Every finding on record at Seaside HHC @ Atlantic Shore

Based on observation, resident interview and staff interview, the facility staff failed to ensure previous survey results were posted in a place readily available to residents, families and visitors.The findings included:On 11/25/2025 at 1:00 p.m., a group interview was conducted with four alert and oriented residents. All four stated that they were not aware that they could see the results of the previous survey. They stated they did not know where the results were located. A large bulletin board was located in the entry hallway across from the receptionist's desk in the nursing center. There was a notice on the bottom of the bulletin board which stated Survey Results Located: ___________( Assisted Living and Nursing Home names redacted) Reception Desk and ______ (Nursing Home Name redacted) Nurses Station. Please inquire to see a copy of the results. Thank you.There was a silver 3 part letter organizer noted in front of a black binder. There were papers listed as Resident Comment Cards standing in the letter organizer and were obscuring the words on the front of the black binder.After the Group interview/Resident Council meeting conducted on 11/25/2025, the Administrator was asked about the availability of the previous survey. She stated the survey results were available at the receptionist's desk in a blue binder. The Administrator was informed of the statements from the residents during the group interview. The Administrator went into the hallway and pointed to the sign on the bulletin board. The Administrator was informed that the survey results are supposed to be available to the residents, family and visitors. They should not have to inquire to see a copy as instructed per the sign. The Administrator stated that the Social Worker informed residents of the location of the survey results during their admissions. On 11/25/2025 at approximately 3:50 p.m., an interview was conducted with the Social Worker who stated the survey results were located on the receptionist's desk in a blue binder. The Social Worker stated residents should know the location because she did tell them upon their admissions. The Social 'Worker stated she was going to change the wording on the sign to make sure residents knew they did not have to ask to see the results. She also stated she would discuss the location of the survey results in the next Resident Council meeting. During the end of day debriefing on 11/25/2025, the findings were discussed with the Administrator and Director of Nursing. They stated residents should know where the survey results were located and not have to ask to see them. No further information was provided.

Based on staff interviews and a clinical record review, the facility staff failed to review and revise the person-centered care plan for 1 of 21 residents (Resident #3) in the survey sample. The findings included: Resident #3 was initially admitted to the facility on [DATE] and readmitted on [DATE] after an acute care hospital stay. The resident's diagnoses included pneumonia, heart failure, and dementia. The admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 11/3/25, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 7 out of a possible 15. This indicated that Resident #3's cognitive abilities for daily decision-making were severely impaired. A review of Resident #3's person-centered care plan revealed a problem dated 10/27/25, which stated the resident had congestive heart failure. The goal stated that the resident would be free of peripheral edema through the review date, 2/3/26. The interventions included: monitor/document and report as need any signs/symptoms of congestive heart failure: dependent edema of legs and feet, periorbital edema, shortness of breath upon exertion, cool skin, dry cough, distended neck veins, weakness, weight gain unrelated to intake, crackles and wheezes upon auscultation of the lungs, orthopnea, weakness and/or fatigue, increased heart rate, lethargy and disorientation and daily weight- notify MD for weight gain of 3 pounds (lbs), or more in 24 hours or weight gain of 5 lbs, or more in one week.A review of the resident's Physician's Order Summary (POS) revealed an order dated 11/21/25 for a weight upon admission and weekly times four, every 7 days.An interview was conducted with the Director of Nursing (DON) on 11/25/25 at approximately 5:07 PM. The DON stated that the order dated 11/21/25 and the care plan dated 10/27/25 were different, and she would speak with the Provider to clarify which is most appropriate for the resident.On 11/25/25 at approximately 5:15 PM, a final interview was conducted with the Administrator and the DON. The above concern was addressed, and an opportunity was given for the facility's staff to address and supply information they believed was pertinent to the findings. They offered no comments and voiced no concerns.

Based on observations, staff interviews, and a clinical record review, the facility staff failed to implement customary routines, interests, preferences, and choices for 1 of 21 residents (Resident #3) who exhibited episodes of inappropriate behaviors during activities of daily living (ADL) in the survey sample. The findings included: Resident #3 was initially admitted to the facility on [DATE] and readmitted on [DATE] after an acute care hospital stay. The resident's diagnoses included dementia. The admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 11/3/25, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 7 out of a possible 15. This indicated that Resident #3's cognitive abilities for daily decision-making were severely impaired.In section F0400. Interview for Daily Preferences: the resident was coded as stating that it was very important to choose his own bedtime, to have his family or a close friend involved in discussions about his care, to have a place to lock his things to keep them safe, and to choose what clothes to wear.In section GG0130. Self-Care: the resident was coded as requiring partial/moderate assistance with eating, oral hygiene, upper body dressing, and personal hygiene, and substantial/maximal assistance with toileting hygiene, shower/bathe, lower body dressing, and putting on/taking off footwear.A review of Resident #3's person-centered care plan revealed a problem dated 10/27/25, which stated the resident had impaired cognitive function and/or impaired thought processes related to dementia. The goal stated that the resident would be able to communicate basic needs on a daily basis through the review date, 2/3/26. The interventions included keeping the resident's routine consistent and trying to provide consistent caregivers as much as possible in order to decrease confusion.Resident #3 was observed seated outside the facility, accompanied by his spouse, on 11/25/25 at approximately 1:10 PM. The resident was observed attempting to get up and frown. The spouse brought the resident back inside the facility and stated it was too windy outside.A review of the nurse's notes dated 11/23/25 at 1:23 PM stated that during ADL care, the resident touched the staff's breast and punched her in the stomach. The nurse's note stated that redirection was ineffective. Another nurse's note dated 11/24/25 at 9:27 AM said that the resident was combative and sexually inappropriate to staff and the spouse during ADL care. The nurse's note also stated that redirection was ineffective. Another nurse's note dated 11/24/25 at 10:41 AM stated that an order was given for Seroquel Oral Tablet 25 MG. Give 0.5 tablet by mouth every 12 hours as needed for severe agitation, unable to be redirected for safety. An interview was conducted with the Director of Nursing (DON) on 11/25/25 at approximately 5:07 PM. The DON stated that the resident had exhibited behaviors during care twice on 10/28/25, and there were two additional episodes of inappropriate behaviors during ADL on 11/23/25 and 11/24/25. The DON also stated that redirection was the only documented intervention, and it had not been effective. The DON further stated that Resident #3 allowed her to provide his ADL care that afternoon without an incident, and they would explore additional options to encourage the resident's tolerance with care. She stated that the spouse shared that the resident was not a morning person; therefore, allowing him to sleep later would be implemented as they explore and implement other interventions. The DON also stated that the Psych Physician comes in on Fridays, and the resident would be assessed for the use of the prescribed antipsychotic medication. On 11/25/25 at approximately 5:15 PM, a final interview was conducted with the Administrator and the DON. The above concern was addressed, and an opportunity was given for the facility's staff to address and supply information they believed was pertinent to the findings. They offered no comments and voiced no concerns.

Based on staff interviews, record review, and facility document review, the facility staff failed to establish an effective infection prevention and control program (IPCP) that included an antibiotic stewardship program with antibiotic use protocols and a system to monitor antibiotic use for facility residents.Findings include: The facility staff failed to consistently monitor the assessment of antibiotic use.On 11/24/25 at approximately 1:45 PM, an interview was conducted with RN-2 on the facility's antibiotic stewardship program, and she replied, I am not sure as I don't know what that is, (name of the Infection Control Nurse) handles all of that.On 11/24/25 at approximately 2:10 PM, an interview was conducted with LPN-1 on did the facility have an antibiotic stewardship program and she replied Well, I don't know. I don't know what that is?On 11/24/25 at approximately 2:20 PM, an interview was conducted with the Infection Preventionist (ADM-3) on the facility's Infection Prevention and Control Program (IPCP). According to her the facility had identified gaps in the facility's IPCP policies on surveillance and tracking and Antibiotic Stewardship for the required assessment of antibiotic use since the previous Infection Preventionist left a few weeks ago and that they had written a Performance Improvement Plan (PIP).A review of the Performance Improvement Plan (PIP) revealed Area of Concern:-Antibiotic Stewardship practices are not consistently followed, including completion of required Infection Screening Evaluation and Antibiotic Time-Out at 48-72 hours after initiation.- Documentation and reassessment of ongoing antibiotic need, indication, and duration are incomplete or missing.Action Plan included:-Goal of Ensure all antibiotic time-outs and infection control screenings are completed-Action steps Review all antibiotic orders daily; complete Infection Control Screening Evaluation and time-out documentation within 24-48 hours -Evidence of completion Audit logs and MAR review The review of the Performance Improvement Plan (PIP) failed to provide evidence that the facility had corrected the Area of Concern as there was no evidence to support this was done for week 1 dated 11/4/25, week 2 dated 11/11/25 and week 3 dated 11/18/25 and the PIP was initialed by the Director of Nursing and Infection Preventionist.At approximately 3:00 PM, an interview was conducted with the Director of Nursing on the facility's Performance Improvement Plan (PIP) for Infection Monitoring Survey Readiness and she replied that she was surprised that the facility had not been consistently assessing antibiotic therapy and that they had developed the PIP. When asked where the Infection Screening Evaluations and Antibiotic Time-Outs were for current residents with orders for antibiotics she was not able to provide evidence that they had been completed.The Administrator provided a copy of the facility's policy entitled Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes. A review of the policy revealed:1. As part of the facility Antibiotic Stewardship Program, all clinical infections treated with antibiotics will undergo review by the Infection Preventionist (IP), or designee.2. The IP, or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics (including susceptibility, duration of therapy and culture results and clinical findings do not indicate continued need for the antibiotic)3. At the conclusion of the review, the provider will be notified of the review findings.4. All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The information gathered will include the resident's name and medical record number, unit and room number, date symptoms appeared, name of antibiotic, start and stop date of antibiotic, pathogen identified, site of infection, date of culture, total days of therapy, outcome, and any adverse events.On 11/24/25 at approximately 3:30 PM, concerns were shared with the Director of Nursing, and no further information was provided.

