Every finding on record at Rowlett Health and Rehabilitation Center

Based on observation, interview and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 10 of 15 resident rooms on the 500 hall (Resident rooms #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10), and residents eating in the dining room, reviewed for environment.Based on observation, interview and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 10 of 15 resident rooms on the 500 hall (Resident rooms #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10), and residents eating in the dining room, reviewed for environment. 1. The facility failed to ensure Resident rooms #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10, were thoroughly cleaned and sanitized. 2. The facility failed to ensure the serving table in the dining room was thoroughly cleaned and sanitized. These deficient practices could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. Findings include: An observation on 07/22/25 at 9:21 AM in the facility's main dining room revealed a large white serving table, which was used for drinks and condiments. The table had black and brownish stains along the front and side panel of the table and also on the bottom portion of the table. An observation on 07/22/25 at 11:04 AM of resident room [ROOM NUMBER] reflected the air condition vents had dark dirt stains on and between the vents. The shower floor in the bathroom had white and brown stains on it. The corners and edges of the bathroom floor had dirt build up in the corners and behind the toilet. An observation on 07/22/25 at 11:08 AM of resident room [ROOM NUMBER] reflected the air condition vents had dark stains on and between the vents. The shower floor in the bathroom had white and brown stains on it. The corners and edges of the bathroom floor had dirt build up in the corners and behind the toilet. A wastebasket in the bathroom had no trash bag and the inside bottom of the wastebasket had brownish stains and dried up dirt in it. An observation on 07/22/25 at 11:12 AM of resident room [ROOM NUMBER] reflected the air condition vents had dark stains on and between the vents. The corners of the room floor had white dirt particles and dirt build up. An observation on 07/22/25 at 11:16 AM of resident room [ROOM NUMBER] reflected the air condition vents had dark stains on and between the vents. The corners and edges of the bathroom floor had dirt build up in the corners and behind the toilet. A nightstand in the room had dirt and dust particles on top of it. A chest of drawers in the room had thick dust on top of it and a dirty shoe was sitting on top of it. A wastebasket in the bathroom had no trash bag and the inside bottom of the wastebasket had brownish stains and dried up dirt in it. An observation on 07/22/25 at 11:22 AM of resident room [ROOM NUMBER] reflected the air condition vents had [NAME] stains on and between the vents. The bathroom shower floor had rust stains from a shower chair in the shower. The bathroom floor had brown stains along the corners of the floor and behind the toilet. An observation on 07/22/25 at 11:29 AM of resident room [ROOM NUMBER] reflected the air condition unit filters had dust in them. The air condition vents had dark stains on and between the vents. An observation on 07/22/25 at 11:33 AM of resident room [ROOM NUMBER] reflected the air condition unit filter had dust in it. The air condition vents had dark stains on and between the vents. There was a roll of tissue paper lodged between the bathroom lights. An observation on 07/22/25 at 11:37 AM of resident room [ROOM NUMBER] reflected a privacy curtain with large brownish stains on both sides of the curtain. The bathroom floor had brown stains along the corners of the floor and behind the toilet. An observation on 07/22/25 at 11:41 AM of resident room [ROOM NUMBER] reflected the air condition unit filters had dust in them. The air condition vents had dark stains in them. An observation on 07/22/25 at 11:43 AM of resident room [ROOM NUMBER] reflected the air condition vents had dark stains in them. The cover of the air condition unit was slightly separated from the unit. The bathroom shower floor had yellow and black stains along the edges of the floor. The tile on the bathroom shower wall had dried up cement plastered all over the bottom of the wall and along a corner of the wall. The bathroom floor had brown stains along the corners of the floor and behind the toilet. In an interview on 07/24/25 at 8:52 AM, Housekeeping D stated she had been at the facility for 3 years. She stated she cleaned the 500 hall rooms. She stated she was responsible for cleaning the room floors, the air condition units, the air filters, wiping down the furniture, the bathrooms floors, toilets, showers, and she took down the privacy curtains to wash them. She stated she had the curtains cleaned when she saw they were dirty or had a smell and every two weeks. She stated they did not have a checklist to use when cleaning the room. She stated the housekeeping supervisor checked the rooms once she had finished. She was shown pictures of the concerns observed in Resident rooms #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10 and she stated they were responsible for cleaning the areas mentioned. She stated the areas that required repairing, such as the bathroom tile in the shower was mentioned to the to the Housing Supervisor and maintenance but it had not been fixed yet. She stated the CNAs had place the toilet paper between the light fixture to prevent the resident from making a mess with it. She stated not cleaning the areas mentioned could cause allergy problems and impact the residents' health. In an interview on 07/24/25 at 9:13 AM, the Housekeeping Supervisor stated he had been at the facility for 3 years. He stated the staff did not use a checklist to clean the rooms because he had a tenured staff. He stated he assigned housekeeping resident halls to work so that he knew who cleaned the resident rooms on the halls if he had complaints or concerns. He stated they were responsible for cleaning the floors, wiping down surface areas, and cleaning the entire bathroom. He stated they only had 4 replacement privacy curtains, so they tried to have them cleaned if they were dirty. He was shown pictures of the concerns observed in Resident rooms #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10 and he stated his staff was responsible for cleaning the areas mentioned. He stated if there was maintenance work to be done, his staff should have notified maintenance to resolve the issue. He stated maintenance had repaired the shower wall in room [ROOM NUMBER] and could have done a better job buffing out the concrete used to install the tiles. He stated the concerns observed could impact the resident from having a home-like environment and he would not like his mother to be in rooms that were not cleaned. He was shown pictures of the serving table in the dining area, and he stated his night cleaning staff should have wiped it down at night. He stated there were stains on the table that could not be cleaned, and he had already met with maintenance to have it repainted on 07/23/25. He stated not having the table cleaned did not represent a home-like environment. In an interview on 07/24/25 at 11:22 AM, the Administrator stated he was briefed by the housekeeping supervisor of the concerns observed in the resident rooms on Hall-500. He stated the areas mentioned should have been cleaned by the housekeeping. He was shown pictures of the concerns observed in Resident rooms #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10 and the serving table in the main dining room. He stated his housekeeping supervisor was normally great at checking resident rooms to ensure they were properly cleaned and areas in the facility are thoroughly cleaned. He stated the rooms were scheduled to be remodeled and he thought that maintenance and housekeeping may have gotten complacent in thoroughly cleaning the bathroom floors and repairing the tiles in the bathroom showers. He stated not addressing the concerns does not present a homelike environment. Record review of the facility's policy on Environmental Services - Housekeeping revised 2022, reflected Housekeeping and Maintenance services include the cleaning, sanitization, and care for rooms and common areas of the facility to ensure that the facility is safe for all who reside, work, and visit. All rooms of residents will be cleaned regularly. These duties include a. Sweeping and mopping of the resident's room and restroom. b. Clean with disinfectant high touch surfaces such as doorknobs, tray stands, dressers, sink, etc.c. Properly clean and disinfect the restroom which includes the toilet, sink, mirror, and floor. d. Change/pick up trash from the trash receptacles in the room and restroom.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food and nutrition services. Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food and nutrition services. 1. The facility failed to place a cover on top of the tea dispenser to avoid air borne contaminants. 2. The facility failed to ensure food in the freezer and dry storage area was labeled and dated when stored. 3. The facility failed to ensure expired food in the refrigerator and dry storage area was discarded. 4. The facility failed to ensure the ice machine and ice scoop holder were thoroughly cleaned. These failures could place residents at risk for cross contamination and food-borne illnesses. Findings include: Observations on 07/22/25 from 9:07 AM to 9:20 AM in the facility's only kitchen revealed: One zip lock bag of frozen chicken nuggets, located in the freezer, was not labeled with the date stored. One large container of honey mustard dressing, located in the refrigerator, had a disposal date of 6/17/25, and was not discarded. Packages of hot dog buns, hamburger buns, and white bread, located in the dry storage area, were not labeled with the date stored. One large tea dispenser, located in the kitchen area, had tea in it, but it did not have a lid placed on the top of the dispenser to avoid air-borne contaminants. An ice machine, located in the kitchen had stains and dirt particles along the door openings and the inside of the door. The ice machine scoop holder, hanging on the wall, had brown dirt particles on the inside bottom of the holder. In an interview and observation on 07/22/25 at 9:20 AM, the Dietary Manager was shown the concerns observed in the kitchen and she stated the tea was just recently prepared and should have been covered once it was done. She stated she was responsible for ensuring food was labeled and dated and ensuring food was discarded once it expired but the items mentioned were overlooked. She stated the ice machine was cleaned at least once a week by the night team, and they should have also cleaned the ice scoop holder. She stated not addressing the areas mentioned could result in residents getting sick. In an interview on 07/24/25 at 11:22 AM, the Administrator stated he was briefed by the Dietary Manager of some of the concerns observed in the kitchen. He was shown pictures of the concerns observed in the kitchen. He stated he was a little surprised to hear of some of the findings because the Dietary Manager stayed on top of labeling, dating, discarding of expired food, and cleaning kitchen equipment. He stated his expectation was for the kitchen to follow state guidelines. He stated not meeting these expectations could be harmful to the residents' health. Record review of the facility's policy on Dietary Services/ Food Storage (08/2007), revealed It is the policy of this facility that food storage areas shall be maintained in a clean, safe, and sanitary manner. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipped areas. Ice which is used in connection with food or drink shall be from a sanitary source and shall be handled and dispensed in a sanitary manner. Record review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, Food shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306.

Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Resident #76 and Resident #79) of twenty-four residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #76's room was in a position that was accessible to the resident on 07/22/2025.The facility failed to ensure the call light system in Resident #79's room was in a position that was accessible to the resident on 07/22/2025.This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings included:Resident #76 Record review of Resident #76's Face Sheet, dated 07/23/2025, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #76 had diagnoses which included Alzheimer's disease (loss of memory and cognitive ability that interferes with daily life) and unsteadiness on feet. Record review of Resident #76's Quarterly MDS (tool used to assess functional capabilities and health needs) Assessment, dated 06/03/2025, reflected severely impaired cognition with a BIMS (tool used to assess cognition) score of 0. Section GG (functional abilities) indicated Resident #76 required assistance with self-care and mobility needs.Record review of Resident #76's Comprehensive Care Plan, dated 01/27/2025, reflected Resident #76 was at risk for falling related to impaired mobility and impaired cognition. One intervention was to keep the call light within reach and encourage the resident to use it to call for assistance as needed. During an interview and observation on 07/22/25 at 9:20 AM, Resident #76 was lying in bed awake. The bed was in the lowest position. The resident's recliner was to the right of Resident #76's bed. Resident #76's call light was on the floor on the opposite side of the recliner and not within the resident's reach. When asked if the resident used her call light, she stated no. Resident #76 was unable to answer further questions because of her cognitive status. During an interview on 07/22/2025 at 9:27 AM, CNA C stated Resident #76's call light should have been placed within reach. She stated it was important for residents to have their call light in reach in case they needed something. She stated whether or not a resident used their call light, they should always be able to reach the call light. She stated a resident might try to get up without assistance and fall. During an interview on 07/24/2025 at 11:42 AM, LVN A stated the call light should have been in reach. He stated it was important for all residents to have their call light in reach because that was how staff knew when a resident needed help.Resident #79Record review of Resident #79's Face Sheet, dated 07/23/2025, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #79 had diagnoses which included hemiplegia (one-sided paralysis or weakness) following a stroke (blood flow to the brain is blocked), cognitive communication deficit, and the need for assistance with personal care. Record review of Resident #79's Quarterly MDS Assessment, dated 07/12/2025, reflected severely impaired cognition with a BIMS score of 0. Section GG indicated Resident #79 was dependent on staff for self-care needs and mobility needs.Record review of Resident #79's Comprehensive Care Plan, dated 01/15/2025, reflected Resident #79 was at risk for falling related to reduced mobility and a stroke with hemiplegia. During an observation on 07/22/25 at 9:40 AM, Resident #79 was lying in bed asleep. The bed was in the lowest position. Resident #79's call light was on the floor behind the roommate's bed. The call light was not within the resident's reach. During an interview on 07/22/2025 at 9:51 AM, CNA D stated all residents should have their call light within reach. He stated Resident #79 did not use the call light but it should have been where she could reach it. He stated it was important for the call light to be within reach in case the resident had an emergency or needed assistance. During an interview on 07/22/2025 at 11:52 AM, the ADON stated her expectation was for all residents to have their call light within reach. She stated Resident #76 and Resident #79 should have had their call lights in reach. She stated it was important for residents to have their call light to reach staff for assistance. She stated a potential risk of not having the call light within reach was a resident would be unable to call for assistance. During an interview on 07/24/2025 at 11:35 AM, the DON stated Resident #76 and Resident #79 should have had their call lights within reach. She stated some residents had dementia and may throw their call light. She stated it did not matter if a resident used their call light or not, all residents should be able to reach their call light. She stated it was important for residents to be able to reach staff when they needed something. During an interview on 07/24/2025 at 2:00 PM, the Administrator stated it was important for the residents to have their call lights within reasonable reach and this should be checked on every round. He stated it was important for residents to have access to help when they needed it. She stated she had in-serviced staff. Review of the facility's policy Policy/Procedure - Nursing Clinical: Call Light/Bell, revised 05/2020, reflected It is the policy of this facility to provide a means of communication with nursing staff.5. Leave the resident comfortable. Place the call light within the resident's reach before leaving room.

Based on observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two (Resident #1 and Resident #63) of six residents reviewed for respiratory care.The facility failed to ensure Resident #1's yankauer suction tip (device used to suction fluids and secretions from the oral cavity) was stored in a bag when not in use on 07/22/2025. The facility failed to ensure Resident 63's oxygen tubing was properly stored in a bag when not in use on 07/22/2025.This failure could place the residents at risk for respiratory infection and not having their respiratory needs met. Findings included: Resident #1Review of Resident #1's Face Sheet, dated 07/24/2025, reflected the resident was a [AGE] year-old male who originally admitted to the facility on [DATE]. Resident #1 had diagnoses which included cerebral infarction (blood flow to the brain if blocked), dysphagia (difficulty swallowing), and hemiplegia (one-sided paralysis or weakness). Record review of Resident #1's Physician Orders, dated 08/18/2024 reflected oral suction as need for increased secretions. Record review of Resident #1's Quarterly MDS Assessment, dated 04/25/2025, reflected a BIMS test was not conducted because the resident was rarely/never understood. The MDS Assessment indicated Resident #1 was moderately impaired in the area of cognitive skills for daily decision making. Section O (special treatments, procedures, and programs) reflected Resident #1 received hospice services. Record review of Resident #1's Comprehensive Care Plan, dated 06/16/2025, reflected Resident #1 was admitted to hospice services, per family request, related to cerebral infarction. Interventions included to work cooperatively with hospice to ensure resident's physical needs were met, symptoms controlled, and maximum comfort was provided for the resident An observation on 07/22/2025 at 10:10 AM revealed Resident #1 lying in bed asleep. A machined used to suction oral secretions was on Resident #1's nightstand. Suction tubing was connected to the machine and the yankaeur suction tip was lying on the nightstand behind the suction machine. It was not stored in a bag. During an interview on 07/22/2025 at 10:15 AM, LVN B stated the suction tip should have been covered. He stated it had not been used for a long time because Resident #1 was not having a lot of secretions. He stated it was kept there in case it was needed. He stated if someone touched it or sneezed on it, it would contaminate the suction tip and put Resident #1 at risk for getting an infection. During an interview on 07/24/2025 at 11:35 AM, the DON stated the yankauer suction tip in Resident #1's room should have been stored in a bag. She stated if it were not frequently used, staff could have placed a new sealed yankauer suction tip next to the machine in case it was needed. She stated the risk was contamination and it placed the resident at risk for infection. She stated she had already in-serviced staff about it Resident #63Record review of Resident #63's Face Sheet, dated 07/24/2025, reflected the resident was an [AGE] year-old female who admitted to the facility on [DATE]. Resident #63 had diagnoses which included COPD (disease of lung and airway that affects breathing), hypertension (high blood pressure), acute respiratory failure (life threatening condition where there is not enough oxygen in the blood), and difficulty in walking. Record review of Resident #63's Quarterly MDS Assessment, dated 07/22/2025, reflected intact cognition with a BIMS score of 15. Section I (active diagnoses) reflected Resident #63 was treated for COPD and acute respiratory failure. Record review of Resident #63's Physician's Orders, dated 07/17/2025, reflected an order for oxygen at 3 liters continuous via nasal cannula every shift related to acute respiratory failure.Record review of Resident #63's Comprehensive Care Plan, dated 07/18/2025, reflected Resident #63 had altered respiratory status/difficulty breathing related to acute on chronic respiratory (worsening of a chronic condition) respiratory failure. Interventions included to provide oxygen as ordered, monitor for signs and symptoms of respiratory distress, and report to medical doctor as needed.During an observation and interview on 07/22/2025 at 11:20 AM, Resident #63 was sitting up in bed. Resident was receiving oxygen via a nasal cannula and the oxygen concentrator was set at 3 liters. The wheelchair was next to Resident #63's bed and had a portable oxygen tank on the back of the wheelchair. The oxygen tubing was connected to the concentrator and was looped over the top of the oxygen concentrator. It was not bagged. Resident #63 stated she did not know it if was supposed to be bagged but she had no concerns with her care. During an interview on 07/22/2025 at 11:28 AM, LVN B stated the tubing on the wheelchair should have been stored in a bag since the resident was not using it. He stated it was important to keep the oxygen tubing covered to prevent contamination and the risk for infection to the resident. LVN B removed the tubing and disposed of it. He stated he would get new tubing and ensure it was placed in a bag. During an interview on 07/22/2025 at 11:52 AM, the ADON stated the oxygen tubing on Resident #63's wheelchair should have been bagged. She stated the risk to the resident was contamination and infection. During an interview on 07/24/2025 at 11:35 AM, the DON stated all respiratory tubing should be bagged when not in used. She stated it was important to prevent infection and respiratory issues. She stated sometimes therapy got new tubing and connected it to the oxygen cannister on a residents wheelchair and did not put it in a bag. She stated she had in-serviced nursing and therapy staff about ensuring respiratory items were covered when not in use. Review of the facility's policy Licensed Nurse Procedures - Oxygen Equipment, reflected It is the policy of this facility to maintain all oxygen therapy equipment in a clean and sanitary manner. E. When mask or cannula is temporarily not being used, it will be covered loosely to prevent contamination from airborne microorganisms. It will not be covered tightly. The policy was undated.

Based observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #78) of six residents observed for infection control. The facility failed to ensure that CNA E changed gloves and performed hand hygiene, did not carry gloves in her pocket, and did not blow on her hands to dry the hand sanitizer, while providing incontinent care to Resident #78 on 07/22/2025.These failures could place the residents at risk of cross-contamination and development of infections.Findings included:Resident #78Review of Resident #78's Face Sheet, dated 07/23/2025, reflected the resident was a [AGE] year-old female who originally admitted to the facility on [DATE]. Resident #78 had diagnoses which included dementia (decline in cognitive function) and the need for assistance with personal care Record review of Resident #78's Quarterly MDS Assessment, dated 06/11/2025, reflected severely impaired cognition with a BIMS score of 0. Section H (bowel and bladder) indicated Resident #78 was always incontinent of bowel and bladder. Record review of Resident #78's Comprehensive Care Plan, dated 06/30/2025, reflected Resident #78 was at risk for pressure ulcer related to incontinence of bowel and bladder. One intervention was to immediately notify nurse of any new area of skin breakdown noted during bath or daily care. An observation and interview on 07/22/2025 at 2:40 PM revealed CNA E preparing to provide incontinence care to Resident #78. CNA E explained to Resident #78 what she was going to do and pulled the curtain for privacy. CNA E had incontinence care items placed on the bedside table. CNA E used hand sanitizer, removed two gloves from the pocket of her scrub top and put the gloves on her hands. CNA E pulled down the front of Resident #78's brief and used a single wipe for each pass to clean the resident. CNA E did not change gloves and use hand sanitizer. CNA E assisted Resident #78 to turn to her left side and took Resident #78's right hand, with the hand used to clean the resident, and placed the resident's right hand on the side rail of the bed. CNA E cleaned Resident #78's bottom. She removed her gloves and used hand sanitizer. CNA E pulled gloves from the pocket of her scrub top, softly blew on her hands to dry the sanitizer, and put on the clean gloves. CNA E secured the tabs on the resident's brief and pulled up the blanket to cover the resident. CNA E washed her hands in Resident #78's restroom before exiting the room. CNA E stated she had been a CNA since 1986, and started the prior week at the facility, working on an as needed basis. CNA E stated she should have removed her gloves and used hand sanitizer after cleaning Resident #78. CNA E stated she should not have blown on her hands to dry the hand sanitizer. CNA E stated she should not carry gloves in her pockets because they can get contaminated. CNA E stated she received training when she started working at the facility on resident care. CNA E stated it was important to prevent residents from getting an infection.During an interview on 07/24/2025 at 11:35 AM, the DON stated she had in-serviced staff related to incontinence care, hand washing, and not putting gloves in their pockets. She stated it was important to prevent contamination and infection. During an interview on 07/24/2025 at 11:50 AM, LVN A stated CNA E should have followed infection control measures when providing incontinence care for Resident #78. He stated staff were frequently in-serviced about incontinence care. LVN A stated sometimes PRN staff forgot routine hygiene practices. He stated as a nurse, when he observed CNAs not following proper procedures, it was a teaching moment for him. LVN A stated it was important to follow measures to prevent contamination and the spread of infection. Review of the facility's policy, Policy/Procedure - Nursing Clinical: Incontinent Care, revised 05/2007, reflected It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene based on accepted standards. All personnel shall follow the handwashing/hand hygiene procedure to help prevent the spread of infections to other personnel, residents, and visitors.

Based on observation, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food storage, labeling, dating, and kitchen sanitation. The facility failed to ensure food in the facility's refrigerator, was labeled and dated according to guidelines. The facility failed to ensure food in the facility's freezer, was labeled and dated according to guidelines. The facility failed to ensure the ice machine scoop holder, located in the facility's kitchen, was cleaned. The facility failed to ensure kitchen equipment (storage bins) was cleaned and sanitary. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings included: Observations on 06/18/24 from 09:05 AM to 09:25 AM in the facility's only kitchen reflected: Observation of the ice machine, in the facility kitchen revealed the ice scoop was stored in a blue container, and the bottom of the containers had black stains in it. Two large white storage bins containing sugar and flour had black dirt stains along the outer and inner entrance of the container. The sugar had black particles in it. Two medium white storage bins containing brown sugar and rice had black dirt stains along the outer and inner entrance of the containers. One large bag of bread sticks with the date 6/17, and there was no other expiration or discatrd date. Facility policy dictates that the month, day and year should be listed, not just day and month. One bag of large pretzels with the date 6/7 and there was no other expiration or discatrd date. Facility policy dictates that the month, day and year should be listed, not just day and month 10 large frozen tubes of meat were unlabeled undated. The items apppeared to be in its original package but there were no visible label indicating the type of meat and date items were receiverd. An interview on 06/19/24 at 1:00 PM with the Dietary Manager and the dietitian, they were advised of the findings in the kitchen. The Dietary Manager advised that she had made all the corrections that were observed during the initial walkthrough on 06/18/24. The Dietary Manager advised that she had dropped the ball in ensuring that the foods were stored, labeled, and dated correctly. She stated that all of the items mentioned should include the full [NAME] day and year when labeling items being stored upon arrival. The DM stated that she would in-service her team on proper labeloinng and dating items upon arrival and ensure the bins are checked for cleanliness for frequently. They advised the risk of these concerns not being addressed could result in cross contamination and airborne illnesses. An interview on 06/20/24 at 10:45 AM with the DON, he was made aware of the findings in the kitchen. He stated that he expects his kitchen staff to meet all required expectations. He stated the risk of the concerns not being addressed could result in residents getting sick. Record Review of the Facility's policy on Food Storage dated 08/2007, revealed It is the policy of this facility that food storage areas shall be maintained in a clean, safe, and sanitary manner. 1. Food storage areas shall be clean at all times. Review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S 3-202.18. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306.

Based on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for areas in the facility for 6 (Resident room [ROOM NUMBER], #513, #515, #517, #519, and #522) of 14 resident rooms observed for a safe, clean, comfortable, and homelike environment. The facility failed to ensure that Residents room [ROOM NUMBER], #513, #515, #517, #519, and #522 were cleaned and sanitized. This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. Findings included: An observation on 06/18/24 at 10:50 AM of Resident room [ROOM NUMBER]'s reflected the air conditioning located in the room had dirt particles and black dirt grime on the top and between the vents of the units. The air filters had a thick layer of dust on them. One of the two lights in the resident bathroom was out. The corners of the bathroom floor had built up thick dirt and grime. An observation on 06/18/24 at 10:54 AM of Resident room [ROOM NUMBER] reflected the air conditioning located in the room had dirt particles and black dirt grime on the top and between the vents of the units. The air filters had a thick layer of dust on them. The corners of the bathroom floor had built up thick dirt and grime. The faucet on the bathroom sink had thick built up calcium deposits along the base of the faucet. An observation on 06/18/24 at 10:58 AM of Resident room [ROOM NUMBER] reflected the air conditioning located in the room had dirt particles and black dirt grime on the top and between the vents of the units. The air filters had a thick layer of dust on them. The corners of the bathroom floor had built up thick dirt and grime. The faucet on the bathroom sink had thick built-up calcium deposits along the base of the faucet. The top of one of the nightstands had thick milky stains all over the top of it. An observation on 06/18/24 at 11:02 AM of Resident room [ROOM NUMBER] reflected the air conditioning located in the room had dirt particles and black dirt grime on the top and between the vents of the units. The air filters had a thick layer of dust on them. An observation on 06/18/24 at 11:04 AM of Resident room [ROOM NUMBER] reflected the air conditioning located in the room had dirt particles and black dirt grime on the top and between the vents of the units. The air filters had a thick layer of dust on them. The corners of the bathroom floor had built up thick dirt and grime. The faucet on the bathroom sink had thick built-up calcium deposits along the base of the faucet. An observation on 06/18/24 at 11:07 AM of Resident room [ROOM NUMBER] reflected the air conditioning located in the room had dirt particles and black dirt grime on the top and between the vents of the units. The air filters had a thick layer of dust on them. The airduct along the wall had black dirt stains. An interview on 06/19/24 at 1:33 PM with Housekeeping D, she stated she had been at the facility for 18 months. She stated that when she first started, she was told to pick up trash, mop and sweep floor, wipe down doors, windowsills, and the nightstands. She stated they are supposed to clean the air conditioner unit. She stated they are supposed to clean the outer part of the unit. She stated that she thinks maintenance cleans the air filters. She was shown pictures of the concerns observed in the resident room [ROOM NUMBER], #513, #515, #517, #519, and #522, and she stated that maintenance was needed to replace the heavily stained faucets, fix the tiles, and clean the air filters. She stated she would get someone from maintenance to clean the air filters. She stated the housekeeping supervisor was on vacation this week and she was in charge until their return. She stated the risk of the filters not being cleaned thoroughly could prevent the resident from getting fresh air. An Interview on 06/19/24 at 1:46 PM with the Maintenance Director, he stated he had been at the facility for two years. He stated maintenance was supposed to change the air filters quarterly. He stated housekeeping was supposed to clean the air filters in the air condition unit in the rooms while they are cleaning the unit itself. He was shown pictures of the concerns observed in rooms #511, #513, #515, #517, #519, and #522, he stated that maintenance only cleans the unit in the ceiling and the main unit. He stated he would coordinate with housekeeping to ensure that the filters in the 500-hall were cleaned. He was advised of the faucets in the resident rooms that had a lot of calcium buildup. He stated the risk of the air condition units not being cleaned thoroughly could cause medical issues for the resident. Review of the facility's policy on Safe/Comfortable/Homelike Environment (Revised 2022) reflected Housekeeping and Maintenance services include the cleaning, sanitization, and care for rooms and common areas of the facility to ensure that the facility is safe for all who reside, work, and visit.

