM, the DON was asked, Should Resident #28 have been provided 120 mL water flush with medications and 300 free water flush with medication pass on 07/31/2024 at 08:53 AM? She stated, Yes, ma'am. When asked, Why should resident #28 have been given 120 mL water flush with medications and 300 free water flush with medication on pass on 07/31/2024 at 08:53 AM? She stated, Because it's a physician order and its scheduled. e. Facility provided a policy titled, Enteral Tube Feeding via Syringe (Bolus) with a revision date of November 2018 documented, Preparation: 1. Verify that there is a physician's order for this procedure. 2. Review the resident's care plan and provide any special needs of the resident. 3. Assemble equipment and supplies needed. 3. Review of Resident #103's Admission Record dated 05/23/2024 revealed a diagnosis of sleep apnea. a. On 07/29/24 at 10:29 AM, the Surveyor observed a Continuous Positive Airway Pressure (CPAP) mask at Resident #103's bedside with CPSP mask sitting on bedside table not in a bag. Resident stated, I have sleep apnea. b. Review of Resident #103's Order Summary Report, active as of 07/29/2024, did not document CPAP usage. c. On 08/01/24 at 8:26 AM, the Surveyor observed residents CPAP mask at the bedside not in a storage bag. No storage bag is present. d. Review of Resident #103's Care plan does not document CPAP usage. e. Review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/30/2024 revealed Section O0110.Special Treatments, Procedures, and Programs documented the resident does not use a CPAP. f. On 08/01/24 at 3:45 PM, the Surveyor interviewed the Assistant Director of Nursing at Resident #103's bedside and asked, Does Resident #103 have a CPAP sitting on her bedside table? She stated, Yes, and it's not in a bag. When asked, Should there be a physician's order for the CPAP? She stated, Yes absolutely. When asked, Should it be on the care plan? She stated, Yes. When asked, Why should it be on the care plan? She stated, It's a treatment. Any respiratory therapy should be and it's an intervention. g. On 08/01/24 at 3:51 PM, the Surveyor interview the Director of Nursing (DON) and asked, Should Resident #103 have a physician's order for CPAP usage? She stated, Yes, yes you have to have settings for those you have to have a physicians order for those. When asked, Should it be on the care plan? She stated, Yes. When asked, Why should it be on the care plan? She stated, Because it's part of their plan of care. h. On 08/02/24 at 2:31 PM, the Surveyor interviewed Minimum Data Set (MDS) Coordinator and asked, If a resident uses a CPAP machine should it be on the care plan? She stated, Yes. When asked, Why should it be on the care plan? She stated, To make sure it's being put on the resident, staff awareness, and care of the resident. i. The facility provided a policy titled, 'Care Plans, Comprehensive Person-Centered' with a revision date of December 2016 that documented, Policy Statement A comprehensive person- centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 4. Review of Resident #462's Admission Record dated 04/29/2024 revealed a diagnosis of Alzheimer's disease, and Dementia, Severity, with Agitation. a. Review of Nursing (NSG) Progress Notes dated 05/09/2024 at 9:08 AM documented, 08/01/24 Incident Description: Called to 700 Hall per staff of facility regarding resident exiting out of building. Resident exited out of building by pushing handle for 15 secs and then access was given to leave out of door. No injuries or bruising noted on resident. No distress noted. Immediate Intervention: Resident assisted back into facility per staff. Redirected and oriented to facility and room. b. Review of resident #462's care plan did not document attempted elopement on 05/09/2024. c. Review of Nursing Progress note dated 5/10/2024 at 11:08 AM revealed, Nsg-I&A (Incident and Accident) Follow Up Late Entry: Date and I&A Description: Called to 700 Hall per staff of facility regarding resident exiting out of building. Resident exited out of building by pushing handle for 15 seconds and then access was given to leave out of door. No injuries or bruising noted on resident. No distress noted. Long Term Intervention: extra CNA placed in 700 pod Added to the Care Plan: yes. d. Review of facility NSG (Nursing) Elopement Risk with Care plan V-1 dated 05/14/2024 revealed the resident is high risk to wander, has a history of wandering, and has a wandered in the past month. e. On 08/01/24 at 2:58 PM, the Surveyor interviewed LPN #26 and asked, Can you tell me what happened when Resident #462 eloped from the facility? She stated, I came into the pod by my office by 701 and I seen someone standing outside on the other end on the sidewalk area. She was past the poles. I dropped my stuff and ran. I tried to coax her in, and she started swing on me she missed. I moved her away from the edge because she would've fallen. The Med tech was nowhere to be found. I finally got med tech to come after I already had Resident #462 half way in. f. On 08/01/24 at 3:21 PM, the Surveyor interviewed Licensed Nursing Home Assistant Administrator and asked, Can you tell me what happened on 5/9/2024 when Resident #462 eloped from the facility? She stated, On the 9th I know when I got here I was notified we had some elopements that we would keep eyes on them, so it didn't happen again. We made sure people were watching them, placed stop signs on the exit doors to help redirect we in-serviced and re-did elopement assessments and did elopement binders on residents at risk and how to handle it. g. On 08/02/24 at 2:31 PM, the Surveyor interviewed the Minimum Data Set (MDS) Coordinator and asked, When a resident elopes from the facility should their care plan be revised to reflect the elopement and interventions? She stated, Yes. When asked, Why should the care plan be revised to reflect the elopement? She stated, To protect the resident from potentially exiting form the facility and make everyone aware of the risks. 5. Review of Resident #31's Admission Record dated 4/3/2024 noted diagnoses of asthma, chronic obstructive pulmonary disease (COPD), emphysema, wheezing, and chronic cough. a. Review of Resident #31's Care Plan dated 12/09/2023 that documented, The resident has a HX (history) of recurring Urinary Tract Infections. Contact Isolation Precautions. b. Review of Resident #31's Order Summary Report dated 07/29/2024 does not document an order for contact precautions. c. On 07/29/24 at 8:54 AM, the Surveyor observed resident #31 have contact precaution signs on door along with sign that states see nurse before entering. Resident #88 is the roommate in the room. d. On 07/29/24 at 8:57 AM, the Surveyor interviewed Registered Nurse (RN) #24 outside of resident #31 and #88's room and asked, Can you tell me which resident is on contact isolation and what they are on contact isolation for? He stated, I believe it has something due to residents urine, I'm new here and didn't know the system. e. On 07/29/24 at 9:00 AM, the Surveyor observed staff entering Resident #31 & #88's room with contact precautions signs on door with no gown, gloves or mask. f. On 07/29/24 at 9:01 AM, the Surveyor interviewed Certified Nurse Aide (CNA) and asked, What should you have on when entering a contact precautions room? She stated, Gown, mask, and gloves. When asked, Did you have those on? She stated, No. When asked, Can you tell me why? She stated, I see the stuff on the door, and it has been there for weeks, and I wasn't notified it was a possible threat or anything. When asked, If signs are on the door for contact precautions should they be followed? She stated, Yes. When asked, Why should they be follow? She stated, For infection. g. On 07/29/24 at 9:07 AM, RN #24 came to Surveyor and stated, I'm not sure what it is, but I messaged my boss to find out. h. On 07/29/24 at 9:16 AM, the Surveyor interviewed RN #24 and asked, If a resident is on contact precautions should they have a roommate? He stated, Not usually, no. When asked, Why should they not have a roommate? He stated, Spread of infection. i. On 07/30/24 at 9:06 AM Surveyor observed staff entering resident #31's room with no PPE on. Surveyor interviewed Certified Nurse Aide (CNA #12) and asked, Should you were appropriate PPE when entering a contact isolation room? She stated, Yes, ma'am when providing direct patient care. When asked, Why should you have on PPE when entering a contact isolation room? She stated, To protect yourself and the resident. j. On 07/30/24 at 9:08 AM, the Surveyor observed LPN #26 in Resident #31's room doing a zoom call with no PPE on. The Surveyor interviewed Admissions Director and asked, Should you were appropriate PPE when entering a contact isolation room? She stated Ya, that why I just told you I was coming to get my stuff I didn't realize she was one it. When asked, Why should you have on PPE? She stated, Cause [Resident #31] is on isolation [Resident #31] has ESBL I believe. k. On 08/02/24 at 2:28 PM, the Surveyor was informed by the Director of Nursing (DON) that resident #88 has been removed from the room with resident #31. l. On 07/30/2024 at 2:23 PM, the Surveyor observed Licensed Practical Nurse (LPN) #27 during medication pass with resident #371 and LPN #27 did not sanitize her hands or put on a gown in an enhanced barrier room. LPN #27 put on gloves, opened IV tubing, and spiked antibiotic bag. LPN #27 placed tubing in IV pump and primed the line. LPN #27 removed green