Every finding on record at Seal Beach Health and Rehabilitation Center

Based on interview, medical record review, and P&P review, the facility failed to develop a comprehensive person-centered care plan for one of seven sampled residents (Resident 1). * The facility failed to develop a care plan addressing Resident 1's refusal with bathing and or showering. This failure had the potential to not providing appropriate and individualized care to Resident 1.Findings: Review of facility's P&P titled Care Plans, Comprehensive Person-Centered revised 3/2022 showed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident. Medical record review for Resident 1 was initiated on 8/26/26. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's MDS assessment dated [DATE], showed Resident 1's BIMS score was 12, indicating moderate cognitive impairment. Review of Resident 1's Shower Sheets from 7/28 to 8/26/26, showed Resident 1 refused a shower and/or a bed bath on 7/31, 8/7, 8/21, 8/25, and 8/26/26. Review of Resident 1's medical record failed to show a care plan was developed to address the resident's refusal of showers and or bed bath. On 8/27/26 at 0855 hours, an interview and concurrent medical record review was conducted with the Unit Manager. The Unit Manager stated Resident 1 refused to receive shower and/or receive bed baths since 7/16/26. The Unit Manager further stated the CNAs must document and report any refusal of care to the charge nurses. The Unit Manager stated the licensed nurses must develop a care plan after three consecutive refusals of care or noncompliance. The Unit Manager verified there was no care plan developed for Resident 1's refusals of showers and or bed bath. On 8/28/26 at 1700 hours, the Administrator was informed and acknowledged the findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the care and services were provided to prevent the development of a pressure ulcer for one of seven sampled residents (Resident 1). * The facility failed to ensure Resident 1's skin inspection was performed daily and as needed during ADL care. The failure had the potential to negatively impact on the health outcome and delay treatments of the resident.Findings: Review of facility's P&P titled Prevention of Pressure Injuries dated revised 4/2020 showed to inspect the skin on a daily basis when performing or assisting with personal care or ADLs.a. identify any signs of developing pressure injuries (ie. non-blanchable erythema). For darkly pigmented skin, inspect for changes in skin tone, temperature and consistency;b. inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.)c. wash the skin after any episodes of incontinence, using pH balanced skin cleanser;d. moisturize dry skin daily; ande. reposition resident as indicated on the care plan On 8/26/26 at 1059 hours, an interview was conducted with Resident 1. Resident 1 stated he did not have any wounds when he was admitted to the facility. Resident 1 stated he felt tenderness to his heels, so he asked the physician to check his skin. Resident 1 stated the physician checked and did not find any concerns. Resident 1 stated prior to 7/28/26, no one changed his socks for a week. Resident 1 stated he felt tenderness to his right foot and asked the staff to check it. Resident 1 stated he needed help to transfer and ambulate, and was dependent on staff to help him remove his socks. Medical record review for Resident 1 was initiated on 8/26/26. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's Nursing admission assessment dated [DATE], showed left knee revision with knee immobilizer and PICO wound vac dressing intact. There were no other skin issues noted. Review of Resident 1's care plan for left total knee arthroplasty with hinge prosthesis initiated 6/10/26, showed interventions including to perform a weekly skin assessment. Review of Resident 1's medical record shows no skin issues documented prior to 7/28/26. Review of Resident 1's eINTERACT Change in Condition Evaluation report dated 7/28/26, showed Resident 1 was found with a pressure ulcer on the right heel. Review of Resident 1's Wound Consult assessment dated [DATE], showed the resident had a right lateral heel unstageable wound with eschar, mild sanguinous exudate and with wound measurements of 4.8 cm in length and 6.1 cm in width. Review of Resident 1's Order Summary Report dated 8/27/26, showed an order for the right heel diabetic ulcer to clean with normal saline, pat dry, apply medical grade honey (honey that has been sterilized and processed specifically for use in medical settings, particularly for wound care) and apply calcium alginate (a highly absorbent dressing made from seaweed-derived fibers, commonly used to manage wounds with moderate to heavy exudate) and wrap with rolled gauze one time a day for wound management. On 8/27/26 at 1451 hours, an interview was conducted with LVN 2. LVN 2 stated Resident 1 did not have any open wound upon admission. LVN 2 stated she was informed by a CNA Resident 1 refused a bed bath/shower on 7/28/26. LVN 2 came to the room to speak with the resident and observed discharge on the bed sheet under the right heel. LVN 2 removed the sock to conduct an assessment and noticed the right heel had an open wound. LVN 2 assumed no skin was checked prior to 7/28/26. LVN 2 further stated there would be signs of a pressure ulcer developing like redness days before developing to purplish then black color. On 8/27/26 at 1553 hours, an interview was conducted with Treatment Nurse. The Treatment Nurse stated there would be signs of blanchable erythema and progress from there purplish then DTI. The Treatment Nurse stated it would take days the skin to open into a wound and the DTI or eschar to develop despite Resident 1 with history of diabetes. The Treatment Nurse further stated the CNAs are expected to inspect and report any skin problems to the licensed nurses when providing care to the residents including bathing and/or showering. On 8/28/26 at 1700 hours, the Administrator was informed and acknowledged the findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to establish and maintain the infection control program and practices designed to help prevent the development and transmission of diseases and infections for one of seven sampled residents (Resident 1). * The facility failed to ensure the clean linens were not placed on top of the soiled linen barrel. * The facility failed to obtain an order for EBP for Resident 1 who was receiving wound care treatment. These failures placed the residents at risk for infections and potentially transmit communicable diseases to other residents throughout the facility.Findings: 1. Review of facility's P&P titled Laundry and Bedding, Soiled revised 9/2022 showed soiled laundry/bedding shall be handled, transported and processed according to best practices for infection prevention and control. Clean linen is protected from dust and soiling during transport and storage to ensure cleanliness. On 8/27/26 at 0630 hours, CNA 3 was observed placing clean linens on top of the soiled linen barrel outside of Room A. CNA 3 verified the linens were clean and stated she wiped the top of the soiled linen receptacle at the beginning of the shift. CNA 3 further stated it was her normal process to place clean linens on top of the soiled linen barrel.On 8/27/26 at 0705 hours, an interview was conducted with LVN 1. LVN 1 stated clean linens must be brought to the resident's room and not be placed on top of the soiled linen barrel despite the surface of soiled linen barrel were cleaned or sanitized. 2. Review of facility's P&P titled Enhanced Barrier Precautions dated 4/2024 showed EBP are used as an infection prevention and control intervention to reduce the spread of multidrug resistant organisms (MDROs) to residents. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include:a. dressing;b. bathing/showering;c. transferring;d. providing hygiene;e. changing linens;f. changing briefs or assisting with toileting;g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); andh. wound care (any skin opening requiring a dressing). Review of Resident 1's Order Summary Report dated 8/27/26, showed an order for daily dressing change for the right heel diabetic ulcer. Further review of the Order Summary Report failed to show an order for EBP was obtained.On 8/27/26 at 0755 hours, an observation and concurrent interview was conducted with the LVN 1. LVN 1 verified Resident 1 had a right heel diabetic ulcer and did not have an EBP signage posted outside the door. LVN 1 stated staff must wear gloves, gown and mask when providing high contact activities providing care, changing linens, transferring, and wound care for residents on EBP. LVN 1 further stated she did not wear a gown since there was no signage for EBP, but will wear gloves when providing care. On 8/28/26 at 1500 hours, an interview was conducted with the IP. The IP verified Resident 1 had no order for EBP. The IP further stated all residents with open wounds requiring a dressing change should have an order for EBP and signage must be posted outside the door for staff to follow when providing direct resident care. On 8/28/26 at 1700 hours, the Administrator was informed and acknowledged the findings.

Based on observation, interview, medical record review, and facility document review, the facility failed to ensure one of five sampled residents' (Resident 5) responsible party was notified prior to the resident receiving grooming services. * Resident 5's responsible party (Family Member 1) was not notified the resident received a hair cut from an unauthorized staff member (CNA 3). This failure resulted in Resident 5 receiving a haircut from an unauthorized staff member without prior notification to the Resident 5's responsible party.Findings: On 7/21/26, at 1344 hours, a telephone interview was conducted with Family Member 1. Family Member 1 stated she made the decisions for Resident 5. Family Member 1 stated she was concerned the facility failed to inform her the resident would be getting a haircut before CNA 3 cut Resident 5's hair. Family Member 1 stated she knew Resident 5 liked her hair prior to the haircut because Resident 5 was a cancer survivor and liked having her hair down to her back. Family Member 1 stated she was upset because Resident 5's hair was cut without consulting Family Member 1. Closed medical record review for Resident 1 was initiated on 7/21/26. Resident 5 was admitted to the facility on [DATE]. Review of Resident 5's H&P examination dated 6/29/25, showed Resident 5's diagnoses included a history of stroke and aphasia. Family Member 1 was listed as the care conference contact for Resident 5. On 7/22/26, at 1035 hours, an interview and concurrent facility document review for Resident 5 was conducted with the DON. The DON verified CNA 3 did not follow the facility's process for the resident to get a haircut. The DON stated the residents who wanted a haircut were to be placed on a list, which was then provided to the beautician who goes to the facility. The DON stated Resident 5 was not placed on this list for the facility's beautician to cut Resident 5's hair. Review of the facility's Grievance form dated 3/10/26, showed Family Member 1 filed a grievance related to Resident 5's hair being cut without notifying Family Member 1. The Grievance form showed CNA 3 did not consult with Family Member 1 prior to Resident 5 receiving a haircut. The DON stated she apologized to Family Member 1 for not informing her prior to Resident 5 getting a haircut. The DON stated she was not informed CNA 3 was going to cut Resident 5's hair. On 7/23/26 at 0904 and 1515 hours, telephone interviews were attempted to reach CNA 3. CNA 3's telephone was not set up to receive voicemails.

Based on observation, interview, and medical record review, the facility failed to ensure reasonable accommodation of needs was provided for one of five sampled residents (Resident 3). * Resident 3's call light was not within reach of the resident. This failure had the potential to negatively impact the resident.Findings: On 7/21/26 at 1250 hours, an interview was conducted with Resident 3. Resident 3 stated about three weeks ago at 0540 hours, the CNA who had changed Resident 3's disposable underwear forgot to place Resident 3's bed remote and call light near Resident 3. Resident 3 stated he liked having his bed remote within his reach so he could raise and lower the head of his bed to reposition his upper body. Resident 3 stated the CNA left the bed remote to the left side, and the call light to the right side of Resident 3's head. Resident 3 further stated both the bed remote and call light were not within his reach. Resident 3 stated he had limited mobility of both his arms and was unable to move his arms high enough to reach the bed remote left next to his head. On 7/22/26 at 0900 hours, an observation and concurrent interview was conducted with Resident 3. Resident 3 was observed lying in his bed with the call light on the floor to the left side of the bed. Resident 3 stated on 7/22/26 at around 0530 hours, he asked CNA 2 to leave the call light near Resident 3. Resident 3 slowly used his fingertips to press buttons on his bed remote. Resident 3 stated he was able to press his call light if it was left close to him. On 7/22/26 at 1447 hours, an observation and concurrent interview was conducted CNA 4. CNA 4 verified Resident 3's call light was on the floor this morning at 0900 hours. CNA 4 further stated he had not noticed the call light was on the floor this morning until he brought Resident 3's breakfast. On 7/23/26 at 1426 hours, a telephone interview was conducted with CNA 2. CNA 2 verified he was assigned Resident 3 during the night shift on 7/21/26. CNA 2 stated he placed Resident 3's call light over Resident 3's abdomen prior to leaving the room. CNA 2 was informed Resident 3's call light was observed on the floor on 7/22/26. CNA 2 acknowledged he might not have clipped Resident 3's call light to Resident 3's bed prior to leaving Resident 3's room. Medical record review for Resident 3 was initiated on 7/21/26. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's plan of care showed the following care plans:- dated 4/9/26, a care plan for risk for falls related to limited mobility. Staff were to place personal items within Resident 3's reach;- dated 4/9/26, a care plan for mobility performance deficits. The resident needed one person assistance to reposition and turn in bed; and- dated 4/23/26, a care plan for language barrier. Staff were to anticipate and meet the resident's needs, and ensure the call light was within reach. Review of Resident 3's H&P examination dated 4/10/26, showed Resident 3 did not have cognitive impairment. Resident 3 was bedbound, had decreased strength, and poor mobility.

Based on interview, medical record review, and facility document review, the facility failed to ensure an allegation of resident to resident physical abuse was reported as required to the appropriate agencies for one of five sampled residents (Resident 3). * The facility did not report Resident 3's allegation of Resident 4 telling Resident 3 to shut up, using profanity and hitting Resident 3's hands and feet to the appropriate agencies on 7/4/26. This failure had the potential to negatively impact the well-being of the residents in the facility.Findings: On 7/21/26 at 1250 hours, an interview was conducted with Resident 3. Resident 3 stated he reported an abuse allegation to the staff about three weeks ago. Resident 3 stated about three weeks ago at around 0540 hours, the CNA who had changed his (Resident 3) disposable underwear forgot to place Resident 3's bed remote and call light near Resident 3. Resident 3 stated he started screaming for the nurse to come into his room to provide Resident 3 his call light and bed remote. Resident 3 stated Resident 4 told Resident 3 to shut up and used profanity towards Resident 3. Resident 3 stated Resident 4 then went to Resident 3 and hit Resident 3's hands and feet. Resident 3 stated he reported this to a male nurse. Resident 3 further stated he never recanted this incident and reported the same information to all the staff and involved agencies who asked him about the incident. On 7/21/26 at 1600 hours, an interview was conducted with Resident 4. Resident 4 stated he remembered the incident happened a while back. Resident 4 stated Resident 3 was screaming for a nurse. Resident 4 could not remember the exact time or date. Resident 4 stated he told Resident 3 to shut up and because Resident 3 did not shut up. Resident 4 stated he then got up from Resident 4's bed and went to Resident 3. Resident 4 said he stood at the foot of Resident 3's bed and moved Resident 3's feet because Resident 3 was yelling and had woken Resident 4 up from sleep. When asked if Resident 4 used his call light to summon staff's help before telling Resident 3 to shut up and before going to make physical contact with Resident 3, Resident 4 stated he did not use his call light to summon for staff help. Resident 4 stated he saw an unidentified female nurse walking in the hallway and requested the nurse come into the room. Medical record review for Resident 3 was initiated on 7/21/26. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's Progress Note dated 7/4/26, showed during a blood glucose check at 0630 hours, Resident 3 reported he felt unsafe because Resident 4 got up, walked to his (Resident 3) bed and started to hit him on his hand because he (Resident 3) was making some noise looking for his bed control and looking at his cell phone. The RN Supervisor was made aware about this claim immediately, and Resident 3 was assessed with no skin marks, discoloration or skin tear noted. On 7/24/26 at 0800 hours, a telephone interview was conducted with RN 1. RN 1 stated she interviewed Resident 3 and Resident 3 recanted his statement. RN 1 stated she reported this incident to the DON. RN 1 stated Resident 3 verbalized he made up the allegation because he wanted a room change. RN 1 stated when Resident 3 made this statement, she then did not think the incident was abuse. RN 1 stated she did not continue with the abuse investigation process because Resident 3 recanted his statement. On 7/24/26 at 1545 hours, a telephone interview was conducted with LVN 3. LVN 3 stated when he went into Resident 3's room to check blood sugars, Resident 3 reported Resident 4 punched Resident 3's hands. LVN 3 stated he then reported this incident to RN 1. LVN 3 stated Resident 3 was moved to another room to separate the two residents. LVN 3 stated RN 1 interviewed Resident 4 and another roommate who was residing in the same room. On 7/24/26 at 1600 hours, a telephone interview was conducted with the Administrator and DON. The above findings were discussed with the Administrator and DON. The Administrator and DON were informed there was a concern with the facility not reporting the Resident 3's initial abuse allegation after the resident reported it to facility staff. The Administrator and DON verbalized they did not report Resident 3's abuse allegation to the appropriate agencies within the required time frame after 7/4/26, because Resident 3 recanted the allegation within 45 minutes of them initiating the abuse investigation. Resident 3 told the staff he made up the abuse allegation because Resident 3 wanted a room change. The Administrator and DON verbalized after Resident 3 recanted the abuse allegation to RN 1, the Administrator and DON stopped the abuse investigation and did not report the allegation of abuse to the appropriate agencies. Cross reference to F610.