Based on observation and facility document review, the facility staff failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles, to include the expiration date.Findings include:The facility staff failed to ensure medications and COVID-19 test kits were within expiration date for eleven (11) COVID-19 kits in the medication room and three (3) bottles of Lorazepam liquid (an anti-anxiety medication used to treat symptoms of anxiety) with open date on the box or bottle in the medication refrigerator.On 11/24/25, an Inspection of the Medication Room was completed which revealed ten (10) COVID-19 test kits ([NAME] brand) with expiration date 4/2025 and one (1) kit (iHealth brand) with expiration date 4/25/25 in the cabinets.On 11/24/25, an inspection of the Medication Room refrigerator was completed which revealed three (3) bottles of Lorazepam liquid: 1 bottle dispensed 7/2/25 - open, not dated upon opening 1 bottle dispensed 5/23/25 - open, not dated upon opening 1 bottle dispensed 6/11/25 - open, not dated upon openingPer instructions on the box, the medication is to be discarded 90 days upon openingAt 12:20 PM, an interview was conducted with LPN-2 on how a nurse would know when to discard the bottle as the instructions on the box read discard 90 days after opening and she replied, the nurse should date the bottle once opening.At 12:30 PM, an interview with LPN-1 was conducted on how a nurse would know when to discard the bottle as the instructions on the box read discard 90 days after opening and she responded, the nurse is to date the bottle when she opens it.At approximately 1:15 PM, an interview was conducted with the Director of Nursing (ADM-2) on her expectations of following manufacturer's guidelines for expiration of multi-dose vials and she stated, the nurse is to date the bottle upon opening She provided a copy of the facility's policy Medication Labeling and Storage. Page 2: Medication Labeling, 5. Multi dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.The Administrator (ADM-1) provided a copy of the facility's policy #ASCA-HC-000 entitled COVID -19 testing. Page 2 Antigen Tests bullet point #3 Discard tests and tests components that have exceeded the expiration date or show signs of damage or discoloration.On 11/24/25, at the end of day, the Administrator (ADM-1) and Director of Nursing (ADM-2) were made aware of the concerns, and no further information was provided.

Based on observations, staff interviews, record reviews, and facility document reviews, the facility staff failed to maintain an effective infection control program that included a comprehensive surveillance system and effective infection control practices to prevent communicable diseases or infections in the one (1) nursing unit.Findings included: 1. The facility lab tech failed to remove personal protective equipment appropriately upon exiting the resident room, and facility staff failed to follow the facility's policy for the surveillance and monitoring of infection control practices and monitoring of infectious disease trends. On 11/24/25, a female was observed exiting a resident's room wearing a white disposable gown. She was observed walking to the nurse's station, looking at documents on the nurse's desk, and then walking back down the hall while wearing the white disposable gown. An interview was conducted with the Director of Nursing, who was coming down the hall, regarding her expectations for staff when donning/doffing personal protective equipment (PPE). She responded, That was the lab tech; everyone is to remove their gowns and gloves before leaving the room, and never wear personal protective equipment in the hallway. I saw that and spoke to her about removing the gown before leaving the room. On 11/24/25 at approximately 2:10 PM, an interview was conducted with the Lab Tech regarding donning/doffing (putting on and taking off) personal protective equipment. She replied, Yes, you put on the gown and gloves when you enter and take them off before you leave. On 11/24/25 at approximately 2:20 PM, an interview was conducted with LPN-1. The LPN was asked when she dons and doffs personal protective equipment (put on and take off), and she replied, We put on the gown and gloves when we go into a room with isolation and remove them before we leave that room. On 11/24/25 at 3:00 PM, an interview was conducted with C.N.A-2 on when to don and doff personal protective equipment (put on and take off), and according to the C.N.A., Staff are to put on the gown and glove when going into the room before touching the resident and then to remove them before leaving the room. The Administrator provided a copy of the facility's donning and doffing policy for personal protective equipment. Review of the facility's policy Sequence for Donning and Removing Personal Protective Equipment (PPE) revealed: Sequence for Removing Personal Protective Equipment (PPE) states except for respirator, remove PPE at doorway or in anteroom. Remove respirator after leaving patient room and closing the door. 2. On 11/24/25 an interview with the Infection Preventionist (ADM-3) was conducted on the facility's Infection Control Tracking log and according to her the surveillance/tracking was in their electronic medical record system. A request for a copy of the past 3 months of surveillance/tracking logs was made and per the Infection Preventionist (ADM-3) she stated that they were not complete. The Administrator provided a copy of the facility's Infection Prevention and Control Program policy. A review of the policy revealed: Page 1, #4 - The elements of the infection prevention and control program consist of coordination/oversight, policies and procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. Page 2, #7 - Surveillance a. Process surveillance (adherence to infection prevention and control practices) and outcome surveillance (incidence and prevalence of healthcare acquired infections) are used as measures of the Infection Prevention and Control Program (IPCP) effectiveness. Page 2, #7 - Surveillance b. Surveillance tools are used for recognizing the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics, monitoring adherence, to infection prevention and control practices, and detecting unusual pathogens with infection control implications. Page 2, #9 - Data Analysis a Data gathered during surveillance is used to oversee infections and spot trends. Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes #4 All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The information gathered will include: resident name and medical record number, unit and room number, date symptoms appeared, name of antibiotic, start and stop date of antibiotic, pathogen identified, site of infection, date of culture, total days of therapy, outcome and any adverse events. On 11/24/25 at approximately 3:30 PM, the Director of Nursing was made aware of the concerns that the infection control surveillance/tracking logs were not complete per facility policy, and no further information was provided.

Based on observation, staff interview, and review of facility policy, the facility failed to ensure foods stored in the kitchen were labeled, dated when opened, sealed closed, and outdated food disposed. Also, employees failed to wash their hands when entering the kitchen and wear a hair covering. These failures had the potential to affect all 38 residents in the facility who ate food from the kitchen. Findings include: Review of the facility's policy titled, Food Labels, dated October 1997, documented . All prepared and leftover food intended for storage will be covered, labeled, and dated according to posted FDA guidelines and department standard. The day food item is opened or prepared is considered day one. Item is to be placed in proper refrigerator, freezer, or dry storage. 1. On 01/03/22 at 10:00 AM, the following observations were made with and verified by the Food and Beverage Director (FBD). The dry storage room contained one bag of brown rice with a use-by-date of 11/13/21, one bag of white rice with a use-by-date of 10/20/21, one bag of potato chips with a use-by-date of 12/24/21, and one bag of pretzels with a use-by-date of 12/26/21. The dry storage also contained one box of stuffing mix, one box of rice pilaf, dried croutons on a baking sheet, one box of crackers, one bag of white chocolate chips, and strawberry/banana pudding that were opened, not sealed, and had not been labeled with a use by date. The FBD confirmed food items should be discarded when out-of-date, open foods should be labeled with a use by date, and open food items should be sealed. 2. On 01/03/22 at 10:15 AM, the walk-in freezer contained six slices of frozen bread on the floor. The freezer also contained one box of frozen white bread, one box of pumpernickel bread, and one tray of pecan crusted salmon was not covered and open to air. The FBD confirmed foods should be covered in the freezer. 3. On 01/03/22 at 10:25 AM, the walk-in refrigerator contained one tray of sweet potatoes not covered and open to air. The refrigerator also contained a package of Havarti cheese with a use-by-date of 12/11/21 and one package of Feta cheese with a use-by-date of 12/29/21. 4. Observation in the kitchen on 01/03/22 at 10:40 AM with the FBD present revealed two dietary employees walked through the kitchen without hair coverings in place. The FBD confirmed the observation, and the employees were prompted to put on a hat or hair net.

Based on interview, record review, and facility policy review, the facility failed to provide Form CMS- (Centers for Medicaid and Medicare Services) Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to two of three residents (Residents (R) 16 and R22) reviewed for liability notices out of a total sample of 17 residents. The form should have included the type of service provided and the estimated cost to continue receiving the services. The failure to provide the SNFABN prevented the responsible party the ability to make an informed decision related to the cost of continued therapy services. Findings include: On 01/04/22 the facility provided the directions to complete the ABN printed from the Centers for Medicare and Medicaid Services (CMS) website. The directions stated, . Medicare inpatient hospitals and skilled nursing facilities (SNFs) use other approved notices for Part A items and services when notice is required to shift potential financial liability to the beneficiary . 1. Review of the electronic medical record (EMR) Profile tab revealed R16 was admitted to Medicare part A therapy services on 11/15/21. Further review revealed R16's last covered day of Part A therapy services was 12/17/21. The SNFABN was not issued by the Social Worker (SW). R16 had days remaining of Part A Medicare services. 2. Review of the EMR Profile tab revealed R22 was admitted to Medicare part A therapy services on 11/22/21. Further review revealed R22's last covered day of Part A therapy services was 12/10/21. The SNFABN was not able to be located by the SW; R22 had remaining and remained in the facility. During interview on 01/03/22 at 5:15 PM, the SW stated she did not issue R16 the SNFABN form as the resident would begin skilled services once she was released to a weight bearing status. The SW stated she could not locate the SNFABN issued to R22. The SW was asked to provide a copy of the facility policy and procedure for the SNFABN.

