Every finding on record at Shea Post Acute Rehabilitation Center

Based on observations, interviews, and a review of facility policy and procedure, the facility failed to ensure all drugs and biologicals were secure and inaccessible to unauthorized staff and residents when a medication cart was left unattended. The sample was 23 residents, and the universe was 109 residents. The deficient practice could result in unauthorized persons having unrestricted access to medications and medical supplies. Findings include:An observation was conducted on August 6, 2026 at 2:10 p.m. in hallway A. Medication cart A1 was observed to be unlocked when Registered Nurse (RN/staff #50) walked away from the medication cart and down the hallway connecting hallway A and hallway B. The medication cart drawers were observed facing outwards to the hallway, with the backside of the medication cart facing the nurses station half-wall, that was roughly 4 feet tall. The medication cart lock was observed to be unlocked, as was indicated by the lock protruding approximately one inch from the front of the medication cart. Multiple facility staff members were observed sitting at the nurses station behind the half-wall, without a view of the front side of the medication cart, the medication cart locking mechanism, or the medication storage drawers. The RN (Staff #50) came back to the medication cart, retrieved an object from the top of the medication cart and walked away from the medication cart. The medication cart remained unlocked during and after this occurred. During this time one Certified Nursing Assistant, other staff members, and residents, were observed passing by the medication cart in hallway A. At 2:13 p.m. the Assistant Director of Nursing (ADON/Staff #465) was observed walking up to the medication cart and pushed the locking mechanism on the cart to the lock position. The Assistant Director of Nursing (ADON/Staff #465) stated that the medication cart was unlocked and that she locked it at that time. The ADON identified the nurse assigned to the cart as RN/Staff #50 and told the RN that she had left the medication cart unlocked. An interview was conducted on August 6, 2026 at 2:14 p.m. in hallway A with RN (Staff #50) and with the ADON (Staff #465) in attendance. The RN stated that the risk of leaving the medication cart unlocked and unattended was that anyone could go in the medication cart and take medications they aren't supposed to have. During the interview conducted with RN (Staff #50), the ADON (Staff #465) told the RN that the risk of leaving the medication cart unlocked was that anyone could grab medications out of the cart without the nurse being aware. An interview was conducted on August 6, 2026 at 2:47 p.m. with RN (Staff #52), who stated that before walking away from a medication cart nurses must lock the cart by pushing in the metal mechanism where the key goes in. The RN also stated that nurses only have the keys to their own assigned cart and when the shift changes and they do the shift report, the keys are passed to the next shift nurse. The RN further stated the risk of leaving the medication cart unlocked could result in patients removing medications from the medication cart without staff knowing, which could affect the residents health. An interview was conducted on August 7, 2026 at 12:21 p.m. with the Director of Nursing (DON/Staff #410), who stated that the risk of leaving a medication cart unlocked and unattended could result in a resident or family members removing medications without staff knowing. The DON also stated that the metal locking mechanism should be pushed in to be locked, and that lock controls all of the drawers except for the narcotics drawer which required a separate key to unlock. The DON further stated that during new hire orientation training nurses are educated to lock and unlock the medication carts. The DON further stated that she expected all nursing staff to lock medication carts if they notice that the medication cart is not locked. A review of the Skills Checklist- RN & LPN Floor Orientation for RN (Staff #50) revealed training for Card/Med Security that was completed, signed and dated June 2, 2026. A facility policy titled, Medication Access and Storage, E Kit Access, revised June 2026, revealed that only licensed nurses, the consultant pharmacist and those lawfully authorized to administer medications (e.g., medication aides) are allowed access to medications. The facility policy also stated that medication rooms, carts, and medication supplies are locked or attended by persons with authorized access.

Based on observations, staff interviews, and facility policy review, the facility failed to ensure that laundry for one out of five residents (#16) was handled, stored and processed to ensure a safe, clean, comfortable homelike environment. The universe was 98. The deficient practice could result in room odors, lack of available clothing for the resident, a potential infection control issue and psychosocial harm.Findings include:Resident #16 was admitted on [DATE] with diagnosis including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side and right dominant side, abnormalities of gait and mobility, related falls, and need for assistance with personal care.An admission Minimum Data Set (MDS) assessment dated [DATE] revealed a brief interview of mental status (BIMS) score of 15 indicating intact cognition. A further review of the MDS revealed documentation noting that the resident had impaired upper extremity range of motion and that the resident required substantial/ maximal assistance with upper body dressing, was dependent for lower body dressing, (the resident does none of the effort in completing this task). The care plan, initiated June 25, 2026 revealed a focus area noting that the resident was at risk for impaired cognitive function or impaired thought process due to history of cerebrovascular accident (CVA) with interventions including that social services was to provide psychosocial support as needed. An additional focus area noted that the resident had an ADL (activities of daily living) self-performance deficit due to generalized weakness with interventions including to promote dignity and that all procedures/ tasks are to be explained before starting. The care plan also revealed that the resident had a focus area regarding bowel/ bladder incontinence with interventions including that clothing needed to be changed after incontinence episodes and to use of disposable briefs which were to be changed each shift and as needed.An observation was conducted on August 4, 2026 at 10:10 AM in the room of Resident #16. The resident was observed to be sitting in bed wearing a wrinkled, untied hospital gown. To the right of the bed was a laundry hamper that was observed to be overflowing with dirty clothes. A stale, damp, earthy odor was present in the room. The Resident stated that he preferred to be wearing shorts and a t-shirt instead of a hospital gown but that he did not have a choice. The resident stated that he had told multiple certified nursing assistants (CNA's) about the laundry and stated that no one had addressed it. He stated that he did not recall the names of all the CNA's that he had told but did recall one CNA was staff #40. He stated that the laundry had not been done since admission to the facility on June 24, 2026. Another observation was conducted on August 5, 2026 at 9:15 AM. Resident #16 was wearing what appeared to be a the same hospital gown and stated that he still did not have his personal clean clothes to wear, pointing to his laundry hamper/ basket which was still next to the right side of the bed and overflowing with dirty laundry. The stale, damp, earthy odor was still evident.An interview was conducted on August 5, 2026 at 11:26 AM with a CNA (staff #36), who stated that a resident can choose what they would like to wear. The CNA stated that if a resident wanted to wear shorts and a t-shirt, staff would assist the resident if assistance with dressing was needed. The CNA stated that a resident should never be left in a hospital gown if the resident wanted to be dressed. The CNA stated that she was familiar with resident #16, but did not recall any issues regarding his laundry. The CNA stated that the risk for not having clean clothes to be dressed in would include the resident not feeling happy and that it could make them feel depressed.An interview was conducted on August 5, 2026 at 11:39 AM with Licensed Practical Nurse (LPN/ staff #130), who stated that a resident should be assisted with dressing and given the option of what to wear. The LPN stated that if a resident was not afforded that opportunity it could cause a lack of dignity and frustration with staff. The LPN further stated that if she saw that a resident's personal clothing needed to be washed that she would bag and label the clothing, and personally take the clothing to the laundry room. She stated that the risk of dirty clothes piling up in the residents room could result in un-healthy conditions for the residents.An interview was conducted on August 5, 2026 at 1:49 PM with a CNA (staff #6), who stated that CNA's were responsible for removing the resident's soiled clothing from the room, unless family chose to do the laundry. The CNA stated that a resident's personal clothing is labeled and bagged with the resident's name and room number and then taken to the soiled room or directly to the laundry staff. She stated that the turn around time for resident laundry is generally a day or two. She further stated that if laundry is left to pile up in a resident's room the risk could result in infection and/or contamination.An interview was conducted on August 5, 2026 at 2:00 PM with the Infection Preventionist (IP/ Staff #63), who stated that the expectation regarding residents personal laundry included the facility laundering the clothing, unless the family had requested to wash the clothing. The IP stated that staff would label, take the soiled clothes and bag them up. The IP reviewed the resident electronic health record for Resident #16 and stated that she did not find documentation that the family was doing the laundry for Resident #16. An interview was conducted with resident #16 and the IP (staff #63) on August 5, 2026 at approximately 2:03 PM. Resident 16 told the IP that the facility should be doing his laundry. The IP told the resident that she would remove the laundry and have it taken care of. The resident stated that he had heard that before from other staff and it was never taken care of. The IP stated that if the laundry is not done, then the resident will not have anything clean to wear and this will be an infection control issue.Another observation was conducted on August 6, 2026 at 10:00 AM. Resident #16 was observed to be sitting in bed wearing what appeared to be a clean hospital gown. The resident stated that his laundry was taken the previous day (August 5, 2026) by a staff member but his laundered clothes had not been returned yet. The stale, damp, earthy odor was no longer present.An interview was conducted on August 6, 2026 at 10:39 AM with the housekeeping/ laundry supervisor (staff #42) who stated that there are 2 soiled rooms on each hallway where soiled clothing/ linens were deposited for the laundry team to pick up. She stated that her staff would pick up the laundry from the soiled rooms to bring back to the laundry room. She stated that CNA's collect the linens and personal laundry for each resident when they change the resident's sheets, unless there was a sign inside the resident's room that the family will be doing the laundry. She stated that she was not aware that laundry for Resident #16 had pilled up in his laundry basket and was not picked up for laundry.A follow-up interview was conducted on August 6, 2026 at 1:16 PM with the IP (staff #63) who stated that she took the laundry out the resident's room right away. She further stated that the overflowing laundry basket was an infection control issue and if there was urine on the any of the soiled clothing articles in the basket it could potentially cause odors and potential for multi-drug resistant organism (MDRO) build-up inside the room of Resident #16.A telephonic interview was conducted on August 7, 2026 at 10:25 AM with CNA (staff #78), who stated that she usually works on the hall where Resident #16 was residing and that Resident #16 had a preference for wearing shorts and t-shirts, but that she had frequently saw him wearing hospital gowns. She further stated that she assisted the resident with showers on approximately 3 occasions and that she did not recall seeing the overflowing laundry basket in the resident's room. The CNA further stated that if someone preferred to wear shorts and a shirt but was left in a hospital gown that it could impact their dignity. The CNA stated that CNA's are in charge of removing the resident's personal laundry from the room, unless family members are doing the laundry for the resident. She stated that CNA's would bag up the laundry, label the bag and ensure that it is received by the laundry staff. The CNA stated that if laundry was left for a long time, more than a week, in the resident's room, then the resident could feel neglected.An interview was conducted on August 7, 2026 at 11:56 AM with the Administrator (staff #430), who stated that the facility provides laundry services and it is outlined the resident welcome packet. The Administrator stated that staff should honor requests for laundry assistance within a reasonable timeframe and launder personal items unless a notice in the resident's room indicated the family would perform the service. However, there was no evidence of any posting indicating that the family would be doing the resident's laundry. The Administrator further stated that staff should bag laundry and transport it to the laundry room, noting that failure to do so in a timely manner could result in odors.The Administrator stated that expectation for residents who require and have asked for assistance with laundry was that the was that the request would be honored within a reasonable timeframe and that the facility would launder the resident's personal items unless they had specified that the family would be doing their laundry. She stated that if the family was doing the resident's laundry, it would be posted in their room. However, there was no evidence of any posting indicating that the family of resident #16 would be doing his laundry. Staff #430 further stated that her expectation was for staff to bag the laundry and to take it to the laundry room. The administrator stated that the risk of not taking care of the laundry in a timely manner would be odor.The facility policy titled Dignity and Respect, reviewed September 2024, revealed that all residents should be treated with kindness, dignity and respect. The policy further noted that resident's individual preferences regarding such things as menus, clothing, religious activities, friendships, activity programs, and entertainment are elicited and respected by the facility. Additionally, the policy noted that residents will be appropriately dressed in clean clothes arranged comfortably on the persons and well groomed.A review of the facility policy titled Infection Control with a revision date of September 2024 revealed that the elements of the infection prevention and control program consist of coordination/ oversight, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection and employee health and safety. The policy further outlined goals to include to identify and correct problems relating to infection control. Process surveillance within the policy outlined that some of the processes directly related to resident care would include but are not limited to linen management (handling, storage, processing and transport).

Based on clinical record review, facility documentation, policy review and interviews, the facility failed to ensure two residents (#71 and #51) were free from abuse from other residents ( #263 AND #261). The deficient practice could result in residents suffering from psychosocial harm. Findings include: Regarding Resident #51 and #261: - Regarding Resident #51: Resident #51 was admitted to the facility on [DATE] with a diagnosis of schizophrenia, anxiety disorder, cognitive functions, traumatic brain injury and bipolar disorder. A review of the residents current MDS (Minimum Data Set) dated August 29, 2024, revealed a BIMS (Brief Interview of Mental Status) score of 00, which indicates severe cognitive impairment. - Regarding Resident #261: Resident #261 was admitted to the facility on [DATE] with a diagnosis of atrial fibrillation and major depressive disorder. A review of the residents current MDS, dated [DATE], revealed a BIMS score of 14, which indicates no cognitive impairment. A facility reported incident was reported to the state agency claiming a staff member had witnessed an inappropriate interaction between two residents. The report stated that resident #261's hand was on the left thigh, under the shorts of resident #51. An interview was conducted on December 11, 2024 at 11:22 AM with staff member #42. She stated that on Thursday, February 29, 2024 at approximately 12:00 PM she was walking down the hall looking around, walking past the day room where she saw resident #261 with his hand on resident #51's left thigh but it was under resident #51's shorts. She stated she stopped and was shocked at what she saw, and as soon as resident #261 realized staff #42 saw it, he immediately removed his hand from under resident #51's shorts. She stated she separated them and went to the DON (Director of Nursing) and the ED (Executive Director) and told them what she saw. Review of a physician's progress note dated February 29, 2024 at 12:55 PM stated Staff reported that the patient was found resting his hand on another resident's thigh recently. When asked about this, the patient states that he placed his hand on his thigh but did not touch any other areas of the patient's body. Staff made the DON aware who reported this incident. Both the DON and I had a lengthy conversation with the patient regarding inappropriate behaviors to include touching someone on their thigh without consent and the patient understands and states that he will not do this again. The patient appears apologetic for his actions. An interview was conducted on December 12, 2024 at 8:54 AM with Social Services Director (staff #163). She stated that resident #261 said he was only trying to comfort resident #51 because he was tremoring. She stated even though his hand was under his shorts, he claimed he was only trying to comfort him. When she asked why resident #261 was discharged to another facility on March 7, 2024, staff #163 stated that it was a direct result of the incident. Regarding Resident #71 and Resident # 263: - Regarding Resident #71: Resident #71 was admitted to the facility on [DATE] with a diagnosis of rheumatoid arthritis, major depressive disorder, mood disorder, anxiety disorder and cognitive communication disorder. A progress note dated March 13, 2024 stated that resident #71 was involved in an altercation with a male resident on 3/12/2024. The note stated resident #71 accused the male resident of purposely bumping into the back of her right knee with his manual wheelchair after exchanging words. The note further included that resident #71 expressed concern regarding the male residents' actions and has been placed on 72 hour change of condition monitoring. The note stated on March 13, 2024 resident #71 was showing no signs of distress or anxiety and verbalized satisfaction with the outcome following the investigation into the altercation. A review of the most recent MDS dated [DATE] revealed a BIMS score of 11, which indicates moderate cognitive impairment. - Regarding Resident #263: Resident # 263 was admitted to the facility on [DATE] with a diagnosis of aftercare following a surgical amputation, cerebral infarction and aphasia. A review of the most recent MDS dated [DATE] revealed a BIMS score of 14, which indicates no cognitive impairment. Review of documentation for resident #263 revealed he was verbally abusive toward staff, especially female staff. A progress note dated March 6, 2024 for resident #263 stated that When CNA (Certified Nursing Assistant) came back resident was rude and told her she took to long and didn't want her to help. The note included that another CNA tried to assist resident and resident had stated that women didn't know anything and told her to leave. The note stated the CNA stayed outside door of shower room to monitor for safety and when a male CNA came to assist, resident stated, get them bitches out of here. The note stated the male CNA took over assisting resident. Review of progress note dated March 13, 2024 stated that resident was involved in altercation with female resident where the resident #71 accused resident #263 of purposely bumping her in the back of her right knee with his manual wheelchair after exchanging words. The note stated resident #71 expressed concern regarding resident #263's actions. With resident #263's consent, the note stated the facility sought alternate placement for him to support his psychosocial wellbeing as well as to support the psychosocial wellbeing of other residents. Review of the facility's five-day investigation of this incident, the report states It is acknowledged that there may have been an altercation or disagreement between two cognitively capable adults without eyewitnesses. Consequently, educational initiatives will be implemented for both staff and residents to promote appropriate behavior and mutual respect between residents within the facility. The facility's policy, Freedom From Abuse, Neglect, Exploitation, dated April 2019 with the latest revision on September 2024, statesIt is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Residents also have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

Based on review of records, staff interviews and review of policies and procedures, the facility failed to ensure that medications were administered per physician ordered parameters for one resident (#194); and failed to ensure medications were not left at the bedside for one resident (#83). The facility census was 94, and the sample was 19 residents. The deficient practice has the potential for residents not receiving medications as ordered by the physician. Findings include: -Resident #194 was admitted on [DATE] with diagnoses of right arm humerus fracture, muscle weakness, hemiplegia and hemiparesis, and protein-calorie malnutrition. The care plan dated May 24, 2023 included the resident was prescribed with an opioid for acute on chronic pain. Interventions included to administer opioid as prescribed. The pain care plan dated May 24, 2023 revealed the resident had acute/chronic pain related to arthritis and right humerus fracture s/p (status post) GLF (ground level fall). Interventions included pain assessment every shift, administer analgesia medication as per ordered and follow pain scale to medicated as ordered. The NP (nurse practitioner) progress note dated May 24, 2023 revealed the resident was alert and oriented x 4. Assessment included right humeral fracture. Interventions included to manage acute pain. A physician order dated May 24, 2023 included for Lidocaine patch 4% (topical analgesic) to apply to right arm topically one time a day for right arm pain management on 12 hours; off 12 hours and remove per scheduled. The order for Lidocaine patch was transcribed onto the MAR (medication administration record) and was transcribed to be applied at 9:00 a.m. and removed at 8:59 p.m. An observation of a registered nurse (RN/staff #73) and a charge nurse was conducted on May 31, 2023 at 8:03 a.m. The RN entered the resident's (#194) room, removed a lidocaine patch from the resident's right shoulder and applied new lidocaine patch onto the right shoulder. After the RN administered the new lidocaine patch to the resident, an interview was conducted with a registered nurse (RN/staff #73) on May 31, 2023 at 8:07 a.m. The RN stated the lidocaine patch was ordered to be placed on for 12 hours, and removed for 12 hours. Further, the RN stated that she removed the lidocaine night patch and replaced it with the new patch without 12 hours between applications. In an interview with a charge nurse (staff #74) conducted on May 31, 2023 at 8:15 a.m., staff #74 reviewed the physician order for the lidocaine patch and stated that the order was to remove the lidocaine patch after 12 hours; and that, the lidocaine patch should be removed by the night nurse and not in the morning. During the interview, a review of the clinical record was conducted with staff #74 who stated that the documentation in the MAR (medication administration record) revealed that the lidocaine patch was marked as removed by the night nurse on May 30, 2023; however, the patch had not been removed as it was still in place this morning. Staff #74 stated that this did not follow the physician orders and that the facility; and that, they should have looked at the physician order prior to administration of the patch. She stated that the facility policy was to follow physician orders as written; and that, she and the RN (staff #73) did not notice the order was followed until it was brought to their attention after the observation. Staff #74 stated that the new patch that was just placed on the resident's right shoulder should be removed because leaving it on without 12 hours between applications could result in skin breakdown. She also stated that the night nurse should not have documented that the patch was removed if she did not remove it; and that, this was an incorrect documentation, and did not follow the facility process. Further, staff #74 stated that she would notify the NP and would ask for an updated order. -Resident #83 was admitted on [DATE] with diagnoses of muscle weakness, right calcaneus fracture, hyperlipidemia and protein-calorie malnutrition. The order summary report included the following medications: -Miralax (laxative) give 17 gm (gram) by mouth one time a day for bowel care (order date: May 5, 2023); and, -Simethicone (gastrointestinal agent) 80 mg (milligram) give 1 chewable tablet by mouth four times a day for gas (order date: May 2, 2023). During an observation conducted on May 31, 2023 at 7:53 a.m., the nurse placed a clear medicine cup with Miralax and simethicone tablets on resident #83's bedside table, and proceeded to exit the room. The Nurse did not stay to observe the resident taking the medications. In an interview conducted with the DON (staff #41) on June 1, 2023 at 9:33 a.m., the DON stated that it is their policy for the nurse to stay with the resident until all medications are administered. The DON stated that the risk could result in the resident not taking the medications as ordered and the staff not knowing whether medications were taken or not., Review of the facility policy on Administration of Medication revealed that medications should be administered as prescribed by the attending physician. Medications must be administered in accordance with the written orders of the attending physician including following parameter orders. If a medication is withheld, refused, or given other than at the scheduled time, the documentation will be reflected in the clinical record. The person administering medication must remain with the resident until all medication has been swallowed.