cap from the PICC port, scrubbed port with alcohol pad, then connected 0.9% normal saline flush to port and flushed line with 10 mL of normal saline. LPN #27 removed normal saline flush from port and connected IV to port. LPN #27 removed gloves and set pump at 96 milliliters (mL)/ hour (hr.) and 48 mL/ hr. m. Surveyor interviewed LPN #27 outside of resident #371's room and asked, Should you wear a gown in an Enhanced Barrier Precaution room when you administer medication through the PICC line? She stated, Yes. When asked, Can you tell me why you should wear a gown? She stated, In case of contact. When asked, Should you sanitize your hands prior to donning gloves to administer medication through a PICC line? She stated, Yes. When asked, Why should you sanitize your hands prior to donning gloves and administering medication through a PICC line? She stated, Because its infection control. n. On 07/31/24 at 8:53 AM, the Surveyor observed the Assistant Director of Nursing (ADON) #16 during medication pass with Resident #28 who has a (Percutaneous )PEG tube, and the ADON #16 did not sanitize her hands or put on a gown while administering medications and tube feeding to Resident #28. o. On 07/31/24 at 9:42 AM, the Surveyor interviewed the ADON #16 outside of Resident #28's room and asked, Should you sanitize your hands prior to initially donning gloves for the PEG tube medication administration? She stated, Yes. When asked, Why should you sanitize your hands prior to donning gloves? She stated, Infection control. When asked, Should you have worn a gown to do the PEG tube feeding? She stated, I don't believe that is correct, but I guess so. I honestly did not know that. When asked, Why should you wear a gown in an enhanced barrier precautions room while administering medications and water flush to Resident #28? She stated, Because to protect him and I both due to the site. p. On 07/31/24 at 10:19 AM, the Surveyor observed the Transport Aid with her hand over her nose and mouth with no mask on during facility Coronavirus-19 (COVID-19) outbreak by the central shower room near the 200 hallway nurses' station. Surveyor interviewed the Transport Aid and asked, Should you have a mask on over your nose and mouth? She stated, Yes. When asked, Why should you have a mask on? She stated, Because were in outbreak. q. Facility provided door signs that were present on Resident #31's door that documented, Please see nurse before entering; Contact Precautions (in addition to standard precautions) with a copy right date of 2007 that documented, Stop: Visitors: Report to nurse before entering. Gloves: Don gloves upon entry into the room or cubical. Wear gloves whenever touching the patient's skin or surfaces and articles in close proximity to the patient. Remove gloves before leaving patient room; Hand Hygiene according to standard precautions; Gowns don gown upon entry into the room or cubicle. Remove gown and observe hand hygiene before leaving the patient-care environment. Facility also provided door signs for Sequence for putting on Personal Protective Equipment (PPE) and How to safely remove personal protective equipment (PPE) Example 1. 6. A review of the Order Summary revealed that Resident #363 had diagnosis of malnutrition, and pressure ulcer at an unspecified site and an unspecified stage. A review of the Order Summary revealed that Resident #363 had an order for Treatment to unstageable pressure injury to coccyx: cleanse with wound cleanser or sterile water. Apply thin layer of [named brand of burn gel] cover with calcium alginate. Cover with 6 X 6 border foam daily and PRN until resolved. Every day shift for wound treatment may substitute as necessary. Reassess in 14 days. Start Date 7/23/2024 A review of the Order Summary reveals that Resident #363 had an order entered for Enhanced Barrier Precautions related to wound care on 07/29/2024 at 01:26 PM. A review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 07/20/2024 reveals that Resident #363 scored a 13 (cognitively intact) on the Brief Interview for Mental Status. A review of the Care Plan revealed that Resident #363 Focus: Resident requires Enhanced Barrier Precautions related to Wounds added on 07/29/2024 by MDS Coordinator #19. A review of the Assessments revealed no wound and skin evaluations completed. On 07/29/2024 at 6:32 AM Surveyor observed staff leaving Resident #363's room with bags. Surveyor observed that no enhanced barrier precautions signage posted on the door, and that no personal protective equipment was set up nearby. On 07/30/2024 at 10:00 AM, the Surveyor observed that enhanced barrier precautions were set up with enhanced barrier precautions signage on the door frame and a small plastic bin for supplies next to the door. On 08/01/2024 at 11:15 AM, the MDS Coordinator #19 stated that they input the orders while working on the care plans to add enhanced barrier precautions, for Resident #363 it was inputted on 07/29/2024 at 1:27 PM. The resident was admitted on [DATE]. 7. A review of the Order Summary reveals that Resident #366 had diagnoses of paralytic syndrome affecting right side with a stroke, anxiety disorder and major depressive disorder. A review of the Order Summary reveals that Resident #366 had an order for Treatment to moisture associated skin damage (MASD) to coccyx: cleanse with wound cleanser or sterile water. Apply coloplast. Cover with 4 X 4 on Monday, Wednesday, Friday, and PRN (as needed) until resolved. Start Date 07/24/2024. A review of the Order Summary reveals that Resident #366 had an order entered for Enhanced Barrier Precautions related to wound care on 07/29/2024 at 1:06 PM. A review of the Care Plan reveals that Resident #366 does not have pressure ulcers implemented in the baseline care plan. A review of the Care Plan reveals that Resident #366 Focus: Resident requires enhanced barrier precautions related to wounds inputted on 07/29/2024 MDS Coordinator #19. A review of the Assessments revealed no wound and skin evaluations completed. On 07/29/2024 at 6:35 AM Surveyor observed staff entering Resident #366's room to get them up and ready for breakfast. There was no enhanced barrier precaution signage posted on the door, and no personal protective equipment was set up nearby. On 07/30/2024 at 10:00 AM Surveyor observed that enhanced barrier precautions had been set up with enhanced barrier precaution signage on the door and a small bin for supplies set up next to the door. On 08/01/2024 at 11:15 AM During an interview the MDS Coordinator #19 stated that they updated the care plan while inputting the orders for enhanced barrier precautions, for Resident #366 this occurred on 07/29/2024 at 1:06 PM. MDS Coordinator #19 confirmed that Resident #366 was admitted to the facility with pressure ulcers. MDS Coordinator #19 stated that resident was admitted to the facility on [DATE]. A review of the Order Summary reveals that Resident #367 had diagnoses of type 2 diabetes mellitus, and traumatic partial amputation of right foot. A review of the Order Summary reveals that Resident #367 had an order for Enhanced Barrier Precautions related to wounds on 07/29/2024 at 1:36 PM. A review of the Order Summary reveals that Resident #367 had an order for Wound care orders: present on admission right mid foot amputation site: wound vac change Monday, Wednesday, Friday and PRN (as needed). Continuous high suction at 125 MMHG with foam. Clean wound bed with wound cleanser prior to wound vac placement. If wound vac leaks or malfunctions, attempt to fix with Tegaderm or tape. If unsuccessful, remove all pieces of foam and pack with saline, damp to dry dressing. Contact APRN. A review of the Care Plan reveals that Resident #367 Focus: Resident requires enhanced barrier precautions related to wounds inputted on 07/29/2024 by MDS Coordinator #19. A review of the Assessments revealed no wound and skin evaluations completed. On 07/29/2024 at 7:35 AM Surveyor observed a wound vac sitting on a table on the left side of the bed. Surveyor observed that no enhanced barrier signage was posted on the door and no personal protective equipment was set up nearby. On 07/30/2024 at 10:00 AM Surveyor observed that enhanced barrier precautions had been set up with enhanced barrier precaution signage on the door and a small bin for supplies set up next to the door. On 08/01/2024 at 11:15 AM During an interview the MDS Coordinator #19 stated that that they updated the care plan while inputting the orders for enhanced barrier precautions, for Resident #367 this happened on 07/29/2024 at 1:36 PM. The resident was admitted on [DATE]. A review of the Order Summary reveals that Resident #371 had diagnoses of endocarditis, and type 2 diabetes mellitus. A review of the Order Summary reveals that Resident #371 had an order for Cefazolin Sodium Intravenous Solution Reconstituted 2 GM Use 2 gram intravenously every 8 hours for endocarditis until 07/31/2024 at 11:59 PM. Start date 06/28/2024 A review of the Order Summary reveals that Resident #371 had an order for Treatment to stage 2 to coccyx: cleanse with wound cleanser or sterile water, pat dry with 4 X 4 gauze. Apply thin layer of hydrocolloid to wound bed. Cover with 4 X 4 mepilex border foam on Monday, Wednesday, Friday, and PRN (as needed) until resolved. Start Date 06/28/2024 A review of the Order Summary shows an order for Enhanced Barrier Precautions related to PICC line entered on 07/31/2024 at 8:32 AM. No Enhanced Barrier Precaution Orders