Every finding on record at Spring View Manor Healthcare and Rehabilitation

The facility reported a census of 40 residents. Based on interview and record review, the facility failed to develop, implement, and permanently maintain an in-service training program for Certified Nurse Aide (CNAs) with the required topics and no less than 12 hours per year for two out of five staff reviewed.Findings included:- On 03/16/26 at 12:44 PM, review of training records for five Certified Nurse Aides (CNAs) employed by the facility for more than one year revealed two CNAs had less than 12 hours of documented in-service training for the previous 12 months. CNA P, with a start date of 12/20/23, had eight hours of documented training, and CNA Q, with a start date of 07/22/24, had seven hours of documented training. On 03/17/26 at 09:18 AM, Administrative Nurse E confirmed that all CNAs were required to have 12 hours of training annually and stated that there were no records of additional training for those CNAs. The facility did not provide a policy.

The facility reported a census of 40 residents with one kitchen. Based on observation, interview, and record review, the facility failed to provide sanitary conditions for food storage and preparation to prevent the potential spread of foodborne illness to the residents of the facility. Findings included:- Initial tour of the facility kitchen on 03/15/26 at 08:05 AM with Dietary Staff (DS) EE, revealed the following areas of concern:Three open plastic bags of food in the freezer have ice crystals formed directly on the food items inside the bags.One unsealed bag of meat. One package of opened cheese. During an observation on 03/16/26 at 11:17 AM, DS EE checked the dishwasher water temperature with a thermometer. The thermometer recorded the dishwasher's water temperature at 103 degrees Fahrenheit (F). During an interview with DS EE on 03/16/26 at 11:20 AM, DS EE said the water temperature of the dishwasher should be 120 degrees F. to properly disinfect/sanitize dishware/cookware in the dishwasher. During an observation on 03/15/26 at 11:36 AM, DS CC carried a resident's meal plate on a tray. DS CC placed their thumb on the eating surface of the plate as they delivered it to the resident. During an observation on 03/15/26 at 11:37 AM, DS DD carried two resident meal plates on a tray and placed their thumb on the eating surface of the plates as they delivered them to the resident.Review of the Clean Slate Kitchen Service Report dated 01/30/26 revealed the following water temperatures in the dishwasher:Wash Temp 123.0 degrees F.Final Rinse Temp 123.0 degrees F. Review of the Clean Slate Kitchen Service Report dated 02/25/26 revealed the following water temperatures in the dishwasher:Wash Temp 122.0 degrees F.Final Rinse Temp 122.0 degrees F.On 03/16/26 at 11:25 AM, DS BB revealed that the pilot light on the water heater went out at times. DS BB said the staff should monitor the dishwasher water temperatures, and dishes/cookware should not be run through the dishwasher if the water temperature is not at least 120 degrees F. Review of the Dishwashing: Machine Operation Policy/guideline and Procedure Manual dated 2020 revealed it did not include a specific temperature to clean, disinfect, or sanitize kitchen cookware or dishware.

The facility identified a census of 40 residents. The sample included 12 residents with five reviewed for immunization status. Based on record reviews, and interviews, the facility failed to offer or obtain informed declinations, consent, or a physician-documented contraindication for the influenza (highly contagious viral infection that attacks the lungs, nose, and throat and can be deadly in high-risk groups) vaccination for Resident (R) 28.Findings included:- On 03/15/26, R28's clinical record revealed he was admitted on [DATE]. The Electronic Medical Record (EM) under the Immunization tab lacked documentation of whether the influenza vaccination was offered or declined, and lacked documentation of a historical administration or physician-documented contraindication. The facility provided a declination for the annual influenza vaccination dated 03/16/26.On 03/16/26 at 03:50 PM, Administrative Nurse E, the facility's Infection Preventionist, stated she was the person responsible for tracking immunizations. She stated she had left a message regarding R28's immunizations with his legal representative. Administrative Nurse E stated the legal representative had declined the influenza vaccination.The facility's Influenza Vaccination policy dated 06/ 11/25 documented it was the policy of the facility to minimize the risk of acquiring, transmitting, or experiencing complications from influenza by offering the residents, staff members, and volunteer workers annual immunization against influenza.