Based on observation, record review, interview statements and policy review, the facility failed to ensure that two (Resident (R) 85 and R8) of three residents reviewed for pressure sores received necessary treatment and services to promote healing. R85 had a delay in treating and completing an assessment of a known pressure ulcer upon admission and R8 did not receive a physician ordered treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: Review of the facility's policy titled, Pressure Ulcer Prevention and Management dated June 2021 directed that, Each resident's skin condition is assessed upon admission. The assessment is documented in the clinical record .The resident representative is notified of any new wound or worsening wound and this is documented in the clinical record .Every effort is to be made to complete the skin evaluation within two (2) hours of admission .Pressure ulcers are assessed to location, type, stage, size, shape, depth, size and depth of [MEDICATION(S)] track, surrounding tissue, and drainage (type, color, odor, and amount), wound bed, wound edges, progress toward healing, signs of infection, treatment plan, and related pain Initial status is documented in the medical record .Daily monitoring is to be in place to assess the effectiveness of the plan and to ensure the care plan is followed i.e.: wound status pain, s/s [signs and symptoms] infection or change and the need to notify the physician .Weekly progress will be documented by the nurse to assess to type, location, stage, size, shape, depth size and depth of [MEDICATION(S)] track, surrounding tissue, and drainage (type, color, odor, amount), wound bed, wound edges, progress toward healing, signs of infection, treatment plan, and related pain. 1. Review of R85's Profile located under the Profile tab in the electronic medical record (EMR) revealed R85 was admitted to the facility on [DATE] and discharged on [DATE]. Review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/12/20 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The assessment also documented the resident was always incontinent of urine, frequently incontinent of bowel, and had one Stage 2 pressure ulcer that was present on admission to the facility. Review of the Nursing Admission assessment dated [DATE] located in the Assessments tab in the EMR revealed the resident had sacral pressure ulcer identified, however, there was no further assessment of the sacral pressure ulcer documented. Review of physician Orders in the Orders tab in the EMR revealed there was no skin treatment ordered upon admission. Review of R85's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a nursing Progress Note dated 11/09/20 (four days following admission to the facility) located in the Progress Note tab of the EMR revealed, Wound measures 1.9 x 1 cm. [centimeter] Received orders from . NP [Nurse Practitioner] to dress the wound w/ [with] calcium alginate [dressing used in the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The note did not include documentation of stage, depth, or presence/absence of exudate related to the pressure injury. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan revealed a care plan problem that included interventions and identification of R85's actual impairment to skin integrity was not initiated until 11/23/20. During an interview on 01/05/22 at 12:22 PM, the FNP stated she first saw R85's wound on 11/18/20. She stated she assessed the pressure ulcer as a full thickness wound verses a Stage III and acknowledged that the wound deteriorated over the course of the resident's stay. The FNP stated that the tan, purple color was indicative of deep tissue injury (DTI) within the wound. The FNP acknowledged R85 had a delay in treatment upon admission to the facility. 2. Review of R8's Profile located under the Profile tab of the EMR revealed R8 was admitted to the facility on [DATE]. Review of the Admission MDS with an ARD of 11/04/21 revealed the resident BIMS score 15 out of 15, indicating intact cognition. The assessment also documented R8 had two unstageable pressure ulcers with suspected deep tissue injury. Review of the 11/03/21 FNP Progress Note, located under the Progress Note tab of the EMR revealed the pressure ulcers were described as follows: Left heel eschar [dead tissue] measures 1.5 x 2.5 cm [centimeter] wound edged separated and draining purulent drainage .Right heel eschar measures 3.5 x 3.2 cm. Eschar is stable, no drainage. Review of physician Orders dated 01/02/22 located in the Orders tab of the EMR revealed, Dakins [solution is used to prevent and treat skin and tissue infections that could result from cuts, scrapes and pressure sores -1/4 strength] Solution 0.125 % (Sodium Hypochlorite) Apply to left heel only topically every day shift for wound infection Clean with Dakins, apply hydrogel, cover with dry dressing and Hydrogel Gel (Carbomer Gel Base) Apply to left foot topically every day shift for wound care cleanse L [left] foot with Dakins, apply Hydrogel, cover with dry dressing. During a concurrent observation and interview on 01/05/22 at 2:01 PM, the FNP performed the wound treatments for R8 while the resident was in bed. Prior to starting, the resident stated that the treatments were last done on 01/03/22 when she went to the vascular clinic. The FNP removed a 4 cm x 4 cm methylplex (soft and highly [MEDICATION(S)] antimicrobial foam dressing that absorbs and maintains a moist wound environment) dressing from R8's left heel and acknowledged that the facility did not have that type of dressing. When the FNP visualized a 4 cm x 4 cm methylplex dressing on the R8's right heel, the FNP sighed and acknowledged there is no order for this. The FNP stated the right heel eschar was stable and was supposed to be open to air so it did not accumulate moisture and destabilize saying it would heal itself if it remained intact. The FNP acknowledged that the resident's wound treatment orders were for daily treatments. Review of Treatment Administration Record (TAR) dated 01/04/22 in the orders tab reports of the EMR revealed a nurse signed that the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 01/06/22 at 1:09 PM, RN1 reported that although he signed for the administration of R8's wound treatment on 01/04/22 prior to performing it, he was called away to do something else on the way to the resident's room and forgot to perform the treatment.

Based on observations, interviews, and review of posted staffing information, the facility failed to ensure that staffing information included hours for all types of licensed nursing staff on duty, documented the current census, and was readily available to residents and visitors daily. Findings include: On 01/03/22 at 2:51 PM, observation was made of the posted daily staffing. The daily staffing post included all shifts and coverage hours for Licensed Practical Nurses (LPN), and Certified Nursing Assistants (CNA). It also included the resident census. The posting did not contain coverage hours for Registered Nurses (RNs) or the resident census. Interview with the Interim Director of Nursing (IDON) at the time of observation revealed that he did not know why RNs were not included on the daily staff posting. He stated, an RN was on duty. Observations on 01/04/22 at 9:30 AM, 11:12 AM, 1:34 PM, and 4:05 PM revealed the daily staffing information was not posted. On 01/05/22 at 8:15 AM, the daily staffing information was posted and included RN hours. The resident census was not included. Interview on 01/06/22 at 9:03 AM with the Nurse Consultant revealed the staff posting should be completed daily at the beginning of the shift.

Based on observation, interview, and facility policy review, the facility failed to ensure face coverings were worn by all those who entered the facility to include vendors that made deliveries to the kitchen. On 1/6/22 at 11:45 AM observation of the lunch tray line was conducted with the Registered Dietician (RD) present. An outside bread vendor entered the kitchen without a mask, walked past the tray line and went into the storage room. The RD was asked why the vendor did not have on a mask to which the vendor had no response. The RD asked the vendor to put on a mask and he walked by the tray line and went into an office to obtain a mask. Interview on 1/6/22 at 11:53 AM with the vendor revealed that he always came through the back delivery door to enter the kitchen. He said he had never been asked to wear a mask. During an interview on 1/6/22 at 3:13 PM the Nurse Consultant stated that masks were required by everyone entering the building.

Based on staff interview, record review, facility policy review, and review of guidance from the Centers for Disease Control and Prevention (CDC), the facility failed to offer and administer the pneumococcal vaccination in a manner consistent with CDC recommendations and professional standards. The failure affected three of five residents (Resident (R) 8, R15, and R17) reviewed for immunizations. Findings include: Review of the facility's policy titled, Pneumococcal Vaccine, with a revision date of October 2019, revealed, 1. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated .2. Assessments of pneumococcal vaccination status will be conducted within five (5) working days of the resident's admission if not conducted prior to admission .7. Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. Review of the Centers for Disease Control (CDC), website https://www.cdc.gov/vaccines/vpd/pneumo/hcp/recommendations.html, CDC recommends routine administration of pneumococcal [MEDICATION(S)] vaccine (PPSV23) for all adults [AGE] years or older. In addition, CDC recommends PCV13 based on shared clinical decision-making for adults [AGE] years or older who do not have an immunocompromising condition, [CONDITION(S)], or cochlear implant and have never received a dose of PCV13. Clinicians should consider discussing PCV13 vaccination with these patients to decide if vaccination might be appropriate . For adults [AGE] years or older who do not have an immunocompromising condition, [CONDITION(S)], or cochlear implant and want to receive PCV13 AND PPSV23: Administer 1 dose of PCV13 first, then give 1 dose of PPSV23 at least 1 year later. If the patient already received PPSV23, give the dose of PCV13 at least 1 year after they received the most recent dose of PPSV23. Anyone who received any doses of PPSV23 before age 65 should receive 1 final dose of the vaccine at age 65 or older. Administer this last dose at least 5 years after the prior PPSV23 dose. 1. Review of R17's Profile located under the Profile tab in the electronic medical record (EMR) revealed R17 was over [AGE] years old and was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/24/21, located under the EMR MDS tab, revealed the R17 had severe impaired cognitive skills for daily decision making. Review of R17's active physician Orders, located in the orders tab of the EMR, dated 05/14/20 directed, Pneumococcal and Influenza vaccines per facility policy. Review of the Immunizations under the Immunizations tab in the EMR revealed R17 had historical documentation of receiving [MEDICATION(S)] dose 1 on 02/01/16. There was no other information in the record regarding pneumococcal vaccination, indicating the resident did not receive the Pneumococcal [MEDICATION(S)] Vaccine (PPV23) and [MEDICATION(S)] per the CDC guidelines. 2. Review of R8's Profile located under the Profile tab in the EMR revealed R8 was over [AGE] years old and was admitted to the facility on [DATE]. Review of the Admission MDS with an ARD of 11/04/21 located in the EMR MDS tab revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. Review of R8's active physician Orders, located in the orders tab of the EMR, dated 12/12/21 directed, Pneumococcal and Influenza vaccines per facility policy. Review of the Immunizations under the Immunizations tab in the EMR revealed R15 had received the PPV23 on 02/02/17. There was no further information available regarding R8's pneumococcal vaccination series, indicating the resident did not receive PPV23 and [MEDICATION(S)] per the CDC guidelines. 3. Review of R15's Profile located under the Profile tab in the EMR revealed R15 the resident was over [AGE] years old and was admitted to the facility on [DATE]. Review of the Admission MDS with an ARD of 11/17/21 located in the EMR MDS tab revealed the resident had a BIMS score of eight out of 15, indicating the resident had moderate cognitive impairment. Review of R15's active physician Orders, located in the orders tab of the EMR, dated 11/05/21 directed, Pneumococcal and Influenza vaccines per facility policy. Review of the Update Immunization report provided by the facility's Infection Control Preventionist (ICP) documented R15 had consented to receive the influenza vaccine on 11/09/21. Review of the Immunizations under the Immunizations tab in the EMR revealed no documentation showing the facility provided the influenza vaccine after obtaining consent on 11/09/21. Documentation showed R15 had the PPV23 administered on 11/15/20 but no evidence [MEDICATION(S)] had been discussed and/or offered by the facility. The resident did not receive PPV 23 and [MEDICATION(S)] per the CDC guidelines. During an interview on 01/06/22 at 2:55 PM, the Infection Control Preventionist (ICP) stated it was facility policy for all residents to have the influenza and pneumococcal vaccination offered upon admission. The ICP stated that this was accomplished by the admitting nurse and Unit Manager ensuring that the residents were offered the vaccinations. All residents had a standing order to receive the flu and pneumococcal vaccination in accordance with facility policy and CDC guidelines. She confirmed R8, R15, and R17 did not receive pneumococcal vaccination in accordance with CDC and facility guidelines. She confirmed there was a delay in administering the influenza vaccine to R17 and was unsure as to why he had not received it since consent had been obtained.