Based on observations, review of the clinical record, staff interviews and policy review, the facility failed to ensure the medication error rate was not 5% or greater, by failing to administer medications as ordered to three residents (#88, #194, #83). The medication error rate was 8.11%. The deficient practice could result in further medication errors. Findings include: -Resident #88 Resident #88 was admitted on [DATE] with diagnoses of left patella fracture, right clavicle fracture, anxiety disorder, gastro-esophageal reflux disease, and adjustment disorder with anxiety and depressed mood. A physician order dated May 11, 2023 included for calcium Carbonate-Vitamin D (supplement) tablet 500-200 mg/unit (milligram-unit) Give 1 tablet by mouth one time a day for supplement. During the medication administration observation conducted with a registered nurse (RN/staff #73) on May 31, 2023 at 8:24 a.m., the RN removed a bottle of vitamins from the resident's side table drawer, removed one tablet and placed it in a clear medication cup, then administered the medication to resident #88. Further review of clinical record revealed no evidence of an order for medication self-administration and for medications to be left at the bedside. The clinical record also revealed no evidence of a self-administration assessment for resident #88. An interview was conducted on June 1, 2023 at 8:37 a.m. with a licensed practical nurse (LPN/staff #11) who stated that the expectation was to administer medications following physician orders; and that, medication for self-administration required a physician order and an assessment. The LPN stated residents were not allowed to keep medications at the bedside or in a bedside table; and that, any home medications would be placed in the medication cart. Further, the LPN said that keeping a medication at bedside would not be following the facility policy. A review of the clinical record was conducted with the LPN during the interview. The LPN stated that there was an order for oyster shell vitamin D-3 500/200; however, there was no physician order that medications may be left at bedside nor was there a medication self-administration assessment found in the clinical record. In an interview with resident #88 conducted on June 1, 2023 at 9:08 a.m., the resident stated she received the vitamins when she was at an orthopedic appointment. She stated that she informed a nurse at the facility who asked her if she wanted to keep the medication in her bedside drawer. An interview was conducted on June 1, 2023 at 9:24 a.m. with the Director of Nursing (DON/staff #41) who stated that it was not the facility policy to keep medications at the bedside in a drawer. She stated the risk of leaving medications at the bedside could result in someone else taking the medication. She also stated that the facility policy was to complete an assessment prior to leaving a medication at the bedside; and, this would require a physician order. The DON stated that when a medication is kept at bedside, the drawer needed to be locked; and that, an assessment would be completed on a medication self-assessment form in the clinical record. During the interview, a review of the clinical record was conducted with the DON who stated there is no physician order for medications to be left at bedside, or for medication self-assessment for resident #88. The DON also stated the nurses should have completed the medication self-assessment and received a physician order as soon as they were aware that resident #88 had a medication in the bedside drawer. -Resident #194 was admitted on [DATE] with diagnoses of right arm humerus fracture, muscle weakness, hemiplegia and hemiparesis, and protein-calorie malnutrition. A physician order dated May 24, 2023 included for Lidocaine patch 4% (topical analgesic) to apply to right arm topically one time a day for right arm pain management on 12 hours; off 12 hours and remove per scheduled. The order for Lidocaine patch was transcribed onto the MAR (medication administration record) and was transcribed to be applied at 9:00 a.m. and removed at 8:59 p.m. An observation of a registered nurse (RN/staff #73) and a charge nurse was conducted on May 31, 2023 at 8:03 a.m. The RN entered the resident's (#194) room, removed a lidocaine patch from the resident's right shoulder and applied new lidocaine patch onto the right shoulder. After the RN administered the new lidocaine patch to the resident, an interview was conducted with a registered nurse (RN/staff #73) on May 31, 2023 at 8:07 a.m. The RN stated the lidocaine patch was ordered to be placed on for 12 hours, and removed for 12 hours. Further, the RN stated that she removed the lidocaine night patch and replaced it with the new patch without 12 hours between applications. In an interview with a charge nurse (staff #74) conducted on May 31, 2023 at 8:15 a.m., staff #74 reviewed the physician order for the lidocaine patch and stated that the order was to remove the lidocaine patch after 12 hours; and that, the lidocaine patch should be removed by the night nurse and not in the morning. During the interview, a review of the clinical record was conducted with staff #74 who stated that the documentation in the MAR (medication administration record) revealed that the lidocaine patch was marked as removed by the night nurse on May 30, 2023; however, the patch had not been removed as it was still in place this morning. Staff #74 stated that this did not follow the physician orders and that the facility; and that, they should have looked at the physician order prior to administration of the patch. She stated that the facility policy was to follow physician orders as written; and that, she and the RN (staff #73) did not notice the order was followed until it was brought to their attention after the observation. Staff #74 stated that the new patch that was just placed on the resident's right shoulder should be removed because leaving it on without 12 hours between applications could result in skin breakdown. She also stated that the night nurse should not have documented that the patch was removed if she did not remove it; and that, this was an incorrect documentation, and did not follow the facility process. Further, staff #74 stated that she would notify the NP and would ask for an updated order. -Resident #83 Resident #83 was admitted on [DATE] with diagnoses of muscle weakness, right calcaneus fracture, hyperlipidemia and protein-calorie malnutrition. The order summary report included the following medications: -Miralax (laxative) give 17 gm (gram) by mouth one time a day for bowel care (order date: May 5, 2023); and, -Simethicone (gastrointestinal agent) 80 mg (milligram) give 1 chewable tablet by mouth four times a day for gas (order date: May 2, 2023). During an observation conducted on May 31, 2023 at 7:53 a.m., the nurse placed a clear medicine cup with Miralax and simethicone tablets on resident #83's bedside table, and proceeded to exit the room. The Nurse did not stay to observe the resident taking the medications. In an interview conducted with the DON (staff #41) on June 1, 2023 at 9:33 a.m., the DON stated that it is their policy for the nurse to stay with the resident until all medications are administered. The DON stated that the risk could result in the resident not taking the medications as ordered and the staff not knowing whether medications were taken or not. Review of the facility policy titled, Administration of Medication, revealed that medications should be administered as prescribed by the attending physician. Medications must be administered in accordance with the written orders of the attending physician including following parameter orders. If a medication is withheld, refused, or given other than at the scheduled time, the documentation will be reflected in the clinical record. Review of the policy titled, Medication Administration Oral, revealed the person administering medication must remain with the resident until all medication has been swallowed. Review of the policy titled, Self-Administration of Medications, revealed that if a resident desire to participate in self-administration, the interdisciplinary team will assess and periodically re-evaluate the resident based on change in the resident's status. If the resident is a candidate for self-administration of medications, this will be indicated in the chart. Storage and location of drug administration (e.g., resident's room) will comply with state and federal requirements for medication storage. Review of the policy titled, Medication Access and Storage, revealed it is the policy to store all drugs in locked compartments under proper temperature controls. The medication supply is accessible only to licensed nursing personnel, or staff members lawfully authorized to administer medications. Medications intended for internal use are stored in a medication cart or other designated area. Should a resident's medications be kept at bedside, it shall be placed in a locked container. No medications shall be kept at bedside without an assessment or physician's order.

Based on observations, clinical record review, staff interviews, and policy and procedure, the facility failed to provide a consistent program of activities that met the interests and supported the well-being for one resident (#64). The census was 94, and the sample was 19. The deficient practice could impact the psychosocial and physical well-being of residents. Findings include: Resident #64 was admitted on [DATE] with diagnoses of fracture of first lumbar, dysphagia, and dementia. The initial admission record dated May 17, 2023 included resident was alert and oriented to place and person, was able to follow simple commands, was able to make self understood and was able to understand others. Per the documentation, preferred language spoken was Chinese. The activity admission evaluation dated May 17, 2023 revealed the resident does not speak English and the family had to translate majority of questions. Per the documentation, resident will be provided with an easy board to translate something she may need or want. The documentation included the resident had the following current activity interests: watching televsision, talking and conversing. The initial care plan dated May 18, 2023 revealed no focus, goal, or interventions that addressed the resident's primary language of Chinese or risk for communication problems related to language barrier, or activity preferences. Review of a social services note dated May 17, 2023, revealed resident has verbalized the need of an interpreter to communicate with a doctor or healthcare staff yes, Mandarin. The note revealed no evidence that a translator was used. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the Brief Interview for Mental Status (BIMS) score of 0 which indicated severe cognitive impairment. Per the assessment the resident required extensive assistance with all ADL's (activity of daily living); and the following daily preferences were marked as very important to the resident: family or a close friend involved in discussion about care and doing favorite activities. The following activity preferences were marked as somewhat important for the resident: choosing bedtime, listening to music, keeping up with the news, doing things with groups of people, going outside to get fresh air when the weather is good and paticipating in religious services or practices. The clinical record revealed no documentation of any activities provided for resident #64. An initial observation of resident #64 was conducted on May 30, 2023 at 11:09 a.m., resident lying in bed, was not able to respond to interview questions. The resident's roommate stated that staff have difficulty communicating with resident #64, they point at things on the bedside table. The television was off, and no radio or other self-directed activities were observed in the resident's room. An interview was conducted with the resident's daughter on May 30, 2023 at approximately 12:00 p.m., who stated that her mother does not speak English, and her communication is not good due to dementia. She also stated that she has brought this to the attention of staff, and did bring in cue cards, but she has not seen them lately. She also stated that when staff do use the translation phone line the translation is not 100% correct, and her mother cannot understand. The resident's daughter stated that the translator phone line is not convenient for staff to use. She further stated that her mother may not be able to do activities due to the communication barriers. An observation was conducted on June 01, 2023 at 11:44 a.m., resident #64 was observed in her room lying in bed, with no television (TV) or music playing, newspapers written in Mandarin were observed lying on the resident's dresser. Another observation was conducted on June 01, 2023 at 11:53 a.m., the resident was lying in bed, a lunch tray was on the bed tray in front of resident, who was not eating. There was no TV or music playing in the resident's room at this time. In an interview conducted with the Director of Activities (staff #28) on June 1, 2023 at 12:45 p.m., the activities director stated that they use a translation board and music portal to engage residents that do not speak English or have communication deficits. She stated that that the music portal does not currently work so they were not able to use that for an activity for residents. During the interview, a review of the clinical record was conducted with the activities director who stated that resident #64 was assessed as not English speaking. She stated activity staff complete an activity sheet for all residents which were kept in a notebook in the activity office, and then updated into the clinical record at the end of every month. The activities director stated that she had 1:1 visit with resident #64 daily. However, review of the May 2023 activity sheet conducted with the staff #28 revealed there was no documentation of 1:1 activity May 27 through 31, 2023 (8 out of 14 days). She stated that she did see the resident but had not documented on the activity sheet yet. Staff #28 also said that per facility policy, she should have completed documentation of activity provided on the day it occurred or the day after; however, she did not do this. She stated that when she goes in the resident's room she turns on the TV, if the resident chooses; however, for resident #64, the TV was just for background noise and was not necessarily in Mandarin. She stated that she saw resident #64 today and turned the TV on for the resident; but, it may had been turned off. Staff #28 stated that an activity care plan should be completed within the first 3-5 days after admission; however, the clinical record for resident #64 revealed that there was no care plan for activities at this time. She stated that the expectation was that the activity portion of the care plan should have been completed by May 24, 2023; however, it was not. The activity director stated the risk of not completing the care plan could result in staff not knowing what the resident wanted for activities. An interview was conducted on June 01, 2023 at 01:05 p.m. with the Director of Nursing (DON/staff #41), who stated that she would expect that there was an activity focus in the care plan, and that all activities provided to residents be documented in the clinical record. She also reviewed the activity admission evaluation and stated that the assessment revealed that the resident doesn't speak English, and that they would provide the resident with an easy board to translate something she may need or want. The DON then entered the resident's room, and stated that she did not see any evidence of an easy board or communication cards, and that they were not readily available, per the activity evaluation. She stated that this did not meet her expectations for providing functional communication devices/services to residents with communication barriers. Review of the facility policy titled, Activities, revealed that some activities can be adapted to accommodate the resident's functioning due to physical or cognitive limitations that included translation tools, audio/video in the resident's language. Review of the facility policy titled, Communication: Language Access Policy, and stated that the facility will provide individuals with limited English Proficiency (LEP) and disabilities meaningful and equal access to health programs and activities in accordance with all applicable laws. The facility will use only qualified interpreters for language assistance services, not require family to serve as interpreters for an individual with LEP or disability, except in the event of an emergency, document language needs and services provided in the individual's care plan.

Based on observations, clinical record review, family and staff interviews, and facility policy and procedure, the facility failed to provide care and services related to communication for one resident (#64) assessed with communication/language barriers. The census was 94, and the sample was 19. The deficient practice could result in residents not maintaining their communication abilities. Findings include: Resident #64 was admitted on [DATE] with diagnoses of fracture of first lumbar, dysphagia, and dementia. The initial admission record dated May 17, 2023 included resident was alert and oriented to place and person, was able to follow simple commands, was able to make self-understood and was able to understand others. Per the documentation, preferred language spoken was Chinese. The activity admission evaluation dated May 17, 2023 revealed the resident does not speak English and the family had to translate majority of questions. Per the documentation, resident will be provided with an easy board to translate something she may need or want. The initial care plan dated May 18, 2023 revealed no focus, goal, or interventions that addressed the resident's primary language of Chinese or risk for communication problems related to language barrier, or activity preferences. The PA (physician assistant) note dated May 19, 2023 included resident does not speak English but seemed to comprehenad somewhat of what was being said. Review of a social services note dated May 24, 2023 revealed the resident had verbalized the need of an interpreter to communicate with a doctor or healthcare staff; and that, the primary language was Mandarin. The 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident needed an interpreter to communicate with a doctor or health care staff with preferred language of Chinese. The Brief Interview for Mental Status (BIMS) revealed a score of 00 which indicated severe cognitive impact. The assessment included the resident required extensive assistance with all ADLs (activity of daily living). During an observation conducted on May 30, 2023 at 11:09 a.m., resident #64 was lying in bed and was not able to respond to questions asked. The resident's roommate stated that staff had difficulty communicating with resident #64; and that, staff would point at things on the bedside table. A translation phone number was posted on the wall above the resident's bed; however, there were no communication cards available for resident use found in the resident's room. An interview was conducted with the resident's family on May 30, 2023 at approximately 12:00 p.m. the family stated that resident #64 does not speak English and her communication was not good either due to dementia. The family stated she had brought this communication issue to the attention of staff who provided cue cards; however, she had not seen these cards with the resident lately. She also stated that when staff use the translation phone line the translation was not 100% correct; the resident cannot understand staff; and that, the translator phone line was not convenient for staff to use. The family further stated that the resident may not be able to do activities due to the communication barriers. An observation was conducted on June 01, 2023 at 11:44 a.m., resident #64 was observed in her room lying in bed, with no television or music playing, newspapers written in Mandarin were observed lying on the resident's dresser. An interview was conducted on June 1, 2023 at 12:01 p.m. with a Licensed Practical Nurse (LPN/staff #11) who stated that nurses will document use of an interpreter in the progress notes; and that, social services and case management document this too. The LPN stated that the staff could also use family members, and communication cards to assist with resident communication; and that, these communication cards would be within easy reach on the resident's night stand. During the interview, a review of the clinical record was conducted with the LPN who stated that a resident with a language barrier that should be care planned with interventions upon admission. The LPN said that resident #64 was identified as having a language barrier; however, the care plan with interventions regarding language barriers/communication was only initiated on June 1, 2023. In another observation of resident #64 conducted with a certified nursing assistant (CNA/staff #88) on June 1, 2023 at 12:14 p.m., the CNA stated there were no communication cards or easy board for translation in the resident's room. He stated the resident had difficulty with communication; and, he does not use the translation line because he asks easier questions. The CNA further stated that he would expect that there would be communication cards in the resident's room. An interview was conducted with the Director of Rehab (staff #58) and Speech Therapist (ST/staff #108) on June 1, 2023 at 12:23 p.m. Both staffs stated that when a resident is identified with a language barrier is identified, therapy would receive an order for an assessment; and that, therapy would conduct training for use of a communication board, and communication cards. A review of the clinical record was conducted during the interview. The ST stated that therapy did not receive an order for communication evaluation for resident #64; and that, she would expect that therapy would have been consulted for a communication evaluation for resident #64. In an interview conducted with the Director of Activities (staff #28) on June 1, 2023 at 12:45 p.m., the activities director stated that they use a translation board and music portal to engage residents that do not speak English or have communication deficits. She stated that that the music portal does not currently work so they were not able to use that for an activity for residents. During the interview, a review of the clinical record was conducted with the activities director who stated that resident #64 was assessed as not English speaking. She stated that the activity department would provide the resident with an easy board to translate something the resident may need. An interview was conducted on June 01, 2023 at 01:05 p.m. with the Director of Nursing (DON/staff #41) who stated that the expectation was that a resident with a language barrier would be identified in the care plan on admission; and that, the baseline care plan should be reviewed with the resident or family, and signed, within the first 5 days. During the interview a review of the clinical record was conducted with the DON who stated that the initial nursing assessment dated [DATE] included that the resident's preferred language is Chinese, but the resident was not able to read related to dementia. The DON stated that the resident would not have been aware to show her family the baseline care plan form that was left at bedside on May 26, 2023. The DON also stated that she would expect that there would be a care plan focus that included the preferred language is Chinese. An observation of the resident's room was conducted with the DON during the interview. The DON stated that she did not see any evidence of an easy board or communication cards and these cards were not readily available; and that, this did not meet her expectations for baseline care plan completion. In another interview with ST (staff #108) conducted on June 1, 2023 at 2:34 p.m., the ST stated that she remembered using communication cards with the resident on Tuesday, May 30, 2023; however, there were no communication cards in the resident's room for staff to use. The facility policy on Activities revealed that some activities can be adapted to accommodate the resident's functioning due to physical or cognitive limitations that included translation tools, audio/video in the resident's language. Review of the facility policy titled, Communication: Language Access Policy, and stated that the facility will provide individuals with limited English Proficiency (LEP) and disabilities meaningful and equal access to health programs and activities in accordance with all applicable laws. The facility will use only qualified interpreters for language assistance services, not require family to serve as interpreters for an individual with LEP or disability, except in the event of an emergency, document language needs and services provided in the individual's care plan.