The facility identified a census of 40 residents. The facility identified 10 residents on Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record review, observations, and interviews, the facility failed to ensure Resident (R) 37 and R5's nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) masks were stored in a sanitary manner when not in use. The facility also failed to ensure staff wore the required personal protective equipment (PPE) for EBP and sanitized hands when doing direct care.Findings included:-Observation on 03/15/26 at 09:01 AM revealed Certified Medication Aide (CMA) R & Certified Nurse Aide (CNA) N applied gloves but did not perform hand hygiene when entering R8's room. CNA N raised the bed and grabbed the trash can around the rim of the can. CMA R opened R8's incontinence brief and wiped R8's peri area. CNA N took a wipe and wiped R8's peri area. CNA N removed R8's soiled brief and CMA R attached the clean brief. CNA N removed her gloves and washed her hands, while CMA R continued pulling up R8's pants with her soiled gloves. CMA R then removed her gloves and applied a clean pair of gloves without performing hand hygiene. CMA R put on R8's shoes, and both staff assisted R8 to a seated position in bed.On 03/15/26 at 09:33 AM, R37 sat on the recliner next to the window. R37's nebulizer mask lay directly on the bedside table, not in a sanitary container, next to his bed across the room.On 03/15/2026 at 11:53 AM, R5's nebulizer lay directly on her bedside table with a small amount of fluid in the chamber. R5's nebulizer mask was not in a sanitary container. On 03/16/26 at 09:00 AM, Licensed Nurse (LN) G entered R3's room and performed a dressing change on R3's enteral (within or via the small intestine) feeding site. LN G donned and doffed gloves during the dressing change. LN G took gloves from his pants pocket and donned them to complete the dressing change. LN did not don a gown for this direct care. LN G discarded R3's feeding syringe from the container, opened the new syringe from the package, removed the plunger from the new feeding syringe, and then placed the plunger into the soiled container. On 03/16/26 at 01:25 PM, LN G donned gloves, which he removed from his pants pocket, and a gown, then entered R1's room to perform a wound dressing change. LN G left the room to verify R1's treatment order for the dressing change, then returned to R1's room without changing his gloves or performing hand hygiene. He knelt on the floor and removed R1's socks, then left the room to retrieve an item from the treatment cart. LN G assisted R1's roommate, who was in a wheelchair, into the room. Wearing the same gloves, LN G knelt again onto the floor and opened the gauze dressing packages. LN G cleansed the wound with wound cleanser and dried the wound with the gauze dressings. Continuing with the same soiled gloves, LN G applied Skin-prep (liquid skin protectant) around the wound edges, then applied the clean dressing to R1's wound. LN G retrieved a marker from his pocket and dated the new wound dressing.On 03/16/26 at 03:13 PM, Administrative Nurse D stated the nebulizer should be placed in a bag between treatments. On 03/16/26 at 03:55 PM, LN G stated the nebulizer tubing and masks were changed weekly on Sundays. LN G stated the nebulizer should be placed in a bag between treatments. LN G stated he should have worn the right PPE, including a gown, for R3's dressing change. LN G stated he should have cleaned the container prior to placing the syringe plunger into the soiled container and said he should have performed hand hygiene and changed his PPE during R1's wound care.On 03/16/26 at 04:10 PM, Administrative Nurse E, the facility's Infection Preventionist, stated staff should perform hand hygiene between glove changes. She stated that gloves should be changed between soiled and clean. She stated PPE should be worn during any dressing change.The facility's Hand Hygiene policy dated 06/11/25 documented that all staff would perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility.The facility's Enhanced Barrier Precautions policy dated 04/01/24 documented that it was the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms.

The facility reported a census of 40 residents. The sample included 12 residents with four residents reviewed for hospitalization. Based on interview and record review, the facility failed to provide Resident (R) 50 with a written notification of transfer to the resident and/or his representative as soon as practicable and failed to send a copy of that notification to the ombudsman.Findings included:-R50's Electronic Medical Record (EMR) revealed a diagnosis of obesity (excessive body fat), dependence on supplemental oxygen, cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), and skin cancer. R50's Nurse's Note dated 12/11/25 at 05:34 PM documented R50 was short of breath, coughing up yellow sputum, and had an oxygen saturation (percentage of oxygen in the blood) level of 88 percent (%). New medication orders were given at that time, as well as lab orders and an order for a mobile chest X-ray.R50's Nurse's Note dated 12/11/25 at 06:21 PM documented the nurse left a message for the responsible party that R50 was going to the hospital.R50's Nurse's Note dated 12/11/25 at 06:33 PM documented R50 was leaving with emergency services for the hospital.R50's Nurse's Note dated 12/22/25 at 06:01 PM documented R50 returned to the facility at 11:30 AM and would be receiving skilled therapy services.R50's EMR had a bed hold assessment with a verbal confirmation for R50.R50's EMR lacked documentation of written notification to the resident and/or her representative, which explained the reason for the transfer to the hospital.On 03/16/26 at 8:08 AM, R50 wheeled himself from the dining room to his room. R50 stated he was supposed to sign the bed hold, but they did not give it to him before he left for the hospital.On 03/16/26 at 8:11 AM, Social Service X stated that Social Service Y obtained the bed holds when a resident left the facility. Social Service X was not aware of a letter to the residents or representatives.On 03/16/26 at 8:16 AM, Social Service Y stated she did a verbal bed hold and would get it. Social Service Y was not sure whether to send a letter to the resident or representative or send it to the ombudsman.On 03/16/26 at 2:52 PM, Administrative Nurse E stated the facility has not been sending a notification to the family in writing with the reason for the transfer, nor have they sent it to the ombudsman notification. The facility sent an email one month ago, then not again.The facility's Transfer and Discharge (including AMA) policy dated 07/14/25 documented that a transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided:a. The specific reason and basis for transfer or discharge.b. The effective date of transfer or discharge.c. The specific location (such as the name of the new provider or description and/or address if the location is a residence) to which the resident is to be transferred or discharged .d. An explanation of the right to appeal the transfer or discharge to the State.e. The name, address (mailing and email), and telephone number of the State entity that receives such appeal hearing requests.f. Information on how to obtain an appeal form.g Information on obtaining assistance in completing and submitting the appeal hearing request.h. The name, address (mailing and email), and phone number of the representative of the Office of the State Long-Term Care Ombudsman.i. For nursing facility residents with intellectual and developmental disabilities (or related disabilities) or with mental illness (or related disabilities), the notice will include the name, mailing and e-mail addresses, and phone number of the state agency responsible for the protection and advocacy of these populations.