Based on interview, medical record review, and facility document review, the facility failed to ensure an allegation of resident to resident physical abuse was investigated as required for one of five sampled residents (Resident 3). * The facility did not investigate Resident 3's allegation of Resident 4 telling Resident 3 to shut up, using profanity and hitting Resident 3's hands and feet after it was reported to the facility on 7/4/26. This failure had the potential to negatively impact the well-being of the residents in the facility.Findings: On 7/21/26 at 1250 hours, an interview was conducted with Resident 3. Resident 3 stated he reported an abuse allegation to the staff about three weeks ago. Resident 3 stated about three weeks ago at around 0540 hours, the CNA who had changed his (Resident 3) disposable underwear forgot to place Resident 3's bed remote and call light near Resident 3. Resident 3 stated he started screaming for the nurse to come into his room to provide Resident 3 his call light and bed remote. Resident 3 stated Resident 4 told Resident 3 to shut up and used profanity towards Resident 3. Resident 3 stated Resident 4 then went to Resident 3 and hit Resident 3's hands and feet. Resident 3 stated he reported this to a male nurse. Resident 3 further stated he never recanted this incident and reported the same information to all the staff and involved agencies who asked him about the incident. On 7/21/26 at 1600 hours, an interview was conducted with Resident 4. Resident 4 stated he remembered the incident happened a while back. Resident 4 stated Resident 3 was screaming for a nurse. Resident 4 could not remember the exact time or date. Resident 4 stated he told Resident 3 to shut up and because Resident 3 did not shut up. Resident 4 stated he then got up from Resident 4's bed and went to Resident 3. Resident 4 said he stood at the foot of Resident 3's bed and moved Resident 3's feet because Resident 3 was yelling and had woken Resident 4 up from sleep. When asked if Resident 4 used his call light to summon staff's help before telling Resident 3 to shut up and before going to make physical contact with Resident 3, Resident 4 stated he did not use his call light to summon for staff help. Resident 4 stated he saw an unidentified female nurse walking in the hallway and requested the nurse come into the room. Medical record review for Resident 3 was initiated on 7/21/26. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's Progress Note dated 7/4/26, showed during a blood glucose check at 0630 hours, Resident 3 reported he felt unsafe because Resident 4 got up, walked to his (Resident 3) bed and started to hit him on his hand because he (Resident 3) was making some noise looking for his bed control and looking at his cell phone. The RN Supervisor was made aware about this claim immediately, and Resident 3 was assessed with no skin marks, discoloration or skin tear noted. On 7/24/26 at 0800 hours, a telephone interview was conducted with RN 1. RN 1 stated she interviewed Resident 3 and Resident 3 recanted his statement. RN 1 stated she reported this incident to the DON. RN 1 stated Resident 3 verbalized he made up the allegation because he wanted a room change. RN 1 stated when Resident 3 made this statement, she then did not think the incident was abuse. RN 1 stated she did not continue with the abuse investigation process because Resident 3 recanted his statement. On 7/24/26 at 1545 hours, a telephone interview was conducted with LVN 3. LVN 3 stated when he went into Resident 3's room to check blood sugars, Resident 3 reported Resident 4 punched Resident 3's hands. LVN 3 stated he then reported this incident to RN 1. LVN 3 stated Resident 3 was moved to another room to separate the two residents. LVN 3 stated RN 1 interviewed Resident 4 and another roommate who was residing in the same room. On 7/24/26 at 1600 hours, a telephone interview was conducted with the Administrator and DON. The above findings were discussed with the Administrator and DON. The Administrator and DON were informed there was a concern with the facility not thoroughly investigating Resident 3's initial abuse allegation after Resident 3 reported the allegation to the facility staff on 7/4/26. The Administrator and DON verbalized they did not report Resident 3's abuse allegation to the appropriate agencies within the required time frame after 7/4/26, because Resident 3 recanted the allegation within 45 minutes of them initiating the abuse investigation. Resident 3 told the staff he made up the abuse allegation because Resident 3 wanted a room change. The Administrator and DON verbalized after Resident 3 recanted the abuse allegation to RN 1, the Administrator and DON stopped and did not continue to investigate the abuse allegation. Cross reference to F609.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the resident's medical record was accurate for four of 35 final sampled residents (Residents 16, 59, 93, and 201). * Resident 16's POLST was incomplete and failed to show the resident had an inaccurate date for the resident's current Advance Directive. * Resident 59 and 201's MARs were incomplete. * The facility failed to ensure Resident 93 had signed a COVID-19 vaccine declination. These failures resulted in incomplete and inaccurate medical records, which have the potential to negatively impact continuity of care and clinical decision making.Findings: 1. Medical record review for Resident 16 was initiated on 6/30/26. Resident 16 was admitted to the facility on [DATE]. Review of Resident 16's AHCD dated 7/8/25, showed Health Care Agent 1 as the resident's chosen health care agent. Review of Resident 16's POLST form dated 6/10/25, showed the resident's AHCD dated 7/8/25, was reviewed. The form was left blank for the resident's health care agent's name and telephone number. On 7/1/26 at 1215 hours, an interview and concurrent record review was conducted with the SSD. The SSD reviewed Resident 16's AHCD and POLST, and verified the POLST was incomplete and failed to show the resident's designated Health Care Agent as shown in her AHCD. 2. Medical record review for Resident 59 was initiated on 6/30/26. Resident 59 was readmitted to the facility on [DATE]. Review of Resident 59's MAR for June 2026 showed the following were undocumented for the 11-7 (2300-0700 hours) shift on 6/21/26:- An order dated 10/3/25, to monitor the resident's hours of sleep for the trazodone (medication to treat depression) use.- An order dated 10/3/25, to monitor the resident for side effects for the mirtazapine (anti-depressant medication) use: nausea, vomiting, anxiety, sexual dysfunction, insomnia, dizziness, weight loss or gain, tremors, sweating, drowsiness, fatigue, dry mouth, diarrhea, constipation, headaches, and increased risk for fall every shift.- An order dated 10/3/25, to monitor the resident for signs and symptoms of opioid overdose including but not limited to pinpoint pupils, slow, shallow breathing, falling asleep, difficult to wake, unconscious, pale, blue, or cold skin, and choking or gurgling sounds every shift. Contact the physician or 911 immediately if noted.- An order dated 10/3/25, to monitor the resident's level of pain (0-10 scale) every shift. With 0 for no pain, 1-3 for mild pain, 4-6 for moderate pain, and 7-10 for severe pain.- An order dated 10/3/25, to implement and document the nonpharmacological interventions used for pain each shift.- An order dated 10/3/25, to monitor the resident for side effects for the trazadone (anti-depressant medication) use: nausea, vomiting, anxiety, sexual dysfunction, insomnia, dizziness, weight loss or gain, tremors, sweating, drowsiness, fatigue, dry mouth, diarrhea, constipation, headaches, and increased risk for fall every shift.- An order dated 10/3/25, to implement and document nonpharmacological behavioral interventions used each shift to alleviate behaviors and their effectiveness.- An order dated 2/10/26, to monitor the resident's oxygen saturation every shift for PRN oxygen use. Notify the physician if less than 89%.- An order dated 6/18/26, to administer oxygen 2 LPM via nasal cannula continuously every shift for shortness of breath. On 7/2/26 at 1110 hours, an interview and concurrent record review was conducted with the DON. The DON reviewed Resident 59's MAR and verified the above findings were undocumented, and should have been documented to show they were completed. 3. Medical record review for Resident 201 was initiated on 6/30/26. Resident 201 was admitted to the facility on [DATE]. Review of Resident 201 MAR for June 2026, showed the following:- A physician's order dated 6/29/26, for celecoxib (nonsteroidal anti-inflammatory drug used to relieve pain, stiffness, and inflammation) 200 mg, scheduled to be administered at 0800 hours. The order was discontinued on 6/30/26 at 1040, however the MAR failed to show if the medication was administered or held on 6/30/26 at 0800 hours. - A physician's order dated 6/29/26, to monitor for orthostatic hypotension every day on the 7-3 (0700-1500 hours) shift, for the risperidone (antipsychotic medication) use. There was no documentation to show it was monitored on 6/30/26.- A physician's order dated 6/29/26, to record the resident's intake and output every shift for seven days. There was no documentation to show it was completed on the 3-11 (1500-2300 hours) shift on 6/29/26, and on the 7-3 shift on 6/30/26.- A physician's order dated 6/29/26, to monitor the resident for paranoid feelings every shift for lurasidone (an antipsychotic medication) use. There was no documentation to show it was completed for the 7-3 shift on 6/30/26.- A physician's order dated 6/29/26, to monitor the resident for side effects and adverse reactions for lurasidone use. There was no documentation to show it was completed for the 7-3 shift on 6/30/26.- A physician's order dated 6/29/26, to monitor the resident every shift for hyperglycemia including but not limited to increased thirst, frequent urination, confusion, blurred vision, fatigue, weight loss, or headache. If symptoms are present, check blood sugar and notify the physician. There was no documentation to show the monitoring was completed for the 7-3 shift on 6/30/26.- A physician's order dated 6/29/26, to monitor the resident every shift for hypoglycemia including but not limited to increased sweating, clammy skin, shaky, nervous, irritability, confusion, increased pulse, dizzy/lightheadedness, feeling weak, clumsiness, hunger, or nausea. If symptoms are present, check the resident's blood sugar and take steps to increase glucose levels. There was no documentation to show the monitoring was completed for the 7-3 shift on 6/30/26.- A physician's order dated 6/29/26, to monitor the resident every shift for signs and symptoms of opioid overdose including but not limited to pinpoint pupils, slow, shallow breathing, falling asleep, difficult to wake, unconscious, pale, blue, or cold skin, and choking or gurgling sounds. Notify the physician or 911 immediately if symptoms are noted. There was no documentation to show the monitoring was completed for the 7-3 shift on 6/30/26.- A physician's order dated 6/29/26, to monitor the resident's level of pain (0-10 scale) every shift. With 0 for no pain, 1-3 for mild pain, 4-6 for moderate pain, and 7-10 for severe pain. There was no documentation to show the monitoring was documented as completed for the 7-3 shift on 6/30/26.- A physician's order dated 6/29/26, to implement and document nonpharmacological behavioral interventions used each shift to alleviate behaviors and their effectiveness. There was no documentation to show the monitoring was documented as completed for the 7-3 shift on 6/30/26.- An order dated 6/29/26, to implement and document nonpharmacological interventions used for pain each shift. There was no documentation to show the monitoring was documented as completed for the 7-3 shift on 6/30/26.- An order dated 6/29/26, to monitor the resident for the inability to process external stimuli causing stress every shift for the risperidone (an antipsychotic medication) use. There was no documentation to show the monitoring was documented as completed for the 7-3 shift on 6/30/26.- An order dated 6/29/26, to monitor the resident for side effects and adverse reaction to the risperidone medication use. There was no documentation to show the monitoring was documented as completed for the 7-3 shift on 6/30/26.- An order dated 6/29/26, to monitor the resident for depression manifested by verbalizing the extreme feeling of sadness every shift. There was no documentation to show the monitoring was documented as completed for the 7-3 shift on 6/30/26.- An order dated 6/29/26, to monitor for side effects for the venlafaxine (anti-depressant medication) medication use to include nausea, vomiting, anxiety, sexual dysfunction, insomnia, dizziness, weight loss or gain, tremors, sweating, drowsiness, fatigue, dry mouth, diarrhea, constipation, headaches, and an increased risk for fall every shift. There was no documentation to show the monitoring was documented as completed for the 7-3 shift on 6/30/26. On 7/2/26 at 1110 hours, an interview and concurrent record review was conducted with the DON. The DON reviewed Resident 201's MAR for June 2026 and verified the above findings, and stated the MAR documentation should have been completed. 4. Medical record review for Resident 93 was initiated on 6/30/36. Resident 93 was admitted to the facility on [DATE]. Review of Resident 93's medical record showed the resident had not received a COVID-19 vaccine. However, the resident's records failed to show the resident declined the COVID-19 vaccine. On 7/3/26 at 0809 hours, an interview and record review was conducted with the IP. The IP stated she recalled she provided Resident 93 with COVID-19 vaccine information and consent form, but the resident declined the COVID-19 vaccine. The IP stated she left the consent form with the resident to sign, but she was unable to locate the consent form but will see if she can locate it. On 7/3/26 at 0940 hours, a follow up interview and record review was conducted with the IP. The IP provided Resident 93's Vaccine Consent form undated, which showed the COVID-19 vaccine was declined by the resident. The form was incomplete and not signed by the resident or by staff to show the resident provided a verbal declination. The IP verified the form was incomplete.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care and services for four of 35 final sampled residents (Residents 5, 96, 116, and 166) and one nonsampled resident (Resident 38). * The facility failed to ensure oxygen was administered to Resident 5 in accordance with the physician's order. * The facility failed to ensure Resident 38's nasal cannula for her portable oxygen and for the oxygen concentrator were both dated and labeled. * The facility failed to ensure Resident 96's oxygen set up was administered and was connected to a humidifier per physician's order. * The facility failed obtain a physician's order or develop a care plan for Resident 116's use of CPAP. * The facility failed to ensure Resident 166's oxygen nasal canula tubing was labeled with a date. These failures posed the risk for the residents to develop complications related to oxygen use.Findings: 1. On 6/30/26 at 1039 hours, Resident 116 was observed lying in bed. A CPAP machine with a mask was observed stored on the right side of the bed. Medical record review for Resident 116 was initiated on 6/30/26. Resident 116 was admitted to the facility on [DATE]. Review of Resident 116's H&P examination dated 6/1/26, showed Resident 116 had the capacity to understand and make medical decisions. Review of the Resident 116's Order Summary Report dated 7/1/26, did not show an order for the CPAP. On 7/1/26 at 1208 hours, an observation and concurrent interview was conducted with Resident 116 and Resident Representative 1. Resident 116 stated she was using a CPAP machine since her admission to the facility, and the facility staff assisted her with putting the CPAP mask on each night and removing it each morning. Resident Representative 1 stated Resident 116 received the CPAP machine from an outside clinic prior to her admission to the facility. Resident 116 was observed lying in bed. A CPAP machine with mask was observed to be stored on the right side of the bed. Review of Resident 116's medical record failed to show a care plan was developed for the use of a CPAP for Resident 116. On 7/1/26 at 1210 hours, an observation, interview, and concurrent medical record review for Resident 116 was conducted with LVN 8. LVN 8 verified a CPAP machine was present at the resident's bedside. LVN 8 reviewed the medical records and confirmed there was no physician's order for the CPAP, nor was it addressed in the care plan. LVN 8 stated the use of a CPAP machine in the facility requires a physician's order and the staff must ensure the machine was functioning properly. 2. On 6/30/26 at 1025 hours, Resident 5 was observed lying in his bed eyes closed. The oxygen was observed running at 2 LPM via nasal cannula. The nasal cannula was observed on the resident's chin, not nose. Resident 5 was observed breathing normally. Medical record review for Resident 5 was initiated on 6/30/26. Resident 5 was admitted to the facility on [DATE]. Review of Resident 5's H&P examination dated 10/30/25, showed Resident 5 had no capacity to make decisions. Review of Resident 5's MDS assessment dated [DATE], showed Resident 5 had severe cognitive impairment and required substantial staff assistance for his activities of daily living. Review of Resident 5's Order Summary Report showed the following physician's orders: - dated 5/7/25, for oxygen to administer at 2 LPM via nasal cannula continuously every shift; and - dated 5/7/25, to monitor oxygen saturation every shift and to notify physician if oxygen saturation is less than 89%. On 7/1/26 at 0853 hours, Resident 5 was observed lying in his bed eyes closed. The oxygen was observed running at 2 LPM via nasal cannula. The nasal cannula was observed on the resident's chin, not nose. Resident 5 was observed breathing normally. On 7/2/26 at 0951 hours, an observation and concurrent interview was conducted with LVN 8. Resident 5 was observed lying in his bed eyes closed. The oxygen was observed running at 2 LPM via nasal cannula. The nasal cannula was observed on the resident's chin, not nose. Resident 5 was observed breathing normally. LVN 8 verified Resident 5's nasal cannula was positioned on his chin, resulting in the resident not receiving oxygen as ordered by the physician. LVN 8 checked Resident 5's oxygen saturation, which measured at 85% without oxygen. LVN 8 then repositioned the nasal cannula correctly, and Resident 5's oxygen saturation increased to 90% with 2 LPM of oxygen. LVN 8 stated Resident 5 had a habit of removing his nasal cannula. When asked whether the physician had been notified of this behavior and whether it was addressed in the care plan, LVN 8 was unable to provide documentation demonstrating that these steps had been taken. On 7/3/26 at 1019 hours, an interview was conducted with the DON. The DON was informed of and acknowledged the above findings. 3. Review of facility's P&P titled Oxygen Administration, revised October 2010 showed in part, the purpose of this procedure is to provide guidelines for safe oxygen administration. Verify there is a physician's order for the procedure. Review the physician's order or facility protocol for oxygen administration. Review the resident's care plan to assess any special needs of the resident. Assemble the equipment and supplies as needed. The following equipment and supplies will be necessary when performing this procedure: Portable oxygen cylinder, nasal cannula, nasal catheter, mask, humidifier bottle, No Smoking /Oxygen in use signs, Regulator and personal protective equipment. On 6/30/26 at 0950 hours, during the initial tour, Resident 96 was observed lying on his bed receiving oxygen at 3 LPM via nasal cannula using the oxygen concentrator machine. There was no humidifier bottle on the oxygen machine connected to the oxygen tubing going to Resident 96 nose. On 6/30/26 at 1144 hours, during an observation, Resident 96's oxygen set up showed oxygen at 3 LPM via nasal cannula with no humidifier bottle on the oxygen machine connected to the oxygen source. Medical record review for Resident 96 was initiated on 7/1/26. Resident 96 was initially admitted to facility on 8/21/25 and readmitted on [DATE], with diagnosis of acute and chronic respiratory failure with hypoxia and hypercapnia, and COPD with acute exacerbation. Review of Resident 96's Order Summary report showed a physician order dated 2/27/26, for oxygen at 4 LPM via nasal cannula continuously every shift for respiratory failure and to change oxygen humidifier every week on Wednesday and as needed when consumed (with name and date label) every night shift every Wednesday. On 7/1/26 at 1500 hours, an observation and concurrent interview was conducted with LVN 2. LVN 2 verified Resident 96's oxygen was set at 2 LPM using the oxygen concentrator machine and there was no humidifier bottle on the oxygen machine. On 7/1/26 at 1518 hours, an interview and concurrent medical record review for Resident 96 was conducted with LVN 2. LVN 2 verified the physician's order for oxygen was for 4 LPM via nasal canula. On 7/3/26 at 1055 hours, an interview was conducted with the DON. The DON verified and acknowledged the above findings. 4. Medical record review for Resident 38 was initiated on 6/30/26. Resident 38 was re-admitted to the facility on [DATE]. Review of Resident 38's Order Summary Report showed the following physician's orders: - dated 2/10/26, to change the oxygen nasal cannula every Wednesday night and PRN with resident's name and date; and - dated 2/10/26, to administer oxygen at 2 LPM via nasal cannula continuously. On 6/30/26 at 0814 hours, Resident 38 was observed with two other residents, all in their wheelchairs, lined up against the hallway wall by the activity/dining room. Resident 38 was observed with a nasal cannula in use. On 6/30/26 at 1257 hours, Resident 38 was observed in her wheelchair in her room with CNAs 2 and 5 at her bedside. An oxygen cylinder was observed on the back of the resident's wheelchair with the nasal cannula tubing unlabeled and undated. Resident 38 was transferred to the bed, and a nasal cannula attached to the oxygen concentrator was applied to the resident. The nasal cannula tubing was also unlabeled and undated. LVN 1 then entered the room. LVN 1 stated oxygen tubing should be dated, labeled, and changed weekly. LVN 1 observed Resident 38's nasal cannula tubing, and verified both nasal cannulas used by Resident 38 were unlabeled and undated. 5. On 6/30/26 at 1518 hours, an observation and concurrent interview was conducted with Resident 166 in the facility's patio. Resident 166 was sitting in the wheelchair and talking to other residents. Resident 166 was observed wearing the oxygen tubing via nasal canula which connect to a portable oxygen tank with oxygen running at 2 LPM. The oxygen tubing was not labeled with a date. Resident 166 stated the oxygen was changed maybe a few days ago. On 6/30/26 at 1520 hours, an observation and concurrent interview was conducted with the Unit Manager. The Unit Manager verified Resident 166's oxygen tubing was not labeled with date. The Unit Manager stated Resident 166's oxygen tubing should include the date it was last changed. The Unit Manager further started it should be changed weekly and as needed to minimized the risk of infection. Medical record review for Resident 166 was initiated on 6/30/26. Resident 166 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 166's H&P examination dated 1/2/26, showed Resident 166 had capacity to make medical decisions. Review of Resident 166's Order Summary Report showed the following physician's orders: - dated 12/31/25, oxygen at 2 LPM via nasal cannula continuously every shift; and - dated 5/13/26, change oxygen nasal cannula every week on Wednesday and PRN (with name and date label) every night shift every Wednesday. On 7/2/26 at 1031 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menus were followed for 17 residents who received a fortified diet. * The facility failed to ensure one ounce of margarine was added to the lunch meal trays, and whole milk was provided to breakfast meal trays for the residents who were on fortified diets. This failure had the potential to not meet the resident's nutritional needs for the 17 of 173 residents who received a fortified diet. Findings: Review of the facility's matrix (undated) showed 173 residents consumed food prepared in the facility's kitchen. Review of the facility's P&P titled Enhanced Diet (Protein Enhanced) revised 4/2024 showed the diet is used when additional amounts of protein are needed but the resident is unable to ingest larger quantities of food or additional supplements.The diet includes the Enhancement of three menu items per day with a protein supplement.The Enhanced Diet is based on the regular diet with Whole Milk instead of 2%; thus, three meals per day.The diet features three enhanced menu items per day. a. Review of the facility's document titled Melted Margarine dated Spring 2026 showed to melt two tablespoons (one ounce) of margarine and pour over hot entree, starch, and/or vegetables. Review of the facility's document titled Therapeutic Spreadsheets dated 7/1/26, showed under the Week 4 Tuesday lunch, Fortified/High Protein diets should receive one ounce melted margarine. On 6/30/26 at 1145 hours, an observation of the lunch meal tray line and concurrent interview was conducted with Dietary Aide 1 in the kitchen. Resident 3 and 109's meal trays showed Fortified/High Protein diet. Resident 3 and 109's meal trays did not show the one ounce of melted margarine was added to their trays. The Dietary Aide 1 stated a Fortified/ High Protein diet gets whole milk, but Residents 3 and 109 did not like milk, so Resident 3 was given an alternative high protein nourishment and Resident 109 was given chocolate milk. On 6/30/26 at 1300 hours, an interview was conducted with the Dietary Services Supervisor. The Dietary Services Supervisor stated the residents on a fortified diet should have received one ounce of margarine on their meal trays. The Dietary Services Supervisor confirmed the one ounce of melted margarine was not visible on the tray and could not verify if the one ounce of melted margarine was added to the meals. b. Review of the facility's document titled Therapeutic Spreadsheets dated 7/1/26, showed under the Week 4 Wednesday breakfast, Fortified/High Protein diets should receive eight ounces of whole milk. On 7/1/26 at 0838 hours, an observation of the breakfast meal for Resident 10 was conducted in Resident 10's room. Resident 10's meal tray ticket listed Fortified/ High Protein Diet. Resident 10's breakfast meal tray was observed with juice, cereal, puree breakfast slider, and puree hashbrowns. There was no whole milk on Resident 10's breakfast meal tray. On 7/1/26 at 0924 hours, an interview was conducted with the Dietary Services Supervisor. The Dietary Services Supervisor confirmed the therapeutic spreadsheet should be followed. The Dietary Services Supervisor verified Resident 10 did not receive whole milk on her tray. The Dietary Services Supervisor confirmed Resident 10 was on a fortified diet and should have received whole milk or a substitute. On 7/1/26 at 0927 hours, an interview was conducted with the RD. The RD confirmed the therapeutic diet spreadsheets should be followed. The RD confirmed Resident 10 did not receive whole milk or an appropriate substitute to comply with the fortified diet therefore the diet was not fortified.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the infection control practices were followed for two of two final sampled residents (Residents 7 and 22) and six nonsampled residents (Residents 29, 65, 99, 130, 176, and 202) reviewed for infection control. * The facility failed to ensure the staff performed hand hygiene after administering a GT medication and before administering a Lovenox (blood thinner) injection to Resident 202. * The facility failed to ensure the staff sanitized the inhalers after administering a dose to Resident 7 and before storing it in the medication cart. * The facility failed to ensure Resident 99, who had an active C-diff infection, was properly isolated and not cohorted with Resident 29, who had a history of C-diff. * The facility's infection control program reporting inaccurately showed Residents 65, 130, and 176's suspected UTIs met the criteria for a true infection. This failure resulted in inaccurate infection control data for April and May 2026, being reported to the monthly QA Committee. * The facility failed to ensure Resident 22's indwelling foley catheter drainage bag was not lying on the floor. These failures posed the risk for transmission of disease-causing microorganisms and infections.Findings: 1. Review of the facility's P&P titled Handwashing/Hand Hygiene dated 10/2023 showed the facility considered hand hygiene the primary means to prevent the spread of healthcare-associated infections. The hand hygiene is indicated in the following instances: - immediately before touching a resident; - before performing an aseptic task (for example, placing an indwelling device or handling an invasive medical device); - after contact with blood, body fluids, or contaminated surfaces; - after touching a resident; - after touching the resident's environment; - before moving from work on a soiled body site to a clean body site on the same resident; and - immediately after glove removal. On 7/1/26 at 0920 hours, a medication administration observation for Resident 202 was conducted with LVN 8. LVN 8 was observed preparing medications for administration through the GT and preparing a Lovenox medication (anticoagulant) injection for Resident 202. LVN 8 performed hand hygiene, donned gloves, and administered the GT medication. LVN 8 was then observed removing her gloves, donning a new pair, and administering the Lovenox medication injection subcutaneously to Resident 202's right lower abdomen. LVN 8 did not perform hand hygiene after administering the GT medication and before donning the new pair of gloves for the Lovenox injection. On 7/1/26 at 0946 hours, an interview was conducted with LVN 8. LVN 8 verified the above observations and acknowledged she did not perform hand hygiene after administering the GT medication and before putting on the new pair of gloves for the Lovenox medication injection. LVN 8 stated she should have performed hand hygiene between glove changes after administering the GT medication and before administering the Lovenox medication injection to Resident 202. 2. On 7/1/26 at 0958 hours, a medication administration observation for Resident 7 was conducted with LVN 5. The following was observed: - LVN 5 was observed preparing oral medications and the multi dose inhaler Incruse Ellipta (used to relax the airway muscles in adults with chronic obstructive pulmonary disease) 62.5 mcg; - LVN 5 performed hand hygiene, entered the room, administered the oral medication and one puff of the Incruse Ellipta inhaler, and instructed the resident to rinse his mouth; - LVN 5 then performed hand hygiene and placed the Incruse Ellipta inhaler back into the medication cart without sanitizing it; - LVN 5 was next observed preparing a second multi dose inhaler, fluticasone propionate (corticosteroid that treats inflammation, itching, and allergy symptoms) 250 mcg/50 mcg; - LVN 5 performed hand hygiene, entered the room, administered one puff of the fluticasone propionate inhaler to Resident 7, instructed the resident to rinse his mouth, and then performed hand hygiene; and - LVN 5 then stored the fluticasone propionate inhaler in the medication cart without sanitizing it. On 7/1/26 at 1029 hours, an interview was conducted with LVN 5. LVN 5 verified the above observations and stated he forgot to sanitize the Incruse Ellipta and fluticasone propionate inhalers after administering the doses and before placing them back in the medication cart. LVN 5 stated he should have sanitized both inhalers before storing them in the cart. 3. Review of facility's P&P titled Clostridium Difficile dated 10/2018 showed Clostridium Difficile infection is suspected in residents with acute, unexplained onset of diarrhea (three or more unformed stools within 24 hours). Resident considered at high risk of developing symptoms associated with C. Diff includes those with advancing age, previous confirmed infection with C Diff.the primary reservoir for C-diff are infected people and surfaces. Resident with diarrhea and suspected CDI (i.e. residents who are colonized and symptomatic) are placed on contact precautions while awaiting laboratory results. Resident who are colonized with C-diff but are asymptomatic do not require contact precaution. Resident with CDI are placed in a private room if available. If private room is not available, resident will be cohorted with a dedicated commode for each resident. Review of CDPH HAI Program titled Clostridium Difficile Infection (CDI) prevention for Public Health and Healthcare Providers dated 4/16/25, showed to isolate the resident with diarrhea pending CDI confirmation. Use contact precautions for the duration of diarrhea plus 48 hours. Review of the CDC article titled Clinical Guidance for C-diff infection prevention in Acute care facilities dated 5/13/26, showed patient with a diarrhea should be isolated while evaluation for the cause is ongoing. For example, the resident remains isolated for trials off laxatives. Place symptomatic patients on contact precautions in a single patient room with a dedicated toilet. If single-patient room is not available, room patient with confirmed CDI test together. On 6/30/26 at 0845 hours, an observation of Room G and concurrent interview was conducted with LVN 9. Room G was observed closed and a contact isolation sign was posted outside the room. LVN 9 stated the contact isolation was in place for C-diff infection. LVN 9 further stated Resident 99 resided Room G and had an active C-diff infection. LVN 9 stated Resident 29 (who also resided in Room G) had a history of C-diff infection and was not currently symptomatic. a. Medical record review for Resident 29 was initiated on 6/30/26. Resident 29 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 29's Lab Results dated 5/16/26, showed the C-diff toxin was detected. Review of Resident 29's Documentation Survey report for June 2026 showed Resident 29 had three episodes of loose/diarrhea on 6/16/26. b. Medical record review for Resident 99 was initiated on 6/30/26. Resident 99 was admitted to the facility on [DATE]. Review of Resident 99's acute care hospital face sheet dated 6/4/26, showed C-diff as the admitting diagnosis. Review of Resident 99's Documentation Survey report for June 2026 showed Resident 99 had three episodes of loose/diarrhea/watery bowel movement on 6/17/26. Review of Resident 99's Lab Results dated 6/19/26, showed the C. diff toxin and antigen were detected. On 7/9/26 at 0916 hours, an interview and medical record review for Residents 29 and 99 was conducted with the IP and IP Resource. The IP stated any resident experiencing three or more loose stools within a 24 hour period was required to be isolated to rule out C-diff infection. When asked whether a resident with a history of C-diff who develops more than three loose stools in 24 hours should also be isolated, the IP confirmed isolation is required; however, testing is not recommended because such residents may produce false positive results. The IP verified Resident 29 tested positive for C-diff on 5/16/26 and remained in isolation until 5/30/26. The IP verified Resident 29 was transferred to an acute care hospital on 5/30/26, and was readmitted on [DATE] to Room G, where Resident 99 resided. Upon readmission, Resident 29 had no loose stools and was not placed on isolation. The IP verified Resident 29 experienced more than three loose stools within 24 hours on 6/16/26. When asked if Resident 29 was placed on isolation at that time, the IP stated the resident was not isolated. The IP verified Resident 29 should have been isolated for suspected C-diff due to the resident's history and symptoms, and should have remained in isolation until free of loose stools for 48 hours. The IP stated Resident 29 had no further loose stools after 6/16/26. The IP then verified Resident 99 was admitted to the facility on [DATE] to Room G, sharing a room with Resident 29. The IP stated upon admission, Resident 99 did not have three or more loose stools in 24 hours and did not require isolation. The IP also confirmed Resident 99 developed more than three loose stools on 6/17/26, and tested positive for C-diff on 6/19/26. When asked whether Resident 99's C-diff infection may have been transmitted from Resident 29, who had symptoms on 6/16/26 and was not isolated, the IP and IP Resource stated no, citing Resident 29's history of C-diff. The IP resource added facility staff follow hand hygiene, and infection control practices. The IP verified when Resident 99 was admitted to the facility the Resident 99 did not require isolation and had no loose stool more than three episodes in 24-hour period, so Resident 99 was placed in the room of Resident 29. The IP further stated both Residents 29 and 99 did not require isolation at that time. The IP further stated that when Resident 99 tested positive for C-diff, the facility did not move the resident to a private room because one was not available at that time. The IP stated Resident 99 remained in the shared room with Resident 29, who did not have active infection or diarrhea. When asked whether she attempted to move Resident 99 to a private room once one became available, the IP stated she did not attempt to do so. On 7/3/26 at 1019 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 4. On 7/3/26 at 0940 hours, an interview, medical record review, and review of the Facility's Infection Control Program binder was conducted with the IP and IP Resource. The IP stated she started as an IP at the facility in the end of February 2026 and the IP Resource trained her. The IP Resource stated the process is to use Loeb's criteria prior to initiating antibiotics, and once all diagnostic test results are in, to use McGeer's criteria to determine if it is a true infection. The facility's Infection Screening Evaluation tool is Loeb's and McGeer's criteria merged into one tool. However, the tool should always be reviewed to ensure the data is correct and to use McGeer's criteria to verify the tool's findings. The IP stated the infection control data, to include infections that met and did not meet criteria, are presented in the monthly QA Committee. a. Review of the facility's Infection Surveillance Report for April 2026 showed Resident 176 had a UTI. The IP stated the resident's infection did meet the criteria for infection. Review of Resident 176's medical record failed to show an Infection Screening Evaluation tool was completed. In addition, the resident's medical record failed to show the resident's symptoms met McGeer's criteria for a UTI. The IP verified the resident's infection did not meet McGeer's Criteria for a UTI, and had been incorrectly reported to the QA Committee. b. Review of the facility's Infection Surveillance Report for April 2026 showed Resident 130 had a UTI. The IP stated the resident's infection did meet the criteria for infection. Review of Resident 130's medical record failed to show an Infection Screening Evaluation tool was completed. In addition, the resident's medical record failed to show the resident's symptoms met McGeer's criteria for a UTI. The IP verified the resident's infection did not meet McGeer's Criteria for a UTI, and had been incorrectly reported to the QA Committee. c. Review of the facility's Infection Surveillance Report for May 2026 showed Resident 65 had a UTI. The IP stated the resident's infection did meet the criteria for infection. Review of Resident 65's medical record failed to show an Infection Screening Evaluation tool was completed. In addition, the resident's medical record failed to show the resident's symptoms met McGeer's criteria for a UTI. The IP verified the resident's infection did not meet McGeer's Criteria for a UTI, and had been incorrectly reported to the QA Committee. 5. Review of facility's P&P titled Catheter Care, Urinary, revised August 2022 showed in part, the purpose of this procedure is to prevent urinary catheter-associated compilations, including urinary tract infections. Under General Guidelines-Infection Control, use aseptic technique (specific practices used in healthcare and laboratory settings to prevent the spread of harmful microorganisms to protect patients from infection during procedures) when handling or manipulating the drainage system. Be sure the catheter tubing and drainage bag are kept off the floor. On 6/30/26 at 0926 hours, an observation was conducted of Resident 22. Resident 22 was lying in bed in a low position. Resident 22's indwelling urinary foley catheter bag was observed touching the floor. Medical record review for Resident 22 was initiated on 6/30/26. Resident 22 was initially admitted to facility on 7/25/23, and readmitted on [DATE], with diagnoses including Neuromuscular Dysfunction of the Bladder. Review of Resident 22's Order Summary Report showed a physician order dated 5/19/26, for foley catheter size FR # 16/10 cc to bed side drainage due to diagnosis of hydronephrosis and neurogenic bladder. On 6/30/26 at 1136 hours, an observation and concurrent interview was conducted with LVN 5. LVN 5 verified Resident 22's entire indwelling urinary foley catheter bag was lying on the floor. LVN 5 stated the indwelling urinary foley catheter bag should not touch the floor. On 7/3/26 at 1102 hours, an interview was conducted with the DON. The DON verified and acknowledged the above finding, and stated the staff should always make rounds to ensure the indwelling urinary foley catheter bag was kept off the floor.