Based on observations, clinical record review, family and staff interviews, and facility policy and procedure, the facility failed to develop a baseline care plan was developed and implemented related to communication and activity needs for one resident that one resident (#64). The facility census was 94, and the sample size was 19 residents. The deficient practice could result in resident care needs not being met. Findings include: Resident #64 was admitted on [DATE] with diagnoses of fracture of first lumbar, dysphagia, and dementia. The initial admission record dated May 17, 2023 included resident was alert and oriented to place and person, was able to follow simple commands, was able to make self-understood and was able to understand others. Per the documentation, preferred language spoken was Chinese. The activity admission evaluation dated May 17, 2023 revealed the resident does not speak English and the family had to translate majority of questions. Per the documentation, resident will be provided with an easy board to translate something she may need or want. The eMAR (electronic medication administration record) note dated May 18, 2023 included the resident was Chinese-speaking. The initial care plan dated May 18, 2023 revealed no focus, goal, or interventions that addressed the resident's primary language of Chinese or risk for communication problems related to language barrier, or activity preferences. Review of a social services note dated May 24, 2023 revealed the resident had verbalized the need of an interpreter to communicate with a doctor or healthcare staff; and that, the primary language was Mandarin. According to the documentation the case manager met and discussed with the resident plan and length of stay; however, the note did not indicate whether or not a translator was used. The 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident needed an interpreter to communicate with a doctor or health care staff with preferred language of Chinese. The Brief Interview for Mental Status (BIMS) revealed a score of 00 which indicated severe cognitive impact. The assessment included the resident required extensive assistance with all ADLs (activity of daily living). The baseline care plan and physician acknowledgement form dated May 26, 2023 included the resident received a copy of the baseline care plan and physician orders; however, the form was not signed by the resident or the family; and that, there was no evidence the baseline care plan was reviewed and discussed with the family or resident. The form revealed a hand-written note that read left at bedside, resident aware written on the resident/representative signature line. The note did not indicate whether or not a translator was use during this encounter. Further Review of the clinical record did not reveal evidence that the baseline care plan was reviewed and discussed with the resident/family. The care plan with a focus of risk for communication problems related to language barrier was not initiated until June 1, 2023. The goal was that the resident will be able to make basic needs known on a daily basis. Interventions included to provide translator as necessary to communicate with the resident; and that resident had limited English proficiency (LEP) and competent language assistance will be provided through the use of auxiliary aids, bilingual/multilingual qualified staff and qualified interpreter services. During an observation conducted on May 30, 2023 at 11:09 a.m., resident #64 was lying in bed and was not able to respond to questions asked. The resident's roommate stated that staff had difficulty communicating with resident #64; and that, staff would point at things on the bedside table. A translation phone number was posted on the wall above the resident's bed; however, there was no communication cards available for resident use found in the resident's room. An interview was conducted with the resident's family on May 30, 2023 at approximately 12:00 p.m. the family stated that resident #64 does not speak English and her communication was not good either due to dementia. An interview was conducted on June 1, 2023 at 12:01 p.m. with a Licensed Practical Nurse (LPN/staff #11) who stated that nurses will document use of an interpreter in the progress notes, and this was also included social services and case management. She stated that the facility could also use family members, and communication cards to assist with resident communication; and that, communication cards would be within easy reach on the resident's night stand. She stated that there should also be a care plan implemented for any resident with a language barrier and this should have been initiated upon admission. During the interview, a review of the clinical record was conducted with the LPN who stated that resident #64 was identified to have language barrier; and that, there was no care plan regarding language barriers/communication prior to its initiation on June 1, 2023. The LPN said that the care plan with interventions to address the resident's communication barriers should have been initiated prior to June 1, 2023. An interview was conducted on June 01, 2023 at 01:05 p.m. with the Director of Nursing (DON/staff #41) who stated that the expectation was that a resident with a language barrier would be identified in the care plan on admission; and that, the baseline care plan should be reviewed with the resident or family, and signed, within the first 5 days. During the interview a review of the clinical record was conducted with the DON who stated that the initial nursing assessment dated [DATE] included that the resident's preferred language is Chinese, but the resident was not able to read related to dementia. The DON stated that the resident would not have been aware to show her family the baseline care plan form that was left at bedside on May 26, 2023. The DON also stated that she would expect that there would be a care plan focus that included the preferred language is Chinese. An observation of the resident's room was conducted with the DON during the interview. The DON stated that she did not see any evidence of an easy board or communication cards and these cards were not readily available; and that, this did not meet her expectations for baseline care plan completion. Review of the facility policy titled, Baseline care plan, revealed that the interdisciplinary team (IDT) shall develop and implement a baseline care plan for each resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care. The facility team will provide a written summary of the baseline care plan to the resident or resident representative. Review of the facility policy titled, Comprehensive Person-Centered Care Planning, which revealed the IDT shall develop and implement a baseline care plan for each resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care.

Based on clinical record review and staff interviews, the facility failed to ensure the clinical record related to advance directives accurately reflect the wishes for one resident (#53). The deficient practice could result in resident wishes not respected and followed. Findings include: Resident #53 was admitted on [DATE], with diagnoses of acute respiratory failure with hypercapnia, cognitive communication deficit, acute and chronic respiratory failure with hypoxia, Parkinson's disease, hypoxemia, depression, and paranoid schizophrenia. The advanced directive form signed by resident #53 and dated [DATE] revealed the resident was a full code. An advance directive statement form dated [DATE] revealed that the resident wished to be a DNR; and that, in the event of cardiac or respiratory arrest, the resident does not want any resuscitation measures including but not limited to CPR (cardiopulmonary resuscitation), endotracheal intubation and other advanced airway management, artificial ventilation, defibrillation and related emergency procedures. Despite documentation of a change of code status for resident #53, the clinical record revealed no evidence that the code status was changed. Review of the physician order summary report revealed an order for CPR and full code. Per the documentation, this order was active and had an order date of [DATE]. An interview was conducted on [DATE] at 1:28 p.m. with a hospitality aide (staff #135) who stated she does know anything about hard copy of a resident's advanced directive; or, how to check the resident's code status. She stated that she was not sure what to do in an event a resident is found unresponsive or in cardiac arrest. In an interview with registered nurse (RN/staff #65) conducted on [DATE] at 1:35 p.m., the RN stated that she would check the resident's code status in the electronic records. The RN stated there might a book of code status for all the residents; but she had not use it in a long time and was not sure if they still use this book. The RN proceeded to ask the DON who informed the RN that there was a book of code status for all the residents at the facility. During an interview conducted with Director of Nursing (DON/Staff #41) on [DATE], the DON stated that the expectation was for the nurses to be aware of the advance directive binder. The DON stated she does not expect everyone to know about the binder for the code status for all their residents; however, the nurses should be aware of it. Regarding resident #53, the DON stated that resident #53 was a full code; but the advance directives dated [DATE] was signed by the resident's legal guardian with the resident signature next to it. The DON said that the physician signed the form and the form had a check mark next to DNR. The DON stated that resident #53 was a full code; and that the form that marked the DNR was not accurate. Review of the facility policy revised in [DATE] included that the facility will notify the attending physician of advance directives so that, if necessary, appropriate orders can be documented in the residents' medical records and plan of care. The facility policy on Documentation and Charting included that it is their policy to provide a complete account of the resident's care, treatment, response to the care, signs, symptoms, etc. as well as the progress of the resident's care; and to provide a legal record that protects the resident, physician, nurse and the facility.

Based on observations, clinical record reviews, facility documentation, staff interviews and policies and procedures, the facility failed to ensure that two residents (#30, #40) received the necessary services to maintain good grooming and personal hygiene. The deficient practice could result in residents not being groomed or showered. Findings include: - Resident #30 was admitted on [DATE] with diagnoses that included Atherosclerotic heart disease of coronary artery, chronic obstructive pulmonary disease with exacerbation, and chronic respiratory failure with hypoxia. Review of shower schedule revealed the resident was scheduled for showers every Tuesday and Friday morning. A care plan initiated on August 11, 2021 documented the resident had a self-care deficit and would be encouraged to shower. Review of January 2023 shower sheets and Certified Nursing Assistant (CNA) Point of Care (POC) Task documentation revealed evidence that only two showers were provided during January 2022. There was no evidence that the resident had declined any showers that month. A quarterly Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition, and was dependent on staff for personal hygiene. The MDS also included that bathing had not occurred during the 7 day look back period from January 23, 2023 through January 29, 2023. Review of skilled nursing notes from January 1, 2023 through March 20, 2023 revealed no documentation that the resident was offered, refused, or was provided any showers or bed baths. Review of February 2023 shower sheets and CNA POC Task documentation revealed no evidence that a shower was provided, or had been refused on: - Friday, February 10, 2023 -Friday, February 17, 2023 -Tuesday February 21, 2023 Review of March 2023 shower sheets and CNA POC Task documentation revealed no evidence that a shower was provided or had been refused on March 3, 2023, Friday. An interview was conducted on March 20, 2023 at 4:48 PM with the Director of Nursing (DON/Staff #4), who reviewed the clinical record for resident #30 and that she did not see any evidence in the clinical record or on shower sheets that showers/baths had been offered/provided/refused on seven occasions in January 2023, three occasions in February 2023 and one in March 2023. She stated that this did not meet the facility policy for providing/offering showers twice a week. - Resident #40 was admitted on [DATE] with diagnoses that included multiple sclerosis, atrial fibrillation, and long-term use of anticoagulants. Review of shower schedule revealed the resident was scheduled for showers every Thursday and Sunday mornings. A quarterly Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment, dependent on staff bathing. A care plan initiated on August 11, 2022 documented the resident had a self-care deficit and required encouragement. Review of skilled nursing notes from January 1, 2023 through March 20, 2023 revealed no documentation that the resident was offered, refused, or was provided any showers or bed baths. Review of January 2023 shower sheets and CNA POC Task documentation revealed no evidence that showers were provided or had been refused on the following dates: -Sunday, January 8, 2023 -Sunday, January 15, 2023 -Sunday January 22, 2023 Further review of January 2023 shower sheets and CNA POC Task documentation revealed evidence that showers were offered and refused on the following dates: -January 19, 2023 -January 29, 2023 Review of February 2023 shower sheets and CNA POC Task documentation revealed no evidence that showers were provided or had been refused on the following dates: -Sunday, February 5, 2023 Review of March 2023 shower sheets and CNA POC Task documentation revealed no evidence that showers were provided or had been refused on the following dates: -Sunday, March 12, 2023 An interview was conducted on March 20, 2023 at 2:59 PM with a Licensed Practical Nurse (LPN/staff #3), who stated that the facility process is to offer showers twice a week. She further stated that CNA's provide the showers as scheduled, unless a resident would request additional showers. She also stated that CNA's document if a shower/bath/bed bath was provided in the clinical record. The LPN stated that they would document if a shower/bath/bed-bath was offered and refused by the resident. An interview was conducted on March 20, 2023 at 3:48 PM with a CNA (staff #6), who stated that showers/baths are provided twice a week for all residents, unless they request more. He also stated that when a shower/bath is offered, provided or refused it is documented in the clinical record, and on a shower form. An interview was conducted on March 20, 2023 at 4:48 Pm with the Director of Nursing (DON/Staff #4), who stated that residents should receive showers twice a week or more per request according to the facility policy. She also stated that showers/baths are documented on shower sheets, and that she is working with CNA's to document in the clinical record. She further stated that shower sheets or the clinical record should contain documentation regarding showers/baths being provided or refused. She reviewed the clinical record and stated that Resident #40 was not provided a shower, on 5 occasions between January 1, 2023 and March 20, 2023. The DON stated that this did not meet the facility policy. She stated that not providing/offering showers/bed-baths/baths to residents regularly could result in infection or skin issues not being identified. Review of the facility policy titled, Showers/bed baths, revealed that showers and bed baths will be provided to residents in accordance with resident's shower schedule provided. Showers and bed baths will be documented in the medical record/POC.

Based on staff interviews, review of facility documentation, policy and procedure, and the Centers for Medicare and Medicaid Services (CMS) Interim Final Rule related to Long-Term Care (LTC) Facility Testing Requirements and COVID-19 Health Care Staff Vaccination, the facility failed to ensure three unvaccinated contract staff were tested based on parameters set for COVID-19 testing frequency. The deficient practice can result in COVID positive staff not being identified and the spread of infection to residents and staff. Findings include: Review of facility documentation revealed the facility had approximately 37 contract staff on board. A review of the facility's documentation of staff vaccination status revealed the following contract staff were unvaccinated and had an exemption: -Hospice certified nursing assistant (CNA/staff #112); -Hospice registered nurse/case manager (RNCM/staff #111); and, -X-ray technologist (staff #113). Regarding the X-ray technologist (staff #113) The exemption request signed by staff #113 and dated December 2, 2021 included that staff #113 agreed to weekly testing either PCR (polymerase chain reaction) or antigen test to mitigate the transmission and spread of COVID-19. Review of the punch detail record for the staff #113 for January 2022 through March 2022 revealed that staff #113 punched in on the following dates: -January 17, 20 and 31; -February 2; and, -March 9. The facility tracking calendar for January 2022 revealed the facility had an outbreak on January 4, 2022 with a high transmission rate. Review of the Complete COVID line audit from January 2022 revealed the facility was on outbreak mode testing of all staff. Review of the facility tracking calendar for February 2022 revealed high transmission rate, with the last staff testing positive on February 8 and the last resident testing positive on February 16. The Complete COVID line audit for February 2022 revealed the facility was on outbreak mode testing of all staff. There was no evidence that staff #113 was tested . Further, there was no evidence that staff #113 was tested for COVID from January through March 2022. Regarding the Hospice certified nursing assistant (CNA/staff #112) Review of the punch detail record revealed that staff #112 punched in on January 17 at 1:15 p.m. The facility tracking calendar for January 2022 revealed the facility had an outbreak on January 4, 2022 with a high transmission rate. Review of the Complete COVID line audit from January 2022 revealed the facility was on outbreak mode testing of all staff. There was no evidence that staff #112 was tested . The exemption request signed by staff #112 and dated February 24, 2022 included that staff #112 agreed to weekly testing either PCR (polymerase chain reaction) or antigen test to mitigate the transmission and spread of COVID-19. Regarding the Hospice registered nurse/case manager (RNCM/staff #111) The exemption request signed by staff #111 and dated February 24, 2022 included that staff #111 agreed to weekly testing either PCR (polymerase chain reaction) or antigen test to mitigate the transmission and spread of COVID-19. Review of the punch detail record for March and April 2022 revealed that staff #111 punched in on the following dates: -March 9 and 30; and, -April 6 and 13. The Complete COVID line audit for March 2022 revealed staff testing frequency of once a week. There was no evidence that staff #111 was tested . The Complete COVID line audit for April 4 and 7, 2022 revealed staff testing frequency of twice a week. There was no evidence that staff #111 was tested . The facility's Complete COVID line audits from January through April 7, 2022 did not include testing of their contract staff. Further review of facility documentation revealed no evidence their contract staff were tested for COVID-19 based on parameters set for testing frequency from January through April 7, 2022. In an interview conducted on April 11, 2022 at 9:50 a.m., the Infection Control Preventionist (IP/staff #106) stated that the facility had an outbreak in January 2022. She stated during the outbreak, she focused on testing all staff for COVID but has not tested their contract staff including an unvaccinated contract provider who has an exemption. Staff #106 further stated that the unvaccinated contract provider had come into the facility to see residents during their outbreak in January 2022. In another interview with staff #106 conducted on April 13, 2022 at 2:11 p.m., she stated contract staff included providers, hospice staff and X-ray/diagnostic staff. She said that unvaccinated contract staff have not been tested twice weekly as they should. The IP stated that it did not dawn on her that they are considered the facility's staff; and that they should be tested as well. Staff #106 further stated that staff are considered up-to-date with vaccination if they had the required number of doses of the vaccine plus the booster. She said that staff including contract staff not up-to-date with their vaccination are tested twice a week regardless of whether they work as direct care or not. In a later interview with staff #106 conducted on April 14, 2022 at 12:08 p.m., she stated that there was no COVID-19 testing conducted for contract staff since the outbreak in January 2022. The facility's policy on COVID-19 Vaccine for Staff included that the facility has established a process to comply with the Federal mandate that all staff are vaccinated against COVID-19 unless they have a medical or religious exemption, to help reduce the risks residents and staff have of contracting and spreading COVID-19. Staff requesting a medical or religious exemption that complies with the above requirements may receive a reasonable accommodation of exemption from the facility's vaccination requirement where such accommodation does not pose an undue hardship to the facility. Precautions intended to mitigate the transmission and spread of COVID-19 will be implemented for staff who are not fully vaccinated for COVID-19. Exempt staff members will be required to take such precautions as a condition of continued employment. The CMS QSO-20-38-NH revised on March 10, 2022 stated that facilities are required to test residents and staff based on parameters and a frequency set forth by the Department of Human and Health Services. Facility staff includes employees, consultants, contractors, volunteers and caregivers who provide care and services to residents on behalf of the facility, and students in the facility's nurse aide training programs or from affiliated academic institutions. The facility is required to obtain documentation that the required testing was completed during the timeframe that corresponds to the facility's testing frequency. Routine testing of staff who are not up-to-date should be based on the extent of the virus in the community. The facility should test all staff who are not up-to-date at the frequency prescribed in the Routine Testing table based on the level of community transmission reported in the past week. The CMS QSO 22-09-ALL revised on April 5, 2022 revealed the regulation requires facilities to ensure staff who are not yet fully vaccinated, or who have pending or been granted an exemption, or who have a temporary delay as recommended by the CDC (Centers for Disease Control and Prevention), adhere to additional precautions that are intended to mitigate the spread of COVID-19. There are a variety of actions or job modifications a facility can implement to potentially reduce the risk of COVID-19 transmission including but are not limited to: -Reassignment to non-patient care areas, duties that can be performed remotely, or duties which limit exposure to those most at risk; -Follow additional CDC recommended precautions, such as adhering to universal source control and physical distancing measures; -Requiring at least weekly testing for exempted staff and staff who have not completed their primary vaccination series; and, -Requiring staff who have not completed their primary vaccination series to use a NIOSH-approved N95 or equivalent or higher-level respirator for source control regardless of whether they are providing direct care to or otherwise interacting with patients. Further, the QSO memo revealed that staff who have been granted an exemption to COVID-19 vaccination requirements should adhere to national infection prevention and control standards for unvaccinated health care personnel.