The facility identified a census of 40 residents. The sample included 12 residents with three reviewed for Center for Medicare and Medicaid Services (CMS) Beneficiary Lability notices. Based on record review and interviews, the facility failed to provide form CMS-10055 Skilled Nursing Facility (SNF) Advanced Beneficiary Notice of Non-Coverage (ABN- which included the estimated cost for continued services) to the resident or their representative for Resident (R) 6 and R25.Findings included: - R6's Electronic Medical Record (EMR) documented a Medicare Part A episode beginning on 09/18/25 and ending on 10/20/25. R6 remained in the facility for custodial care. R6's EMR lacked evidence that the ABN was provided. Review of the R25's EMR documented a Medicare Part A episode that began on 10/25/25 and ended on 12/24/25. R25 remained in the facility for custodial care. R25's EMR lacked evidence that the ABN was provided. On 3/17/26 at 07:45 AM, Social Service Staff X stated she was not aware she needed to complete and issue the ABN. She reported she discussed this with Administrative Nurse D and started a progress improvement plan. Upon request, the facility was unable to provide evidence that the Form CMS-10055 was provided to R6 and R25. The facility policy Advance Beneficiary Notices reviewed 05/07/25 documented the facility to provide timely notices regarding Medicare eligibility and coverage. The facility shall inform Medicare beneficiaries of their potential liability for payment. A liability notice shall be issued to Medicare beneficiaries upon admission or during the residents' stay before the facility provides an item or service that is usually paid for by Medicare, but may not be paid for in a particular instance because it is not medically reasonable and necessary or custodial care.

The facility reported a census of 40 residents and one kitchen. Based on observation, interview, and record review, the facility failed to ensure staff served meals at safe and appetizing temperatures. The facility also failed to follow the recipe of pureed green beans, which altered the nutritive content. Findings Included:- During an observation on 03/16/26 at 11:08 AM, Dietary Staff (DS) EE added tap water to the green beans during the puree process of the green beans. Immediate review of the facility recipe for pureed green beans revealed that if the puree consistency needed to be thinned, the staff were to gradually add an appropriate hot liquid such as broth, gravy, milk, or reserved cooking liquid.During an observation on 03/16/2026 at 11:35 AM, DS EE handed the cooked pureed spaghetti to DS BB, who then took the cooked pureed spaghetti to a resident in the dining room. Upon prompting/request, DS BB obtained a temperature of the pureed spaghetti and reported it was 127 degrees Fahrenheit (F).During an observation on 03/16/26 at 12:01 PM, DS BB delivered a hall meal tray. The hall meal was plated onto a heated covered plate that was transported to room [ROOM NUMBER] in an enclosed insulated food box on a cart. Upon prompting/request, DS BB obtained the temperature of the cooked spaghetti delivered and noted it was 130 degrees F. DS BB then obtained a temperature on the Italian tossed salad at 52 degrees F.During an interview on 03/16/26 at 12:05 PM, Resident (R)7 stated that when the staff served food to R7's room, the food was not hot, but it was kind of warm.During an interview on 03/16/26 11:34 AM, DS EE stated they do not obtain temperatures on cooked food or on cooked pureed food before sending it to the dining room to be served to residents. During an interview on 03/16/26 at 11:50 AM, DS BB stated the facility expected cooked pureed spaghetti to maintain a holding temperature of 135 degrees F or above before serving it to a resident. DS BB stated this ensured the food was not in the danger zone and was at the appropriate safe temperature to prevent foodborne illness.During an interview on 03/16/26 at 12:01 PM, DS BB stated the temperature of the cooked spaghetti should be maintained at 135 degrees or above before serving it, and the Italian tossed salad should maintain a holding temperature of 41 degrees F or below before serving it.The facility's policy Monitoring Food Temperatures for Meal Service guideline and Procedure Manual dated 2020, documented that the serving/holding temperature of a hot food item should be 135 degrees F or higher, and the serving/holding of a cold food item should be at 41 degrees F or below.

The facility reported a census of 40 residents. Based on observation, interview, and record review, the facility failed to ensure the posted daily nurse staffing sheets included accurate and identifiable information to include actual staff hours, as required.Findings included:- During an observation on 03/16/26 at 08:36 AM, the daily staffing sheet hung on the wall near the nurse's station. The daily nurse staffing form for 03/16/26 was posted and lacked the actual hours worked per shift for licensed and unlicensed staff providing resident care.On 03/16/26 at 08:35 AM, Licensed Nurse (LN) G stated that the nurse does not change the time or add actual hours on the posted staffing sheet. An example is today, there was a staff member who was late, and he would not write anything on the sheet. The business office will do it later.On 03/16/26 at 08:47 AM, Administrative Nurse E stated she put the staff sheet out, and at the end of the week, the office put actual hours on the sheet. No actual hours are adjusted until then.On 03/16/26 at 12:12 PM, the daily nurse staffing form for 03/16/26 was posted and lacked the actual hours worked per shift for licensed and unlicensed staff providing resident care.On 03/16/26 at 12:12 PM, Administrative Nurse D stated the nurse should put the actual hours on the posted staffing sheet and not wait until the end of the week.The facility's Nurse Staffing Posting Information policy last reviewed on 02/05/25, documented the Nurse Staffing Sheet will be posted on a daily basis and will contain the name of the facility, date, resident census, the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: Registered Nurses, Licensed Practical Nurses/Licensed Vocational Nurses, and Certified Nurse Aides. The facility will post the Nurse Staffing Sheet at the beginning of each shift, and the information shall reflect staff absences on that shift due to call-outs and illness. After the start of each shift, actual hours will be updated.