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their antibiotic stewardship program to ensure physician notification for three nonsampled residents (Residents 65, 130, and 176) who received antibiotics for infections that did not meet McGeer's criteria. * The facility failed to notify Resident 65's physician to reassess the need for continued antibiotic therapy after the resident's symptoms failed to meet the criteria for a UTI. * The facility failed to notify Resident 130's physician to reassess the need for continued antibiotic therapy after the resident's symptoms failed to meet the criteria for a UTI. * The facility failed to notify Resident 176's physician to reassess the need for continued antibiotic therapy after the resident's symptoms failed to meet the criteria for a UTI. These failures created a potential risk to the residents' well being by exposing them to unnecessary antibiotic therapy, which could contribute to the development of multidrug resistant organisms (MDROs).Findings: Review of the facility's Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes revised December 2016 showed all clinical infections treated with antibiotics will be reviewed by the IP. The IP will identify any situations not consistent with appropriate antibiotic use, and will notify the provider. On 7/3/26 at 0940 hours, an interview, medical record review, and review of the Facility's Infection Control Program binder was conducted with the IP and the corporate IP Resource. The IP stated the facility uses McGeer's criteria to determine if the resident has a true infection. For infections that do not meet McGeer's Criteria, the physician is notified to reassess the resident's need for antibiotics. a. Review of the facility's Infection Surveillance Report for April 2026 showed Resident 176 had a UTI. The IP stated the resident's infection did meet the criteria for infection. Review of Resident 65's IV Administration Record for April 2026 showed an order dated 4/5/26, for ertapenem sodium 1 gm intravenously, daily for five days, for a UTI. The record showed the resident received five days of antibiotic therapy. Review of Resident 176's medical record failed to show the resident's symptoms met McGeer's criteria for a UTI. The IP verified the resident's infection did not meet McGeer's Criteria for a UTI, and the physician had not been notified to reassess the need for antibiotics. b. Review of the facility's Infection Surveillance Report for April 2026 showed Resident 130 had a UTI. The IP stated the resident's infection did meet the criteria for infection. Review of Resident 130's MAR for April 2026 showed an order dated 4/28/26, for Cipro (an antibiotic) 500 mg by mouth twice a day for a UTI. The Resident EHR showed the resident received the antibiotics for five days. Review of Resident 130's medical record failed to show the resident's symptoms met McGeer's criteria for a UTI. The IP verified the resident's infection did not meet McGeer's Criteria for a UTI, and the physician had not been notified to reassess the need for antibiotics. c. Review of the facility's Infection Surveillance Report for May 2026 showed Resident 65 had a UTI. The IP stated the resident's infection did meet the criteria for infection. Review of Resident 65's IV Administration Record for May 2026 showed an order dated 5/15/26, for Meropenem (an antibiotic) 1 gm intravenously every eight hours for ESBL in the urine. The record showed the resident received 10 days of antibiotic therapy. Review of Resident 65's medical record failed to show the resident's symptoms met McGeer's criteria for a UTI. The IP verified the resident's infection did not meet McGeer's Criteria for a UTI, and the physician had not been notified to reassess the need for antibiotics.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure comfortable home like environment was provided for five of 35 final sampled residents (Residents 22, 50, 79, 93, and 142) and two nonsampled residents (Resident 177 and 204) reviewed for home like environment. * The facility failed to provide an environment with comfortable sound levels for Residents 50, 79, 93, 142, 177, and 204. * The facility failed to ensure Resident 22's room (Room A) was in good repair, when there was a large area of chipped paint and a non-penetrating hole on the wall near Resident 22's bed. These failures had the potential to prevent the residents from resting or sleeping, negatively impact their health and psychosocial wellbeing, and diminish their overall quality of life.Findings: Review of the facility's P&P titled Homelike Environment dated 2/2021 showed the residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Staff provides person-centered care that emphasizes the resident's comfort, independence and personal needs and preferences. The facility staff and management maximize to the extent possible, the characteristics of the facility reflect a personalized, homelike setting. These characteristics include clean, sanitary and orderly environment, inviting colors and décor, and comfortable sound levels. 1.a. On 6/30/26 at 1055 hours, an interview was conducted with Resident 50 in Room B. Resident 50 stated the resident in Room C frequently screams and keeps the television volume excessively loud at all times, including during the night. Resident 50 reported the noise was bothering him and preventing him from sleeping and resting adequately. Resident 50 stated he informed the staff and they were aware of the noise, however nothing had been done to resolve the issue. Resident 50 stated this has been going on for a long time but could not recall the exact duration. Medical record review for Resident 50 was initiated on 6/30/26. Resident 50 was admitted to the facility on [DATE]. Review of Resident 50's H&P examination dated 4/24/26, showed Resident 50 had the capacity to make medical decisions. Review of Resident 50's MDS assessment dated [DATE] showed Resident 50 was cognitively intact. b. On 6/30/26 at 1057 hours, an interview was conducted with Resident 204 in Room B. Resident 204 stated he was also affected by the noise coming from Room C. Resident 204 stated he reported the resident in Room C kept the television volume loud throughout the day and during the night. Resident 204 further stated the staff had not taken any action to address the issue. Medical record review for Resident 204 was initiated on 6/30/26. Resident 204 was admitted to the facility on [DATE]. Review Resident 204's H&P examination dated 6/26/26, showed Resident 204 had the capacity to understand and make decisions. On 7/2/26 at 1144 hours, an interview was conducted with LVN 6. LVN 6 stated Resident 204 reported the loud television noise coming from Room C during the night approximately two days ago. LVN 6 stated she reported the concern to the night shift nurse to address the issue. LVN 6 stated she did not follow up on the complaint. LVN 6 further stated she did not notify the social services or initiate a grievance on behalf of the resident. On 7/2/26 at 1151 hours, an interview was conducted with CNA 6. CNA 6 stated the resident in Room C was usually was loud and preferred to keep the television volume high. CNA 6 stated Resident 50 from Room B had been complaining about the noise for approximately two weeks. CNA 6 added the residents who were across Room C also complained about the noise, however they were recently discharged . CNA 6 stated she had notified the charge nurse once or twice about the issue, but did not make any additional reports because she believed the staff were already aware of the issue. On 7/2/26 at 1443 hours, an interview was conducted with the SSD. The SSD stated if a resident had concerns regarding excessive noise in the facility and staff were aware of the issue, the staff should notify the social services. The SSD further stated the staff may file a grievance on behalf of the resident, and the social services would work to address and resolve the concern. The SSD stated she was not notified of the residents' complaints regarding the loud television and screaming from the resident in Room C. On 7/3/26 at 1019 hours, an interview was conducted with the DON. The DON was informed and acknowledged above findings. c. On 6/30/26 at 0855 hours, an observation and concurrent interview was conducted with Residents 93 and 142 inside their room (Room D). Prior to entering Room D, the door was closed. Residents 93 and 142 stated they preferred the door closed because Resident 79 was always yelling out and screaming. Residents 93 and 142 stated Resident 79 screams all night and it was hard for them to sleep. Residents 93 and 142 stated they could hear Resident 79's screams even with the door closed. Residents 93 and 142 stated the staff were aware Resident 79 was loud and often tell the resident to quiet down. On 6/30/26 at 0927 hours, a noise was heard in the hallway. Someone shouted out hey, hello please! while in the hallway. Upon inspection, the noise was coming from Room E where Resident 79 was observed moving around in bed, and repeatedly shouting out help! help me! Room E was two doors down and across the hall from Room D. Resident 79 continued to shout help please! and help me! intermittently, from his bed. On 7/1/26 at 0842 hours, upon entering Room E, the resident started shouting out help me, what do you want, and help me! A CNA entered the room to check on the Resident 79. Resident 79 stated she did not want anything and did not know what was going on. When the CNA left the room, Resident 79 started to shout out again help me! On 7/1/26 at 0845 hours, during an observation, Resident 79 yelled out help me! repeatedly. LVN 7 was observed informing Resident 79 would be there in a minute and sent a CNA to see what the resident needed. Resident 79 shouted for LVN 7 by name, and insisted she talk with LVN 7. As soon as the CNA left the room, Resident 79 started shouting out help me, help me, please intermittently. On 7/1/26 at 1536 hours an interview was conducted with CNA 7. CNA 7 stated Resident 79 will constantly call out for help and when you go to assist the resident, she replies she just needs help without giving more information. CNA 7 stated sometimes the residents in Room F (located across the hall and one room down) complain about Resident 79's behaviors being disruptive. On 7/2/26 at 0945 hours, an interview was conducted with the SSD. The SSD stated she recently spoke with Resident 79 and attended the resident's IDT care plan meeting on 6/22/26. The SSD stated she was not notified of any disruptive behaviors by the staff or other residents. On 7/2/26 at 1540 hours, an interview was conducted with Resident 177 and Family Member 1 in Room F. Family Member 1 stated she heard Resident 79's screaming episodes with yesterday being the last time she heard it. Family Member 1 stated they usually take out Resident 177's hearing aids before she leaves so Resident 177 would not be bothered by Resident 79's screaming. 2. On 6/30/26 at 0926 hours, an observation was conducted of Room A. Resident 22 was observed lying on his bed inside the room. The wall along the right side of Resident 22's bed had a large round area of chipped paint, and a non-penetrating hole. On 6/30/26 at 1203 hours, an observation and concurrent interview was conducted with the Maintenance Director. The Maintenance Director verified there was a large area of chipped paint and a non-penetrating hole on the wall of Room A. The Maintenance Director stated when there was a need for a repair, the facility staff would let him know what the repair needed was and where it was located. The Maintenance Director verified he did not know a repair was needed for Room A. On 7/1/26 at 0955 hours, an interview was conducted with Resident 22. Resident 22 was sitting on his wheelchair at the side of his bed. Resident 22 stated he noticed the large round area of chipped paint and the non-penetrating hole, and further stated it was huge and did not look good. On 7/3/26 at 1035 hours, an interview was conducted with the Administrator and the DON. The findings were discussed with the Administrator and DON. The Administrator acknowledged the findings and stated the Maintenance Director would do a further inspection to all the rooms.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide reasonable accommodations to meet the needs for one of 35 final sampled residents (Resident 8) * The facility failed to ensure Resident 8's call light was within the resident's reach. This failure had the potential to delay care and negatively impact the resident's well-being.Findings: Review of the facility's P&P titled Answering the Call Light (undated) showed to ensure the call light is accessible to the resident when in bed, from the toilet, from shower or bathing facility and from the door. On 6/30/26 at 1042 hours, an observation and concurrent interview was conducted with Resident 8. Resident 8 was lying in bed. Resident 8's call light was on the floor on left side of the bed, about two feet away from the resident. Resident 8 stated the call light was always on the floor and staff did not pick it up. CNA 1 walked in to assist Resident 8's roommate, but did not notice Resident 8's call light was on the floor and out of Resident 8's reach. CNA 1 walked out of the room. On 6/30/26 at 1051 hours, an observation and concurrent interview was conducted with CNA 1 in Resident 8's room. CNA 1 verified Resident 8's call light was on the floor on the left side of the resident's bed, and was out of the resident's reach. CNA 1 was observed about to pick the call light up, but Resident 8 then leaned his body to the left side to reach the call light. Resident 8's body was halfway out of bed. CNA 1 asked the resident to not to reach because he could fall out of bed, but Resident 8 still insisted to reach it. CNA 1 assisted Resident 8 to pick up the call light, cleaned it with wipes and placed on the bed for the resident. Medical record review for Resident 8 was initiated on 6/30/26. Resident 8 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 8's care plan for risk for falls related to having a history of a fall initiated on 1/13/25 and last revised on 6/25/26, showed interventions including to keep the call light within reach and answer promptly. On 7/1/26 at 0905 hours, an interview was conducted with the DON. The DON was informed of the above observation including how Resident 8 was leaning over and was halfway out of the bed attempting to retrieve his call light. The DON verified Resident 8's call light should have been within reach for the resident to use when he needed assistance. The DON verified and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to maintain a copy of an advance directive in the medical record for two of five sampled residents (Residents 50 and 154) reviewed for advance directives. * The facility failed to follow up and obtain a copy of Resident 50 and 154's advance directive, and did not maintain it in the medical record. These failures had the potential to prevent Resident 50 and 154's healthcare and treatment decisions from being honored.Findings: Review of the facility's P&P titled Advance Directives revised 9/2022 showed if the resident or the resident's representative has executed one or more advance directive(s), or executes one upon admission, copies of these documents are obtained and maintained in the same section of the resident medical record and are readily retrievable by any facility staff. 1. Medical record review for Resident 50 was initiated on 6/30/26. Resident 50 was admitted to the facility on [DATE]. Review of Resident 50's POLST dated 4/21/26, showed Resident 50 had no advance directive. Review of Resident 50's Social Services assessment dated [DATE], showed Resident 50 had an advance directive and the facility had requested a copy from the resident. Review of Resident 50's H&P examination dated 4/24/26, showed Resident 50 had the capacity to make medical decisions. Review of Resident 50's medical record failed to show a copy of the advance directive was maintained in Resident 50's medical record. On 7/2/26 at 1044 hours, an interview and concurrent medical record review for Resident 50 was conducted with the SSD. The SSD confirmed there was no copy of Resident 50's advance directive in the medical record, nor was it uploaded into the EHR. The SSD further verified she was unable to find documentation indicating whether the staff had followed up to obtain the resident's advance directive. The SSD stated a copy of the advance directive should have been maintained in Resident 50's medical record and should be readily retrievable by facility staff. On 7/2/26 at 1135 hours, an interview was conducted with Resident 50. Resident 50 stated he had an advance directive. Resident 50 could not recall if the facility had requested a copy, and stated he would ask his family to bring a copy of the advance directive during their next visit. On 7/3/26 at 1019 hours, an interview was conducted with the DON. The DON was informed and acknowledged above findings. 2. Medical record review for Resident 154 was initiated on 6/30/26. Resident 154 was admitted to the facility on [DATE], and readmitted on [DATE]. Reviewed of Resident 154's Social Services assessment dated [DATE], showed Resident 154 had an advance directive and facility requested a copy from the resident's daughter. Review of Resident 154's H&P examination dated 5/29/26, showed Resident 154 had the capacity to make medical decisions. Review of Resident 154's medical record failed to show a copy of the advance directive was maintained in Resident 154's medical record. On 7/1/26 at 1113 hours, an interview and concurrent medical record review for Resident 154 was conducted with the SSD. The SSD verified there was no copy of Resident 154's advance directive in the medical record, nor was it uploaded in Resident 154's EHR. The SSD stated Resident 154 had an advanced directive according to the resident's family member. The SSD stated she should have documented the follow up with the family member and obtained a copy of the resident's advance directive. The SSD further stated a copy of the advance directive should have been maintained in the Resident 154's medical record and should be readily retrievable by the facility staff so the facility can follow the plan of care and honor the resident wishes. On 7/3/26 at 1155 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. The DON further stated the SSD should have documented the follow up and obtain a copy of the advanced directive and place in the chart.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to follow the resident's plan of care and document behavior monitoring for one of two final sampled residents (Resident 79) investigated for behavior and emotional status. * Resident 79's medical record did not show behavior monitoring for the resident's behaviors targets valproic acid (a psychotropic medication used for mood-stabilizing). This failure resulted in a lack of data available for monitoring the resident's behavioral trends, to evaluate the effectiveness of nursing and medical interventions, and the potential to negatively impact the resident's health outcomes and psychosocial well-being.Findings: Review of the facility's P&P titled Psychotropic Medication Use dated 7/2022 showed psychotropic medication management includes adequate monitoring for efficacy. Medical record review for Resident 79 was initiated on 6/30/26. Resident 79 was admitted to the facility on [DATE]. Review of Resident 79's H&P examination dated 12/16/25, showed the resident was diagnosed with bipolar disorder, schizoaffective disorder, and Alzheimer's Disease. Further review showed the resident received valproic acid 250 mg twice a day. Review of Resident 79's Care Plan Report showed a focus plan initiated 3/30/26 and revised 3/31/26, for bipolar disorder and recurrent behavior fluctuations from depressed behaviors to manic behaviors and vice versa. Further review of the care plan showed interventions included to monitor and record the resident's mood to determine if problems may be related to external causes, for example medications, treatments, concern over diagnosis. Review of Resident 79's Psychiatric SNF Follow Up Note dated 4/15/26, showed the resident continued to experience ongoing symptoms of mood swings, with episodes of irritability and agitation, and reports of verbal and physical aggression towards staff. Further review showed a plan to increase the resident's valproic acid. Review of Resident 79's MAR for June 2026 showed a physician's order dated 4/16/26, to administer valproic acid 250 mg every morning, and 500 mg every evening, for bipolar disorder manifested by recurrent behavior fluctuations from depressed to manic behaviors. Review of Resident 79's medical record failed to show routine monitoring and documentation of the resident's behaviors target by valproic acid. On 6/30/26 at 0927 hours, Resident 79 was observed in bed, shouting help please! and help me! intermittently. On 7/1/26 at 0842 hours, during an observation, Resident 79 started shouting out help me, what do you want, and help me! A CNA entered the room to check on the Resident 79. Resident 79 stated she did not want anything and did not know what was going on. When the CNA left the room, Resident 79 started to shout out again help me! On 7/1/26 at 0845 hours, during an observation, Resident 79 yelled out help me! repeatedly. LVN 7 was observed informing Resident 79 would be there in a minute and sent a CNA to see what the resident needed. Resident 79 shouted for LVN 7 by name, and insisted she talk with LVN 7. As soon as the CNA left the room, Resident 79 started shouting out help me, help me, please intermittently. On 7/1/26 at 1536 hours, an interview was conducted with CNA 7. CNA 7 stated Resident 79 would constantly call out for help and when you go to assist the resident, she replies she just needs help without giving more information. CNA 7 stated sometimes Resident 79's roommate complains about Resident 79's behaviors being disruptive. On 7/2/26 at 1501 hours, an interview and concurrent medical record review for Resident 79 was conducted with ADON 2. ADON 2 stated the Resident 79's valproic acid dose was changed in April 2026. ADON 2 verified Resident 79's care plan showed to monitor and document behaviors, and Resident 79's medical record failed to show it was routinely completed. On 7/2/26 at 1530 hours, an interview and concurrent medical record review for Resident 79 was conducted with LVN 7. LVN 7 stated the behavior monitoring was documented in the MAR. LVN 7 reviewed Resident 79's MAR and verified there was no documentation to show the behavior monitoring tracking was completed.

Based on observation, interview, medical record review, and P&P review, the facility failed to develop a comprehensive person-focused care plan for one of 35 final sampled residents (Resident 112). * The facility failed to develop a care plan to address Resident 112's use of positioning pillows (a device used to help prevent bedsores, reduce pain, and improve circulation for elderly individuals). This failure posed the risk of not providing appropriate, consistent, and individualized care to the resident.Findings: Review of facility's P&P titled Care Plans, Comprehensive Person-Centered revised 3/2022 showed in part, a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The interdisciplinary team, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. If the participation of the resident and his/her resident representative in developing the resident's care plan is determined to not be practicable, an explanation is documented in the resident's medical record. The explanation should include what steps were taken to include the resident or representative in the process. Medical record review for Resident 112 was initiated on 7/1/26. Resident 112 was admitted to the facility on [DATE]. On 6/30/26 at 0928 hours, during the initial tour, Resident 112 was observed in bed covered with light blanket up to level of his chin, bed in a low position with floor pad on the right side of bed, and an overbed table on the left side. Resident 112 was observed with a positioning pillow device on the mattress at the right side of his bed. On 7/1/26 at 1125 hours, an observation and concurrent interview was conducted with LVN 2. LVN 2 verified Resident 112 had positioning pillow devices on both sides of the bed. LVN 2 stated Resident 112's family member had requested the pillows for comfort. LVN 2 stated she had seen the positioning pillows on Resident 112 before during her shift. LVN 2 was asked a care plan was developed for the use of the positioning pillow devices. LVN 2 stated she was not sure but would check the resident's record. Review of Resident 112's medical record failed to show a care plan for the use of positioning pillow devices was initiated. On 7/1/2026 at 1143 hours, an interview and concurrent medical record review for Resident 112 was conducted with ADON 2. ADON 2 reviewed Resident 112's medical record and verified there was no care plan or monitoring completed for the resident's use of the positioning pillow devices.