Based on observations, interviews and record reviews, the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents ' choices for 1 (Resident #46) of 1 resident reviewed. for quality of care. The facility failed to to obtain physician orders and assess Resident #46 for a scoop mattress and obtain physician orders prior to installing the scoop mattress. This failure could prevent the resident to be free from of any physical or chemical restraints. Findings included: Record review of Resident #46's Face Sheet, dated 06/19/2024, revealed she was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included unspecified dementia (memory decline), lack of coordination, and repeated falls. Record review of Resident #46's Quarterly Minimum Data Set (MDS) dated [DATE] revealed, she had a Brief Interview for Mental Status (BIMS) score of 06 (severe cognitive impairment) and for ADL care it stated, for transfers, toileting, and bathing, the resident required moderate assistance. Record review of Resident #46's physician orders dated 06/19/24 revealed no orders for a scoop mattress. Observation on 06/18/24 at 11:03 AM of Resident #46's bed revealed she was observed having a scoop mattress. An interview and observation on 06/19/24 at 10:00 AM with LVN L, she stated she was the nurse for Resident #46. She stated the resident is totally independent and did not require assistance to get into or out of her bed. She stated the resident should not have a scoop mattress. LVN L went into Resident #46's room and observed that the resident did have a scoop mattress on her bed. She stated she was not sure how the resident got the mattress. She stated the resident had just changed rooms and they may have just left the scoop mattress and not replace it. She stated the risk of the resident having the scoop mattress without physician orders or an assessment could result in the result having a fall when trying to get into and out of bed. An interview on 06/20/24 at 10:45 AM with the DON, he stated he was made aware of Resident #46 having a scoop mattress. He stated the residents had recently changed rooms and when the resident was moved into the room, staff failed to change the mattress. He stated they have since changed out the mattress to a more appropriate one. He stated the risk of the resident having a scoop mattress could result in her injuring herself. Record review of facility policy on Physician orders, dated 08/2007, stated It is the policy of this facility to ensure that no resident is placed in physical restraints for the purpose of discipline or convenience and that restraints are only applied to treat the resident's medical symptoms. All residents requiring physical restrains will be assessed for least restrictive measures prior to restraint application and restraints will be reduced as appropriate to the resident's medical condition. No resident will have a physical restraint placed for positioning purposes unless there is clearly no other alternative.

Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one (Resident #78) of eight residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #78's rooms were in a position that was accessible to the residents. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. Findings included: Review of Resident #78's Face Sheet, dated 06/19/2024, reflected that resident was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included difficulty walking, unsteadiness of feet, and weakness. Review of Resident #78's Quarterly MDS Assessment, dated 04/19/2024, reflected Resident #78 had a moderate impairment in cognition with a BIMS score of 11. Resident #15 required moderate assistance for upper body dressing and lower body dressing. Review of Resident #78's Comprehensive Care Plan, dated 05/02/2024, reflected Resident #78 was at risk for falls related to poor balance and lack of coordination, and weakness and one of the interventions be sure the call light is within reach and encourage to use it to call for assistance as needed. Review of Resident #78's Joint Mobility Evaluation, dated 05/22/2024, reflected resident had limited range of motion to both shoulders, both elbows, and both wrists. Review of Resident #78's Fall Risk Assessment, dated 05/16/2024, reflected resident had a minimum risk for fall. Observation and interview with Resident #78 on 06/18/2024 at 11:25 AM revealed that Resident #78 was sitting at the side of her bed. Resident #78's call light was noted pinned between the bed and the wall. Resident #78 reached out her left arm and tried to pull the cord of the call light but stated she cannot pull it because it was trapped between the bed and the wall. She stated that whoever fixed her bed did not notice that the call light could not be accessed and was not able to pull it back to put it on top of the bed. She stated she would use her roommates call light if she needed assistance. She said the staff should put her call light where she could reach it because her arms were not strong enough to pull it. Observation on 06/19/20204 at 7:55 AM revealed that Resident #78 was sitting on her bed talking to a visitor. Her call light was still pinned between the bed and the wall and resident still cannot pull it. In an interview with CNA C on 06/19/2024 at 10:57 AM, CNA C stated she was assigned on Resident #78's hall. CNA C said she did her round at the start of her shift to check if any resident needed to be changed or transferred to the wheelchair. She said she also monitor if the call lights were with the residents. She said she did not notice that Resident #78's call light was pinned between the bed and the wall and cannot be pulled. She said Resident #78 seldom use the call light but said she must still make sure the call light was accessible when needed. She said call light must always be accessible because the residents use them to call the staff for any need and in cases of emergencies. CNA C added that if the call lights were not with the residents, the needs of the resident will not be known and addressed. She said she was responsible in ensuring the call lights were accessible for her assigned residents. She said she would her round and make sure the call lights were accessible to her assigned residents. In an interview with the DON on 06/19/2024 at 11:18 AM, the DON stated the call lights were inside the residents' rooms for a reason. He added the residents used the call lights to call for assistance, for a glass of water, for a pain medication, or for incontinent care. The DON added without the call lights, the residents would not be able to tell the staff what they needed and eventually their needs would not be met. The DON further added when the residents cannot pull or access their call lights, unfavorable incidents like falls, minor hurts, or major injuries could happen. The DON said the expectation was for the staff to ensure that the call lights were within reach of the residents at all times. The DON concluded that moving forward, he would educate the staff of the importance of call lights for the residents and would include the issue on their morning meeting. In an interview with LVN A on 06/20/2024 at 7:32 AM, LVN A stated call lights should be within the reach of the residents at all times. LVN A said the call lights should not be in position where the resident cannot pull it or access it. She said for some residents, the call light was their sense of protection that if something happened to them, they would be able to call the staff for help. She said the residents also use the call lights if they needed to be changed or they needed a pain medication. LVN A said the residents might fall trying to get up and get what they needed. LVN A said everybody was responsible in making sure the call lights were with the residents, whether the resident was independent or not. She said she would check her rooms to see if the residents had their call lights Record review of facility's policy Call Light/Bell Policy/Procedure - Nursing Clinical revised 05/2007 revealed, Policy: It is the policy of this facility to provide the resident a means of communication with nursing staff . Procedures . 5 . Place the call device withing resident's reach before leaving room.

Based observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #49 and Resident #89) of eight residents observed for infection control. The facility failed to ensure that CNA D changed his gloves and perform hand hygiene while providing incontinent care to Resident #49 and Resident #89. This failure could place the residents at risk of cross-contamination and development of infection. Findings included: Resident #49 Review of Resident #49's Face Sheet, dated 06/19/2024, reflected resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included hemiplegia (paralysis of one side of the body) and weakness. Review of Resident #49's Comprehensive MDS Assessment, dated 04/13/2024, reflected Resident #49 had a severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated Resident #49 was always incontinent for bowel and bladder. Review of Resident #49's Comprehensive Care Plan, dated 06/06/2024, reflected resident was incontinent of bowel and bladder related to impaired mobility and one of the interventions was to wash, rinse, and dry perineum (the space between the anus and the genitals). Observation on 06/18/2024 at 10:27 AM revealed CNA D was about to transfer Resident #49 to bed from the shower chair via mechanical lift. While waiting to be transferred, Resident #49 had a bowel movement and soiled the Hoyer sling. CNA D put on some gloves and continued to transfer the resident with the assistance of another staff. He did not wash his hands before putting on the gloves. After the transfer, CNA D rolled the resident towards the wall, rolled the soiled Hoyer sling and bed padding towards the center of the bed and tucked them under the resident. After tucking the soiled Hoyer sling and padding, CNA D took the new brief and placed it at the side of the resident. He did not change his gloves nor sanitized his hands before touching the new brief. CNA D then cleaned the resident's bottom. After cleaning the resident's bottom, CNA D took the new brief and put it under the resident's bottom and then rolled back the resident. He did not change his gloves nor sanitized his hands before putting the new brief on the resident's bottom. He then pulled the soiled Hoyer sling and padding, fixed the brief, and taped it on both sides. He took off his gloves but did not wash his hands after the incontinent care. Resident #89 Review of Resident #89's Face Sheet, dated 06/19/2024, reflected resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included hemiplegia and weakness. Review of Resident #89's Comprehensive MDS Assessment, dated 04/13/2024, reflected Resident #49 had a severe impairment in cognition with a BIMS score of 06. The Comprehensive MDS Assessment indicated Resident #89 was always incontinent for bowel and bladder. Review of Resident #89's Comprehensive Care Plan, dated 04/22/2024, reflected resident had an ADL self-care performance deficit related to CVA (cerebrovascular disease: stroke) and one of the interventions was for staff to assist with ADLs with needed assistance. Observation on 06/18/2024 at 10:59 AM revealed CNA D was about to transfer Resident #89 to his wheelchair. CNA D stated he would clean the resident first and change his clothes. CNA D put on his gloves. He did not wash his hands before putting on his gloves. CNA D unfastened the tape on both sides of the brief, pushed it between the legs of the resident, then rolled the resident to one side. He then proceeded to clean the resident's bottom. After cleaning the resident's bottom, CNA D pulled the soiled brief. He then changed his gloves but did not sanitize his hands. CNA D then took the new brief that was placed on the side of the resident's leg. The brief fell on the floor. CNA D picked it up and placed it on the resident's bottom. CNA D did not get another brief to replace the brief that fell on the floor. CNA D instructed and assisted the resident to roll back. CNA D then cleaned the front part of the resident, pulled the front part of the brief, and taped it on both sides. CNA D did not change his gloves nor sanitize his hands after cleaning the front part of the resident and before touching the new brief again. He then went to the resident's drawer to get new shorts. CNA D did not change his gloves nor sanitize his hands before touching the clean shorts. CNA D then took off the resident's hospital gown and put on the t-shirt that was prepared earlier and the shorts that was taken from the resident's drawer. CNA D took off his gloves and threw them in the trash can. He did not wash his hands after incontinent care. In an interview with CNA D on 06/18/2024 at 1:40 PM, CNA D stated he did not wash his hands before and after cleaning Resident #49 and Resident #89 but did put on new gloves before doing incontinent care. CNA D acknowledged that he did not change his gloves after cleaning the residents and before touching the new brief. He said he should had taken off his gloves, washed or sanitized his hands, and then put on new gloves after cleaning the resident and before getting the new brief. He said he should have replaced the brief that fell on the floor. He said not washing the hands before and after incontinent care, not changing the gloves before touching the new brief and clothes, not sanitizing the hands in between changing of gloves, and not replacing the brief that fell on the floor could cause cross contamination and infection. He said they do have in-services for infection control, handwashing, and incontinent care always. In an interview with the DON on 06/19/2024 at 11:18 AM, the DON stated he was made aware by the CNA involved about the infection control issue during incontinent care. The DON said every staff should wash their hands before and after every care. He said gloves should be changed and the hands should be sanitized after cleaning the resident's buttocks or the resident's front part before touching the any clean items. He said not washing the hands, not changing the gloves, and not sanitizing the hands in between changing of gloves could result to cross contamination and infection. The DON also added if the brief had fallen to the floor, it should not be used anymore for a simple reason that it was already dirty. The DON said the expectation was for the staff would remember to wash their hands and change their gloves when transitioning from a dirty area to a clean area, sanitize their hand when changing their gloves, and not to use items that had fallen to the floor. The DON said he already did a one-on-one in-service with CNA D but would do an infection control in-service for all the staff. He concluded that he would continually remind the staff to be attentive to the procedures for infection control and that he would personally monitor infection control. In an interview with LVN A on 06/20/2024 at 7:32 AM, LVN A stated the right procedure was to wash the hands and change the gloves after cleaning the bottom of the resident and before getting the new brief. She said the purpose of the method was to prevent cross contaminations and infections. She said microorganism could easily transfer if the gloves were not changed throughout incontinent care. LVN A added microorganisms could transfer from the soiled gloves to the new brief as well as to the clothes of the resident. She also said the brief should have been replaced because it already fell on the floor. She said the CNA should have not picked it up in the first place. She said she would remind the CNAs on her hall about the importance of washing hands before and after every care, changing gloves from dirty area to clean area, and sanitizing the hands in between changing of gloves. Record review of facility's policy, Hand Hygiene Infection Control Prevention and Control Program revealed Policy: This facility considers hand hygiene the primary means to prevent the spread of infections . b. Before and after direct contact with residents . h. Before moving from a contaminated body site to a clean body site during resident care . i. After contact with a resident's intact skin . j. After contact with blood or bodily fluids . m. After removing gloves . hand hygiene is the final step. Record review of facility's policy, Infection Control Prevention and Control Program revealed Policy: The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program . Goals: Promote individual resident's rights and well-being while trying to prevent and control the spread of infection.

Based on observations, interviews, and record review, the facility failed to ensure that Residents, who needed respiratory care, was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 (Resident #321 and Resident #322) of ten residents reviewed for respiratory care. The facility failed to ensure Resident #321's nebulizer masks and nasal cannula was properly stored. The facility failed to ensure Resident #322's nasal cannula was properly stored. The facility failed to ensure a Physician's Order was in place for Resident #322's oxygen administration. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met. Findings included: Resident #321 Review of Resident #321's Face Sheet, dated 06/19/2024, reflected that resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) with exacerbation and acute respiratory failure with hypoxia (insufficient amount of oxygen in the body). Review of Resident #321's Comprehensive MDS Assessment, dated 06/08/2024, reflected resident had a severe impairment in cognition with a BIMS score of 07. The Comprehensive MDS Assessment indicated Resident #321's primary medical condition was chronic obstructive pulmonary disease with exacerbation. Review of Resident #321's Comprehensive Care Plan, dated 06/08/2024, reflected resident had an altered cardiovascular status related to COPD (chronic obstructive pulmonary disease) and respiratory failure and the interventions were to administer nebulizer treatment and oxygen as ordered. Review of Resident 321's Physician Order, dated 06/04/2024, reflected, Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML. 1 vial inhale orally three times a day for wheezing, sob (shortness of breath). Review of Resident 321's Physician Order, dated 06/18/2024, reflected, O2 AT 2-4 L/MIN CONTINUOUS PER via NC, every shift. Observation and interview with Resident #321 on 06/18/2024 at 9:40 AM revealed that Resident #321 was on her bed resting. Resident #321 was on oxygen administration via nasal cannula. It was also noted that her mask for breathing treatment was on top of the side table. The breathing mask was not bagged. Resident #321 also had a portable oxygen tank at the back of her wheelchair. A nasal cannula was attached to the portable oxygen tank. The tubing of the nasal cannula was hanging on the backrest of the wheelchair with the prongs of the nasal cannula touching the seat of the wheelchair. The nasal cannula was not bagged. According to the resident, she had breathing treatment every morning. She said the nurse would put it on and would take it off. Observation and interview with CNA B on 06/19/2024 at 7:51 AM, CNA B stated the Resident #321's nasal cannula was hanging at the backrest of her wheelchair. She said the nasal cannula should not be hanging and touching the wheelchair because the wheelchair could be dirty. She said it should be bagged when the resident was not using it so the nasal cannula will not be contaminated. She said whoever assist the resident from transferring from wheelchair to bed should put the nasal cannula in a bag. CNA B went inside the room to get the nasal cannula but then stopped halfway and said she would call the nurse to replace the nasal cannula. Observation and interview with LVN A on 06/19/2024 at 8:38 AM, LVN A stated the breathing mask and the nasal cannula should not have been exposed nor touching anything because it could cause contamination and possible infection. LVN A said the breathing mask and the nasal cannula should be bagged when not in use. LVN A went to Resident #321's room and saw the nasal cannula at the back of the wheelchair. LVN A disconnected the nasal cannula from the portable oxygen and threw it on the trash can. She said she would get a new nasal cannula for Resident #321. She said she would also change Resident #321's breathing mask because it was placed on top of the table. Resident #322 Review of Resident #322's Face Sheet dated 06/19/2024 reflected that resident was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia (long term condition where the lungs cannot get enough oxygen into the blood). Review of Resident #322's Care Plan on 06/19/2024 reflected no care plan for oxygen administration. Review of Resident #322's Physician Order on 06/19/2024 revealed no Physician Order for oxygen administration. Observation and interview with Resident #322 on 06/18/2024 at 9:48 AM revealed Resident #322 was on her bed, resting. It was noted that the resident had an oxygen concentrator at bedside. The oxygen concentrator was off. A nasal cannula was connected to the oxygen concentrator. The nasal cannula was hanging on top of the concentrator and was not bagged. Resident #322 stated she only use the oxygen if she needed it, like if she was having a hard time to breath. She said she had no recollection when was the last time she used her oxygen. Observation and interview with LVN A on 06/19/2024 at 8:41 AM, after coming out of Resident #321's room, LVN A then went to Resident #322's room and saw the nasal cannula hanging on the oxygen concentrator. LVN A disconnected the nasal cannula hanging on the oxygen concentrator and threw it on the trash can. She went to the supply room to get a new nasal cannula, a breathing mask, and plastic bags. LVN A stated she needed to change the nasal cannula and the breathing mask to prevent any respiratory infection. Observation and interview with LVN A on 06/20/2024 at 8:12 AM, LVN A stated Resident #322's order for oxygen was PRN. She logged on to her laptop to verify the order. LVN A said there was no order for oxygen. She said there should be an order for Resident #322's oxygen supplement so the staff would know that the resident had respiratory needs. She said the order for oxygen should be reflected on the resident's physician orders on the system. LVN A said since resident #322 as her resident, she was responsible in putting in the order for oxygen. She added she would put in the order and then started typing the order in the system. In an interview with the DON on 06/19/2024 at 11:18 AM, the DON stated the breathing mask and the nasal cannula should be bagged when not in use. The DON said it was the proper way to store the breathing mask and the nasal cannula. He said if those breathing apparatus were not bagged, exposed, or touching surfaces that were not clean, then oxygen administration could be compromised. The DON said it could also result to contamination and infection. He said the staff, including him, were responsible for monitoring that the nasal cannula and the breathing mask were bagged when not in use. He said that if a resident was using some oxygen, there should be an order specific for oxygen concentration to reflect the amount of oxygen, the duration, and the delivery device. He said the order is essential so the staff would be on the same page in caring for the respiratory need of the resident. He said without the order, the respiratory need of the resident will not be met. He said the expectation was for the breathing mask and the nasal cannula would be stored properly. He continued that another expectation was the staff to put the order on the system if there was an order for oxygen administration. The DON concluded that moving forward, he would educate the staff and would continually remind them to be diligent in making sure the procedures for respiratory care were followed. Record review of facility's policy, Oxygen Administration Nursing Manual - Nursing Care rev. 06/2020 revealed Purpose: To prevent or reverse hypoxemia and provide oxygen to the tissues . III. Infection Control . A. All oxygen tubing, humidifiers, masks, and cannulas . B. Oxygen items will be stored in a plastic bag at the resident's bedside to protect the equipment from dust and dirt when not in use. Record review of facility's policy, Physician's Order, Telephone Orders and Recapitulation Process revised 11/2007 revealed, Policy: 1. Physician's orders shall be obtained prior to the initiation of any medication or treatment . Guidelines . 1 . order to the facility is necessary to show that the resident was admitted by a physician to this level of care . b.) Medication (Name, strength/dose, frequency, route of administration, diagnosis, PRN is to include specific reason).

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for one (Residents #1) of six residents reviewed for clinical records. RN A and LVN B failed to document on Resident #1's August 2023 Medication Administration Record accurate medication times of her insulin on the following dates: 08/01/23, 08/02/3, 08/05/23, 08/06/23,08/07/23, 08/08/23,08/10/23, 08/11/23, 08/12/23,08/13/23, 08/14/23, and 08/15/23. This failure could place residents at risk for inaccurately documented medical records. Findings included: Review of Resident #1's Face Sheet, dated 08/21/23, revealed the resident was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses cognitive communication deficit and type 1 diabetes. Review of Resident #1's Quarterly MDS assessment, dated 07/21/23, reflected Resident #1 had a BIMs score of 15 indicating she was cognitively intact. She had diagnoses of stroke, diabetes, hyperglycemia (high blood sugar), and cognitive communication deficit. Review of Resident #1's Care Plan dated 08/21/23 reflected she had diabetes Mellitus and would have no complicates related to diabetes through target date 09/03/23. Review of Resident #1's Physician's Orders dated 08/21/23 revealed the following physician's orders: Insulin Glargine inject 25 units subcutaneously in the morning scheduled at 08:00 AM for Diabetes Mellitus, order dated 06/11/23; discontinue date 08/06/23. Insulin Aspart inject 6 units subcutaneously one time a day before meals with lunch scheduled at 12:00 PM related to hyperglycemia, order date 03/11/23. Insulin Aspart inject 4 units subcutaneously one time a day before meals with dinner scheduled at 05:00 PM related to hyperglycemia, order date 03/11/23. Insulin Aspart inject as per sliding scaled if 151-200=2units; 201-250=4 units; 251-300=6 units; 301-350=8 units; 351-999=10 units; subcutaneously before meals scheduled at 06:30 AM, 11:30 AM, 04:30 PM, and at bed time scheduled at 09:00 PM related to type 1 Diabetes Mellitus order date 03/11/23. Review of Resident #1's facility Medication Administration Records for August 2023 reflected: RN A documented Resident #1's scheduled 08:00 AM dose of Insulin Glargine 25 units was administered on 08/06/23 at 09:24 AM. RN A documented Resident #1's scheduled 12:00 PM dose of Insulin Apart 4 units was administered on 08/13/23 at 02:03 PM. RN A documented Resident #1's scheduled 06:30 AM dose of Insulin Aspart per sliding scale was administered on 08/05/23 at 07:38 AM, the scheduled 08/12/23 dose was administered at 08:19 AM, and the scheduled 08/06/23 dose was administered at 09:24 AM; the scheduled 11:30 AM dose was administered at 12:52 PM. LVN B documented Resident #1's scheduled 05:00 PM dose of Inulin Apart 4 units before dinner was administered on 08/01/23 at 10:21 PM, the scheduled 08/02/23 dose was administered at 06:48 PM, the scheduled 08/07/23 dose was administered at 06:49 PM, the scheduled 08/08/23 dose was administered at 09:52 PM, the scheduled 08/10/23 dose was administered at 06:56 PM, the scheduled 08/11/23 dose was administered at 10:03 PM. LVN B documented Resident # 1's scheduled 04:30 PM dose of Insulin Aspart per sliding scale was administered on 08/08/23 at 09:51 PM, the scheduled 08/09/23 dose was administered at 06:07 PM, the scheduled 08/11/23 dose was administered at 10:02 PM, the scheduled 08/14/23 dose was administered at 06:05 PM, and the scheduled 08/15/23 dose was administered at 06:21 PM; the scheduled dose at 09:00 PM was administered at 10:30 PM. In an interview on 08/18/23 at 10:02 AM Resident #1 stated she received her insulins sometimes before, at times after a meal, and bedtime. Resident #1 stated the times she was served her meals varied and facility staff were to provide her insulins right before she ate a meal. Resident #1 stated she explained to staff her insulins should be given right before she ate which never happened. In an interview on 08/21/23 at 08:21 AM RN A stated she was aware of Resident #1's scheduled medication administration times by checking the resident's medication administration record. RN A stated with Resident #1's insulin she had to provide it to the resident at the specified time the medication administration record indicated it was due. RN A stated he had to administer Resident #1's insulin within 15 minutes before she received her meals. RN A stated immediately after she administered insulin, she should have documented on the resident's medical administration record it was given. RN A stated at times she had documented the administration of Resident #1's insulin 30 minutes beyond its scheduled time as she had to wait on her meal to be ready. RN A stated without looking at the specific August 2023 medication administration record for Resident #1 she could not remember the times she charted Resident #'1s administration of insulin. RNA stated she had administered Resident #1's insulins timely but documented the administration times late on her medication administration record. RN A stated at times if she had charted beyond the 30 minutes after a scheduled dose of insulin was due for Resident #1 she could have been called away to do something and documented the insulin as administered later in her shift because she was busy. RN A stated she had administered medication late to Resident #1 and the risk of documenting Resident #1's insulin administration late would be it could be considered a medication error because the resident's medication needed to be administered per physician's orders. In an interview on 08/21/23 at 08:41 AM LVN B stated she was aware of when a resident's insulin was to be administered by checking the medication administration record. LVN B stated she was to provide a resident's insulin 10 minutes before a meal was served. LVN B stated she had administered Resident #1's insulin each time she worked with the resident within the scheduled time as indicated on the resident's medication administration record, she then wrote the time she administered the medication on a paper and documented it in the electronic medication administration record later in her shift. LVN B stated in those instances where she documented in Resident #1's electronic medical record late administration times of insulin she had been called away from the task of documentation for reasons like a resident had fallen, she had an admission, or an incident had occurred keeping her from documenting in real time. LVN B stated the risk of late documentation would indicate she had not administered Resident #1's medication as physician ordered. In an interview on 08/21/23 at 09:57 AM Resident #1's attending physician stated facility staff should instantly document the administration of Resident #1's medication in her medication record as they had given her scheduled doses of insulin. He stated he had no indication staff were not administering Resident #1's insulins timely but discussed with the facility as part of the Quality Assurance meeting the issue of staff completing their medication pass for Resident #1 and then documenting the administration later in the shift. In an interview on 08/21/23 at 12:00 PM the DON stated when staff administered Resident #1's insulin they should immediately document in the resident's electronic medication record that the task had been completed. The DON stated he had encountered times in which Resident #1's insulin administration had not been documented timely by staff. The DON stated there were instances in which nursing staff were delayed from documenting real time administration of insulins because they may have to retrieve a meal from the dining room. The DON stated RN A and LVN B should have documented the administration of Resident #1's insulin immediately after providing it to her and not later in their shift. The DON stated in some instances nursing staff failed to document in the moment when they had administered a resident's insulin because they could become busy with caring for a resident that had fallen or displayed behaviors related to dementia and document later in the shift their administration of a resident's insulin. The DON stated if RN A and LVN B should have requested assistance from other staff to respond to situations that may have distracted them from documenting immediately the administration of Resident #1's insulin. The DON stated the risk of not documenting the timely administration of a resident's insulin was it would indicate in a resident's medical record the inaccurate administration of medications. Review of facility policy titled, Policy/Procedure-Nursing Clinical Section: Medication Administration revised 05/2007 reflected . Policy: It is the policy of this facility that medications shall be administer as prescribed [NAME] the attending physician. Procedures .7. Medications may not be set up in advance and must be administered within one (1) hour before or after their prescribed time. NOTE: Before and/or after meal orders must be administered as orders .13. The nurse must enter an explanatory note on the reverse side of the Medication Administration Record when drugs are withheld, refused, or given other than at scheduled times .

Based on observations, interview, and record review, the facility failed to maintain an infection prevention and control program that must include, at a minimum, written standards, policies, and procedures for the program which included standard and transmission-based precautions to be followed to prevent spread of infections for one (LVN C) of seven staff reviewed for infection control. LVN C failed to perform hand hygiene between glove changes as he checked blood sugars and provided insulin for Resident #1. This failure could affect residents by placing them at risk for the spread of infection. Findings included: An observation on 08/18/23 at 11:22 AM of LVN C performing a blood sugar check and insulin medication administration for Resident #1 revealed LVN C washed his hands with soap and water and donned gloves after he entered the resident's room. LVN C used an alcohol pad to cleanse the finger of Resident #1 and allowed it to dry. LVN C using a single use needle pricked the finger to Resident #1's right hand and applied a drop of blood to the glucometer test strip and noted a glucometer blood sugar reading of 111 mg/dL. LVN C disposed of lancelet, test strip, and gloves. Without performing hand hygiene, LVN C donned new gloves and disinfected the glucometer with disinfectant wipes and allowed it to dry before returning it to the medication cart. LVN C disposed of his gloves and the disinfectant wipes. Without performing hand hygiene LVN C donned new gloves and removed Resident #1's Insulin Flexpen from the medication cart, verified the physician's medication order and prepared Resident #1's insulin for administration. LVN C took the resident's Insulin Flexpen into Resident #1's room, Resident #1 exposed her abdomen, and with an alcohol pad LVN C cleansed the skin to Resident #1's left lower abdomen and allowed to air dry. LVN C administered the insulin medication to Resident #1's left lower abdomen quadrant. LVN C disposed of the Insulin Flexpen needle, disinfected the resident's Insulin Flexpen with an alcohol pad, removed his gloves and sanitized his hands with ABHR. In an interview on 08/18/23 at 11:34 AM LVN C stated he should perform hand hygiene by either washing his hands with soap and water and or by using ABHR before and after care and when changing his gloves. LVN C stated he performed hand hygiene initially when he entered Resident #1's room but not when changing gloves during the resident's care. LVN C stated it was important to perform hand hygiene when changing gloves to reduce the risk infection to a resident. In an interview on 08/21/23 at 12:00 PM the DON stated staff should perform hand hygiene at the beginning of any task by hand washing or the use of ABHR. The DON stated hand hygiene should also be performed by staff during a task before putting on new gloves, when gloves and or hands were visibly soiled, and when staff were in contact with bodily fluids like blood. The DON stated LVN C should have performed hand hygiene each time he changed his gloves to prevent the risk of infection to the resident. Review of facility policy titled; Hand Hygiene revised 10/2022 reflected It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene based on accepted standards. Purpose: Hand hygiene is one of the most effective measures to prevent the spread of infection .Procedure .2. Use alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations .b. Before and after direct contact with residents; c. Before preparing or handling medications .m. After removing gloves .r. After removing and disposing of personal protective equipment

Based on observation, interview and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment along with to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #1) of 4 residents observed for infection control. The facility failed to remove soiled bed linens from Resident #1's bed. This failure could place residents at risk for the spread of infection. Findings included: Observation on 6/27/23 at 9:57am during the surveyor's initial observation of the Alzheimer unit, surveyor smelled a foul odor and observed multiple dry brown stains covering a large portion of the sheet on the Resident #1's bed sheets. Record review of Resident #'1's face sheet revealed a [AGE] year-old female with a current admitted [DATE]. Her diagnoses included unspecified dementia, unspecified severity, with other behavioral disturbances, unsteadiness on feet, generalized anxiety disorder, muscle weakness, cognitive communication deficit, delusional disorders, and major depressive disorder. Record review of Resident #1's MDS dated [DATE] revealed resident was unable to complete a BIMS due to cognitive impairment. The MDS revealed the resident required extensive assistance from staff with transfers, bed mobility, transfers, dressing, toileting, and personal hygiene. Interview with Aide A assigned to Resident #1's room on 6/27/23 at 1:06pm, revealed the resident was incontinent of bowel and bladder. Aide A revealed the aides are responsible to change linens. Aide A revealed she was unaware of when Resident # last slept in the bed and when Resident #1's room was last cleaned. Aide A revealed when a resident's bed had soiled linens the soiled linens needed to be taken off, the Aide needed to clean the bed and then make the bed. Aide A revealed the risk of leaving soiled linens on a bed could cause a resident to be sick. Aide A revealed the linens were changed routinely and as needed. Aide A revealed the residents that were on hospice had a hospice aide that came Monday-Friday for showers and changed the bed linens. Interview with LVN on 6/27/23 at 1:15pm LVN revealed Resident#1 was bowel and bladder incontinent. LVN revealed the aide was responsible daily to change the bed linens, but ultimately everyone was responsible to change the bed linens. The LVN revealed the resident last slept in her bed on 6/23/23 prior to going to the hospital. The LVN revealed if a resident goes to the hospital all lines are taken off the resident's bed and clean linens are put on the bed. The LVN revealed she made sure herself to change the linens when Resident #1 left for the hospital on 6/23/23. The LVN revealed the resident would return to the same bed. The LVN revealed the risk of leaving soiled linens could be bacteria, wounds, infections, skin compromised, hygiene issues. Interview on 6/27/23 at 1:45pm the DON revealed Resident #1 was assigned to bed 522B, but she was currently in the hospital. The DON revealed Resident #1 went to the hospital on 6/23/23. The DON revealed Resident #1 had a roommate. Resident #1 had a roommate, but the roommate was asleep each time surveyor attempted to interview her. The DON revealed Resident #1 was incontinent of bowel and bladder. The DON revealed the aides and LVNs are responsible to change the bed lines each morning and as needed. The DON revealed the last time Resident #1 slept in her bed was the night before she went to the hospital. The DON revealed the risk of leaving soiled bed linens on beds could cause infection control issues. The DON revealed the LVNs do their rounds each shift and the management team does rounds each morning. Record review of the facility Policy for Infection Control Prevention and Control Program dated, 9/2017 revealed in part: Policy Statement The infection Prevention and Control Program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. Goals: The goals of the Infection Control Program are to: a. Decrease the risk of infection to residents and personnel. b. Recognize infection control practices while providing care. c. Identify and correct problems relating to infection control practices. d. Ensure compliance with state and federal regulations relating to infection control. e. Promotion individual resident's rights and well-being while trying to prevent and control the spread of infection. f. Monitor employee health and safety.