The facility reported a census of 34 residents. Based on interview and record review, the facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS) with complete and accurate direct staffing information based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS i.e., Payroll Base Journal (PBJ), related to licensed nursing licensed and certified nursing staffing information when the facility failed to accurately report weekend staffing for the second quarter 2023 January through March and fourth quarter 2023 July through September 2023. Findings included: - Review of the nursing staff schedule for the second quarter 2023 January through March 2023 and fourth quarter 2023 July through September, revealed multiple changes/additions in staffing for the weekends with agency staff utilized. Review of the PBJ Staffing Data Report, for the second quarter 2023, revealed the PBJ triggered for Excessively Low weekend Staffing. Review of the PBJ Staffing Data Report, for the fourth quarter 2023, revealed the PBJ triggered for Excessively Low weekend Staffing. Interview, on 05/02/24 at 12:20 PM, with Administrative Staff A, revealed the corporate office submitted the Payroll Base Journal (PBJ), and did not include the agency staff used to supplement the nursing staff employed by the facility which resulted in the inaccurate reporting of hours. The facility lacked a policy for Payroll Base Journal (PBJ) submission. The facility failed to accurately report weekend staffing for second quarter 2023 January through March 2023 and fourth quarter 2023 July through September 2023 as required.

The facility reported a census of 34 residents. Based on record review and interview, the facility failed to ensure four out of five Certified Nurse Aides (CNA) who were employed over a year, and Certified Medication Aides (CMA/CNA) reviewed, received annual evaluations as required. Findings included: - Review of the personnel file for five certified Nurse Aides (CNA) and Certified Medication Aides (CMA) employed over one year, revealed the following areas of concern: CNA N, with hire date 02/10/21, lacked an annual evaluation. CNA M, with hire date 02/10/21, lacked an annual evaluation. CNA O, with hire date 09/03/22, lacked an annual evaluation. CMA R, with hire date 01/13/20, lacked an annual evaluation. Interview on 05/01/24 at 03:22 PM, with consultant GG revealed she would expect staff to have evaluations annually. The facility policy Evaluation Process, implemented 12/01/19, instructed staff to review the work performance of employees with a formal written evaluation annually. The facility failed to ensure certified staff received annual evaluations as required.

The facility reported a census of 34 residents with five residents reviewed for immunizations. Based on interview and record review, the facility failed to ensure staff provided education for informed decision making for the 2023 influenza vaccine for two of the five residents, Resident (R)21 and R11. The facility failed to ensure one of the five residents received education for informed decision making for the pneumococcal vaccine, R21. The facility failed to ensure three of the five residents received education for informed decision making for the Covid-19 vaccination. Findings included: - Review of Resident (R)21's electronic medical record revealed the resident admitted to the facility 01/19/24. The Immunization tab documented the last influenza vaccine as 12/12/22 and the last covid-19 vaccine as 12/03/21. The medical record lacked documentation of pneumonia vaccine status. The medical record lacked evidence of education provided for informed decision making for receipt/declination for the vaccines. Review of R11's electronic medical record revealed the resident admitted to the facility 03/31/22. The Immunization tab documented the resident refused the influenza vaccine. The declination for the influenza vaccine lacked a date. The received the covid-19 vaccine on 10/21/22. The medical record lacked evidence the resident received education for informed declinations for 2023 or 2024. Review of R3's electronic medical record revealed the resident admitted to the facility 01/05/22. The Immunization tab documented the resident received a covid-19 vaccine 10/21/22. The medical record lacked evidence the resident received education for informed declinations for the 2023/2024 vaccines. Interview, on 05/02/24 at 11:40 AM with Administrative Nurse D, confirmed lack of declinations/undated declinations for the above-mentioned residents. The facility policy Influenza Vaccination implemented 11/01/19, instructed staff to offer residents the annual immunization against influenza. The facility policy Pneumococcal Vaccine implemented 11/01/19, instructed staff to offer residents the immunization against pneumococcal disease in accordance with the Center for Disease Control (CDC) guidelines and recommendations. The facility policy Covid-19 Vaccination dated 09/06/22, instructed staff the to educate and offer residents the covid-19 vaccine to minimize the risk of acquiring, transmitting, or experiencing complications from covid-19. The facility failed to provide/ensure R21, R11 and R 3 education to make informed decision and opportunity to accept/decline the influenza, pneumococcal and/or covid-19 vaccine as per their preference as required.