Based on clinical record reviews, resident and staff interviews, and policy reviews, the facility failed to ensure care and services provided met professional standards for 4 residents, by failing to ensure one resident (#4) had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #83) had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The sample size was 20. The deficient practice could negatively impact residents' care. Findings include: -Resident #4 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS assessment indicated the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] An observation was conducted on April 11, 2022 at 10:49 AM, the resident was lying in bed, with a PRAFO boot lying on the floor next to the bed. The resident stated that the PRAFO is used for the left foot drop, and needs to be on when he is in bed, and that it is supposed to be used daily. He further stated that the PRAFO is applied only when he asks. However, review of the clinical record from December 9, 2021 through April 11, 2022 did not reveal an order for [MEDICAL RECORD OR PHYSICIAN ORDER] An interview was conducted on April 12, 2022 at 10:29 AM with a Certified Nursing Assistant (CNA/staff #90), who stated that she had applied the PRAFO boot to the resident's left leg once, when the resident requested. She further stated that she did not know if there was a physician's order for placement of the boot. An interview was conducted on April 12, 2022 at 10:39 AM with a Registered Nurse (RN/staff #59), who stated that the resident does not have a boot that she is aware of and that they would need a physician's order to apply a boot. The RN entered the resident room and stated that she did see a PRAFO boot on the floor next to the resident's bed. She asked the resident about the boot and he stated that he uses the boot occasionally. He further stated to the RN that he has pain in his foot now, so she applied the PRAFO boot to his left foot/leg at that time. The RN reviewed the medical record and stated that there was no physician's order regarding application of the PRAFO boot, she further stated that there was nothing on the MAR (Medication Administration Record) or TAR (Treatment Administration Record) regarding application/use of the boot. She further stated that there was not a previously discontinued order for a PRAFO boot in the physician's orders. The RN stated that she would expect that if the resident had a PRAFO boot in his room, there should be a physician's order for application of the boot. She also stated that the CNAs would not know to apply the boot, if there was no physician's order. The RN stated the PRAFO boot should not have been applied without an order, and the risk could result in incorrect placement, or restrictions to mobility. The RN further stated that applying the boot without a physician's order could do more harm than good. The nurse stated that she will notify the physician regarding placement of the PRAFO boot today. Further interview was conducted with the resident at that time. He stated that his foot needs to be kept in one position. The resident also stated that he has had the boot for about 3 years, and that he experiences pain in his left foot related to [CONDITION(S)]. Review of therapy progress notes dated April 12, 2022 at 11:32 AM, revealed the resident is requesting a PRAFO boot for comfort and that the resident had been screened for the use of a PRAFO boot. Review of the physician's orders revealed an order dated April 12, 2022 for the resident to wear the LLE (left lower extremity) PRAFO boot for comfort at the resident request and to the resident tolerance. A review of the care plan regarding Activities of Daily Living self-care performance deficit revealed updated interventions on April 12, 2022 that included: May wear LLE PRAFO for increased comfort at his request and to his tolerance. An additional interview was conducted with the resident on April 12, 2022 at 12:14 PM, who stated that the PRAFO boot was placed on his left leg two days ago by an LPN (Licensed Practical Nurse/staff #105). The resident further stated that he has been asking staff to apply the PRAFO boot three times a week for approximately 2 months. An interview was conducted with an LPN (staff #105) on April 13, 2022 at 10:15 AM, who stated the resident is independent, and uses the PRAFO boot for his comfort and tolerance. She also stated that the resident will ask staff for assistance to apply the boot. The LPN stated that she has assisted with application of the PRAFO a few times a week. The nurse reviewed the medical record and stated that the order for the application of the PRAFO boot was started on April 12, 2022. After further review of the medical record, the LPN stated that she did not see any previous orders for application of the boot. She also stated that since there was not an order, she should not have applied the boot. The LPN stated that they would need a physician's order to apply the PRAFO boot, and the risk of applying without a physician's order could result in skin breakdown or injury. She further stated that this did not follow the facility policy. An interview was conducted on April 13, 2022 at 11:06 AM with the Director of Nursing (DON/staff #54), who stated that according to the facility policy a physician's order would be needed for placement of a PRAFO boot. She stated that if it was the resident's preference to use the boot, they would need therapy to evaluate, and a physician's order. The DON stated it would be hard to say what the risk would be of placing a PRAFO boot without a physician's order. She reviewed the medical record and stated that therapy placed an order on April 12, 2022 for application of the PRAFO boot. She further stated that if staff were applying the boot prior to this order, they would have needed a physician's order. The DON reviewed the medical record and stated that there were no orders for application of the PRAFO boot prior to the order dated April 12, 2022. An interview was conducted on April 14, 2022 at 8:01 AM with the facility Administrator (staff #7), who stated they do not have a policy relating specifically to positioning, mobility and range of motion, and that the closest they have is the restorative care policy. Review of the facility policy titled, Restorative Care, revealed that any therapeutic interventions, including restorative interventions, splints, hand rolls, etc., will be provided under physician orders. -Resident #52 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan initiated on November 24, 2019 revealed a focus area related to Diabetes Mellitus with a goal to not have complications related to diabetes. The interventions stated diabetes medication as ordered by the physician and monitor/document for side effects and effectiveness. Review of a quarterly MDS assessment dated [DATE] included a BIMS score of 10, indicating the resident had moderate cognitive impairment. A physician's order dated April 4, 2020 revealed for [MEDICATION(S)] Solution (Insulin [MEDICATION(S)]), Inject as per sliding scale: blood sugar level 201-250 = 2 units; 251-300 = 4 units; 301-350 = 6 units; 351-400 = 8 units; [PHONE NUMBER] = 10 units and notify MD, subcutaneously before meals and at bedtime for DM. Review of the Medication Administration Record (MAR) revealed that the resident's blood sugar levels were documented over 401 as follows: February 2022: 7 times March 2022: 7 times April 2022: 4 times Review of the medical record revealed no evidence that the physician had been notified. An interview was conducted on April 11, 2022 at 10:23 AM with the resident who stated that his blood sugar is hard to control, and that he has talked to the nurse because he gets dizzy. An interview was conducted on April 12, 2022 at 10:39 AM with a RN (staff #59), who stated that the resident is challenging, and refuses oral medications. She further stated that he will allow blood sugar testing and insulin. She also stated that his blood sugar levels can be erratic due to his diet restrictions due to religious reasons. An interview was conducted with an LPN (staff #105) on April 13, 2022 at 10:15 AM, who stated that nursing should notify the physician when a blood sugar level is over 401, per the physician orders, and document the call in the medical record. She further stated that the MAR documentation flows into the progress notes. She also stated it is the facility policy to notify the MD for a blood sugar level over 400, and to recheck the blood sugar. She reviewed the physician's order regarding [MEDICATION(S)] Solution (Insulin [MEDICATION(S)]), and stated the physician should be notified for a blood sugar level over 401. The LPN further stated that the facility policy is to follow physician orders as written. She stated the physician should be notified for a blood sugar over 400 even if the recheck blood sugar level is lower. The LPN also stated that they would document the physician notification in the medical record that the physician is aware. She reviewed the medical record and progress notes including the MAR: - February 2022 - the LPN stated that there were seven times during the month that the resident's blood sugars were over 401. -March 2022 - the LPN stated that there were seven times that the blood sugar levels were documented as being over 401 for the month, with no documentation that the physician had been notified. -April 2022 - the LPN stated that the resident had documented blood sugars over 401, four times this month, and there was no documentation that the physician had been notified. She stated that she remembered that she did call the physician, but she did not document the call. She further stated that this did not follow the physician's orders or meet the facility policy. An interview was conducted on April 13, 2022 at 11:06 AM with the DON (staff #54), who stated that the resident likes to pick and choose what he likes to do. She also stated that the facility policy is to follow physician orders as written including parameters, and to notify the physician per orders. She further stated that the physician should be notified by phone, and the call should be documented in the medical record. The DON also stated that they had completed recent audits and found that nursing had not been documenting physician notification calls, per orders. She stated that they have had a nurse in-service regarding physician notification. The DON further stated that it is facility policy to notify the physician as ordered, and then to document the call. She reviewed the medical record including progress notes and the MAR: - February 2022 - the DON stated that there were seven times during the month that the documentation of the resident's blood sugars was over 401, and there was no documentation that the physician had been notified. -March 2022 - the DON stated that the resident had documented blood sugar levels seven times this month that were over 401, and there was no documentation that the physician had been notified. -April 2022 - the DON stated that the resident had blood sugar levels documented over 401 four times this month, with no documentation of physician notification in the medical record. The DON stated after review of the MARs, Physician Orders and progress notes, that she would expect the physician would be notified for blood sugars above 401 per the physician orders, and that the call would be documented. She further stated that the facility policy is to follow physician's orders as ordered, including those with parameters. She stated the risk of the physician not being notified could result in the physician not being aware if the resident was hypoglycemic or hyperglycemic. -Resident #35 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's order dated November 19, 2021 included [MEDICATION(S)] solution 100 unit/ml (milliliter) (Insulin [MEDICATION(S)]), inject as per sliding scale: If 0-60 = 0 units Asymptomatic or Symptomatic BS (Blood Sugar) 60 and below, see PRN (as needed) orders; 61-150 = 0 units; 151-200 = 0 units; 201-250 = 2 units; 251-300 = 4 units; 301-350 = 6 units; 351-400 = 8 units; 401+ = 10 units Recheck, if still elevated in 60 minutes call MD (Medical Doctor), subcutaneously before meals and at bedtime for DM. Review of the comprehensive care plan dated February 14, 2022 included that the resident had diabetes mellitus. The goal was that the resident will be free from any signs and symptoms of [CONDITION(S)]. Interventions included diabetes medication as ordered by the physician and to monitor/document for side effects and effectiveness. Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 13 which indicated the resident is cognitively intact. The MDS assessment also revealed that the resident received insulin. Review of the MAR from January 2022 through April 2022 revealed the resident's blood sugar was over 401, three times in January 2022, one time in February 2022, three times in March 2022, and two times in April 2022. Continued review of the clinical record did not reveal evidence that the resident's blood sugar was rechecked after an hour and that the physician was notified when the resident's blood sugar was over 401. An interview was conducted with an LPN (staff #101) on April 13, 2022 at 3:25 pm. She stated that the process of administering insulin is to check the resident's blood sugar and administer insulin per the sliding scale. The LPN stated if the insulin order has a sliding scale and the resident's BS is 401 or higher, then the process is to administer insulin as ordered, inform the physician, recheck the blood sugar in an hour and let the physician know if the BS is still elevated. She stated if the recheck BS is less than the previous reading but still above 400 then she will still notify the physician. She stated the staff should document this in the progress notes or in the e-MAR (electronic MAR) notes. She stated it is important to follow the physician's ordered parameters and notify the physician in order to maintain the resident's BS and to make sure the resident's BS did not stay elevated. The LPN stated resident #35's BS had been stable for her shift but that she had received a report from the morning shift that the resident's BS had been high. The LPN stated as the resident's BS ran high in the morning, the staff needed to notify the physician so that the physician could keep record of it to know the reason why the resident's BS were high. An interview was conducted with the DON (staff #54) on April 13, 2022 at 3:38 pm. She stated her expectation from the staff is to monitor for signs and symptoms of hyper or [CONDITION(S)] in residents who are diabetic and follow the physician's order for insulin. The DON stated her expectation from the staff is to document physician notification of a resident's high blood sugar and any interventions done in the e-MAR notes or progress notes. The DON stated it is important to notify the physician of high blood sugar levels so that the physician can add orders or update the insulin dose to maintain the resident's blood sugar. The facility policy titled Blood Glucose Monitoring reviewed May 2021 stated the facility policy is to check and monitor finger stick blood glucose levels as ordered by the physician. The facility policy titled Administration of Drugs reviewed August 2021 stated medications must be administered in accordance with the written orders of the attending physician, physician notification will be documented in the clinical record. Review of the facility policy titled, Physician Orders, revealed to accurately implement orders only upon the written order of a licensed and authorized person. -Resident #83 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the care plan initiated on March 23, 2022 revealed the resident had an activities of daily living self-care performance deficit related to generalized weakness and an unsteady gait. Interventions stated to monitor/document/report to the physician as needed any changes, any potential for improvement, reasons for self-care deficit, expected course, and declines in function. Review of the clinical record revealed a physician order dated March 24, 2022 for Triamcinolone [MEDICATION(S)] cream 0.1%, apply to back topically two times a day for [CONDITION(S)] for one day. The order ended March 25, 2022. Review of the admission MDS assessment dated [DATE] revealed the BIMS score was 15 which indicated the resident was cognitively intact. The assessment also included the resident had applications of ointments/medications other than to feet. During an observation conducted on April 11, 2022 at 11:00 am, resident #83 was observed applying Hydrocortisone cream 1% to her back. The resident stated that her back was itching and that she can apply the cream but needed staff assistance to apply the cream all over her back. A second observation was conducted of the resident on April 12, 2022 at 2:48 pm. The Hydrocortisone cream 1% was observed in the pink emesis basin on top of the tray table. The resident stated that one of the nurses gave her the Hydrocortisone cream and the nurses helped apply the cream as she is not able to reach all of her back. The resident stated she last applied the cream the day before. She stated she did not remember the name of the nurse who gave her that medication. The resident stated no one has asked to take the medications and that the medication is not a prescription medication. However, review of the clinical record did not reveal an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with an RN (staff #59) on April 13, 2022 at 11:41 am. She stated when a resident complains of a rash or itching, the process is to assess the resident, contact the physician and obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated resident #83 had not complained of any itching or rash to her and she did not know if the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] An interview was conducted with the DON (staff #54) on April 13, 2022 at 11:51 am. She stated that the facility had OTC Hydrocortisone cream as in-house supply and depending on the percentage of the medication, the cream gets delivered from the pharmacy. The DON stated if a resident is using the hydrocortisone cream, an order is required for its use. She stated the residents sometimes order OTC medication from an online website or they bring medications from home and the staff has to educate the residents that the medication has to have an order before they can use the medication. She stated resident #83 self-administering medication without an order did not meet expectations. The facility's policy titled Self-Administration of Medications revised May 2021 stated that if the resident is a candidate for self-administration of medications, this will be indicated in the chart. The facility's policy titled Administration of Drugs reviewed August 2021 stated that medications must be administered in accordance with the written orders of the attending physician.

Based on observations, resident and staff interviews, clinical record review, and policy review, the facility failed to ensure that dignity was maintained for one resident (#6). The sample size was 20. The deficient practice could result in residents not being treated with dignity. Findings include: Resident #6 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The comprehensive care plan dated March 18, 2022, revealed the resident has activity of daily living (ADL) deficit related to recent hospitalization . The care plan interventions included promoting dignity and privacy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 14 which indicated the resident is cognitively intact. The MDS assessment stated the resident needed extensive assistance with bed mobility, dressing and personal hygiene. During an observation conducted on April 11, 2022 at 10:28 a.m., the resident's room door was observed wide open, the resident's bed was near the door. The privacy curtain was partially pulled between the resident and the resident's roommate. The resident was lying in bed without a shirt on, on the right side facing the window. The resident was only wearing an incontinent brief, covered with a thin white sheet, with the brief exposed from the back. Several staff were in and out of the resident's room, looked at the resident but no one pulled the sheet to cover the resident, or pull the privacy curtain around the resident. An interview was conducted with the resident immediately following the observation. The resident stated he did not have any clothes since he was admitted in July last year because the clothes were left in the facility where he came from. He stated the social worker was notified and told him she would follow up, but the clothes never came. He stated he followed up with the social worker several more times, he was always told it was coming; he just gave up on it. He stated he would wear a shirt if he had shirts, but he would not wear a hospital gown because it makes his skin itch, and chokes him around the neck. The resident stated there are shirts in his closet but those shirts are not his, they are too small and do not fit him because he wears bigger shirts. Following the interview, an observation of the resident's closet was conducted which revealed approximately seven shirts hanging in the closet with sizes from medium to large. Review of an undated form titled, Inventory of Personal Effects, revealed the resident was admitted with only a wallet, a phone, and a charger. Further review of the clinical record revealed no evidence that the resident refused to wear regular clothes daily. A second observation was conducted on April 12, 2022 at 7:53 a.m. The resident was lying in bed with no shirt on, drinking a hot beverage in a coffee mug. The resident was only wearing an incontinent brief covered with a thin white sheet. The resident stated he only wears a brief in bed since he was admitted to the facility. He stated he did not have a shirt on because he did not have any shirts and nobody is doing anything about it. The resident stated the staff would only offer him a hospital gown, so he has given up on following up with the staff about having a regular shirt. An interview was conducted on April 12, 2022 at 2:39 p.m. with a social worker (staff #62), who stated she checked the clothes in the resident's closet and found that those clothes belong to his roommate. She stated the roommate's closet did not have a bar to hang clothes, so someone used resident's #6 closet instead. The social worker also stated she found donated clothes that will fit the resident, offered it to resident #6, and he agreed to wear them. The social worker provided a copy of the inventory list and stated the resident was admitted with only a wallet, a phone, and a charger. She stated the clothes and the motorized wheelchair was left in another facility. The social worker stated she placed a call to the other facility and that she would continue to follow up. An observation was conducted on April 13, 2022 at 9:53 a.m. The resident was lying in bed facing the window, watching a show on his cell phone. The resident was observed wearing a maroon and white striped shirt. The resident was smiling, very social, and in good spirits. The resident stated he was so happy to have a shirt on, it made him feel better. He stated he did not like to wear hospital gowns because they made him itch and made him feel like he was in the hospital. The resident stated he will wear a different shirt every day now that he has shirts that fits him. An interview was conducted on April 13, 2022 at 10:09 p.m. with a Licensed Practical Nurse (LPN/staff #53), who stated she did not know the resident did not have any clothes because he was moved from another station. She stated she saw the resident this morning and he looked happy, had a smirk on his face, he looked better. An interview was conducted on April 14, 2022 at 10:53 a.m. with a Certified Nursing Assistant (CNA/staff #30). The CNA stated the process when a resident is admitted without personal clothing, is to access the donated clothes located in the therapy room. She stated if a resident refused to wear a hospital gown, she would notify the charge nurse so they can get the clothing items that fit the resident. An interview was conducted on April 14, 2022 at 11:41 a.m. with the Director of Nursing (DON/staff #54), who stated it is her expectation that those residents who were admitted without personal clothing, obtain clothes from the donated items located in the therapy room. The DON also stated it is her expectation that residents wear street clothes during the day if they wished. A facility policy titled, Resident Rights, stated it is the policy of the facility that all resident rights be followed per state and federal guidelines as well as other regulatory agencies. The resident rights policy included the resident has the right to be treated with dignity and individuality, and to keep and use personal clothing.