Based on observation, interview, medical record review, and facility document review, the facility failed to ensure the necessary care and services were provided to prevent the development of pressure injuries for one of two final sampled residents (Resident 97) reviewed for pressure injuries. * The facility failed to ensure Resident 97's LAL mattress is not set in static mode while resident in bed. This failure had the potential for Resident 97 to develop pressure injuries or worsening of the existing pressure injuries. Findings: Review of the facility's document titled Med-Aire Melody Alternating Pressure Low Air Loss Mattress Replacement System Operator's manual (undated) showed the mattress provides a firm surface that makes it easier for the patient to transfer or reposition in static mode. The static mode prevents the patient from bottoming out when in a sitting position. On 6/30/26 at 0936 hours, an observation of Resident 97 was conducted in the resident's room. Resident 97 was in bed and lying on a LAL mattress. The mattress setting was set at normal pressure and on static mode. Resident 97 stated he believed he has a bed sore, and he receives treatment every day. Resident 97 did not know the stage of his bedsore. Medical record review for Resident 97 was initiated on 6/30/26. Resident 97 was admitted to the facility on [DATE]. Review of Resident 97's H&P examination dated 4/17/26 , showed the resident had capacity to make medical decisions. Review of Resident 97's Order Summary Report showed the following physician's orders:- dated 4/17/26, may have LAL mattress; and- dated 5/29/26, may have LAL mattress due to unstageable pressure ulcer of sacral region. On 6/30/26 at 1114 hours, an observation and concurrent interview was conducted with LVN 1 in Resident 97's room. LVN 1 verified Resident 97's LAL setting on the mattress was in static mode. LVN 1 further stated the LAL mattress setting should not be on static mode. LVN 1 stated Resident 97 was a high risk for developing a pressure ulcer due to immobility and having a preexisting unstageable pressure injury. LVN 1 stated the static mode should only be used when providing care and when get resident out of bed. LVN 1 stated if Resident 97 was in bed, the static mode should be turned off. On 7/2/26 at 0848 hours, an interview was conducted with the DON. The DON stated the static mode should not be on when a resident was in bed and lying on a LAL mattress. The DON further stated the static mode on the LAL was only used during ADL care and when transfer. The DON was informed and acknowledged Resident 97's LAL mattress setting was inaccurate.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure appropriate care and services for the use of the GT for one of one nonsampled resident reviewed for tube feeding. * The facility failed to ensure LVN 1 elevated Resident 202's head of bed (HOB) to 30 degrees or higher during GT feeding and prior to administering the medication through the GT. This failure posed a potential risk for aspiration, which could result in respiratory complications, including aspiration pneumonia.Findings: Review of the facility's P&P titled Enteral Tube Feeding Via Gravity Bag dated 11/2018 showed to position the head of the bed at 30-45 ( semi-Fowler's position) for feeding, unless medically contraindicated. Medical record review for Resident 202 was initiated on 7/1/26. Resident 202 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 202's Care Plan dated 1/21/26, showed a plan of care addressing the feeding tube and Resident 202 was at risk for complication such as aspiration. The Intervention included to elevate the head of the bed at 30-45-degree angle during feeding. Review of Resident 202's MDS assessment dated [DATE], showed Resident 202 had a feeding tube. Review of Resident 202's H&P examination dated 6/29/26, showed Resident 202 was a GT dependent and had no capacity to make decisions. On 7/1/26 at 0910 hours, Resident 202 was observed in bed receiving an enteral feeding via the GT. The head of the bed was not elevated to at least a 30 degree angle. Using the phone application Measure, the head of bed angle showed as 22-degrees. On 7/1/26 at 0920 hours, medication administration observation for Resident 202 was conducted with LVN 8. Resident 202 was observed receiving an enteral feeding via the GT. LVN 8 was observed pausing the feeding and administering Resident 202's medication through the GT while the head of the bed remained at a 22 degree angle. LVN 8 was not observed elevating the head of the bed to more than a 30 degree angle prior to administering the medication. On 7/1/26 at 0946 hours, an observation and concurrent interview was conducted with LVN 8. LVN 8 stated the head of the bed for the residents should be elevated to at least a 30 degree angle during the enteral feeding and medication administration via GT. The angle of the head of the bed for Resident 202 was measured using the phone application Measure and was showed as 22 degrees. LVN 8 verified this measurement and confirmed the head of the bed for Resident 202 was not elevated to more than a 30 degree angle during tube feeding and medication administration via GT. On 7/3/26 at 1019 hours, an interview was conducted with the DON. The DON was informed of and acknowledged the above findings. The DON stated the head of the bed of the resident should be elevated to more than a 30 degree angle during the GT feeding and medication administration via GT.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the vascular access device was maintained consistent with professional standards of practice for two of 35 final sampled residents (Residents 6 and 154). * The facility failed to provide IV heplock dressing changes every seven days and as needed to Resident 6. * The facility failed to change Resident 154's IV fluid bag of normal saline within 24 hours. These failures had the potential to compromise the effectiveness of the IV therapy, and negatively impact the residents' health outcomes. Findings: Review of the facility's P&P titled General Policies for IV Therapy dated 3/2023 showed in part, only an RN or IV certified LVN may start intravenous infusions or administer approved IV solutions. IV medications may be administered by RNs. IV peripheral sites will be rotated when clinically indicated (e.g., unresolved complication, discontinuation of infusion therapy, or when no longer necessary for the care plan). Dressing change performed at least every 7 days and PRN. No IV solution will hang for period greater than 24 hours. 1. On 6/30/26 at 0910 hours, an observation was conducted of Resident 6 in the resident's room. Resident 6 was observed lying in bed. A CNA was observed preparing Resident 6 for shower. Resident 6's IV heplock on his right arm had a dressing dated 6/16. The dressing was covering most of the tubing. On 6/30/26 at 1122 hours, an observation was conducted of Resident 6 in the resident's room. The dressing on Resident 6's IV heplock on right arm was still dated 6/16. Medical record review for Resident 6 was initiated on 6/30/26. Resident 6 was initially admitted to the facility on [DATE], and readmitted on [DATE]. On 6/30/26 at 1149 hours, an observation and concurrent interview was conducted with RN 1. RN 1 stated the purpose of the IV heplock was to keep the vein open for antibiotic administration or IV hydration. RN 1 verified the dressing was dated 6/16. RN 1 further stated the dressing should have been changed at least every seven days and when soiled. On 7/3/26 at 1048 hours, an interview was conducted with the DON. The DON verified and acknowledged the above findings. 2. On 6/30/26 at 1000 hours, an observation was conducted in Resident 154's room. Resident 154 had an IV fluid bag of Sodium Chloride Intravenous solution 0.9% connected via IV access running at 50 ml/hr. The IV fluid bag label was dated 6/28/26 at 1800 hours. Medical record review for Resident 154 was initiated on 6/30/26. Resident 154 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 154's IV Administration Record for June 2026 showed Resident 154 had the following orders: - dated 6/28/26, to give Sodium Chloride Intravenous Solution 0.9%, use 1000 ml intravenously one time only for hydration until 6/28/26 at 2359 hours; and - dated 6/29/26, to give Sodium Chloride Intravenous Solution 0.9%, use 50 ml/hr intravenously every shift for hydration for one liter for one day. Review of Resident 154's Order Summary Report showed a physician's order dated 6/29/26, to administer Sodium Chloride Intravenous Solution 0.9%, use 50 ml/hr intravenously every shift for hydration for one liter for one day. On 6/30/26 at 1106 hours, an observation and concurrent interview was conducted with RN 1 in the Resident 154's room. RN 1 verified the resident's IV fluid bag of Sodium Chloride was dated 6/28/26, which was more than 24 hours. RN 1 stated IV bags should be changed every 24 hours. On 7/3/26 at 1120 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development or worsening of the pressure ulcers for one of two sampled residents (Resident 1). Resident 1 was readmitted to the facility with a non-blanchable pressure ulcer to the sacrococcyx (tailbone area) on 10/26/21, which had progressed to a Stage 3 pressure ulcer on 1/12/22. * The facility failed to provide wound care treatments as ordered by the physician. * The facility failed to ensure Resident 1's skin assessments were consistently conducted to prevent the worsening of the pressure ulcer. * The facility failed to conduct the weekly IDT wound meetings to ensure the pressure ulcer was healing. These failures resulted in Resident 1's development of a worsening pressure ulcer and delayed healing. Findings: Review of the facility's P&P titled Wound Care revised 10/20, showed the purpose of this procedure is to provide guidelines for the care of wounds to promote healing healing. Preparation - 1. Verify that there is a physician's order for this procedure .Documentation - The following information should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given .4. The name and title of the individual performing the wound care. 5. Any change in the resident's condition. 6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound .9. If the resident refused the treatment and the reason(s) why. 10. The signature and title of the person recording the data. According to the National Pressure Injury Advisory Panel, a pressure ulcer is defined as a localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The National Pressure Injury Advisory Panel redefined the definition of a pressure ulcers in 2016. They are as follows: - Stage 1 pressure ulcer - intact skin with a localized area of non-blanchable [CONDITION(S)] (redness). - Stage 2 pressure ulcer - partial thickness skin loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough (dead tissue). May also present as an intact or open/ruptured serum-filled blister. - Stage 3 pressure ulcer - full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling (damage to tissue beneath the skin surrounding the pressure ulcer). Closed medical record review for Resident 1 was initiated on 1/24/22. Resident 1 was admitted to the facility on [DATE], readmitted on [DATE], and discharged from the facility on 1/16/22. Review of the Re-Admission Braden Scale for Predicting Pressure Sore Risk dated 10/26/21, showed Resident 1's risk score was 17, which meant the resident was at risk for developing the pressure ulcers. Review of the untitled document dated 10/27/21, showed Resident 1's skin assessment showed a pressure injury (same as pressure ulcer) described as non-blanchable redness to the coccyx. Review of the Order Summary Report showed a physician's order dated 10/27/21, to apply [MEDICATION(S)] ointment 20% to sacrococcyx topically every shift for non blanchable redness, wash with warm water and mild soap, pat dry, apply [MEDICATION(S)], and leave open to air every shift and as needed. Review of Resident 1's plan of care showed a care plan problem dated 10/27/21, addressing redness to Resident 1's sacrococcyx. The interventions included to perform the treatments as ordered. Review of the Wound Evaluation Flow Sheet dated 10/27/21, showed Resident 1 had a Stage 1 non-blanchable pressure ulcer to the sacrococcyx, measuring 4.0 cm (length) x 4.0 cm (width). Further review of the Wound Evaluation Flow Sheet showed the last wound evaluation conducted for Resident 1 was documented on 12/23/21. Review of the Skin/Wound Progress Note dated 1/12/22, showed Resident 1's pressure ulcer regressed to a Stage 3 and noted few islands of partial thickness tissue loss, open areas over redness, close approximal to each other and the entire site, measuring 4.6 cm (length) x 5.6 cm (width) x 0.2 cm (depth). On 1/24/22 at 1130 hours, an interview was conducted with CNA 1. CNA 1 stated all CNAs were required to conduct daily skin checks for the residents. CNA 1 stated the skin checks occurred while providing care to the resident and the CNAs were required to report to the Charge Nurse if they observed any changes to the resident's skin. On 1/24/22 at 1150 hours, an interview was conducted with LVN 2. LVN 2 stated Resident 1 was no longer at the facility. LVN 2 stated Resident 1 was readmitted to the facility with a Stage 1 non-blanchable ulcer on the sacralcoccyx. LVN 2 stated Resident 1 had a physician's order for skin treatments to the wound. LVN 2 stated she was off from work and when she returned on 1/12/22, she assessed Resident 1's skin and found the resident's pressure ulcer had worsened. LVN 2 stated the pressure ulcer progressed from a Stage 1 to Stage 3. LVN 2 stated the facility's policy was to conduct skin wound assessments weekly, which included measurements, description, and location of the wound. On 1/24/22 at 1225 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 stated Resident 1 was alert and oriented, able to carry a conversation, and compliant with care. LVN 1 verified Resident 1 was admitted to the facility with a Stage 1 non-blanchable pressure ulcer and on 1/12/22, the pressure ulcer had worsened to a Stage 3. On 1/24/22 at 1237 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 stated the facility's policy for skin assessments included conducting skin assessments on the new residents upon admission. LVN 3 further stated CNAs should be conducting skin checks during the resident's shower days, peri-care, and bed baths. The CNAs were to report any changes to the charge nurse. LVN 3 stated Resident 1 was admitted with foot [CONDITION(S)] and redness on her coccyx. LVN 3 reviewed Resident 1's Treatment Administration Record and verified Resident 1 had a physician's order to apply [MEDICATION(S)] ointment 20% to sacralcoccyx topically every shift for non-blanchable redness. LVN 3 stated the nurses who provided the treatments would document in the Treatment Administration Record and the nurse's initials would appear. Further review of Resident 1's Treatment Administration Record showed the following: * The Treatment Administration Record dated 10/1 to 10/31/21, showed blank, unsigned treatments on the following dates: - On 10/28/21 and 10/29/21, during the 11-7 shifts - On 10/30/21, during the 3-11 and 11-7 shifts - On 10/31/21, during the 11-7 shift A total of four treatments were missed for October 2021. * The Treatment Administration Record dated 11/1 to 11/30/21, showed blank, unsigned treatments on the following dates: - On 11/1/21, during the 3-11 and 11-7 shifts - On 11/4/21, during the 11-7 shift - On 11/6/21, during the 3-11 shift - On 11/8/21, during the 11-7 shift - On 11/9/21, during the 3-11 and 11-7 shifts - On 11/10/21, during the 3-11 shift - On 11/13/21, during the 11-7 shift - On 11/20/21, during the 7-3 shift A total of 10 treatments were missed in November 2021. * The Treatment Administration Record dated 12/1 to 12/31/21, showed blank, unsigned treatments on the following dates: On 12/2/21, during the 3-11 shifts On 12/12/21, during the 7-3 shift On 12/14/21, 12/19/21, 12/20/21 and 12/24/21, during the 3-11 shift On 12/25/21, during the 11-7 shift On 12/26/21, during the 7-3 and 3-11 shifts On 12/28/21, during the 3-11 shift On 12/30/21 and 12/31/21, during the 11-7 shift A total of 12 treatments were missed in December 2021. * The Treatment Administration Record dated 1/1 to 1/31/22, showed blank, unsigned treatments on the following dates: - On 1/1/22, during the 3-11 shift - On 1/2/22, during the 11-7 shift - On 1/3/22, Resident 1 did not receive treatments on each of the three shifts for the day - On 1/4/22, during the 3-11 and 11-7 shifts - On 1/5/22, during the 11-7 shift - On 1/6/22, during the 3-11 and 11-7 shifts - On 1/7/22, during the 3-11 shift - On 1/9/22 and 1/10/22 during the 7-3 shifts - On 1/11/22 during the 3-11 and 11-7 shifts - On 1/12/22, Resident 1's wound progressed to a Stage 3 and the new orders from the physician were received. A total of 14 treatments were missed in January 2022 prior to the discovery of Resident 1's Stage 3 wound. LVN 3 verified the blank boxes in Resident 1's Treatment Administration Record meant the treatments were missed and not provided to the resident. LVN 3 further stated the residents with a pressure ulcer must have had the weekly assessments documented in the electronic medical record or paper weekly wound assessments and must have had the weekly IDT wound management meetings. LVN 3 reviewed Resident 1's medical record and verified she could not find any weekly electronic skin/wound evaluation/assessments conducted for Resident 1. LVN 3 stated there were no weekly IDT wound management notes pertaining to Resident 1's Stage 1 pressure ulcer. LVN 3 verified an IDT wound management note was dated for 1/13/22, in regards to the in-facility development of Resident 1's Stage 3 pressure ulcer. On 1/24/22 at 1607 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified Resident 1's Stage 3 pressure ulcer was discovered on 1/12/22. The DON reviewed Resident 1's medical record and stated an IDT meeting for the worsening of the wound was conducted on 1/13/22, but could not find other IDT wound notes relating to the pressure ulcer. On 3/1/22 at 1616 hours, a telephone interview was conducted with the DSD. The DSD stated the Treatment Nurses were expected to document and assess the wounds weekly, and the IDT wound management meetings should be conducted weekly for the residents as well. The DSD stated the assessments and meetings should be documented in the electronic health record; however, some treatment nurses still documented on paper record and those assessments were in the binder. On 3/3/22 at 1432 hours, a telephone interview and concurrent medical record review was conducted with the DON. The DON stated all physician's orders should be followed accordingly. The DON verified if a treatment was ordered every shift, then the order should be followed. If there was a discrepancy in the order, the physician should be notified and the order had to be clarified. The DON stated the nurses should be conducting skin assessments daily, especially when the nurse was providing a treatment, and the assessment should be documented. The DON reviewed Resident 1's medical record and verified the above findings on Resident 1's Treatment Administration Record for the months of October 2021 - January 2022, and verified there was a physician's order for [MEDICATION(S)] ointment 20% to sacrococcyx topically every shift for non-blanchable redness. The DON verified the above treatments were missed and not documented. The DON verified the treatment orders should have been followed as per the physician's order, and the weekly wound evaluation and assessments should have been documented.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development of pressure ulcers and promote the pressure ulcer healing processes for five of 26 sampled residents (Residents 10, 12, 22, 2, and 23) as evidenced by: * The facility failed to identify, assess, and provide treatments and interventions for Resident 10's facility-acquired pressure ulcers. As a result, Resident 10 developed a Stage 2 pressure ulcer on the sacrococcyx, which deteriorated to a Stage 3. In addition, Resident 10 developed four additional pressure ulcers on the buttock areas that were not assessed, care planned, monitored for their healing progress, and communicated to the attending physician for proper treatments. * Resident 12 was identified as high risk to develop skin breakdown due to [DIAGNOSES REDACTED]. Resident 12 did not have preventative measures for his heel initiated before he developed a blood filled blister. The LVN determined the wound was an arterial ulcer 24 days after being identified, without a [DIAGNOSES REDACTED]. * Resident 22 was admitted to the facility without a pressure ulcer and identified as high risk to develop skin breakdown due to immobility and [MEDICAL CONDITION]. Resident 21 developed a Stage 1 left heel pressure ulcer 10 days after admission, which deteriorated to an UTD blood filled blister five days later. The preventative measures were not initiated until after the ulcer was identified. * Resident 2 was identified as high risk to develop skin breakdown; however, her heels were not offloaded as a preventative measure. As a result, Resident 2 developed a new Stage 2 left heel pressure ulcer. * Resident 23 was admitted to the facility without a pressure ulcer and was identified as high risk to develop skin breakdown due to [MEDICAL CONDITION] and DM. The facility failed to put preventative measures in place to prevent the development of the pressure ulcers, such as offloading the heels or use of heel protectors. As a result, Resident 23 developed bilateral heel blisters 24 days after admission and was unable to participate in PT for transfer training to improve strength and balance due to the pressure ulcers. Findings: Review of the facility's P&P titled Prevention of Pressure Ulcers revised 9/2013 showed: -Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time, causing increased pressure. -The most common site of a pressure ulcer is where the bone is near the surface of the body. -If pressure ulcers are not treated when discovered, they quickly get larger, become very painful for the resident, and often times become infected. -Once a pressure ulcer develops, it can be extremely difficult to heal. Pressure ulcers are a serious skin condition for the resident. -The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family, and addressed. -Interventions and preventive measures included: Allow resident to use a side rail as an enabler if indicated. When in bed, every attempt should be made to float heels (keep heels off of the bed). Use pillows, wedges or other off-loading devices to keep bony prominences such as knees or ankles from touching each other. 1. Review of the facility's P&P titled Pressure Ulcers/Skin Breakdown - Clinical Protocol revised 3/14 showed in part: Assessment and Recognition: 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure ulcer including location, stage, length, width and depth, presence of exudates or necrotic tissue. Clinical record review for Resident 10 was initiated on 8/22/17. Resident 10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident 10's Admission/Readmission Nursing Data Tool dated 4/6/17, showed the resident did not have pressure ulcers when she was admitted to the facility and the Braden Scale showed she was at risk for developing a skin/pressure ulcer. Review of the Quarterly Risk Assessments dated 7/13/17, (over three months after her admitted ) showed the resident was still at risk for developing a skin/pressure ulcer. Review of the Wound Evaluation Flow Sheet dated 7/14/17, (over three months after her admission to the facility) showed the resident acquired a Stage 2 pressure ulcer on the sacrococcyx. Review of the IDT Wound Management assessment dated [DATE], showed the resident had a facility-acquired Stage 2 pressure ulcer on the sacrococcyx. Review of the IDT Wound Management assessment dated [DATE], (22 days after the last IDT Wound Management Assessment) showed the resident's Stage 2 pressure ulcer had become worsened and was now a Stage 3 pressure ulcer. Review of the Wound Evaluation Flow Sheet dated 8/19/17, showed the resident continued having one Stage 3 pressure ulcer on the sacrococcyx. Review of the resident's care plan showed a care plan problem dated 8/6/17, titled Pressure Ulcer: Altered skin integrity related to the sacrococcyx Stage 3 pressure ulcer. The goal was to minimize the risk for further pressure sore. The interventions included to assess weekly progress of the pressure ulcer and observe/report new areas of pressure sore, open areas, or redness. However, there were no assessed needs and/or interventions to include any pressure relief devices to relieve the pressure on the sacrococcyx/buttock areas and facilitate the healing process for the Stage 3 pressure ulcer on the sacrococcyx. On 8/22/17 at 1310 hours, an interview was conducted with LVN 5. LVN 5 stated Resident 10 acquired one pressure ulcer at the sacrococcyx after her admission to the facility and the pressure ulcer became worse from a Stage 2 to the current Stage 3. On 8/22/17 at 1430 hours, an observation of Resident 10's wound dressing change was observed with LVN 5 and CNA 5. Before LVN 5 changed the resident's wound dressing, LVN 5 asked the resident if she was in pain. Resident 10 stated she was in pain in the wound area and it hurt. LVN 5 postponed the wound dressing change. On 8/22/17 at 1625 hours, (two hours after the first attempt at dressing change) an interview was conducted with LVN 5. LVN 5 stated Resident 10 was still complaining of pain; the nurse had given Resident 10 her pain medication at 1430 hours(two hours earlier). LVN 5 was waiting until the pain was relieved before performing the dressing change. On 8/23/17 at 1606 hours, an observation of the resident's wound dressing change was conducted with LVN 5 and CNA 8. After LVN 5 removed a dressing from Resident 10's buttocks, there were four additional wounds noted: a. Wound 1: an open area measured approximately 2.5 inches (in length) x 2.5 inches (in width) on the right buttock, with slough noted around the wound edge. b. Wound 2: an open area measured approximately 0.3 inches x 0.3 inches above the tail bone, with slough noted around the wound edge, approximately an inch away from Wound 1. c. Wound 3: an open area measured approximately 0.2 inches x 0.2 inches on the left buttock, with slough noted around the wound edge, approximately 0.5 inch away from Wound 2. d. Wound 4: an unopened area measured approximately 0.5 inches x 0.2 inches on the left buttock with purplish color, approximately 0.5 inch away from Wound 3. On 8/23/17 at 1640 hours, an interview was conducted with LVN 5. LVN 5 confirmed the findings. When asked what the stages were for Wounds 2 and 3, LVN 5 stated they were Stage 3 pressure ulcers because of the presence of slough. LVN 5 stated she noted the three new wounds (Wounds 2, 3, and 4) last Friday (five days earlier), but she did not document her findings in the resident's clinical record. LVN 5 confirmed there was no documented evidence to show the new pressure ulcers were assessed, care planned, monitored for their healing progress, and communicated to the attending physician for proper treatments. Review of the IDT Wound Management assessment dated [DATE], failed to showed assessments, treatments, and other interventions for the newly acquired pressure ulcers (Wounds 2, 3, and 4). Review of the Wound Evaluation Flow Sheet dated 8/19/17, failed to show assessments, treatments, and other interventions for the newly acquired pressure ulcers (Wound 2, 3, and 4). Review of the Weekly Nursing Progress Note dated 8/19/17, failed to show the identifications of the newly acquired pressure ulcers (Wound 2, 3, and 4). 2. Medical record review for Resident 12 was initiated on 8/22/17. Resident 12 was admitted to the facility on [DATE]. Resident 12's history and physical examination [REDACTED]. On 8/23/17 at 0815 hours, Resident 12 was observed sitting up in bed eating breakfast. Resident 12's left leg was amputated below the knee. Resident 12's right leg was crossed over his left with his right heel resting on the bed and a dressing covering his heel. There were no off-loading devices on the bed. On 8/23/17 at 0823 hours, an interview was conducted with CNA 4. CNA 4 verified Resident 12 had a wound on his heel. CNA 4 stated Resident 12 had a boot to relieve pressure on his heel, but he took it off. CNA 4 found the boot in Resident 12's closet and stated it must not have been on last night. Review of Resident 12's MDS dated [DATE], showed he needed limited assistance from one person for bed mobility and transfers. Resident 12's MDS dated [DATE], showed he had declined and now needed extensive assistance from one person for bed mobility and transfers. Review of the Wound Evaluation Flow Sheet dated 7/14/17, showed a blood filled blister was identified on Resident 12's right posterior heel measuring 4 cm (length) x 5 cm (width) x UTD (depth). The area to document the stage of the wound was blank. Review of Resident 12's Order Summary Report dated 7/24/17, showed a physician's orders [REDACTED]. Review of Resident 12's physician's progress note dated 7/18/17, showed there was a new area of blistering on the right heel and evidence of deep tissue injury due to pressure. The impression was a pressure ulcer of the right heel with stage indeterminate. There appears to be deep tissue injury. Review of Resident 12's Order Summary Report dated 7/24/17, showed a physician's orders [REDACTED]. Review of Resident 12's physician's orders [REDACTED]. On 8/23/17 at 0900 hours, an interview was conducted with LVN 5. LVN 5 stated Resident 12 was at high risk to develop a pressure ulcer due to severe peripheral artery disease and noncompliance with elevating his leg. LVN 5 verified Resident 12's wound started as a blood blister on 7/14/17. LVN 5 stated she had not staged the blood blister as UTD, she simply stated it was a blood blister. LVN 5 stated she determined the wound to be an arterial ulcer due to the arterial ulcer on the anterior portion of his foot and clarified the order on 8/7/17 (24 days after the blood blister was identified). LVN 5 stated Resident 1 went out of the facility to see a physician who assessed the wounds. LVN 5 verified the physician had not determined the [DIAGNOSES REDACTED]. When asked to see documentation regarding preventive measures initiated for Resident 12 prior to developing the blood blister, LVN 5 was unable to locate anything. On 8/23/17 at 1230 hours, an interview was conducted with RN 1. RN 1 verified Resident 12 was at high risk for skin breakdown due to severe peripheral artery disease and dementia. RN 1 confirmed the physician's orders [REDACTED]. RN 1 verified the physician needed to determine the [DIAGNOSES REDACTED]. RN 1 verified her nursing progress note dated 7/14/17 at 1505 hours, showed awareness of Resident 12's noncompliance and reminders being given, but no other interventions documented. On 8/24/17 at 1500 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified Resident 12 was at high risk to develop a pressure ulcer and was noncompliant by refusing to wear shoes when self-propelling the wheelchair and removing the boot that protected the heel. The DON verified the noncompliance was not included in the care plan problems. The DON stated a blood blister should be identified/staged as UTD. The DON was able to locate two occasions in the nursing progress notes where the nurse stated Resident 12 was instructed or elevated the right foot on 7/9/17 at 0940 hours and 7/10/17 at 1052 hours. The DON verified no other documentation was located regarding the preventative measures being initiated before the blood blister was identified. The DON stated the care plan problem interventions were increased/initiated after the breakdown was identified. 3. Medical record review for Resident 22 was initiated on 8/24/17. Resident 22 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident 22's clinical record titled Admission/Readmission Nursing Data Tool dated 8/6/17, showed: - The resident did not have pressure ulcers to her bilateral heels when she was admitted to the facility. - The resident's Braden Scale showed she was at risk for developing a skin/pressure injury. Review of the MDS dated [DATE], showed Resident 22 needed extensive assistance from one person for bed mobility. Review of Resident 22's Wound Evaluation Flow Sheet dated 8/15/17, identified a left heel Stage 1 pressure ulcer, measuring 4 cm (length) x 4 cm (width) x 0 cm (depth). An entry dated 8/20/17, identified the left heel with a deep tissue injury pressure ulcer, measuring 5 cm x 5 cm x 0 cm. Review of Resident 22's care plan showed a care plan problem dated 8/8/17, titled Pressure Ulcer/ skin integrity related to impaired mobility, [MEDICAL CONDITION] on [MEDICAL TREATMENT], and episodes of incontinence. The interventions showed to: - minimize skin friction/rubs/shearing -handle gently -encourage to get out of bed every day as tolerated -keep clean and dry. Review of Resident 22's care plan problem dated 8/15/17, (when the Stage 1 to left heel pressure ulcer was identified) titled Pressure Ulcer: Altered skin integrity related to pressure ulcer on left heel showed interventions to: - float heel(s) with pillow while in bed if indicated - apply heel protectors to bilateral heels when in bed. Review of Resident 22's physician's orders [REDACTED]. Review of Resident 22's physician's orders [REDACTED]. On 8/24/17 at 0825 hours, an interview with Resident 22 was conducted. Resident 22 confirmed she had a sore on her left heel. Resident 22 stated she did not have much feeling in her feet so she did not have pain. Resident 22 stated she had never had a sore on her heels before. Resident 22 stated the facility started elevating her foot after she got the sore and then started with the heel protectors. On 8/24/17 at 0835 hours, an interview was conducted with LVN 7. LVN 7 stated Resident 22 usually lay in bed with the head of the bed up and did not like to be turned. On 8/24/17 at 1015 hours, an interview was conducted with CNA 15. CNA 15 stated the treatment nurse told him when he needed to offload a resident's heels. CNA 15 stated Resident 22 liked to lay flat in the bed and did not like to turn. CNA 15 stated he could not remember if he elevated Resident 22's heels before she developed a pressure ulcer. CNA 15 stated he did not document if the residents heels were offloaded. On 8/24/17 at 1500 hours, an interview was conducted with the DON. The DON verified there was no documentation regarding preventive measures for Resident 22's heels before the pressure ulcer was identified. The DON stated once the pressure ulcer was identified, they increased the care plan by adding the interventions, such as offloading and applying the heel protectors. The DON confirmed documenting of the interventions started after the pressure ulcer was identified. 4. Medical record review was initiated for Resident 2 on 8/22/17. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of Resident 2's MDS dated [DATE], showed Resident 2 had severe cognitive impairment, needed extensive assistance with bed mobility and transferring, and had impairment on both sides of her lower extremities. Review of the Admission/Readmission Nursing Data Tool dated 6/13/17, showed Resident 2 was readmitted from an acute care hospital with a new GT and a Stage 2 pressure ulcer to her sacrococcyx area. Review of the Braden Scale for Predicting Pressure Ulcer Risk dated 6/14/17, showed Resident 2 was at risk for developing a skin/pressure injury. Review of the IDT Wound Management Update form dated 6/30/17, showed Resident 2's sacrococcyx pressure ulcer resolved on 6/28/17, and to continue the plan of care for skin management. Review of Resident 2's care plan showed a care plan problem with a revision date of 6/15/17, addressing Resident 2's risk for pressure ulcer/impaired skin integrity. The goal was to have skin that showed/demonstrated healing. The interventions included to check every two hours for soiling and wetness, keep clean and dry, minimize skin friction, and monitor nutritional status. The care plan failed to show to offload the heels with a pillow. Review of the Change in Condition Form dated 7/28/17, showed Resident 2 had a left medial heel fluid filled blister that was first observed on 7/28/17. The summarization of the observation at the time the blister was discovered failed to show Resident 2 had a pillow in place to offload her heels. Review of the Wound Evaluation Flow Sheet dated 7/28/17, showed Resident 2 had a left medial heel fluid filled blister documented as a Stage 2 pressure ulcer first observed on 7/28/17. Review of Resident 2's physician's orders [REDACTED]. - Bilateral heel protectors while in bed. May remove during care every shift. - Offload heels with pillows while in bed every shift. On 8/23/17 at 1040 hours, an interview was conducted with CNA 2. When asked about the pressure ulcer prevention, CNA 2 stated prior to Resident 2 acquiring the pressure ulcer on her heel, she checked Resident 2 every two hours to make sure she was clean and repositioned Resident 2. CNA 2 stated she did not offload Resident 2's heels until after the pressure ulcer to her heel was discovered. CNA 2 stated Resident 2 needed assistance for turning and repositioning and could not do it on her own. On 8/23/17 at 1105 hours, an interview and concurrent observation was conducted with LVN 6 while at Resident 2's bedside. LVN 6 stated Resident 2 was at very high risk for developing a pressure ulcer. LVN 6 stated Resident 2 was very weak and lethargic due to her history of dehydration and decreased oral intake and stated Resident 6 had improved since the GT was placed. LVN 6 was asked what interventions were in place to prevent the pressure ulcers. LVN 6 stated turning and repositioning Resident 2 every two hours and keeping her clean and dry. LVN 6 stated Resident 2's heels were not offloaded with pillows until after the pressure ulcer to her left heel was discovered. 5. Medical record review for Resident 23 was initiated 8/2/17. Resident 23 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE], showed Resident 23 was cognitively intact and needed extensive assistance with ADL care. On 8/24/17 at 0750 hours, Resident 23 was observed in bed, awake, lying on her back with the call light within reach. The bed was observed without the side rails or assistive devices. Review of the Admission/Readmission Nursing Data Tool dated 6/23/17, showed Resident 23 was identified at risk for developing a skin/pressure injury. Review of the SBAR Communication Form dated 7/17/17, showed a CNA observed a blister on Resident 23's left heel and no pillow was noted in place to float the heel at the time the blister was found. Review of the Wound Evaluation Flow Sheet dated 7/17/17, showed Resident 23 had left and right heel fluid filled blisters. The heels were mushy and boggy with purplish discoloration. On 8/24/17 at 1435 hours, an interview and concurrent medical record review was conducted with LVN 6. LVN 6 was asked when Resident 23 developed the bilateral heel blisters. LVN 6 stated Resident 23 developed the bilateral heel blisters while in the facility on 7/16/17, and the new physician's orders [REDACTED]. LVN 6 was asked if Resident 23 was a high risk for developing pressure ulcers and what measures were used to prevent the occurrence. LVN 6 confirmed Resident 23 was identified as high risk through the nursing admission assessment, but specific measures to prevent the development of pressure ulcers were not included in the plan of care. LVN 6 stated it was not understood why the resident developed heel blisters because she moved well and walked. LVN 6 verified offloading the resident's heels should have been included in the resident's plan of care as a preventative measure as she was identified as requiring extensive assistance. On 8/25/17 at 0830 hours, an interview was conducted with CNA 9. CNA 9 was asked to explain what Resident 23's care needs were. CNA 9 stated Resident 23 needed assistance with all her ADL care because she was weak and scared to turn over in bed for fear of falling. Resident 23 was alert and could reposition herself, but she would not move because she did not have side rails. CNA 9 stated Resident 23 was able to walk with the walker and he talked with the nurses about Resident 23's request for side rails, but they stated the State doesn't want anyone to have side rails. On 8/25/17 at 0845 hours, an interview and concurrent medical record review was conducted with ADON 1. ADON 1 was asked the process of evaluating the residents for the use of side rails. The ADON 1 stated the IDT team decided to remove all the side rails on the empty beds first. Then the team removed all the side rails from the residents who did not need them and the team decided which residents should have a grab bar or pole. ADON 1 was asked how was Resident 23 assessed for the use of assistive devices. ADON 1 reviewed the Admission assessment dated [DATE], for side rail usage and it showed Resident 23 did not need the side rails. DON 1 was asked if Resident 23 was assessed for assistive devices. ADON 1 confirmed no assessment was completed for the use of side rails or other assistive devices and she did not know if the PT assessed the need for a grab bar. ADON 1 was asked if Resident 23 requested side rails to assist with repositioning herself. ADON 1 stated she did not know if Resident 23 asked for the side rails. On 8/25/17 at 1050 hours, an observation and concurrent interview was conducted with Resident 23. Resident 23 was observed in bed without the side rails or assistive devices. Resident 23 was asked if she was able to reposition herself in bed. Resident 23 stated she was afraid to move in bed because she might fall and she asked the nurses several times to put the side rails on the bed, but nothing happened. Resident 23 stated she needed the side rails to help move her body around. On 8/25/17 at 1130 hours, an interview and concurrent medical record review was conducted with PT 1. Review of the Physical Therapy Plan of Care dated 8/22/17, showed Resident 23 was referred to physical therapy for transfer training after sustaining a skin tear on the right lower leg. Resident 23 required maximum assistance of two persons with transfers and was unable to walk due to fluid filled blisters to the right and left heels. Documentation showed Resident 23 would benefit from skilled PT services to improve strength, balance, improve ability to transfer from the bed to the wheelchair and gait with less burden for care and with proper orthotic device to prevent further skin injury to the lower extremities. The Physical Therapy Plan of Care also noted therapy necessity for noted decline in transfer training. Documentation showed without therapy, Resident 23 was at risk for further skin injury, development of joint tightness/contracture, and further decline in functional mobility. PT 1 confirmed Resident 23 was receiving range of motion exercises only because she had blisters on the heels and she could not walk. On 8/29/17 at 1330 hours, an interview was conducted with PT 2 for Resident 23. PT 2 was asked if Resident 23 was evaluated for assistive devices to assist with mobility in bed. PT 2 stated no, she evaluated Resident 23 specifically for mobility related to the skin tear on her leg and the IDT decided if a resident needed the side rails or assistive devices. If these devices were needed, the IDT would call for a physician's orders [REDACTED].>