Based on observation, interview, and record review, the facility failed to ensure special eating equipment and utensils were provided for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals and snacks for 1 of 3 residents (Resident #69) reviewed for feeding assistance. The facility failed to provide Resident #69 an adaptive aid to assist her to eat independently. The failure could place residents who required adaptive feeding equipment at risk for loss of self-worth and empowerment for independent eating, which could lead to unplanned weight loss. Findings: Record review of Resident #69s quarterly MDS assessment dated [DATE] reflected Resident #69 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses unspecified severe protein-calorie malnutrition (Malnutrition is an imbalance between the nutrients your body needs to function and the nutrients it gets) Rheumatoid arthritis (A chronic inflammatory disease that affects the joints. This results in painful joints, swelling and stiffness in the joints.), pain in right arm, unspecified lack of coordination, and muscle weakness generalized. Resident #69 BIMS was 15 which indicated cognitive intact. She required limited assistance with eating. Record review of Resident #69's Comprehensive Care Plan, dated 11/10/22, reflected the following: recommend use of divided plates for all meals . Goal: maintain adequate nutritional status . Interventions: follow diet ordered by physician and aid with meals as needed. Record review of Resident #69 weights revealed on 04/02/23, the resident weighed 86.2 lbs. On 05/03/2023, the resident weighed 86.2 pounds which is a 0.00 % Gain. On 12/02/22, the resident weighed 82.6 lbs. On 05/03/23, the resident weighed 86.2 pounds which is a 4.36 % Gain. Record review of Resident #69's orders revealed divided plate with all meals ordered by phone on 04/18/2023. Resident#69 orders revealed continue total assist with meals for weight loss ordered by phone on 01/20/23. During an interview and observation on 05/08/23 at 01:00 PM Resident #69 had trouble lifting her food off her plate. I get so tried trying to eat the food off of the plate, I give up most of the time. Resident#69 stated the divided plate was helpful and she did not have to chase her food around her plate. Resident#69 stated she was having trouble today gripping her utensil and she was still hungry and liked the food. Surveyor asked Resident#69 if she wanted staff to assist her and she stated no. During observation on 05/10/23 at 08:42 AM Resident#69's plate did not have dividers and Resident#69 had orange juice and was not ready to eat her breakfast plate. During interview and observation on 05/10/23 at 08:42 AM the DON stated that Resident#69'plate did not have dividers. DON stated it was the kitchen staff responsibility to make sure residents' food was plated on the correct plate. During interview on 05/10/23 at 11:45 AM Occupational Therapist T stated patients could use the plate dividers to help lift food. Occupational Therapist T stated not having the plate dividers would not cause the resident harm, but it would make the process of eating take longer to do. Occupational Therapist T stated that Occupational Therapy and Speech Therapy work ed together to determine the residents needs and goals. Occupational therapist T stated they have tried different assistive equipment with the resident and saw what would work the best. The Dietary Manager and Charge nurse should receive printed tickets with special equipment needs noted. Occupational Therapist T stated someone is supposed to make sure she finished her meals. Occupational Therapist T stated one of Resident#69 goals are to independently feed herself. Occupational Therapist T stated the Ticket system recently changed at the beginning of last week. Occupational therapist T stated Occupational therapy made sure resident information was updated and correct. During interview on 05/10/23 at 12:05 PM, the Speech Therapist stated they usually consult ed with Occupational therapy to see what the best things for resident will be, copy of order for divided plate was given to kitchen and nursing. Speech Therapist M stated the care plan was updated with information for special equipment. Speech Therapist M stated the divided plates made it easier to eat. Speech T herapist M stated she had assisted Resident#69 with feeding her cereal and she was able to get toast on her own. During interview on 05/10/23 at 12:17 PM DON stated it would take the resident longer to finish eating if the plate did not have the dividers. The kitchen staff was supposed to check the tray to make sure residents are getting the right things. DON stated Resident#69 would have asked for help from nursing staff when she needed it. DON stated Resident#69 usually does not ask for assist. During interview and Record review a on 05/10/23 at 01:50 PM with Regional Dietitian, she stated not having the divided plates would mess up the resident by mouth intake and could cause weight loss. The Regional Dietitian stated the facility switched over to a new meal ticket system the previous week and she thought she had transferred all the information over. Record review revealed dietary instructions were in Resident#69 orders and care plan. During an interview and observation on 05/10/23 at 2:30 PM, the Dietary Manager stated dietary staff were made aware of orders for adapted devices such as divided plates for their meals. Dietary Manager stated the facility recently switched over to a new ticket system for their trays. Dietary Manager pointed to a section on the ticket titled Tray Instructions and stated any orders for things like divided plates and weighted silverware would show there. Dietary Manager stated in their other facilities, the ticket system communicated with the facility's Electronic Medical Record System-Point Click Care so orders automatically carried over. That was not the case in this facility, and they worked to correct it. Dietary Manager stated all new orders were sent to the Regional Dietitian, who manually entered all orders. She stated the Speech Therapist gave her a list of all residents requiring adaptive aides and that was sent to the Regional Dietitian as well. The Dietary Manager stated, without the dividers, the residents would be unable to get the food onto their utensil and food would wind up on the table, and not in their mouth. The Dietary Manager stated this could lead to weight loss and lack of nutrition needed for healing and well-being. Dietary Manager stated staff was in service on 05/10/23 on the new ticketing system. Record review of the facility physician orders (revised 05/2007), revealed no policy related to assistive devices.

Based on observation, interview, and record review, the facility failed to maintain medical records on each resident that are complete, accurately documented and readily accessible for one (Resident #85) of five residents reviewed for clinical records. The facility failed to ensure that Resident #85's physician's orders for tramadol were written to be given orally and not enterally. This failure could place residents at risk of inaccurate medical records that could affect monitoring and medical services provided. Findings included: Review of Resident #85's face sheet, dated 05/10/23, revealed she was an [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included cognitive communication deficit, unspecified dementia, and schizoaffective disorder. Review of Resident #85's physician's orders reflected: Tramadol tablet 50 MG, give 50 MG enterally every 6 hours as needed for for lower back pain [sic] with a start date of 09/11/20. Review of Resident #85's most recent quarterly MDS assessment, dated 01/10/23, reflected she had a BIMS of 01 indicating severe cognitive impairment. An observation and interview on 05/10/23 at 12:30 PM with Resident #85 revealed she was sitting in the dining room area at a table eating her lunch. Resident #85 was not able to answer questions but there was no indication she had a g-tube. An interview on 05/10/23 at 12:35 PM with MA G revealed she did not provide Resident #85 her PRN tramadol, but that the nurse did instead. MA G said Resident #85 should receive all her medications by mouth since she did not have a g-tube. An interview on 05/10/23 at 1:10 PM with LVN T revealed Resident #85 had not been provided her PRN Tramadol for a while because she had not needed it. LVN T said that Resident #85 did not use a g-tube and should receive all her medications by mouth instead. LVN T said she had only been at the facility for a little while and was not sure why the Tramadol order was written to be given to her enterally when that was not an option for her. An interview on 05/10/23 at 1:25 PM with the DON revealed Resident #85 did not have a g-tube and should receive her medications by mouth and not enterally. The DON said he was not sure why Resident #85's tramadol was written to be given enterally instead of by mouth. The DON did not provide a concern regarding the medication order written incorrectly. Review of the facility's policy, revised 05/07, reflected: 6. Orders for medications must include: .D. Route of administration if other than oral; .

Based on observation, interview, and record review, the facility failed to assure that medications were secure and inaccessible to unauthorized staff and residents for 1 (medication aide cart) of 4 medication carts reviewed for medication storage. The facility failed to ensure the medications were placed inside of the medication cart when MA H left the medication cart on the hallway. This failure could place residents at risk of ingesting unprescribed medications resulting in adverse health consequences. Findings included: Observation on 05/08/23 at 09:20 AM during the medication administration revealed MA H leaving the resident's medication on top of the medication cart and stated she was going to get a blood pressure machine. When MA H returned, she proceeded to the resident's room. The medications were still on top of the medication cart. There were staff members on the hallway going in an out of the residents rooms. In an interview on 05/08/23 at 09:48 AM with MA H she stated she forgot the medications on top of the cart when she left to get the blood pressure machine. MA H stated the medications were to be locked in the medication cart when she was not near the medication cart to prevent someone from taking the medications. In an interview on 05/10/23 at 12:25 PM with DON he stated MA H had informed him of leaving cards of medications on top of the medication cart when she went to another resident's room. DON stated the staff was supposed to be locking up the medication in the medication cart due to the safety because anyone can pick up the medications from the cart. DON stated he completed an in-service with all the medication aides and check off completed on medication administration. In-service reviewed. Review of the facility policy revised 05/2007 and titled Medication Administration reflected, .9. The medication cart is to be kept in clear view and in reach of the person administering medications at all times. It is to be locked when the medication nurse is away from the cart.

Based on observations, interview, and record review, the facility failed to handle, store, process, and transport linens so as to prevent the spread of infection for one (300-unit shower room) of four facility shower rooms reviewed for infection control. The facility failed to ensure soiled laundry and bedding was not stored in the 300-unit shower room to prevent the spread of infection. This failure could affect staff and residents placing them at risk for the spread of infection. Findings included: An observation on 03/15/23 at 8:42 AM of the 300-unit shower room revealed, assorted towels, one blanket, and a pair of resident's socks in direct contact with the shower floor. The soiled resident's laundry and bedding was not bagged. An interview and observation on 3/15/23 at 8:45 AM with the ADON revealed, he observed assorted linens, a towel, and a pair of resident's socks in direct contact with the shower room floor not bagged. The ADON stated soiled laundry should be placed in a plastic bag and then placed in a yellow bin for laundry personnel to retrieve. He stated the items in direct contact with the floor not being bagged posed an infection control issue with the potential for transmission of germs to anyone who would handle them. In an interview on 03/15/23 at 12:20 PM the DON stated, facility staff were in serviced 03/15/23 on Infection Control/Disposal of Soiled Linens. He stated they were in serviced that resident laundry and linens should be bagged in the shower room as they are completing a shower and once bagged should be placed in the yellow laundry barrel. He stated, resident laundry and linens should not be placed in direct contact with the floor due to the risk of infection control and to prevent cross contamination of dirty and clean materials. Review of the facility policy dated 08/29/17 titled Infection Prevention and Control Program Section Infection Prevention and Control Program-Linens reflected, I. Policy Soiled laundry/bedding shall be handled in a manner that prevents gross microbial contamination of the air and persons handling the linen. II. 1. Soiled laundry and bedding (e.g. personal clothing, uniforms, scrub suits, gowns, bedsheets, blankets, towel, etc.) contaminated with blood or other potentially infectious materials must be handled as little as possible and with a minimum of agitation. 2. Place contaminated laundry in a bag or container at the location where it is used and do not sort or rinse at the location of use. 3. Place and transport contaminated laundry in bags or containers in accordance with established policies governing the handling and disposal of contaminated items.

Based on observation, interview, and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment, which included but not limited to receiving treatment and supports for daily living safely for one (Resident #1) of four residents reviewed for environment. The facility failed to ensure Resident #1's walls in her room were in good repair. This failure could place residents at risk for a diminished quality of life due to the lack of a homelike environment. Findings include: Record review of Resident #1's Annual MDS assessment, dated 02/02/23, revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included hypertension, diabetes, hyperlipidemia, schizophrenia, and Non-Alzheimer's Dementia. Her BIMS score was 0 out of 15, which revealed she was severely cognitively impaired. Observation on 03/09/23 at 11:36 AM of Resident #1's room revealed there was a hole in her wall behind the headboard of her bed. The hole in her wall was aproximately 1 ft long and 6 inches wide. Resident #1 was not at the facility during the observation and did not return prior to surveyor exiting the facility. Resident #1's RP was not contacted. Review of the monthly grievance log for December 2022 - February 2023, reflected there were no concerns regarding holes in residents' walls. Interview with the Maintenance Supervisor on 03/09/23 at 11:51 AM revealed he was responsible for facility repairs. He stated 03/09/23 was the first time he had been in Resident #1's room. He stated he had not received any maintenance requests to repair the wall in her room. He stated he did not know how long the hole had been in the wall. He stated the hole was caused by her bed being positioned too close to the wall. He stated the hole was too large to be patched. He stated he would have to replace the drywall where the hole was located. He stated the hole in the wall did not create any physical risk but was a cosmetic issue. He stated the hole in the wall did not create a home like environment for Resident #1. Interview with the Administrator on 03/09/23 at 3:29 PM revealed he was not aware there was a hole in the wall behind Resident #1's bed. He stated the Maintenance Supervisor was currently making repairs to the wall in Resident #1's room. He stated the hole in Resident #1's wall did not create a homelike environment. He stated wear and tear was normal and the facility was constantly being made. He stated his expectation was for needed repairs to be reported to the Maintenance Supervisor and for repairs to be completed. Record review of the facility policy titled Environmental Services-Housekeeping, dated November 2016, revealed Housekeeping and Maintenance services include the cleaning, sanitization, and care for rooms and common areas of the facility to ensure that the facility is safe for all who reside, work, and visit.

Based on interview and record review, the facility failed to ensure that all injuries of unknown origin were reported no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for one (Resident #1) of six residents reviewed for abuse. MA A, LVN B and LVN C failed to immediately report an allegation of suspected abuse to the abuse coordinator when they noticed bruises on Resident #1 This failure could place residents at risk for abuse and neglect. Findings include: Review of Resident #1's face sheet, dated 01/23/23, reflected the resident was an [AGE] year-old female. She was admitted to the facility on [DATE]. She was admitted with dementia, generalized anxiety, dysphagia (difficulty swallowing foods or liquids) major depressive disorder, hypertension (high or raised blood pressure), speech and language deficit and lack of coordination. Review of the quarterly MDS (Minimum Data Set) assessment, dated 12/03/22, reflected Resident #1 had a BIMS (Brief Interview Mental Status) score of 1, indicating Resident #1 had a severe cognitive impairment. She had minimal difficulty with hearing, she had unclear speech, and needed limited to extensive assistance with activities of daily living. Review of the care plan not dated reflected Resident #1 had cognitive impairment related to dementia, also indicated the resident had impaired communication related to impaired cognition. Review of the skin assessment for Resident #1, dated 01/05/23, reflected the resident had a bruise to left knee and another bruise to the right chest measuring 1cm x 1cm and the bruise was fading. In an interview on 01/23/23 at 10:18 am with MA A, he stated he had taken care of the resident. MA A stated Resident #1 was able to respond to simple commands. The resident needed extensive assistance with activities of daily living with one staff. MA A said towards the end of last month, when she was taking care of the resident, she had bruises to both breasts. He stated the bruises were medium sizes, they were in the front area of the breast. The resident did not complain of pain to the bruised area. MA A stated he was not aware what had caused the bruises. The bruises were still present, but they were fading away. When MA A stated he did not report the bruises to anyone because he assumed the bruises had been reported by the charge nurse. He stated he was aware that if a resident had bruise or injury of unknow origin, it was to be reported to the Administrator who was the abuse coordinator. An interview on 01/2/23 on 11:12 am with LVN B revealed she was the charge nurse for the resident. She stated Resident #1 was pleasant, but very confused but at times she was able to voice needs. The resident used a wheelchair to get around and she needed extensive assistance with activities of daily living. The resident was incontinent of bowel and bladder and some days she would say she wanted to use the bathroom. The resident was showered on Tuesday, Thursday, and Saturday. LVN B also stated the resident's skin assessment was completed weekly and the last time she completed the resident's skin assessment was on 01/19/23 and the resident had old bruises to the chest/breast area and left knee and the bruises were yellowish. LVN B stated the bruises on both breasts were quarter size and the bruises were spreading to the chest area but the bruise on the chest area was a small area. The staff stated she was not the one who initially noticed the bruises, but she was the one completing the weekly skin assessments because she worked in the morning shift. LVN B stated the bruises had been there since the beginning of the month. She stated she thought the bruises were caused from the resident leaning on the bedrail although she had not seen the resident leaning on the side rails. LVN B stated she did not report the bruises to anyone because they looked like old bruises. She also stated for any bruises or injury of unknown origin she was supposed to report to the Administrator because he was the abuse coordinator. An interview with LVN C on 01/23/23 at 1:30 pm revealed she had worked in the memory care unit for about 2 years on the 2-10 shift. LVN C stated she took care of Resident #1, and the resident was oriented to her name, and she was confused. She was able to follow simple commands, but she was anxious at times. She required extensive assistance with activities of daily living. She was incontinent and sometimes she will use the toilet by herself without assistance. LVN C stated Resident #1 had old bruising to bilateral lower extremities, chest areas including breast areas, no bruises on the upper thighs. She stated she noticed the bruises on the chest area around Christmas. She stated she did not report to anyone of the bruises, because she assumed it had been reported. LVN C stated the last time she saw the bruises was on 01/19/23 before the resident was being transferred to the hospital. She stated the bruises were still there, but they were yellowish, and they were fading away. Bruises on the chest area spread towards the right and left breast. The bruises were dime sized on each leg and they were yellowish. She stated the cause of breast bruises on the chest area was due to the resident pressing on the side rail when getting up. LVN C stated she had not been concerned of the resident bruises because the resident transferred herself or positioned herself in bed which might have caused the bruises. She also stated the bruises on the lower extremities could have been caused from resident hitting somewhere although LVN C had not witnessed the resident hit anywhere. She stated she was not aware if the bruises had been reported to the abuse coordinator. An interview on 01/23/23 at 1:48 pm with the ADON revealed the facility did not currently have a DON. He stated he was not aware of Resident #1 having bruises until it was reported from the hospital. He stated when he reviewed the resident's records after it had been reported that the resident had bruises, he noticed the staff had documented the resident having bruises. The ADON stated his expectation, for the staff, was to report immediately to the abuse coordinator any bruises or injury of unknown origin and then fill out an incident report. The ADON stated even if the charge nurse knew what had caused the bruise, they still had to report it. Failure of the staff to report cases of bruises, placed residents at risk of abuse. In an interview on 01/23/23 at 2:13 pm with the clinical resource nurse, she stated she had been in the facility since the DON quit, that was early this year. She stated she noticed there were some issues with documentation, communication amongst the staff members and she had completed in-services. She stated there were concerns identified with skin in the facility and there was a skin assessment on all of the residents on 01/05/23. She on 01/05/23 it was documented bruise was noted on Resident #1's chest area and knee. In-services were provided and reviewed. In an interview on 01/23/23 at 2:25pm with the Administrator, he stated he was the abuse coordinator. He stated the facility staff were to report to him, immediately, any bruises or injuries of unknown origin. He stated he was not aware Resident #1 had bruises until it was reported from the hospital. He stated after the report of the bruises, he started the investigation immediately. On 01/22/23 he completed safe surveys and none of the residents indicated being abused. He stated he also in-serviced the staff on abuse and neglect. The Administrator stated he had not reported any incident of abuse to HHS pertaining to the resident. Review of the facility policy titled Abuse: Prevention of and Prohibition Against, revised 10/2022 reflected, It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation.E. Identification. 1. Facility staff with knowledge of an actual or potential violation of this policy must report the violation to his or her supervisor or the facility administrator immediately. The facility will assist to identify abuse, neglect . 2. Because some cases of abuse are not directly observed, understanding resident outcomes of abuse can assist in identifying whether abuse is occurring or had occurred. Possible indicators of abuse include, but are not limited to: Bruises, skin tears and injuries on unknown source .