for Wound Care. A review of the Care Plan reveals that Resident #371 did not have their pressure uclers or PICC line in care plan. A review of the Care Plan reveals that Resident #371 Focus: Resident requires enhanced barrier precautions related to PICC line. A review of the Assessments revealed two incomplete Skin and Wound Evaluations on 07/10/2024. No other skin and wound evaluations have been conducted. On 07/31/2024 at 01:40 PM Surveyor observed that enhanced barrier precautions had been set up with enhanced barrier precaution signage on the door and a small bin for supplies set up next to the door. On 07/31/2024 at 2:15 PM Surveyor observed LPN #14 return to the room, to disconnect the intravenous antibiotic from the PICC line. LPN #14 did not don personal protective equipment, performed hand hygiene and donned gloves. LPN #14 then disconnected the line and hung it up on the intravenous pole and flushed the PICC line. During an interview LPN #14 stated they were not aware that enhanced barrier precautions were used for central lines, we just recently had an in-service about this. I feel like we need more education as I still do not understand enhanced barrier precautions. LPN #14 confirmed that they did not use personal protective equipment when hanging or disconnecting the intravenous medication. LPN #14 stated that a PICC line is invasive, and it goes into the artery, the enhanced barrier precautions would help prevent infection, especially since they have a diagnosis of endocarditis. On 08/01/2024 at 11:15 AM During an interview the MDS Coordinator #19 that that they updated the care plan while inputting the orders for enhanced barrier precautions for Resident #371 this occurred on 07/31/2024 at 08:32 AM. MDS Coordinator #19 stated that Resident #371 was admitted on [DATE]. MDS Coordinator # 19 confirmed that they were not aware that Resident #371 had wounds and did not set up enhanced barrier precautions for it. MDS Coordinator #19 stated It is very important to care plan accurately, and it is hard to care plan when you don't know. I have been on the floor a lot the last several weeks and we are trying to keep up. What do you do when you want the residents taken care of on the floor and at the same time you are behind on care plans and MDS. Both of us MDS Coordinators are working six days a week up to 120 hours in a two week period. A lot of systems are broken, our previous treatment nurses stepped down without notice. The MDS Coordinator #19 stated that the importance of the wound assessment is to make sure the wound is not getting worse and it is healing. MDS Coordinator #19 stated when discussing Resident #367's wound assessments that it is To assess what is need and this resident has a new amputation, measurements, prevent worsening, and ensure healing. Confirmed that wound assessments have not been completed for Resident #363, Resident #366, and Resident #367. Confirmed that a wound assessment has been started on 07/10/2024 for Resident #371 and no others have been done since admission. The two new treatment nurses started yesterday, and they are working on a baseline for the wounds in the building. We have hired 16 people to try and start filling the gaps. The MDS Coordinator #19 stated that usually the treatment nurses would set up wound and evaluation assessments, set up wound care orders, and set up interventions for pressure ulcers in the baseline care plan. Then stated that they were two new treatment nurses in training, as the previous treatment nurses quit without notification. MDS Coordinator stated that the admission assessments for Resident #367 are five days overdue, they were locked on 07/29/2024 and most of them are social assessments. On 08/01/2024 at 11:44 AM During an interview with the Quality of Life Specialist stated they are currently training a new social services employee, they had been working on getting caught up on discharges this week. We were planning on starting training for the admission assessments today, and we have three social service employees usually at a time. At this moment we only have one social service employee in training, with no other staff. Confirmed that the admission assessment for Resident #367 was overdue and not done in a timely manner. On 08/01/2024 at 11:50 AM During an interview the Director of Nursing stated it is important to accurately code MDS and care plans to give the best care for the residents. The DON stated that they have just start this new job, and they have not been in long term care before. On 08/01/2024 at 9:25 AM Human Resources stated that they do not have a training checklist or any new hire training. Stated You may find some competencies in the older files, but currently I am newer to this job and have not seen any newer competencies. Stated that they do not do performance reviews for nurses, but they do in-services to ensure staff is competent. On 8/02/24 at 2:31 PM During an interview the MDS Coordinator #20 confirmed pressure ulcers should be on the care plan. To let the staff know what's going on, so we can do proper assessments, preventative care to prevent worsening and so treatment orders can be put in and noted on the care plan are ongoing. MDS Coordinator #20 confirmed a PICC line should be on the care plan. MDS Coordinator #20 stated it should be For infection control so we can have proper barrier in place such as EBP. If getting antibiotics through the PICC line we put on the care plan what we're treating so we know were working with. A review of the facility policy Care Plans, Comprehensive Person-Centered states A comprehensive person-centered care plan that include measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. A review of the facility policy Wound Care states that Documentation: The following information should be put into the resident's medical record; 6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. An Enhanced Barrier Precautions Inservices was performed in March 2024. An Infection Control Inservices was performed on February 15th, 2024. A review of the Enhanced Barrier Precautions states 2. Enhanced barrier Precautions (EBPs) employ targeted gown and gloves use during high contact resident care activities when contact precautions do not otherwise apply. 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding [TRUNCATED]

Based on observation, record review and interview, the facility failed to ensure all pharmaceuticals were available for the residents during medication administration. The finding are: 1. Resident #31's Admission Record dated 4/3/2024 noted a diagnoses of asthma, chronic obstructive pulmonary disease (COPD), emphysema, wheezing, and chronic cough. a. Resident #31's physician orders dated 4/23/2024 documented, Advair HFA Inhalation Aerosol 115-21 mcg/ ACT (Fluticason-Salmeterol) 2 puff inhale orally two times a day related to Chronic Obstructive Pulmonary Disease. Wait 1 minute between puffs. Rinse and spit after administration. Montelukast Sodium oral tablet 10 mg (Montelukast Sodium) give 10 mg by mouth one time a day for COPD/ Asthma. b. On 7/30/2024 at 8:39 AM, during observation of medication administration for 600 hallway with Registered Nurse (RN) #25, Resident #31 did not receive Advair HFA Inhalation Aerosol, and Montelukast Sodium. c. On 7/31/24 8:55 AM, the Surveyor interviewed RN #25 and asked, Should all medications for resident #31 be available when due? She stated, Yes, yes they should. I did reorder them just now. d. Review of the Medication Administration Record (MAR) documented the resident did not receive Advair HFA Inhalation Aerosol 115-21 mcg/ ACT (Fluticasone-Salmeterol) 2 puff inhale orally two times a day related to Chronic Obstructive Pulmonary Disease. Montelukast Sodium oral tablet 10 mg (Montelukast Sodium) give 10 mg by mouth one time a day for COPD/ Asthma. 2. Resident #28's Admission Record dated 2/11/2020 noted a diagnosis of Dry Eye Syndrome of Bilateral Lacrimal Glands, Blepharitis Eye and Eyelid, and Disorder of Eye and Adnexa. a. Resident #28's physician orders dated 3/2/2022 documented, Refresh Lacri-Lube Ointment (White Petrolatum-Mineral Oil) Instill 1 ribbon in right eye two times a day for lagophthalmos. b. Review of the MAR documented the resident did not receive Refresh Lacri-Lube Ointment (White Petrolatum-Mineral Oil) Instill 1 ribbon in right eye two times a day for lagophthalmos. c. On 7/31/2024 at 8:53 AM, Assistant Director of Nursing (ADON) #16 stated, It was last ordered in March. Resident #28 uses a different pharmacy so I can't reorder it on the computer I have to call. e. On 07/31/24 at 8:53 AM, during observation of medication administration for 500 hallway with ADON #16,, resident #28 did not receive Refresh Lacri-Lube Ointment (White Petrolatum-Mineral Oil) Instill 1 ribbon in right eye two times a day for lagophthalmos. d. On 7/31/24 at 9:19 AM, the Surveyor interviewed ADON #16, and asked, Should all medications for the resident be available when due? She stated, Yes, of course they should be. I'll have to look later it's obstructing my time limit. e. The facility provided a policy titled, Medication Orders and Receipt Record with revision date of April 2007 that documented, Policy Interpretation and Implementation 3. The Director of Nursing Services will designate individuals to be responsible for completing medication order/receipt forms. 4. Medications shall be ordered in advance, based on the dispensing pharmacy's required lead time.