Based on interview, observation, clinical record review, review of the facility's abuse P&P, and facility document review, the facility failed to implement their P&P related to abuse prevention and investigation of injuries of unknown origin to rule out abuse for two of 27 sampled residents (Residents 7, and 20) and one nonsampled resident (Resident K). * The facility failed to provide thorough investigations for injuries of unknown origin to rule out abuse as specified in their P&P for two of two months reviewed. If a resident with impaired cognition sustained an injury of unknown origin, the facility failed to interview staff members who provided their care, family members and/or the resident's roommates who might have witnessed something to determine if abuse had occurred. This lack of investigation did not allow the facility to identify patterns and trends which could prevent further injuries or help identify if abuse had occurred. * According to the facilities Skin and Other Incidents Log, a total of 48 non-pressure related skin injuries were identified for the months of August and September 2014. Of these 48 incidents, 27 had not been investigated (56%). This had a high potential for abuse to go unrecognized. * Resident 7 had a history of [REDACTED]. These injuries had occurred over time starting shortly after his admission in March 2014. * Resident 20 had an injury of unknown origin involving bruising of her left shoulder, left armpit, and right forearm. This injury was not thoroughly investigated. * The facility failed to identify and investigate injuries of unknown origin for Resident K. Resident K was non-verbal and sustained an injury of unknown origin to his left lower arm, resulting in a 4 cm x 2 cm purple discoloration which was not investigated as to the cause of the injury. * The facility failed to ensure criminal background checks were obtained prior to hire for two of five employee files (LVN 2 and DOR). This placed the residents at risk for potential abuse. * The facility failed to ensure RN 2 was aware of the procedures to take when there was an allegation of abuse against an employee. This had the potential of not protecting all residents against possible abuse. Findings: According to the facility's undated P&P titled Abuse Program, the facility will identify and investigate all suspicious or allegations of abuse (such as suspicious bruising of residents, neglect or misappropriation of resident property); reviewing the occurrence, patterns and trends that may constitute abuse. This information will be used to determine the direction of the investigation. *Unknown falls, bruises, and skin tears will be investigated to rule out abuse. *Occurrences, patterns, and trends will be assessed by licensed staff and/or IDT to determine the direction of the investigation. * The Administrator will keep the resident or his/her representative informed of the progress of the investigation. 1. An interview with the Administrator was initiated on 9/22/14 at 1100 hours. The Administrator was asked about the injuries of unknown origin. She stated the charge nurse did the initial report, from there the ADON would look at the reports, and then submit the reports to the DON. The Administrator was asked if she reviewed or read the reports. She stated, no, she trusted them to do the investigation correctly. An interview with the DON and Administrator was initiated on 9/22/14 at 1330 hours. The DON stated she oversaw the injuries of unknown origin investigations. When asked about the interviews and/or the investigations, the DON stated charge nurses on the floor would provide the initial investigation. On 9/25/14 at 1300 hours, the DON was asked to provide all investigations, Incident Investigation Statements, Interdisciplinary Team Conference Records or any other documentation the facility might use to show investigations into injuries of unknown origin were completed for the months of August and September 2014. The DON provided the Skin and Other Incident Logs dated August 2014 and September 2014. Included with these logs were the available investigations for injuries of unknown origin. A review of the facility's Skin and Other Incident Logs dated August 2014 showed 30 incidents of injuries which were identified as occurring throughout the month of August, including skin tears, bruises or redness, and a swollen hand. A review of the Skin and Other Incident Logs dated September 2014, showed 18 incidents of injuries which were identified as occurring from September 1-24, 2014. Review of the Incident Investigation Statements and the Interdisciplinary Team Conference Record for the month of August 2014, showed 15 of the 30 incidents had no investigation (50%). Of the 15 investigations which were done, two injuries were documented as having been caused by staff members while providing care. On three occasions, the residents were alert, oriented, and able to explain there injuries. On two occasions, a staff member from a previous shift had been asked if they had witnessed the injury of the resident; however, no other investigation or interviews were provided. On eight occasions, the injured residents were documented as being confused or having cognition/memory problems. These residents were asked what happened but could not verbalize how their injuries occurred. Staff, family, or roommate interviews were not documented as having been done for these eight residents. The Incident Investigation Statement and the Interdisciplinary Team Conference Record for September 2014, showed 18 incidents of injuries occurring from 9/1/14 through 9/24/14. These injuries included discolorations to the skin and skin tears. Eleven incidents had no investigations as of 9/25/14 (61%). Of the seven investigations initiated, one injury was documented as having been caused by a staff members while providing care. One residents was alert, oriented, and able to explain her injury. One resident was injured while exercising, which was witnessed by a staff member. Four residents were documented as being confused or having cognition/memory problems and sustained an injury of unknown origin. These residents could not verbalize how their injuries occurred. Staff, family, or roommate interviews were not documented as having been done for these four residents. An interview and concurrent review of the facility's Incident Investigation Statements and the Interdisciplinary Team Conference Records was conducted with the DON on 9/25/14 at 1500 hours. When asked why half of the investigations were not completed, the DON stated she thought all the investigations were included in the log. The DON stated she would recheck to ensure the investigation reports were not misfiled; however, no additional investigation reports were provided. When asked why staff, family, or roommates were not interviewed as part of the investigations, the DON confirmed in most cases the injuries were not witnessed, so no one else was interviewed. When asked how the facility could prevent further injuries without having a complete investigation and rule out if residents were being abused, the DON did not provide an answer. When asked if the facility had other documentation to show the facility followed their P&P regarding investigating injuries of unknown origin, the DON did not provide further documentation. 2. Clinical record review for Resident 7 was initiated on 9/18/14. Resident 7 was admitted to the facility on [DATE]. Review of the MDSs dated 6/16/14 and 3/22/14, showed Resident 7 had severe cognitive impairment. Review of the care plan showed a care plan problem dated 3/13/14, to address Resident 7 being "At Risk For Falls and Related Injuries." It showed Resident 7 had impaired safety awareness. The goals were to have no falls or injuries for 90 days. The approach/plan included to assist the resident with transfers and walking, anticipate his needs, and offer assistance with ADL care. The plan of care failed to show interventions to address the resident's needs for supervision, his frequent injuries of unknown origin, or interventions to address what was causing the resident's frequent injuries. Review of the clinical record showed Resident 7 sustained the following injuries for which the facility failed to show documented evidence of the investigations to rule out the underlying causes of the injuries to prevent further injuries or help identify if abuse had occurred: a. Resident 7's clinical record showed an Incident Investigation Statement dated 4/22/14. The documentation showed the CNA discovered Resident 7 had a purplish discolored and swollen foot and reported the findings to the charge nurse. There were no other staff, family, or roommate interviews documented. Review of the Interdisciplinary Team Conference Record dated 4/22/14, showed Resident 7 had a left foot discoloration and swelling. The documentation showed "Based on investigation, interview and record review, this incident is unavoidable." However, no investigation or interviews were documented. An interview and concurrent record review with the DON was initiated on 9/22/14 at 1330 hours. When asked about the investigation of the resident's swollen discolored left foot, the DON stated the incident was thought to be a result of [MEDICAL CONDITION] (an accumulation of fluids causing swelling of the lower extremities); however, she confirmed no investigation was done to investigate the underlying cause of the left foot swelling and discoloration. b. Review of the Interdisciplinary Team Conference Record dated 6/27/14, showed a skin tear was discovered on Resident 7's left knee and right shin approximately one inch long by a CNA who reported it to the charge nurse. The documentation showed Resident 7 was asked what happened and was unable to explain how he was injured. The IDT was not able to determine what happened to the resident. Further review of the report failed to show documented evidence of an investigation into the cause of the resident's left knee and right shin skin tears. An interview with the DON was initiated on 9/22/14 at 1330 hours. The DON was asked about the investigation of the resident's left knee and right shin skin tears. The DON confirmed no investigation was done. c. Review of the Interdisciplinary Team Conference Record dated 6/30/14, showed Resident 7 was found to have swelling and a purplish discoloration on the left pinky finger. The record showed an RNA reported to the Charge Nurse that Resident 7's finger was swollen and discolored. Resident 7 would grimace with pain when the finger was touched. The IDT recommended to monitor the resident for pain. The finger was splinted and the IDT further recommended to instruct the resident about current conditions to prevent injuries. Review of the Incident Investigation Statement dated 6/30/14, showed Resident 7 received an x-ray which confirmed the resident had fractured his left pinky finger. The documentation showed Resident 7 had been asked to explain what happened to his finger but could not provide an explanation as to what happened. Documentation showing Resident 7's roommate, family members, or any staff members were not asked if they had witnessed the resident's injury or might have an idea as to when or where the injury could have occurred was not found. Documentation to show the facility investigated the actual cause of the injury in an effort to try to prevent any further injuries or rule out abuse was not available. An interview and concurrent record review with the DON was conducted on 9/22/14 at 1330 hours. The DON was asked about the investigation of the resident's fractured finger. The DON stated Resident 7 liked to be in the wheelchair and probably injured himself while in the chair. The DON was unable to provide further documentation regarding an investigation into the cause of the resident's fractured finger. d. On 7/2/14, the SBAR showed Resident 7 was found with a "noted skin tear to l.(left) lat.(lateral) leg". The SBAR showed the resident was up in the wheelchair with the foot rests on and scraped his leg. The SBAR was not clear if the incident was witnessed and by whom. The Interdisciplinary Team Conference Record for this incident had no further investigation documented. An interview of Resident 7's family member was initiated on 9/19/14 at 0945 hours. Resident 7's family member was asked if the facility had informed her about the injuries of unknown origin. The family member stated she was not the primary contact person for Resident 7 and was not aware the resident had fractured his finger. She stated she had noticed Resident 7 had a lot of injuries since his admission to the facility, and she had some concerns. She further stated this was the first time the resident had been in a facility like this and she thought these injuries were part of being in a facility. An interview with CNA 6 was conducted on 9/25/14 at 1630 hours. CNA 6 was asked if she had any idea why Resident 7 had so many injuries. CNA 6 stated she could not be sure; however, Resident 7 occasionally resisted care and might be injuring himself at that time. e. Resident 7's clinical record showed a SBAR dated 8/14/14, documenting Resident 7 had a new skin tear above the right eyebrow. Review of the Incident Investigation Statement dated 8/14/14, showed the resident was discovered to have a skin tear over his right eye. The statement showed the resident could not explain what happened. Further review showed no staff members, family members, or Resident 7's roommate were interviewed to try to determine what might have happened to Resident 7. An interview with the DON was initiated on 9/22/14 at 1330 hours. The DON was asked about the investigation of the resident's skin tear over the right eye. The DON stated Resident 7 liked to be in the wheelchair and probably injured himself while in the chair. When asked how the wheelchair could have caused an eye injury, the DON did not explain. f. Review of the SBAR for Resident 7 dated 9/9/14, showed the resident was found to have a cut under his lip on the left side of the face. Further review showed no staff members, family members, or Resident 7's roommate were interviewed to try to determine what might have happened to Resident 7. On 9/22/14 at 1330 hours, the DON was asked to provide an investigation for the incident. She confirmed no investigation was available. 3. Clinical record review for Resident 20 was initiated on 9/18/14. Review of the MDS dated [DATE], showed Resident 20 had severe cognitive impairment. Review of the Incident Investigation Statement for Resident 20 dated 8/7/14, showed a CNA had discovered discolorations (bruises) on Resident 20's right shoulder, right underarm, and left forearm and informed the charge nurse. The documentation showed Resident 20 would sometimes resist care and become stiff. Further review of the document failed to show interviews of staff members who provided care for the resident, family members, or the resident's roommate were conducted to determine what might have happened to Resident 20. An interview with the DON was initiated on 9/25/14 at 1500 hours. The DON confirmed no other interviews were conducted to investigate the cause of Resident 20's injuries. An interview with CNA 6 was initiated on 9/29/14 at 1330 hours. CNA 6 was asked about Resident 20's injuries of unknown origin. The CNA stated she often informed the charge nurse about Resident 20's skin discolorations and other residents as well. She stated, sometimes these incidents were investigated and sometimes they were not. 4. An initial tour of the facility was conducted with the ADON on 9/16/14 at 1130 hours. Resident K was observed wearing geri sleeves (protective arm sleeves). When the ADON asked to removed Resident K's geri sleeves to observe the resident's skin integrity, a purple skin discoloration measuring 4 cm x 2 cm was observed on Resident K's left lower arm. The ADON was asked if she was aware of what happened to Resident K. The ADON stated she did not know what happened. An interview was conducted with the DON on 9/17/14 at 1420 hours. When asked if there was an investigation to identify the cause of the purple skin discoloration to Resident K left lower arm, the DON stated they did not investigate. 5. Review of the facility's undated P&P titled Abuse Prevention showed all employees will be properly screened for criminal backgrounds. The facility will not employ individuals who have had a finding entered into the Office of the Inspector General Data base. On 9/22/14 at 1135 hours, a review of five employee files was conducted with the DSD. a. Review of LVN 2's personnel file showed a hire date of 8/20/14. The Office of the Inspector General form for LVN 2 printed out on 8/19/14, showed two similar names were identified as having findings. The DSD stated when the report was run for LVN 2 on 8/19/14, the results showed two names similar to LVN 2. The DSD stated she called Human Resources and informed them LVN 2 was cleared for background screening. The DSD verified she did not follow up on the results of the search. b. Review of the DOR's personnel file showed a hire date of 4/29/14. The Office of the Inspector General form for the DOR was printed out on 9/22/14. Documentation to show the background check was obtained prior to the date of hire was not found. The DSD verified the finding. On 9/22/14 at 1200 hours, a follow-up interview and concurrent personal file review was conducted with the DSD. The DSD was unable to provide the documentation showing the background checks were cleared upon hire for LVN 2 and the DOR. The DSD stated she printed out the Office of the Inspector General forms for LVN 1 and the DOR on 9/22/14. 6. Review of the facility's P&P titled Abuse Prevention dated 1/2013, showed if the suspected perpetrator is an employee of the facility the following is to occur: a. remove employee immediately from the care of any resident. b. suspend employee during the investigation. The facility's undated P&P titled Abuse Program states the Abuse Coordinator is the Administrator. On 9/17/14 at 1530 hours, an interview was conducted with RN 2. When asked what she would do in the event that an allegation of staff abuse to a resident was reported, RN 2 stated she would talk to the resident and the alleged abuser and would assign the staff member to another resident. When asked what she would do in the case of a family member reported an allegation of abuse against a staff member, RN 2 stated she would have the family member write a letter and give it to the DSD. The DSD would then talk to the alleged abuser. RN 2 stated in both cases she would notify the Abuse Coordinator who was the DON and DSD.