Based on observation, interview and record review, the facility failed to ensure 2 (Residents #53 and #249) of 4 residents reviewed for pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. 1. The facility failed to prevent Resident #249 from developing three, Stage III pressure ulcers and one, Stage IV pressure ulcer. As a result, Resident #249's pressure ulcers deteriorated until the wounds became infected and she had to be hospitalized . 2. The facility failed to implement pressure relieving measures, to prevent the worsening of existing pressure ulcers and the development of new pressure ulcers for Resident #53. As a result, Resident #53 had pressure ulcer on both his heels. An Immediate Jeopardy (IJ) was identified on 03/14/19. While the IJ was removed on 03/18/19, the facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy and a scope of pattern because the facility was still monitoring the effectiveness of the Plan of Removal. These failures had the potential to affect residents by placing them at risk for infection and the development and worsening of pressure ulcers. Findings included: 1. Resident #249's Admission Record dated 03/13/19 revealed the [AGE] year-old female resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was discharged to the hospital on [DATE] due to a wound infection and [MEDICAL CONDITION] related to pressure ulcers. She did not return to the facility after her discharge from the hospital. In an interview on 03/13/19 at 3:30 PM the Wound Care Physician, who treated Resident #249's pressure ulcers in the facility, said he saw the resident initially for a pressure ulcer to her sacrum, which healed, but she later developed additional pressure ulcers. He said the resident's wounds deteriorated quickly becoming necrotic and infected. He said he believed the resident needed to be discharged to the hospital on [DATE] to be treated with IV antibiotics for the infection. He said he believed the pressure ulcers had the potential to heal. He said he believed the resident developed the pressure ulcers because she was left in one position too long. He said the resident was up in her wheelchair, at times, when he would visit but the last 4 to 6 weeks, prior to her discharge to the hospital, she was always in bed. Resident #249's Hospital Clinical Summary dated 03/12/18 revealed a [DIAGNOSES REDACTED]. She had no pressure ulcers. Her labs for her nutritional status were within normal limits and included: [MEDICATION NAME] 4.1 (normal range 3.5 - 5.0), total protein 7.9 (normal range 6.0 - 8.3). Resident #249's Admission Progress Note dated 03/13/18 at 12:30 AM revealed the resident was admitted to the facility on [DATE] from the hospital for rehabilitation following surgery. An incision was present to the resident's left hip area. The incision was closed with Dermabond and had no signs or symptoms of infection. The resident had no pressure ulcers. Resident #249's Weekly Skin Check dated 03/12/18 at 7:00 PM revealed the resident had old bruises to her right and left elbows and her left forearm. She had a surgical incision enclosed with Dermabond to her left trochanter (hip). The order was to clean with normal saline, pat dry and cover with ABD pad. No signs or symptoms of infection were noted. Resident #249's Braden Scale for Predicting Pressure Sore Risk dated 03/12/18 at 11:19 PM revealed the form was to be completed on admission for four weeks and then quarterly thereafter. The resident was documented as bedfast with very limited mobility. Her nutrition was documented as adequate. Her risk for developing pressure ulcers was moderate with a score of 13 (a score of 13-14 indicated a moderate risk). Resident #249's Physician order [REDACTED]. Resident #249's Care Plan dated 03/13/18 revealed she was at risk for pressure ulcer related to a history of pressure ulcers, decreased mobility, incontinence and impaired cognition. The goal was for the resident to not develop a pressure ulcer. The interventions included to assess the resident using the Braden score, provide preventative equipment, if indicated, skin assessment upon admission and at a minimum weekly thereafter and to turn and reposition the resident per facility protocol. Resident #249's MDS dated [DATE] revealed she was admitted to the facility from the hospital on [DATE]. She was severely cognitively impaired with a BIMS of 0 (a score of 0-7 indicated severe cognitive impairment). She did not refuse care. She required extensive assistance of two staff for bed mobility and transfers. She was not ambulatory. She was incontinent of bowel and bladder. She had no pain. She was 5 feet 5 inches tall and weighed 99 pounds. She was assessed to be at risk for pressure ulcers but did not have any pressure ulcers on admission. She did have a surgical wound to her left leg related to her fracture. The resident was assessed to need a pressure reducing device for her bed, nutrition or hydration interventions to manage skin problems and surgical wound care. Resident #249's Nurses' Progress Note dated 03/19/18 at 6:51 AM an open skin area was noted to the resident's sacral area with redness to both her buttocks. A new order was obtained to cleanse the sacral area with normal saline, pat dry, apply TAO with dry dressings until the resident was seen by the wound physician. Barrier cream was to be applied to both buttocks. The surgical site was intact with no signs or symptoms of infection. Resident #249's Nurses' Progress Note dated 03/19/18 at 8:25 PM revealed a wound consult was sent to the resident's physician. A new wound care order was received to clean with normal saline, pat dry and apply calcium alginate and bordered dressing until the wound consult. A Weekly Skin Check was not completed and there was no documentation regarding the description of the open skin area. Resident #249's Braden Scale was never updated to reflect the change in her skin integrity or assess additional risk factors. In an interview on 03/14/19 at 3:46 PM ADON B said Resident #249's Braden Scale was not updated, when she had a change in her condition, and the only one in her clinical record was dated 03/12/18. In an interview on 03/14/19 at 3:46 PM the RNC said it was the facility's policy was to update the Braden Scale quarterly and whenever there was a change of condition, such as, the development of a new pressure ulcer. Resident #249's Wound Care Physician's Evaluation dated 03/21/18 revealed the resident had an unstageable deep tissue injury to her sacrum which measured 10.0 cm x 9.2 cm; the depth could not be measured. The wound was documented to be at least 5 days in duration. The wound etiology was documented as pressure and the objective was to heal the wound. The wound care physician performed surgical excisional debridement to the wound. The treat plan included the following wound care treatments, Santyl to be applied once a day for 30 days, zinc ointment once a day for 30 days, calcium alginate once a day for 30 days and a dry protective dressing to applied once a day for 30 days. The recommendations included to off-load the wound and reposition per facility protocol. The resident's appetite was documented to be good. There was no documented indication of pain. Review of the facility's Weekly Pressure Sore QI Log dated 03/22/18 revealed Resident #249 had a facility acquired pressure ulcer to her sacrum, identified on 03/16/18, that measured 1.0 cm x 9.2 cm. Wound care treatments included Santyl, zinc, and calcium alginate. The preventative measures included to off load, reposition and an air mattress. Resident #249's Wound Care Physician's Evaluations from 03/21/18 - 05/09/18 revealed the resident was being seen and treated weekly by the wound care physician. Resident #249's Wound Care Physician's Evaluation dated 05/09/18 revealed, after 51 days, the resident's pressure ulcer to her sacrum was healed. The physician documented to re-consult him, as needed, and continue the present skin care and breakdown prevention. Resident #249's Nurses' Progress Note dated 05/10/18 at 1:10 PM revealed the resident's wound to her sacrum was healed. The week of 05/03/18 - 05/19/18 there was no documented Weekly Skin Check. Resident #249's Nurses' Progress Note dated 05/24/18 at 9:31 AM revealed the CNA notified the nurse the resident had some redness to her buttocks during her shower. The nurse informed the CNA to apply barrier cream on the resident's buttock and each time after incontinent care. The week of 05/20/18 - 05/26/18 there was no documented Weekly Skin Check. The week of 05/27/18 - 06/02/18 there was no documented Weekly Skin Check. The week of 06/10/18 - 06/16/18 there was no documented Weekly Skin Check. Resident #249's Nurses' Progress Note dated 06/16/18 at 12:11 PM the CNA notified the nurse the resident had redness on both side of her hip while changing. The nurse applied barrier cream and staff will turn resident every two hours. The DON and the resident's responsible party were notified of the redness on both of her hips. In a telephone interview on 03/14/19 at 11:25 AM the former DON said she was out a lot during her employment at the facility. She said she did not remember Resident #249 or the circumstances surrounding her stay. Resident #249's Weekly Skin Check dated 06/17/18 at 5:24 PM revealed the form was checked yes, the resident had skin impairments. The form noted to document the areas of skin impairment; however, that section was blank. No other information regarding the skin impairment was documented. Resident #249's Nurses' Progress Note dated 06/20/18 at 2:08 PM a new order was received for skin prep. Resident #249's Nurses' Progress Note dated 06/24/18 at 9:24 PM revealed to continue with the skin prep to both the resident's hips and reposition every two hours. The week of 06/24/18 - 06/30/18 there was no documented Weekly Skin Check. Resident #249's Wound Care Physician's Evaluation dated 06/27/18 revealed the resident had three Stage III pressure ulcers at least 4 days in duration. The first pressure ulcer on her left hip measured 0.7 cm x 1.6 cm x 0.2 cm. The second pressure ulcer on her left ischium measured 1.9 cm x 1.0 cm x 0.2 cm. The third pressure ulcer was on her right ischium and measured 1.5 cm x 1.0 cm x 0.2 cm. The wound care physician performed surgical excisional debridement to all three pressure ulcers. The treatment plan included the following wound care treatments, Santyl to be applied once a day for 30 days, calcium alginate once a day for 30 days and a dry protective dressing to applied once a day for 30 days. The recommendations included to off-load the wound and reposition per facility protocol, multivitamin once daily, zinc [MEDICATION NAME] 220 mg once daily for 14 days. The resident's appetite was documented to be good. There was no documented indication of pain. Resident #249's Physician order [REDACTED]. Resident #249's Nurses' Progress Note dated 06/27/18 at 4:54 PM revealed the resident was seen by the wound care physician and he gave a new order for the resident's left hip wound measuring 1.6 cm x 0.7 cm and the left buttock that measured 1.9 cm x 1.0 cm, both wounds to be cleaned with normal saline, pat dry and apply calcium alginate and cover until healed. Continue turning and repositioning resident while in bed and in her wheelchair. There was no documentation in the Nurses' Progress Notes prior to this date regarding the pressure ulcers or the wound care physician consult. Resident #249's Acute Care Plan dated 06/28/18 revealed the resident had three Stage III pressure ulcers. The goal was for the ulcers to remain free of infection. The interventions included treatment per the protocol or current orders, to reassess the treatment at minimum of every two weeks and evaluate for changes in treatment if improvement not noted, treatment nurse or designee will assess wounds and measure on a weekly basis, dietary intervention and supplements for wound healing, low air loss mattress, as needed. The care plan did not include a pressure relieving cushion to her wheelchair or turning and repositioning. In an interview on 03/14/19 at 3:46 PM ADON B said Resident #249 did not have a care plan regarding pressure ulcers prior to the one above dated 06/28/18. Resident #249's Medication Administration Record [REDACTED]. The resident's pain was assessed every shift and no pain was indicated. In an interview on 03/14/19 at 11:38 AM LVN C said Resident #249 was on her hall for a little while and the resident had a pressure ulcer to her sacrum. She said the resident did not have an air loss mattress. In an interview on 03/14/19 at 12:48 PM LVN A said Resident #249 was on his hall for a little while and he believed she did have an air loss mattress but staff was to still turn and reposition her every two hours due to her pressure ulcers. He said he believed she had a pressure relieving cushion in her wheelchair because she was up in her wheelchair for meals. In an interview on 03/14/19 at 1:18 PM the Wound Care Nurse said she had been employed, as the wound care nurse, since (MONTH) 2019. She said prior to (MONTH) 2019 she worked as a floor nurse but she did not work with Resident #249 and she never saw or heard anything about the resident's pressure ulcers. She said the nurses were supposed to do the weekly skin assessments and notify the wound care nurse of any pressure ulcers. In an interview on 03/14/19 at 2:02 PM the RNC said the documentation, in Resident #249's clinical record was scarce. She said she could only locate three weekly skin assessment that were completed during the resident's stay from 03/12/18 to 07/19/18. She said the nurses should have completed weekly skin assessments, in addition to, the wound care physician's documentation. She said the only documentation regarding a pressure relieving mattress was on 03/12/18 but the order was discontinued on 03/13/18. She said she could not find any documentation, in the resident's clinical record, that an air loss mattress was used but she would try to gain information from the rental company the facility used. She said most of the employees, who worked with Resident #249, had since left their employment. In an interview on 03/14/19 at 4:20 PM the RNC said Resident #249's order on admission for a pressure relieving mattress was just for a regular mattress and not an air loss mattress. She said if the resident had an order for [REDACTED]. She said the facility did not document if a resident was turned every two hours. She said the air loss mattress, wheelchair cushion and turning and repositioning should have been documented on the resident's care plan. Resident #249's Wound Care Physician's Evaluation dated 07/05/18 revealed the resident had three Stage III pressure ulcers. The first pressure ulcer on her right hip (note the previous evaluation dated 06/27/18 documented the wound was on the resident's left hip) measured 5.0 cm x 9.0 cm x 0.2 cm. The wound care physician documented the Stage III pressure wound of the right hip had deteriorated due to generalized decline of the resident and the resident was non-compliant with wound care. The second pressure ulcer on her left ischium measured 2.3 cm x 1.2 cm x 0.2 cm. The wound care physician documented the Stage III pressure wound of the left ischium had deteriorated due to generalized decline of the resident and the resident was non-compliant with wound care. The third pressure ulcer was on her right ischium and measured 2.4 cm x 2.2 cm x 0.2 cm. The wound care physician documented the Stage III pressure wound of the right ischium had deteriorated due to generalized decline of the resident. The wound care physician performed surgical excisional debridement to all three pressure ulcers. The treatment plan included the following wound care treatments, Santyl was to be applied once a day for 30 days, calcium alginate once a day for 30 days and a dry protective dressing to applied once a day for 30 days. The recommendations included to off-load the wound and reposition per facility protocol, multivitamin once daily, zinc [MEDICATION NAME] 220 mg once daily for 14 days and a low air loss mattress. There was no documented indication of pain. There was no documentation that Resident #249's was ever non-compliant with the wound care. Resident #249's MDS dated [DATE] revealed the resident did not reject care. She required extensive assistance of two staff for bed mobility and transfers. She was always incontinent of bowel and bladder. She had no pain. Her weight was 104 pounds. She was at risk for pressure ulcers and had three Stage III pressure ulcers (full thickness tissue loss). The skin and ulcer treatments included nutrition or hydration intervention to manage skin problems and pressure ulcer care. The skin and ulcer treatments did not include a pressure relieving device for her chair or bed, or turning and repositioning. Resident #249's Weekly Skin Check dated 07/16/18 at 7:30 PM revealed the resident had wounds to her coccyx that measured 3 cm x 2 cm, right trochanter (hip) that measured 3 cm x 3 cm and left trochanter that measured 4 cm x 3.5 cm. Resident #249's Nurses' Progress Note dated 07/16/18 at 8:15 PM revealed the CNA informed the nurse the resident's dressing was soiled. The nurse documented the wound might be infected due to the odor. The nurse called the physician and [MEDICATION NAME] 100 mg was ordered for 7 days and the order for Tylenol 3 with [MEDICATION NAME] was changed from every 12 hours to every 6 hours as needed for pain; the resident's responsible party was notified. There were no other Nurses' Progress Notes regarding the pressure ulcers from 06/29/18 to 07/16/18. Resident #249's Nurses' Progress Note dated 07/17/18 at 7:15 PM revealed the resident was receiving antibiotic therapy for a wound infection. The resident was crying and facial grimacing was present. The resident's pain medication was administered. Resident #249's Wound Care Physician's Evaluation dated 07/19/18 revealed the resident had three Stage III pressure ulcers. The first pressure ulcer on her right hip (note the previous evaluation dated 06/27/18 documented the wound was on the resident's left hip) measured 3.8 cm x 3.7 cm x 1.6 cm. The wound care physician documented the Stage III pressure wound of the right hip had deteriorated due to generalized decline of the resident and a deep wound culture was performed. The second pressure ulcer on her left ischium measured 4.5 cm x 3.0 cm x 0.2 cm. The wound care physician documented the Stage III pressure wound of the left ischium had deteriorated due to generalized decline of the resident. The third pressure ulcer was on her right ischium and measured 3.3 cm x 5.0 cm x 0.2 cm. The wound care physician documented the Stage III pressure wound of the right ischium had deteriorated due to generalized decline of the resident. A Stage IV pressure ulcer on her left hip was documented to be at least 6 days in duration and measured 1.0 cm x 1.8 cm x 0.9 cm. The wound care physician performed surgical excisional debridement to all four pressure ulcers. The treatment plan included the following wound care treatments for the first pressure ulcer, [MEDICATION NAME] gel was ordered to be applied once a day for 30 days and the previous order was discontinued; for the second and third pressure ulcers, Santyl to be applied once a day for 30 days, calcium alginate once a day for 30 days and a dry protective dressing to applied once a day for 30 days. There was no dressing treatment plan documented for the Stage VI pressure ulcer. The recommendations included to off-load the wound and reposition per facility protocol, multivitamin once daily, zinc [MEDICATION NAME] 220 mg once daily for 14 days and a low air loss mattress. There was no documented indication of pain. Resident #249's Nurses' Progress Note dated 07/19/18 at 11:27 AM revealed the resident was seen by the wound care physician. He debrided the wounds and drainage was present.[MEDICAL CONDITION] was suspected. He requested the resident be sent to the emergency room for evaluation and treatment. There was no documentation the resident's responsible party was aware of her transfer to the hospital. In a telephone interview on 03/14/19 at 3:46 PM Resident #249's primary physician said he had no real memory of any specifics regarding the resident's stay in the facility. Resident #249's un-dated Situation, Background, Assessment, Recommendation (SBAR) Communication Form revealed the resident had pressure ulcers, was having new pain, the location was not documented. The non-verbal signs of pain were documented as occasional labored breathing with a short period of hyperventilation, repeated troubled calling out, loud moaning or groaning, crying, facial grimacing, rigid, fists clenched, knees pulled up, pushing and pulling away, distracted but reassured by voice or touch. There was a place on the form to document the responsible party was notified of the change in condition; however, it was left blank. Resident #249's Nursing Home to Hospital Transfer Form dated 07/19/18 at 2:11 PM the resident was being transferred to the hospital due to a wound infection. Her vital signs were within normal limits, blood pressure was 120/60, heart rate was 70, respirations were 16, temperature 97.6, O2 saturation was 98% and her weight was 103.9 pounds. In an interview on 03/14/19 at 6:10 PM the RNC said she was unable to locate any additional weekly pressure ulcer documentation or evidence of when or if an air loss mattress was used for Resident #249. 2. Resident #53's admission record sheet revealed a [AGE] year old male who admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #53's Braden Scale for Predicting Pressure Sore Risk dated 02/11/18 revealed the form was to be completed on admission for four weeks and then quarterly thereafter. The resident was documented as chairfast with no limitation for mobility. His nutrition was documented as adequate. His risk for developing pressure ulcers was moderate with a score of 15 (a score of 15-18 indicated at risk). Review of comprehensive care plan for Resident #53 revised on 03/14/19 documented the following: Problem: The resident has pressure ulcer stage 4 to rt heel, and lt heel r/t Immobility/DM/[MEDICAL CONDITION] right heel stage 4 (rt heel resolved 1/30/19) Date Initiated: 08/20/2018 and revised on 03/14/2019. Goal: The resident's will Pressure ulcer (s) will show signs of healing and remain free from infection by/through review date. Date Initiated: 08/20/2018 Revision on: 02/12/2019 Target Date: 05/06/2019 Interventions: 1. Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 08/20/2018 Revision on: 08/20/2018. 2. Apply skin prep daily to right heel. Date Initiated: 02/05/2019 Revision on: 03/07/2019. 3. Follow facility policies/protocols for the prevention/treatment of [REDACTED]. 4. Left heel treat with collagen powder/calcium alginate and cover with dry protective dressing daily and PRN. Date Initiated: 02/05/2019 Revision on: 03/14/2019. 5. Moisturizer to right heel Date Initiated: 02/05/2019 Revision on: 03/15/2019. 6. Monitor nutritional status. Serve diet as ordered, monitor intake and record. Date Initiated: 08/20/2018. 7. Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx of infection, wound size (length X width X depth), stage. Date Initiated: 08/20/2018 8. Obtain and monitor lab/diagnostic work as ordered. Report results to Wound Care Doctor and follow up as indicated. Date Initiated: 08/20/2018 9. Offload bilateral heels while in bed, skin protectors to bilateral heels while in bed, Nursing to Therapy started for positioning device to wheelchair to keep heels off of floor. Podiatry consult ordered to eval for orthotic shoes. Date Initiated: 03/14/2019 Revision on: 03/14/2019. 10. The resident requires supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing. Supplements and diet to promote wound healing. ([MEDICATION NAME], Protein powder, Multi-vitamin with minerals, Vitamin C, Zinc. Diet: FMP and Large portions) Date Initiated: 08/20/2018 Revision on: 03/07/2019. 11. Treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort. Date Initiated: 08/20/2018. 12. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Under direct care of specialized agency wound physician, seen on a weekly basis. Date Initiated: 08/20/2018 Revision on: 03/07/2019. Review of Resident #53's wound evaluation and management summary dated 01/30/19 revealed, .Stage 4 Pressure wound of the right heel (resolved on 01/30/19) recommendations: Reposition per facility protocol; off-load wound; float heels in bed .Stage 4 pressure wound of the left heel-improved evidence by decreased surface area, increased granulation, decreased slough. Dressing treatment plan: [REDACTED]. Recommendations: off-load wound. Review of Residents #53's weekly skin checks a total of 6 assessments, revealed: 1. Effective date: 02/20/19 Site- Right heel: Dry skin, old resolved wound, skin prep daily. Left heel: Open area, treatment in place, Wound Care Physician rounds on a weekly basis. 2. Effective date: 02/22/19 Site- Left heel: open area-rounds done weekly by Wound Care Physician, treatment in place. Right heel: Dry skin, old resolved wound, skin prep daily. 3. Effective date: 02/25/19 Site- Left heel: open area. Wound Care Physician evaluated wound weekly. Dressing order available. Right heel: closed wound, dry skin, skip prep applied. 4. Effective date: 02/27/19 Site- Left heel: open area, treatment in place, Wound Care Physician rounds on weekly basis. Right heel: closed area, old scare tissue, and skin prep daily. 5. Effective date: 03/11/19 Site- Left heel: open area-rounds done weekly by Wound Care Physician, treatment in place. Right heel: scar tissue, skin prep daily as preventative. 6. Effective date: 03/14/19 Site- Left heel: stage 4 being followed by Wound Care Physician. Right heel: 2 ½ cm x 2 cm dry callous overlying scare tissue. Review of Residents #53's Nurses' Progress Note dated 01/31/19 revealed, Wound Care nurse made rounds with Wound Care Physician yesterday evening, are to right heel resolved, will continue to apply skin prep per facility protocol for next 2 weeks as preventative and to monitor area, Received order to continue treatment of [REDACTED]. Review of Residents #53's weekly wound progress a total of 1 assessments revealed: 1. Date of Assessment: 03/06/19 Left heel: 1.2 [MEDICAL CONDITION]. Managed by wound care physician weekly, staff to continue to provide care daily and watch for change in baseline and change in wound appearance. Pain assessments completed pre/post treatments. Resident and staff educated and encouraged to offload heels while in bed to help promote healing and further damage. Wound Care Physician notified of change of treatment: Apply collagen powder, calcium alginate with silver, and dry protective dressing daily and PRN, until resolved. Review of Resident #53's weekly wound progress dated 03/13/19 revealed, left heel pressure ulcer stage 4: 1.1cmx1.4cmx0.3cm. Managed by wound care physician weekly staff to continue to provide care daily and watch for change in baseline and change in wound appearance. Pain assessments completed pre/post treatments. Resident educated and encouraged to offload heels while in bed to help promote healing and further damage. Apply collagen powder, calcium alginate and dry protective dressing daily and PRN, until resolved. Observation on 03/12/19 at 1:20 PM revealed Resident #53 was in a wheelchair in the dining room. Resident #53 had only socks on both feet. His heels were pressed and glided on the floor. His feet were not offloaded to prevent pressure from the floor. Observation on 03/13/19 at 12:30 PM revealed Resident #53 was in a wheelchair in the dining room. The resident continued to only have socks on both feet. The heels of his feet were pressed on the ground as he propelled himself out of dining room. His heels were pressed and glided on the floor. No protectors were present to prevent pressure to his feet/heels. Observation on 03/14/19 at 11:30 AM revealed Resident #53 was in a wheelchair in the hallway. The resident continued to only have socks on both feet. The heels of Resident #53's feet were pressed on the ground as he propelled himself to the dining room. His heels were pressed and glided on the floor. No protectors present to prevent pressure to his feet/heels. In an interview on 03/14/19 at 2:10 PM the Wound Care Nurse revealed Resident #53's the right heel had healed and only required skin prep. She stated she was responsible for daily checks of identified resident's with pressure ulcers in the facility. The Wound Care Nurse's work schedule included: Monday-Friday. Weekend staff were responsible for daily checks for wound care On Saturday and Sunday. She stated every Wednesday the Wound Care Physician completed wound care rounds with the Wound Care Nurse. The Wound Care Physician and Wound Care Nurse measured the size of pressure ulcers of residents and any change of treatment or intervention that was needed. The Wound Care Nurse had the responsible and ability to implement needed wound care interventions. The Wound Care Nurse determined the appropriate interventions if a pressure ulcer was staging or unstageable. The Wound Care Nurse denied observing any concerns of Residents #53's pressure ulcers on the right and left heel. Review with The Wound Care Nurse of the current physician treatment orders reflected for Resident #53's right heel: Stage 4 pressure wound of right heel resolved on 01/30/2019 required daily skin prep and reposition per facility protocol, off-load wound, and float heels in bed. The left heel treatment included: collagen powde