bBased on observation, record review and facility policy, review of medication pass on 7/30/2024, and 7/31/2024 it was determined the facility failed to ensure physician orders were followed to maintain a medication rate of less than 5% to prevent complications for 2 (Residents # 31, and #28) of 3 residents observed during medication pass resulting in medication errors. The findings are: 1. Resident #31's Admission Record dated 4/3/2024 noted a diagnoses of Asthma, Chronic Obstructive Pulmonary Disease (COPD), Emphysema, Wheezing, and Chronic Cough. a. Resident #31's physician orders dated 4/23/2024 documented, Advair HFA Inhalation Aerosol 115-21 mcg/ ACT (Fluticason-Salmeterol) 2 puff inhale orally two times a day related to Chronic Obstructive Pulmonary Disease(COPD). Wait 1 minute between puffs. Rinse and spit after administration. Montelukast Sodium oral tablet 10 mg (Montelukast Sodium) give 10 mg by mouth one time a day for COPD/ Asthma. b. On 7/30/2024 at 8:39 AM, during observation of medication administration for 600 hallway with Registered Nurse (RN) #25, resident #31 did not receive Advair HFA Inhalation Aerosol, and Montelukast Sodium. c. On 7/31/24 8:55 AM, the Surveyor interviewed RN #25 and asked, Should all medications for resident #31 be available when due? She stated, Yes, yes they should. I did reorder them just now. d. Review of the Medication Administration Record (MAR) documented the resident did not receive Advair HFA Inhalation Aerosol 115-21 mcg/ ACT (Fluticasone-Salmeterol) 2 puff inhale orally two times a day related to Chronic Obstructive Pulmonary Disease. Montelukast Sodium oral tablet 10 mg (Montelukast Sodium) give 10 mg by mouth one time a day for COPD/ Asthma. 2. Resident #28's Admission Record dated 2/11/2020 noted a diagnosis of Dry Eye Syndrome of Bilateral Lacrimal Glands, Blepharitis Eye and Eyelid, and Disorder of Eye and Adnexa. a. Resident #28's physician orders dated 3/2/2022 documented, Refresh Lacri-Lube Ointment (White Petrolatum-Mineral Oil) Instill 1 ribbon in right eye two times a day for lagophthalmos. b. Review of the MAR documented the resident did not receive Refresh Lacri-Lube Ointment (White Petrolatum-Mineral Oil) Instill 1 ribbon in right eye two times a day for lagophthalmos. c. On 7/31/2024 at 8:53 AM, Assistant Director of Nursing (ADON) #16 stated, It was last ordered in March. Resident #28 uses a different pharmacy so I can't reorder it on the computer I have to call. e. On 07/31/24 at 8:53 AM, during observation of medication administration for 500 hallway with ADON) #16, resident #28 did not receive Refresh Lacri-Lube Ointment (White Petrolatum-Mineral Oil) Instill 1 ribbon in right eye two times a day for lagophthalmos. d. On 7/31/24 at 9:19 AM, the Surveyor interviewed ADON #16, and asked, Should all medications for the resident be available when due? She stated, Yes, of course they should be. I'll have to look later it's obstructing my time limit.

Based on observation, record review and interview, the facility failed to ensure meals were prepared and served according to the planned written quantified recipe and menu to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect 2 residents who received pureed diets and 10 residents who received enhanced food diets from 1 of 1 kitchen. The findings are: 1. The menu for breakfast documented the residents who received pureed diets were to receive 1 #8 scoop (1/2 cup) of hot cereal. a. On 07/31/24 at 7:50 AM, Dietary [NAME] (DC) #7 used a #16 scoop (1/4 cup) to a serve a single serving of pureed oatmeal to the residents on pureed diets, instead of a #8 scoop (1/2 cup) as specified on the facility menu. b. 07/31/24 at 8:16 AM, the surveyor asked DC #7 what scoop size she used to serve pureed oatmeal and how many servings she gave to each resident. She stated, I used the blue scoop #16 and gave a serving each. 2. On 7/31/24 a facility breakfast recipe for super cereal documented for 10 residents use 8 ounces margarine solid pure vegetable, 2.5 cups of dry milk, 1 7/8 quart of hot cereal, and 2 cups of brown sugar. Mix all ingredients together until smooth and creamy. On 07/31/24 at 8:17 AM, during the breakfast meal service, the surveyor asked DC #7 who was on the tray line serving enhanced oatmeal to the residents how it was prepared. She stated, I used a bag of brown sugar, and one cup of dry milk, The surveyor asked DC #7 what else was used. She stated, That's all. The surveyor asked (DC) #7 if she looked at the recipe for enhanced oatmeal before preparing it. She stated, No. The surveyor asked DC #7 if she looked at the recipe before she prepared enhanced cereal served to the residents who required enhanced food diets. She stated, No. Instead of 2 cups of dry milk and 8 ounces of margarine as specified in the recipe.