Based on observation, clinical record review, resident and staff interviews, and policy reviews, the facility failed to ensure one resident (#83) was assessed for self-administration of a medication. The sample size was 20. The deficient practice could result in residents unsafely administering medications. Findings include: Resident #83 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The initial admission record dated March 23, 2022 revealed the self-administration of drugs was marked 'No' which indicated the resident did not desire to self-administer drugs. The skin evaluation note dated March 24, 2022 stated that resident #83 had a mid-upper back red, raised rash, provider was made aware and Triamcinolone cream was applied per physician order. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician note dated March 24, 2022 stated that the resident had a rash on the back of 1-day duration which was itchy. The note further included a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of admission Minimum Data Set assessment dated [DATE] revealed the BIMS score was 15 which indicated the resident was cognitively intact. The MDS assessment also revealed that the resident had no impairment to the upper extremities. An observation was conducted on April 11, 2022 at 11:00 am of resident #83. The resident was observed lying in bed wearing a green printed hospital gown. Resident #83 stated her back was itching and was observed applying Hydrocortisone cream 1% on her right lateral lower back with her right hand. She stated she can apply the cream but needed staff assistance to apply the cream all over her back. The resident stated her entire back was itching and the staff had applied the cream on her back before. The Hydrocortisone Cream 1% observed to have an expiration date of October 2024. A second observation was conducted of the resident on April 12, 2022 at 2:48 pm. The Hydrocortisone cream 1% was observed in the pink emesis basin on top of the tray table. Following the observation an interview was conducted with the resident. She stated that one of the nurses gave her the Hydrocortisone cream. The resident stated the nurses help apply the cream as she is not able to reach all of her back. She stated she last applied the cream the day before. The resident stated she did not remember the name of the nurse who gave her that medication. She stated no one has asked to take it and that the medication is not a prescription medication. An interview was conducted on April 13, 2022 at 11:56 am with the resident. She stated that her back was still itching and she finished the Hydrocortisone cream 1% tube. The resident stated she will ask the staff to get her another tube of Hydrocortisone cream. Further review of the resident's clinical record did not reveal the resident was assessed to self-administer medications. An interview was conducted with a Registered Nurse (RN/staff #59) on April 13, 2022 at 11:41 am. She stated resident #83 had not complained of any itching or rash to her and she did not know if the resident had Hydrocortisone cream. She stated she did not know the resident had been using Hydrocortisone cream. The RN stated the resident should be assessed for self-administration of medication before the resident is allowed to self-administer medication. She stated the resident should be assessed for self-administration of medication to make sure the resident is cognitively intact and physically able to administer their own medication properly. An interview was conducted with the Director of Nursing (DON/staff #54) on April 13, 2022 at 11:51 am. She stated residents are able to self-administer their own medications but there should be an assessment prior to use of the medication. She stated the residents should be assessed for self-administration to determine if the resident is able to safely self-administer their medication. The DON stated resident #83 self-administering medication without an order, did not meet expectation. The facility's policy titled Self-Administration of Medications revised May 2021 stated the facility policy is to respect the wishes of alert, competent residents to self-administer prescribed as allowable under state regulations. The policy stated if a resident desires to participate in self-administration, the interdisciplinary team will assess and periodically re-evaluate the resident based on change in the resident's status. The policy further stated that if the resident is a candidate for self-administration of medications, this will be indicated in the chart and the resident will be instructed regarding proper administration of medication by the nurse. The facility policy titled Administration of Drugs reviewed August 2021 stated that only licensed medical and nursing personnel or other lawfully authorized staff members may prepare, administer, and record the administration of medications.

Based on review of the clinical record, staff interviews, review of staff education records and review of policies and procedures, the facility failed to ensure that resident's (#1) representative was notified of the resident's transfer to a hospital for significant changes in the resident's physical and mental status. The deficient practice could result in additional resident representatives not being notified of transfers to hospital, and significant changes in physical and mental status. Findings include: Resident #1 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nursing note dated June 22, 2020 at 3:23 am by a Licensed Practical Nurse (LPN/staff #30) included that resident #1 was transferred to a hospital after the provider had been notified that the resident was unresponsive, had a drop in the resident's blood pressure, and altered mental status. Review of the clinical record for resident #1 did not reveal any documented evidence that the resident's representative had been notified of the resident's significant change in physical and mental status including unresponsiveness, the drop in the resident's blood pressure, and that resident #1 had been transferred to a hospital. A review of facility documentation revealed that in-service staff training had been provided regarding notification of resident representatives, and change of condition notification on February 11, February 23, and July 9, 2021. Review of sign in sheets attached to the in-service training included multiple nurse's signatures. During an interview conducted on August 2, 2021 at 11:00 a.m. with an LPN (Licensed Practical Nurse/staff #30), he stated that he did not remember resident #1 being transferred out of the facility on June 22, 2020, and that he did not remember contacting the resident's representative at any time during the resident's admission. During an interview conducted on August 2, 2021 at 2:45 p.m. with the DON (Director of Nursing/staff #22), she stated that there was no documentation that the representative of resident #1 was notified on June 22, 2020. Staff #22 stated that when she took the DON position in May of 2020, she identified a trend of not documenting notifications to providers or families for a change of condition, and that training for notifications and auditing of charts has been conducted by the DON and Assistant Director of Nursing. A facility policy titled Change of Condition Reporting, included that all changes in resident condition will be communicated to the physician and documented. The policy also included that for an acute medical change of condition the responsible party will be notified that there has been a change in the resident's condition and what steps are being taken. The policy included that all nursing actions will be documented in the licensed progress notes as soon as possible after the resident's needs have been met.

Based on observation, staff interviews, policy and procedure, and Centers for Disease Control (CDC) guidelines, the facility failed to ensure that staff screening logs were fully completed, that a glucometer designated for multi-resident use was disinfected according to facility policy, and to ensure staff donned appropriate PPE. The deficient practice could result in an increased spread of COVID-19 within the facility resulting in further illness or death. - Findings include: Regarding screening: An entrance interview was conducted on December 17, 2020, at 8:50 a.m., with Executive Director (staff # 23) and Director of Nursing (DON/Staff # 15). The Executive Director stated that the staff on the COVID unit are screened at the front entrance then go to the unit door for entrance into the COVID unit. Staff at other units are screened at the main entry or at the entry door that is located next to the laundry department. Review of staff screening logs, dated November 16, 2020 through December 16, 2020, revealed multiple instances where no temperature was documented. Instances of incomplete documentation included: -missing/not documented temperature values at the beginning of the shift on 5 occasions. An interview with the facility entrance screener (Staff # 19) was conducted at 1:03 p.m. on December 17, 2020. She stated the DON is responsible for reviewing the screening forms. The front office screening is for administration, medical records and second shift nurses (2pm - 10pm). She stated the expectation is to complete all the questions and document temperatures. An interview at 2:37 p.m. on December 17, 2020 with DON (staff # 15) was conducted. The DON stated that the screeners have not had formal training, but she inserviced them on answering the questions on the form. The DON further stated that her expectation is that the temperature be completed on the screening form for all staff, and agreed that the temperature was missing on the 5 screening forms reviewed. The facility policy titled, COVID-19 Screening Policy: Staff, Healthcare Providers (HCP), Visitors, stated that any person entering the facility at any time will be screened for COVID-19 symptoms following current CDC (Centers for Disease Control and Prevention), CMS (Centers for Medicare & Medicaid Services), state and county guidelines. Screening will be conducted prior to entering resident care areas. It further included, that any individual not complying with screening requirements will not be permitted to enter the facility. Any individual with a fever, will not be permitted to enter, unless secondary screening by a designated facility staff is completed. Review of the facility policy titled, Infection Control and Prevention Policy, included to increase monitoring of residents and staff, and that healthcare personnel (HCP) should be screened on a daily basis. Including HCP monitoring for COVID-19 symptoms and fever. The CDC guidance titled, Preparing for COVID-19 in Nursing homes, dated June 25, 2020 and updated November 20, 2020, included Core Practices which should remain in place even as nursing homes resume normal activities. The Core Practices include evaluation and management of healthcare personnel (HCP), indicating that HCP should be screened at the beginning of their shift for fever and symptoms of COVID-19, including actively taking their temperature and documenting absence of symptoms consistent with COVID-19. The CMS guidance titled, Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Nursing Homes, dated March 13, 2020 and updated November 28, 2020, included additional guidance. To implement active screening of residents and staff, at the beginning for their shift, for fever and respiratory symptoms. To actively take their temperature and document absence of shortness of breath, new or change in cough and sore throat. - Regarding cleaning of glucometer. An Interview was conducted, on the 200 Unit (Non-COVID) with RN (staff # 51) at 9:50 a.m. on December 17, 2020. The RN stated that there is 1 glucometer for the unit and it is disinfected between each resident use with micro-kill wipe, then left to dry. An Observation of nurse (LPN/Staff #200) was conducted on December 17, 2020 at 10:20 am. (200 Unit, non-COVID). The LPN was in the resident room and proceeded to take the resident's blood sugar. She then took the glucometer to the medication cart and set it down on top of the cart. The LPN then opened an alcohol wipe, wiped the glucometer with the alcohol wipe, and then immediately placed the glucometer in the medication cart drawer. An interview was conducted, with nurse (LPN/Staff # 200) on December 17, 2020 at 10:27 a.m The nurse stated that to clean the glucometer, she wipes it down with an alcohol wipe, and further states she does not know what the policy says, but that's what she does. During this interview, at 10:33 a.m , the DON (staff # 15) stated that the facility policy is to sanitize the glucometers after each use with a sanitizing wipe, then wrap the glucometer in the wipe and leave wrapped for 3 minutes. The DON educated the LPN (staff #200) at that time and stated she will do an inservice. The DON (staff # 15) then asked the LPN (staff #200) how she had cleaned the glucometer, the nurse stated that she cleaned it with an alcohol wipe and then placed the glucometer in the drawer. The DON stated that the staff member did not clean the glucometer according to the facility policy, and that it poses an infection control risk, and that the other products in the drawer might have been contaminated. A Review of an In-service Attendance Record, that hand been completed on December, 17 2020, between the DON (staff # 15) and LPN (staff #200) was conducted. The form documentation revealed that glucometer checks and cleaning in-service had been provided to the LPN on December, 17, 2020. It further stated that the glucometer should be wrapped in a bleach wipe for 3 minutes, then placed on a barrier to dry, before use and between each patient. A review of the facility policy titled, Infection Control and Prevention Policy, was completed. The policy included that all non-dedicated, non-disposable medical equipment used for patient care should be cleaned and disinfected according to manufacturer's instructions and facility policies. This is to ensure that environmental cleaning and disinfection procedures are followed consistently and correctly. Routine cleaning and disinfection procedures to frequently touched surfaces or objects are appropriate for [DIAGNOSES REDACTED]-CoV-2 in healthcare settings. A review of another facility policy titled, Cleaning and Decontamination of Glucometer, was completed. It states to disinfect after each use the exterior surfaces following the manufacturer's directions or may use a cloth/wipe with either an EPA-registered detergent/germicide with a tuberculocidal or HBV/HIV label claim. A review was conducted of the Centers for Disease Control and Prevention (CDC), Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated December 14, 2020. It states that indirect contact transmission involves the transfer of an infectious agent through a contaminated intermediate object or person. Patient care devices (e.g.: electronic thermometers, glucose monitoring devices) may transmit pathogens if devices contaminated with blood or body fluids are shared between patients without cleaning and disinfecting between patients. A review was conducted of the Centers for Medicare & Medicaid Services (CDC) guidance titled, Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Nursing Homes, updated on September 28, 2020. It included to properly clean, disinfect and limit sharing of medical equipment between residents and areas of the facility. A review of CDC guidance titled, Preparing for COVID-19 in Nursing Homes, updated November 20,2020 included, to develop a schedule for regular cleaning and disinfection of shared equipment. Ensure EPA-registered, hospital-grade disinfectants are available to allow for frequent cleaning of high-touch surfaces and shared resident care equipment. Ensure HCP are appropriately trained on its use. - Regarding PPE During the entrance interview on December 17, 2020 at 8:50 a.m. with Executive Director (staff # 23) and Director of Nursing (DON/staff # 15), the DON stated that the whole facility is on droplet precautions at this time. An observation of the 200 Unit (non-COVID) at 9:45 a.m. on December 17, 2020, revealed that there were signs on the wall by resident doors for Droplet Precautions and Contact Precautions. Signage outside the resident rooms had pictorial for sequence for putting on (donning) PPE: gown, mask or respirator, goggles or face shield, gloves. An interview was conducted with RN (staff # 51), at 9:50 a.m. on December 17, 2020, on the 200 Unit (non-COVID). The RN stated that gowns are to be worn in all resident rooms. An Observation of nurse (LPN/Staff #200) on December 17, 2020 at 10:20 a.m. (200 Unit, non-COVID) was conducted. The LPN was in the resident room with gloves, mask and eyewear, no gown, setting up to assist the resident. The Nurse was standing by the resident bedside, she then walked around the resident bed, and went back to the door stating, I forgot my gown. She then donned the gown, walked back to the patient bedside, and proceeded to take the resident's blood sugar. Upon leaving the room she removed the gown/gloves and sanitized her hands. An interview was conducted, with nurse (LPN/Staff # 200) on December 17, 2020 at 10:27 a.m., who stated that she has not had a PPE inservice, but someone came by to remind her to use mask, goggles, gloves and gowns. She further stated that all residents in the facility are on droplet precautions. She stated that she was not wearing a gown when she initially entered the resident's room, that she set the pills on the windowsill, and then went back and put on a gown. She stated that the glucometer had been in her scrub pocket prior to completing the blood glucose procedure. She also verbalized that she should have put on a gown before entering the resident's room. An interview was conducted on December 17, 2020 at 10:45 a.m. with CNA (staff # 110) who stated that a gown must be worn in all resident rooms. An interview was conducted with with the DON (staff #15), on December 17, 2020 at 2:37 p.m. The DON stated that she had already inserviced the LPN (staff # 200) regarding the use of gowns in all resident rooms. A review of the In-service Attendance Record form, that had been completed by the DON (staff # 15) with LPN (staff #200) on December 17, 2020, revealed that all rooms are on contact and droplet precautions at this time. A gown, gloves, goggles, face mask should be worn in every room. A review was conducted of the facility policy titled, Infection Control and Prevention Policy. It included, to adhere to standard and transmission based precautions, assume that every person is potentially infected or colonized with a pathogen that could be transmitted in the healthcare setting. To Increase transmission-based precautions, consider having HCP wear all recommended PPE (gown, gloves, eye protection, N-95 respirator) for the care of all residents, regardless of presence of symptoms. Attention should be paid to training and proper donning (putting on), doffing (taking off), and disposal of any PPE. It further states that Health Care Personnel (HCP) who enter the room of a patient with known or suspected COVID-19 should adhere to standard precautions and use a respirator or facemask, gown, gloves and eye protection. Instructions to donn gowns include: put on an isolation gown upon entry into the patient room or area. A review of the Centers for Disease Control and Prevention (CDC) guidance titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated December 14, 2020, was conducted. The guidance states to implement universal use of personal protective equipment. HCP working in facilities located in areas with moderate to substantial community transmission, are more likely to encounter asymptomatic or pre-symptomatic patients with [DIAGNOSES REDACTED]-CoV-2 infection. CDC recommends using additional infection prevention and control practices during the COVID-19 pandemic, along with standard practices recommended as a part of routine healthcare delivery to all patients. These practices are intended to apply to all patients, not just those with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection. COVID-19 PPE for healthcare personnel include gown, gloves, faceshield or goggles, face mask or N-95. HCP who enter the room of a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection should adhere to Standard Precautions and use an approved N95 or equivalent respirator (or facemask if a respirator is not available), gown, gloves, and eye protection. A review of CDC guidelines titled, Strategies for Optimizing the Supply of Isolation Gowns, updated October 9, 2020, included that facilities should provide HCP with required education and training, including having them demonstrate competency with donning and doffing, with any PPE ensemble that is used to perform their job responsibilities, such as provision of patient care. Nonsterile, disposable patient isolation gowns, which are used for routine patient care in healthcare settings, are appropriate for use by HCP when caring for patients with suspected or confirmed COVID-19.