The facility reported a census of 34 residents with 12 residents selected for review, which included three residents reviewed for activities of daily living (ADL's). Based on observation, interview, and record review, the facility failed to provide personal grooming for one of the three, Residents (R)10, reviewed for activities of daily living. Findings included: - Review of Resident (R)10's undated Physician Order Summary revealed diagnoses that included hemiplegia (paralysis on one side of the body,) hemiparesis (muscular weakness on one side of the body,) cerebral vascular accident (CVA/stroke sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain,) and major depressive disorder (major mood disorder.) The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of seven, which indicated severe cognitive impairment. The resident had functional impairment on one side of the upper and lower extremities. The ADL (Activity of Daily Living) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 01/10/24, assessed the resident required staff assistance with ADLs, and encouragement to participate in the performance of tasks. The Care Plan reviewed 04/24/24, instructed staff the resident was dependent on staff for bathing and personal hygiene. The Bathing Schedule revealed the resident received showers on Tuesday during the day, and on Friday evenings. The Task Bathing in the electronic medical record, revealed the resident received a shower on 04/06/24, 04/09/24, 04/16/24 and 04/23/24. The resident refused a shower on 04/13/24, 04/19/24 and 04/27/24. Observation, on 04/30/24 at 11:39 AM, revealed the resident seated in his wheelchair, in the common dining area. The resident had several days' worth of facial hair growth. Observation, on 05/01/24 at 09:57 AM, revealed Certified Nurse Aide (CNA) M and N transferred the resident with a mechanical lift. The resident was unshaved with several days' worth of facial hair growth evident. Interview with the resident at that time, revealed he did not desire to grow a beard and the felt itching from the stubble on his face. Interview, on 05/01/24 at 10:00 AM, with CNA M, revealed staff shave R10 on his shower days but did not know when R10's last received a shower and confirmed he needed a shave. CNA M stated the resident did not refuse bathing on day shift but did on the evening shift. Interview, on 05/02/24 at 12:44 PM, with Administrative Nurse D, revealed she would expect staff to provide grooming to R10, but he frequently refused his evening showers and would consider reassigning the resident to day showers. The facility policy Grooming a Resident's Facial Hair, revised 04/02/24, instructed staff to assist resident with grooming facial hair to help maintain proper hygiene as per current standards of practice. The facility failed to ensure R10 received grooming opportunities per his preference to enhance sense of wellbeing.

The facility reported a census of 34 residents with 12 residents selected for review. Based on interview and record review, the facility failed to obtain laboratory values in a timely manner for one of the 12 Residents (R)4, and failed to administer medications according to physician instructions for one of the 12 residents, (R)29. Findings Included: - Review of Resident (R)4's undated Physician Order Sheet revealed diagnoses that included chronic respiratory and heart failure, diabetes (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin ) and kidney failure. On 04/10/24, a licensed nursing noted documented staff notified the physician that R29 had nausea and vomiting for three days. The physician instructed staff to obtain a Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP) on 04/11/24. A nurse note, dated 04/11/24, documented licensed nursing staff notified the physician that the resident continued with nausea and vomiting, and the facility failed to obtain the CBC and CMP. On 04/12/24 the facility obtained the labs, two days later. A Nurse Note dated 04/13/24, documented the licensed nurse reported to the physician that R29 continued with nausea and vomiting and reported the labs to the physician. The physician instructed staff to send the resident to acute care. Interview, on 05/02/24 at 01:56 PM, with Administrative Nurse D, revealed the facility had difficulty obtaining the labs due to the laboratory did not provide a phlebotomist (a trained staff member to obtain a blood sample) in a timely manner to obtain the labs. Administrative Nurse D stated she would expect staff to report results as soon as possible as per the standard of care and did not know why staff did not report the laboratory data to the physician on 04/12/24. The facility lacked a policy for following physician orders. The facility failed to ensure staff provided services to R4 to obtain and report laboratory values in a timely manner. - Review of Resident (R) 29's electronic medical record revealed diagnoses that included hypertension (high blood pressure) , heart failure, and chronic kidney disease. On 06/14/23, the physician instructed staff to administer Bumex (a medication used to remove excess fluid) 0.5 milligrams (mg), every 24 hours, as needed, for weight gain of two pounds overnight. Review of the March 2024 Medication Administration Record (MAR) revealed the following area of concern: On 03/13/24, the resident weight was 197 pounds (lbs.) and on 03/14/24, the resident's weight was 199 lbs., a two-pound increase. The March 2024 Medication Administration Record (MAR) lacked documentation that staff administered Bumex for the two-pound increase as ordered by the physician. Review of the April 2024 MAR revealed the following area of concern: On 04/29/24 the resident weight was 196.5 lbs. and on 04/30/24 the resident's weight was 199 lb., a two-and-a-half-pound increase. The Medication Administration Record (MAR) for April, lacked documentation that staff administered the Bumex, as instructed by the physician for the two-and-a-half-pound increase. On 12/14/23 the physician instructed staff to administer Lisinopril 2.5 mg in the morning for hypertension. The physician instructed staff to hold the medication if the systolic (the pressure of the heart when it forces blood out of the heart, the top number of a blood pressure reading) blood pressure was less than 100 millimeters of mercury (mmHg) or the diastolic (minimum level of blood pressure measured between contractions of the heart; the bottom number of a blood pressure reading) blood pressure was less than 50 mmHg. Review of the March 2024 Medication Administration Record (MAR) revealed the following areas of concern: On 03/01/24, staff recorded the blood pressure as 94/53 mmHg and documented the medication as administered. On 03/20/24, staff recorded the blood pressure as 98/58 mmHg and documented the medication as administered. Interview, on 05/02/24 at 1:20 PM with Administrative Nurse D revealed she would expect staff to follow parameters as instructed by the physician. The facility lacked a policy for following physician orders. The facility failed to ensure staff followed physician orders to ensure R29 received/held the required medications for blood pressure and weight gain.