Based on interviews, review of the staffing records, and facility policy review, the facility failed to ensure the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for one of the 67 days reviewed (12/26/21). Findings include: Review of the facility policy titled Staffing, dated 04/07, indicated, .facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met. Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services .Staffing includes an RN onsite at least eight consecutive hours a day, seven days a week . Review of the facility-provided Staffing Records, dated 11/01/21 through 01/06/22, revealed the records disclosed the names, titles, and hours worked for each staff person on the unit. Continued review of the staffing records revealed that an RN was present for one hours and not in the facility for eight consecutive hours on 12/26/21. Interview on 01/05/22 at 1:00 PM with the Assistant Administrator of Assisted Living Facility (ALF), stated, an RN had been scheduled for that day, called off and was not replaced. During an interview with the Nurse Consultant on 01/06/22 at 9:03 AM, she stated, the regulations should have been followed for an RN to be on the unit eight hours a day, seven days a week.

Based on observation, interview, record review, and facility policy review, the facility failed to develop and implement a comprehensive person-centered care plan to address functional limited range of motion (ROM) for one (Resident (R) 15) reviewed for mobility/positioning in a total sample of 17 residents. Findings include: Review of the facility's policy titled Care Plans, Comprehensive Person-Centered with a revision date of December 2016 directed A comprehensive, person-centered care plan that includes measurable objectives and timetables resident's physical, to meet the psychosocial and functional needs is developed and implemented for each resident .The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Review of R15's Profile located under the Profile tab in the electronic medical record (EMR) revealed R15 was admitted to the facility on [DATE]. Review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/17/21 revealed the resident had a Brief Interview for Mental Status (BIMS) score of eight out of 15, indicating moderate cognitive impairment. The assessment also documented R15 had a functional limitation in range of motion on an upper extremity on one side. Review of the Care Area Assessment (CAA) triggers from this Admission MDS revealed, ADL Functional/Rehabilitation Potential triggered for inclusion on the resident's care plan. Review of the Care Plan tab in R15's EMR revealed a Care Plan initiated on 11/12/21 and identified as current. The care plan did not address the resident's limited range of motion in his left hand and did not include any interventions related to this functional limitation. During a concurrent observation and resident interview on 01/03/22 at 5:03 PM, R15's left hand was close fisted tightly and R15 stated that his left hand was permanently damaged from a nerve problem. He further explained he could not move his left hand/fingers independently and that no staff at the facility had assessed and/or discussed any treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . When the resident opened his left-hand fingers slightly, there were finger depressions in the palms of his left hand from the pressure. R15 stated that the fist did bother him slightly and he would be willing to wear a splint. During an interview on 01/05/22 at 3:22 PM, the Physical Therapist (PT)1 acknowledged that the resident had received physical therapy treatment; however, he did not receive occupational therapy or any treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] During a concurrent interview and record review on 01/06/22 at 10:30 AM, the MDS Coordinator acknowledged that she documented the resident's functional upper extremity impairment on the Admission MDS with an ARD of 11/17/21 based on review of physician records; however, she did not perform a visual assessment of R15 at that time. At 10:40 AM the MDS Coordinator went to R15's bedside with the surveyor. R15 sat in a chair with his left-hand fingers tightly fisted. When the surveyor asked the resident to again open his left hand/fingers with his right hand, depressions on the palm of his hand were present and the MDS Coordinator said, Oh my! The MDS Coordinator confirmed R15's comprehensive care plan should have encompassed his limited range of motion and included interventions to reduce further decline in range of motion and potential skin breakdown.

Based on medical record review, staff interviews and facility document review the facility staff failed to ensure that individual plan of care summary was sent with 3 of 22 Residents in the survey sample upon transfer to the hospital, Resident #22, #19, and #88. 1. The facility staff failed to ensure that Resident #22's plan of care summary was sent upon transfer to the hospital on [DATE]. 2. Facility staff failed to send Resident #19's care plan summary when discharged to the hospital. 3. The facility staff failed to ensure Resident #88 plan of care summary was sent upon transfer to the hospital on [DATE] and 6/30/18. The findings included: 1. Resident #22 was a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent comprehensive Minimum Data Set (MDS) assessment was a 60 day with an assessment reference date (ARD) of 1/10/19. Resident #22's Brief Interview for Mental Status (BIMS) was a 10 out of a possible 15 which indicated that the resident had moderate cognitive impairment but capable of daily decision making most days. Resident #22's most recent Minimum Data Set (MDS) assessment was a Discharge Assessment with assessment reference date (ARD) of 1/27/19. Resident #22's Comprehensive Care Plan was reviewed and revealed the following facility identified problems for the resident: Nutrition, allergies [REDACTED]. Resident #22's Skilled Assessment Note dated 1/27/19 at 6:45 AM was reviewed and is documented in part, as follows: Patient had combative behaviors this am. She spit out all her medications, she threw her prostat and [MEDICATION NAME] on this nurse. She tried to hit this nurse in the face with a water pitcher. She was crying out Mommy at times. Her daughter was in this shift as this nurse was calling the oncall to inform of behaviors and temperature of 101.2- then recheck was 100.5. Daughter stated she was trying to hit her several times and yelling at her. Clinching teeth. NP (Nurse Practitioner) was requested about maybe extending antibiotic for UTI (urinary tract infection), since today was last day for Keflex. NP only wanted STAT labs as they were done this am anyway and vital signs every 4 hours. Informed daughter of NP orders she stated no, she wanted her mother to be checked in the ER (emergency room ) d/t (due to) increasing behaviors and wanting her urine rechecked as well as medicated for behaviors since she was seeing how combative her mother was. Called 911 after calling NP oncall back and telling them of her daughter request to send out. Called 911 and gate house to inform them of calling, called (Hospital Name) ER at 12:45 P.M. and spoke to RN (Registered Nurse) on duty to give them report. Called at 4:15 pm to check on patient being admitted or not, she was still being evaluated. She left facility via Stretcher at 12:50 PM. The facility Model Transfer Form: Nursing Facility to Emergency Department/Hospital for Resident #22 was reviewed and is documented in part, as follows: Date: 1/27/19 Time of Transfer: 12:50 PM Reason for Transfer/Actions Taken Prior to transfer: Last day of UTI medications, increased behaviors noted-severe combativeness this am-refused all meds. this am. Needs Eval. Verbal Communication to ED (emergency department) staff: (Name) Time: 12:45 PM On 1/28/19 at approximately 1:30 P.M. an interview was conducted with the Director of Nursing regarding Resident #22's hospital transfer on 1/27/19. The Director of Nursing was asked if the facility had send an individual plan of care summary with Resident #22 when she was transferred to the hospital on [DATE]. The Director of Nursing stated, We send the transfer form with them but not the care plan. On 1/28/19 at 7:00 P.M. a pre-exit de-briefing was conducted with the Administrator and the Director of Nursing where the above information was shared. Prior to exit no further information was provided. 2. The facility staff failed to send Resident #19's care plan summary when discharged to the hospital. Resident #19 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The Admission Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 01/10/2019 coded Resident #19 with a BIMS (Brief Interview for Mental Status) score of zero (0) indicating severe cognitive impairment. In addition, the Minimum Data Set coded Resident #19 as requiring extensive assistance with Activities of Daily Living. On 01/28/2019 at approximately 6:10 p.m., an interview was conducted with the Director of Nursing (DON). The DON was asked, When was Resident #19 discharged from the facility? The DON provided copy of a nurse note stating that Resident #19's caretaker signed Resident #19 out of the facility on 12/24/2018 and took him to the hospital. Resident #19 was admitted to the hospital with [REDACTED].? The DON could not produce any evidence that the care plan was sent. The facility does not have a policy regarding issuing a care plan at time of transfer or discharge. On 01/28/2019 at approximately 7:15 p.m., at pre-exit meeting the Administrator and the Director of nursing was informed of the findings. The facility did not present any further information about the findings. 3. The facility staff failed to ensure Resident #88 plan of care summary was sent upon transfer to the hospital on [DATE] and 6/30/18. Resident #88 was originally admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A closed record review was conducted. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/2/18 coded the Resident #88 with 13 out of possible 15 score for Brief Interview for Mental Status (BIMS) indicating minimal cognitive impairment. The clinical note dated 6/23/18 at 6:48 P.M. revealed the following: received resident in bed. a&o x4. Thirty minutes later unable to speak. Out of bed up in wc bedside, refused to eat any dinner. Found with his chin in his chest drooling. BS 0815 230. Manual BP 90/45. This nurse call for assistance getting him into bed. Observed he is cold clammy and still unable to speak. Opened his eyes and looked when his name was spoken. Hand grasps average strength equal. Smile unable to be checked. 95% o2 sat on ra, no sob noted. On call md notified. 911 called. Supervisor notified and family made aware. Manual bp 140/70 lying flat in Trendelenburg. EMT responds and resident unable to verbalize. Transported to (Hospital Name), family made aware. Admission confirmed with hospital and family. Oof (out of facility) to hospital 0900. The clinical note dated 6/30/18 at 4:26 P.M. revealed the following: Called to room approximately 12:45 pm. Patient had just had a small amount of emesis noted right after lunch. This emesis was not observed via this nurse. MDS nurse was in room and Social Worker was bringing a v/s machine. Resident had a b/p of 149/66, heart rate 58, POX 97% on room air. Noted to be diaphoretic, BS was checked and noted 194. Patient was lethargic, but able to be aroused. He then had noted to have a very thick white emesis (large amount). It was projectile. Patient was then in and out of responsiveness. Sternum rub performed several times. Social worker called on-call, no return call. 911 was called, patients' blood pressure was noted to be 87/37, still in and out of consciousness. Left facility at 1:20 pm to (Hospital Name) ER. An interview was conducted with the facility Director of Nursing on 1/28/19 at 1:30 P.M. who stated, We send out a patient summary that includes face sheet, meds, treatments, but not a care plan. The facility policy titled Required Documentation for a Planned Discharge with issued date 4/2002 and revised date 2/2018 was reviewed and is documented in part, as follows: Purpose: To ensure that all residents upon discharge receive the information required for a safe discharge. Procedure: 3. Complete discharge paperwork is resident is going home. If the resident is being transferred to another facility, you are required to complete a transfer summary and provide discharge paperwork. Facility could not provide policy or procedure specific to care plan included with resident transfer. The facility Administrator was informed of the findings during the pre-exit meeting on 1/28/19 at approximately 7:00 P.M. The facility did not have any further questions or present any further information at that time.