Based on observation, interview and record review, the facility failed to maintain an Infection Control Program designed to provide a safe, sanitary and comfortable enfironment and to help prevent the development and transission of disease and infection for one (Resident #9) of eight residents reviewed for infection control as evidenced by: 1) LVN F failed to practice good infection control procedures: a) LVN F failed to wash her hands or use hand sanitizer before assessing and treating Resident #9's pressure ulcers. b) LVN F placed wound care supplies for treating Resident #9's pressure ulcers on his bed and then onto his dirty and cluttered over bed table. c) LVN F failed to wash or sanitize her hands between treating the two pressure ulcers on his right hip and ischium (back lower part of the hip bone). 2) LVN E failed to practice good infection control procedures: a) LVN E failed to wash her hands, use hand sanitizer or change her gloves between pressure ulcers after removing the old dressing, cleaning or replacing the dressing between wounds. b) LVN E used the same gloved hand to clean the multiple pressure ulcers of Resident #9. c) LVN E dropped Resident #9's feet with multiple pressure ulcers onto the dirty incontinent pad under his feet during pressure ulcer cleaning and treatments. d) LVN E failed to clean or sanitize her scissors after cutting Resident #9's dirty bandage off his right foot, before cutting tape to use, and before cutting off the left foot's dirty dressings and cutting tape. e) LVN E discontinued the wound VAC (negative pressure wound therapy) suction to Resident #9's right hip, right ischium and left hip pressure ulcers, and left the old wound vac dressing on for at least six hours. These failures could have contributed to the decline and infection of Resident #9's pressure ulcers resulting in discomfort, pain, multiple admissions to the hospital, delayed healing and the resident's ultimate admission to hospice. These failures could possibly affect all 22 residents, including Resident #9, who resided on Hall 500 and received care from LVN E and LVN F. Findings included: 1) Resident #9 was a [AGE] year-old male who was admitted to the facility on [DATE], per his admission MDS assessment, dated [DATE], with [DIAGNOSES REDACTED]. Further review revealed he had one Stage IV pressure sore and one unstageable pressure sore, and the Stage IV pressure sore measured length 3.6cm X width 3cm X depth 2cm. The tissue type for the pressure sore at the most advanced stage was "eschar-black, brown, or tan that adheres firmly to the wound bed or ulcer edges." This document also reflected Resident #9 weighed 176 pounds. During the initial tour on [DATE] at 9:04 AM, LVN E described Resident #9 as alert and oriented to his name, his family and where he was, but not to date and time. LVN E said he stayed in bed, had a Foley catheter (a thin flexible, sterile tube that is inserted through the urethra and into the bladder to drain urine) and was incontinent of bowel. LVN E said both of his legs were contracted, he had pressure sores and had wound vac therapy, one to each buttock and pressure sores on his bilateral feet. LVN E informed the surveyor Resident #9 came to the facility with all his wounds, fed himself in his room, and his weight was stable. On [DATE] at 11:55 AM, Resident #9 was in his bed, under a sheet. He had a Foley catheter with clear yellow-colored urine output via the catheter tubing and the bag was inside a privacy bag. Resident #9 was awake and alert and watching TV. Resident #9 had a PICC Line (an IV catheter inserted in the superior vena cava for long-term infusion of bolus or continuous delivery of therapeutics (i.e., drugs, fluids, nutrients, chemotherapy)) in his right upper arm and there was an empty bag of the antibiotic Meropenem hanging on the IV pole on his right side of the bed. The IV antibiotic was not attached to Resident #9's PICC line. The surveyor noted Resident #9's legs were contracted bilaterally, but his arms and hands had full range of motion. There was a clear thick rubber tube going out from the sheet on his right and left sides. These tubes went up over the back of his bed and connected to vacuum machines which were sitting behind the head of his bed. The tubes had a dark brownish-colored liquid moving through the tubing into canisters which was attached to the machines. The surveyor could not tell how much liquid was collected in the canisters. Resident #9's legs were contracted and leaning towards his right side although his back appeared to be flat against his bed and the HOB was up approximately 30 degrees. The surveyor explained why she was there and asked his permission to watch wound care and incontinent care for which Resident #9 agreed. On [DATE] at 1:25 PM, the surveyor asked LVN E about Resident #9's wound care. LVN E informed the surveyor she did his wound VAC care every other day, but on Monday he had been admitted to Hospice and the Hospice nurse was supposed to come on this day and would probably discontinue the [DEVICE]. LVN E said she did not know what the new treatment order would be and she had changed the dressings on his feet that morning and the wound VAC had been changed on the previous day. LVN E told the surveyor she would wait until the surveyor came in the morning to change Resident #9's dressings. Resident #9's admission orders [REDACTED]. The admission orders [REDACTED]. 2 tabs, topical Q daily PRN." and the [DIAGNOSES REDACTED]." They further reflected he had a follow-up appointment in one week. Resident #9's physician's telephone order, dated and signed by LVN F on [DATE] (untimed), reflected orders received from a follow up appointment with the ID physician addressing his right hip and ischium wounds as follows: "Continue the IV antibiotics times four more weeks, orders for labs and Vitamin C (supplement) 500mg PO BID and Zinc (supplement) 220 mg PO every day." Resident #9's admission orders [REDACTED]"Nebcin 300 mg + NS 0.9% 50.0 ml Apply to wound with dressing changes." And, "[MEDICATION NAME] 250 mg 2 tab topical qd as needed wound care." There were no other wound treatment orders. Resident #9's hospital records provided to the surveyor on [DATE] by the facility's Administrator, were dated "Date of Consultation; [DATE]," and reflected the following description of Resident #9's wounds: "Right lateral heel measures 1.0 x 1.0 cm. There is no depth. There is skin overlying this area. There are signs of deep tissue injury with some bruising overlying skin. Right lateral knee wound measures at 3.0 x 2.0 x 0.1 cm. This is covered by light brown eschar (a slough or piece of dead tissue that is cast off from the surface of the skin). There is no exudate (a fluid rich in protein and cellular elements that oozes out of blood vessels due to inflammation and is deposited in nearby tissues), no [DIAGNOSES REDACTED] (redness of the skin or mucous membranes, caused by hyperemia of superficial capillaries), no odor. Right hip posteriorly wound measures at 7.0 x 8.0 x 2.8 cm in depth. There is undermining from the ,[DATE] o'clock of 4.5 cm. There is muscle and tendon exposed. I also see adipose (fat under the skin and surrounding major organs). There is a small amount of necrotic (pertaining to the death of tissue) adipose. I can palpate (examine by feeling and pressing with the palms of the hands and fingers) down to bone using a sterile swab. This is at the level of the trochanter (part of the femur connecting to the hip bone). Right ischium wound measures at 4.5 x 5.5 x 2.7 cm. There is undermining from ,[DATE] o'clock of 4.4 cm. There is muscle exposure with minimal [MEDICATION NAME] (protein helping blood to clot) and slough. Left dorsal (near or on the back) foot has a wound measuring 1.0 x 1.2 x 0.1 cm. This is a partial thickness wound with a red base. There is no exudate, no [MEDICATION NAME] or slough. No periwound [DIAGNOSES REDACTED]. Left hip posteriorly measures at 6.5 x 9.0 x 2.1 cm. There is undermining from ,[DATE] o'clock of 2 cm. There is some necrotic fat at the base of the wound bed. There is tendon and muscle exposure as well. There is moderate amount of serosanguineous (containing or consisting of both blood and serous fluid) exudate without any odor. Left heel wound measures at 4.5 x 5.7 x 0.1 cm. This is covered with eschar. There are some minimal [MEDICATION NAME] and slough around the border of the wound approximately 0.5 cm. There is small serosanguineous exudate without any odor. Left lateral ankle wound measures 0.3 x 0.9 x 0.1 cm. This is covered with eschar. Left lateral foot wound measures at 2.8 x 1.6 x 0.1 cm. This is fully covered with eschar. Left medial plantar foot measures at 5.0 x 1.0 x 0.1 cm. This is fully covered with eschar. Right medial heel wound measures at 1.8 x 2.0 x 0.1 cm. This is fully covered with eschar. Overlying the right fifth metatarsal head at the plantar aspect, there is a wound measuring at 0.9 x 0.7 x 0.8 cm. I do see tendon exposed at the base of the wound bed. There is minimal [MEDICATION NAME] and slough, small serosanguineous exudate without any odor. Right lateral foot wound measures at 2.6 x 2.0 x 0.8 cm. There is also tendon exposed at the base of this wound. There is some moderate red granulation tissue, small [MEDICATION NAME] and slough, small serosanguineous exudate without any odor." Further review of Resident #9's hospital record, dated [DATE], under "Assessment:" revealed the following: "1. Right hip posterior stage IV pressure ulcer with exposed muscle, tendon and bone. 2. Right ischium stage IV pressure ulcer with exposed muscle. 3. Left hip posterior stage IV pressure ulcer with exposed tendon and muscle. 4. Left heel, left lateral ankle, left lateral foot, left medial plantar foot, right lateral knee, right medial heel unstageable pressure ulcers with overlying eschar. 5. Right fifth metatarsal head at the plantar aspect stage IV pressure ulcer with tendon exposure. 6. Right lateral foot stage IV pressure ulcer with tendon exposure. 7. Left dorsal foot stage II pressure ulcer with tendon exposure. 8. Right lateral heel deep tissue injury... ...11. Skin and soft tissue infections with multi gram-negative organism." During an interview with LVN E on [DATE] at 8:45 AM, when asked if she was ready to provide wound care for Resident #9, she informed the nurse the hospice nurse had come the previous night and discontinued the wound vac treatments for his wounds, but had not written any new orders for treatments they were supposed to do. LVN E said she called the hospice nurse that morning and asked her what treatments they were supposed to do and the hospice nurse told her they were coming back and would bring supplies and write orders. The surveyor asked LVN E if the wounds were just left open without any dressings on them and she said, "No, the dressings (black sponges) are still intact. I just unhooked the vacuum." LVN E said she hoped they (the hospice nurse) would come that morning. On [DATE] at 8:47 AM, the surveyor observed Resident #9 in his bed, under a sheet. He appeared well-groomed and his catheter was patent with clear yellow-colored tubing out via gravity with the catheter bag being inside a privacy bag. Resident #9's PICC line was gone in his right upper arm and when the surveyor asked him about it he said they took it out. Resident #9 said they had told him he did not need it anymore as they had stopped the IV antibiotics. Resident #9 said he was told they could use it for blood draws, but it was a "port for infection so they pulled it." Resident #9 asked the surveyor, "Can they put another one in if I need it? Would they use my other arm?" The surveyor noted the tubing from the wound vac still appeared to be attached to Resident #9's dressings on his hips, but the wound vac machine was not running. On [DATE] at 11:00 AM, the surveyor showed CNA M the wound vac tubing in Resident #9's bed was not attached to his dressing and was just on the bed. Resident #9's left hip had a black-colored sponge dressing on it with a coil of small tubing on top of it. Resident # 9's legs and feet were contracted and lying to his right side. His feet were on a pillow and he had pillows under his legs on his right side. Resident #9's back was against the bed and the HOB was up approximately 20 degrees. On [DATE] at 1:35 PM, the surveyor asked ADON A along with LVN, why Resident #9's dressings had still not been changed. ADON A said the hospice nurse had changed them on the previous day and they were waiting for her to bring the new supplies. The surveyor informed ADON A the hospice nurse had not changed the dressings but had only discontinued the previous dressing; however, the wound vac dressing was still on and the suction was off. ADON A said "Oh no, we will go ahead and change it." The surveyor informed ADON A Resident #9's suction had been off since the previous day at 4:00 PM, and LVN E jumped in and said she had disconnected the suction that morning. ADON A said, "Well, we still have to change it and clean it with whatever we have." On [DATE] at 1:40 PM, LVN E began setting up dressing supplies onto an over bed table out in the hall by Resident #9's room. LVN E placed a sheet of wax paper onto the over bed table and placed on top of this five plastic six ounce cups. LVN E placed a small stack of 4 x 4 inch gauze squares in all five of the cups and poured NS into each cup using numerous NS bullets. LVN E placed four ABD pads, scissors, tape, and gloves on top of the wax paper. LVN E wheeled the table into Resident #9's room and then asked him if he was in any pain. Resident #9 was still on his back with the HOB up approximately 30 degrees and his legs contracted and leaning towards his right. (Note this was how he was laying at 11:00 AM.) Resident #9 told LVN E he was having pain and when she asked him if he wanted a pain pill he replied, "Yes." LVN E left the room, went back to her cart and retrieved Resident #9 a [MEDICATION NAME] pain pill, and came back in and gave him the pain medicine with a sip of water. LVN E then looked at the surveyor and said she would come back, took the over bed table out of the room, threw away the five cups with 4 x 4 gauze in them, put all other supplies back into her cart and took the over bed table back to the room it came out of. When the surveyor asked LVN E when she wanted her to come back for the dressing change she said, "Fifteen minutes or so. I'm supposed to be off the clock though..." On [DATE] at 2:15 PM, the Hospice LVN said she had come to write a new treatment order as the Hospice physician had changed what treatment he wanted on Resident #9's wounds as he now wanted [MEDICATION NAME] (an antimicrobial) placed in the wounds. The Hospice LVN said she would write the order to start when the [MEDICATION NAME] arrived. When asked about the wound vac orders Hospice LVN informed the surveyor, ADON A, LVN E and LVN F all knew the wound vac dressing was to stay intact until the new treatment items arrived. When asked if the Hospice RN had meant for the suction to remain on, the Hospice LVN said she thought so, but would call the Hospice RN and find out for sure. On [DATE] at 2:17 PM, LVN F said she had been there on the previous day when the Hospice RN wrote the orders and the Hospice RN had said, "to keep the wound vac hooked up until the new treatment items had arrived for the treatment change." On [DATE] at 2:18 PM, LVN E said, "Yes, I unhooked it this morning...He wanted to get up today...I did it...I removed the suction." On [DATE] at 2:22 PM, the Hospice LVN came back from calling the Hospice RN and asked LVN E if she had discontinued the suction. LVN E replied, "Yeah, I did this morning." The Hospice LVN said the Hospice RN did not intend for the vacuum to be turned off until the new wound supplies were brought to the facility. The Hospice LVN asked to see the wounds so she could maybe get a temporary order until the [MEDICATION NAME] arrived. On [DATE] at 2:25 PM, the Hospice LVN, LVN F and the surveyor went down to Resident #9's room. LVN F without washing her hands donned gloves, uncovered Resident #9 and verbally told the Hospice LVN and the surveyor where his pressure ulcers were. The Hospice LVN told LVN F she needed to actually see the pressure ulcers so she would know what to order for temporary treatments. Resident #9 was in his bed, on his back, and his legs were contracted up to his abdomen with his left foot almost touching his left buttock and his right leg folded under his left one with his left foot pointing down and showing underneath his right foot. There was no pillow between his legs and his right foot was resting on a pillow and his left foot was sitting on top of his right lower leg and ankle. There was a pillow on the side of his right leg and one under his right foot. The dressing on his left hip was clear over a black-colored sponge with a small tubing coiled on it, and the date [DATE] written on it in black marker. Resident #9's bilateral feet were wrapped in [MEDICATION NAME] bandages (an antimicrobial bandage) with the left foots bandage extending to above his ankle area,and the date [DATE] written in black-colored marker. LVN F left the room, went to her treatment cart and retrieved a red bag, package of gauze 4 x 4s, multiple NS bullets and a box of gloves, came back into the room, placed the package of gauze 4 x 4s, the multiple NS bullets and the box of gloves onto Resident #9's dirty and cluttered over bed table. LVN F opened the red bag and placed it at the foot of the bed, put a new pair of gloves on and removed the dressing from Resident #9's left hip. The Hospice LVN and LVN F decided a wet-to-dry dressing was appropriate so LVN F changed her gloves, went back to her cart and set up wound care supplies (scissors, NS bullets, tape and a black-colored marker) onto a sheet of wax paper. The pressure ulcer on Resident #9's hip was approximately L 9 x W 6 x D 1 cm with a yellowish-colored slough wound bed approximately 85 % and granulation approximately 15 %. The peri wound was dark pink-colored to red-colored. LVN F brought back her supplies wrapped in the wax paper and placed them on the foot of Resident #9's bed. LVN F changed her gloves (she had not washed her hands or used sanitizer) and opened the package of gauze 4 x 4s, and took a small stack and placed them inside a plastic cup. LVN F then opened a bullet of NS and sprayed it onto the gauze 4 x 4s, cleaned the pressure ulcer, got more 4 x 4s wet with NS and cleaned the peri wound, changed her gloves, wet ,[DATE] gauze 4 x 4s with NS in a cup, took gloves off to cut the tape, donned new gloves and placed the 4 - 5 gauze 4 x 4s into the left hip pressure ulcer, changed her gloves and placed one dry gauze 4 x 4 over them and taped them in place, changed her gloves and put the date on the tape, and picked up the wax paper with the supplies on it and placed them on Resident #9's dirty and cluttered over bed table. LVN F washed her hands, went to her treatment cart and retrieved more supplies to set up for Resident #9's right hip and ischium pressure ulcers. LVN F and the Hospice LVN turned Resident #9 onto his left side. LVN F changed her gloves and removed the old wound vac dressing with the date [DATE], and there was a foul odor noted when the dressing was removed. Resident #9's larger pressure ulcer on his right hip was approximately L 6 x W 6 x D 1.5 cm. This wound bed was approximately 90 % granulation tissue, 10 % yellow-colored slough tissue about the edges and the peri wound looked normal in color. The smaller pressure ulcer on his right ischium was approximately L 4 x W 5 x D 1.5 cm. The wound bed was approximately 85 % granulation tissue and 15 % yellow-colored slough along the ,[DATE] o'clock side of the pressure ulcer. LVN F changed her gloves, took some gauze 4 x 4s and wet them with saline, cleaned out the largest pressure ulcer, and changed her gloves, wet ,[DATE] gauze 4 x 4s with NS and packed them in the pressure ulcer. LVN F changed her gloves again placed a dry 4 x 4 over the wet ones and taped then dated it. LVN F without washing her hands performed the same treatment to the smaller pressure ulcer. She then asked Resident #9 if he was tired and/or hurting, and he said yes, so she stopped and told him she would come back later to dress his feet. Together the two nurses pulled Resident #9 up in his bed, covered him after placing pillows under his feet and one on his left legs. LVN F then took the trash to the cart came back into the room washed her hands, picked up the wax paper with the rest of the supplies took it out of the room and placed it on top of her treatment cart, put the gloves and what was left of the package of gauze 4 x 4s and the tape in the middle drawer of the cart and put the scissors and left over NS bullets in the top drawer of the cart. On [DATE] at 3:22 PM, the DON brought the surveyor two "Quality Assurance/Performance Improvement" plans, one about labs and the other about [DEVICE]. When asked, the DON said she had just heard about the wound vac dressing being left on Resident #9's pressure ulcers without being hooked up to the suction. The DON said that was just leaving a pocket of bacteria against the wound which would cause an increased risk of infection. Review of the "Quality Assurance/Performance Improvement," provided by the DON and dated [DATE], revealed "Resident had wound dressing still applied to wound without any suction x 4 hours. Nurse turned off suction while leaving dressing applied. PLAN: All negative [DEVICE] will have either Intermittent or Continuous Suction to the wound. If the suction is turned off or becomes disconnected, the dressing must be removed and a wet to dry dressing applied until suction can resume rather it be Intermittent or Continuous." This plan further reflected "IMPLEMENTATION: Representative from (Company providing the facility the [DEVICE]) will complete and (sic) in-service on the application, procedure, discontinuing procedure [DATE] during the survey. All Charge Nurses that manage wound vac must complete this in-service before they can manage negative pressure wound therapy." This plan was electronically signed by the Director of Clinical Operations. On [DATE] at 8:30 AM, Resident #9 was in his bed, under a sheet he had an air mattress, his catheter was patent with clear yellow-colored urine output in the tubing. The HOB was up 45 degrees, and he had his breakfast tray in front of him with nothing eaten. Resident #9 was looking ahead with a blank look on his face. When the surveyor asked him why he was not eating his breakfast. Resident #9 said he was going to die in two weeks. Resident #9 said his brother had come the previous night and told him he was going to die in two weeks because he had an infection and they had stopped giving him the antibiotics through his PICC line. Resident #9 asked the surveyor if he could die from an infection and why would the facility do that to him? Resident #9 said his brother told him he needed to talk with God and get right with him so he could go to Heaven, and he "only had two weeks to 30 days to do that before he died ." On [DATE] at 9:30 AM, LVN E had already set up all her treatment supplies on wax paper on an over bed table, she then pushed the table into Resident #9's room, washed her hands and greeted Resident #9. LVN E gloved and uncovered Resident #9. Resident #9 was on his back with his legs leaning slightly to his right side. He had a pillow between his knees, one beside his right leg and one under his feet. There was a disposable incontinent pad under his bilateral feet with the outer edge of his right foot against it on the pillow. Resident #9's right outer knee had a 4 x 4 inch island dressing on it with the date of [DATE] written on it in black-colored marker. Resident #9's bilateral feet were wrapped in [MEDICATION NAME] bandages so LVN E picked up the scissors and cut the bandages off of Resident #9's right foot and removed all of the dressings. When she picked up his foot the surveyor noted a red drop of blood on the incontinent pad under the outer edge of his right foot. Resident #9's right proximal and back of heel had a pressure ulcer approximately L 4 x W 3 x D 0.5 cm with approximately 15 % black-colored eschar, 45 % yellow-colored slough and 40 % granulation there was a moderate amount of grayish-colored drainage noted on the bandage when it was removed. There was another pressure ulcer on the top outer area of his right foot which was approximately L 2.5 x W 1.5 x D unmeasurable cm of black-colored eschar. LVN E sanitized her hands and put on a new pair of gloves. LVN E then used gauze 4 x 4 squares from a plastic cup which she wet with NS and cleaned out the pressure ulcer on Resident #9's right outer heel. Without drying the pressure ulcer, washing her hands, sanitizing them or changing her gloves, LVN E then used a Q-tip she retrieved from a package of open Q-tips which were laying on the over bed table, dipped it into a white-colored ointment which was in a small plastic portion cup and spread it into the pressure ulcer. LVN E repeated this procedure, retrieving another Q-tip, dipping it into the white-colored ointment and spreading it into the pressure ulcer two more times. Without changing her gloves, washing or sanitizing her hands, LVN E retrieved a packet of skin prep, opened it and wiped the other pressure on top of his right foot with it, opened and placed a [MEDICATION NAME] 4 x 4 pad over the heel pressure ulcer. LVN E the removed her gloves and left the room, went to her treatment cart and retrieved a roll of [MEDICATION NAME] bandage, came back into the room and went into the bathroom and washed her hands for approximately 5 seconds came back, put on gloves and picked up the [MEDICATION NAME] bandage to begin wrapping his right foot. The surveyor asked her what about his right outer foot which was lying on the incontinent pad, and she said there were no areas on his outer right foot. The surveyor asked her why there was a spot of blood on the incontinent pad and she said, "Let me look again," and picked up his right foot and the surveyor observed three pressure ulcers. Resident #9's right outer heel had a pressure ulcer approximately L 2 x W 2 x D unmeasurable cm of tannish/brown-colored eschar, there was a pressure ulcer on his mid-lateral foot approximately 1.5 x 1 x unmeasurable cm of tannish/brown-colored eschar and a third area on his outer, lateral distal foot approximately L 1.5 x W 0.5 X unmeasurable cm of tannish/brown-colored eschar. LVN E put his foot back on the incontinent pad. LVN E did not change her gloves, did not wash the pressure ulcers with NS, and retrieved then opened a packet of skin prep, picked up Resident #9's right foot, wiped it on the right outer heel pressure ulcer, dropped his foot onto the incontinent pad, retrieved another packet of skin prep, opened it, picked up Resident #9's right foot and wiped it on the mid-lateral pressure ulcer, dropped his foot again, picked up another skin prep packet, opened it, picked up his right foot and wiped it onto the lateral distal foot pressure ulcer. LVN E then opened another [MEDICATION NAME] dressing, picked up Resident #9's foot and placed it on the right outer heel pressure ulcer, put his foot down, picked up the roll of [MEDICATION NAME], picked up his right foot and began to wrap it with the [MEDICATION NAME] bandage holding the [MEDICATION NAME] on the outer heel and the putting the [MEDICATION NAME] back on the inner heel as it had moved off of the pressure ulcer. LVN E then wrapped the right foot and secured it with tape. Without washing her hands, changing her gloves, sanitizing her hands or the scissors she had used to cut the bandage off Resident #9's right foot, still standing on the right side of Resident #9, LVN E picked up the scissors and cut the bandage off Resident #9's left foot and removed the dressings. Resident #9 had a pressure ulcer on his left outer heel which was approximately L 3 x W 3 x D 0.5 cm with 60 % granulation tissue and 40 % yellow/tan-colored slough along the ,[DATE] o'clock edges. Resident #9 had a second pressure ulcer on the left outer medial foot which was approximately L 2 x W 2 x D unmeasurable cm of 100 % tannish-colored necrotic tissue. Resident #9 had a third pressure ulcer on his left outer distal foot approximately L 1.5 x W 2 x D 0.1 which was 100 % granulation tissue. LVN E changed her gloves without washing or sanitizing her hands, wet some gauze 4 x 4s with NS, picked up a handful of NS soaked gauze 4 x 4s into her left hand and using her right hand took one gauze 4 x 4 out of her left hand two times and cleaned the distal outer foot pressure ulcer, took another one out of her left hand and cleaned the outer medial pressure ulcer then took another gauze 4 x 4 out of her left hand two times and cleaned the left outer heel pressure ulcer. LVN E without changing her gloves, sanitizing her hands or drying the pressure ulcers, picked up Q-tips one at a time, dipped them into the white-colored ointment and wiped it into each pressure ulcers wound bed. LVN E then opened three [MEDICATION NAME] dressings placing one over each pressure ulcer. Without changing her gloves LVN E picked up Resident #9's left foot. Resident #9 had a pressure ulcer on his distal inner left foot just under the great toe which was approximately L 1.5 x W 0.5 x unstageable cm and was 100 % brownish/black-colored eschar. Resident #9 had another pressure ulcer on his inner medial left foot which was approximately L 2 x W 0.5 x D unstageable cm and 100 % brownish/black-colored eschar. LVN E wet some gauze 4 x 4's with NS, picked up his left foot cleaned the distal outer pressure ulcer, lay his foot back onto the pillow, and picked up another wet gauze 4 x 4, picked up his foot and cleaned the medial pressure ulcer and lay his foot back onto the pillow. Without washing or sanitizing her hands or changing her gloves, LVN E opened two skin preps, wiped one pressure ulcer, lay his foot down, picked up and opened the second skin prep, picked up his foot and wiped it on the second pressure ulcer, lay his foot down on the pillow. LVN E picked up and opened a [MEDICATION NAME] 4 x 4, picked up Resident #9's foot and placed it on the distal outer pressure ulcer, and picked up a roll of [MEDICATION NAME] and wrapped Resident #9's left foot then secured it with tape. It was 9:40 AM, and LVN E began to pull the sheet up over Resident #9 when the surveyor asked her about his right outer knee. LVN E looked at it, went out of the room to her treatment cart and retrieved more treatment supplies. When LVN E came back into his room, she put the supplies on the over bed table, went into the bathroom and washed her hands again in about five seconds. LVN E came back gloved and removed the old dressing from Resident #9's right outer knee. Resident #9 had a pressure ulcer to his right outer knee approximately L 2.5 x W 2 x D 0.1 cm which was 100 % granulation tissue. LVN E, without changing her gloves, took some NS moistened gauze 4 x 4s and cleaned the pressure ulcer to his right outer knee, without drying it placed the white-colored ointment onto the pressure ulcer, opened a 4 x 4 inch island dressing, placed it over the pressure ulcer, dated and signed the dressing, covered Resident #9 with a sheet, cleaned up the mess, and washed her hands again for approximately 5 seconds. On [DATE] at 10:50 AM, the surveyor asked the DON how she expected her nurses to provide wound care treatments when a resident had multiple wounds. The DON said, "She cross contaminated didn't she?" The surveyor informed her of how LVN E had performed the dressing changes on Resident #9. The DON said, "Oh no,...I knew when you asked that question she had..." The DON said they are to do one pressure ulcer or wound at a time, change their gloves and sanitize their hands between taking the old dressing off, cleaning the wound, applying ointment and plac