Based on observation, interview, and record review the facility failed to develop and maintain an infection control program designed to prevent the spread of [DIAGNOSES REDACTED] CoV-2 (the novel coronavirus which causes COVID-19), when they failed to quarantine two of nine sampled residents (Resident 22 and Resident 15) for 14 days following admission to the facility, per the Centers for Disease Control's (CDC) guidelines. These failures had the potential to spread [DIAGNOSES REDACTED] CoV-2 and infect other residents and staff and cause a potential outbreak in the facility. Findings: Resident 22: During the entrance conference on 07/08/2020 at 1:00 PM, the Director of Nursing (DON) and the Administrator in Training (AIT) explained that the facility had 3 resident hallways, 100, 200, and 300. The 100 hallway was the unit where newly admitted residents were co-horted during the 14 day observation period, and the other two hallways were for long term care residents. The end of hallway 100 was where COVID positive residents would be housed. They also explained that the whole care area of the facility was under isolation precautions, and any who entered the care area would need don (put on) Personal Protective Equipment (PPE). Observed the donning and doffing area prior to entering the resident care area on 07/08/2020 at 1:15 PM. Stations were clearing marked with instructions at each station directing staff to don or doff PPE and perform hand hygiene. Each step was consistent with CDC guidance on the donning and doffing sequence. Observed door to Resident 22's room was closed on 07/08/2020 at 1:30 PM. The resident's room was located on the 300 hallway. A small portable cart with PPE was just outside the doorway between two resident rooms. Two staff members were observed to exit Resident 22's room at 1:40 PM. Both staff removed an outer isolation gown, hung it on the wall and washed their hands. When they entered the hallway they had a base layer isolation gown, a mask, and eye protection and again, performed hand hygiene. One of the staff members carried a closed bag of trash down the hallway and the other staff stopped and was interviewed by the surveyor. Licensed Nurse (LN) 1 stated on 07/08/2020 at 1:45 PM that she had worked in the facility for about 2 years. When asked if the PPE cart indicated one of the rooms, or residents were on isolation precautions, she stated One room is but was unsure of which room. She then clarified that the facility had just today implemented every resident was on transmission based precautions due to a facility outbreak of COVID-19. When asked what precautions they used, she explained that in addition to all staff wearing an isolation gown, mask, and eye protection when entering the care area of the facility, staff were to don (put on) another isolation gown that was kept just inside of each resident's room. Double gown and wear gloves. Then doffing the outer gown after completing care for the resident place it back on a hook by the door so it could be reused, then remove gloves and wash hands. Resident 22's electronic health records were reviewed on 7/9/2020. The Admission Record read Resident 22 was admitted to the facility on [DATE] from another skilled nursing facility with a primary [DIAGNOSES REDACTED]. The Census List indicated Resident 22 had been admitted to a room on the 100 hallway on 04/30/2020 and moved to a room on the 300 hallway on 05/07/2020. A single SAR-CoV-2 respiratory test collected on 05/06/2020 read negative. An Order Recap report of all orders between 04/30/2020 and 07/31/2020 revealed an order which read Isolation Precautions- contact, droplet every shift dated 4/30/2020 and discontinued on 05/07/2020, 7 days after admission. Progress notes revealed a note written by the Case Manager on 05/07/2020 and read Resident cleared from isolation and moved to a long term care room. CDC Guidance titled Responding to Coronavirus (COVID-19) in Nursing Homes dated reviewed: April 30, 2020 provided guidance for new admissions and readmission to the facility. It read, Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Options include placement in a single room or in a separate observation area so the resident can be monitored for evidence of COVID-19. All recommended COVID-19 PPE should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. Testing residents upon admission could identify those who are infected but otherwise without symptoms and might help direct placement of asymptomatic [DIAGNOSES REDACTED]-CoV-2-infected residents into the COVID-19 care unit. However, a single negative test upon admission does not mean that the resident was not exposed or will not become infected in the future. Newly admitted or readmitted residents should still be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE. Testing should not be required prior to transfer of a resident from an acute-care facility to a nursing home. New residents could be transferred out of the observation area or from a single to a multi-resident room if they remain afebrile and without symptoms for 14 days after their last exposure (e.g., date of admission). Testing at the end of this period could be considered to increase certainty. During an interview with the DON on 07/10/2020 at 11:46, the DON was asked about Resident 22's quarantine period and subsequent precautions being discontinued at less than 14 days when moved from the new admissions co-horted on the 100 hallway. The DON described the facility's admission policy as allowing the discontinuation of the observation period after two negatives tests for COVID-19. When asked if the transmission based precautions would have been continued once moving to the long term care hallway, she sated If we moved him over to the long term care side then he would not have been on the isolation. When informed the surveyor only identified one test in the resident's medical record, collected on 05/06/2020, the DON reviewed Resident 22's medical record and stated I don't see the second one here. The DON agreed to provide additional documentation of a second test if located. This additional documentation was not provided to surveyor. Surveyor requested the new admissions policy and procure on 07/10/2020 as the topic was not addressed in the Emerging Infectious Disease (EID) Emergency Plan Coronavirus 2019 (COVID-2019) provided during the entrance conference. The surveyor was provided the New admission/14 day observations Policy and Procedures dated 05/20/2020. It read in part, New admits with unknown COVID 19 results will be swabbed for COVID 19. The (sic) will remain on droplet/isolation precautions until results are reported. If the results are positive the (sic) will be transferred to a COVID 19 facility. If results are negative, they will come off droplet/isolation but will be required to wear the mask with all care of out of room. All new admissions will continue to be monitored during this initial 14 day period. Resident 15: On 07/08/2020 at 2:10 PM, observed Resident 15's room at the end of the 100 hallway. The door was closed and a small portable cart with PPE was just outside the doorway between two resident rooms. Two signs were posted on the door. One read Droplet precautions and the other read Doffing PPE Example 1. Resident 15's electronic health records were reviewed on 7/9/2020. The Admission Record indicated the resident was most recently admitted on [DATE] from an acute care hospital. The Order Recap Report for the time period 06/16/2020 to 07/31/2020 read Patient to be sent out to (local) hospital for blood transfusion related to a [DIAGNOSES REDACTED]. The resident's Census List read the resident was admitted to a room on the 100 hallway on 06/17/2020, and then moved to the 200 hallway on 06/26/2020 (Day 9 of admission). Two separate isolation orders were identified on the Order Recap Report. One dated prior to admission on 06/10/2020 and discontinued on 06/23/2020 read Isolation Precautions- contact, droplet every shift. The other was initiated on 07/07/2020 and read Isolation Precautions- contact, droplet every shift for covid+. Lab results in the record revealed a COVID-19 test was collected on 06/18/2020 (1 day after admission) which read negative and one collected on 06/30/2020 (Day 13 after admission and 4 days after being moved off of the 100 hallway.) The 06/30/2020 COVID-19 test was not reported back to the facility until 07/07/2020 and it read COVID-19 was detected. The Census List revealed Resident 15 was transferred back to the 100 hallway on 07/07/2020. Reviewed Progress Notes for 06/26/2020, the day resident was transferred off of the 100 hallway, there were no notes relating to the room move. A nursing note dated 07/03/2020 read Resident 15 had developed a temperature of 100.0 and audible chest congestion. The note indicated the physician was notified, new orders were received, and a COVID-19 test was pending. An Interdisciplinary Team (IDT) note dated 07/07/2020 read Chart reviewed, discussed with members of IDT. Resident placed on contact droplet isolation with skilled respiratory assessment due to (+)Covid19 on 7/7/20. A review of the June and July Medication Administration Record [REDACTED]. During the time between June 23rd and July 7th no entries on the MAR indicated [REDACTED]. One nursing note during this time documented the use of precautions. This note dated 6/30/2020 read Patient on isolation droplet, contact precautions. A Change of Condition for COVID-19 positive note dated 7/9/2020 at 06:30 AM read that Resident 15 developed acute symptoms which included altered mental status, cough, congestion, shortness of breath, low blood pressure and low oxygen readings while on 4 liters of oxygen. The resident was transferred to an acute care hospital at 04:30 AM. The DON was interviewed on 07/10/2020 at 12:30 PM regarding Resident 15. When asked why an isolation order had been implemented on 06/10/2020 before the resident was readmitted , she replied We put the building on isolation on June 10th, because of the positive (case). She was not put on isolation. When asked to describe what the building on isolation involved, she described that all staff donned the following PPE before entering the care area, gown, face mask, and eye protection. Gloves and hand hygiene was performed between each resident contact. This type of facility isolation was implemented to extend the limited supply of PPE. She clarified, that for residents on the 100 hallway where new admissions were co-horted reusable gowns were used on top of the base layer gown to maintain the transmission based precautions in place. Double gowning only occurred in the rooms for people who were on Precautions. The surveyor asked to clarify that staff wore the same PPE for all residents except those on transmission based precautions. The DON stated Yes. Starting on June 10th. When asked if Resident 15 was placed on the isolation precautions upon return from the hospital on [DATE], she replied When she came from hospital, she was considered a new admission. She was unable to explain the discontinuation of the isolation order. She confirmed the resident was moved off of the new admission co-hort hallway (100) on 06/26/2020, onto a long term care hallway, before the 14th day after admission. During the same interview, the DON explained that on 07/07/2020 when two residents tested positive for COVID-19, the facility implemented the double gowning for every resident in the facility. Surveyor clarified that prior to 07/07/2020, the residents on the long term care hallways were not under individual transmission based precautions, just the facility isolation implemented on 06/10/2020. The DON confirmed this. During a phone interview on 7/11/2020 at 10:51 AM, the Administrator was questioned about the development of the policy on New admissions/14 day observation. He stated that in mid-May, 2020 they had changed to testing for COVID-19 twice, We had a whole host of calls with the State. Due to an expected in-flux of residents in mid-May he thought the smartest thing to do was to get the residents off the new admission unit as quickly as possible, and their understanding was that testing residents changed their status to known. When asked how he could ensure that a resident who was tested before the completion of their observation period, would not then convert to positive after the test and before the 14th day, he was not able to describe how that was achieved. The CDC's Clinical Questions about COVID-19: Questions and Answers on Transmission read, Based on existing literature, the incubation period (the time from exposure to development of symptoms) of [DIAGNOSES REDACTED]-CoV-2 and other coronaviruses (e.g., MERS-CoV, [DIAGNOSES REDACTED]-CoV) ranges from 2-14 days. https://www.cdc.gov/coronavirus/2019-ncov/hcp/faq.html

Based on interview and record review the facility failed to maintain to accurately document the presence of possible COVID-19 signs and symptoms on the monitoring tool implemented for residents for 4 of 9 sampled residents (Residents 22, 18, 15 and 9). These records did not contain an accurate representation of the actual experience of the residents and could mislead healthcare providers and public health experts when reviewing these records and/or evaluating the residents' progress and/or changes in conditions. Findings: Resident 22's electronic health record reviewed on 07/09/2020 for documentation of monitoring for signs and symptoms of COVID-19. The Temp Summary page read on 07/01/2020 at 22:22 temperature as 100.1 F. The O2 Sats Summary read on 07/02/2020 at 16:12, Oxygen saturation on room air was 73% (a normal range for oxygen saturations is generally above 95% for health adult, and above 88% for person with significant lung disease). A nursing progress note dated 07/02/2020 read MD notified of Temp of 100.1 @ 2200 7/1/2020. Covid 19 testing was done 6/11/2020 and was negative. Slight cough noted without (shortness of breath, nausea or vomiting, or headache). MD ordered Covid 19 screen to be done. No progress notes addressed the low oxygen level recorded. The facility's COVID-19 symptom monitoring was located on the Medication Administration Record (MAR). Directions on the July 2020 MAR read Document Temp/O2 sats and monitor for the following symptoms: Fever, Cough, Shortness of breath or difficulty breathing, Chills, Repeated shaking with chills, Muscle pain, Headache, Sore throat, New loss of taste or smell, GI Symptoms: Diarrhea/Nausea/ Vomiting every shift **Notify NP/MD if present There is a space for Licensed Nurses to record the presence or absence of symptoms under -/+, Blood pressure, temperature, pulse, respirations, oxygen saturations, and initial for the shift. While both the abnormal temperature reading and oxygen saturation readings were recorded, the space for symptom presence was marked with negative notation. Interviewed Licensed Nurse (LN) 3 on 07/10/2020 at 09:35 AM about COVID-19 monitoring and documentation of resident signs and symptoms. LN3 stated the nurses monitored residents throughout their shift for signs and symptoms such as temperature and O2 sats, cough, respiratory things or chest pains. Any kind of pains really. She demonstrated how the monitoring was entered into the electronic monitoring task and showed the surveyor how the resident's most recent vital signs were displayed and selected for entry. The last step before signing off LN3 said was you enter a negative sign if there were no signs or symptoms, and plus sign if they were. You have to enter a note as well . a change of condition note or COVID-19 note. When asked how a nurse would document a positive symptom if she had already signed off the monitoring, she stated they would have make a change of condition note, or they could enter a COVID-19 note, but they could not go back into the monitoring and change it. When asked who looks at the monitoring, she stated The nurses, the DON, and nursing assistants When asked if physician would also use it to evaluate the resident's history she said Oh yes the physicians too. During an interview on 07/10/2020 at 11:46 AM the DON confirmed she was aware of Resident 22's temperature spike on 07/01/2020. When asked if she was aware the negative entry for symptoms she stated she was not. When asked if she was aware of the documented low saturation reading of 78% recorded on 07/02/2020. She said she was not. She stated her expectation when a reading was low like that, was the nursing assist should alert the nurse and recheck the reading. When asked if she thought it may be a data entry error, she replied The nurse should have seen it and struck it out. The DON agreed that the COVID-19 monitoring did not reflect an accurate account of the monitoring being done. Resident 18's electronic health record reviewed on 07/09/2020 for documentation of monitoring for signs and symptoms of COVID-19. Progress notes revealed a nursing noted dated 07/09/2020 at 10:46 AM which read, Respiratory rate, rhythm, sound deviates from baseline. Active (symptom): cough. Another nursing note dated 07/09/2020 at 07:50 AM read Productive cough noted and continues to have temps @ 99.6. O2 Sats remain above 90% . Stat Chest Xray ordered per Dr. The COVID-19 signs and symptom monitoring recorded on the MAR for the day shift on 07/09/2020 read negative. Resident 15's electronic health record was reviewed on 07/09/2020 for documentation of monitoring for signs and symptoms of COVID-19. Progress notes revealed two separate nursing notes dated 07/07/2020 that described the presence of a productive cough. A nursing noted dated 07/08/2020 also described a productive cough. A Change of Condition for COVID-19 positive note dated 7/9/2020 at 06:30 AM read that Resident 15 developed acute symptoms which included altered mental status, cough, congestion, shortness of breath, low blood pressure and low oxygen readings while on 4 liters of oxygen. The resident was transferred to an acute care hospital at 04:30 AM. Resident 15's COVID-19 signs and symptom monitoring recorded on the MAR for negative for the Day shift on 07/07/2020, Day shift on 07/08/2020, Evening shift on 07/08/2020 and were not recorded for the Evening shift of 07/07/08 or the Night shift of 07/07/2020. The MAR did reveal a positive notation for the Night shift of 07/08/2020 when the resident was sent to the hospital. Resident 9's electronic health record was reviewed on 07/09/2020 for documentation of monitoring for signs and symptoms of COVID-19. The Temperature summary read on 07/04/2020 at 11:11 AM the resident's temperature was 100.2 F. Progress notes reviewed did not reveal a note addressing this temperature, however a nursing note dated 07/04/2020 at 12:33 PM read that Tylenol 500mg had been administered. A different nursing note dated 07/04/2020 at 14:53 read the resident had occasional loose productive cough that lung sounds were diminished. Resident 9's COVID-19 signs and symptom monitoring recorded on the MAR for both the Day shift and Evening shift read negative. The temperature reading of 100.2 was also not recorded on the monitoring for either shift. During the interview with the DON on 7/10/2020 these inaccuracies were discussed. When brought to the attention of the DON, she stated The monitoring on the MAR does not reflect the actual monitoring they are doing.

Based on clinical record review, staff and resident interviews, hospital documentation and policy and procedures, the facility failed to ensure that one out of two sampled residents (#11) received care and services related to an indwelling urinary catheter, in accordance with professional standards of practice. The deficient practice resulted in the resident being sent to the hospital for an invasive procedure, with the potential to result in further complications. Findings include: Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was readmitted to the facility on [DATE]. Review of the clinical record revealed the resident was admitted with an indwelling urinary Foley catheter (a catheter which drains urine from the bladder and is inserted through the urethra opening). However, a care plan initiated on May 6, 2019 included the resident had an indwelling supra pubic catheter (a catheter which drains urine from the bladder and is inserted through a small hole in the lower abdomen). The care plan included goals and interventions. Despite this, there was no clinical record documentation that the resident had a supra pubic catheter, only documentation that the resident had an indwelling urinary Foley catheter in place. A physician's orders [REDACTED]. A physician's orders [REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The assessment also included that the resident had an indwelling urinary catheter. According to a physician progress notes [REDACTED]. Review of a late entry nursing note dated November 13, 2019 revealed that on November 12, 2019 at 5:35 p.m., nursing staff attempted to change the resident's Foley catheter with some difficulty and that a new catheter was inserted by the charge nurse at 6:00 p.m. (The size of the catheter used was not documented). Per the note, the catheter drainage bag was checked at 7:30 p.m. with no urine noticed in the bag. The catheter was rechecked and the catheter balloon would not deflate. The resident's bladder was palpated for fullness, and the bladder was lightly extended. The resident was sent out due to a catheter malfunction and the Director of Nursing (DON) and physician were notified. Review of the hospital records dated November 12 and 13, 2019, revealed that the resident was initially seen by the physician in the Emergency Department at 11:14 p.m. on November 12. The note included the resident had a history of [REDACTED]. The resident presents with a malfunctioning Foley catheter. The resident reported that nursing staff attempted to replace the catheter, however, the balloon was inflated prior to obtaining return of urine. Staff were not able to withdraw the catheter and unable to obtain any drainage. Staff then cut the catheter in an attempt to deflate the balloon, without success. Per the note, the resident was complaining of fullness to his abdomen and feeling sweaty, which happens to him when his bladder gets too full. The resident had a Foley catheter extending about 4.5 centimeters past the end of his penis, and the catheter tubing had been cut. The resident had a palpable distended bladder. At 11:40 p.m., hospital nursing staff attempted to deflate the catheter balloon without success. A bedside ultrasound was performed which was unable to locate the catheter balloon within the resident's bladder. The ultrasound also indicated the resident had a very full bladder. At 12:15 a.m., there was an attempt to deflate the catheter balloon with a guidewire without success. The results of a Computed Tomography (CT) scan at 12:50 a.m., revealed the catheter balloon was inflated within the proximal portion of the resident's urethra, and the resident's bladder had prominent distention with a calculated volume of approximately 1.6 liters. At 2:30 a.m., the resident was taken to [MEDICATION NAME] radiology where a CT-guided technique was used to puncture the catheter balloon, removed the Foley catheter, and a new Foley catheter was placed. The hospital records included that the resident did not have sensation in the lower extremities and he did not feel pain in this area, however he stated that he experienced shakiness and diaphoresis (sweating) instead of pain. Review of the clinical record revealed the resident was readmitted to the facility on [DATE], with an indwelling urinary Foley catheter in place. Review of the physician orders [REDACTED]. Review of a nurse practitioner progress note dated November 20, 2019 revealed the resident reports that the Foley is leaking and wants it changed. Evaluated today and no signs of leaking. An interview was conducted with the resident on December 2, 2019 at 10:05 a.m. He stated that staff in the facility had put his catheter in wrong and he had to go to the hospital and have a procedure to take it out. He said he had a lot of swelling and bleeding afterward. He said that the swelling had since gone down, but the catheter in now was too small and has started to leak. He said he had recently asked to have his catheter changed because it was leaking, but no one would change it. An observation of catheter care was conducted on December 3, 2019 at 2:21 p.m., with a Certified Nursing Assistant (CNA/staff #15). The resident had a Foley urinary catheter in place. During the observation, the resident again stated that his catheter had been leaking, because it was too small. At this time, there was no leaking observed and the size of the catheter was a 14 French (which is smaller than a 16 French catheter, which is the size that was ordered by the physician). An interview was conducted with a Registered Nurse (RN/staff #112) on December 4, 2019 at 2:32 p.m. He stated that he remembered the incident involving difficulty in changing the resident's catheter. He said he was working as the charge nurse, when the resident's nurse (staff #11) came to him and said that the resident's catheter would not flush. He said he went to help remove the catheter, and then he inserted a new catheter. He said the catheter returned urine during the insertion, and he instructed the nurse to monitor the catheter for urine output. He said his shift ended and he went home. He said he later learned that the resident had been sent to the hospital. He said he did not participate in cutting the resident's catheter tubing, as that occurred after his shift ended. An interview was conducted with a RN (staff #11) on December 4, 2019 at 2:43 p.m. She said she was the nurse caring for the resident during the incident when there had been difficulty changing his catheter. She said that she and two nurses (staff #112 and staff #76) tried to remove the catheter, but the balloon would not deflate. She said a new catheter was inserted, and that there was a little urine draining into the bag, but within one hour of insertion she noticed no additional urine was draining. She said that she knew something was wrong, so she and two other nurses tried to cut the catheter tubing as a last resort to see if it would drain urine from the bladder. She said cutting the tubing would not be a normal procedure. She said it did not work and they could not remove the catheter, so they had to send the resident to the hospital. An interview was conducted with a Licensed Practical Nurse (LPN/staff #76) on December 5, 2019 at 2:29 p.m. He said staff #11 had called him over because she could not remove the resident's catheter. He said he attempted to draw fluid out of the catheter balloon, but it did not work. He said they got the charge nurse (staff #112), who was able to deflate the balloon, remove the catheter and insert a new one. He said later in the evening, staff #11 said the resident's new catheter was not draining urine. He said he and the night nurse (RN/staff #24) assisted staff #11 to try to remove the resident's catheter. He said it appeared like the catheter might have been kinked inside the resident's urethra. He said he and staff #24 tried to un-kink the catheter, with no success. He said he had never seen anything like it, as the catheter balloon would not deflate. He said he suggested to staff #24 that maybe if they cut the catheter it would help to remove the kink and release fluid. He said he and staff #24 cut the catheter, but it did not work. He said then the resident was sent to the hospital. An interview was conducted with a RN (staff #24) on December 5, 2019 at 2:41 p.m. He stated that staff #76 came to him because he was trying to flush the resident's catheter. He said the catheter was twisted and they could not get it untangled. He said staff #76 had an idea to cut the catheter to help it unravel. He said they cut it, but it did not help so they called 911. He said he did not cut the catheter, it was the other nurse. An interview was conducted with the DON (staff #123) on December 5, 2019 at 3:12 p.m. She stated her expectation is if a nurse was troubleshooting a resident's catheter, they should attempt several times to inflate, deflate, insert or remove the catheter, according to the situation. She said if the attempts were unsuccessful, the nurse should call the physician and send the resident to the emergency room . She said she would not expect staff to cut the resident's catheter. Review of the facility's policy regarding indwelling catheter insertion revealed that the insertion of a Foley catheter is completed to maintain drainage of urine from the bladder. The procedure should be done by qualified personnel. Instructions included to not force the catheter into the urethra, to insert the catheter until urine begins to flow, and to advance the catheter 1.5 inches beyond the point of urine flow. Hold the catheter in place with one hand and attached a pre-filled syringe to the balloon part of the catheter. Slowly inject sterile water, do not force, if the water does not inject easily or if the resident complains of pain, deflate completely and advance the catheter farther, then re-inflate. Gently pull on the catheter until resistance is felt. This positions the balloon correctly. Check urinary flow frequently and document information.