Based on interview, clinical record review, and observation, the facility failed to provide the necessary care and services to attain the highest practicable physical, mental, and psychosocial well-being for two of 27 sampled residents (Resident 10, and 17) and one nonsampled resident (Resident J ). * For Resident 17, the nursing staff failed to regularly assess Resident 17's wounds and inform the physician of the wound conditions when the wounds had not responded to the wound treatments, resulting in deterioration of the resident's left heel and calf wounds. The resident's left heel wound size had increased from 4 cm x 5 cm to 4.5 cm x 7 cm and the left calf wound size had increased from 5 cm x 2 cm to 6 cm x 2.8 cm. In addition, the facility failed to inform the physician of not administering the Prostat (protein supplement) to Resident 17 when the resident was at the [MEDICAL TREATMENT] center three times a week. * For Resident J, the nursing staff failed to assess the resident's groin rashes and blisters when the resident had self-administered the treatment as ordered to evaluate the effectiveness of treatment. As a result, Resident J continued to have itchiness and increased pain levels due to ongoing groin rashes and blisters. In addition, the nursing staff failed to inform the physician of the resident's urine culture results and the recommendations from the laboratory to repeat the urine culture test due to a possible contamination of urine sample, creating the risk of not providing necessary care and services related to urinary system for this resident. * For Resident 10, the nursing staff failed to assess the resident's stasis ulcer wounds and document wounds descriptions, including sizes, color of wound bed, and surrounding tissue, creating the risk of not providing necessary care and evaluating the effectiveness of wound treatment to promote wound healing. Findings: According to Lippencott Nursing.com, Assessing Venous Ulcers dated 2005, the assessment of venous ulcers should include documenting wound size, appearance, condition of surrounding skin, presence, characteristics of exudates (drainage), and any signs and symptoms of infection. According to the California Vocational Nursing Practice Act with Rules and Regulations dated 4/1/11, Article 4, Licenses: Scope of Vocational Nursing Practice 2518.5, licensed vocational nurses may perform services requiring technical and manual skills. Licensed Vocational nurses may collect data, participate in planning, execute interventions, and contribute to the evaluation of individualized interventions related to the care plan or treatment plan. Performing a clinical assessment is not included in the scope of vocational nursing practice. According to the facility's P&P titled Wound Care dated 10/2010, while providing wound care or doing a wound observation, the following information should be recorded in the resident's clinical record: wound bed color, size, drainage, and any changes in the resident's condition. 1. Review of clinical record for Resident 17 was initiated on 9/18/14. The Admission Record dated 8/5/14, showed Resident 17 was admitted to the facility on [DATE]. a. Review of the Wound Evaluation Flow Sheet dated 8/3/14, showed the following: * Resident 17's left heel ulcer was a Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough or eschar) with 100% [MEDICATION NAME] tissue (the tissue covering the wound appearing pink or white denoting normal wound healing), measuring 4 cm (length) x 5 cm (width) with a superficial wound depth. * Resident 17's left calf ulcer was a Stage II ulcer with 100% [MEDICATION NAME] tissue, measuring 5 cm x 2 cm with a superficial wound depth. However, review of the initial H&P documented by Physician 1 dated 8/4/14, showed the resident was admitted to the facility with an unstageable (can not determine the stage of the wound due to the presence of dead tissue which obscures the depth of the ulcer) pressure ulcer to the left heel with black eschar covering the entire heel. In addition, the physician documented Resident 17 had an area of black eschar to the left calf, measuring 1 cm x 4 cm. The physician's order dated 8/4/14, showed to apply iodine to the left heel and left calf pressure ulcers and wrap with a rolled gauze for 30 days. The Wound Evaluation Flow Sheets showed on 8/7, 8/14, and 8/21/14, both wounds remained the same sizes. The wounds had 100% necrotic tissue (dead tissue). However, the wound assessment dated [DATE], showed no measurements and descriptions of these wounds. Both wounds were classified as vascular ulcers. The physician's order dated 8/27/14, showed the same wound treatments for the left heel and calf wounds were ordered for 30 more days. Further review of the clinical record showed no assessments and measurements of the left heel and calf wounds after 8/21/14. There was no change of wound treatments for the left heel and calf wounds since 8/4/14. b. The physician's order dated 8/27/14, also showed to cleanse the left 5th toe lateral and medial wounds with normal saline, apply iodine, and wrap with a rolled gauze. Review of the care plan addressing the skin problem dated 8/28/14, showed Resident 17 had new vascular ulcers on the left 5th toe. However, the care plan did not describe how many wounds/ulcers were present on the resident's left foot. Further review of the clinical record showed no description of the new vascular ulcers as to the size, appearance, condition of surrounding skin, presence, and characteristics of exudates, or any signs and symptoms of infection. There was no Wound Evaluation Flow Sheets for these new vascular ulcers showing the baseline measurements and descriptions of these wounds. There was no documented evidence the nursing staff had regularly assessed the resident's vascular ulcers on the left 5th toes. An interview with LVN 5 was initiated on 9/18/14 at 1100 hours. LVN 5 was asked about the wound/ulcer assessments. He stated the facility's practice was to monitor the resident's pressure ulcers on a weekly basis. This monitoring included measuring of the wounds/ulcers, describing of the wounds on the Wound Evaluation Flow Sheets, and meeting with the RN or DON weekly to determine if the pressure ulcers were healing, or any follow-up with the physician may be necessary. LVN 5 stated only pressure ulcers were assessed and discussed during this meeting. He stated other wound types, such as vascular ulcers, gangrene wounds, or surgical wounds would not be discussed in this meeting. When asked if other types of wounds were discussed with the RN or DON in other meetings, LVN 5 stated no. When asked how he determined if the wounds/ulcers had improved or deteriorated. He stated he treated the wounds usually on a daily basis and could determine by looking at the wound if it was healing or deteriorating. He stated the wound care treatment orders were usually prescribed for 14-21 days. If the wounds responded to the treatments, he would recommend to the physician to continue with the wound treatment orders. If the wound deteriorated, he would notify the physician and request to change the treatment orders. LVN 5 further stated once Resident 17's pressure ulcers were reclassified as vascular ulcers, no further wound assessments were necessary. He confirmed Resident 17's ulcers/wounds remained unchanged since he had stopped measuring the wounds on 8/21/14, and the wound treatments also remained the same. During a wound observation and interview with Resident 17 and LVN 5 on on 9/22/14 at 1445 hours, the resident was observed to have one wound on the left heel, one wound on the left calf, and two wounds on the left 5th toe. All wounds were covered with black eschar. The resident stated she recently had a surgery for [REDACTED]. Resident 17 stated the wounds were painful. LVN 5 was asked to measure the resident's wounds. The resident's wounds measurements were as follows: left heel wound measured 4.5 cm x 7 cm with an undetermined depth, left calf wound measured 6 cm x 2.8 cm with an undetermined depth, and the left pinky toe wounds measured 1.7 cm x 1.5 cm with an undetermined depth and 1.5 cm x 2 cm with an undetermined depth. An interview with Physician 1 was initiated on 9/22/14 at 1500 hours. Physician 1 stated the pressure ulcers or vascular ulcers needed to be assessed and measured at least on a weekly basis. He stated he visited the facility weekly and LVN 5 told him the resident's wounds had improved. The facility's nurses failed to regularly assess Resident 17's wounds and inform the physician of the wound conditions when the wounds had not responded to the wound treatments and increased in sizes. The left heel wound size had increased from 4 cm x 5 cm to 4.5 cm x 7 cm and the left calf wound had increased from 5 cm x 2 cm to 6 cm x 2.8 cm. There was no wound treatments changed since 8/4/14. In addition, the facility's nurse failed to document the left 5th toe wounds descriptions when they were first identified on 8/27/14, and regularly assess these wounds to evaluate the effectiveness of wound treatments and progress of the wounds healing. c. Resident 17's clinical record also showed the resident received [MEDICAL TREATMENT] (a treatment used when the kidneys do not work well) between 1100 hours to 1600 hours three times a week at a [MEDICAL TREATMENT] center. Further review of clinical records for Resident 17 showed a physician's order dated 8/12/14, to administer Prostat 30 mg three times a day with medication pass. Review of the MAR showed Prostat 30 mg was to be given at 0900 hours, 1300 hours, and 1700 hours. All entries were signed off by the licensed nurses to indicate Prostat was given three times a day to the resident from 9/1/14 through 9/21/14. An interview with LVN 3 was conducted on 9/22/14 at 1050 hours. LVN 3 stated if the licensed nurses signed the MAR, it meant the Prostat had been given to the resident by the licensed nurses. However, LVN 3 confirmed the Prostat was not given to Resident 17 as documented on the MAR because the resident was at the [MEDICAL TREATMENT] center. LVN 3 confirmed the physician had not been notified that the Prostat was not given when the resident was at the [MEDICAL TREATMENT] center between 1100 hours to 1600 hours three times a week. There was no physician's order to hold the Prostat when the resident went to the [MEDICAL TREATMENT] center. 2.a. During an interview with Resident J on 9/25/14 at 1530 hours, Resident J stated she had painful redness and blisters in her groin and vagina for more than one month. When asked how much pain she was having, Resident J stated when this first happened the pain level was 10 on a pain scale 0-10, but now the pain level was 5. When asked how the redness and blisters were treated, Resident J stated she showered daily and put diaper lotion on her groin area several times a day. When asked how often the nurses assessed the resident's groin, Resident J stated the nurses did not assess the groin area. Clinical record review for Resident J was initiated on 9/25/14. Resident J was admitted to the facility on [DATE], with diagnoses, including [MEDICAL CONDITION] (a disease in which the immune system attacks the protective sheath that covers the nerves disrupting the communication between the brain and the rest of the body), [MEDICAL CONDITION], and [MEDICAL CONDITION] (more then 100 pounds over the ideal body weight). The SBAR form dated 8/3/14, showed documentation the resident had rashes, bumps, and multiple blisters to the groin area. The resident complained of itching and had pain level of 8. The documentation showed the resident stated she might had gotten it after the antibiotic medication was discontinued on 8/1/14. Review of the physician's orders showed an order dated 8/3/14, for Resident J to self-administer diaper rash lotion to the groin area PRN. The Licensed Nurses Progress Note dated 8/3/14 at 1430 hours, showed Resident J was seen by the Nurse Practitioner. The resident refused to have the Nurse Practitioner assess the affected groin area and requested for the treatment nurse to assess instead. Resident J complained of pain in the affected area and was medicated with [MEDICATION NAME] for pain. The Licensed Nurses Progress Note dated 8/3/14, for the 3-11 shift showed "Resident is being monitored for a skin scratch, burning upon urination, and painful right groin blister." Review of the plan of care showed a short-term care plan problem (for a problem expected to be resolved in less than 30 days) for vesicular (fluid filled blister) lesion at the bilateral groins was developed on 8/3/14. The approaches included using indwelling urinary catheter (a catheter is inserted into the bladder to drain urine into a urine drainage bag) for skin management, applying diaper rash lotion PRN, and notifying the physician and family for significant changes. The long-term care plan problems addressing the groin rashes/blisters and indwelling catheters were also developed on 8/3/14. Review of the Nurses Weekly Progress Note dated 8/7/14, showed the resident had bumps/blisters and redness to the groin area on 8/3/14. The Quarterly Interdisciplinary Team Conference Record dated 8/26/14, showed the resident had no new [DIAGNOSES REDACTED]. The resident was continent of bowel and bladder during the day shift and incontinent by choice for evening and night shifts. The resident had an indwelling catheter for vesicular lesion on the groin area as of 8/3/14, and self-administered diaper rash lotion to the groin area. However, there was no documentation of the assessments of the resident's rashes and blisters and evaluations for effectiveness of the skin treatment. Review of the Licensed Nurses Progress Notes and the Nurses Weekly Progress Notes from 9/1 through 9/25/14, failed to show documented evidence the nursing staff had assessed or attempted to assess Resident J's groin and vaginal reddened areas and blisters. Further review of the clinical record failed to show documented evidence the resident's groin rashes and blisters were regularly assessed and evaluated for the effectiveness of skin treatment and healing process. There was no documented evidence explaining why the assessments and evaluations of the resident's groin rashes and blisters were not done. On 9/25/14 at 1630 hours, when discussed with RN 1, RN 2, and LVN 5 regarding the resident's condition, LVN 5 stated he would go and look at Resident J's groin immediately. Few minutes later, LVN 5 returned and stated Resident J refused to have LVN 5 assess her groin. When asked how long it had been since Resident J's groin was assessed and evaluated for the appropriateness of current treatment, no one answered. When asked if a skin culture of Resident J's vaginal/groin blisters was done, RNs 1 and 2 stated no skin culture was done. On 9/25/14 at 1720 hours, RN 2 stated she would review the Licensed Nurses Progress Notes and Nurses Weekly Progress Notes from 9/1 through 9/25/14, to locate documentation of Resident J's groin/vaginal area assessments. After reviewing Resident J's clinical record, RN 2 stated she could not find documentation of an assessment or an attempted to assess Resident J's vaginal/groin area from 9/1/14 through 9/25/14. b. Review of the physician's order showed an order dated 8/3/14, to insert an indwelling catheter for vesicular lesion on the groin area. The Licensed Nurses Progress Note dated 8/3/14 at 1430 hours, showed the treatment nurse had inserted the indwelling catheter. Review of the Nurses Weekly Progress Note dated 8/7/14, showed the resident complained of pain/burning urination on 8/6/14. The physician ordered to perform a urinalysis (a laboratory test on urine) with culture and sensitivity (a laboratory test for specific bacteria which cause infections and identification of appropriate antibiotics to eliminate the bacteria) if indicated. The urine laboratory report dated 8/7/14, showed the positive results for leukocyte esterase (leukocytes are a type white blood cells indicating an infection, normal = negative) and blood (normal = negative). A hand written notation on the laboratory report showed the results were reported to the Nurse Practitioner at 1320 hours, and to wait for the urine culture report. The result of the urine culture dated 8/9/14, showed "multiple organisms present, probable contamination. Please repeat the culture if clinically indicated." Further review of the clinical record showed no documented evidence the physician or the Nurse Practitioner was notified regarding the urine culture test results and recommendations to repeat the urine culture test. There was no documented evidence the urine culture test was repeated as per the laboratory's recommendations. There was no documented evidence explaining why the urine culture test was not repeated. After the results of the urinalysis dated 8/7/14, were reviewed with RNs 1 and 2, they were asked if a follow-up urinalysis had been done. Both of them stated there was no repeat urinalysis done. They confirmed the finding. 3. Clinical record review for Resident 10 was initiated on 9/17/14 at 0850 hours. Resident 10 was admitted to the facility on [DATE], with diagnoses, including [MEDICAL CONDITION], diabetes mellitus, and pressure ulcer of the sacral area. a. Further review of the clinical record showed Resident 10 had a history of [REDACTED]. The Pressure Ulcer Admission assessment dated [DATE], showed the resident had 3+ [MEDICAL CONDITION] (4-6 mm noticeably deep, may last more than a minute, and dependent extremity looks swollen and fuller) and stasis ulcers, and multiple open wounds from popped blisters to the left and right lower legs. There were no measurements and descriptions of the open wounds on both legs, including color of wound bed, surrounding tissues, and drainage. The care plan problem addressing alteration of skin integrity for the right and left lower legs dated 4/15/14, showed to monitor and record the wounds weekly. The Licensed Nurses Progress Note dated 6/13/14, showed the left leg stasis ulcer had healed and the treatment was discontinued. The documentation showed the resident continued to have the right leg stasis ulcers. However, further review of the clinical record failed to show documented evidence the nurses had assessed the resident's bilateral legs wounds weekly since admission as per the resident's care plan. There was no documentation of weekly wound measurements and descriptions of the resident's bilateral legs wounds, including size, color of wound bed, surrounding tissues, and drainage. b. Review of the Physician and Telephone Order dated 9/15/14, showed the resident had an opened blister "red, tender, and warm to touch" to the left lateral leg. The physician's order showed to administer Keflex (antibiotic) 500 mg one tablet twice a day for seven days and clean the left leg opened blister with normal saline and apply [MEDICATION NAME] (antibiotic) ointment daily for 14 days. Further review of the clinical record failed to show documented evidence as to when and how the resident's left lateral leg popped blister was first identified. There were no measurements and descriptions of the opened blister on the left lateral leg, including size, color of wound bed, surrounding tissues, and drainage. On 9/17/14 at 1055 hours, a wound treatment observation was conducted with LVN 7. Resident 10's left lateral leg was observed to have reddened area, measuring 17 cm x 11 cm, with multiple scattered scabs and two open wounds. Two open wounds measurements were 9 cm x 5 cm and 2 cm x 2 cm (no wound depth documented). On 9/18/14 at 0930 hours, an interview was conducted with LVN 7. She stated the facility did not measure or conduct weekly assessments for non-pressure ulcer wounds. Resident 10 had a stasis ulcer which considered as a non-pressure ulcer wound, and it was not a popped blister. LVN 7 further stated there was no other way to know as to whether the wound had improved except visually assessing the wound. On 9/19/14 at 0950 hours, an interview and concurrent clinical record review was conducted with the DON. The DON was asked how the licensed nurses monitored Resident 10's skin conditions and how the DON would know if the right or left leg stasis ulcers had improved or deteriorated. The DON showed the Nurses' Weekly Progress Note dated 9/14/14, showing "no new skin breakdown noted" documented under the skin assessment section. When asked if the resident had no new skin breakdown on 9/14/14, why a new treatment order was written for the left lateral leg opened blister "red, warm, and tender to touch" on 9/15/14, the DON was unable to answer. On 9/22/14 at 1500 hours, an interview was conducted with Resident 10's physician. He stated all wounds should be measured weekly regardless the types of wounds. He further stated there was no way to know how the wounds had responded to treatments without the measurements.

Based on observation, interview, and clinical record review, the facility failed to ensure one of six sampled residents (Resident 13) maintained acceptable parameters of nutritional status. The facility failed to notify the physician when Resident 13 lost 9 pounds, or 6.9 % of his weight within one week. The facility failed to follow up on the RD's recommendation for Resident 13. The facility failed to reevaluate Resident 13's weight loss and need for meal assistance, and assist Resident 13 with meals. This resulted in significant weight loss for Resident 13. Findings: Review of the facility's P&P titled Weight Variance Assessment and Intervention revised 9/09, showed significant/severe weight change is identified as having unexpected loss of five pounds or more in one month, unexpected loss of 5% or more of the resident's weight in 30 days, unexpected loss of 7.5% or more in 90 days, or unexpected loss of 10% or more in 180 days. Further review showed the Committee continues to monitor the resident's progress for a minimum of four consecutive weeks. Review of Resident 13's clinical record was initiated on 1/31/12. The resident was admitted to the facility on [DATE]. The MDS (an assessment tool) dated 11/5/11, showed the resident's cognition was intact; he had no limitation in range of motion, and was independent in eating. Review of the physician's orders [REDACTED]. Another physician's orders [REDACTED]. Review of the Annual Weight Progress Record showed on 10/1/11, the resident's weight was 122.6 pounds. On 11/2/11, his weight was 128.6 pounds. The weight was rechecked on 11/4/11, and was found to be 130.2 pounds. Review of the Registered Dietitian-Dietetic Technician Registered Progress Notes dated 11/16/11, showed Resident 13 was on a carbohydrate controlled fortified regular diet; eight ounces of house nourishment three times a day between meals, and four ounces of house nourishment twice a day between meals at 1000 hours, and 1400 hours. The form showed the resident had significant weight gain that was desirable. The RD's recommendation was to discontinue four ounces of nourishment, but continue with 8 ounces of supplement between meals. Review of the Licensed Personnel Weekly Progress Notes from 11/25/11 to 12/9/11, showed Resident 13 had episodes of confusion. The Licensed Personnel Weekly Progress Notes showed an entry dated 11/25/11 showed the resident needed to be assisted with ADLs. Review of the Annual Weight Progress Record showed on 12/5/11, Resident 13's weight was 127.8 pounds; Review of the physician's orders [REDACTED]. Review of the Dietary Progress Notes dated 12/20/11, showed the RD saw Resident 13 for increase in appetite and increase in confusion. The form showed the resident lost 2.4 pounds, or 1.8% of his weight in one month. The RD's recommendation was to continue with eight ounces of house nourishment drink three times a day. Review of the Annual Weight Progress Record showed on 12/21/11, his weight was 129 pounds. On 12/28/11, his weight was 128.6 pounds; on 1/4/12, his weight was 120 pounds; on 1/5/12, his reweigh was 119.6 pounds. He lost 9 pounds, or 6.9 % of his weight in 8 days. He lost 6.4% of his weight in one month. Review of the Transdisciplinary Occupational Therapy Evaluation showed, under discharge summary dated 12/23/11, Resident 13 needed CG (contact guard, the resident requires hands-on, manual assistance) for feeding. The Resident Weekly Summary dated 12/29/11, and 1/5/12, showed the resident needed supervision in eating. Review of the Registered Dietitian-Dietetic Technician Registered Progress Notes dated 1/10/12, showed Resident 13 had significant weight loss. His weight loss was not desirable and not planned. His weight loss may be due to varying oral intake secondary to episodes of confusion. Resident 13 was identified at risk for weight change due to varying oral intake and diabetes. The RD recommended to check the hemoglobin A1C (to check for average blood sugar in three months), and to continue with weekly weights. The Resident Weekly Summary forms dated 1/5, and 1/12/12, showed Resident 13 lost weight, and was in stable condition. There was no documentation to show the physician was notified of the weight loss. During an interview with RN 3 on 2/1/12 at 0855 hours, the RN reviewed the resident's clinical record and was unable to find documentation to show the physician was notified of Resident 13's weight loss on 1/5/12. She stated the physician was notified on 1/17/12. She also stated she usually notifies the physician about the resident's weight loss within five days. Review of the Physician's Progress Record showed an entry dated 1/4/12. The physician documented the resident's [DIAGNOSES REDACTED]., poor appetite, depression, awaiting psych consult and monitor for dehydration. A physician's orders [REDACTED]. Review of the Weight Variance Committee IDT Meeting dated 1/17/12, showed Resident 13 had significant weight loss. The recommendation was to do Accuchecks (check the blood sugar) and monitor weekly weights. There was no documentation of recommendations to increase Resident 13's calorie intake or to follow up his weight loss by the Weight Variance Committee. There was no discussion of changes in cognition or interventions to ensure adequate meal intake. Review of the Short Term Problems showed a care plan problem dated 1/17/12, to address nine pounds weight loss in one week. The approaches included to assist Resident 13 with meals. During an interview with RN 3 on 2/1/12 at 0855 hours, she reviewed Resident 13's clinical record and was unable to find documentation to show the physician was notified of the RD's recommendation on 1/17/12. Review of the Annual Weight Progress Record showed on 1/21/12, Resident 13's weight was 119 pounds. He lost 10 pounds, or 7.7 % of his weight in one month. On 1/28/12, his weight was 117.8 pounds. He lost 10.8 pounds, or 8.3 % of his weight in one month. The Resident Weekly Summary dated 1/19, and 1/26/12, showed the resident needed extensive assistance for eating. During an interview with RD 1 on 2/1/12 at 1240 hours, RD 1 was asked when she evaluated Resident 13 for his weight loss. The RD reviewed his clinical record and stated she evaluated Resident 13's weight loss on 1/10/12, and 1/17/12. She also stated the Weight Variance Committee met on 1/17/12, to evaluate the resident's weight loss. She was asked what she, or the IDT recommended to maintain Resident 13's weight. She stated Resident 13 will be monitored weekly for his weight. She also stated she reviewed the resident's weekly weights, but did not document or reevaluate the resident's weekly weights unless the resident lost 2% or more of his weight in one week. She stated she did not reevaluate Resident 13 since 1/17/12. Review of the CNA ADL Flow Sheet for the months of December, 2011, and January, 2012, showed the resident had supervision for eating. The form showed supervision means the CNA provides set-up/verbal cues to the resident. During an interview on 1/31/12 at 1330 hours, Resident 10's family member stated Resident 13 had lost 9 pounds and had asked the staff to assist Resident 13 with eating. During an observation on 1/31/12 at 1330 hours, Resident 13 was asleep in his wheelchair with his partially eaten lunch in front of him. No staff member was in Resident 13's room. On 2/1/12 at 0820 hours, Resident 13 was observed sitting on his bed, eating his breakfast. There was no staff with the resident. The resident was observed holding his spoon, feeding himself. He held an empty cup, brought to his mouth, and drank from it. During an interview with RN 3 on 2/1/12 at 0855 hours, she was asked if Resident 13 needs assistant for eating. She reviewed the resident's clinical record and stated Resident 13 requires supervision for eating. She stated a care plan problem does not specify how Resident 13 is to be assisted with meals. During an interview with CNA 8 on 2/1/12 at 1230 hours, CNA 8 was asked if Resident 13 needs assistance with eating. She stated Resident 13 needs a little help to eat. She stated the resident eats well for the breakfast meal, and needs assistance for eating, especially for the lunch meal. During an observation on 2/1/12 at 1305 hours, Resident 13 was observed sitting in his wheelchair, eating his lunch meal. The resident was observed trying to scoop the food on his plate, but was unable. The food was out of reach. There was no staff with the resident. On 2/1/12 at 1310 hours, CNA 8 was approached and asked if Resident 13 needs help with his lunch meal. The CNA was observed going to the resident's room and stated the resident needs assistance with eating. She confirmed his food was out of reach. She was observed rearranging the resident's tray, removing a cup of ice cream next to the resident. She was observed leaving the resident's room. Resident 13 was observed holding a spoon in his right hand, trying to scoop ice cream from the cup, but was unable to scoop the ice cream from the cup. A foam cup of ice cream was observed slipping back and forth on the tray. The resident tried multiple times to scoop the ice cream by using the spoon, but was unable. There was no staff with the resident. During an interview with RN 10 on 2/1/12 at 1315 hours, the RN was asked if Resident 13 needs physical assistance with eating. She reviewed the resident's clinical record and stated the resident needs assistance with meals. She was asked to go to Resident 13's room. She was observed going to the resident's room, and looking at the resident. She stated she will look for someone to assist him with his lunch meal. During an interview with RN 10 on 2/1/12 at 1400 hours, the RN reviewed Resident 13's clinical record and stated the resident was discharged from OT on 12/23/11. She was asked what "CG" (contact guard) for feeding means. She stated the resident needs assistance with feeding. During an interview with OT 1 on 2/1/12 at 1420 hours, the OT reviewed Resident 13's clinical record and stated the resident was discharged from OT on 12/23/11. The OT was asked if Resident 13 needs assistance for eating. He stated the resident can feed himself. However, the OT stated the resident needs contact guard for eating to prevent debility (decline), and to maximize his intake. During a telephone interview with Resident 13's family member on 2/2/12 at 1421 hours, she was asked if the resident needs help to eat. She stated the resident needs assistance for meals. She stated he was independent in eating, but he has needed assistance for eating since six months ago. She was asked if any staff comes to help the resident for meals. She stated she goes to see the resident twice a week, and does not see the staff come to assist the resident with his meals.