The facility reported a census of 34 residents which included 12 residents selected for review. Based on observation, interview, and record review, the facility failed to ensure one of the 12 Residents, Resident (R) 1, received sanitary tube feeding technique, and staff performed hand hygiene prior to insulin administration for one of two residents (R)9 related to insulin administration to prevent possible infections. Findings included: - Review of Resident (R)1's electronic medical record revealed diagnoses that included cerebral vascular accident (CVA, stroke sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) and swallowing disorder. Observation on 05/01/24 at 08:21 AM, revealed Licensed Nurse (LN) G prepared to administer R1's medications through her percutaneous gastrostomy tube (PEG a tube that enters the stomach through a surgical opening in the resident's abdomen for the administration of medications and nutrition when a person is unable to swallow). The syringe for attaching to the PEG tube laid directly on a paper towel on the resident's bedside table. LN G did not clean/sanitize the PEG tube or syringe before administering the medications. Interview, on 05/02/24 at 12:54 PM, with Administrative Nurse D, revealed she would expect staff to cleanse/sanitize the tube/syringe before administering medications. Administrative Nurse D stated the resident often moved the syringe out of the storage box and placed it in various places in her room. The facility policy Care and Treatment of Feeding Tubes, undated, instructed staff to utilize infection control precautions and related techniques to minimize the risk of contamination. The facility failed to ensure staff provided medication administration through R1's PEG tube to prevent the spread of infection. - Review of Resident (R)9's electronic medical record, revealed a diagnosis of diabetes (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). Observation on 05/01/24 at 08:51 AM, revealed Licensed Nurse (LN) G administered insulin (a medication given beneath the skin into the fat layer to decrease/normalize the blood sugar level) to R27. LN G did not perform hand hygiene after the administration and picked up R9's Lispro insulin pen and dialed the pen to 12 units and proceeded to prepare to administer the insulin to R 9 however, LN G verified she should sanitize her hands and did so prior to administration of the insulin to R9. Interview, on 05/02/24 at 12:50 PM with Administrative Nurse D, revealed she would expect staff to perform hand hygiene between residents when administering insulin. The facility policy Insulin Pen, implemented 01/01/20, instructed staff to perform hand hygiene and don gloves prior to administration and remove gloves and perform hand hygiene afterwards. The facility failed to provide sanitary insulin administration for R9 to prevent the spread of infection.

The facility reported a census of 34 residents. Based on interview and record review, the facility failed to ensure the daily staff posting contained actual hours worked as required. Findings included: - Review of the Daily Staff Postings from February 2024, March 2024, and April 2024, revealed lack of actual hours worked for staff. Interview, on 05/02/24 at 12:20 PM, with Administrative Staff A, revealed confirmed the facility lacked recording of the actual hours worked for staff on the daily staff postings. Administrative Staff A stated the business office documented the actual hours worked through a computer program and did not record the hours on the daily staff posting sheets. The facility lacked a policy for daily staff posting. The facility failed to ensure staff recorded the actual hours worked by staff on the daily staff posting as required.

The facility reported a census of 28 residents with 13 selected for review. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for one of the residents, Resident (R)9 for use of CPAP (continuous positive airway pressure)/BiPAP (bi-level positive airway pressure) equipment. Findingsincluded: - The Medical Diagnosis tab for Resident (9) included diagnoses of sleep related non-obstructive alveolar (air sacs where the lungs and the blood exchange oxygen and carbon dioxide during the process of breathing in/out), hypoventilation (abnormally slow rate of breathing resulting in increased amount of carbon dioxide in the blood), and obstructive sleep apnea (disorder of sleep characterized by periods without respirations). The Admission Minimum Data Set (MDS) dated [DATE] revealed R9 admitted to the facility on [DATE]. He had a Brief Interview of Mental Status (BIMS) score of 15, indicating cognitively intact. He required oxygen use and CPAP/BiPAP while a resident and prior to admission. The Quarterly MDS dated [DATE] for R9 revealed he required oxygen use in the past 14 days and the staff did not conduct his BIMS score or staff assessment for mental status. The Care Plan dated 08/05/22 revealed R9 required supplemental oxygen and staff should change the oxygen tubing per facility protocol. The care plan lacked use of a CPAP/BiPAP machine. On 11/01/22 at 01:56 PM observed R9 in his room sitting on the side of the bed with his oxygen in place per nasal cannula. A CPAP/BiPAP machine was on the overbed table with the hose and mask connected to it and draped across the bedside table. On 11/01/22 at 01:58 PM, R9 stated that was his CPAP machine and Sometimes my fiance cleans it. On 11/09/22 at 02:12 PM, Certified Nurse Aide (CNA) M reported R9 wore the CPAP mask at night. CNA M stated he works the day shift and when he arrived in the morning, he switches R9 from the CPAP mask to the oxygen nasal cannula. CNA M stated he thought the night shift cleans the tubing and mask of the CPAP and there was a bag on the walker to put the CPAP mask in, and R9 would put the mask in the bag. On 11/09/22 at 02:32 PM, observation revealed the resident's CPAP mask laying with direct contact with the floor, connected to the hose. A black bag was on the side of the CPAP machine. On 11/09/22 at 02:32 PM, Administrative Nurse E stated R9 controlled the CPAP himself and the mask should be in a black bag when not in use. The CPAP should be on the care plan and the IDT (interdisciplinary) team updates the care plan. On 11/09/22 at 02:38 PM, Administrative Nurse D stated the resident's CPAP use should be on the care plan. The facility policy Comprehensive Care Plans dated 02/01/20, revealed it was the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan would describe, at minimum, the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The facility failed to develop a comprehensive care plan for this resident that included use of CPAP/BiPAP equipment and required care.