44852 Based on observation, record review, and interview, the facility failed to ensure food was prepared by methods that maintained flavor, appearance; hot foods were served hot and cold foods were served cold to maintain palatability and encourage adequate nutritional intake for 1 of 1 meal observed on the 400 Hall, 600 Hall, and 700 Hall. The failed practice had the potential to affect 9 residents who received meal trays in their room on 100 Hall 9 residents who received meal trays in their rooms on 200 Hall, 8 residents who received meal trays in their rooms on 300 Hall, 26 residents who received meal trays in their rooms on 400 Hall, 13 residents who received meal trays in their rooms on 500 [NAME]. 29 residents who received meal trays in their rooms on 600 Hall and 9 residents who received meal trays in their rooms on 700 Hall. as documented on a list provided by Dietary manager on 07/31/2024 at 9:30 AM. The findings are: 1. Resident #90 Minimum Data Set with an assessment reference date of 7/3/24 indicated resident received a score of 15 on the Brief Interview for Mental Status. On 7/29/24 at 9:14 AM, the resident reported that she was less than satisfied with the food. Residents described the food as frequently cold and often it is too spicy. 2. Resident #24's Minimum Data Set with an assessment reference date of 4/19/2024 indicated resident received a score of 10 on the Brief Interview for Mental Status. On 07/29/24 at 10:28 AM, the resident stated, the food we are served is not good. It's cold sometimes and doesn't taste good. How do you screw up mac and cheese? 3. On 07/29/24 at 12:44 PM, Resident #48 stated, The food .doesn't taste good, sometimes cold. 4. Resident #23's Resident Minimum Data Set with an assessment reference date of 5/14/2024 indicated resident received a score of 15 on the Brief Interview for Mental Status. On 7/30/24 at 9:50 AM resident stated, The food we get is cold if delivered to us in the room. It's not the best flavor most of the time. On 7/31/24 at 1:50 PM, a test tray consisted of ground chicken, turnip greens, mixed vegetables, mashed potatoes, macaroni and cheese, pureed macaroni and cheese, and a whipped strawberry dessert. Dietary Manager #18 tasted the mixed vegetables, and stated, It was over seasoned. Macaroni and cheese need more salt. The surveyor described the cheese as forming a film and feeling as if it had adhered to her teeth and tongue. Upon tasting the pureed cheese and macaroni Dietary Manager #18 confirmed the negative assessment of the cheese product. Dietary Manager #18 described the cheese as a canned product vs actual fresh cheese. When the mashed potatoes were tasted, Dietary manager #17 and Dietary manager #18 described it as needing more salt. and strawberries with whipped mix as being tart vs. sweet. 5. On 07/31/24 01:11 PM, an unheated cart that contained 26 trays for lunch was delivered to the 400 Hall by Dietary Aide #8. At 1:19 PM, immediately after the last resident received their tray in their room, the temperatures of the food items on a test tray from the food cart was checked and read by the Certified Nursing Assistant (CNA)#12 and milk was 43.7 degrees Fahrenheit. 6. On 07/31/24 01:18 PM, first an unheated cart that contained 13 trays for lunch for 500 and 600 Hall was delivered to the 600 Hall by Dietary Aide #8. At 1:28 PM, immediately after the last resident received their tray in their room, the temperatures of the food items on a test tray from the food cart were checked and read by CNA #11 fried chicken was 114.8 degrees Fahrenheit. 7. On 07/31/24 at 1:26 PM, an unheated cart that contained 29 trays for lunch for 500 and 600 [NAME] was delivered to the 600 Hall by Dietary Aide #8. At 1:34 PM, immediately after the last resident received their tray in their room, the temperatures of the food items on a test tray from the food cart were checked and read by the CNA #12 milk 45.5 was degrees Fahrenheit.

49689 Based on observation, record review, interview, and facility policy, the facility failed to ensure a resident who is on contact isolation does not have a roommate and that staff wear appropriate personal protective equipment (PPE) while entering the room for 1 (Resident #31) of 1 sample mix resident reviewed for contact isolation; ensure staff while providing care to a resident in an enhanced barrier precautions room wore appropriate personal protective equipment (PPE) for 4 (Resident #363, #366, #367, #371) of 4 residents reviewed for enhanced barrier precautions; ensure staff while providing percutaneous endoscopic gastrostomy (PEG) medication administration and tube feeding wore appropriate personal protective equipment (PPE) and sanitized hands for 1 (Resident #28) of 1 sample mix residents reviewed for medication pass; to ensure staff maintained aseptic technique during an ordered wound care treatment for 1 (Resident #367) of 1 resident reviewed for wound care treatment; to ensure continuous positive airway pressure (CPAP) face masks were contained in a storage bag when not in use for 1 sample mix resident reviewed for CPAP. The findings are: a. Review of resident #31's Admission Record dated 4/3/2024 noted a diagnoses of asthma, Chronic Obstructive Pulmonary Disease (COPD), Emphysema, wheezing, and chronic cough. Review of Resident #31's Care Plan dated 12/09/2023 revealed, The resident has a HX (history) of recurring urinary tract infections. Contact Isolation Precautions. Review of Resident #31's Order Summary Report dated 07/29/2024 does not document an order for contact precautions. On 07/29/24 at 8:54 AM, the Surveyor observed resident #31 have contact precaution signs on door along with a sign that states see nurse before entering. Resident #88 is the roommate in the room. On 07/29/24 at 8:57 AM, the Surveyor interviewed Registered Nurse (RN) #24 outside of Resident #31 and #88's room and asked, Can you tell me which resident is on contact isolation and what they are on contact isolation for? He stated, I believe it has something due to resident's urine, I'm new here and didn't know the system. On 07/29/24 at 9:00 AM, the Surveyor observed staff entering Resident #31 & #88's room with contact precautions signs on door with no gown, gloves or mask. On 07/29/24 at 9:01 AM, the Surveyor interviewed Certified Nurse Aide (CNA) #23 and asked, What should you have on when entering a contact precautions room? She stated, Gown, mask, and gloves. When asked, Did you have those on? She stated, No. When asked, Can you tell me why? She stated, I see the stuff on the door, and it has been there for weeks, and I wasn't notified it was a possible threat or anything. When asked, If signs are on the door for contact precautions should they be followed? She stated, Yes. When asked, Why should they be followed? She stated, For infection. On 07/29/24 at 9:07 AM, RN #24 came to Surveyor and stated, I'm not sure what it is, but I messaged my boss to find out. On 07/29/24 at 9:16 AM, the Surveyor interviewed RN #24 and asked, If a resident is on contact precautions should they have a roommate? He stated, Not usually, no. When asked, Why should they not have a roommate? He stated, Spread of infection. 07/30/24 9:06 AM, Surveyor observed staff entering Resident #31's room with no PPE on. The surveyor interviewed CNA #12 and asked, Should you were appropriate PPE when entering a contact isolation room? She stated, Yes, ma'am when providing direct patient care. When asked, Why should you have on PPE when entering a contact isolation room? She stated, To protect yourself and the resident. On 07/30/24 at 9:08 AM, the Surveyor observed LPN #26 in Resident #31's room doing a zoom call with no PPE on. Surveyor interviewed Admissions Director and asked, Should you were appropriate PPE when entering a contact isolation room? She stated Ya, that why I just told you I was coming to get my stuff I didn't realize she was one it. When asked, Why should you have on PPE? She stated, Cause [Resident #31] is in isolation she has ESBL (extended spectrum beta-lactamase) I believe. On 08/02/24 at 2:28 PM, the Surveyor was informed by the Director of Nursing (DON) that Resident #88 has been removed from the room with Resident #31. b. On 07/30/2024 at 2:23 PM, the Surveyor observed Licensed Practical Nurse (LPN) #27 during medication pass with Resident #371 and LPN #27 did not sanitize her hands or put on a gown in an enhanced barrier room. LPN #27 donned gloves opened IV tubing and spiked antibiotic bag. LPN #27 placed tubing in IV pump and primed the line. LPN removed green cap off from the (Peripherally Inserted Central Catheter) PICC port, scrubbed port with alcohol pad, then connected 0.9% normal saline flush to port and flushed line with 10 mL of normal saline. LPN removed normal saline flush from port and connected IV to port. LPN removed gloves and set pump at 96 milliliters (mL)/ hour (hr.) and 48 mL/ hr. Surveyor interviewed LPN #27 outside of Resident #371's room and asked, Should you wear a gown in an Enhanced Barrier Precaution room when you administer medication through the PICC line? She stated, Yes. When asked, Can you tell me why you should wear a gown? She stated, In case of contact. When asked, Should you sanitize your hands prior to donning gloves to administer medication through a PICC line? She stated, Yes. When asked, Why should you sanitize your hands prior to donning gloves and administering medication through a PICC line? She stated, Because its infection control. c. On 07/31/24 at 8:53 AM, the Surveyor observed Assistant Director of Nursing (ADON) #16 during medication pass with Resident #28 who has a PEG (Percutaneous Endoscope Gastronomy) tube, and the ADON did not sanitize her hands or put on a gown while administering medications and tube feeding to Resident #28. On 07/31/24 at 9:42 AM, the Surveyor interviewed the ADON outside of Resident #28's room and asked, Should you sanitize your hands prior to initially donning gloves for the PEG tube medication administration? She stated, Yes. When asked, Why should you sanitize your hands prior to donning gloves? She stated, Infection control. When asked, Should you have worn gown to do the PEG tube feeding? She stated, I don't believe