Based on observations, staff interviews and facility document review, the facility staff failed to store and label food in accordance with food service safety guidelines. The findings included: On 1/24/19 at approximately 2:30 P.M. on the way to the main kitchen staff members were observed in the Seaside Grill kitchen area with the refrigerator open. The Seaside Grill is the main dining room for the facility residents. The area has a kitchenette with 2 refrigerators. The first refrigerator had 4 doors on it. The Director of Health Care Food Services was also in the kitchenette. The refrigerator was inspected with the following observations noted: 1. 2 full chocolate cheese cakes covered but not labeled with date. 2. Half a chicken salad sandwich on a plate wrapped but not labeled with date. 3. 1 small fruit cup covered but not labeled with date. The Director of Health Care Food Services was asked about the unlabeled items and stated, These came over today from the kitchen and would be served tonight. Surveyor asked if they should be labeled when they were prepared and if so why. She stated, Definitely, to make sure they are safe for the resident's. On 01/24/19 2:45 PM the Initial Kitchen Inspection was completed with the Head Chef. In the Dry Storage Room the following observations were made: 1. One bottle of regular and one bottle of white balsamic vinegar opened but not labeled with date opened or use by date. 2. Half a bag of whole pecans opened but not labeled with date opened or use by date. 3. One Box of Penne Pasta opened but not labeled with date opened or use by date. In the open kitchen area there were 3-25 gallon closed bins noted, 2 bins contained flour and 1 bin contained sugar. There was no label as to when the dry ingredients were added or a use by date on the 3 bins. On 1/24/19 at approximately 3:15 P.M. the Head Chef was asked if the open items in the dry storage room should have been labeled when opened/use by dates and if so why. The Head Chef stated, Yes everything that is opened should be labeled so that we will know when is expires and to protect the resident from any food born illnesses. I agree we have a labeling issue with opened items we will get right on it. The facility policy titled Food Labels revised (MONTH) (YEAR) was reviewed and is documented in part, as follows: POLICY: To establish a system for handling food items while in storage. Procedure: 1. All prepared and leftover food intended for storage will be covered, labeled, and dated according to posted FDA Guidelines and department standard. Dating charts are available in each area. 2. Day item is opened or prepared is considered day one. 3. Item is to placed in proper refrigerator, freezer or dry storage. On 1/28/19 at 7:00 P.M. a pre-exit de-briefing was conducted with the Administrator and the Director of Nursing where the above information was shared. The Administrator was asked what where her expectations regarding the labeling and storage of foods in the facility kitchens. The Administrator stated, I expect that if foods are opened for then to be labeled with the date they were made or opened and the use by date as well. Prior to exit no further information was shared.