The facility reported a census of 28 residents with 13 selected for review, including one reviewed for respiratory care services. Based on observation, interview, and record review, the facility failed to change out oxygen tubing per physician order and failed to obtain physician order for use, settings, and care of one of the resident's, Resident (R)9's use of his CPAP (continuous positive airway pressure)/BiPAP (bi-level positive airway pressure) equipment, which increased risk of R9 developing a respiratory infection. Findings included: - The Medical Diagnosis tab for Resident (9) included diagnoses of sleep related non-obstructive alveolar (air sacs where the lungs and the blood exchange oxygen and carbon dioxide during the process of breathing in/out), hypoventilation (abnormally slow rate of breathing resulting in increased amount of carbon dioxide in the blood), and obstructive sleep apnea (disorder of sleep characterized by periods without respirations). The Admission Minimum Data Set (MDS) dated [DATE] revealed R9 admitted to the facility on [DATE]. He had a Brief Interview of Mental Status (BIMS) score of 15, indicating cognitively intact. He required oxygen use and CPAP/BiPAP while a resident and prior to admission. The Quarterly MDS dated [DATE] for R9 revealed he required oxygen use in the past 14 days and the staff did not conduct his BIMS score or staff assessment for mental status. The Care Plan dated 08/05/22 revealed R9 required supplemental oxygen and staff should change the oxygen tubing per facility protocol. The care plan lacked use of a CPAP/BiPAP machine. The Orders tab for R9 included an order, dated 03/10/22, for staff to change the oxygen tubing, date the tubing, and rinse the filter every week, on Sunday. The orders lacked instruction for cleaning and changing the CPAP/BiPAP machine/equipment. The Orders tab for R9 included an order, dated 07/20/22, for oxygen at two liters per nasal cannula, continuous. The orders lacked instruction for CPAP/BiPAP use. On 11/01/22 at 01:56 PM, observed R9 in his room, sitting on the side of the bed with his oxygen in place, per nasal cannula. The date on the tubing was 10/24/22 (eight days prior). The top of the oxygen concentrator had a dried yellow substance on it as well as a build-up of dust. A CPAP/BiPAP machine was on the overbed table with the hose and mask connected to it, and it draped across the bedside table. On 11/01/22 at 01:58 PM, R9 stated the staff usually changed the tubing weekly and the Guy that was diligent about changing it every week was not there. R9 stated he had not seen the staff clean the concentrator. R9 stated that was his CPAP machine and Sometimes my fiance cleans it. On 11/09/22 at 02:12 PM, Certified Nurse Aide (CNA) M stated R9 wore the CPAP mask at night. CNA M stated he works the day shift and when he arrived in the mornings, he switches R9 from the CPAP mask to the oxygen nasal cannula. CNA M stated he thought the night shift cleaned the tubing and mask of the CPAP and there is a bag on the walker to put the CPAP mask in, and R9 would put the mask in the bag. CNA M stated the night shift should change out the resident's oxygen tubing. On 11/09/22 at 02:30 PM, observation revealed the CPAP mask laying with direct contact with the floor, connected to the hose. A black bag was on the side of the CPAP machine. The oxygen concentrator continued to have a dried substance on the top and lint/dust present. On 11/09/22 at 02:32 PM, Administrative Nurse E stated staff should clean the concentrator, the oxygen tubing should be changed, and the machine cleaned every Sunday. Administrative Nurse E stated R9 controlled the CPAP himself and the mask should be in a black bag when not in use. On 11/09/22 at 02:38 PM, Administrative Nurse D stated staff should change the oxygen tubing weekly. The CPAP equipment should be cleaned weekly at that time and there should be a physician order for use of the CPAP as well as a cleaning schedule. The facility policy Noninvasive Ventilation [CPAP, BiPAP, AVAPS, Trilogy(R)] dated 01/20/21, included it was the policy of the facility to provide noninvasive ventilation as per physician's orders and current standards of practice. The facility would obtain an order for the use of a CPAP, BiPAP, AVAPS or Trilogy (R) device and setting from the practitioner. A personal CPAP/BiPAP/AVAPS, or Trilogy (R) device may/may not be brought into the facility for resident's use. If brought in, the nurse/respiratory therapist would verify the settings on the machine prior to use. The facility policy CPAP/BiPAP Cleaning dated 01/20/21, revealed it was the policy of the facility to clean CPAP/BiPAP equipment in accordance with current enters for Disease Control (CDC) guidelines and manufacturer recommendations to prevent the occurrence or spread of infection. Clean the mask frame daily after use with CPAP cleaning wipe or soap and water, dry well, cover with a plastic bag or completely enclosed in machine storage when not in use. Weekly cleaning activities included washing headgear/straps in warm, soapy water and air dry and wash tubing with warm, soapy water and air dry. Replace the equipment routinely in accordance with the manufacturer's recommendations. General guidelines included the face mask and tubing once every three months, headgear, non-disposable filters, and humidifier chamber once every six months, and disposable filters twice monthly. The facility policy Oxygen Concentrator dated 2022, revealed the nurse responsibilities included changing the oxygen tubing weekly and as needed if it becomes soiled or contaminated and the main body cabinet should be dusted when needed and could be wiped clean with a damp cloth and mild household cleaner if necessary. The facility failed to change R9's oxygen tubing weekly, clean the oxygen concentrator, obtain physician order for CPAP/BiPAP use and routine cleaning schedule, in order to prevent the occurrence of infection.