that is correct, but I guess so. I honestly did not know that. When asked, Why should you wear a gown in an enhanced barrier precautions room while administering medications and water flush to Resident #28? She stated, Because to protect him and I both due to the site. A review of a facility policy titled, Handwashing/Hand Hygiene, October 2023, indicated, Hand hygiene is indicated: a. immediately before touching a resident; b. before performing an aseptic task; c. after contact with blood, body fluids, or contaminated surfaces; d. after touching a resident; e. after touching a resident's environment; f. before moving from work on a soiled body site to a clean body site on the same resident; and g. immediately after glove removal. A review of the Admission Record, indicated the facility admitted Resident #367 with diagnoses that included partial traumatic amputation of right foot. A review of Order Summary Report, revealed Resident #367 had an order for wound vac change every Monday, Wednesday, and Friday and as needed. Continuous high suction at 125 millimeters of mercury with foam. During an observation on 07/31/2024 at 1:42 PM, Licensed Practical Nurse (LPN) #14 applied a clean pair of gloves. Then, with gloves in place touched the bed remote to raise the bed and removed resident covers from lower extremity, removed wound vac carry bag and placed on bedside shelf. Changed gloves without performing hand hygiene and placed a new pair of gloves. Clamped wound vac tubing and removed dressing in place. With the same gloves in place cleaned wound with moistened gauze and laid a new piece over the wound bed. During an observation on 07/31/2024 at 1:48 PM, LPN #14 removed gloves and with bare hands removed cartridge of drainage from wound bed and placed in red biohazard bag. Placed a new cartridge in the wound vac and opened packaging for the dressing change. Reached in scrubs pocked for scissors and placed on dressing package. LPN #14 then applied a new pair of gloves and connected new tubing for the wound vac, then cleansed scissors and cut foam to size. Measured wound and applied new foam and transparent dressing. When finished applying dressing removed gloves. During an observation on 07/31/2024 at 2:04 PM, Applied a new pair of gloves and cut a hole in the top of the dressing for the suction tubing to be applied. Turned on wound vac to check for leaks, wrote on dressing and removed personal protective equipment (PPE) at this time. During an observation on 07/31/2024 at 2:09 PM, LPN #14 performed hand hygiene at this time using alcohol-based hand gel. This was done following the removal of the last pair of gloves. During an interview on 08/01/2024 at 5:50 PM, the LPN #14 stated she should have changed gloves with each new task and performed hand hygiene with each glove change to prevent cross contamination. During an interview on 08/02/2024 at 12:11 PM, the Nurse Consultant stated that gloves should be changed anytime they become contaminated, when changing from clean to dirty, and before or after a task. Glove change and hand hygiene is performed to prevent cross contamination and decrease the risk of infection. 1. A review of the Order Summary revealed Resident #363 had diagnosis of malnutrition, and pressure ulcer at an unspecified site and an unspecified stage. A review of the Order Summary revealed Resident #363 had an order for Treatment to unstageable pressure injury to coccyx: cleanse with wound cleanser or sterile water. Apply thin layer of [named brand of burn gel] cover with calcium alginate. Cover with 6 X 6 border foam daily and PRN until resolved. Every day shift for wound treatment may substitute as necessary. Reassess in 14 days. Start Date 7/23/2024 A review of the Order Summary revealed Resident #363 had an order entered for Enhanced Barrier Precautions related to wound care on 07/29/2024 at 01:26 PM. A review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 07/20/2024 reveals that Resident #363 scored a 13 (cognitively intact) on the Brief Interview for Mental Status. A review of the Care Plan reveals that Resident #363 Focus: The resident has Stage unstageable PU to coccyx, on admission. 2. A review of the Order Summary reveals that Resident #366 had diagnoses of paralytic syndrome affecting right side with a stroke, anxiety disorder and major depressive disorder. A review of the Order Summary reveals that Resident #366 had an order for Treatment to moisture associated skin damage (MASD) to coccyx: cleanse with wound cleanser or sterile water. Apply coloplast. Cover with 4 X 4 on Monday, Wednesday, Friday, and PRN (as needed) until resolved. Start Date 07/24/2024. A review of the Order Summary reveals that Resident#366 had an order entered for Enhanced Barrier Precautions related to wound care on 07/29/2024 at 1:06 PM. A review of the Care Plan reveals that Resident #366's pressure ulcers were not care planned. 3. A review of the Order Summary reveals that Resident #367 had diagnoses of type 2 diabetes mellitus, and traumatic partial amputation of right foot. A review of the Order Summary reveals that Resident #367 had an order for Wound care orders: present on admission right mid foot amputation site: wound vac change Monday, Wednesday, Friday and PRN (as needed). Continuous high suction at 125 MMHG with foam. Clean wound bed with wound cleanser prior to wound vac placement. If wound vac leaks or malfunctions, attempt to fix with Tegaderm or tape. If unsuccessful, remove all pieces of foam and pack with saline, damp to dry dressing. Contact APRN (Advanced Practice Registered Nurse). A review of the Care Plan reveals that Resident #367 Focus: The resident has (specify) pressure ulcer (specify location) or potential for pressure ulcer development. 4. A review of the Order Summary reveals that Resident #371 had diagnoses of endocarditis, and type 2 diabetes mellitus. A review of the Order Summary reveals that Resident #371 had an order for Cefazolin Sodium Intravenous Solution Reconstituted 2 GM Use 2 gram intravenously every 8 hours for endocarditis until 07/31/2024 at 11:59 PM. Start date 06/28/2024 A review of the Order Summary reveals that Resident #371 had an order for Treatment to stage 2 to coccyx: cleanse with wound cleanser or sterile water, pat dry with 4 X 4 gauze. Apply thin layer of hydrocolloid to wound bed. Cover with 4 X 4 mepilex border foam on Monday, Wednesday, Friday, and PRN (as needed) until resolved. Start Date 06/28/2024 A review of the Order Summary shows an order for Enhanced Barrier Precautions related to PICC line entered on 07/31/2024 at 8:32 AM. No Enhanced Barrier Precaution Orders for Wound Care. A review of the Care Plan reveals that Resident #371 did not have their pressure ulcers or PICC line in care plan. On 07/29/2024 at 6:32 AM, Surveyor observed staff leaving Resident #363's room with bags. Surveyor observed that no enhanced barrier precautions signage was posted on the door, and that no personal protective equipment was set up nearby. On 07/29/2024 at 6:35 AM, Surveyor observed staff entering Resident #366's room to get the resident ready for breakfast. There was no enhanced barrier precaution signage posted on the door, and no personal protective equipment was set up nearby. Staff did not put on personal protective equipment before performing care. On 07/29/2024 at 7:35 AM, Surveyor observed a wound vac sitting on a table on the left side of the bed. Surveyor observed that no enhanced barrier signage was posted on the door and no personal protective equipment was set up nearby. On 07/29/2024 at 7:40 AM, Surveyor observed staff leaving Resident #371's room with bags no enhanced barrier precaution signage posted on the door and no personal protective equipment nearby. On 07/30/2024 at 10:00 AM, Surveyor observed for Resident #363, Resident #366, and Resident #367 that enhanced barrier precautions had been set up, signs are posted on the door frame and small bins are observed outside the rooms. On 07/31/2024 at 1:40 PM, Surveyor observed for Resident #371 enhanced barrier precautions had been set up, signs are posted on the door frame and small bins are observed outside the room. On 07/31/2024 at 2:00 PM Surveyor observed Licensed Practical Nurse #14 (LPN) leaving Resident #371's room after hanging an intravenous antibiotic for a peripherally inserted central catheter (PICC) line. The LPN #14 did not have personal protective equipment on, performed hand hygiene and left. Enhanced barrier precautions are posted on the door frame and personal protective equipment was nearby to the left of the door. On 07/31/2024 at 2:15 PM Surveyor observed LPN #14 return to the room, to disconnect the intravenous antibiotic from the PICC line. LPN #14 did not put on personal protective equipment, perform hand hygiene or put on gloves. LPN #14 then disconnected the line and hung it up on the intravenous pole and flushed the PICC line. During an interview, LPN #14 stated they were not aware that enhanced barrier precautions were used for central lines, we just recently had an in-service about this. I feel like we need more education as I still do not understand enhanced barrier precautions. LPN #14 confirmed they did not use personal protective equipment when hanging or disconnecting the intravenous medication. LPN #14 stated that a PICC line is invasive, and it goes into the artery, The enhanced barrier precautions would help prevent infection, especially since they have a diagnosis of endocarditis. An Enhanced Barrier Precautions Inservice was performed in March 2024. An Infection Control Inservice was performed on February 15th, 2024. A review of the Enhanced Barrier Precautions states 2. Enhanced barrier Precautions (EBPs) employ targeted gown and gloves use during high contact resident care activities when contact precautions do not otherwise apply. 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.) A review of the Policies and Practices-Infection Control states This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. A review of the Equipment and Supplies Used During Isolation states Appropriate equipment and supplies will be used to maintain sanitary conditions while isolation precautions are in effect.