Based on observations, clinical record review and resident and staff interviews, the facility failed to ensure that one of two sampled residents (#11) received proper care and treatment to maintain good foot health. The deficient practice resulted in a lack of podiatry care resulting in foot complications. Findings include: Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a care plan initiated May 6, 2019, revealed the resident had a self-care performance deficit, with a goal that the resident would maintain his current level of functioning with bed mobility, dressing, grooming, toilet use and personal hygiene through the review date. Interventions included to explain procedures before starting, promote dignity by ensuring privacy, and encourage the resident to participate to the fullest extent possible with each interaction. Review of the admission physician's orders [REDACTED]. A care plan initiated on May 15, 2019 for impairment to skin integrity related to [MEDICAL CONDITION], immobility and history of pressure ulcers included the goal that the resident would be free from injury through the review date. Interventions included to administer wound care per physician orders, a low air loss mattress, and to use caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp or hard surface. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident did not have short term memory problems and had the cognitive skills to independently make decisions regarding tasks of daily living. The assessment also included that the resident required extensive assistance with bed mobility, dressing and personal hygiene, and the resident had functional limitations in range of motion to both lower extremities. A provider progress note dated May 31, 2019 revealed the resident had requested to be seen by podiatry to clip his toenails and that a podiatry consult had been ordered. A physician's orders [REDACTED]. Patient has to be on stretcher lying down or have podiatrist come see him here at the facility. A podiatry progress note dated June 3, 2019 included that the resident's toenails had not received care in over a year. The nails were thick and long on both feet. There was blood on the left and right great toes from subungual hematoma (bleeding and bruising under the nail). All left and right foot toenails were cut, filed and thinned using a mechanical grinder. [MEDICATION NAME] (antibiotic ointment) was applied to the left and right great toes and they were covered with adhesive bandages. The wound nurse was instructed to apply [MEDICATION NAME] and monitor the toes for one week. The note included there was an initial concern that the resident might develop [MEDICAL CONDITION], but the resident was already receiving intravenous antibiotics for another condition, so further antibiotics were not needed. Review of a provider progress note dated July 24, 2019, revealed the resident was not seen that day, due to the resident being out of the building for podiatry. Review of the clinical record revealed no evidence that the resident was seen by the podiatrists in July 2019. A podiatry progress note dated August 7, 2019 revealed the resident was not seen by podiatry, because the resident was out of the building at the dentist. There was no clinical record documentation that the resident was seen by the podiatrist in August 2019. A physician's orders [REDACTED]. However, there was no evidence that the resident was seen by the podiatrist in September 2019. A physician's orders [REDACTED]. Review of the clinical record revealed there was no documentation that the resident was seen by the podiatrist from October 1 through 9, 2019. A nursing note dated October 10, 2019 included the resident complained of an ingrown toenail (did not specify if on the left or right) and the provider was notified and no new orders were received. A provider progress note dated October 10, 2019 revealed the resident was sent to the hospital related to a new onset of fevers and the decline of a wound, which was not on the resident's feet. A podiatry progress note dated October 14, 2019 included that the resident was not seen by podiatry, because the resident was out of the building at the hospital. According to the clinical record documentation, the resident was readmitted to the facility on [DATE]. There was no clinical record documentation that the resident received podiatry services from October 15 through November 19, 2019. A provider progress note dated November 20, 2019, included the podiatrist was to evaluate and trim the resident's toenails, per the resident's request. Further review of the clinical record revealed there was no evidence that the resident was provided podiatry services from November 20 through December 2, 2019. An interview was conducted with the resident on December 2, 2019 at 10:08 a.m. He stated he had been waiting for more than six months for his toenails to be trimmed. He said staff kept telling him he was on the list for podiatry, but that was all they did. He said he believed his toenails were starting to curl. An interview was conducted with a Licensed Practical Nurse (LPN/staff #98) on December 3, 2019 at 11:24 a.m. She stated the podiatrist comes to the facility every three months to treat residents. She said a list of residents is kept for the podiatrist, but the podiatrist would be willing to see additional residents not on the list, during routine visits to the facility. She said some residents were also sent out of the facility to see a podiatrist if needed. An observation of the resident's feet was conducted on December 3, 2019 at 2:21 p.m., with a Certified Nursing Assistant (CNA/staff #15). The resident's right great toe had yellow-green discharge which was partially dried and was attached to and pulling from the inside of the resident's sock, as it was removed. Once the resident's socks were removed, yellow-green discharge was observed on the surface and under the medial nail fold of the right great toe. The resident's right and left great toes appeared reddened. Both the right and the left great toenails were long, extending approximately one centimeter beyond the nail bed. The resident's other toenails were also long. The resident's left great toenail appeared to be partially detached from the nail bed. There was also a dark accumulation of debris which was approximately one centimeter in diameter that was underneath and protruding from the end of the right and left great toenails. Another observation of the resident's feet was conducted on December 3, 2019 at 2:51 p.m., with a Registered Nurse (staff #67). Staff #67 stated she was the wound nurse. She said the resident's right great toe appeared to have an ingrown toenail, and she described the drainage from the right great toe as purulent and greenish. At this time, staff #67 took a sample of the drainage for a culture test. The nail bed of the right great toe began bleeding once the drainage was cleansed and removed. Staff #67 said the resident's toenails were very, very long. She said the resident's left great toenail looked like it was going to come off. She said the accumulation under the right and left great toenails appeared fungal. She said the resident definitely needed a podiatry consultation. She said she would obtain treatment orders from the physician. A follow-up interview was conducted on December 3, 2019 at 3:46 p.m. with staff #67. She said the reason the resident did not receive podiatry care in August and October 2019 was because the resident was out of the facility when the podiatrist was onsite. She said podiatry normally trimmed toenails, but the nurses could initiate and provide other treatments to the resident's feet. She said residents could also be sent out to see a podiatrist if needed. She said it was not necessary to wait for podiatry, in order for a resident's feet to be treated. She said now that a problem has been identified for the resident, it would be treated. Review of a wound nurse progress note dated December 3, 2019, revealed documentation that purulent blood-tinged drainage was noted from the right great toe. Triple antibiotic ointment and a band-aid were applied to the right great toe. A culture from the drainage of the right great toe was sent to the lab. The left foot and toenails were also assessed. A weekly skin assessment dated [DATE] included that the resident's right great toe had some serous drainage noted, with topical treatments applied as ordered. An interview was conducted with a corporate resource nurse (staff #121) on December 4, 2019 at 7:44 a.m. She stated the facility did not have a policy for podiatry care. She said if a resident needed a referral for podiatry, the facility would obtain a referral. An interview was conducted on December 5, 2019 at 1:54 p.m., with the Director of Nursing (DON/staff #123), a corporate resource nurse (staff #121), the Administrator (staff #122) and the resident's physician (staff #125). The DON stated the wound nurse had mistakenly noted that the drainage had been coming from the resident's right great toe, when in fact it was the left great toe that had drainage (however, it was explained that the yellow-green discharge was observed from the resident's right great toe on December 3, not the left toe). She said the resident's left foot had previously been receiving treatments for wound care, and if additional issues had been identified at that time, the appropriate treatments would have been initiated. The DON further stated that very thick toenails must be trimmed by the podiatrist and that in addition to podiatry services, the doctors were present almost daily in the facility and wound rounds were conducted weekly. She said that residents could be sent out of the facility to receive podiatry care, if needed. Staff #121 stated when the nurse aides provide care to the feet, they would notify the nurses of any changes they observed. A follow up observation of the resident's feet was conducted on December 5, 2019 at 2:00 p.m., with staff #121 and #125. The tip of the left great toe was reddened. There appeared to be ointment on the left great toe, but not on the right great toe. Neither the left nor the right great toe had visible drainage above or below the surface of the skin. Staff #125 pointed to the reddened area on the tip of the left great toe and stated that this was where the drainage had been. A physician's progress note dated December 5, 2019 included there was a report of greenish-blood tinged drainage from the left great toe for the past two days. The note included the resident had long nails without evidence of an ingrowing toe nail of the left great toe, and that the culture of the drainage was only growing a few white blood cells.

Based on observations, clinical record reviews, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#6) received the necessary care and services to prevent and promote the healing of an unstageable pressure ulcer, and failed to complete a timely assessment of a pressure ulcer for one resident (#13). Findings include: -Resident #6 was admitted on (MONTH) 11, (YEAR), with [DIAGNOSES REDACTED]. Review of the admission orders [REDACTED]. An admission Minimum Data Set (MDS) assessment dated (MONTH) 18, (YEAR), revealed the resident had a Brief Interview for Mental Status (BIMS) score of 6, which indicated severe cognitive impairment. The MDS included the resident required extensive assistance with bed mobility and transfers. The MDS also included that the resident was at risk for pressure ulcers and had two pressure ulcers which were present on admission and was not on a turning and repositioning program. A care plan identified that the resident had two stage 2 pressure ulcers on the buttocks. Interventions included to administer treatments as ordered, assess/record/monitor wound healing, measure length, width, and depth where possible, assess and document status of wound perimeter, wound bed and healing progress, report improvements and declines to the MD, float heels, notify nurse immediately of any new areas of skin breakdown, weekly head to toe skin assessments and for wound care team to follow. A Braden Scale for Predicting Pressure Ulcer Risk dated (MONTH) 3, (YEAR) included the resident was at high risk for developing pressure ulcers. Review of the clinical record including the weekly skin assessments revealed there was no documentation that the resident had a pressure ulcer to the right foot from admission through (MONTH) 16, (YEAR). There was also no documentation that the resident's heels were floated as care planned from admission through (MONTH) 16, (YEAR). Review of the CNA (Certified Nursing Assistant) ADL (activities of daily living) documentation regarding turning and repositioning revealed there were several notations that it was not applicable to turn and reposition the resident every two hours, and there were multiple shifts with no documentation that the resident was turned and repositioned every 2 hours from admission through (MONTH) 16, (YEAR). Review of a wound care physician's note dated (MONTH) 17, (YEAR), revealed the resident's right lateral dorsal foot had a superficial ulceration which exposed the dermis and had thin slough, with a scant amount of serous drainage. The note did not include any measurements of the wound. This was the first documentation of the right lateral dorsal foot wound. The plan included for Xeroform and a bordered gauze to the right lateral foot daily. However, review of the physician orders [REDACTED]. In addition, there was no documentation that any wound treatments were provided from (MONTH) 17 through 25, (YEAR). The next assessment of the right lateral dorsal foot wound was completed on (MONTH) 26, (YEAR), which was nine days after the previous assessment (on (MONTH) 17). Per the physician's note dated (MONTH) 26, (YEAR), the right foot had a superficial ulceration which exposed the dermis and had thin slough, with a scant amount of serous drainage. The assessment did not include any measurements of the wound. The plan was to monitor closely, as the resident can not turn himself. The note also included for Xeroform and bordered gauze to the right lateral foot daily. A physician's orders [REDACTED]. The order included to cleanse the right lateral dorsal foot with normal saline, cover with [MEDICATION NAME] and bordered gauze every Tuesday, Thursday and Saturday. The next assessment of the right foot pressure ulcer was not completed until 12 days later on (MONTH) 8, (YEAR), by the physician. The physician note included that the right plantar forefoot ulcer began as a bulla and was unstageable. There were no measurements and there was no description of the unstageable pressure ulcer. The plan was to apply [MEDICATION NAME] and gauze to the right plantar forefoot ulcer. Review of a Weekly Skin Evaluation dated (MONTH) 8, (YEAR) revealed the resident had a right plantar forefoot bulla, which measured 4 cm x 3 cm. This is the first documentation of any measurements of the pressure ulcer to the right foot. A Weekly Skin Evaluation dated (MONTH) 10, (YEAR) included the right plantar foot pressure ulcer measured 0.9 cm x 1.3 cm, with black eschar and was unstageable. Review of the Pressure Ulcer Weekly documentation which was completed by the wound nurse dated (MONTH) 13, (YEAR), revealed the right medial foot wound was unstageable with slough and black/brown eschar. The pressure ulcer measured 2.0 cm by 3.0 cm with a no exudate, no odor, wound edges were attached and the surrounding tissue was normal. The documentation included the pressure ulcer was dressed with [MEDICATION NAME] soaked gauze and covered with [MEDICATION NAME], and wrapped in Kerlix. The documentation further noted that the pressure ulcer was not present on admission. This was the first documentation by the wound nurse regarding the right foot wound, which was more than three weeks after the pressure ulcer was discovered. A wound care physician note dated (MONTH) 15, (YEAR) included the right plantar forefoot ulcer began as a bulla and was unstageable. The plan was to apply [MEDICATION NAME] and gauze to the right foot ulcer. A review of the clinical record for the period of (MONTH) 15, (YEAR) through (MONTH) 23, (YEAR) revealed weekly wound care physicians notes, which addressed the right foot wound and frequent modifications of the treatment orders. The wound care physician's note dated (MONTH) 28, (YEAR) indicated the non-healing right plantar forefoot ulceration was debrided at the bedside, which exposed peiosteum on the wound bed. The plan was to continue iodosorb gel and gauze to the right plantar forefoot ulceration, turn every two hours, and continue to mobilize patient out of bed as tolerated. A review of the Licensed Nurse Pressure Ulcer Weekly documentation dated (MONTH) 30, (YEAR), indicated that the right foot wound had slough, was unstageable and measured 1.1 by 1.2 cm with no depth. The wound also had a small amount of serosanguinous exudate and the wound edges were fibrotic and calloused, and the tissue surrounding the wound was normal. Further review of the clinical record revealed the right foot wound continued to be assessed weekly and treatments were provided through (MONTH) (YEAR). A quarterly MDS assessment dated (MONTH) 1, (YEAR) revealed a BIMS score of 7, which indicated severe cognitive impairment. The MDS included the resident required extensive assistance with bed mobility and transfers, and that he had one stage 4 pressure ulcer that was not present on admission. The MDS noted that the resident was not on a turning and positioning program. A review of the (MONTH) 4, (YEAR) Pressure Ulcer Weekly assessment revealed the right foot pressure ulcer was a stage 4 and measured 0.3 cm by 0.3 cm with a depth of 0.3 cm, with no undermining. The wound bed had granulation tissue, and had a small amount of serosanguinous exudate, no odor, and the wound edges were fibrotic and calloused, and the surrounding tissue was normal. A wound care observation was conducted with the wound nurse (Registered Nurse/staff #68) on (MONTH) 10, (YEAR) at 2:00 p.m. The resident was lying on his back with his heals floated, by a foam bridge across the foot of the bed. Staff #68 performed the dressing change in accordance with the current physician's orders [REDACTED]. Staff #68 stated that the wound presented as a stage 4 pressure ulcer with red granulation tissue. During an interview with staff #68 on (MONTH) 10, (YEAR) at 2:05 p.m., the RN stated that this wound began when the resident was in a shorter bed, and his foot would rest against the footboard. The RN stated that the wound started as a small black eschar covered area. Staff #68 said that she had been on leave around the time that this wound developed and that she had been following it weekly since her return. An interview was conducted with the Director of Nursing (DON/staff #119) on (MONTH) 15, (YEAR) at 1:34 p.m. The DON stated that she expects that who ever discovers a new wound would notify the wound nurse and the charge nurse, and the wound nurse would assess the wound and put orders in place. She stated that any nurse can notify the physician. The DON stated that documentation should include describing the wound bed and measuring the wound, and that the physician should be notified of any new wounds. -Resident 13 was admitted on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. A review of the annual MDS assessment dated (MONTH) 23, (YEAR), revealed the resident had a BIMS score of 8, which indicated moderate cognitive impairment. The MDS included that the resident required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene, and was frequently incontinent of urine and bowel. The MDS further revealed the resident was at risk for pressure sores, and had no pressure sores currently. A pressure reducing device was in place for the bed, but no pressure reducing device for the chair, and was not on a turning or positioning schedule. Review of a care plan revealed the resident was at risk for developing pressure ulcers related to incontinence of bowel and bladder and decreased functional mobility. A goal included the resident would be free from injury. Interventions included assist with toileting and/or offer incontinent care on rounds and as needed, keep skin clean and dry, monitor/document location, size, and treatment of [REDACTED]. The care plan further noted that the resident had refused placement of a low air loss mattress. physician's orders [REDACTED]. According to the corresponding MARs, the barrier cream was applied. A review of the clinical record and the Weekly Skin Evaluations from (MONTH) 24, (YEAR) through (MONTH) 7, (YEAR), revealed the resident did not have any skin breakdown or pressure sores. A physician's orders [REDACTED]. Despite having a physician's orders [REDACTED]. There was no documentation of any measurements of the sacral area pressure ulcer, no description of the wound bed and surrounding skin, or if there was any drainage or odor. There was also no staging of the pressure ulcer. In an interview on (MONTH) 9, (YEAR) at 4:41 p.m., resident #13 stated that she had a sore on her tailbone, which developed since she was admitted to the facility. She stated that the nursing assistants had been putting a salve on it but it hurt, so they changed the salve. Review of the Licensed Nurse Weekly Skin Evaluation dated (MONTH) 10, (YEAR), revealed documentation of a stage II pressure ulcer on the sacrum which measured 0.5 cm by 0.3 cm with 0 cm depth, with a pink wound bed and no peri wound skin issues. Wound care provided per MD orders. This was the first assessment of the pressure ulcer on the sacrum, which was completed two days after the physician ordered treatment. A wound treatment observation was conducted with the wound nurse (staff #68) and a Certified Nursing Assistant (CNA/staff #1) on (MONTH) 11, (YEAR) at 10:00 a.m. Staff #68 stated the wound measured 0.3 by 0.3 cm with no measurable depth, and described the wound bed as pink, with healing tissue. Staff #68 stated that the pressure ulcer was a stage II. A review of the Licensed Nurse Skin Pressure Ulcer Weekly Review dated (MONTH) 11, (YEAR) revealed it was the initial evaluation of a stage II pressure ulcer on the sacrum that was not present on admission. The wound measured 0.3 cm by 0.3 cm with no depth, and had a pink wound bed with defined edges and normal surrounding skin. The treatment included for [MEDICATION NAME] covered with foam. In an interview conducted with staff #1 on (MONTH) 15, (YEAR) at 11:13 a.m., staff #1 stated that to prevent pressure ulcers for resident #13, she changed her brief often and applied barrier cream to protect the skin. She stated that she helps the resident turn and change position and that the resident is able to use the bar to pull herself to her side. Staff #1 also stated that the resident developed the pressure sore about a week ago and that she was the CNA who discovered it and reported it to the nurse and the wound nurse. Another interview was conducted with staff #68 on (MONTH) 15, (YEAR) at 12:09 p.m. Staff #68 stated the unit nurses are responsible to document the wound appearance and initiate the standing orders for wound care and they may describe the wound. She said that the wound nurses are the only ones who may stage a wound. Staff #68 stated the wound nurse is responsible to assess the wound, to follow standing orders for wound care, add the resident to the wound rounds list, and update the care plan. She stated every wound should receive an assessment, care orders, and is added to the rounding list by the next day. A review of a policy titled, Wound Management revealed a resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the individual's clinical condition or other factors demonstrate that a developed pressure ulcer was unavoidable and a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable sores from developing. The policy included to provide care and services to promote the prevention of pressure ulcers, promote the healing of pressure ulcers that are present and prevent the development of additional pressure ulcers. The policy further stated that nursing staff are responsible to implement approaches as appropriate and consistent with the resident's care plan, which include stabilizing, reducing or removing any existing underlying risks, reposition the resident, and use pressure relieving/reducing and redistributing devices (including, but not limited to, low air loss mattresses, wedges, pillows, etc.), monitor the impact of interventions and modify interventions as appropriate based on any identified changes in condition.