Based on observation, interview and record review, it was determined the facility failed to ensure a resident who entered the facility without pressure ulcers did not develop pressure ulcers unless the individual's clinical condition demonstrated they were unavoidable; and a resident who had pressure ulcers received the necessary care and treatment to promote healing and prevent new pressure ulcers from developing for one (Resident #14) of eight residents reviewed for pressure ulcers. The facility failed to order a low air loss mattress for Resident #14 when she was identified with suspected deep tissue injury to her sacral area on 05/16/14. The preventative mattress was an intervention on her Care Plan. She did not receive the low air loss mattress until 06/03/14. The facility failed to notify the physician when her wound appearance changed on 05/24/14. The facility failed to implement the Wound Physician's treatment orders written on 05/29/14. The treatment change was not initiated until 06/10/14. The facility failed to Off-load Resident #14's heels and utilize a bed cradle (a frame placed over a bed to prevent sheets or blankets from touching the patient) as ordered. These failures contributed to the deterioration of Resident #14's sacral pressure ulcer, which resulted in the resident requiring surgical debridement (the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue) of muscle tissue and devitalized tissue. Failure to properly off-load Resident #14's feet could slow the healing time of her existing pressure ulcer and placed her at risk for developing additional pressure ulcers to her feet. These failures could affect the 58 residents identified as receiving preventive skin care by placing them at risk for potential deterioration of existing pressure ulcers and the development of new pressure ulcers, which could result in increased time for healing, infection,[MEDICAL CONDITION], discomfort, pain, and the potential need for hospitalization . Findings included: Resident #14's Admission Nursing Evaluation, dated 03/12/14, reflected her admitting [DIAGNOSES REDACTED]. Her "Skin Condition" reflected she had bruising to her left arm and [MEDICAL CONDITION] to her right arm and foot. Resident #14's previous MDS assessment dated [DATE] reflected she had moderately impaired cognition, was at risk for developing pressure ulcers, had no pressure ulcers and no pressure relieving devices were used. Resident #14's MDS assessment, dated 07/01/14, reflected she was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She had severely impaired cognition, required extensive assistance for bed mobility, transfers, dressing, and hygiene. She had impaired range of motion on one side of her body, was frequently incontinent of bladder and incontinent of bowel. The MDS assessment also reflected Resident #14 was at risk for developing pressure ulcers, she had one Stage IV pressure ulcer and one "Unstaged due to dressing." The Stage IV pressure ulcer measured 3.0 x 3.1 x 1.3 with "Slough-yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous (glycoprotein excreted from the tissue)." During the initial tour on 07/01/14 at 9:00 AM, ADON B described Resident #14 as not interviewable, incontinent, and requiring total care with her activities of daily living. When asked whether Resident #14 had any skin breakdown, ADON B stated Resident #14 had unstageable areas to her coccyx, right heel and right fifth toe. At that time, Resident #14 was observed lying in bed on an air mattress. A bed cradle was placed on the bed to prevent direct contact of bedding to her feet. The cradle bar was not being used, and her blanket had been placed directly on top of her legs and feet instead of using the cradle bar to prevent anything from applying pressure to her feet and legs. Resident #14's Interim Plan of Care dated 03/12/14 reflected she was at risk for pressure ulcers and the interventions were turning and repositioning, skin assessments per facility protocol, and incontinent care. Resident #14's SHORT TERM CARE PLAN dated 03/20/14 reflected: she had a pressure ulcer to her Coccyx Sacrum and the interventions were preventative mattress; wheel chair cushion in chair; weekly skin assessment; measure and evaluate weekly; and apply treatment/dressing as ordered. Resident #14's Weekly Skin Integrity Review - Sacrum sheet starting 05/16/14 reflected Open area to sacral area and an unstageable pressure ulcer to her right inner posterior heel Resident #14's Physician's Telephone Orders dated 05/16/14 reflected: "Cleanse sacral area (with) NS. Apply TAO (and) [MEDICATION NAME] daily til resolved." Resident #1's Nurse's Notes, dated 05/16/14, reflected, "Darkened area (with) slit noted to sacral area. (Nurse Practitioner) notified (with) NON cleanse sacral area (with) NS, apply TAO (and) [MEDICATION NAME] daily til resolved...." There were no measurements or further descriptions of the area. In an interview on 07/03/14 at 2:10 PM, the DON was shown Resident #14's Nurse's Note, dated 05/16/14 and subsequent treatment orders, which reflected the first documentation of her sacral wound and asked to identify the nurse. The DON identified the nurse as LVN O and stated the nurse no longer worked at the facility. On 07/02/14 at 11:45 AM, when asked why there was no Low Air Loss mattress ordered for Resident #14 until 06/03/14 (18 days after the area was identified), the DON stated she should have gotten one. Resident #1's Nurse's Notes, dated 05/18/14, reflected, "11:10 AM resident up in w/c. Alert/confused (No) s/s pain or discomfort not. Rt side weakness noted due to dx...Continue tx to buttocks for redness per tx. Orders...." Resident #14's May 2014 Wound Treatment & Progress Record reflected on the back of the pagee reflected on 05/19/14 on the back of the page were measurements and descriptions of eschar (hard, dead tissue). Resident #14's Weekly Skin Integrity Review Sacrum sheet reflected on 05/23/14 the pressure ulcer was old and open. Resident #14's Nurse's Notes, dated 05/29/14, reflected on the 10:00 PM to 6:00 AM shift notes, "...Res in bed sleeping with Hob (up) (no c/o pain at this time...Res referred to wound Doctor...." Resident #14's Nurse's Notes, dated 05/29/14, reflected: "Wound Dr. rounds this shift. Tx to sacral areas cont. Wound bed dark. Eschar noted. Will cont. to observe." The WOUND CARE SPECIALIST INITIAL EVALUATION from the wound care physician dated 05/29/14 reflected the following: "History of Present Illness ...has an unstageable (due to necrosis) of the sacrum of at least 7 days duration ...ETIOLOGY: Pressure ...WOUND SIZE (L X W X D): 3 x 3.2 x Not Measurable cm ...THICK ADHERENT BLACK NECROTIC TISSUE (ESCHAR): 90% YELLOW NECROTIC TISSUE: 10% PROCEDURE: SURGICAL EXCISIONAL DEBRIDEMENT OF SUBCUTANEOUS TISSUE:DESCRIPTION: Wound debrided via surgical excision and subcutaneous tissue removed along with devitalized tissue. Assessment & Plan...Dressing: Foam, hydrogel, [MEDICATION NAME], once daily...." Review of Resident #14's clinical record did not reveal a Physician's Telephone Order for foam, hydrogel, [MEDICATION NAME], once daily. Interview with LVN G on 07/03/14 at 2:30 PM revealed she did not know how some of the discrepancies had occurred. When asked whether she knew why the sacral wound was not measured prior to 05/19/14, LVN G stated she did not know. She stated she and the 2:00 PM to 10:00 PM nurse had noticed some of the wounds had not been measured, so they measured them. When shown the Wound physician's orders [REDACTED]. Interview with LVN H, Resident #14's 2:00 PM to 10:00 PM Charge Nurse, on 07/03/14 at 2:46 PM, revealed she was unaware of the Wound physician's orders [REDACTED]. LVN H stated when she saw the pressure ulcer, it was unstageable with tan, fibrous tissue around the sides. When asked whether she had notified the physician of the change in the pressure ulcer, she stated she thought she asked the day shift nurse, and they called and got orders. On 07/02/14 at 11:45 AM, the DON stated the she had only been working for the facility for about three weeks. She stated they were aware they had problems with skin when she arrived. The DON brought a copy of an agenda from a Quality Measures meeting where they had begun to address the problem. She also brought a copy of a QI Action Plan in which she had further defined actions the nursing administration would take to correct the issues. The DON explained the nursing staff had wound protocols located in the front of every treatment book they were to use to initiate treatments until the wound specialist assessed the resident, including ordering a bed. On 07/02/14 at 10:12 AM, the DON stated the Wound Physician's first visit to Resident #14 was 05/29/14. The DON stated the Wound physician's orders [REDACTED]. When asked who reviewed the treatment sheets to ensure they were written, the DON stated the ADONs checked them to ensure orders were written and she did as well. She stated all treatment sheets should remain in the treatment book. ADON B, who was responsible for Resident #14's hall, was interviewed on 07/03/14 at 3:10 PM. When ADON B was asked how the Wound physician's orders [REDACTED]. onto a Physician's Telephone Order and onto the treatment sheets. She stated she pulled copies of the Telephone Orders every day to ensure the orders were carried out. The Wound Care Specialist Evaluations were to be kept with the treatment sheets as well. When shown Resident #14's Wound Care Specialist Evaluation, dated 05/29/14, and asked how the treatment orders were missed, ADON B stated she did not know. When asked how she would know if a Charge Nurse failed to transcribe the order onto a Physician ' s Telephone Order, she stated, "I won't." The staff continued to use TAO and foam dressing on the sacrum pressure ulcer order from 05/16/14 until 06/10/14 according to Resident #14's May 2014 and June 2014 Treatment Record. Resident #14's Nurse's Notes, dated 05/31/14, reflected, "...Tx to sacrum, dressing changed, no odor or drainage, per tx orders...." Resident #14's SHORT TERM CARE PLAN, dated 03/20/14, reflected the interventions of a low air low mattress on 06/03/14. Resident #14's June 2014 MAR indicated [REDACTED]." The entry was initialed as performed all three shifts from 06/03/14 through 06/30/14. The MAR indicated [REDACTED]." The entry was initialed as performed all three shifts from 06/03/14 through 06/30/14. Resident #14's Physician's Telephone Order, dated 06/03/14, reflected: "1. May have low air loss mattress to bed, check q shift. 2. Reposition and turn as facility protocol...4. Give stress (with) zinc 1 tab po BID X 10 Day." Resident #14's Nurse's Notes, dated 06/04/14 for the 10:00 PM to 6:00 AM shift, reflected: "...Res in bed sleeping with HOB (up)...N/O Air Mattress...." Resident #14's Weekly Skin Integrity Review - Sacrum/coccyx sheet reflected on 06/09/14 the pressure ulcer was old, unstageable and measured 4.0 cm x 4.0 cm. Resident #14's Physician's Telephone Order, dated 06/10/14, reflected: "Clean sacrum (with) n/s, apply Santyl to wound bed, apply Cal Alginate & Dsg qd til debrided." Resident #14's Nurse's Notes, dated 06/10/14, reflected: "2-10 (2:00 PM to 6:00 PM shift) n/o for Santyl to wound on Sacrum til debrided. Has 3 x 3 tan area on Sacrum. Refuses to lye (sic) down. On vitamins for skin and wound will cont to monitor." Resident #14's Nurse's Notes, dated 06/11/14, reflected: "2-10 Initial TX to Sacrum done. Sacrum tan (with) fibrous tissue on the outside. Foul odor noted." Resident #14's Nurse's Notes, dated 06/12/14, reflected, "2-10 Tx to sacrum cont. with santyl to wound bed. Cont to have fibrous tissue around tan color middle. Minimal amount foul drainage. Will cont to monitor." Resident #14's Weekly Skin Integrity Review reflected the following: on 06/18/14 the pressure ulcer on her sacrum was unstageable and measured 4.0 cm x 4.0 cm; and on 06/19/14 the pressure ulcer on her sacrum was a Stage IV. The WOUND CARE SPECIALIST EVALUATION from the wound physician dated 06/19/14 reflected, "History of Present Illness ... has a Stage 4 pressure wound of the sacrum of at least 28 days duration. There is moderate serous exudate associated with the wound...WOUND SIZE (L X W X D): 3 x 3 x Not Measurable cm ...EXUDATE: Moderate Serous THICK ADHERENT BLACK NECROTIC TISSUE (ESCHAR): 90% YELLOW NECROTIC TISSUE: 10% PROCEDURE: SURGICAL EXCISIONAL DEBRIDEMENT OF MUSCLE: DESCRIPTION: Wound debrided via surgical excision and muscle removed along with devitalized tissue. Dressing: Calcium Alginate, Foam, [MEDICATION NAME], Once Daily...." Resident #14's SHORT TERM CARE PLAN, dated 03/20/14, reflected the care plan was reviewed on 06/19/14 and to continue plan of care. The Care Plan also reflected her pressure ulcer was debrided by the wound care physician. Resident #14's Nurse's Notes, dated 06/19/14, reflected: "Wound Dr Here debrided Sacral Wound. Says to Cont Tx with Santyl-Cal Alginate qd." Resident #14's Nurse's Notes, dated 06/20/14, reflected: "2-10 TX to sacral area (changed) to 6-2 (6:00 AM to 2:00 PM) area has large amount of drainage (with) foul odor." The WOUND CARE SPECIALIST EVALUATION dated 06/26/14 reflected, "History of Present Illness ...has a Stage 4 pressure wound of the sacrum of at least 34 days duration. There is moderate serous exudate associated with the wound ...WOUND SIZE (L X W X D): 3 x 3.1 x 1.3 cm ...UNDERMINING: 2 cm at 6 o'clock EXUDATE: Moderate Serous YELLOW NECROTIC TISSUE: 50% GRANULATION TISSUE: 50% PROCEDURE: SURGICAL EXCISIONAL DEBRIDEMENT OF MUSCLE: DESCRIPTION: Wound debrided via surgical excision and muscle removed along with devitalized tissue. Dressing: Calcium Alginate, Foam, [MEDICATION NAME], Once Daily RECOMMENDATION: Limit sitting to 60 minutes, Low Air Loss Mattress, Off-Load Wound, Reposition per facility protocol...." Resident #14's Physician's Telephone Order, dated 06/27/14: "DC Santyl to sacrum wound. Do: Clean (with) NS, Pat dry, apply calcium alginate, Foam, [MEDICATION NAME] qd, limit sitting to 60 min." Resident #14's Weekly Skin Integrity Review reflected on 06/27/14 the pressure ulcer on her sacrum was a Stage IV and on 06/29/14 the sacral wound was still a Stage IV. Resident #14's July 2014 MAR indicated [REDACTED]. The start date was 04/30/14." The entry was initialed as performed on all three shifts on 07/01/14. Resident #14's Nurse's Notes, dated 05/30/14, reflected: "CNA alerted this nurse to resident's feet. This nurse assessed and noted purple/red 2 cm x 2 cm spot to (R) inner heel...(Nurse practitioner) notified and new orders ...Also stated skin prep areas and off load heels when in bed...cont. to monitor." Resident #14's Physician's Telephone Order, dated 05/30/14, reflected, "Skin prep to (R) inner heel...BID until resolved." Resident #14's Nurse's Notes, dated 05/31/14, reflected: "...Tx to R heel redness, skin prep per tx orders; boot applied, +1 pitting noted to lower extremities bilat...." Resident #14's SHORT TERM CARE PLAN, dated 03/20/14, reflected the interventions of a low air low mattress on 06/03/14 and floating her heels on pillows while in bed on 06/03/14. Resident #14's Physician's Telephone Order, dated 06/03/14, reflected: "1. May have low air loss mattress to bed, check q shift. 2. Reposition and turn as facility protocol. 3. Float heels (with) pillows while in bed. 4. Give stress (with) zinc 1 tab po BID X 10 Day." Resident #14's Nurse's Notes, dated 06/05/14, reflected: "10:30 am This nurse noted blister to (R) inner heel (with) fluid. (R) inner heel still purple...Talked to (Nurse Practitioner)...and discussed new orders. New orders as follows 1. D/C previous tx orders. 2. [MEDICATION NAME] spray to affected areas twice daily. Cover (with) dry dsg. Until resolved. TX book updated, Pharmacy faxed...." Resident #14's ADL Plan of Care dated 06/13/14 - present reflected: "...Positioning...resident is to have foot cradle at all times while in bed (Active from 06/19/14 to present)...Avoid pressure on heels...Float heels to avoid pressure...." Resident #14's Weekly Skin Integrity Review reflected on 06/19/14 the pressure ulcer on her right posterior heel was unstageable. Resident #14's SHORT TERM CARE PLAN, dated 06/19/14, reflected she had a pressure ulcer on her right posterior inner heel. The interventions included Apply Treatment/Dressing as ordered. The WOUND CARE SPECIALIST EVALUATION from the wound physician dated 06/19/14 reflected the pressure ulcer to her right posterior heel was unstageable due to necrosis. The pressure ulcer measured 2.8 x 2.5 but the depth was not measurable. It was 100% blister and filled with blood. The dressing was skin prep every shift and the recommendation was to Off-load Wound, Reposition per facility protocol. The WOUND CARE SPECIALIST EVALUATION dated 06/26/14 reflected her right posterior heel was still unstageable and the measurement was 2.8 x 2.5 , but the depth was not measurable. It was still 100% blister and the dressing was skin prep every shift. The recommendations were for an EZ boot (eliminates pressure on the heel for treatment and prevention of heel pressure ulcers) to be worn in bed and chair to off-load wound, Off-load Wound, and Reposition per facility protocol. Review of Resident #14's clinical record did not reveal a physician's orders [REDACTED]. Resident #14's Weekly Skin Integrity Review reflected on 06/27/14 her right posterior heel was still unstageable. Resident #14's July 2014 MAR indicated [REDACTED]." The entry was initialed as performed all three shifts on 07/01/14. Observation on 07/01/14 at 11:30 AM revealed Resident #14 was lying in bed tilted toward her right side, her feet were wrapped in gauze and were in direct contact with the bed instead of being off-loaded. The bed cradle was again not utilized as her crocheted blanket lay over her legs and feet. There were no pillows observed on the lower half of the bed which may have been used to offload her heels. Observation on 07/01/14 at 1:33 PM revealed Resident #14 was served lunch in her room. She was sitting up in bed with her tray table over her lap. Resident #14's heels were directly on the mattress and her blanket was directly over her legs and feet. There were no pillows observed on the lower half of the bed which may have been used to offload her heels. Attempt to interview Resident #14 was unsuccessful. When asked any question, she would repeatedly state "No, no, no" and attempt to motion with her hand. Resident #14 appeared frustrated with her attempts to communicate but would smile and relax when it became apparent what her need was, such as leaving her door open. Observation on 07/01/14 at 2:30 PM revealed Resident #14 received incontinent care from CNA J and CNA K. As the CNAs were gathering supplies, Resident #14 was observed with her heels lying directly on the bed and her blanket was lying directly on her feet. Observation on 07/01/14 at 3:40 PM revealed Resident #14 was sleeping in her bed. Her heels were lying directly on the bed and her bed cradle was not utilized as her crocheted blanket was lying directly over her legs and feet. There were no pillows observed on the lower half of the bed which may have been used to offload her heels. Observation on 07/01/14 at 7:40 PM revealed Resident #14 was sleeping in her bed positioned on her right side. Her heels were again directly on the mattress and her bed cradle was not used. There were no pillows observed on the lower half of the bed which may have been used to offload her heels. On 07/02/14 at 7:45 AM, LVN G, Resident #14's 6:00 AM to 2:00 PM Charge Nurse, was in the dining room assisting residents. Immediately after this, she was asked if she was Resident #14's Charge Nurse. LVN G replied, "I already did her treatment. I was not told to wait." Observation on 07/02/14 at 8:18 AM revealed Resident #14 was in bed, crying loudly, restlessly repeating "No, No, No!" to attempts to ascertain what was troubling her. ADON B was notified of the findings. ADON B retrieved LVN G and both proceeded to assess Resident #14. Resident #14's heels were lying directly on her bed and her bed cradle was not being used. LVN G stated she had changed the dressings to Resident #14's feet earlier that morning. Observation on 07/02/14 at 8:51 AM revealed Resident #14 was sitting up in bed, her breakfast tray was on her bedside table over her lap. She was moaning and picking at her plate. Her feet were still not offloaded. Observation on 07/02/14 at 10:10 AM revealed Resident #14 was in bed with her knees bent. Both feet were lying directly on the bed. On 07/02/14 at 10:50 AM, the DON was asked about Resident #14's EZ Boot. The DON checked the room and located a beige rubber inflatable boot on Resident #14's wheelchair, under a blanket and among other items such as her wheelchair footrests. The boot was underinflated so that if one side was pressed, it would be flat. When the DON was asked how the boot was supposed to be effective if not inflated, she shook her head and stated she would look into it. During an interview on 07/02/14 at 10:55 AM, when LVN G was asked about the Wound physician's orders [REDACTED]. When asked why Resident #14 was not wearing the boot, LVN G explained the CNAs had just finished cleaning her. LVN G stated, "I understand it was not on this morning." When asked why Resident #14's heels had not been offloaded, LVN G stated the CNAs usually did that part. When asked whether she offloaded the resident's heels after she had completed her dressing change that morning, LVN G replied, "I think the Aides did." When asked how often she checked her residents for proper positioning, LVN G stated every two hours. During an interview on 07/03/14 at 11:20 AM, when CNA I (Resident #14's 6:00 AM to 2:00 PM CNA) was asked if she knew what an EZ boot was, she replied, "No." When asked how she knew if a resident needed to wear a boot, CNA I stated the nurse would tell her. When asked about Resident #14, CNA I stated when she cared for her, she used a boot. When the CNA was asked to see the boot she used, she entered Resident #14's room (Resident #14 was still in hospital) and retrieved the beige rubber boot, which was still underinflated. When asked who ensured there was air in the boot, CNA I stated the therapy department did. When asked how they knew when the boot needed to be re-inflated, CNA I replied, "Because they work with her." During an interview on 07/03/14 at 11:28 AM, when LVN G was asked if she knew what an EZ Boot looked like, she stated, "It should have a stabilizer bar on the bottom." When asked whether Resident #14 ever had one, LVN G explained Therapy put a Podus boot on her because she was dragging her foot. When asked if she was referring to the inflatable boot, LVN G replied, "I think." When asked who was responsible for ensuring the boot was properly inflated, LVN G replied, "We nurses and the CNAS should let therapy know if the boot needed air." In an interview on 07/03/14 at 12:05 PM, when ADON B was asked if she could identify an EZ Boot, she walked to the therapy department where the supplies were located and was unable to locate one. When accompanied to Resident #14's room and shown Resident #14's beige inflatable boot, ADON B remarked, "That's not it. They're usually blue." When shown there was very little air in the boot and it was not enough to relieve any pressure, ADON B stated, "You're right." While leaving the resident's room, ADON B stopped CNA J in the hall and asked her if she knew what an EZ boot was. CNA J stated she did not know. During an interview on 07/03/14 at 12:20 PM, when the Director of Rehabilitation was asked about EZ Boots, she stated they were used to relieve pressure. The Director of Rehabilitation retrieved a supply catalog and copied a picture and description of an EZ Boot. The catalog's description reflected, "Removable snap-in bar prevents rotation; Lightweight, durable plastic splint with soft fleece liner...." When the Director of Rehabilitation was asked whether she had ever recommended staff use an air boot instead of an EZ Boot on Resident #14, she replied, "No." She explained Resident #14 had been off physical therapy services since 04/25/14. When informed what LVN G had stated about their recommendation, the Director of Rehabilitation stated they would always ask the physician first if they had any recommendations that went against a physician's orders [REDACTED]. The Director of Rehabilitation checked Resident #14's records and stated the resident had continued Occupational Therapy until 06/10/14 but that was for shoulder range of motion and transfers only. When asked whether the nursing staff could have a boot ordered if the resident was not receiving therapy, she replied, "Absolutely. We can order anything." Interview with LVN H, Resident #14's 2:00 PM to 10:00 PM Charge Nurse, on 07/03/14 at 2:46 PM, revealed when asked whether she was aware of the order for the EZ Boot, LVN H stated she was not. She explained she used the foot cradle, inflatable boot and offloaded Resident #14's heels on her shift. ADON B, who was responsible for Resident #14's hall, was interviewed on 07/03/14 at 3:10 PM. When shown Resident #14's Wound Care Specialist Evaluations dated 06/26/14 and asked how the orders for the EZ Boot were missed, ADON B stated she did not know. When asked how she would know if a Charge Nurse failed to transcribe the order onto the Telephone Orders, she stated, "I won't." Resident #14 was taken to the hospital by ambulance on 07/02/14 at 10:55 AM for high blood pressure and abdominal pain. Resident Hospital #14's hospital Wound Documentation, dated 07/02/14 at 2:00 PM, reflected: Coccyx: PRESSURE ULCER: Unstageable SIZE: 3.0 cm x 2.5 cm x 1.7 cm. UNDERMINING: (INDICATE LOCATION BY CLOCK SYSTEM): (12) 1.5 cm; (3) 1.5 cm; (6) 2.5 cm; (9) 1.8 cm. EXUDATE: ODOR: None TYPE: Serosanguineous, foul AMOUNT: Mod WOUND BED: Bright red, Yellow/Tan Slough WOUND EDGES/SURROUNDING SKIN: Rolled Edges. " The documentation also reflected, "Right Heel: PRESSURE ULCER: Unstageable SIZE: 2.5 cm x 1.8 cm WOUND BED: Black. " The undated Quality Measures (S=Short Stay, L=Long Term) report reflected the following: "Agenda Item ...C. 1. Hi-risk Pressure Ulcer (L) 2. In-house Pressure Ulcer %. Findings ...(x) Trend Identified (see action plan) (x) Action in Progress... Comments/Discussion 100% resident skin assessments completed on 3/31/14. Wound physician continues weekly assessments. 100% chart review and resident assessments completed on 5/12/14 and 5/20/14. Tasks included: TARS reviewed for appropriate forms utilized, appropriate treatment in place, preventative measures, wound measurements, documentation, weekly skin checks performed. Staff education completed 05/12/14, 5/16/14 and 5/17/14. At present, have total of 13 residents with a total of 19 pressure areas. Have a total of 12 residents with in house acquired pressure areas that total 14 areas. Residents assessed for supplemental therapies. Physician and RPs notified of any new orders. Action plan: all admissions and re-admissions will be assessed for skin concerns with the ADONs review post day, TARS will be reviewed daily by the ADONs for completed skin assessments, any new or change in skin will be addressed in morning meeting by the IDT. Wound physician will be consulted as indicated...." On 07/03/14 at 11:30 AM, the Director of Clinical Operations stated the facility would receive special in-service training by an outside representative on 07/11/14 and that was the earliest they could come. The Director of Clinical Operations was asked about the facility's algorithms for ordering air mattresses. When shown the algorithm did not address Deep Tissue Injury (DTI) pressure ulcers and only addressed Stage I-IV pressure ulcers, the Director of Clinical Operations stated it should be common sense to order one for a DTI as those are very serious. During an interview on 07/03/14 at 2:10 PM, the DON was asked how often she updated her wound surveillance reports. The DON explained she looked at wound sheets and counts weekly and sent a report to corporate. She stated she had started a book after she arrived and put together what she could find (from previous DONs). When asked whether she went to look at the resident's wounds, the DON said, thus far, she had been unable to look at them all weekly but, systematically, she would like to. The DON was asked to provide her most recent wound surveillance reports. The DON's Skin Report dated 06/19/14 reflected Resident #14 was identified as having three in-house pressure ulcers. "Date First Noted" was identified as 04/03/14, which was inaccurate. The wound sites reflected: 1 - Rt inner heel 0.4 cm x 0.4 cm unstageable with eschar (this was actually the measurement for Resident #14's left fifth toe wound); 2 - Sacrum 3 cm x 3 cm Stage IV. Interview with the DON on 07/03/14 at 3:50 PM revealed all staff were in-serviced that day and every resident with any skin issues would be placed on the 24-hour-report for follow-up. When asked how the Wound Care Specialist Evaluations were followed-up, the DON stated it was the responsibility of the ADONs to pull the Evaluations, give her a copy and they were responsible for ensuring the orders were transcribed correctly. When shown Resident #14's Evaluations and orders missed, the DON stated she would get the problem fixed. The facility's Form CMS-672, Resident Census and Conditions of Residents, dated 07/02/14 and signed by LVN U reflected 58 residents were receiving preventative skin care.

Based on observation, interview and record review, it was determined the facility failed to ensure all alleged violations involving mistreatment were immediately reported to the Administrator of the facility and to the State survey and certification agency, failed to have evidence of a thorough investigation, and failed to protect residents from further potential mistreatment while the investigation was in progress for one (Resident #6) of 18 residents reviewed for abuse, neglect, mistreatment and misappropriation of property. 1) ADON L failed to immediately report Resident #6's allegation of mistreatment, which occurred on 06/16/13, to the Administrator. 2) The Acting Administrator failed to report Resident #6's allegation of mistreatment to the State agency once she became aware of the allegation. 3) ADON L failed to have evidence of a thorough investigation into Resident #6's allegation of mistreatment. 4) ADON L failed to identify the correct alleged perpetrator and failed to remove alleged perpetrator, until surveyor intervention. These failures left Resident #6 with continuing feelings of anger both at having to sit up long after he wished to go to bed, and the management's perceived indifference to his complaints of mistreatment. These failures could affect any of the 87 residents who resided on the 500 and 300 Halls, by placing them at risk for mistreatment by facility staff, feelings of anger, and reducing their sense of dignity and self-worth. Findings included: During the Entrance Conference, conducted with Interim Administrator DD and the DON on 07/09/13 at 8:40 AM, the surveyor requested the facility's abuse, neglect and misappropriation policies and procedures currently being followed by the facility. During the Entrance Conference, Interim Administrator DD revealed her employment began at the facility on 07/08/13. At this time, Interim Administrator DD stated the facility's Abuse Prohibition Coordinator was the Acting Administrator, who was tempoariliy assigned to another facility in a different city. Interim Administrator DD stated she shared in this responsiblity so far as overseeing and monitoring day to day facility operations, however; employees were likely to report allegations of abuse, neglect or mistreatment to the Acting Administrator because the staff were familiar with her. Resident #6 was an [AGE] year-old male readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the MDS assessment revealed Resident #6 had moderately impaired cognition, he exhibited no behaviors toward others and he required extensive assistance for transfers and toileting. Review of Resident #6's Care Plan dated 02/12/13 and continued on 05/24/13 revealed he required one person assistance to transfer due to weakness and impaired balance/gait. Approaches included transfer using one person. Resident #6's Care Plan reflected he was at risk for falls related to impaired balance and gait and dependent mobility related to weakness. Approaches included using a wheelchair to transport resident. On 07/09/13 at 10:05 AM, Resident #6 was identified by LVN R as alert and interviewable. She explained he recently returned from the hospital after having pneumonia, had a mass on his lungs and was placed on hospice services. Resident #6's Nurse's Notes dated 06/28/13 through 07/11/13 reflected he was discharged from the facility on 06/29/13 and was admitted to the hospital with [REDACTED]. The Notes reflected Resident #6 resided on the 500 Hall before and after his hospital stay. During an interview on 07/09/13 at 1:50 PM, when Resident #6 was asked about his care by facility staff, he stated he had a "personality conflict" with one particular CNA. Resident #6 stated he had been up to the bathroom one night and afterward the staff had gotten him to his wheelchair and parked him in his room. He pointed to an area across the room well out of reach of his call light. He stated later that night, a CNA came by and he asked her to assist him to bed. Resident #6 stated he stayed up until 1:30 AM. He stated he reported it to the "hierarchy" and no one had ever gotten back to him (Note: Complaint/Grievance, dated 06/17/13, reflected this incident occurred on 06/16/13). Resident #6 stated the CNA still worked with him, but he felt she was avoiding him. He stated he could be difficult to work with because if he did not like something, he would say something about it. Resident #6 was unable to identify the CNA by name at that time. Resident #6 appeared agitated and experienced shortness of breath during the interview and requested to continue it another time. During another interview on 07/11/13 at 9:45 AM, Resident #6 stated he was still trying to remember the name of the CNA that had left him up in his chair. CNA F entered his room and Resident #6 asked her if she remembered his complaint about the CNA who left him up. CNA F stated she worked the following shift after the allegation was made and identified the perpetrator as CNA MM. CNA F stated when she came on shift, Resident #6 was "so riled up" he would not get out of bed. When asked if she reported it to anyone, CNA F stated she informed ADON A, who was his charge nurse at the time, and ADON L was also made aware of the situation. During an interview on 07/12/13 at 12:30 PM, ADON A was asked what she knew about the allegation made by Resident #6. ADON A explained she was a Charge Nurse at that time (incident occurred on 06/16/13) and went in his room to speak with him and was surprised to see him still in bed. She stated he was usually out of bed between 5:00 AM and 5:30 AM every morning, and it was after 6:00 AM. ADON A stated Resident #6 told her staff had not put him in bed until 1:30 AM. She stated she reported it to ADON L, got a Grievance form, completed it and gave it to LBSW OO. She stated that was the extent of her involvement with the allegation because ADON L was taking care of it. On 07/11/13 at 9:58 AM, ADON L was asked if she received a complaint related to Resident #6 being left up in the wheelchair and not assisted to bed. ADON L stated, "That was way before this last stay. He had complained and that aide no longer works here." When asked if there was an incident report generated, ADON L stated there was a grievance report given to the Social Worker. Review of a Complaint/Grievance Report dated 06/17/13 revealed Resident #6 had given a "Verbal" complaint about "Care." The report reflected: "On 06/16 - Rsdt (Resident #6) stated abt (about) 8:00 PM he was in the bathroom. CNA came and got him out left him @ bedside, went home early. 10-6 CNA didn't put him in bed till 1 AM. Call light not in reach." The Complaint/Grievance Report's Findings of Investigation reflected, "Spoke with Resident & Staff regarding this Resident was not assisted to bed by 2-10 Shift but 10-6 did assist him." The Plan to Resolve Complaint/Grievance reflected: "Inservice staff on this both shifts." The Report's Results of Action taken reflected: "CNA was moved from his assignment & counseled." The Complaint/Grievance Report reflected the incident was not reportable to the State agency. The Complaint/Grievance Report reflected the grievance was resolved, but no details were documented even though the form requested a description. Further review of the Report revealed the complainant was satisfied, and the investigation results and resolution steps were reported to "Family" and "Resident." The form was signed by ADON L. During another interview with ADON L on 07/11/13 at 4:40 PM, she was asked about the "Inservice" referred to on the Complaint/Grievance form and asked if she had any evidence of the in-services provided. ADON L explained the in-services were her conversations with the nurses on the 500 Hall and there was no documentation available. During an interview on 07/11/13 at 2:13 PM, ADON L was shown the grievance form and asked about her investigation. ADON L stated, "When I went in there, he said there was a lady with braids. He said he was up until 1:30 AM and fell asleep in his chair. My first step was 2-10. I found out the 2-10 PM aide was (CNA EE), she said he was taking his meds, I talked to her about communicating with the next shift." ADON L stated CNA EE wore braids. ADON L revealed she spoke to the evening shift nurse who told her she had informed the night nurse to put Resident #6 in bed. ADON L stated she asked the evening nurse if she checked on Resident #6 and was told another resident on that hall had fallen, and she was busy tending to that resident. ADON L revealed she counseled the nurses on the importance of checking on all the residents. ADON L stated she later spoke to Resident #6 afterward and told him what she had said to the staff. ADON L stated she had gotten written statements that should have been attached to the Grievance form and did not know why they were not. She stated she would look for them. During another interview on 07/11/13 at 6:23 PM, Resident #6 was asked if he described the alleged perpetrator as having braids. He emphatically replied, "I didn't describe her as having braids! She's colored and had like a bun on her head (motioned to top of his head with hand in a downward 'C' shape)." When asked when he last saw her, Resident #6 replied, "I want to say I saw her last week." He added she continued to take care of him after he made the allegation and before he left for the hospital. When asked how the situations made him feel and whether he was in pain sitting up that long, Resident #6 stated he had not been in any pain but he was "Mad!" Review of ADL Reports, completed by the CNAs, did not reveal any entries indicating any care was provided for Resident #6 on the 10:00 PM to 6:00 AM shift beginning on 06/16/13. The facility's in-services did not reflect any regarding Resident #6. Reviews of CNA EE's personnel file did not reflect any counseling or disciplinary action regarding Resident #6's allegation. Interview on 07/11/13 at 3:50 PM with the Director of Human Resources revealed CNA EE resigned from the facility after an altercation with a nurse on 06/27/13. The facility's Daily Sign In Sheet, dated 06/16/13 which was the night of the incident, CNA MM signed in to work on Resident #6's hall. An interview with CNA MM on 07/13/13 at 3:13 PM revealed when she came in (on the 10:00 PM to 6:00 AM shift on 06/16/13), Resident #6 was upset saying no one came in and he was on his light for hours and no one would put him to bed. CNA MM stated she attempted to assist him to bed and, when she did, he fell back into the chair, cussed at her and threw his walker. CNA MM revealed she left the room, and her charge nurse told her to try again later. She stated she went back after rounding on the other residents, and he was sleeping, so she let him sleep. CNA MM went back later and he was awake and angry, so other staff put him to bed. She thought that occurred around 11:00 PM. She stated her charge nurse, LVN T, told her to write a statement and slide it under the ADON's door, and she did. She confirmed she continued to care for him after that incident. CNA MM revealed she was no longer allowed to go in his room. CNA MM stated she was called in and just submitted a written statement to facility management. Review of CNA MM's, undated written statement provided by the facility on 07/15/13, revealed she gave an account as described in her interview and added, "...This was about a month ago. Every day I've worked since this incident I have care for (Resident #6) and we haven't had any problems...." Another interview with ADON L on 07/11/13 at 3:39 PM revealed she found a written statement provided by CNA EE. When asked if she interviewed the 10:00 PM to 6:00 AM shift CNAs regarding the allegation, she replied she was focused on the 2:00 PM to 10:00 PM shift CNA and had interviewed the nurses. She stated she assigned CNA EE to the 400 Hall after the incident. ADON L revealed she only asked the Charge Nurse on the 10:00 PM to 6:00 AM shift to write statement. When asked about the CNAs on the 10:00 PM to 6:00 AM shift, ADON L replied CNA MM did not work on Resident #6's hall and the other CNA was busy assisting the nurse with the resident who had fallen. (Note: The facility's Daily Sign In Sheet, dated 06/16/13, reflected CNA MM signed in to work on Resident #6's hall). When asked if she interviewed other residents to determine if there were other complaints, ADON L responded she had not. When asked what the facility protocol was when receiving a complaint of this nature, ADON L replied to report it to the Administrator. When asked if she reported it to the Administrator, ADON L replied, "They gave it to me to go work." She stated LBSW OO assigned her the investigation. When asked if she had received training on how to investigate allegations, ADON L replied she had not received any specific in-services. She revealed after she completed her investigation, she gave it back to LBSW OO during a morning meeting. Interview on 07/15/13 at 3:50 PM with the DON revealed there had been a breakdown in communication with all of the changes. The DON stated ADON L had not received any training regarding investigations or how to conduct an investigation. An interview with LVN T on 07/13/13 at 3:36 PM revealed Resident #6 was supposed to be in bed by 8:00 PM and was waiting for an aide (on 06/16/13). She explained she gave him a dose of insulin and CNA EE walked in and said, "I'll be right back." Then the aide went home early. LVN T stated, "I had no clue, my mind was 'she is going to come back!'" LVN T went on to explain around 9:30 or 10:00 PM the night CNAs came and told her he was still up. She stated on her way to check on him, another CNA approached her and informed her a different resident was on the floor. She stated she went to handle that. She revealed after that she told the 10:00 PM to 6:00 AM shift CNAs to put Resident #6 in bed. She stated she could not really say if Resident #6 was upset at that time. When asked if she told anyone to write a statement of the events of that night, she replied, "No. Later the ADON told me to write this up." Further interview on 07/13/13 at 3:45 PM with ADON L revealed she did not receive any written statements from the 10:00 PM to 6:00 AM staff regarding Resident #6. She stated she did not ask the CNAs to write anything. She revealed she asked the nurses, but did not have any of them. An interview, on 07/11/13 at 4:11 PM with LBSW OO, revealed when he reviewed Resident #6's Complaint/Grievance form dated 06/17/13, he remembered it was brought up in a morning meeting. When asked about his role regarding grievances, LBSW OO replied he brought them to the necessary staff and to the Administrator. He stated they completed the grievance form, brought it back to him, and then he documented it. When asked who reviewed the document for accuracy, LBSW OO replied he looked them over as well as the Administrator, and the Administrator signed them off monthly. When asked about what he expected to see in regards to the investigation, LBSW OO revealed, "Well, she did an inservice...it is pretty sparse looking." When asked who was responsible for ensuring the investigations were completed, LBSW OO replied the Administrator was the Abuse Prohibition Coordinator, but they should all be responsible. An interview on 07/11/13 at 5:26 PM with the DON revealed when asked if she was aware of the allegations made by Resident #6 regarding the incident on 06/16/13, the DON stated the staff talked about it in a morning meeting. She stated her understanding was Resident #6 was up toward the end of the shift and did not want to go to bed, and the 10:00 PM to 6:00 AM CNA went in and found him asleep in his chair. Then later on rounds, he woke up and was very angry that he had fallen asleep sitting in his chair. The DON revealed she knew ADON L spoke to Resident #6's family and caretaker. During an interview on 07/11/13 at 6:00 PM, the Acting Administrator stated she left the faciity on [DATE] for an out of town assignment and Interim Adm CC took over from 06/20/13 through 07/08/13. When asked about Resident #6's Complaint/Grievance Report regarding the incident on 06/16/13, the Acting Administrator stated she did not remember reviewing it, just hearing about it. The Acting Administrator could not recall exactly when she learned about it, but stated she remembered discussing the resident was upset that he was left up in a chair so ADON L followed up on it. The Acting Administrator stated, "I didn't see this grievance, just knew it was a concern shared. Today I would have investigated further. This happened three weeks ago, this obviously was something that wasn't followed-up." On 07/09/13, Interim Administrator DD provided the facility's current, undated policy to Prohibit the Mistreatment, Neglect, and Abuse of Residents and the Misappropriation of Resident Property, which reflected, "...Each resident has the right to be free from mistreatment...The facility's purpose is to assure that the facility is doing all that is within their control to prevent occurences...The facility prohibits mistreatment...of residents...Protection: It is the up most importance that the resident or residents suspected of being abused and all other residents be protected during the initial identification and investigative process. The facility will initiate immediate procedures to ensure that these residents are protected fully from any further harm or potential harm. Although abuse comes in different types, the facility has one common goal and that is to protect each and every resident. Upon notification of suspected abuse the director of nursing or designee will take two courses of action. (1) When an abuse identifies a perpetrator that is identified by an eyewitness, the facility will immediately remove the perpetrator from the facility, pending outcome of the investigation... If a staff member is mentioned, but the abuse cannot be proved, then the staff member would be re-assigned to other duties and/or areas and be closely monitored for the next 30 days by the charge nurse or other appropriate supervisor. The charge nurses would immediately begin to monitor any areas indicated in the investigation that warrant further monitoring on a daily basis and on all shifts. The director of nursing will coordinate this and ensure that there are no further signs of abuse...Identification: All direct care staff have been trained to identify the three signs that might indicate abuse of residents. Staff are knowledgable in recognizing...sudden changes in resident's behavior or personality; and resident fear and anxiety. During the investigative process, staff is able to recognize the emergence of any type of occurences, patterns, and trends that may constitute abuse. This recognition will determine the direction of the internal investigation...Investigation...All allegations, no matter what types of incidents reported will be investigated fully...All employees who suspect abuse at any time it is identified are to report it to their immediate supervisor. If the supervisor is not the charge nurse then the supervisor will report it to the charge nurse who is responsible for the resident suspected of being abused. The charge nurse receiving the allegation shall immediately contact either one of the following: the nurse on call, who will then report the allegation to the director of nursing, or the assistant director of nursing, the director of nursing, and/or the administrator. The administrator or his/her designee will report this allegation of abuse immediately to the state agecny (DADS) and to the proper local authorities. An immediate investigation will be instigated and the person responsible for the coordination will be the director of nursing...Reporting/Response...Upon completion of an investigation, the director of nurses and administrator will analyze the occurences and determine what changes, if any, are needed to prevent any further occurences. This response will be dictated as to the findings indicating trends and patterns that would warrant a policy and/or procedure change for the betterment of the residents and the prevention of any further abuse." Review of the facility's Department Manager Phone List dated 07/09/13 revealed ADON L was the ADON for Halls 500 and 300. The resident roster, dated 07/09/13 was provided by Interim Administrator DD on 07/09/13 and reflected the resident census was 143. Review of the resident roster revealed there were 37 residents residing on Hall 500 and 50 residents residing on the Hall 300.