Based on medical record review, staff interviews and facility document review the facility staff failed to ensure that a written notice of the Bed-Hold Policy was sent with 3 of 22 Residents in the survey sample upon transfer to the hospital, Resident #22, #19 and #88. 1. The facility staff failed to ensure that Resident #22 received a written notice of the Bed-Hold Policy upon transfer to the hospital on [DATE]. 2. The facility staff failed to provide Resident #19 and/or Resident Representative a written Bed Hold Notice upon transfer to the hospital on [DATE]. 3. The facility staff failed to provide Resident #88 or resident representative with a written notice of the bed hold policy upon transfer to the hospital on [DATE] and 6/30/18. The findings included: 1. Resident #22 was a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED].*Diabetes Mellitus, *[MEDICAL CONDITION], and * [MEDICAL CONDITION]. The most recent comprehensive Minimum Data Set (MDS) assessment was a 60 day with an assessment reference date (ARD) of 1/10/19. Resident #22's Brief Interview for Mental Status (BIMS) was a 10 out of a possible 15 which indicated that the resident was cognitively intact and capable of daily decision making most days. Resident #22's most recent Minimum Data Set (MDS) assessment was a Discharge Assessment with assessment reference date (ARD) of 1/27/19. Resident #22's Skilled Assessment Note dated 1/27/19 at 6:45 AM was reviewed and is documented in part, as follows: Patient had combative behaviors this am. She spit out all her medications, she threw her prostat and [MEDICATION NAME] on this nurse. She tried to hit this nurse in the face with a water pitcher. She was crying out Mommy at times. Her daughter was in this shift as this nurse was calling the oncall to inform of behaviors and temperature of 101.2- then recheck was 100.5. Daughter stated she was trying to hit her several times and yelling at her. Clinching teeth. NP (Nurse Practitioner) was requested about maybe extending antibiotic for UTI (urinary tract infection), since today was last day for Keflex. NP only wanted STAT labs as they were done this am anyway and vital signs every 4 hours. Informed daughter of NP orders she stated no, she wanted her mother to be checked in the ER (emergency room ) d/t (due to) increasing behaviors and wanting her urine rechecked as well as medicated for behaviors since she was seeing how combative her mother was. Called 911 after calling NP oncall back and telling them of her daughter request to send out. Called 911 and gate house to inform them of calling, called (Hospital Name) ER at 12:45 P.M. and spoke to RN (Registered Nurse) on duty to give them report. Called at 4:15 pm to check on patient being admitted or not, she was still being evaluated. She left facility via Stretcher at 12:50 PM. The facility Model Transfer Form: Nursing Facility to Emergency Department/Hospital for Resident #22 was reviewed and is documented in part, as follows: Date: 1/27/19 Time of Transfer: 12:50 PM Reason for Transfer/Actions Taken Prior to transfer: Last day of UTI medications, increased behaviors noted-severe combativeness this am-refused all meds. this am. Needs Eval. Verbal Communication to ED (emergency department) staff: (Name) Time: 12:45 PM On 1/28/19 at approximately 1:30 P.M. an interview was conducted with the Admissions Coordinator regarding the Resident #22's hospital transfer on 1/27/19. The Admissions Coordinator was asked if the facility had sent a written notice of the Bed-Hold Policy upon Resident #22's transfer to the hospital on [DATE]. The Admissions Coordinator stated, When a resident is sent out, we get a computer alert and find out they are admitted to the hospital. I call the family the next day to ask them if they want to hold the bed. If they want to hold the bed I get them to come in and sign the bed-hold agreement. No bed-hold goes out when resident leaves. On 1/28/19 at 7:00 P.M. a pre-exit de-briefing was conducted with the Administrator and the Director of Nursing where the above information was shared. The Administrator was asked if she was aware of the new regulation for bed-holds upon transfer to out of the facility. The Administrator stated, Yes, I must have misinterpreted the new bed-hold policy. Prior to exit no further information was provided. 2. The facility staff failed to provide Resident #19 and/or Resident Representative a written Bed Hold Notice upon transfer to the hospital on [DATE]. Resident #19 was discharged to the hospital on [DATE]. Resident #19 was re-admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #19's Admission Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 01/10/2019 coded Resident #19 with a BIMS (Brief Interview for Mental Status) score of zero (0) indicating severe cognitive impairment. In addition, the Minimum Data Set coded Resident #19 as requiring extensive assistance with Activities of Daily Living. An interview was held with the Administrator and Director of Nursing by another surveyor on 01/28/19 at 1:30 p.m. They stated, When a resident is sent out, we get a computer alert and find out they are admitted to the hospital. I call the family the next day to ask them if they want to hold the bed. If they want to hold the bed I get them to come in and sign the bed hold agreement. (are bed holds given out when resident leaves facility) No. No bed hold goes out when resident leaves. On 01/28/2019 at approximately 6:00 p.m., an interview was conducted with the Administrator. The Administrator was asked, Was a Bed Hold Notice issued to the resident or the resident's representative? The Administrator stated, The Admissions Coordinator called the resident's representative but did not issue the notice. The Administrator was unable to provide any evidence that Bed Hold Notice was provided. On 01/28/2019 at approximately 7:15 p.m., at the pre-exit meeting the Administrator and the Director of Nursing was informed of the findings. The facility did not present any further information about the findings. The facility staff failed to issue a bed hold notice at time of transfer and discharge to the local hospital for three residents. 3. The facility staff failed to provide Resident #88 or resident representative with a written notice of the bed hold policy upon transfer to the hospital on [DATE] and 6/30/18. Resident #88 was originally admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The current Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/2/18 coded the Resident #88 with 13 out of possible 15 score for Brief Interview for Mental Status (BIMS) indicating minimal cognitive impairment. The clinical note dated 6/23/18 at 6:48 P.M. included the following: received resident in bed. a&o x4. Thirty minutes later unable to speak. Out of bed up in wc bedside, refused to eat any dinner. Found with his chin in his chest drooling. BS 0815 230. Manual BP 90/45. This nurse call for assistance getting him into bed. Observed he is cold clammy and still unable to speak. Opened his eyes and looked when his name was spoken. Hand grasps average strength equal. Smile unable to be checked. 95% o2 sat on ra, no sob noted. On call md notified. 911 called. Supervisor notified and family made aware. Manual bp 140/70 lying flat in Trendelenburg. EMT responds and resident unable to verbalize. Transported to (Hospital Name), family made aware. Admission confirmed with hospital and family. Oof (out of facility) to hospital 0900. The clinical note dated 6/30/18 at 4:26 P.M. revealed the following: Called to room approximately 12:45 pm. Patient had just had a small amount of emesis noted right after lunch. This emesis was not observed via this nurse. MDS nurse was in room and Social Worker was bringing a v/s machine. Resident had a b/p of 149/66, heart rate 58, POX 97% on room air. Noted to be diaphoretic, BS was checked and noted 194. Patient was lethargic, but able to be aroused. He then had noted to have a very thick white emesis (large amount). It was projectile. Patient was then in and out of responsiveness. Sternum rub performed several times. Social worker called on-call, no return call. 911 was called, patients' blood pressure was noted to be 87/37, still in and out of consciousness. Left facility at 1:20 pm to (Hospital Name) ER. An interview was conducted with the facility Admission Coordinator on 1/28/19 at 1:30 P.M. who stated, When a resident is sent out, we get a computer alert and find out they are admitted to the hospital. I call the family the next day to ask them if they want to hold the bed. If they want to hold the bed I get them to come in and sign the bed hold agreement. When asked are bed hold notifications provided when resident leaves the facility the Admission Coordinator stated, No. No bed hold goes out when resident leaves. The facility policy titled Notice of Bed Hold effective date 12/15/11 was reviewed and is documented in part, as follows: General Information. When transferring nursing facility residents to the hospital, it is important that the resident and their family or legal representative receive timely notification of the facility's bed hold practices while the resident is in the hospital. The facility Administrator was informed of the findings during the pre-exit meeting on 1/28/19 at approximately 7:00 P.M. The facility did not have any further questions or present any further information at that time.

Based on observation, staff interview, facility documentation review, and in the course of a complaint investigation, the facility staff failed to provide reasonable care for the protection of residents' property from loss for 1 of 22 residents (Resident #88) in the survey sample. The facility staff disposed of Resident #88's cards that had sentimental value. The findings included: Resident #88 was originally admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The current Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/2/18 coded Resident #88 with 13 out of possible 15 score for Brief Interview for Mental Status (BIMS) which indicated no cognitive impairment. Based on a complaint investigation, the complainant alleged facility staff threw away Resident #88's most sentimental valuables when he did not return to the facility. An interview was conducted on 1/28/19 at approximately 1:30 P.M. with the facility administration who stated, Yea, I believe housekeeping went in to clean the room and threw out some cards that were in a drawer. I believe it was a very special card to him. The facility policy titled Resident's Personal Belongings effective date 12/24/17 and revised 7/13/18 was reviewed and is documented in part, as follows: Procedure: 1. Upon discharge, if the family has not picked up the belongings, all resident's item will be packed up neatly by housekeeping staff and placed in the office. All residents' items include, but are not limited to notes, papers, tissues, care items, toiletries, cards, clothing, electronics, and any items that do not belong to the facility. The facility Administrator was informed of the findings during the pre-exit meeting on 1/28/19 at approximately 7:00 P.M. The facility did not have any further questions or present any further information at that time. Complaint Deficiency.

Based on staff interview, facility documentation review, and in the course of a complaint investigation, the facility staff failed to provide appropriate indwelling Foley catheter care for 1 of 22 residents (Resident #88) in the survey sample. 1. The facility staff failed to provide appropriate indwelling Foley catheter care for Resident #88 daily for 5 days in (MONTH) (YEAR). The findings included: Resident #88 was originally admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #88 no longer resided in the facility. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/2/18 coded Resident #88 with 13 out of possible 15 score for Brief Interview for Mental Status (BIMS) indicating minimal cognitive impairment. Based on a complaint, the complainant alleged facility staff did not provide catheter hygiene. The review of resident's Physician order [REDACTED]. A review of the resident's Treatment Administration Record (TAR) Assist report dated 6/6/18 through 6/23/18 revealed no daily catheter care was provided on 6/10/18, 6/11/18, 6/16/18, 6/17/18, and 6/20/18. An interview was conducted on 1/28/19 at approximately 1:30 P.M. with the facility administration who stated, It looks like the resident did not get catheter care for 5 different days while he was here in our facility. The expectation is Foleys are cleaned and cared for daily. The facility policy titled Catheter Care, Urinary with issue date 2/2018 was reviewed and is documented in part, as follows: Purpose: The purpose of this procedure is to prevent infection of the resident's urinary tract. The facility Administrator was informed of the findings during the pre-exit meeting on 1/28/19 at approximately 7:00 P.M. The facility did not have any further questions or present any further information at that time. Complaint Deficiency.