Based on interview, clinical record review and facility document reviews, the facility failed to ensure four of nine sampled residents (Residents 1, 2, 3 and 4) were free from abuse and mistreatment. A CNA put her hand over Resident 1's mouth to quiet her from yelling out. Resident 2 reported to his family member a CNA touched him inappropriately. Resident 3 reported a CNA treated her roughly during a shower and gets mad when she tells the CNA the water is too hot. Resident 4 stated a male staff member yelled at and accused her of stealing a wheelchair. She reported this incident to an LVN and an RN shortly after this happened. When the residents reported these allegations to the direct care staff, the staff failed to take immediate action by failing to inform the abuse coordinator, failing to remove the alleged perpetrators from resident care duties and failing to conduct thorough investigations of these alleged acts. Immediate Jeopardy was identified on 12/8/11 at 0900 hours, related to the facility's lack of action and investigations for residents with allegations of abuse and mistreatment. The Administrator and the DON were made aware of the Immediate Jeopardy on 12/8/11 at 0920 hours. On 12/8/11 at 1615 hours, the Administrator and the DON submitted an acceptable plan of correction which included the following: - A facility re-investigation was initiated related to Resident 1's allegation of abuse. Staff members were to be included in the investigation. The staff member named in the allegation was terminated. - A facility re-investigation was initiated related to Resident 2's allegation of abuse. Staff members were to be included in the investigation. Resident 2's responsible party was updated on the investigation. The staff member named in the allegation remains on suspension. - A facility investigation was initiated related to Resident 3's allegation of abuse. Staff members were to be included in the investigation. - Staff will be inserviced on what constitutes abuse, reporting, protection of residents during an investigation, to include investigation of injuries of unknown origin, prior to providing resident care. - Interviewable residents will be questioned if they witnessed or have been treated in an abusive manner. - Responsible parties will be notified and interviewed for non-interviewable residents. - Department managers and licensed nurses will monitor for compliance twice per week rounds. Any negative findings will be reported to the Administrator/Designee/DON for corrective actions. - All identified summary trend analysis of the findings will be reviewed at the monthly CQI Steering Committee for further evaluation and for additional recommendations. - Revise the facility's Abuse Investigation P&P to include suspending the alleged employee immediately, pending the investigation. On 12/12/11 at 1020 hours, the facility's actions taken to abate the immediate jeopardy were reviewed with the DON and the Administrator. The corrections the facility took were re-investigation of the allegations of abuse involving Residents 1, 2 and 3. Inservices for all staff members were conducted. Surveys were conducted with interviewable residents and family members/responsible parties for non-interviewable residents, related to any allegations of abuse or mistreatment. The P&P was also revised to include suspending the alleged employee immediately, pending the investigation. On 12/12/11, random interviews were done with staff to assess their knowledge of abuse reporting and investigations of alleged abuse and injuries of unknown origin. As of 12/12/11, residents were assessed for abuse and injuries of unknown origin, which included interviews. Family interviews were done for residents who were unable to communicate. On 12/12/11 at 1020 hours, Immediate Jeopardy was abated. Findings: 1. During an entity reported complaint investigation, the facility stated a dietary assistant witnessed CNA 4 placing her hand over Resident 1's mouth to quiet her down. Clinical record review for Resident 1 was initiated on 12/7/11. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's MDS (an assessment tool) dated 10/6/11, shows she has severely impaired cognition, is rarely understood and requires assistance from staff for her ADLs. Review of Resident 1's psychiatrist's consultation dated 6/1/11, showed Resident 1 has long and short term memory impairment, is delusional, agitated and keeps saying six, five, six, five constantly. Review of Resident 1's Change of Condition assessment dated [DATE] at 1500 hours, showed to monitor signs and symptoms to mouth/facial area over cheek for irritation, swelling and redness. Review of Resident 1's Licensed Personnel Weekly Progress Notes dated 12/3/11, 12/4/11, and 12/5/11, show documentation of no facial/mouth pain, irritation or redness. Review of Resident 1's Interdisciplinary Conference notes dated 12/5/11, showed the IDT met to discuss the plan of care regarding the inappropriate physical contact by placing a hand over the resident's mouth. The IDT recommendation was for Resident 1 to have a psychiatric consult to review Resident 1's medications. During an interview on 12/7/11 at 0850 hours, the SSA stated Resident 1 is confused and is unable to carry on a conversation. She stated sometimes Resident 1 talks very loud and keeps repeating words. During an observation on 12/7/11 at 0930 hours, Resident 1 was sitting in her wheelchair in the HUB (a circular area where a number of nursing unit hallways intersect, used for activities). She was constantly mumbling incoherently and had repetitive movements of her arms and legs. Resident 1 was unable to answer simple questions. During an interview on 12/7/11 at 0936 hours, LVN 2 stated Resident 1 is unable to make her needs known. She stated Resident 1 is restless and always attempts to climb out of bed. During an interview on 12/7/11 at 1230 hours, the SSA stated on 12/5/11, she interviewed five residents and no staff members related to the allegation of abuse for Resident 1. During a telephone interview on 12/7/11 at 1545 hours, the dietary assistant stated on Saturday, 11/26/11 at approximately 1845 hours, she was picking up the dinner trays and heard Resident 1 screaming. She stated Resident 1's scream sounded muffled, and she heard someone saying to Resident 1 "be quiet, be quiet." The dietary assistant stated Resident 1's door was slightly opened and she saw a staff member's hand covering Resident 1's mouth, [MEDICATION NAME] a few seconds. She stated on Tuesday, 11/29/11, she reported the incident to the DON. When the dietary assistant was asked the reason she did not report the incident until 11/29/11, she stated, she did not come back to work until 11/29/11. On 12/8/11 at 0845 hours, when the SSA was asked if any further investigation was done related to Resident 1's alleged abuse, she stated she interviewed two more residents, but did not interview any staff members. Review of CNA 4's statement dated 12/7/11 (date ?), showed on 11/26/11, when Resident 1 finished eating, I wiped her mouth and told the resident to be "quiet" with food still in her mouth. Review of LVN 7's Interview Record dated 12/8/11, showed she was notified of Resident 1's allegation of abuse on 12/2/11, and completed a Change of Condition Assessment. 2. During an entity reported complaint investigation, wherein the facility notified the Department, Resident 2 stated CNA 5 came into his room, started massaging his back, reached for his chest and "squeezed" each one of his breasts and then reached for his genital area. Clinical record review for Resident 2 was initiated on 12/7/11. Resident 2 was admitted to the facility in 11/08. Review of Resident 2's MDS dated [DATE], show he is understood. Review of Resident 2's Mental and Behavioral Health Visit Note dated 10/27/11, showed Resident 2 appeared irritable and expressed feelings of annoyance, but could not/would not clearly define the causes. A note dated 11/10/11, show Resident 2 had refused to eat the last few days and appears upset about something he was unable to explain. Resident 2 complained about lack of privacy. Review of Resident 2's Change in Condition Assessment late entry date 11/24/11 at 2030 hours, showed Resident 2's family member informed the charge nurse, Resident 2 repeatedly claimed CNA 5 has been touching him inappropriately. The licensed nurse documented the Administrator was made aware and a voice mail message was left on the DON's answering machine. Review of Resident 2's Licensed Personnel Weekly Progress Notes late entries dated 11/25/11, 11/26/11, and 11/27/11, showed Resident 2 voiced no complaints of a CNA inappropriately touching him. Review of Resident 2's Social Work Progress Notes dated 11/29/11, showed Resident 2's family member was informed of the allegation of sexual abuse on 11/24/11. Review of Resident 2's psychology report dated 12/2/11, showed Resident 2's statement of inappropriate touching by CNA 5 was credible and further investigation is warranted. During an interview on 12/7/11 at 0955 hours, Resident 2 was alert and oriented. He was able to recall being touched inappropriately by CNA 5, and stated he did not like it. Resident 2 stated he was unable to recall how often he was touched inappropriately by CNA 5. During an interview on 12/7/11 at 1000 hours, LVN 10 stated Resident 2 is alert and oriented and able to make his needs known. During an interview on 12/7/11 at 1015 hours, the SSA stated Resident 2 is alert and oriented and able to make his needs known. She stated she was informed on 11/29/11, by the SSD of the inappropriate touching by CNA 5 to Resident 2 and started the investigation. The SSA stated Resident 2 stated it bothered him. When the SSA was asked if other staff members were interviewed during the investigation, she stated, "No, the DON told her to interview residents." During an interview on 12/7/11 at 1030 hours, the SSD stated she was notified via telephone on the evening of 11/24/11, by LVN 11 of CNA 5 inappropriately touching Resident 2. She stated she told LVN 11 to notify the Administrator of the allegation. The SSD stated, when she returned to work on 11/29/11 (5 days later), and inquired about the investigation, she realized the investigation of the alleged abuse was not investigated and "started the ball rolling." She stated no staff was interviewed. During a telephone interview on 12/7/11 at 1140 hours, RN 7 stated on 11/24/11 at approximately 2030 hours, Resident 2's family member informed her CNA 5 was inappropriately touching Resident 2. RN 7 stated she attempted to contact the Administrator, but was unable to reach him and left a message on the DON's voice mail. She stated the DSD was called and informed of Resident 2's allegation of abuse, and the DSD said she would take care of it. During a telephone interview on 12/7/11 at 1150 hours, LVN 11 stated she was informed on 11/24/11, by RN 7 of Resident 2's allegation of sexual abuse. She stated the Administrator was unable to be reached by telephone, and voice mail messages were left on the DON's telephone. LVN 11 stated the DSD was informed of Resident 2's allegation of abuse and said she would contact the Administrator. During a telephone interview on 12/7/11 at 1200 hours, the DON stated she never received voice mail messages on 11/24/11, related to Resident 2's allegation of abuse. She stated on 11/29/11, she was notified of Resident 2's allegation. Review of CNA 5's timesheet showed he worked the 11-7 shift on 11/24/11, 11/25/11, 11/26/11, 11/27/11, and 11/28/11. Review of CNA 5's Progressive Discipline/Termination Notice dated 11/30/11, showed he would be suspended on 12/1/11, 12/2/11 and 12/3/11. CNA 5 was terminated on 12/3/11. Review of RN 7's interview statement dated 12/8/11, showed on 11/24/11, she was unable to reach the Administrator, and left a voice mail message on the DON's voice mail. RN 7 stated LVN 11 spoke with the DSD and informed her of the allegation. The DSD called back and spoke with LVN 11 and told her "everything is taken care of." During an interview on 12/8/11 at 1435 hours, the DSD confirmed she received a telephone call from LVN 11 on 11/24/11 at approximately 2230, informing her of Resident 2's allegation of sexual abuse. She stated the LVN had the wrong telephone number for the Administrator, and she would contact the Administrator and notify him of the allegation. The DSD stated she spoke with the Administrator on 11/24/11 at approximately 2235 hours, and notified him of Resident 2's allegation of sexual abuse. She stated she was unaware of the reason the investigation was not started on 11/29/11. 3. During the investigation of Resident 1's allegation of abuse, an Interview Record dated 12/5/11, showed the SSA interviewed Resident 3 about the care and services she received from CNA 4. The SSA documented Resident 3 stated she did not care for CNA 4. CNA 4 is too rough with her, and when CNA 4 gives her a shower, she rushes her and gets mad when I tell her the water is too hot. During an interview on 12/7/11, Resident 3 stated, about a month ago, CNA 4 had treated her roughly, especially when she was taking a shower. Resident 3 stated she reported the incident to the supervisor. During an interview on 12/7/11 at 1030 hours, the SSA stated during the investigation of Resident 1's allegation of abuse, Resident 3 had told her she had been handled roughly by CNA 4. When the SSA was asked if an investigation had been done on Resident 3's allegation of abuse, she stated, "No, I gave the interview statement to the DON." During an interview with the DON on 12/7/11 at 1200 hours, the DON stated she was aware of Resident 3's allegation of rough handling by CNA 4, but no investigation had been started. During an interview on 12/8/11 at 0845 hours, when the SSA was asked if Resident 3's allegation of rough handling was being investigated, she stated she talked to Resident 3 again and Resident 3 stated everything was okay. No documentation was available to show the allegation of abuse was investigated. 4. During an interview on 12/8/11 at 0715 hours, Resident 4 stated a male staff member yelled at her during the evening of 12/7/11, and accused her of stealing a wheelchair from another resident. Resident 4 stated her wheelchair was being cleaned on 12/7/11, and she needed a wheelchair. Resident 4 found a wheelchair in the hallway. The wheelchair was not labeled with another resident's name. Resident 4 started using the wheelchair and brought it back to her room. A short time later a male staff member came into her room and "really yelled" at her and upset her. The male staff member then took the wheelchair away. After this incident was reported to RN 1 at 1545 hours, and to LVN 1 at 1600 hours on 12/8/11, no investigation was initiated. The staff failed to follow the facility's policy requiring staff to immediately report suspected or alleged incidents of abuse to the Administrator. During an interview with the DON on 12/9/11 at 0900 hours, the DON stated no one had told her about this incident and she had not received an incident report or investigation report from RN 1 or LVN 1 about this incident.

Based on interview and facility P&P review, the facility failed to thoroughly investigate allegations of abuse for four of nine sampled residents (Residents 1, 2, 3, and 4) and investigate injuries of unknown origin for three of nine sampled residents (Residents 3, 5, and 8). Two staff members stated they would reassign staff to other residents when allegations of abuse are made. The facility's abuse P&P failed to specifically outline how staff is to protect the residents from a perpetrator of alleged abuse. This has the potential for the alleged perpetrator to abuse other residents. The Abuse Coordinator's and DON's telephone numbers were not available for two of three stations (Stations 1 and 2) and resident complaints of not feeling safe were not followed up on for two of 176 interviews conducted by facility staff (Nonsampled Residents C and D). In addition, three of five staff personnel files did not contain a criminal background investigation and clearance. This has the potential for the facility to hire individuals who may have a history of abusive behavior, and to leave residents vulnerable to abuse. This has the potential to affect all residents in the facility. Immediate Jeopardy was identified on 12/8/11 at 0900 hours, related to the facility's lack of action and investigations for residents with allegations of abuse and mistreatment. The Administrator and the DON were made aware of the Immediate Jeopardy on 12/8/11 at 0920 hours. On 12/8/11 at 1615 hours, the Administrator and the DON submitted an acceptable plan of correction which included the following: - A facility re-investigation was initiated related to Resident 1's allegation of abuse. Staff members were to be included in the investigation. The staff member named in the allegation was terminated. - A facility re-investigation was initiated related to Resident 2's allegation of abuse. Staff members were to be included in the investigation. Resident 2's responsible party was updated on the investigation. The staff member named in the allegation remains on suspension. - A facility investigation was initiated related to Resident 3's allegation of abuse. Staff members were to be included in the investigation. - Staff will be inserviced on what constitutes abuse, reporting, protection of residents during an investigation, to include investigation of injuries of unknown origin, prior to providing resident care. - Interviewable residents will be questioned if they witnessed or have been treated in an abusive manner. - Responsible parties will be notified and interviewed for non-interviewable residents. - Department managers and licensed nurses will monitor for compliance twice per week rounds. Any negative findings will be reported to the Administrator/Designee/DON for corrective actions. - All identified summary trend analysis of the findings will be reviewed at the monthly CQI Steering Committee for further evaluation and for additional recommendations. - Revise the facility's Abuse Investigation P&P to include suspending the alleged employee immediately, pending the investigation. On 12/12/11 at 1020 hours, the facility's actions taken to abate the immediate jeopardy were reviewed with the DON and the Administrator. The corrections the facility took were re-investigation of the allegations of abuse involving Residents 1, 2 and 3. Inservices for all staff members were conducted. Surveys were conducted with interviewable residents and family members/responsible parties for non-interviewable residents, related to any allegations of abuse or mistreatment. The P&P was also revised to include suspending the alleged employee immediately, pending the investigation. On 12/12/11, random interviews were done with staff to assess their knowledge of abuse reporting and investigations of alleged abuse and injuries of unknown origin. As of 12/12/11, residents were assessed for abuse and injuries of unknown origin, which included interviews. Family interviews were done for residents who were unable to communicate. On 12/12/11 at 1020 hours, Immediate Jeopardy was abated. Findings: 1. Review of the facility's P&P titled Abuse Reporting dated 2/1/00, shows, when a staff member becomes aware of an abusive or reasonably suspects an abusive situation, he or she should report the incident immediately to the Administrator or the DON and initiate a written report. Review of the facility's P&P titled "Abuse Investigation" dated 2/1/00, shows if the suspected perpetrator is an employee, remove the employee immediately from providing care to the resident. Depending on circumstances, employee may be removed from care of other residents. The employee may be suspended during the investigation, in accordance with personnel policies. The Administrator or designee initiates an investigation of the alleged and/or suspected abuse immediately. The investigation may include interview of the involved resident and other parties (volunteers, employees, visitors, etc., who have knowledge of the alleged incident. The facility's policy for Abuse Prevention shows all new employees are screened for drug use, and will have a criminal background investigation. Review of Resident 1's allegation of physical abuse showed a dietary assistant witnessed CNA 4 hold her hand over Resident 1's mouth to quiet her on 11/26/11, but the dietary assistant didn't reported it until 11/29/11. CNA 4 continued to provide resident care until she was suspended six days later on 12/2/11. Review of CNA 4's Progressive Discipline/Termination Notice dated 12/2/11, showed the DON placed her on a three day suspension (12/2/11, 12/3/11 and 12/4/11) pending investigation of the allegation of abuse. Review of CNA 4's timesheet showed she worked the 3-11 shift on 11/26/11, and worked the 7-3 shifts on 11/27/11, 11/28/11, 11/29/11 and 11/30/11. (Cross reference to F223) 2. Review of Resident 2's allegation of sexual abuse by CNA 5 showed the incident occurred on 11/24/11, was reported to the Administrator on 11/24/11, but CNA 5 continued to work until he was suspended four days later on 11/29/11. Review of CNA 5's timesheet showed he worked the 11-7 shift on 11/24/11, 11/25/11, 11/26/11, 11/27/11, and 11/28/11. (Cross reference to F223) 3a. On 12/5/11, the SSA interviewed Resident 3 about the care and services she received from CNA 4. The SSA documented Resident 3 stated she did not care for CNA 4; CNA 4 is too rough with her, and, when CNA 4 gives her a shower, she rushes her and gets mad when she tells her the water is too hot. During an interview on 12/7/11 at 0940 hours, Resident 3 stated, about a month ago, CNA 4 had treated her roughly, especially when she was taking a shower. Resident 3 stated she reported the incident to the supervisor. During an interview on 12/7/11 at 1030 hours, the SSA stated, during the investigation of Resident 1's allegation of abuse, Resident 3 had told her she had been handled roughly by CNA 4. When the SSA was asked if an investigation had been done on Resident 3's allegation of abuse, she stated, "No, I gave the interview statement to the DON." During an interview on 12/8/11 at 0845 hours, when the SSA was asked if Resident 3's allegation of rough handling was being investigated, she stated she talked to Resident 3 again and Resident 3 stated everything was okay. No documentation was available to show the allegation of abuse was investigated. On 12/8/11, an Investigation of Alleged Abuse was started related to Resident 3's statement of CNA 4 handing her roughly. (Cross reference to F223) b. Clinical record review for Resident 3 was initiated on 12/8/11. Review of Resident 3's MDS dated [DATE], showed no memory impaired and the resident is easily understood. Review of Resident 3's physician's orders [REDACTED]. Review of Resident 3's Change in Condition assessment dated [DATE] at 1600 hours, showed Resident 3's left 2nd toe had an open wound with scant bleeding. A facsimile was sent by LVN 2 to Resident 3's physician on 10/26/11, to notify him of the wound on Resident 3's left 2nd toe, with bleeding. Review of Resident 3's Interdisciplinary Conference Notes dated 11/9/11, showed Resident 3 sustained a left 2nd toe open wound. No documentation was available to show an investigation was completed to identify the cause of Resident 3's left 2nd toe open wound with bleeding. During an interview on 12/8/11 at 0750 hours, CNA 6 stated Resident 3 is alert and oriented, able to make her needs known and has no behavioral issues. During an interview on 12/8/11 at 0830 hours, LVN 2 stated Resident 3 is very alert and oriented and able to make her needs known. LVN 2 was unaware of the cause of Resident 3's open toe wound on 10/26/11. During an interview on 12/8/11 at 0835 hours, the treatment nurse stated Resident 3 is alert and oriented. He confirmed he treated Resident 3's open toe wound, but was unaware of the cause of the wound. 4. During an interview on 12/8/11 at 0645 hours, when LVN 8 was asked the procedure he would do if a resident reported an allegation of abuse from a CNA, he stated he would talk to the CNA. LVN 8 stated the CNA would have to continue his/her job without touching that resident again. He stated he would not send the CNA home, but the CNA would be reassigned to different residents. During an interview on 12/9/11 at 0845 hours, the DON confirmed the facility's Abuse P&P was not specific about removing the alleged staff member from the premises following an allegation of abuse. 5. On 12/8/11, clinical record review for Resident 5 was initiated. The MDS dated [DATE], showed Resident 5 was cognitively impaired due to dementia and required extensive assistance from staff for ADLs. The Change in Condition Assessment form dated 10/20/11, showed Resident 5 had open skin with bruising on her left hand. The form did not show how the resident's hand was bruised. The physician was notified and a treatment was ordered. The Licensed Personnel Weekly Progress Notes dated 10/20/11, did not show how the resident's hand was bruised. On 12/8/11 at 1115 hours, during an interview with the DON, the DON stated she did not have an investigation related to the open skin and bruising on Resident 5's hand. 6. On 12/8/11, clinical record review for Resident 8 was initiated. The Change in Condition Assessment form dated 7/30/11, showed Resident 8 had a "skin discoloration" on the right side of her abdomen. The discoloration was "red purplish in color" and irregular shaped. A faxed message sent to the physician dated 7/30/11, showed the discolored area measured 3 cm by 9 cm. Review of the Licensed Personnel Weekly Progress Notes dated 7/30/11, did not show how the discoloration occurred or what the discoloration was from. On 12/9/11 at 1025 hours, during an interview with the DON, the DON stated she did not have an investigation related to the right abdominal discoloration for Resident 8. 7. On 12/8/11 at 0635 hours, during an interview with RN 4, the RN stated if an allegation of abuse was made against a staff member by a resident, she would remove the staff member from caring for the resident. The RN stated she would reassign the staff to care for other residents pending the investigation. 8. On 12/12/11 at 0830 hours, during an observation on Station 2 and interview with RN 5, the RN stated, if she received an allegation of abuse, she would notify the Administrator and the DON immediately. When asked where their phone numbers are located, RN 5 was unable to find them. RN 5 stated there is a list of phone numbers located in the medication room. RN 5 retrieved the list, but it did not contain the current names and phone numbers of the Administrator and DON. The list contained the phone numbers of the Administrator and the DON who no longer worked at the facility. On 12/12/11 at 0835 hours, during an observation on Station 1 and interview with LVN 6, when asked if she had access to the DON and the Administrator's phone numbers, LVN 6 stated they are on a card inside the locked medication room. LVN 6 went inside the medication room, but was unable to find any card with phone numbers on it. LVN 6 asked LVN 4 where the phone numbers are, but she was also unable to locate them. 9. On 12/12/11, the resident interviews conducted by the facility were reviewed. Two of the 176 interviews done showed Residents C and D stated they did not feel safe or were treated with respect and dignity all of the time. However, On 12/12/11 at 0930 hours, during an interview with the SSA, the SSA stated the facility had not yet followed up with the residents who stated they did not feel safe all the time at the facility. 10. During an interview on 12/8/11 at 0715 hours, Resident 4 stated a male staff member yelled at her during the evening of 12/7/11, and accused her of stealing a wheelchair from another resident. Resident 4 stated her wheelchair was being cleaned on 12/7/11, and she needed a wheelchair. Resident 4 found a wheelchair in the hallway. The wheelchair was not labeled with another resident's name. Resident 4 started using the wheelchair and brought it back to her room. A short time later a male staff member came into her room and "really yelled" at her and upset her. The male staff member then took the wheelchair away. After this incident was reported to RN 1 at 1545 hours, and to LVN 1 at 1600 hours on 12/8/11, no investigation was initiated. The staff failed to follow the facility's policy requiring staff to immediately report suspected or alleged incidents of abuse to the Administrator. During an interview with the DON on 12/9/11 at 0900 hours, the DON stated no one had told her about this incident and she had not received an incident report or investigation report from RN 1 or LVN 1 about this incident. (Cross reference to F223) 11. On 12/9/11 review of five facility personnel files was conducted with the DSD. The review showed three of five employee files did not contain a criminal background investigation and clearance. These employees had hire dates in August, 2011, September, 2011 and October, 2011. One additional employee file shows the employee's start of employment was 10/24/11. The criminal background investigation and clearance was not completed until 10/31/11 and the background clearance was not sent to the facility until 12/9/11. During the interview with the DSD on 12/9/11 at 1050 hours, The DSD stated it is the facility's policy to have all required drug testing, licensing/certification verification, references and criminal background clearance in the personnel file before a new employee's start day. When asked who is responsible to make sure all of the required paperwork is completed and in the personnel file, the DSD stated it is her responsibility. The DSD was unable to explain why the criminal background clearances were not in three employees' files or why the criminal background clearance was not completed before an employee's start date.

Based on observation, interview and clinical record review, the facility failed to ensure an indwelling urinary catheter was necessary for one of nine sampled residents (Resident 8). The facility failed to ensure medical justification for the use of an indwelling urinary catheter, conduct an assessment, and an attempt to remove the indwelling urinary catheter for eight months. Resident 8 developed multiple UTIs, including an infection caused by an organism with ESBL (a multiple drug resistant bacterial infection), which required antibiotic therapy. Findings: According to the CDC-Healthcare Infection Control Practices Advisory Committee; Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009, Urinary tract infections are the most common type of healthcare-associated infection. Virtually all healthcare-associated UTIs are caused by instrumentation (catheterization) of the urinary tract. Catheter-associated urinary tract infection (CAUTI) has been associated with increased morbidity, mortality, hospital cost, and length of stay. In addition, bacteriuria commonly leads to unnecessary antimicrobial use, and urinary drainage systems are often reservoirs for multidrug-resistant bacteria and a source of transmission to other patients. CAUTI is the leading cause of secondary nosocomial bloodstream infections. In the nursing home setting, bacteremias are most commonly caused by UTIs, the majority of which are catheter-related. Intermittent catheterization is preferable to indwelling urinary catheters for residents with bladder emptying dysfunction. On 12/8/11 at 0735 hours, Resident 8 was observed lying in bed with an indwelling urinary catheter present. On 12/8/11, clinical record review for Resident 8 was initiated. The MDS dated [DATE], showed Resident 8 was always continent of urine. The physician's orders [REDACTED]. The physician's admission orders [REDACTED]. However, the acute care hospital's history and physical dated 4/11/11, showed Resident 8 had no [DIAGNOSES REDACTED]. The Nursing Admission assessment dated [DATE], showed Resident 8 was readmitted to the facility after being transferred to the acute care hospital, where she had surgery to repair a femur (large bone in the leg) fracture. The assessment showed Resident 8 returned from the acute care hospital with an indwelling urinary catheter; however, the assessment showed no reason documented to continue the use of the indwelling urinary catheter. There was no assessment documented in the urinary section of the assessment form. The care plan problem titled At Risk for UTI dated April, 2011, showed Resident 8 was at risk for UTIs due to the use of an indwelling urinary catheter. A goal was Resident 8 will be free of UTIs. The interventions listed did not show a plan or attempts to discontinue the indwelling urinary catheter. The Change in Condition Assessment form dated 12/8/11, showed Resident 8's indwelling urinary catheter bag contained dark yellow urine and the urine had a strong odor. The physician was notified. The physician's orders [REDACTED]. The Change in Condition Assessment form dated 8/2/11, showed Resident 8 had hematuria (blood in the urine). The form showed the resident's urine color was "red." A faxed message sent to the physician dated 8/2/11, showed there was blood in Resident 8's urine and the color of her urine was "dark red." The laboratory results form dated 8/3/11, showed Resident 8 had a UA with C&S done. The urine color was dark yellow (normal is yellow color) and the urine was cloudy and many bacteria and red and white blood cells were present. The physician's orders [REDACTED]. The laboratory results form dated 5/4/11, showed Resident 8 had a UA with C&S done. The urine was cloudy (indicative of infection, normal urine is clear) and many bacteria and red and white blood cells were present (indicative of infection). The C&S showed Resident 8 had an infection caused by an organism that was ESBL. The Change in Condition Assessment form dated 5/6/11, showed Resident 8 had an infection in her urine caused by an organism that was ESBL. The physician was notified and [MEDICATION NAME] (an antibiotic) 100 mg twice daily for five days was ordered to treat the UTI. On 12/8/11 at 1330 hours, during an interview with LVN 4, the LVN stated the facility had not attempted to remove Resident 8's indwelling urinary catheter. On 12/9/11 at 0830 hours, during a follow up interview with clinical record review with LVN 4, the LVN stated she could not find any physician documentation to show Resident 8 had a [DIAGNOSES REDACTED]. The LVN stated the facility did not have a plan to discontinue the indwelling urinary catheter. LVN 4 stated the assessment for the use of the indwelling urinary catheter should be documented on the nursing admission assessment form. The LVN acknowledged there was no assessment documented on Resident 8's nursing admission assessment form.