Based on observation, interview, and record review, the facility failed to follow the policies and procedures that prohibit mistreatment for one (Resident #6) of 18 residents reviewed for abuse, neglect, and misappopriation of resident property. 1) ADON L failed to immediately report Resident #6's allegation of mistreatment, which occurred on 06/16/13, to the Administrator. 2) The Acting Administrator failed to report Resident #6's allegation of mistreatment to the State agency once she became aware of the allegation. 3) ADON L failed to have evidence of a thorough investigation into Resident #6's allegation of mistreatment. 4) ADON L failed to identify the correct alleged perpetrator and failed to remove alleged perpetrator, until surveyor intervention. These failures left Resident #6 with continuing feelings of anger both at having to sit up long after he wished to go to bed, and the management's perceived indifference to his complaints of mistreatment. These failures could affect any of the 87 residents who resided on the 500 and 300 Halls, by placing them at risk for mistreatment by facility staff, feelings of anger, and reducing their sense of dignity and self-worth. Findings included: During the Entrance Conference, conducted with Interim Administrator DD and the DON on 07/09/13 at 8:40 AM, the surveyor requested the facility's abuse, neglect and misappropriation policies and procedures currently being followed by the facility. During the Entrance Conference, Interim Administrator DD revealed her employment began at the facility on 07/08/13. At this time, Interim Administrator DD stated the facility's Abuse Prohibition Coordinator was the Acting Administrator, who was tempoariliy assigned to another facility in a different city. Interim Administrator DD stated she shared in this responsiblity so far as overseeing and monitoring day to day facility operations, however; employees were likely to report allegations of abuse, neglect or mistreatment to the Acting Administrator because the staff were familiar with her. On 07/09/13, Interim Administrator DD provided the facility's current, undated policy to Prohibit the Mistreatment, Neglect, and Abuse of Residents and the Misappropriation of Resident Property, which reflected, "...Each resident has the right to be free from mistreatment...The facility's purpose is to assure that the facility is doing all that is within their control to prevent occurences...The facility prohibits mistreatment...of residents...Protection: It is the up most importance that the resident or residents suspected of being abused and all other residents be protected during the initial identification and investigative process. The facility will initiate immediate procedures to ensure that these residents are protected fully from any further harm or potential harm. Although abuse comes in different types, the facility has one common goal and that is to protect each and every resident. Upon notification of suspected abuse the director of nursing or designee will take two courses of action. (1) When an abuse identifies a perpetrator that is identified by an eyewitness, the facility will immediately remove the perpetrator from the facility, pending outcome of the investigation... If a staff member is mentioned, but the abuse cannot be proved, then the staff member would be re-assigned to other duties and/or areas and be closely monitored for the next 30 days by the charge nurse or other appropriate supervisor. The charge nurses would immediately begin to monitor any areas indicated in the investigation that warrant further monitoring on a daily basis and on all shifts. The director of nursing will coordinate this and ensure that there are no further signs of abuse...Identification: All direct care staff have been trained to identify the three signs that might indicate abuse of residents. Staff are knowledgable in recognizing...sudden changes in resident's behavior or personality; and resident fear and anxiety. During the investigative process, staff is able to recognize the emergence of any type of occurences, patterns, and trends that may constitute abuse. This recognition will determine the direction of the internal investigation...Investigation...All allegations, no matter what types of incidents reported will be investigated fully...All employees who suspect abuse at any time it is identified are to report it to their immediate supervisor. If the supervisor is not the charge nurse then the supervisor will report it to the charge nurse who is responsible for the resident suspected of being abused. The charge nurse receiving the allegation shall immediately contact either one of the following: the nurse on call, who will then report the allegation to the director of nursing, or the assistant director of nursing, the director of nursing, and/or the administrator. The administrator or his/her designee will report this allegation of abuse immediately to the state agecny (DADS) and to the proper local authorities. An immediate investigation will be instigated and the person responsible for the coordination will be the director of nursing...Reporting/Response...Upon completion of an investigation, the director of nurses and administrator will analyze the occurences and determine what changes, if any, are needed to prevent any further occurences. This response will be dictated as to the findings indicating trends and patterns that would warrant a policy and/or procedure change for the betterment of the residents and the prevention of any further abuse." Resident #6 was an [AGE] year-old male readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the MDS assessment revealed Resident #6 had moderately impaired cognition, he exhibited no behaviors toward others and he required extensive assistance for transfers and toileting. Review of Resident #6's Care Plan dated 02/12/13 and continued on 05/24/13 revealed he required one person assistance to transfer due to weakness and impaired balance/gait. Approaches included transfer using one person. Resident #6's Care Plan reflected he was at risk for falls related to impaired balance and gait and dependent mobility related to weakness. Approaches included using a wheelchair to transport resident. On 07/09/13 at 10:05 AM, Resident #6 was identified by LVN R as alert and interviewable. She explained he recently returned from the hospital after having pneumonia, had a mass on his lungs and was placed on hospice services. Resident #6's Nurse's Notes dated 06/28/13 through 07/11/13 reflected he was discharged from the facility on 06/29/13 and was admitted to the hospital with [REDACTED]. The Notes reflected Resident #6 resided on the 500 Hall before and after his hospital stay. During an interview on 07/09/13 at 1:50 PM, when Resident #6 was asked about his care by facility staff, he stated he had a "personality conflict" with one particular CNA. Resident #6 stated he had been up to the bathroom one night and afterward the staff had gotten him to his wheelchair and parked him in his room. He pointed to an area across the room well out of reach of his call light. He stated later that night, a CNA came by and he asked her to assist him to bed. Resident #6 stated he stayed up until 1:30 AM. He stated he reported it to the "hierarchy" and no one had ever gotten back to him (Note: Complaint/Grievance, dated 06/17/13, reflected this incident occurred on 06/16/13). Resident #6 stated the CNA still worked with him, but he felt she was avoiding him. He stated he could be difficult to work with because if he did not like something, he would say something about it. Resident #6 was unable to identify the CNA by name at that time. Resident #6 appeared agitated and experienced shortness of breath during the interview and requested to continue it another time. During another interview on 07/11/13 at 9:45 AM, Resident #6 stated he was still trying to remember the name of the CNA that had left him up in his chair. CNA F entered his room and Resident #6 asked her if she remembered his complaint about the CNA who left him up. CNA F stated she worked the following shift after the allegation was made and identified the perpetrator as CNA MM. CNA F stated when she came on shift, Resident #6 was "so riled up" he would not get out of bed. When asked if she reported it to anyone, CNA F stated she informed ADON A, who was his charge nurse at the time, and ADON L was also made aware of the situation. During an interview on 07/12/13 at 12:30 PM, ADON A was asked what she knew about the allegation made by Resident #6. ADON A explained she was a Charge Nurse at that time (incident occurred on 06/16/13) and went in his room to speak with him and was surprised to see him still in bed. She stated he was usually out of bed between 5:00 AM and 5:30 AM every morning, and it was after 6:00 AM. ADON A stated Resident #6 told her staff had not put him in bed until 1:30 AM. She stated she reported it to ADON L, got a Grievance form, completed it and gave it to LBSW OO. She stated that was the extent of her involvement with the allegation because ADON L was taking care of it. On 07/11/13 at 9:58 AM, ADON L was asked if she received a complaint related to Resident #6 being left up in the wheelchair and not assisted to bed. ADON L stated, "That was way before this last stay. He had complained and that aide no longer works here." When asked if there was an incident report generated, ADON L stated there was a grievance report given to the Social Worker. Review of a Complaint/Grievance Report dated 06/17/13 revealed Resident #6 had given a "Verbal" complaint about "Care." The report reflected: "On 06/16 - Rsdt (Resident #6) stated abt (about) 8:00 PM he was in the bathroom. CNA came and got him out left him @ bedside, went home early. 10-6 CNA didn't put him in bed till 1 AM. Call light not in reach." The Complaint/Grievance Report's Findings of Investigation reflected, "Spoke with Resident & Staff regarding this Resident was not assisted to bed by 2-10 Shift but 10-6 did assist him." The Plan to Resolve Complaint/Grievance reflected: "Inservice staff on this both shifts." The Report's Results of Action taken reflected: "CNA was moved from his assignment & counseled." The Complaint/Grievance Report reflected the incident was not reportable to the State agency. The Complaint/Grievance Report reflected the grievance was resolved, but no details were documented even though the form requested a description. Further review of the Report revealed the complainant was satisfied, and the investigation results and resolution steps were reported to "Family" and "Resident." The form was signed by ADON L. During another interview with ADON L on 07/11/13 at 4:40 PM, she was asked about the "Inservice" referred to on the Complaint/Grievance form and asked if she had any evidence of the in-services provided. ADON L explained the in-services were her conversations with the nurses on the 500 Hall and there was no documentation available. During an interview on 07/11/13 at 2:13 PM, ADON L was shown the grievance form and asked about her investigation. ADON L stated, "When I went in there, he said there was a lady with braids. He said he was up until 1:30 AM and fell asleep in his chair. My first step was 2-10. I found out the 2-10 PM aide was (CNA EE), she said he was taking his meds, I talked to her about communicating with the next shift." ADON L stated CNA EE wore braids. ADON L revealed she spoke to the evening shift nurse who told her she had informed the night nurse to put Resident #6 in bed. ADON L stated she asked the evening nurse if she checked on Resident #6 and was told another resident on that hall had fallen, and she was busy tending to that resident. ADON L revealed she counseled the nurses on the importance of checking on all the residents. ADON L stated she later spoke to Resident #6 afterward and told him what she had said to the staff. ADON L stated she had gotten written statements that should have been attached to the Grievance form and did not know why they were not. She stated she would look for them. During another interview on 07/11/13 at 6:23 PM, Resident #6 was asked if he described the alleged perpetrator as having braids. He emphatically replied, "I didn't describe her as having braids! She's colored and had like a bun on her head (motioned to top of his head with hand in a downward 'C' shape)." When asked when he last saw her, Resident #6 replied, "I want to say I saw her last week." He added she continued to take care of him after he made the allegation and before he left for the hospital. When asked how the situations made him feel and whether he was in pain sitting up that long, Resident #6 stated he had not been in any pain but he was "Mad!" Review of ADL Reports, completed by the CNAs, did not reveal any entries indicating any care was provided for Resident #6 on the 10:00 PM to 6:00 AM shift beginning on 06/16/13. The facility's in-services did not reflect any regarding Resident #6. Reviews of CNA EE's personnel file did not reflect any counseling or disciplinary action regarding Resident #6's allegation. Interview on 07/11/13 at 3:50 PM with the Director of Human Resources revealed CNA EE resigned from the facility after an altercation with a nurse on 06/27/13. The facility's Daily Sign In Sheet, dated 06/16/13 which was the night of the incident, CNA MM signed in to work on Resident #6's hall. An interview with CNA MM on 07/13/13 at 3:13 PM revealed when she came in (on the 10:00 PM to 6:00 AM shift on 06/16/13), Resident #6 was upset saying no one came in and he was on his light for hours and no one would put him to bed. CNA MM stated she attempted to assist him to bed and, when she did, he fell back into the chair, cussed at her and threw his walker. CNA MM revealed she left the room, and her charge nurse told her to try again later. She stated she went back after rounding on the other residents, and he was sleeping, so she let him sleep. CNA MM went back later and he was awake and angry, so other staff put him to bed. She thought that occurred around 11:00 PM. She stated her charge nurse, LVN T, told her to write a statement and slide it under the ADON's door, and she did. She confirmed she continued to care for him after that incident. CNA MM revealed she was no longer allowed to go in his room. CNA MM stated she was called in and just submitted a written statement to facility management. Review of CNA MM's, undated written statement provided by the facility on 07/15/13, revealed she gave an account as described in her interview and added, "...This was about a month ago. Every day I've worked since this incident I have care for (Resident #6) and we haven't had any problems...." Another interview with ADON L on 07/11/13 at 3:39 PM revealed she found a written statement provided by CNA EE. When asked if she interviewed the 10:00 PM to 6:00 AM shift CNAs regarding the allegation, she replied she was focused on the 2:00 PM to 10:00 PM shift CNA and had interviewed the nurses. She stated she assigned CNA EE to the 400 Hall after the incident. ADON L revealed she only asked the Charge Nurse on the 10:00 PM to 6:00 AM shift to write statement. When asked about the CNAs on the 10:00 PM to 6:00 AM shift, ADON L replied CNA MM did not work on Resident #6's hall and the other CNA was busy assisting the nurse with the resident who had fallen. (Note: The facility's Daily Sign In Sheet, dated 06/16/13, reflected CNA MM signed in to work on Resident #6's hall). When asked if she interviewed other residents to determine if there were other complaints, ADON L responded she had not. When asked what the facility protocol was when receiving a complaint of this nature, ADON L replied to report it to the Administrator. When asked if she reported it to the Administrator, ADON L replied, "They gave it to me to go work." She stated LBSW OO assigned her the investigation. When asked if she had received training on how to investigate allegations, ADON L replied she had not received any specific in-services. She revealed after she completed her investigation, she gave it back to LBSW OO during a morning meeting. Interview on 07/15/13 at 3:50 PM with the DON revealed there had been a breakdown in communication with all of the changes. The DON stated ADON L had not received any training regarding investigations or how to conduct an investigation. An interview with LVN T on 07/13/13 at 3:36 PM revealed Resident #6 was supposed to be in bed by 8:00 PM and was waiting for an aide (on 06/16/13). She explained she gave him a dose of insulin and CNA EE walked in and said, "I'll be right back." Then the aide went home early. LVN T stated, "I had no clue, my mind was 'she is going to come back!'" LVN T went on to explain around 9:30 or 10:00 PM the night CNAs came and told her he was still up. She stated on her way to check on him, another CNA approached her and informed her a different resident was on the floor. She stated she went to handle that. She revealed after that she told the 10:00 PM to 6:00 AM shift CNAs to put Resident #6 in bed. She stated she could not really say if Resident #6 was upset at that time. When asked if she told anyone to write a statement of the events of that night, she replied, "No. Later the ADON told me to write this up." Further interview on 07/13/13 at 3:45 PM with ADON L revealed she did not receive any written statements from the 10:00 PM to 6:00 AM staff regarding Resident #6. She stated she did not ask the CNAs to write anything. She revealed she asked the nurses, but did not have any of them. An interview, on 07/11/13 at 4:11 PM with LBSW OO, revealed when he reviewed Resident #6's Complaint/Grievance form dated 06/17/13, he remembered it was brought up in a morning meeting. When asked about his role regarding grievances, LBSW OO replied he brought them to the necessary staff and to the Administrator. He stated they completed the grievance form, brought it back to him, and then he documented it. When asked who reviewed the document for accuracy, LBSW OO replied he looked them over as well as the Administrator, and the Administrator signed them off monthly. When asked about what he expected to see in regards to the investigation, LBSW OO revealed, "Well, she did an inservice...it is pretty sparse looking." When asked who was responsible for ensuring the investigations were completed, LBSW OO replied the Administrator was the Abuse Prohibition Coordinator, but they should all be responsible. An interview on 07/11/13 at 5:26 PM with the DON revealed when asked if she was aware of the allegations made by Resident #6 regarding the incident on 06/16/13, the DON stated the staff talked about it in a morning meeting. She stated her understanding was Resident #6 was up toward the end of the shift and did not want to go to bed, and the 10:00 PM to 6:00 AM CNA went in and found him asleep in his chair. Then later on rounds, he woke up and was very angry that he had fallen asleep sitting in his chair. The DON revealed she knew ADON L spoke to Resident #6's family and caretaker. During an interview on 07/11/13 at 6:00 PM, the Acting Administrator stated she left the faciity on [DATE] for an out of town assignment and Interim Adm CC took over from 06/20/13 through 07/08/13. When asked about Resident #6's Complaint/Grievance Report regarding the incident on 06/16/13, the Acting Administrator stated she did not remember reviewing it, just hearing about it. The Acting Administrator could not recall exactly when she learned about it, but stated she remembered discussing the resident was upset that he was left up in a chair so ADON L followed up on it. The Acting Administrator stated, "I didn't see this grievance, just knew it was a concern shared. Today I would have investigated further. This happened three weeks ago, this obviously was something that wasn't followed-up." Review of the facility's Department Manager Phone List dated 07/09/13 revealed ADON L was the ADON for Halls 500 and 300. The resident roster, dated 07/09/13 was provided by Interim Administrator DD on 07/09/13 and reflected the resident census was 143. Review of the resident roster revealed there were 37 residents residing on Hall 500 and 50 residents residing on the Hall 300.