Based on interviews, record review, and facility policy review, the facility failed to update person-centered care plans to reflect the residents needs for three Residents (Residents #45, #23, and #462) of four residents reviewed for care plans. The facility failed to accurately document code status on the care plan which could result in a negative outcome as staff could provide lifesaving measures contradictory to the residents' choice. The facility failed to develop and implement any interventions for the moderate hearing loss for Resident #45. The facility failed to update the care plan to include elopement interventions for one (Residents #462) who had attempted to elope from the facility as documented in the progress notes. The findings are: On 07/29/24 at 8:45 AM, attempted to interview resident and found the resident to be non-interview able due to her cognitive state and hearing deficit. During an interview with Advanced Practice Nurse (APRN) #30, she confirmed resident #45 had a moderate hearing deficit. When asked if there was a hearing deficit, MDS nurse #19 stated, I know she has a little hearing issue, but I've never had an issue talking to her. On 07/29/24 at 10:29 AM, R #45 upon record review, quarterly MDS in section B dated 6/10/24 the option moderately impaired is checked. There were no interventions listed in the care plan dated 6/24/24 addressing her moderately impaired hearing issue. On 07/30/24 at 9:20 AM, during a resident interview, Resident #23 stated, I want to be a Do Not Resuscitate [DNR]. On 07/30/24 at 9:40 AM, upon record review, care plan dated 06/12/24 states both full code and DNR. Residents face sheet shows a full code status. On 08/01/24 at 9:20 AM, during an interview, MDS Nurse #19 was asked to pull up the resident and look at the face sheet for code status. On Resident #23's face sheet, the MDS nurse read her code status, and stated, She's a full code. Upon review of the MDS and care plan, MDS stated, It says here she is a full code, wait, it also states she is a DNR. I'm not sure if she has a new code status signed. Review of records show she has a document scanned which is her code status (DNR) signed 3/20/2020. 1. Review of Resident #462's Admission Record dated 04/29/2024 revealed a diagnosis of Alzheimer's disease, and Dementia, Severity, with Agitation. a. Review of Nursing (NSG) Progress Notes dated 05/09/2024 at 9:08 AM documented, 08/01/24 Incident Description: Called to 700 Hall per staff of facility regarding resident exiting out of building. Resident exited out of building by pushing handle for 15 seconds and then access was given to leave out of door. No injuries or bruising noted on resident. No distress noted. Immediate Intervention: Resident assisted back into facility per staff. Redirected and oriented to facility and room. b. Review of resident #462's care plan did not document attempted elopement on 05/09/2024. c. Review of Nursing Progress note dated 5/10/2024 at 11:08 AM revealed, Nursing-I&A (Incident and Accident) Follow Up Late Entry: Date and I&A Description: Called to 700 Hall per staff of facility regarding resident exiting out of building. Resident exited out of building by pushing handle for 15 seconds and then access was given to leave out of door. No injuries or bruising noted on resident. No distress noted. Long Term Intervention: extra CNA placed in 700 pod Added to the Care Plan: yes. d. Review of facility Nursing Elopement Risk with Care plan V-1 dated 05/14/2024 revealed the resident is high risk to wander, has a history of wandering, and has a wandered in the past month. e. On 08/01/24 at 2:58 PM, the Surveyor interviewed the Licensed Practical Nurse #26 Admissions and asked, Can you tell me what happened when resident #462 eloped from the facility? She stated, I came into the pod by my office by 701 and I see someone standing outside on the other end on the sidewalk area. She was past the poles. I dropped my stuff and ran. I tried to coax her in, and she started to swing on me she missed. I moved her away from the edge because she would've fallen. The eMed tech was nowhere to be found. I finally got med tech to come after I already had resident #462 halfway in. f. On 08/01/24 at 3:21 PM, the Surveyor interviewed Assistant Administrator and asked, Can you tell me what happened on 5/9/2024 when Resident #462 eloped from the facility? She stated, On the 9th I know when I got here, I was notified we had some elopements that we would keep eyes on them, so it didn't happen again. We made sure people were watching them, temporary stop signs, adhered with hook and loop fasteners, were on the exit doors to help redirect we in serviced and re-did elopement assessments and did elopement binders on residents at risk and how to handle it. g. On 08/02/24 at 2:31 PM, the Surveyor interviewed the Minimum Data Set (MDS) Nurse #19 and asked, When a resident elopes from the facility should their care plan be revised to reflect the elopement and interventions? She stated, Yes. When asked, Why should the care plan be revised to reflect the elopement? She stated, To protect the resident from potentially exiting form the facility and make everyone aware of the risks

Based on observation, record review, interview, and facility policy review, the facility failed to ensure the comprehensive care plan addressed and individualized appropriate care and services for 1 (Resident #103) of 1 sample mix residents. The findings are: 1. Review of Resident #103's Admission Record dated 05/23/2024 revealed a diagnosis of sleep apnea. a. On 07/29/24 at 10:29 AM, the Surveyor observed a Continuous Positive Airway Pressure (CPAP) mask at Resident #103's bedside with CPAP mask sitting on bedside table not in a bag. Resident #103 stated, I have sleep apnea. b. Review of Resident #103's Order Summary Report, active as of 07/29/2024, did not document CPAP usage. c. On 08/01/24 at 8:26 AM, the Surveyor observed Resident #103's CPAP mask at the bedside not in a storage bag. No storage bag was present. d. Review of Resident #103's Care Plan did not reveal CPAP usage. e. Review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/30/2024 revealed Section O0110. Special Treatments, Procedures, and Programs documented the resident does not use a CPAP. f. On 08/01/24 at 3:45 PM, the Assistant Director of Nursing#16 confirmed Resident #103's CPAP mask was sitting on the bedside table and not in a bag, that there should be a physician's order for the CPAP, and that it should be on the care plan because, It's a treatment. Any respiratory therapy should be and it's an intervention. g. On 08/01/24 at 3:51 PM, the Director of Nursing (DON) confirmed Resident #103 should have a physician's order that included settings for CPAP usage, and that CPAP usage should be on the care plan, because it's part of their plan of care. h. On 08/02/24 at 2:31 PM, MDS Nurse #20 confirmed CPAP machine usage should be on the care plan, to make sure it's being put on the resident, for staff awareness, and care of the resident. i. The facility provided a policy titled, 'Care Plans, Comprehensive Person-Centered' with a revision date of December 2016 that documented, Policy Statement A comprehensive person- centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.