Based on closed record review, staff interviews, and facility policy, the facility failed to provide preventative measures to prevent the development of pressure ulcers for two residents (#s 99 and 174). Both residents sustained actual harm. The sample size was three. Findings include: -Resident #99 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident had a prior history of a stage ll, pressure ulcer. However, there was no documentation in the clinical record that pertained to a pressure ulcer on admission. A care plan for the risk for pressure ulcers with a October 5, 2010, onset date, had the following problems for ulcers secondary to decreased/impaired mobility and incontinency. The care plan goal was to have no pressure ulcers through next review. The interventions consisted of diet, snacks, and supplements as ordered, medication and treatment as ordered, pressure reducing device to bed and wheelchair, assist resident with incontinent care, apply barrier cream as needed, weekly skin checks, notify physician (MD) of noted signs and symptoms of impaired skin integrity, low air mattress in place, long sleeved clothing, fold arm across body for transfers, and make sure to use gait belt. Although the resident had a history of [REDACTED]. The quarterly Minimum Data Set (MDS) dated [DATE], assessed that the resident had short/long term memory problems. A further review of the MDS coded the resident with severely impaired cognitive decision making for daily living. Also, the resident was able to usually be understood and sometimes understand. Transfer and bed mobility was coded as totally depend with one/two person physical assist. Ambulation did not occur and there was no pain. The resident was at risk of developing a pressure ulcer. However, the resident had no unhealed nor healing pressure at stage one or higher. A further review of the same MDS had the resident coded with no skin problems such as wounds or ulcers. The weekly pressure sore record had an entry for February 1, 2011, for a stage lll, wound with the measurements of 1.0 x 1.0 x 0.1 cm (centimeter). Also, the record documented that the pressure ulcer had developed in the facility. There was no A review of the clinical record and physician progress notes [REDACTED]." A further review of the note revealed a plan, which included the facility's wound nurse to assess and wound care. The admission and weekly skin integrity action tool dated February 8, 2011, documented a stage lll, pressure ulcer on the left buttock. Another weekly pressure sore record notes dated February 8, 2011, had a wound note, which documented a treatment with [MEDICATION NAME] (an occlusive to promote autolytic debridement) dressing. Again, a review of a weekly pressure sore record notes, which was dated February 15, 2011, documented a stage lll, wound with a measurements of 1.0 x 1.0 x 0.1 cm, with 50 percent slough and was worse. Also, there was an order to discontinue the [MEDICATION NAME] dressing, and change to Maxsorb Ag (an antimicrobial silver dressing). However, a review of the admission and weekly skin integrity action tool for February 15, 2011, documented a stage lV, on the ischium. A Braden scale was completed on February 17, 2011, and the resident scored a 14 which was considered moderate risk for the development of a pressure ulcer. The departmental notes dated February 17, 2011, at 8:21 a.m. documented that the "CNA (certified Nursing Assistant) noted small open area on left bottom." The physician was notified concerning "new open areas and said to leave a note for him to assess tomorrow." The departmental note further documented that the wound was cleaned, and [MEDICATION NAME] (over the counter protective paste) was applied along with a clean dressing. The staff would continue to monitor. However, a review of the physician orders revealed no order to apply [MEDICATION NAME] to the open area. In addition, there was no documentation of the "new open area" on the weekly skin integrity action tool that was used to document weekly skin issues. Another physician progress notes [REDACTED]. Wound care and an air mattress was part of the plan. The departmental notes with an entry date of February 18, 2011, at 5:04 p.m., was reviewed and revealed a physician's visit and new orders, for the wound nurse to evaluate the left buttock and provide an air mattress. However, the clinical record review revealed no evidence of a previous order for an air mattress as a preventive measure nor prior to developing a stage lll, pressure ulcer. A February 22, 2011, weekly pressure sore record documented a stage lll, wound that measured 3.0 x 3.0 x 0.1 cm, with 100 percent slough and was worse. While reviewing the February 22, 2011, wound note on the weekly pressure sore record revealed that the wound had a 100 percent eschar. However, there was no documentation of a call to the physician nor evidence that the resident's wound treatment plan was changed or continuing the same per physician's order. Although the February 22, 2011, weekly pressure sore record included a space for the documentation of the physician and/or family notification, there was no documented evidence, which identified either the physician and/or family was notified. Again, a review of the weekly skin integrity action tool for February 22, 2011, was conducted and revealed documentation of a stage lV, on the ischium. Another review of the clinical record revealed no documentation nor clarification of the stage lll/lV pressure ulcer location, which was documented on the weekly skin integrity action tool. The documentation was inconsistent, and the unit manager (UM) was unable to clarify when questioned. The review of the E-TAR (Electronic Treatment Administration Record) for February 2011, revealed no transcribed order for [MEDICATION NAME] (barrier cream with zinc) nor FYI (for your information) as an application prn (as needed). A further review of the same E-TAR revealed no transcribed order for [MEDICATION NAME] dressing. An entry dated March 1, 2011, on the weekly pressure sore record documented a stage lV, wound with a measurements of 3.0 x 3.0 x 0.3 cm, with purulent exudates, no odor, 75 percent eschar, and was worse. The March 1, 2011, entry on the weekly skin integrity action tool, had documented a stage lV, on the left ischium. A collaborative health advisory team documentation for March 2, 2011, included a Braden scale score of 14, with a description of the current skin condition as a stage lV on the left ischium that measured 3 x 3 x 0.2 cm with black soft eschar at the center. The documentation further revealed a summarization of events since last review, which included Santyl ointment to black eschar. However, there was no physician's order for the Santyl in the clinical record review. A further review revealed no evidence of a physician's order for a change in treatment nor was there a transcribed order on the March 2011, E-TAR. A review of the clinical record and physician progress notes [REDACTED]. The March 8, 2011, physician progress documented gluteal "decub increased in size," "foul odor". A further review revealed that the pressure ulcer "apparently gotten wore over weekend." The progress note further revealed "D/W (discussed with) DON (Director of Nurses) I was not notified of worsening." Again, the March 8, 2011, physician progress notes [REDACTED]." On March 8, 2011, at 12:50 p.m., the departmental notes had a new order for a transfer to the hospital, secondary to possible wound infection [MEDICAL CONDITION]. New treatment orders to apply a clean dry dressing to the left buttocks, which measured 10 cm x 11 cm. The wound was documented to have a foul odor with drainage. The March 8, 2011, the Transfer/Discharge Summary-Post Discharge Plan of Care, documented a skin assessment, which included these comments: "A-open wound 10 x 11 cm, black, strong odor, drainage" with dressing to open site. Also, there was documentation that the area was a pressure ulcer and had signs with symptoms of infection. Interview with the DON on June 29, 2011, at 7:30 a.m., concerning the pressure ulcers protocol. The wound would be assessed during the treatment either daily, twice a day, or every three days as ordered. The MD would be called if the treatment or the wound had changed or not improved. All the treatment orders are placed on the TAR or ETAR. When there was a change in treatment, then the new order would be placed on the pressure ulcer sheet. During the interview at 11:15 a.m. conducted on June 29, 2011, the DON stated the wound size had tripled, and the area had widen to include the new area and made the wound larger. However, there was no documented evidence nor a wound assessment, which had this conclusion. Furthermore, the MD documented that the pressure ulcer was worse. An interview was conducted with the Licensed Practical Nurse (LPN) on June 29, 2011, at 9:45 a.m. The LPN stated the UM would do the treatments after the unit manager has assessed and staged the wound. The UM would call the MD for further orders, but the unit nurse would call the MD for the initial wound care orders. The UM was responsible for the the assessment and staging of the pressure ulcers. The unit manager would document the assessment on the "Weekly Pressure Sore Record." On June 29, 2011, an interview was conducted with the DON and UM at 11 a.m. The UM stated the weekly skin assessment was completed by the unit nurse but was used to documented skin issues by the UM's and nurses. The UM further stated the coding of the location was an error because the documentation of the buttock and ischium was interchanged, and needed clarification. The nurses have received education and inservice concerning the documentation of the wound locations on the form (Admission and Weekly Skin Integrity Action Tool). The UM also stated there was no order for the Calazine nor the Hydrogel. -Resident #174 was admitted on [DATE], with [MEDICAL CONDITIONS], [DEVICE], dementia, [MEDICAL CONDITION], diabetes mellitus, hypertension, [MEDICAL CONDITION], and [MEDICAL CONDITION]. A review of the clinical record revealed a nurse's admission assessment dated [DATE], documented no pressure ulcer. The resident's Braden Scale for November 4, 2010, had a sore of 14, which was considered a moderate risk for the development of a pressure ulcer. The care plan for the potential for pressure ulcers, which was dated November 4, 2010, had these problems listed: ulcers related to decreased mobility and incontinency. The care plan goal was to have no pressure ulcers through the next review. The interventions consisted of diet, snacks, and supplements as ordered, medication and treatment, pressure redistributing device to bed and wheelchair, assist resident with incontinent care, apply moisture cream, skin check every week, notify MD of noted signs and symptoms of impaired skin integrity. However, a review of the physician's orders found no evidence of an order for [REDACTED]. The admission MDS dated [DATE], assessed the resident to be unable to understand or be understood. The resident was totally dependent with transfers and bed mobility with one/two person physical assist. Also, ambulation did not occur. The resident was at risk of the development of a pressure ulcer. However, there was no documented evidence on the MDS that the resident had no unhealed nor healing pressure at stage one or higher. Nursing assessment notes dated November 19, 2010, at 11 p.m., documented the resident was "...found to have three blisters on rt. (right) side 0.8 x 1.2 cm, 1 x 1.7 cm, 0.5 x 1 cm, with the top sites being broken and 3rd one was still intact..." The notes further documented that the resident also had a stage ll, which measured 2.5 x 1.3 cm, on the sacrum with an order for [REDACTED]. The weekly pressure sore record dated the onset as November 19, 2010. The sacrum pressure ulcer was developed in the facility and measured 2.5 x 1.3 x <0.1. There were no further nursing assessment notes from November 20 until November 23, when there was documentation that identified that the resident now had a stage III pressure ulcer on the sacrum. Another, weekly pressure sore record for November 23, 2010, was review and revealed a stage lll, pressure ulcer on the sacrum that measured 4.0 x 2.2 x 0.1 cm, which had slough. The physician order dated November 23, 2010, discontinued the previous order. The order was changed to [MEDICATION NAME] Ag and to cover with [MEDICATION NAME] for the treatment of [REDACTED]. In addition, the previous order included an overlay air mattress order. However, there was no previous order for a pressure relieving device or preventive interventions prior to the stage lll. Again, a physician's orders dated November 24, 2010, was reviewed and revealed an order for [REDACTED]. A further review of the nursing assessment notes found no further documentation from November 24 through December 4, 2010, regarding the care and treatment of [REDACTED]. The physician progress notes [REDACTED]. The treatment included [MEDICATION NAME]. A review of the physician's order for November 29, 2010, had an order for [REDACTED]. The November 30, 2010, weekly skin integrity action tool documented a skin integrity issue at a stage lll, on the coccyx, which had a line drawn through the location of the sacrum. The nursing assessment notes for December 4, 2010, at 2:00 p.m., documented a dressing change to the coccyx. However, there was no further documentation as to the location of the sacrum verse the coccyx. Also, there was no staging, measurement nor consistent documentation of the pressure ulcer or ulcers. Again, the December 7, 2010, admission and weekly skin integrity action tool again documented a skin integrity issue at a stage lll, on the sacrum. Another weekly skin integrity action tool was reviewed and revealed documentation of an open area to the coccyx, which was healing. On December 8, 2010, the Transfer/Discharge Summary-Post Discharge Plan of Care, documented a skin assessment concerning a stage lll, to coccyx. Also, there was documentation of a pressure ulcer, which had signs with symptoms of infection. Interview with the CNA on June 29, 2011, at 10 a.m., concerning the repositioning of residents. According to the CNA, each CNA would keep track of their own residents, because there was no schedule time to turn or reposition the residents. The residents were to be repositioned every two hour or more as needed. An interview with the DON and UM was conducted on June 29, 2011, at 11 a.m. The UM was unsure of the timeline for the placement of the air mattress or if the air mattress was in place prior to the stage lll pressure ulcer. Interview with the LPN was conducted on June 29, 2011, at 9:45 a.m. The LPN stated CNAs would inform the unit nurse of any changes in the skin. The nurse on the unit cannot stage the wounds, only the UM would stage the wounds. The staff on the unit would notify the UM of any changes in the resident's skin, and the UM would do the initial assessment. The resident's skin changes would be reported through the shift report in a.m. After the initial assessment, the unit nurse would continue the treatment as ordered by the MD. Documentation on the "Admission and Weekly Skin Integrity Action Tool" was done by the unit nurse, but no staging was documented on the tool. The tool would include any open areas, changes in the skin, and place the area on the picture to show location. The treatments are found on the ETAR or TAR and MD orders. Interview with the UM on June 29, 2011, at 10:45 a.m., concerning pressure ulcers. The skin checks were completed on admission and weekly. There were weekly skin rounds with the MD as needed. The unit manager would look at all types of wounds. The admission assessment would be placed on the initial assessment. The unit nurse should document the wound location, without staging the wound. Blister's (residents) are documented as stage ll. The unit nurse can measure the wound but not stage. The unit nurse would call the MD and document the location, description, on the weekly tool. The unit nurse would document in the nurse's notes. any new orders or sites. The unit manager would stage and complete the pressure sheet. An interview was conducted with the UM LPN for unit A on June 27, 2011, at 9:30 a.m. The UM stated, that she has attended many seminars and classes on wound care and was working on her wound nurse certification but did not have the certification at this time. Review of the facility policy titled "Content of the Health Record Writing Physician's Orders" documented "...All treatment orders must state the name of the product to be used, the site, the problem or reason and the frequency. Avoid using PRN (as needed) treatment orders...If the orders have not been completed in detail they would be given back to the Unit Manager to obtain all needed information...All physician's orders must be communicated to the Health Information Department for input into the computer system. Therefore, all orders written by physicians within the facility are to be documented on telephone order form...All orders received from physicians, verbal, or written...must be written on telephone order form...When making order changes on the Medication Administration Record, [REDACTED]. Discontinue the first order and put the date it was discontinued. Write the new order on a separate line. Indicate the start date. All telephone orders must be reviewed by the Director of Nursing/Unit Manager Designee prior to data entry by the Health Information Department. All orders require the initials of the Director of Nursing or Unit Manager indicating their review and approval of the order..." The facility policy titled "Pressure Sore Staging Protocol" documented "...When eschar was present, accurate staging of the pressure ulcer was not possible until the eschar has sloughed or the wound has been debrided..." Review of the facility policy titled "Pressure Sore Monitoring" documented "...It was the goal of the facility to maintain skin integrity. A resident who has developed a pressure sore would receive necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. The purpose would be to prevent further complications during wound healing process, to promote wound healing by ensuring all interventions are in accordance with facility wound care protocols, to gather accurate, objective and consistent data for the purpose of implementing an individualized Plan of Care designated to meet the residents needs, and to evaluate the outcome. On identifying a pressure sore upon admission, weekly head to toe skin assessments or other assessments the licensed nurse would perform the following procedures: Notify the physician for orders to treat each pressure sore identified...Transcribe orders onto Treatment Administration Record (TAR)...Residents who have developed a pressure sore regardless of their Braden Scale assessment score would be considered "High Risk."...Nursing personal would begin implementation of the Braden Pressure Sore Intervention guideline tool recommendation within 24 hours and as circumstances allow within 72 hours...Complete and or update the Weekly Skin Integrity Action Tool ensuring that all pressure sores identified are noted and all interventions are documented...The Director of Nursing/designee would be responsible to ensure that documentation was accurate and performed in a timely manner..." A review of the facility policy titled "Pressure Sore Monitoring (Assessment and Documentation) Weekly Wound Round Record" documented "...On identifying a pressure ulcer a baseline nursing assessment of the ulcer as well as causative factors was completed. The Weekly Pressure Sore Record was used for the initial baseline assessment tool as well as for weekly outcome documentation...Wound Assessment...This assessment was very important as it would largely drive the topical treatment choice..."