Based on observation, interview and record review, the facility failed to ensure residents who entered the facility without pressure ulcers did not develop pressure ulcers and those residents received the necessary treatment and services to promote healing for two (Residents #1 and #2) of seven residents reviewed for pressure ulcers. 1) Staff failed to obtain Diabetic shoes for Resident #1 to "protect her feet," which were ordered by the resident's physician on 05/22/13, until surveyor intervention on 07/13/13. 2) Staff failed to address Resident #1's reddened area on her right heel when CNA BBB reported it. CNA BBB failed to document Resident #1's reddened area when she saw it approximately six weeks ago. 3) Staff failed to address Resident #1's heel problems when CNA II reported the area and the resident's pain to the area. CNA II also failed to document Resident #1's heel problems when she saw it approximately three to four months ago. 4) LVN V failed to see Resident #1's hard callus on her right heel when she assessed the resident's skin on 07/02/13. LVN V failed to assess Resident #1's wound as a hardened callus and documented the wound as dried skin after it was pointed out to her by the surveyor. LVN V failed to notify the physician and obtain treatment orders, after seeing the wound, on 07/09/13. She said she called the physician on 07/10/13, but the order and Nurse's Note were dated 07/11/13. These failures contributed to Resident #1's Stage II pressure ulcer to her right heel. 5) CNA AA failed to report Resident #2's deep purple area on the ball of the resident's foot, which the CNA said had been there for several months. 6) LVN V, who saw the area on Resident #2's foot a week prior, failed to document the area, report it to the physician or obtain treatment orders. She said it was not "that bad" when she saw the area during a skin assessment on 07/03/13 7) Staff failed to put anything between Resident #2's feet to prevent skin breakdown. Resident #2's legs were contracted at the knees and the resident's feet rested on top of each other. These failures contributed to Resident #2's unstageable blistser on her left foot. These failures could affect the other 27 residents, who resided on Hall 200, by placing them at risk for pressure ulcers, delayed care, and pain. Findings included: 1. Resident #1 was an [AGE] year-old female readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the MDS assessment revealed she had moderately impaired cognitive skills, required extensive assistance for ADLs including two-person assistance for bed mobility and transfers. The MDS assessment also reflected she was not at risk for developing pressure ulcers, and she did not have any pressure ulcers at the time of the assessment, but had "Other skin problems" and had "ointments/medications" applied. Resident #1's Braden Scale for Predicting Pressure Sore Risk, dated 04/27/12, reflected a score of 13, which indicated she was moderately at risk for developing pressure ulcers. Resident #1's Care Plan dated 05/13/13 reflected she was at risk for impaired skin integrity related to dependence with mobility, positioning and urinary/bowel incontinence. Approaches included: "Follow house protocol/regimen for treating breaks in skin integrity/pressure ulcers...Lic. (licensed) nurse will conduct weekly skin assessments w/ (with) documentation. Resident #1's Care Plan also reflected she was at risk for complications related to known [DIAGNOSES REDACTED]." Resident #1's Physician's Telephone Order dated 05/22/13 reflected: "Diabetic Shoes to aid circulation and protect feet." An interview on 07/13/13 at 11:26 AM, when LVN TTT was asked if Resident #1 had diabetic shoes he replied, "I don't know, I have only seen her in socks." LVN TTT entered Resident #1's room, looked around and was unable to locate any. On 07/13/13 at 11:35 AM, ADON G, who was responsible for Resident #1's hall, was asked if he knew anything about the diabetic shoes ordered in May. He stated he did not but would look into it. On 07/13/13 at 3:51 PM, interview with ADON G revealed he had contacted the company the facility used to provide diabetic shoes. ADON G stated he was told they had been to the facility to measure but were awaiting payment and the documentation would be faxed to the facility. Review of the shoe company's faxed documents provided by ADON G on 07/15/13 revealed a Diabetic Shoes O/P Prescription for Resident #1 dated 05/22/13 that reflected a [DIAGNOSES REDACTED]. (Diabetes Mellitus with circulatory impairment)." Further review of the documents revealed a Physician's Certifying Statement for Therapeutic/Diabetic Footwear dated 07/13/13 for Resident #1. The form reflected: "By signing below, I certify that: A. This patient has diabetes mellitus. B. I am treating this patient under a comprehensive plan of care for his/her diabetes. C. This patient needs special shoes due to his/her diabetic complications and believe the patient should obtain and benefit from diabetic shoes and inserts." Primary Diagnosis: [REDACTED]." Resident #1's June 2013 consolidated physician's orders [REDACTED].= Weekly skin assessment completed on Monday; 2-10 Shift...." The order was initiated on 04/20/12. Review of Resident #1's Weekly Skin Integrity Review dated 07/02/13 revealed: "Skin Intact" and "Pinkness to buttocks." The entry was signed by LVN V. Resident #1's untimed Nurse's Notes dated 07/09/13 reflected, "N/O (new order): Tylenol 325 mg 1-2 tabs (every) 4 hrs (hours) PRN (as needed) for pain/fever...." Resident #1's Physician Telephone Orders dated 07/09/13 reflected, "Tylenol 325 mg 1-2 tabs q 4-6 hrs PRN." An observation on 07/09/13 at 2:57 PM revealed Resident #1 received incontinent care from CNAs Y and Z. During care, a thick, large yellow/white callus was on Resident #1's right heel extending almost 1.0 cm above the surface of her heel. Both CNAs stated they were unfamiliar with Resident #1 and had not seen the area before. The surveyor stepped out of the resident's room to summon the Charge Nurse, LVN V. When the surveyor returned with LVN V, CNA Z stated the upper portion of the thick, large yellow/white piece of skin had fallen off during cleaning. A thick, yellow area was observed in its place approximately 1.5 cm X 1.5 cm. LVN V stated she had not seen the area on Resident #1's heel and identified herself as the nurse responsible for Resident #1's head to toe skin assessments. Resident #1's toes had long, thick toenails some of which were curling under the tips of her toes and there was a thick, yellow scaly buildup between each of her toes. When this was pointed out to LVN V, she stated, "I can put her on a podiatry list." When asked what she would normally do under the circumstances, LVN V replied, "She should see a podiatrist." Review of Resident #1's Weekly Skin Integrity Review he next entry dated 07/09/13 reflected: "Skin intact" and "Dry skin/bil. (bilateral) feet & Dry skin to R (right) heel." The entry was signed by LVN V. During an interview on 07/13/13 at 10:35 AM, LVN TTT, Resident #1's Charge Nurse, stated he had worked with Resident #1 since February, 2013 and was not aware of any issues with her feet. During an interview on 07/14/13 at 10:55 AM, CNA BBB stated she observed a reddened area on Resident #1's heel about six weeks ago. CNA BBB revealed she reported it to the Charge Nurse at the time, but could not remember who that was. She stated she did not document it on a form. During an interview on 07/14/13 at 3:14 PM, CNA II stated at one time, Resident #1 started to get something on her heel, but it was three or four months ago. She stated Resident #1 complained of heel pain "off and on." When asked if she reported what she found, CNA II stated she had, but she did not document on a form. An observation of Resident #1 on 07/11/13 at 7:20 AM with ADON G revealed the resident had a thick, dry, yellow area to her right heel. The edge was peeling back and Resident #1 complained of pain when the area was touched by ADON G. Resident #1's Braden Scale for Predicting Pressure Sore Risk, dated 07/11/13, reflected a score of 15, which indicated she was at risk for developing pressure ulcers. An interview with LVN V on 07/11/13 at 2:39 PM revealed when asked about Resident #1's heel, she replied she called the physician and received an order for [REDACTED]. away. It's just a real dried area. I went down and put A&D ointment on it." When asked if she had documented it, she replied that if she had not, she would. She stated she talked to the doctor about "a lot of heels." When asked if she had called the physician on 07/09/13 after the initial observation, LVN V replied it was 07/10/13 when she called and obtained the order. She stated she had put triple antibiotic ointment on it the first night. When asked what the protocol was if a new skin area was identified, LVN V stated they were supposed to call the physician and obtain an order. When asked about measuring the wound, she replied, "Yeah, you measure the wound." Resident #1's untimed Nurse's Notes dated 07/11/13 reflected, "Called (nurse practitioner) & informed her that upon assessment noted dryed (sic) hard callos (sic) area to r (right) heel measuring 3 cm X 1.5 cm N/O: bil. (bilateral) heels - cleanse (with) NS (normal saline), pat dry & apply A & D ointment (every) shift until resolved...." Resident #1's Physician Telephone Orders dated 07/11/13 reflected "Podiatry consult...." Resident #1's Physician Telephone Orders dated 07/11/13 reflected, "Bil. Heels-Cleanse (with) NS pat dry & apply A & D oint (every) shift until resolved." Resident #1's Nurse's Notes dated 07/12/13 at 1:00 PM reflected: "Late entry for 7-11-13-1000 (10:00 AM) received order from Dr. (Physician KK) for podiatry consult (with) Dr.(Physician LL) for dry feet & long, thick toenails...." During an interview on 07/13/13 at 12:13 PM, the DON was asked about the Wound Care Specialist's visit with Resident #1. The DON stated the Wound Care Specialist removed the callus and there was a pressure sore beneath. Review of a Wound Care Specialist Initial Evaluation dated 07/12/13 revealed the following HPI (History of Present Illness) Statement: "[AGE] year old female patient has a Stage 2 pressure wound of the right heel of at least 1 days duration. There is light serous exudate associated with the wound...Periwound radius: Callus...Additional Information: callus shaved...Assessment and Plan: Dressing: [MEDICATION NAME], dry protective dressing, once daily. Recommendation: Elevate leg(s), float heels in bed, off-load wound, sponge boot, protect from trauma, cleanse with NS prior to dressing." Retrieved on 07/29/13 from http://www.diabetes.org/living-with-diabetes/complications/foot-complications/ "Calluses Calluses occur more often and build up faster on the feet of people with diabetes. This is because there are high-pressure areas under the foot. Too much callus may mean that you will need therapeutic shoes and inserts. Calluses, if not trimmed, get very thick, break down, and turn into ulcers (open sores). Never try to cut calluses or corns yourself - this can lead to ulcers and infection. Let your health care provider cut your calluses...." 2. Resident #2 was an [AGE] year-old female readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the MDS assessment revealed she had moderately impaired cognition, required extensive assistance for bed mobility, transfers, dressing and hygiene and she had limited range of motion on all of her extremities. The MDS assessment reflected she was at risk for developing pressure ulcers, had "other" skin problems and received ointments/medications to her skin. Resident #2's last Assessment of Pressure Sore Potential completed 10/29/12 reflected a score of 11, which indicated "Follow Pressure Sore Protocol." Review of Resident #2's Care Plan dated 06/17/13 revealed "potential for breakdown related to decreased mobility and incontinence of both bowel and bladder." Approaches included: "Treatment as ordered by physician. Keep clean and dry at all times. Observe for irritation. Routine skin care each shift...." Resident #2's July 2013 consolidated physician's orders [REDACTED].= Weekly skin assessment completed on Wednesday; 2-10 Shift ..." The order was initiated on 05/26/10. Review of Resident #2's Weekly Skin Integrity Review entry dated 07/03/13 revealed there was no breakdown on her feet. Observation on 07/10/13 at 9:23 AM revealed Resident #2 received incontinent care from CNAs Z and AA. Observation on 07/10/13 at 9:23 AM revealed Resident #2 provided incontinent care by CNAs Z and AA. A hoyer lift sling was in her wheelchair near her bed. When CNA AA was asked about the sling, she stated Resident #2 could not bear weight and had to be transferred by Hoyer Lift. During care, Resident #2 had her legs bent at the knee with her legs close together throughout the care. When Rsident #2 was lying on her side, her feet rested one on top of the other. When queried, CNA AA stated she always kept her legs bent like that and she was unable to extend them. When Resident #2 was asked how far she could straighten her legs, she attempted to stretch them but was unable to extend them all the way. Resident #2 was grimacing during the attempt. When asked if she had pain in her joints, she nodded yes. When asked if it was arthritic type pain, she nodded yes. When asked if she was always in pain, she shook her head no, and when asked if it mainly hurt with movement, she nodded yes. When the CNAs were asked if Resident #2 was receiving restorative care or range of motion exercises, they both stated they were not sure. During care, an approximately quarter sized area was on the left ball of Resident #2's foot. The area was very dark purple with a black area in the center approximately 1.0 cm in diameter. When asked, CNA AA stated the area had been there as long as she had been there, several months, and she thought the nurses were aware. Resident #2 had long, thick toenails. The surveyor stepped out of the resident's room to summon the Charge Nurse, and returned with ADON G, who stated he was unaware of any issues with Resident #2's feet. ADON G stepped out to obtain a measuring tape and returned with LVN U. LVN U, Resident #1's Charge Nurse, and ADON G were asked to look at the wound and both stated they were unaware of the area. LVN U measured the wound as 2.0 cm X 2.0 cm. When Resident #2's toenails were pointed out to LVN U she stated, "Oh yeah, she needs a podiatrist." An interview with LVN V on 07/11/13 at 2:39 PM revealed when asked about the wound on Resident #2's foot, she replied she had seen the area on the resident's foot but it "wasn't that bad, it was my fault for not putting it on the assessment sheet that night." When asked when she had first seen it, LVN V stated, "Probably last week is when I first saw it." LVN V stated she obtained the orders for the treatment the afternoon on 07/10/13 and did the initial treatment. She stated she was sitting with LVN U at shift change when the order was obtained. Resident #2's Weekly Skin Integrity Review entry dated 07/10/13 reflected a dark area to her left foot that measured 2.0 cm X 2.0 cm. During an interview on 07/10/13 at 11:55 AM, ADON G was asked how the resident's skin was monitored in the facility by administration. ADON G explained, he pulled the Weekly Skin Integrity Reviews, entered the information into a database and gave the information to the DON. Resident #2's Nurse's Notes dated 07/10/13 at 9:45 AM reflected, "...noted dark, hard area 2 cm X 2 cm to ball of L foot, (no) drainage or s/s of pain to area, (physician) notified n/o (new order) clean (with) NS, apply santyl & tender wet cover (with) drsg qd...." Resident #2's Physician's Telephone Order dated 07/10/13 reflected: "Clean ball of L (left) foot (with) NS. Apply Santyl, [MEDICATION NAME] and cover (with) drsg (dressing) qd." Resident #2's Physician's Telephone Order dated 07/10/13 reflected: "Clean area on L foot (with) sH2O (sterile water), pat dry, apply [MEDICATION NAME] spray & cover (with) gauze q day until resolved. D/C (discontinue) previous tx (treatment) order to area." Review of Resident #2's Wound Care Progress Note dated 07/11/13 revealed she had an unstageable blister to her left foot that measured 3.0 cm X 2.5 cm with black eschar. Resident #2's Physician's Telephone Order dated 07/12/13 reflected: "Podiatry consult (with) Dr. (Physician LL) for long, thick toenails." 3. An interview with the DON on 07/11/13 at 5:26 PM revealed when asked how she ensured the accuracy of her skin surveillance reports, she replied she made random skin rounds and had personally done skin sweeps three times in the past three months. The DON stated she had the staff conduct a skin sweep after she learned of the issues with Residents #1 and #2. She revealed they did not find any new pressure areas, but they did find a lot of dry skin. When she was asked about Resident #1 and the lack of documentation after the findings on 07/09/13, she stated she would have expected the staff to address the issue. An interview with the Director of Clinical Operations on 07/14/13 at 12:00 PM revealed when asked how often Braden Scale assessments were completed by nursing staff, she replied the assessments should be done on admission, weekly times four weeks, when any new issue was found and quarterly. 4. Review of the skin surveillance reports for the months of May 2013 through July 2013 revealed neither Resident #1's heel nor Resident #2's foot were documented. 5. Review of the facility's undated Skin Management System identified as current by the DON revealed the following: "1. A complete body assessment will be completed upon every resident upon admission or readmission. A. Pressure Ulcers, Venous Ulcers, Arterial Ulcers, and surgical sites will be documented on SCC-005.Use one form per wound. Wound progress is to be documented each week with measurements and wound descriptions ...B. Bruises, rashes and other non-pressure areas are to be documented on the Weekly Skin Integrity Form ... 2. Routine weekly checks will be completed on every resident; if skin is intact it will be noted as such. If a new pressure sore is noted, a progress record will be started. 3. CNA's will note any alteration in skin integrity during care on the MP5460 and turned in to the Charge Nurse. 4. Braden Scales will be completed on all residents upon admission or readmission and interventions noted on the Interim Plan of Care. 5. Braden Scales will be completed every quarter on either hard copy or in LTC... 8. A weekly skin report will be completed and reviewed in Standard's of Care...." Review of the MP 5460 form revised April 2007 reflected: "Complete this form daily during usual care, bath care and repositioning or per facility policy. Circle the location of any red, open, dry areas and/or other skin concerns on the diagram below...Give completed form to nurse." The form reflected diagrams of a full body from the front view as well as the back view. Adjacent to the body were diagrams of feet as viewed from the front, the back and beneath. The back of the form MP 5460 reflected: "Many studies and professional documents identify risk factors that increase a resident's susceptibility to develop or to not heal pressure ulcers. Examples of these risk factors include, but are not limited to: Impaired/decreased mobility and decreased functional ability; Co-morbid conditions, such as end stage [MEDICAL CONDITIONS] disease or diabetes mellitus...impaired diffuse or localized blood flow...Cognitive impairment...." 6. The resident roster, dated 07/09/13 and provided by Interim Administrator DD on 07/09/13, reflected 29 residents resided on Hall 200.

Based on observation, interview and record review, it was determined the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for two (Residents #6 and #15) of 18 residents reviewed for abuse. 1) Interim Administrator CC failed to implement the facility's written policies and procedures that prohibit mistreatment of [REDACTED]. There was confusion on the part of staff regarding who they were to report mistreatment to. The facility failed to ensure there was evidence of a thorough investigation, and to protect residents from further potential mistreatment while the investigation was in progress. 2) The DON failed to follow the facility's written policies and procedures that prohibit mistreatment and abuse of residents. The DON did not ensure ADON L was properly trained to identify and thorpoughly investigate an allegation of neglect. These failures could affect any of the 87 residents who resided on the 500 and 300 Halls placing them at risk for mistreatment by facility staff. Findings included: (1) During the Entrance Conference, conducted with Interim Administrator DD and the DON on 07/09/13 at 8:40 AM, the surveyor requested the facility's abuse, neglect and misappropriation policies and procedures currently being followed by the facility. During the Entrance Conference, Interim Administrator DD revealed her employment began at the facility on 07/08/13. At this time Interim Administrator DD stated the facility's Abuse Prohibition Coordinator was the Acting Administrator who was temporarily assigned to another facility in a different city. Interim Administrator DD stated she shared in this responsiblity so far as overseeing and monitoring day to day facility operations, however; employees were likely to report allegations of mistreatment to the Acting Administrator because the staff were familiar with her. (2) On 07/09/13, Interim Administrator DD provided the facility's current, undated policy to Prohibit the Mistreatment, Neglect, and Abuse of Residents and the Misappropriation of Resident Property, which reflected, "...Each resident has the right to be free from mistreatment...The facility's purpose is to assure that the facility is doing all that is within their control to prevent occurences...The facility prohibits mistreatment...of residents...Protection: It is the up most importance that the resident or residents suspected of being abused and all other residents be protected during the initial identification and investigative process. The facility will initiate immediate procedures to ensure that these residents are protected fully from any further harm or potential harm. Although abuse comes in different types, the facility has one common goal and that is to protect each and every resident. Upon notification of suspected abuse the director of nursing or designee will take two courses of action. (1) When an abuse identifies a perpetrator that is identified by an eyewitness, the facility will immediately remove the perpetrator from the facility, pending outcome of the investigation... If a staff member is mentioned, but the abuse cannot be proved, then the staff member would be re-assigned to other duties and/or areas and be closely monitored for the next 30 days by the charge nurse or other appropriate supervisor. The charge nurses would immediately begin to monitor any areas indicated in the investigation that warrant further monitoring on a daily basis and on all shifts. The director of nursing will coordinate this and ensure that there are no further signs of abuse...Identification: All direct care staff have been trained to identify the three signs that might indicate abuse of residents. Staff are knowledgable in recognizing...sudden changes in resident's behavior or personality; and resident fear and anxiety. During the investigative process, staff is able to recognize the emergence of any type of occurences, patterns, and trends that may constitute abuse. This recognition will determine the direction of the internal investigation...Investigation...All allegations, no matter what types of incidents reported will be investigated fully...All employees who suspect abuse at any time it is identified are to report it to their immediate supervisor. If the supervisor is not the charge nurse then the supervisor will report it to the charge nurse who is responsible for the resident suspected of being abused. The charge nurse receiving the allegation shall immediately contact either one of the following: the nurse on call, who will then report the allegation to the director of nursing, or the assistant director of nursing, the director of nursing, and/or the administrator. The administrator or his/her designee will report this allegation of abuse immediately to the state agecny (DADS) and to the proper local authorities. An immediate investigation will be instigated and the person responsible for the coordination will be the director of nursing...Reporting/Response...Upon completion of an investigation, the director of nurses and administrator will analyze the occurences and determine what changes, if any, are needed to prevent any further occurences. This response will be dictated as to the findings indicating trends and patterns that would warrant a policy and/or procedure change for the betterment of the residents and the prevention of any further abuse." Review of the Operational Policies and Procedures dated 05/14/12 were provided by RN Clinical Consultant GG on 07/14/13 and identified as current. "The facility has been administered in a manner that enables it to use its resources effectivly and efficiently to assist each resident to attain or maintain his/her highest practicable mental, physical and psychosocial well-being. This facility is licensed under all applicable State and local laws. The facility will operate and provide services in compliance with applicable Federal, State and local regulations and codes and with accepted professional standards and principles. The governing body appoints a licensed State administrator, to be responsible for management of the facility...In the absence of the administrator, an appointed designee will be designated." Review of the Operational Policies and Procedures dated 05/14/12 revealed a Letter of Authority and another for Absence of Administrator. On 07/15/13 the Acting Administrator provided the surveyor with completed Letters of Authority, which reflected, "Letter of Authority (Acting Administrator's name) has been designated by the governing body to be accoutable for the overall management and operation of this facility. The administrator will have full authority to manage this facility and carry out all policies and procedures that govern the facility to ensure the well-being and safety of all residents." The Letter of Authority was signed by the individual identified as the governing body of the facility and was not dated. "Absence of Administrator (Interim Administrator CC's name) has been designated by the administrator to be in charge of the facility in the absence of the administrator for any reason. This person will have full authority to operate this facility and carry out all policies and procedures that govern the facility to ensure the well-being and safety of all residents." The Letter of Authority was signed by the the Acting Administrator and was not dated. "Absence of Administrator (Interim Administrator DD's name) has been designated by the administrator to be in charge of the facility in the absence of the administrator for any reason. This person will have full authority to operate this facility and carry out all policies and procedures that govern the facility to ensure the well-being and safety of all residents." The Letter of Authority was signed by the the Acting Administrator and was not dated. (3) Resident #6 was an [AGE] year-old male readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the MDS assessment revealed Resident #6 had moderately impaired cognition, he exhibited no behaviors toward others and he required extensive assistance for transfers and toileting. Review of Resident #6's Care Plan dated 02/12/13 and continued on 05/24/13 revealed he required one person assistance to transfer due to weakness and impaired balance/gait. Approaches included transfer using one person. Resident #6's Care Plan reflected he was at risk for falls related to impaired balance and gait and dependent mobility related to weakness. Approaches included using a wheelchair to transport resident. On 07/09/13 at 10:05 AM, Resident #6 was identified by LVN R as alert and interviewable. She explained he recently returned from the hospital after having pneumonia, had a mass on his lungs and was placed on hospice services. Resident #6's Nurse's Notes dated 06/28/13 through 07/11/13 reflected he was discharged from the facility on 06/29/13 and was admitted to the hospital with [REDACTED]. The Notes reflected Resident #6 resided on the 500 Hall before and after his hospital stay. During an interview on 07/09/13 at 1:50 PM, when Resident #6 was asked about his care by facility staff, he stated he had a "personality conflict" with one particular CNA. Resident #6 stated he had been up to the bathroom one night and afterward the staff had gotten him to his wheelchair and parked him in his room. He pointed to an area across the room well out of reach of his call light. He stated later that night, a CNA came by and he asked her to assist him to bed. Resident #6 stated he stayed up until 1:30 AM. He stated he reported it to the "hierarchy" and no one had ever gotten back to him (Note: The Complaint/Grievance Report, dated 06/17/13, reflected the date of the incident was 06/16/13). Resident #6 stated the CNA still worked with him, but he felt she was avoiding him. He stated he could be difficult to work with because if he did not like something, he would say something about it. Resident #6 was unable to identify the CNA by name at that time. Resident #6 appeared agitated and experienced shortness of breath during the interview and requested to continue it another time. During another interview on 07/11/13 at 9:45 AM, Resident #6 stated he was still trying to remember the name of the CNA that had left him up in his chair. CNA F entered his room and Resident #6 asked her if she remembered his complaint about the CNA who left him up. CNA F stated she worked the following shift after the allegation was made and identified the perpetrator as CNA MM. CNA F stated when she came on shift, Resident #6 was "so riled up" he would not get out of bed. When asked if she reported it to anyone, CNA F stated she informed ADON A, who was his charge nurse at the time, and ADON L was also made aware of the situation. During an interview on 07/12/13 at 12:30 PM, ADON A was asked what she knew about the allegation made by Resident #6 regarding the incident on 06/16/13. ADON A explained she was a Charge Nurse at that time and went in his room to speak with him and was surprised to see him still in bed. She stated he was usually out of bed between 5:00 AM and 5:30 AM every morning, and it was after 6:00 AM. ADON A stated Resident #6 told her staff had not put him in bed until 1:30 AM. She stated she reported it to ADON L, got a Grievance form, completed it and gave it to LBSW OO. She stated that was the extent of her involvement with the allegation because ADON L was taking care of it. On 07/11/13 at 9:58 AM, ADON L was asked if she received a complaint related to Resident #6 being left up in the wheelchair and not assisted to bed. ADON L stated, "That was way before this last stay. He had complained and that aide no longer works here." When asked if there was an incident report generated, ADON L stated there was a grievance report given to the Social Worker. Review of a Complaint/Grievance Report dated 06/17/13 revealed Resident #6 had given a "Verbal" complaint about "Care." The report reflected: "On 06/16 - Rsdt (Resident #6) stated abt (about) 8:00 PM he was in the bathroom. CNA came and got him out left him @ bedside, went home early. 10-6 CNA didn't put him in bed till 1 AM. Call light not in reach." The Complaint/Grievance Report's Findings of Investigation reflected, "Spoke with Resident & Staff regarding this Resident was not assisted to bed by 2-10 Shift but 10-6 did assist him." The Plan to Resolve Complaint/Grievance reflected: "Inservice staff on this both shifts." The Report's Results of Action taken reflected: "CNA was moved from his assignment & counseled." The Complaint/Grievance Report reflected the incident was not reportable to the State agency. The Complaint/Grievance Report reflected the grievance was resolved, but no details were documented even though the form requested a description. Further review of the Report revealed the complainant was satisfied, and the investigation results and resolution steps were reported to "Family" and "Resident." The form was signed by ADON L. During another interview with ADON L on 07/11/13 at 4:40 PM, she was asked about the "Inservice" referred to on the Complaint/Grievance form and asked if she had any evidence of the in-services provided. ADON L explained the in-services were her conversations with the nurses on the 500 Hall and there was no documentation available. During an interview on 07/11/13 at 2:13 PM, ADON L was shown the grievance form and asked about her investigation. ADON L stated, "When I went in there, he said there was a lady with braids. He said he was up until 1:30 AM and fell asleep in his chair. My first step was 2-10. I found out the 2-10 PM aide was (CNA EE), she said he was taking his meds, I talked to her about communicating with the next shift." ADON L stated CNA EE wore braids. ADON L revealed she spoke to the evening shift nurse who told her she had informed the night nurse to put Resident #6 in bed. ADON L stated she asked the evening nurse if she checked on Resident #6 and was told another resident on that hall had fallen, and she was busy tending to that resident. ADON L revealed she counseled the nurses on the importance of checking on all the residents. ADON L stated she later spoke to Resident #6 afterward and told him what she had said to the staff. ADON L stated she had gotten written statements that should have been attached to the Grievance form and did not know why they were not. She stated she would look for them. During another interview on 07/11/13 at 6:23 PM, Resident #6 was asked if he described the alleged perpetrator as having braids. He emphatically replied, "I didn't describe her as having braids! She's colored and had like a bun on her head (motioned to top of his head with hand in a downward 'C' shape)." When asked when he last saw her, Resident #6 replied, "I want to say I saw her last week." He added she continued to take care of him after he made the allegation and before he left for the hospital. When asked how the situations made him feel and whether he was in pain sitting up that long, Resident #6 stated he had not been in any pain but he was "Mad!" Review of ADL Reports, completed by the CNAs, did not reveal any entries indicating any care was provided for Resident #6 on the 10:00 PM to 6:00 AM shift beginning on 06/16/13. The facility's in-services did not reflect any regarding Resident #6. Reviews of CNA EE's personnel file did not reflect any counseling or disciplinary action regarding Resident #6's allegation. Interview on 07/11/13 at 3:50 PM with the Director of Human Resources revealed CNA EE resigned from the facility after an altercation with a nurse on 06/27/13. The facility's Daily Sign In Sheet, dated 06/16/13 which was the night of the incident, CNA MM signed in to work on Resident #6's hall. An interview with CNA MM on 07/13/13 at 3:13 PM revealed when she came in (on the 10:00 PM to 6:00 AM shift on 06/16/13), Resident #6 was upset saying no one came in and he was on his light for hours and no one would put him to bed. CNA MM stated she attempted to assist him to bed and, when she did, he fell back into the chair, cussed at her and threw his walker. CNA MM revealed she left the room, and her charge nurse told her to try again later. She stated she went back after rounding on the other residents, and he was sleeping, so she let him sleep. CNA MM went back later and he was awake and angry, so other staff put him to bed. She thought that occurred around 11:00 PM. She stated her charge nurse, LVN T, told her to write a statement and slide it under the ADON's door, and she did. She confirmed she continued to care for him after that incident. CNA MM revealed she was no longer allowed to go in his room. CNA MM stated she was called in and just submitted a written statement to facility management. Review of CNA MM's, undated written statement provided by the facility on 07/15/13, revealed she gave an account as described in her interview and added, "...This was about a month ago. Every day I've worked since this incident I have care for (Resident #6) and we haven't had any problems...." Another interview with ADON L on 07/11/13 at 3:39 PM revealed she found a written statement provided by CNA EE. When asked if she interviewed the 10:00 PM to 6:00 AM shift CNAs regarding the allegation, she replied she was focused on the 2:00 PM to 10:00 PM shift CNA and had interviewed the nurses. She stated she assigned CNA EE to the 400 Hall after the incident. ADON L revealed she only asked the Charge Nurse on the 10:00 PM to 6:00 AM shift to write statement. When asked about the CNAs on the 10:00 PM to 6:00 AM shift, ADON L replied CNA MM did not work on Resident #6's hall and the other CNA was busy assisting the nurse with the resident who had fallen. (Note: The facility's Daily Sign In Sheet, dated 06/16/13, reflected CNA MM signed in to work on Resident #16's hall). When asked if she interviewed other residents to determine if there were other complaints, ADON L responded she had not. When asked what the facility protocol was when receiving a complaint of this nature, ADON L replied to report it to the Administrator. When asked if she reported it to the Administrator, ADON L replied, "They gave it to me to go work." She stated LBSW OO assigned her the investigation. When asked if she had received training on how to investigate allegations, ADON L replied she had not received any specific in-services. She revealed after she completed her investigation, she gave it back to LBSW OO during a morning meeting. Interview on 07/15/13 at 3:50 PM with the DON revealed there had been a breakdown in communication with all of the changes. The DON stated ADON L had not received any training regarding investigations or how to conduct an investigation. An interview with LVN T on 07/13/13 at 3:36 PM revealed Resident #6 was supposed to be in bed by 8:00 PM and was waiting for an aide (on 06/16/13). She explained she gave him a dose of insulin and CNA EE walked in and said, "I'll be right back." Then the aide went home early. LVN T stated, "I had no clue, my mind was 'she is going to come back!'" LVN T went on to explain around 9:30 or 10:00 PM the night CNAs came and told her he was still up. She stated on her way to check on him, another CNA approached her and informed her a different resident was on the floor. She stated she went to handle that. She revealed after that she told the 10:00 PM to 6:00 AM shift CNAs to put Resident #6 in bed. She stated she could not really say if Resident #6 was upset at that time. When asked if she told anyone to write a statement of the events of that night, she replied, "No. Later the ADON told me to write this up." Further interview on 07/13/13 at 3:45 PM with ADON L revealed she did not receive any written statements from the 10:00 PM to 6:00 AM staff regarding Resident #6. She stated she did not ask the CNAs to write anything. She revealed she asked the nurses, but did not have any of them. An interview, on 07/11/13 at 4:11 PM with LBSW OO, revealed when he reviewed Resident #6's Complaint/Grievance form, he remembered it was brought up in a morning meeting. When asked about his role regarding grievances, LBSW OO replied he brought them to the necessary staff and to the Administrator. He stated they completed the grievance form, brought it back to him, and then he documented it. When asked who reviewed the document for accuracy, LBSW OO replied he looked them over as well as the Administrator, and the Administrator signed them off monthly. When asked about what he expected to see in regards to the investigation, LBSW OO revealed, "Well, she did an inservice...it is pretty sparse looking." When asked who was responsible for ensuring the investigations were completed, LBSW OO replied the Administrator was the Abuse Prohibition Coordinator, but they should all be responsible. An interview on 07/11/13 at 5:26 PM with the DON revealed when asked if she was aware of the allegations made by Resident #6 regarding the incident on 06/16/13, the DON stated the staff talked about it in a morning meeting. She stated her understanding was Resident #6 was up toward the end of the shift and did not want to go to bed, and the 10:00 PM to 6:00 AM CNA went in and found him asleep in his chair. Then later on rounds, he woke up and was very angry that he had fallen asleep sitting in his chair. The DON revealed she knew ADON L spoke to Resident #6's family and caretaker. During an interview on 07/11/13 at 6:00 PM, the Acting Administrator stated she left the faciity on [DATE] for an out of town assignment and Interim Adm CC took over from 06/20/13 through 07/08/13. When asked about Resident #6's Complaint/Grievance Report regarding the incident on 06/16/13, the Acting Administrator stated she did not remember reviewing it, just hearing about it. The Acting Administrator could not recall exactly when she learned about it, but stated she remembered discussing the resident was upset that he was left up in a chair so ADON L followed up on it. The Acting Administrator stated, "I didn't see this grievance, just knew it was a concern shared. Today I would have investigated further. This happened three weeks ago, this obviously was something that wasn't followed-up." (4) Review of a document provided by the Director of Human Resources revealed the names of the facility's Administrators over the past 15 months and their dates of service. The document reflected: Acting Adm: 03/01/13 to 06/16/13 Interim Adm CC: 06/17/13 to 07/08/13 Interim Adm DD: 07/08/13 to 07/11/13 Acting Adm (again): 07/11/13 to present. (5) Interview on 07/15/13 at 4:10 PM with Interim Administrator DD revealed the Acting Administrator was the Administrator on record for this facility and had planned to return when an Administrator was hired for the facility located out of town. She stated when she began her employment in the facility on 07/08/13 no pending investigations had been disclosed or discussed with her. Interview on 07/15/13 at 4:35 PM with the Acting Administrator revealed she had been the Administrator at the facility until she was sent to another facility in a different city where she was the acting administrator there. She stated she was planning to return to this facility when a permanent Administrator was hired for the out of town facility. The Acting Administrator stated she was not the Abuse Prohibition Coordinator at this facility during her absence. She stated if she had received any allegations of abuse or neglect she would have called Interim Administrator CC and DD immediately. (6) Review of the facility's Department Manager Phone List dated 07/09/13 revealed ADON L was the ADON for Halls 500 and 300. The resident roster, dated 07/09/13 was provided by Interim Administrator DD on 07/09/13 and reflected the resident census was 143. Review of the resident roster revealed there were 37 residents residing on Hall 500 and 50 residents residing on the Hall 300.