Based on interview and clinical record review, the facility failed to provide appropriate services to prevent a UTI and to restore as much normal bladder function for two of six sampled residents (Residents 11 and 13). The facility failed to accurately assess the bladder function for Resident 13 and provide a bladder retraining program, or a scheduled toileting program for Resident 13. this poses the risk for further decline in bladder function for the resident. Resident 11 had a urinary drainage catheter due to a [MEDICAL CONDITION] bladder (When the bladder fails to contract to empty the bladder of urine. The facility failed to assess Resident 11 for signs and symptoms of a UTI. This poses the potential for development of UTI for the resident. Findings: 1. Resident 13's clinical record review was initiated on 1/31/12. The resident was admitted to the facility on [DATE]. The MDS (an assessment tool) dated 11/5/11, showed the resident's cognition is intact; he is always continent of bladder. The Bowel and Bladder Assessments dated 8/5, and 11/5/11, showed unclear documentation if the resident is continent or incontinent of bladder. Review of the CNA ADL Flow Sheets for the months from August to December, 2011, and the month of January, 2012, showed Resident 13 had episodes of bladder incontinence, and bladder continence. Review of the care plan showed a care plan problem dated 5/7 (no year), to address self care deficit. The approaches included to check every two hours for incontinence and intervene appropriately. During an interview with RN 8 on 2/1/12 at 0835 hours, the RN stated the resident is incontinent of bladder most of the time. She was asked if the resident is on a bladder retraining program, or a schedule toileting program. She stated, "no." During an interview and clinical record review with RN 3 on 2/1/12 at 0855 hours, the RN reviewed Resident 13's clinical record and stated the Bowel and Bladder Assessments dated 8/5, and 11/5/11, showed the resident is continent of bladder. She reviewed the CNA ADL Flow Sheets and confirmed the resident has episodes of continence, and episodes of incontinence of bladder. She was asked what should be done to prevent further decline in bladder function for the resident. She stated the resident has to be on a bladder retraining program to prevent further decline in bladder function. She was asked for, but was unable to find documentation to show Resident 13 is on a bladder retraining program or a scheduled toileting program. She also confirmed a care plan problem was not developed to address incontinence care for the resident. During an interview with CNA 8 on 2/1/12 at 1230 hours, the CNA stated Resident 13 is incontinent of bladder. She was not sure if the resident is on a scheduled toileting program, or on a bladder retraining program. 2. Review of Resident 11's clinical record was initiated on 1/31/12. The resident was admitted to the facility on [DATE], and had multiple UTIs. Review of the care plan showed a care plan problem dated 12/22/11, to address the risk for UTI. The goal is the resident will be free of signs and symptoms of UTI daily. The approaches include to monitor the urine for sediment, cloudiness, odor, blood; bladder irrigating (flush the bladder with a sterile solution to cleanse it) as ordered as needed. Review of a physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. Review of an urinalysis report dated 1/4/12, showed Resident 11's urine was turbid (cloudy). Review of the urine culture report dated 1/6/12, showed the urine culture was positive for a UTI. On 2/1/12 at 1140 hours, RN 3 was asked if Resident 11's urine characteristics are assessed daily for sediment, cloudiness or odor. She reviewed the resident's clinical record and was unable to find documentation to show the resident's urine was assessed daily for sediment, color, odor, or blood from 12/28/11 to 1/3/12. She was asked if the resident's indwelling urinary catheter was irrigated prior to 1/6/12. She reviewed the resident's clinical record and was unable to find documentation to show the resident's indwelling urinary catheter was irrigated prior to 1/6/12.

Based on interview and clinical record review, the facility failed to ensure treatments were done as ordered for one of 17 sampled residents (Resident 39). Resident 39 had a healing Stage II pressure ulcer (a partial thickness loss of skin presenting as a shallow open ulcer with a red or pink wound bed) on her coccyx with a physician's orders [REDACTED]. The treatments were done once a day. This has the potential for a decline or delay in the healing process. Findings: On 7/12/11, clinical record review for Resident 39 was initiated. The Skin Breakdown Report dated 7/5/11, showed Resident 39 had a Stage II pressure ulcer on her coccyx. The pressure ulcer measured 1.5 cm by 0.5 cm and was superficial with redness. The physician's orders [REDACTED]. The Short Term Problem dated 7/5/11, showed Resident 39 had a Stage II pressure ulcer on her coccyx. A goal listed on the care plan showed the resident's pressure ulcer would heal. An approach listed on the care plan to help meet this goal was to provide the treatment ordered twice daily. Review of the treatment administration record dated July, 2011, showed the treatment was done once daily from 7/9/11 through 7/12/11. On 7/13/11 at 1520 hours, during an interview and clinical record review with LVN 2, the LVN stated she did not do the treatments.

Based on observation, interview, and clinical record review, the facility failed to provide care and services to prevent pressure ulcer development for two of 29 sampled residents (Residents 4 and 21). The facility failed to evaluate and monitor Resident 4's skin condition and failed to implement interventions that are consistent with the resident's needs to prevent the development of pressure ulcers. This resulted in the development of pressure ulcers for Resident 4. Resident 21 developed a Stage I (intact skin with non-blanchable [DIAGNOSES REDACTED] (the redness of the skin does not go away when pressure is applied to the area) of a localized area usually over a bony prominence) pressure area to the right and left heels. The facility failed to monitor the Stage I pressure area, and failed to implement interventions for the Stage I pressure area. This poses the potential for the Stage I heel pressure areas getting worse. Findings: According to the Pressure Ulcer Treatment developed by European Pressure Advisory Panel and National Pressure Ulcer Advisory Panel, weekly assessments provide an opportunity to detect early complications and the need for changes in the treatment plan. The Pressure Ulcer Treatment showed the general recommendations include to avoid prolonged head of bed elevation and a slouched position that places pressure and shear on the sacrum and coccyx while in the bed, to limit head of bed elevation to 30 degrees for an individual in the bed to prevent sliding and friction unless contraindicated by their medical condition, to continue to turn and reposition the individual regardless of the support surface in use, to relieve pressure under the heels by placing the legs to "float the heels" off the bed. According the Lexi-Comp online for [MEDICATION NAME] (same as Santyl), Santyl is used to promote debridement of necrotic (dead) tissue in dermal ulcers. 1. Review of Resident 4's clinical record was initiated on 5/16/11. Resident 4 was admitted to the facility on [DATE]. The MDS (an assessment tool) dated 5/17/10, showed the resident did not have pressure ulcers, or a history of resolved pressure ulcers. The MDSs dated 2/2/11, and 5/5/11, showed the resident is identified at risk of developing pressure ulcers, and did not have unhealed pressure ulcers. The MDSs showed the resident needs extensive assistance in bed mobility, and is totally dependent in transferring. Review of the Physician's Progress Record showed an entry dated 10/28/10 at 1100 hours, identifying Resident 4 had recurrent bilateral heel pressure ulcers and bilateral heel protectors (a device placed on the foot to relieve pressure from the heel) were in place. An entry dated 1/21/11 at 1400 hours, showed the resident had a healed Stage II (partial thickness loss of skin presenting as a shallow open ulcer with a red pink wound bed, without slough (dead tissue). May also present as an intact or open/ruptured blister) pressure ulcer on the left heel. Review of the Resident Weekly Summaries dated 1/25/11, 2/1/11, and 2/22/11, showed the resident had no skin breakdown. a. Review of the Change In Condition assessment dated [DATE] at 0930 hours, showed a 1.1 cm x 1.6 cm closed blister noted on the lateral aspect of the right heel. The surrounding area of the blister was red. The physician was notified. Review of the Skin Breakdown Report dated 2/27/11, showed the Stage II closed blister identified on 2/23/11, Review of the Skin Breakdown Progress Report form for the right heel pressure ulcer showed the Stage II pressure ulcer was resolved (healed) on 3/30/11. Review of the care plan showed a care plan problem dated 3/3/11, to address actual alteration in skin integrity: right lateral aspect of heel closed blister, and open skin on the right buttock. The care plan did not specify to keep the heels off-loaded (floated), or to keep pressure off the bony prominences. Review of the Change In Condition assessment dated [DATE], showed an open skin area noted on the resident's right buttock, measuring 1.5 cm x 1 cm. The right buttock open skin area was round, red and yellow. The physician was notified. Review of the physician's orders [REDACTED]. Review of the Resident Weekly Summary dated 4/19, 4/26, and 5/3/11, showed the resident had a right buttock open skin area. There was no documentation to show the right buttock open skin area was assessed for wound characteristics such as the condition of the wound bed, size, color, exudate, and pain. On 5/16/11 at 1245 hours and 1625 hours, Resident 4 was observed sleeping in the bed, lying on her back. The head of bed was elevated approximately 30 degrees or more. The resident wore socks and had no heel protectors on. The heels were resting on the mattress, and were not off-loaded. On 5/16/11 at 1445 hours, Resident 4 was observed lying on her back, and moving her legs. The resident's heels were observed sliding up and down on the mattress. The head of the bed was elevated approximately 30 degrees. The resident did not have heel protectors on. On 5/17/11 at 0745 hours and 0815 hours, the resident was observed lying on her back. The head of the bed was elevated approximately 30 to 40 degrees. The resident did not have heel protectors. The heels were resting on the mattress. On 5/17/11 at 0820 hours, CNA 5 was observed elevating the resident's head of the bed up to 90 degrees for the breakfast meal. The CNA did not turn or reposition the resident, and did not put the heel protectors on the resident's feet. On 5/17/11 at 1000 hours, the resident was observed lying on her bed, on her back, moving her legs. Her legs and her heels were observed sliding on the mattress. The head of the bed was elevated between 30 to 45 degrees. The resident did not have heel protectors on. During an interview with LVN 2 on 5/17/11 at 1020 hours, LVN 2 was asked if Resident 4 had heel pressure ulcers. The LVN stated the pressure ulcers on the resident's heels already healed. The LVN was asked what was the treatment for [REDACTED]. The LVN stated "Santyl." An observation was conducted on 5/17/11 at 1030 hours. LVN 2 was observed providing the skin treatment to Resident 4's right buttock open skin. The resident was observed lying on her back. LVN 2 and CNA 3 were observed turning the resident to the left side. The resident's right buttock skin was observed open at the skin fold area, at the pressure point. The right buttock open skin contained approximately 25% of slough, yellow tissue. The wound bed was moist. The wound size was approximately 1 cm x 1 cm. The surrounding area was slightly discolored. The LVN did not measure the right buttock open skin area. The LVN was asked to check the resident's right heel. The LVN was observed raising the resident's right heel. The resident's right heel was observed with a reddened area at the bottom of the heel, at the pressure point, measuring 5 cm x 5 cm. The LVN was asked if the reddened area is blanchable or non-blanchable. The LVN checked the reddened area and stated it is "non-blanchable." The resident's lateral side of the right heel was observed with a 0.5 cm x 0.5 cm open area. This open area was dry and red. The LVN was asked to check the resident's left heel. The LVN was observed raising the resident's left heel. The resident's left heel was observed with an open area measuring 1 cm x 1 cm at the bottom of the heel, at the pressure point. The wound had 10% brownish tissue in the center. The wound bed was dry. The LVN verified there was some brownish tissue in the center of the wound bed. The LVN stated the wounds found on the resident's heels were new to him. He verified Resident 4 had a Stage I right heel pressure ulcer, a Stage II pressure ulcer on the lateral aspect of the right heel, and an unstageable left heel pressure ulcer. The LVN was asked how the right buttock skin fold wound was. The LVN stated he "did not like the way it looks." Further clinical record review showed a physician's orders [REDACTED]. Review of the May, 2011 treatment record on the reverse side showed an entry dated 5/4/11 at 1000 hours, showing the right buttock wound measuring 0.5 x 0.9 cm was open, not healed, continue with current treatment, no redness around the area, the skin was still open, the patient continues out of bed in a wheelchair. There was no documentation to show the right buttock open skin was assessed for wound characteristics such as slough, exudate, or pain. The Resident Weekly Summary dated 5/10/11, showed the right buttock open skin area and the heels were not addressed. Review of the Licensed Personnel Weekly Progress Notes from 4/14/11 to 5/16/11, showed no documentation the right buttock open skin area was assessed for size, color, shape, drainage, or bleeding. There was no documentation to show the right buttock open skin area was getting better or worse. There was no documentation of assessment of the resident's heels. Review of the Skin Breakdown Report dated 5/17/11, showed documentation of a Stage II/shearing left buttock skin fold pressure ulcer identified on 4/14/11. Further review of the Skin Breakdown Report showed the Stage II left buttock skin fold pressure ulcer was getting worse, increased in depth, and developed to a Stage III (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed) pressure ulcer with 10% yellow tissue or slough. During an interview with LVN 2 on 5/17/11 at 1500 hours, LVN 2 stated the Skin Breakdown Report identifying the left buttock wound was actually for the right buttock wound. Review of the wound care report from a wound specialist dated 5/18/11, showed the resident had a wound to her right buttock skin fold. The wound's etiology was pressure. The wound was identified as a Stage III. The wound's duration was described as acute. The wound measured 0.6 cm x 1.0 cm x 0.2 cm. The wound contained 10% of yellow slough and 90% of granulation tissue. Further review of the wound care specialist's report showed the resident presented with a right buttock skin fold wound with dark pigmented surrounding. The wound specialist documented the resident had a previous wound at this area, and if this is true, the area is at high risk for breakdown. On 5/17/11 at 1045 hours, CNA 3 was observed putting a pair of slippers on Resident 4, but no heel protectors. The heels were resting on the mattress. During an interview with RN 2 on 5/17/11 at 1050 hours, the RN review Resident 4's clinical record and was unable to find documentation to show an ongoing assessment of the heels, and weekly or daily assessments for the right buttock skin fold wound. The RN was asked about the care plan problem to address the skin breakdown. The RN reviewed the resident's clinical record and verified the care plan problem was not developed individually to address the skin breakdown. The care plan did not specify to keep pressure off the bony prominences, to keep the heels off-loaded, or to put the heel protectors on the resident's feet. During an interview with CNA 1 on 5/17/11 at 1140 hours, the CNA stated she did not see the heel protectors on the resident's heels sometimes. During an interview with CNA 3 on 5/17/11 at 1200 hours, the CNA stated she put the heel protectors on for the resident when the resident is in bed. When asked if the resident's heels need to be off-loaded, she did not answer. During an interview with LVN 2 on 5/17/11 at 1500 hours, the LVN was asked if he assessed the resident's right buttock skin fold daily or weekly. The LVN stated the right buttock wound was at the skin fold area, so he thought it came from the "shearing" and not from pressure; he did not assess the right buttock skin fold area weekly or daily. when asked about the right buttock skin fold wound, the LVN stated the right buttock skin fold is a Stage III pressure ulcer. The LVN was asked if he should use saline or soap and water to clean the right buttock skin fold wound, he stated he used normal saline solution. When asked what the physician's orders [REDACTED]. He was asked if he assessed the heels for skin breakdown. He stated the pressure ulcers on the heels were healed, so he did not assess the resident's heels. During an interview with CNA 4 on 5/17/11 at 1540 hours, the CNA stated she put the heel protectors on the resident. The CNA was asked if the resident's heels were off-loaded. The CNA stated she put the resident's heels on pillows. An observation and an interview with LVN 2 was conducted on 5/18/11 at 0730 hours. The resident was observed sleeping in the bed, and lying on her back. The head of the bed was elevated approximately 30 degrees. The resident had heel protectors on. The heels were not off-loaded and were resting on the mattress. The LVN confirmed the resident's heels were not off-loaded. He stated the resident's heels should be off-loaded. During an observation and interview with LVN 1 on 5/18/11 at 0925 hours, the resident was observed lying on her back. The head of the bed was elevated to approximately 30 degrees. A heel protector was on the right heel. Another heel protector was on the left calf. The LVN stated the resident tended to move her legs, and kick the heel protectors off. During an observation on 5/18/11 at 1040 hours, the resident was observed sleeping on her left side. The heel protectors were on the heels. The heels were not off-loaded. An observation and interview with CNA 5 was conducted on 5/18/11 at 1330 hours. The CNA stated the resident could not turn or move by herself. The CNA stated the resident needs the staff members to turn or reposition her. The resident was observed sleeping in the bed, lying on her back. The head of the bed was elevated more than 30 degrees. The right heel had a heel protector on. The left heel did not have a heel protector on. Both heels were resting on the mattress. The CNA was observed putting the heel protectors on the resident's feet, putting the resident's heels on the mattress, and leaving the room. The resident's heels were not off-loaded. During an observation on 5/19/11 at 0730 hours, the resident was observed sleeping on a low air loss mattress (a special alternating air mattress to help in the treatment of [REDACTED]. During an interview with CNA 6 on 5/19/11 at 0745 hours, the CNA stated the resident was unable to turn by herself. The CNA also stated the staff members have to turn or reposition the resident. 2. Review of Resident 21's clinical record was initiated on 5/18/11. The resident was admitted to the facility on [DATE]. Review of the MDS dated [DATE], showed the resident is at risk for developing pressure ulcers. Review of the Nursing Admission assessment dated [DATE], showed the resident had redness on the heels and was identified as having pressure ulcers. There was no documentation to showed the heel redness was assessed for the stage or size. Review of the physician's orders [REDACTED]. Review of the treatment record for the months of March, April, and May, 2011, showed heel protectors to both heels while in bed. There was no documentation to show the heel pressure ulcers were assessed daily, or weekly, or routinely. Review of the care plan showed a care plan problem dated 3/18/11, to address the risk for skin breakdown, and redness of the bilateral heels. The approach included heel protectors to both heels as ordered. The care plan did not specify to off-load the heels, or to assess the heels for pressure ulcers. During an observation on 5/18/11 at 0915 hours, the resident was observed with her heels resting on the mattress, with no heel protectors on. During an observation and an interview with LVN 1 on 5/18/11 at 1015 hours, Resident 21 was observed without heel protectors on. The resident was observed moving and sliding the heels on the mattress. The resident's skin was dry. The LVN verified Resident 21 was not wearing heel protectors. The LVN was observed asking CNA 1 to put the heel protectors on Resident 21. The CNA was observed looking for the heel protectors. One heel protector was found in the resident's closet. One foam boot was found in another closet. The CNA stated she was unable to find another heel protector. During an observation on 5/18/11 at 1100 hours, the resident was observed with heel protectors on the heels, and without the heels off-loaded. During an interview with RN 2 on 5/18/11 at 1105 hours, the RN reviewed the resident's clinical record and was unable to find documentation of assessing the heel pressure ulcers of Resident 21. The RN verified the care plan for the heel redness was not specific for Resident 21.

Based on interview and clinical record review, the facility failed to administer water as recommended by the RD and ordered by the physician for nine days, for one of 29 sampled residents (Resident 13). In addition, the facility failed to consistently document Resident 13's tube feeding intake and urine output, conduct 24 hour totals and conduct a weekly intake and output evaluation of the resident's fluid status for those nine days. Resident 13 had a GT (a tube placed through a surgical opening in the abdomen into the stomach for the purpose of feeding), was at high risk for dehydration and dependent on staff for all hydration needs. Resident 13 was transferred to the acute hospital and diagnosed with [REDACTED]. Review of the facility's P&P titled "Intake and Output" dated 8/2000, showed the purpose of intake and output is to maintain an accurate measurement of the resident's fluid balance. The licensed nurse will total the fluids on the intake and output form. The intake and output monitoring will be done on all shifts. According to Nestle Nutrition (www.nestle-nutrition.com), the manufacturer of [MEDICATION NAME] 1.5 calorie tube feeding formula, the formula contains 78% free water. On 5/16/11, clinical record review for Resident 13 was initiated. Resident 13 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with [DIAGNOSES REDACTED]. The physician's "Enteral Orders" dated 4/13/11, showed an order for [REDACTED]. The care plan problem titled Altered Nutritional Support dated 4/15/11, showed Resident 13 was at risk for dehydration due to the use of a GT for fluid intake. A goal listed on the care plan showed Resident 13 will remain well hydrated. An approach listed on the care plan to help meet this goal is to administer fluids as recommended by the RD and ordered by the physician. The "Nutritional Screening & Data Collection Form" dated 4/15/11, showed Resident 13 was NPO (nothing by mouth) and received hydration through a GT. The form showed Resident 13's fluid needs were not met and the RD recommended [MEDICATION NAME] 1.5 tube feeding formula to infuse at 70 ml per hour for 20 hours daily to provide 1400 ml daily, 1090 ml being free water, and water flushes of 400 ml every six hours (1600 ml daily) to meet the resident's estimated needs. The physician's orders [REDACTED]. However, review of the Enteral Medication Sheet dated April, 2011, showed the order for 400 ml every six hours was transcribed as 400 ml every eight hours. The Enteral Medication Sheet dated April, 2011, also showed the [MEDICATION NAME] 1.5 tube feeding formula to infuse at 70 ml per hour for 20 hours daily to provide 1400 ml daily. The MAR indicated [REDACTED]. However, from 4/16/11 through 4/23/11, the water flushes were inconsistently documented. On 4/17/11, 4/18/11, and 4/21/11, the 400 ml water flushes were administered twice, not four times as ordered. The Total Intake and Output Record dated 4/16/11 through 4/24/11, showed the following tube feeding and water flushes were not administered as ordered: 4/16/11 - 800 ml of water flush, not 1600 ml as ordered, and 800 ml of formula, not 1400 ml as ordered (a loss of 1268 ml water - flush and free water combined). No 24 hour total was documented. The urinary output was 1480 ml. 4/17/11 - 1200 ml of water flush, not 1600 ml as ordered, and 1000 ml of formula, not 1400 ml as ordered (a loss of 712 ml water - flush and free water combined). No 24 hour total was documented. The urinary output was 1100 ml, the night shift was blank. 4/18/11 - 1030 ml of water flush, not 1600 ml as ordered, and 828 ml of formula, not 1400 ml as ordered (a loss of 1017 ml water - flush and free water combined). No 24 hour total was documented. The urinary output was 1000 ml, the night shift was blank. 4/19/11 - 1300 ml of water flush, not 1600 ml as ordered, and 1395 ml of formula (a loss of 300 ml water flush). No 24 hour total was documented. The urinary output was 1120 ml, the evening shift was blank. 4/20/11 - 1000 ml of water flush, not 1600 ml as ordered, and 835 ml of formula, not 1400 ml as ordered (a loss of 1041 ml water - flush and free water combined). No 24 hour total was documented. The urinary output was 1000 ml, the evening and night shift was blank. 4/21/11 - 1000 ml of water flush, not 1600 ml as ordered, and 835 ml of formula not 1400 ml as ordered (a loss of 1041 ml water - flush and free water combined). No 24 hour total was documented. No urinary output was documented, all shifts were blank. 4/22/11 - 800 ml of water flush, not 1600 ml as ordered, and 1080 ml of formula, not 1400 ml as ordered (a loss of 1050 ml water - flush and free water combined). No 24 hour total was documented. The urinary output was 700 ml, the day and evening shifts were blank. The physician's orders [REDACTED]. The Total Intake and Output Record dated 4/16/11 through 4/24/11, continued to be reviewed and showed the following was administered: 4/23/11 - 900 ml of water flush, not 1800 ml ordered, and 480 ml of formula, not 1400 ml as ordered (a loss of 1618 ml water - flush and free water combined). No 24 hour total was documented. The urinary output was 800 ml, the day and evening shifts were blank. 4/24/11 - 900 ml of water flush, not 1800 as ordered, and 480 ml of formula, not 1400 ml as ordered (a loss of 1618 ml water - flush and free water combined). No 24 hour total was documented. The urinary output was 700 ml, the day and evening shifts were blank. The Weekly Intake and Output Evaluation section of the form showed no licensed nurse assessment. The section which shows the average 24 hour intake and output was blank. The section also showed urine color, odor, consistency and clarity and mucous membranes and skin turgor (an assessment performed on the skin to check for dehydration) assessments were blank. Review of the clinical record showed Resident 13 was transferred to the acute care hospital on [DATE]. Resident 13's primary care physician (PCP) at the facility continued to care for him at the acute care hospital. Review of the PCP's acute hospital history and physical dated 4/25/11, for Resident 13's admission on 4/24/11, showed Resident 13 apparently spiked a temperature, became hypotensive (low blood pressure), congested; therefore, the resident was transferred to the emergency room for evaluation where he was noted to have a low blood pressure at one time 70-80 systolic, improved after hydration. "The patient's BUN was high also indicating dehydration." Under Physical Examination, the physician documented "SKIN: turgor is poor." and under HEENT (head, eyes, ears, nose and throat) "Mouth, lip and tongue are dry." Resident 13 was admitted to the intensive care unit. According to the Mayo Clinic (www.mayoclinic.com), a BUN (blood urea nitrogen) test shows kidney function. A high BUN result is indicative of impaired kidney function and/or poor fluid intake. Review of the acute hospital's Discharge Summary report dated 5/16/11, for his discharge on 5/4/11, showed Resident 13's BUN was 98 mg/dL (normal range is 8 mg/dL to 26 mg/dL), creatinine was 3.61 mg/dL (normal range is 0.4 mg/dL to 1.0 mg/dL) and sodium was 157 mEq/L (normal range is 135 mEq/L to 145 mEq/L) on admission. The physician documented Resident 13's skin "turgor is poor" and "The patient was dehydrated; therefore, seen by renal consult and IV fluid adjusted...." The physician documented the resident also had urosepsis (an infection which spreads through out the body in the blood stream) due to a urinary tract infection. The final [DIAGNOSES REDACTED]." On 5/18/11 at 1100 hours, during an interview with RD 2, the RD stated not receiving 400 ml per day in water may not be significant for a healthy person, but could make a big difference in a person who has compromised health, including a resident with infections. On 5/18/11 at 1600 hours, during a follow up interview and clinical record review with RD 2, the RD stated Resident 13 needed an estimated 2695 ml of fluids daily and received 1134 ml of water from the tube feeding formula. The RD stated the rest of the fluids the resident needed would come from the water flushes of 400 ml every 6 hours. The RD stated the tube feeding free water and the water flushes ordered would have provided the resident with the fluids he needed and 40 ml over. The RD stated by receiving a water flush of 400 ml every eight hours instead of every six hours, the resident lost 360 ml daily. The RD was unable to explain why the order was transcribed as 400 ml every eight hours and not every six hours as ordered.