Based on the observation of 2 medication carts and 1 medication room; the facility staff failed to dispose of medications on a discharged Resident # 191. The facility staff failed to dispose of an expired controlled medication ([MEDICATION NAME]) and unidentified medications for Resident #191. The findings include: Resident # 191 was admitted to the facility [DATE] from an acute care facility with [DIAGNOSES REDACTED]. Resident # 191 Admission assessment with an assessment reference date (ARD) of [DATE] coded the resident as being able to complete the Brief Interview of Mental Status (BIMS). On [DATE] at approximately 11:27 AM an inspection was being conducted in the medication room. There was a locked box located on the wall in the medication room, consisting of two locks. Licensed Practical Nurse # 4 was asked what was inside of the box and she stated that she didn't know but thought it might be empty. She then stated that the Director of Nursing (DON) was the only person with the keys to open it. Registered Nurse # 1 was also asked if she knew what was in the box, she stated that she was new to the facility and didn't know what was in the locked box. A brief interview was conducted with LPN # 2 (Licensed Practical Nurse) on [DATE] at approximately 11:35 AM concerning the locked medication box on the wall in the medication room. She stated that she will get the DON (Director of Nursing) to open the locked box, because she was the only person with access. On [DATE] at approximately 11:45 AM, The DON entered the medication room with the keys to the wall mounted medication box. Once she unlocked the box she removed 2 unopened [MEDICATION NAME] 25 mcg/HR patches with an expiration date of (MONTH) (YEAR). Attached with the [MEDICATION NAME]es was a controlled medication utilization record dated [DATE] with 2 nursing signatures. She also pulled out 2 zip locked bags of loose pills. One bag had 4 round, white pills and the other bag had 36 round, white pills. There were no medication records found. The DON (Director Of Nursing) stated that the locked box was mostly for keeping discharged patient medications, jewelry or other valuable items. She stated that the pills were brought from home by the resident's family and that she just forgot to waste the pills. On [DATE] at approximately 11:00 AM, the DON stated that she and LPN # 1, had destroyed the expired [MEDICATION NAME]es and two zip locked bags of pills that were brought in by the resident's family. She presented the Controlled Medication Utilization Record which stated that the above medications were destroyed on [DATE] at 12 noon. A brief interview was held with License Practical Nurse # 3 on [DATE] at approximately 3:35 PM. She was asked what should be done if a Resident brought in medication from home to the facility. She stated that she would lock up the medication in her medication cart if the Director Of Nursing wasn't available. She also stated that if the medication was a narcotic that she would count it with another license nurse and put the information on the medication inventory sheet. On [DATE] at approximately 3:40 PM an interview was held with License Practical Nurse # 1 concerning her receiving medications brought in from the resident's family on [DATE]. She stated that a nurses aide caring for the resident informed her that Resident #191 had a bag of pills in her room that her family brought in for her. LPN #1 stated that she took the medications from the resident and locked them in her cart until the DON (Director Of Nursing) was available. She was asked if she had documented the incident in her nursing notes but stated that she didn't. She was also asked if she tried to contact the resident's family to pick up the medication, but stated that she never contacted anyone to pick up the medications. On [DATE] at approximately 12:56 PM The facility's policy was provided by the DON and reviewed. Policy: Titled Disposal Of Medications. PURPOSE: To ensure safely, legally and properly dispose of all outdated or discontinued medications. To ensure that controlled substances are not diverted. To comply with state and federal DEA regulations. RESPONSIBLE PERSONNEL: Licensed Nursing. PR[NAME]EDURE: For Narcotics and Liquid Medication Destruction: All narcotics and liquid medications must be hand delivered to the Director Of Nursing for destruction. Two people must witness the crushing of the narcotic and/ or liquid medication and placing it into a sharp's container for destruction. PRIVATE RESIDENTS LTC-If family is requesting for medications not to be disposed of: (1.) If family is requesting for us not to dispose of the medications because the doctor may prescribe again they must pick up within 72 hours of med. Being discontinued. (2.) Until family picks up medication nursing staff must place all discontinued medications into plastic bag labeled D/C meds. With name date and time and person contacted and pick up. (3.) If family does not pick up within 72 hours, medication will be disposed of per current policy. On [DATE] at approximately 12:50 PM a phone call was made to the facility Pharmacist #4 with concerns involving the facility's medication disposal procedures. She stated that she would like to talk in person concerning the matter. A brief interview was held on [DATE] at approximately, 1:26 PM with the facility Pharmacist # 4 and Pharmacist # 5 concerning procedures involving medications brought in to the facility by residents. Pharmacy # 4 stated that the nursing staff should try to send the medications home within the required time frame. The Pharmacist agreed they are not involved in the destruction of narcotics, but the Director of Nursing should destroy the meds. Pharmacist # 5 stated that if the resident brought in other medications such as inhalers, eye drops etc. they would have licensed staff list medications on the count sheet so they would be aware of what the resident is taking. Pharmacist # 4 stated that the medication was placed in a secure double locked box which was important. On [DATE] at approximately 3:00 PM a debriefing was held with the DON (Director Of Nursing) and facility Administrator concerning the medication incident. The DON stated that the nurse gave her the medication because the resident was self-medicating. She said that she should have put the incident in her nursing note, contacted a family member to pick up the medications, and/or destroyed the medication if family member hadn't showed up in 72 hours. The administration had no comment at this time. On [DATE] at approximately 4:36 PM, received policy from facility administrator titled Proper Medication Disposal. Policy: The facility adheres to all federal, state and local regulations regarding, drug destruction when discarding medication and medical waste. Purpose: (1.)To safely, legally and properly dispose of all outdated or unwanted controlled substances. (2.) To ensure that controlled substances are not diverted. (3.) To comply with state and federal DEA regulations. Procedure: If the medication is supplied in a bubble pack or prescription bottle from another pharmacy, you must do the following: Have another staff witness the destruction, document the amount of pills being destroyed, crush all pills and put in sharps container, crush all pills and place in a sharps container to make sure both staff members witness the destruction and sign the medication destruction form. On [DATE] at approximately 7 PM a pre-exit interview was conducted. The Director Of Nursing (DON) and the Administrator were present. The DON stated that she rarely uses the lock box, and that the medications should have been destructed in 72 hours. On [DATE] the facility Administrator handed surveyor a copy of the following: Title 21 of the Code of Federal Regulations (CFR), 21 CFR 1307.21 (Disposal of Unused or Unwanted Medications). 18VAC[DATE]. Disposal of Drugs by Authorized Collectors. She stated this is what the facility follows.

Based observation, clinical record review, staff and resident interviews, facility staff failed to ensure 1 of 12 residents in the survey sample, Resident #,1 maintain the highest practicable well being in the failure to appropriately manage pain prior to a pressure ulcer dressing change. The findings include: Resident #1 was an [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The current MDS (Minimum Data Set) a quarterly completed on 7/08/10 assessed the resident as having long and short term deficits and moderately impaired decision making skills. Resident #1 required extensive assistance with transfers, bed mobility, personal hygiene, toileting and bathing. Under section M. Skin Conditions the resident was assessed as having a stage III pressure ulcer (a full thickness of skin is lost, exposing the subcutaneous tissues-presents as a deep crater with or without undermining adjacent tissue). Resident #1 was experiencing moderate daily joint pain. Review of the comprehensive care plan indicated the resident was receiving hospice services effective 4/16/10 and one of the approaches for comfort care measures was to kept the Resident #1 comfortable. Review of the care plan evidenced the resident was at risk for pain related to a right femur fracture dated 12/09, pressure sores and [MEDICAL CONDITION], the goal was that the resident would demonstrate adequate relief of pain in 30-45 minutes of intervention. Interventions listed were to assess pain via scale of 1-10, administer medications as ordered, observe for effectiveness of pain regime frequently, observe for non verbal expression of pain ie: facial grimace, restless behavior, moaning or groaning, crying, diaphoresis (sweating), anger. Review of the care plan dated 12/29/09 and reviewed 7/8/10 evidenced the resident has impaired skin integrity evidenced by a pressure ulcer to the right heel and was at risk for further skin breakdown, infection and pain. The goal was that the resident will have no increase in staging through the next review in 90 days with approaches/ interventions to include assessing area daily provide wound care as ordered and administer medications as ordered. Review of the nurse practitioners (NP) notes dated 6/24/10 documented that the resident's right heel ulcer was noted to have a foul odor and the resident continued with severe pain with any palp (palpitation)/ movement. The NP describes the ulcer as chronic and non healing. The resident had a failed arterial reconstruction 3/10 with small peroneal artery function to right foot but other structure non-patent. The ulcer treatment was changed to Dakins solution 25% wet to dry twice a day. Keep pressure off heel. The resident was receiving mechanical debridement using a wet to dry method. Wet to dry dressings adhere to devitalized tissue. Once the dressings are dry-usually within 4 to 6 hours- they can be removed and the devitalized tissue will be removed along with them. According to the U.S Department of Health and Human Services Clinical Practice Guidelines Number 15 treatment of [REDACTED]. According to the Best Practice Evidenced Based Practice Information Sheet for Health Professionals Volume 1, Issue 2, 1997 titled Pressure Sores part II- Management of Pressure Related Tissue Damage reads, Pain relief should always have a high priority. In the case of patients with pressure sores dressing types and frequency, support surfaces and repositioning can both contribute to and provide relief from pain. According to the National Pressure Ulcer Advisory Panel (NPUAP) reads, "Avoid use of gauze dressings for clean, open pressure ulcers because they are labor-intensive to use, cause pain when removed if dry, and lead to desiccation of viable tissue if they dry". Review of the pressure ulcer record identified the resident was admitted to the facility on [DATE] with a stage I pressure ulcer to the right heel measuring 5cm x 3 cm. The current measurements dated 7/08/10 identified the pressure ulcer was a stage III measuring 4cm x 2cm with 0.2 cm depth with foul odor and yellow wound base. Review of the physicians progress notes dated 7/13/10 documented a follow up for pain management that the resident complained of mild chronic right hip and leg pain. The physician recommended continuing with the current medication pain regimen of [MEDICATION NAME] 10/325 mg (milligrams) every 8AM, 12PM, and every 4 hours as needed for pain. Review of the physician order [REDACTED]. According to the Specialized Long-Term Care Nursing Drug Handbook 2008 page 464 states [MEDICATION NAME] is a narcotic [MEDICATION NAME]. The onset of action when taken orally occurs 10-20 minutes following administration. On 7/14/10 at 11:28AM, nurse #2 was observed removing 1 [MEDICATION NAME] 10/325mg tablet (scheduled at 12PM) to administer to Resident #1, the nurse stated to the surveyor, "You have an hour window and I am getting ready to do the dressing". The nurse entered Resident #1's room and stated to the resident, "I want to give you this pill for your foot so you're not hurting " . After administering the [MEDICATION NAME] nurse #2 did not wait 20-30 minutes for the [MEDICATION NAME] onset of action to take place but instead immediately prepared to change Resident #1's right heel pressure ulcer dressing. She went into the resident ' s bathroom, washed her hands came out, donned gloves and began cutting the kerlix dressing off the right heel, upon lifting the resident leg to remove the old dressing the resident was observed grimacing, she then placed the exposed heel and ulcer directly on the clean towel barrier and again the resident was observed to be grimacing. The nurse removed her gloves and placed the glove box near the residents shoulders. The nurse opened a sterile 4x4 package and poured Dakins solution into the package and placed it near the foot of the bed on the barrier towel, she removed her gloves and washed her hands, returned to the bedside, donned on gloves, raised the residents right leg. The resident was observed grimacing when the leg was raised. The nurse grabbed the Dakins soaked 4x4 and began cleaning the ulcer. At this moment Resident #1 stated, "Whoa, that's enough of that!", the resident's body tensed up and she was grimacing, the nurse responded saying, "Yeah, I know". The nurse continued with the dressing change without assessing the resident's pain level, placed the leg back down, removed her gloves, donned on new gloves and opened another sterile 4x4 gauze, poured Dakins solution on it. The nurse grabbed the resident's leg raising it up and placed the soaked Dakins 4x4 directly on the ulcer. The resident moaned "Ow!" at this time and the nurse responded, "I' m sorry", each time the nurse touched the wound or applied pressure to the resident ' s right leg during the dressing change the resident responded in a grimace and tensed up. The nurse continued with the dressing placing dry 4x4 dressings on top of the soaked 4x4 and began wrapping the heel with Kerlix. She then placed a piece of tape on the dressing, took out a pen and dated the dressing. The nurse left the room to obtain a clean net dressing, the residents pain level was assessed by the surveyor. The resident was asked when or if she had pain and the resident responded that she had "pain when working on it (indicating during dressing changes). The resident was asked to rate her pain at this time from 1-10 and replied "1" when asked if she normally has pain she stated, "I don't have any-that much- unless they're working on it" referring to the pressure ulcer. The nurse returned to the bedside and it was noted that the resident had two skin tears to the right calf area by the surveyor that had not been previously identified by the facility. The nurse assessed these two skin tears, left the room and returned with more dressing supplies. She treated the skin tears and during this treatment the resident was observed stating, "Ow! Ow!" several times. The dressing change observation was completed at 12:05PM, indicating the resident received treatment to include the pressure ulcer dressing change and two skin tear dressings which took approximately 37 minutes to complete. As mentioned above, the onset action of the [MEDICATION NAME] takes approximately 10 to 20 minutes. On 7/15/10 at 10:25AM, nurse #2 was interviewed and she stated that this dressing change was the first time she had changed it herself. When asked about the resident's pain, grimacing and tensing up during the dressing change she stated, "She does that, when you touch her leg period, she'll complain of pain, no matter what you do ...I know that no matter how you touch (resident's name) she is hurting ...my concern at that time was to get the treatment done ...had I noticed there was a difference in her reaction I would have stopped and waited". The nurse was asked how long it takes until [MEDICATION NAME] is effective after administering it she stated, "20 to 30 minutes". On 7/16/10 at 1:10PM, the registered nurse hospice case manager for Resident #1 was interviewed. She stated she had not personally done the residents right heel pressure ulcer treatment since the physician changed the order to Dakin's wet to dry (the order was changed on 6/24/10. She stated that the when she did the dressing change that the resident did tell her it "hurt" and would "wince" when she cleansed the wound stating "that is expected", when asked if she had administered the resident any pain medication prior to doing the dressing change she stated, "No, hospice is not allowed to administer medications to the resident's", when asked if she had notified the nursing staff that she was going to do the dressing change to allow them time to administer any pain medication prior to doing the dressing change she stated, "No". She continued to say that would be a "good idea to do, Dakin's [MEDICAL CONDITION] probably hurts her (the resident) more". Review of the hospice nurses notes dated 7/08/10 documented that the during the right heel dressing change the resident was "guarded" and on 7/13/10 documented that the resident had no objective pain or distress until touched, "she becomes very guarded and agitated upon wound care ( right heel pressure ulcer)". Review of the MAR indicated [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. C.N.A #3 was interviewed on 7/16/10 at 2:16PM; she stated she had been providing direct care for Resident #1 for approximately one year. The C.N.A was questioned about the resident's cognition and stated the resident was alert and orientated today to make her needs be known. She was asked about the resident's pain and stated, "she's been hollering since she's been here (the resident)". She stated the resident complains of pain to the right leg, knee and heel when touched. When asked if she believes the resident is in pain she stated, "I believe she is in pain". The facility staff failed to ensure Resident #1's pain was managed effectively during a pressure ulcer mechanical debridement dressing change.