Based on observation, record review, and interview the facility failed to ensure that Registered Dietitian recommendations were following in a timely manner for an enteral bolus feeding for one (Resident #28) of one sampled resident. The findings are: On 7/30/2024 the Director of Nursing (DON) was asked if the facility had a policy for following Registered Dietitian recommendations. The DON provided a document titled UDA-RD Recommendations. Review of an Admission Record indicated the facility admitted Resident #28 with diagnosis of post traumatic seizures and traumatic brain injury on 2/11/2020. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/11/2020 revealed Resident #28 had a Brief Interview for Mental Status (BIMS) of 7, which indicated the resident had severe cognitive impairment. Review of #28 Care Plan initiated 2/25/2020 revealed the resident was at risk for nutritional problems or potential for nutritional problems related to diagnosis. The interventions included Registered Dietitian (RD) to evaluate quarterly and as needed (PRN). Monitor caloric intake, estimate needs. Make recommendations for changes to tube feeding as needed. Record review of Registered Dietitian (RD) note dated 7/25/2024RD Onsite Visit and Recommendation: The RD noted that Resident #28 had a weight loss of 8.9 pounds since 7/5/2024 and the RD recommended increasing the amount of bolus tube feedings from 5 boluses a day to 6 boluses a day to increase calorie intake. Review of the Medication Administration Report (MAR) on 7/29/2024, the bolus was not increased to 6 boluses a day until 7/30/2024. Review of Resident #28's Weight Summary Report dated 7/31/2024, Resident #28 had a weight loss of 5.2% for the month of July. On 7/29/2024 at 9:30 AM, Assistant Director of Nursing (ADON) #16 was asked how many boluses Resident #28 was to receive per feeding. RN#16 stated that Resident # 28 was to receive 5 boluses a day. On 7/30/2024 at 2:07 PM, ADON #16 provided a copy of Progress Notes NEW that showed where the feedings were being increased to 6 times a day starting on 7/30/2024. On 7/30/2024 at 2:30 PM RN # 16 was asked when the bolus feedings should have been increased and RN #16 said that it was her understanding that it should have been increased on 7/25/2024 when the RD recommended it. On 7/30/2024 at 3:30 PM the Director of Nursing (DON) was interviewed and asked when the RD recommendations should be completed. DON stated that RD recommendations should be completed within 72 hours. DON was asked if the bolus feedings were increased within 72 hours of the RD recommendations, and she said that had not been but should have been. On 7/30/2024 at 02:06 PM, the Nurse Consultant confirmed a resident that has a tube feeding scheduled for 08:00 AM should they receive their feeding during the 8:00 AM medication pass, because it's a scheduled feeding and should be given per physician orders.

Based on observations, record review and interview, the facility failed to ensure necessary foot/toenail treatment and care was provided to keep toenails trimmed and dry and to prevent flaky skin to decrease the potential for foot complications for 1 (Resident #22) of 1 sampled resident who were dependent on staff for foot/toenail care. The findings are: 1. Review of a facility policy titled Foot Care, dated 2001, indicated that Residents will receive appropriate care and treatment in order to maintain mobility and foot health. A review of an Admission Record indicated Resident # 22 was admitted on [DATE] with a diagnosis of Acute and Chronic Respiratory Failure and Chronic Obstructive Pulmonary Disease with exacerbation and Type 2 Diabetes Mellitus with foot ulcer. The annual Minimum Data Set (MDS) with an assessment Reference Date (ARD) of 11/10/2023 revealed Resident # 22 had a Brief Interview for Mental Status (BIMS) score of 11 which indicated Resident #22 was moderately impaired. Review of Resident #22's care plan initiated 12/22/2021, revealed that resident had an Activity of Daily Living (ADL) self-care performance deficit related to impaired mobility, morbid obesity, dementia. The care plan indicated that resident was dependent on staff for ADL care. On 7/30/24 at 10:30 AM, Resident #22 was observed during personal care being provided by Certified Nursing Assistant (CNA) #3 providing ADL care. CNA#3 was asked if she provided foot/toenail care for Resident #22, and she stated she did not because Resident #22 was a diabetic. CNA #3 was asked to describe Resident #22's toenails. CNA #3 described the toenails as long and dirty. On 7/30/2024 at 10:40 AM, Assistant Director of Nursing (ADON)#16 was interviewed and asked to observe and describe Resident #22's toenails. RN #16 described the toenails as dirty, thick, long and yellow. RN #16 was asked who should provide nail care for Resident #22 and she said that a nurse would because resident was a diabetic. On 7/30/2024 at 2:30 PM Director of Nursing (DON) was asked who should provide nail care for a diabetic resident. She said that a nurse should. She observed Resident #22's toenails and was asked to describe them. She stated the Resident's foot appeared puffy and stiff, and the toenails are thick, yellow, long and dirty. DON was asked if a podiatrist had seen Resident #22, and she said a podiatrist had not visited Resident #22.

Based on record review and interview, the facility failed to ensure an Admission Minimum Data Set (MDS) was completed in a timely manner for one (Resident #371) of one sampled resident. On 07/29/2024, an Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/11/2024 was reviewed. The Admission MDS was started on 07/08/2024 and was currently 18 days overdue for completion. A review of the policy Resident Assessment Instrument revealed l. The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct(s) timely resident assessments and reviews according to the following schedule: a. Within fourteen (14) days of the resident's admission to the facility; On 08/01/2024 at 11:15 AM, during an interview MDS Coordinator #19 stated that usually total life respite is done by MDS Coordinator #20, but she is not really aware of that and has been training on and off. We both have been working six days a week, on the floor for up to 120 hours. We have not been able to finish this MDS, and it is my fault as MDS Coordinator #20 is still training .The Admission MDS is 21 days overdue, and I will finish it this afternoon. MDS Coordinator #19 stated that Resident #371 was admitted on [DATE].

Based on observation and interview the facility failed to ensure accommodation needs were met by not ensuring the call light was within reach for one (Resident #366) of one sampled resident. The findings include: A review of the Order Summary revealed Resident #366 had diagnoses of paralytic syndrome affecting right side with a stroke, anxiety disorder and major depressive disorder, and that Resident #366 had an order for Treatment to skin tear to L forearm: Cleanse with wound cleanser or sterile water apply xeroform to wound bed. Cover with 4 x 4 bordered foam on MWF (Monday, Wednesday, and Friday) and PRN (as needed) until resolved. Active order as of 07/29/2024. A review of the Care Plan revealed Resident #366 Interventions/Task: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs a prompt response to all requests for assistance. On 07/29/2024 at 6:35 AM, the surveyor observed Certified Nursing Assistant (CNA) #21 and #22 entered Resident #366's room. The surveyor observed CNA #22 state that they will get them (Resident #366) up and ready for breakfast. On 07/29/2024 at 7:24 AM, Surveyor observed Resident #366 in a wheelchair. The surveyor noted the call light is attached to the bed rail, on Resident #366's right side out of reach. Resident #366 stated the call light was not within reach and when asked if they could self-propel over to the call light, the resident shook head no. Resident #366 stated being up for close to forty minutes. Resident #366 then stated needing help after being transferred to wheelchair, due to a skin tear on the left arm. Resident stated the staff left in a hurry before they noticed the skin tear was there. On 07/29/2024 at 7:30 AM, CNA #15 entered the room and confirmed the call light was not within reach of the resident. CNA #15 stated call lights should be within reach of the resident to be able to call for help, and night shift got Resident #366 up today. On 07/29/2024 at 7:50 AM, Surveyor observed Resident #366 sitting in Resident's room with the skin tear still exposed. Resident #366 voiced waiting for the nurse to treat the skin tear. The surveyor observed Resident #366 was tearful and upset. On 07/29/2024 at 8:00 AM, Surveyor observed nursing staff enter the Resident's room to treat the skin tear. Surveyor observed the resident was still tearful and upset during the treatment.