Based on observation, resident interview, staff interview and clinical record review, facility staff failed to provide the care and services to promote healing of pressure ulcers for 1 of 14 residents (Resident #9) in the survey sample. a.) The facility staff failed to define and implement interventions consistent with Resident #9's needs to promote healing of a suspected deep tissue injury surrounded by a stage I pressure ulcer. b.) The facility staff failed to identify and implement interventions for a stage II pressure ulcer of the right heel for Resident #9. The findings include: a.) Resident #9 was a [AGE] year old admitted to the facility on [DATE] following hospitalization after falling at home and fracturing the left ankle requiring surgical intervention, the resident was admitted to the facility for short term skilled services with [DIAGNOSES REDACTED]. The admission MDS (Minimum Data Set) completed on 5/28/10 assessed Resident #9 as having intact long and short term memory with independent daily decision making skills. Resident #9 required extensive assistance with bed mobility, transfers, dressing and toileting. The resident was usually continent of bowel and occasionally incontinent of bladder. Review of skin conditions listed the resident as having one stage I pressure ulcer and desensitized skin to pain or pressure, the resident was receiving ulcer care. Review of the Braden Scale- For Predicting Pressure Sore Risk, completed on 5/18/10, scored the resident as a 19 indicating the resident was low risk for developing pressure ulcers (A total score of 12 or less represents high risk.). Review of the hospital discharge summary indicated a wound nurse consult was requested for skin care recommendations of the resident's left heel with the following findings noted on the morning of 5/18/10; (The resident was discharged from the hospital to the facility on [DATE].) 1. Left heel small suspected deep tissue injury surrounded by stage I. Suspected deep tissue injury measures 1cm X 0.5 cm and stage I measures 2cm x 2cm. Review of the nursing admission assessment, dated 5/18/10, noted marked on a diagram of a body that the resident had a pressure ulcer to the left heel but failed to identify the stage, the right heel was unmarked. The pressure ulcer record, dated 5/19/10, assessed the left heel pressure ulcer as a stage I measuring at 1 cm x 1.5cm bluish in color. Review of the comprehensive care plan, dated 5/25/10, identified as a problem that Resident #9 was at risk for skin breakdown related to: deconditioning, decreased bed mobility, incontinence of bowel and bladder, chair fast status, and ankle fracture. No care plan developed to address the current suspected deep tissue injury or stage I pressure ulcer to the right heel to include interventions or approaches to promote healing, monitoring or assessment of this pressure ulcer. The care plan did not address the use of a soft splint to the left lower extremity. Physician orders, dated 5/18/10, indicated the resident was to be non-weight bearing on the lower left extremity during range of motion, activities of daily living, gait training and transfers, and that the left lower extremity splint was to be kept clean and dry. Review of the MAR (medication administration sheet) dated May 2010 evidenced an entry to keep heels floated off mattress with either waffle boot or one pillow under each leg. There were no nurses initials during the month of May to indicate this was being done during all shifts. Review of the daily skilled nursing notes failed to evidence Resident #9's heels were floated from 5/19/10 through 5/28/10. During that time, on 5/26/10, the left heel pressure ulcer deteriorated to the next stage, increased in size and was described as a stage II measuring 3cm x 3.8cm. On 5/28/10 the day and evening nurses logged on the front of the skilled nursing notes that the resident's heels were floated. On 5/30/10 at 12:00PM, the nurse documented the resident's left lower extremity was elevated. There was no documented evidence the resident's heels were being floated every shift every day. On 5/28/10 the registered dietician recommended that Prostat 30ml be administered three times a day and vitamin c 500mg be given once a day to promote wound healing of the left heel pressure ulcer. 5/31/10 at 2:00PM, the nurse documented that a message was left for the MD for a treatment change for the residents left heel due to "blister worsening" and documented the left heel was elevated on day shift. 6/03/10, the pressure ulcer record showed the left heel pressure ulcer was a stage II measuring 3cm x 2.9cm purplish/ brown intact blister. 6/17/10, the pressure ulcer record indicated the left heel pressure ulcer was unstageable measuring 3cm x 3.2cm. Review of the pressure ulcer record, dated 7/01/10, indicated the left heel pressure ulcer was healed. On 7/16/10 at approximately 10AM, the RN unit manager was interviewed and stated that the MDS coordinator was responsible for the development and revision of care plans. The MDS coordinator was interviewed and stated that she was out on sick leave during the time of Resident #9's initial admission MDS assessment and care planning. She stated that the nurse who took over her role should have care planned the triggered RAP's pressure ulcer problem #16 as an actual pressure ulcer to include interventions. b.) As mentioned above, Resident #9 had a wound nurse consult on the morning of 5/18/10 (the day of discharge from the hospital and admission to the facility) who identified and assessed the resident as having a right heel stage II pressure ulcer (intact blister) measure 2.5cm X 1cm. The facilities nursing admission assessment dated [DATE] failed to identify the stage II intact blister to the resident ' s right heel, and instead documented, "No PA (pressure area) on (r) (right) heel". Two weeks later on 6/01/10 the nurse documented, "blister developing to (R) heel-mess. (message) left for (name of MD)". On 6/03/10, the right heel stage II pressure ulcer was assessed as measuring 2.5cm x 3cm identified as a purplish/ brown intact blister. On 6/10/10, the pressure ulcer record identified the right heel pressure ulcer as unstageable measuring 1.2cm x 2.3 cm. On 6/25/10, the pressure ulcer record identified the right heel pressure ulcer as healed. The facility failed to identify and assess accurately that Resident #9 had a possible deep tissue injury surrounded by a stage I pressure ulcer and failed to develop a pressure ulcer care plan to promote the healing of this pressure ulcer. The facility also failed to accurately assess Resident #9 upon admission as having a stage II blister as identified by the hospital wound nurse and failed to develop a plan of care to promote the healing of this pressure ulcer.