The facility reported a census of 25 residents, with three sampled for medication review. Based on record review and interview, the facility failed to ensure adequate safeguarding of of any residents' with controlled substance medications in the licensed nurses' cart, to prevent diversion. One of the three sampled resident R3's liquid [MEDICATION(S)] in this cart revealed indication of diversion, when a licensed nurse gave the keys to the licensed nurses' treatment cart which held the locked narcotic controlled medications, to a non-licensed staff member and the resident's liquid [MEDICATION(S)] level indicated it increased by 12.75 milliliters indicating diversion. Findings included: - Resident (R)3's significant change of condition Minimum Data Set (MDS), dated [DATE], documented the resident admitted on [DATE]. The resident had a Brief Interview of Mental Status (BIMS) score of 0, indicating severely impaired cognition. The resident required total dependence on staff for all cares. A discharge tracking, dated [DATE], documented the resident expired in the facility. The hospice care plan, dated [DATE], instructed the staff to identify, monitor and record the resident's complaints of pain, and to administer pain medication as ordered by the physician. A physician order, dated [DATE], instructed the staff to admit the resident to Hospice for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A physician order, dated [DATE], instructed the staff to administer the resident [MEDICATION(S)] Sulfate (Concentrate) Solution 20 milligrams/milliliters (MG/ML); Give 0.25 milliliters (ml) by mouth two times a day related to pain. A physician order, dated [DATE], instructed staff to administer the resident [MEDICATION(S)] Sulfate (Concentrate) Solution 20 MG/ML; Give 0.25 milliliters (ml) by mouth every one hour as needed for air hunger and pain. A Nurses' Note, dated [DATE] at 12:40 AM, revealed the charge nurse was unable to obtain vital signs of the resident. Review of the facility's investigation, related to the diversion of the resident's liquid [MEDICATION(S)], found on [DATE], revealed the facility was able to identify that the count was last noted as correct on [DATE] at 06:00 PM. The facility staff were unable to verify the correct count again until Tuesday, [DATE] at 09:30 PM, when the staff noted an increase by 12.75 ml in the resident's [MEDICATION(S)] liquid level. The sign out log documented the amount should have been 22.25 ml and review of the bottle's liquid level was noted at 35 ml, and increase by 12.75 ml. No determination could be made to verify what substance was added to cause the increased liquid [MEDICATION(S)] count discrepancy. At the time of the investigation submission, it could not be determined who was directly responsible for the drug diversion. On [DATE] at 10:30 AM, Administrative Nurse D explained that on [DATE], she received the licensed nurses' keys at an unknown time, from Certified Medication Aide (CMA) R. CMA R told her that LN G handed her the keys to the licensed nurses' cart while she went on break. Administrative Nurse D then returned the keys to LN G when she returned into the facility. CMA R explained LN G and herself did not count the controlled substances medications in the nurses' cart with narcotic medications, prior to LN G leaving on break. Administrative Nurse D reported that LN G was out of the facility approximately ,d+[DATE] minutes. Furthermore, Administrative Nurse D reported that herself and LN G did not count the control substance medications in the nurses' cart when LN G returned from break. On [DATE] at 02:36 PM, License Nurse H reported it was against the facility policy to hand over the licensed nurses' keys to a Certified Medication Aide. The facility policy was that if the licensed nurse needed to leave the facility, they needed to count the control substance medications with another licensed nurse and then hand over the licensed nurses' cart keys to that nurse. LN H reported she did not observe any medication discrepancy in R3's liquid [MEDICATION(S)] during the nurse to nurse counts from [DATE] through [DATE]. On [DATE] at 03:13 PM, LN G reported on the day of the incident, [DATE], she received report and then she counted the controlled substance medications with the night shift nurse, LN J, on [DATE] at 06:00 AM, and did not notice any discrepancy in R3's liquid [MEDICATION(S)] level. LN G reported that she left the facility at 08:30 AM and gave her nurses' keys to CMA R. LN G reported that she was aware it was against policy to give her keys to any other non-licensed staff member. She reported she was unsure how long she was gone. When she returned, she received her keys from Administrative Nurse D. During report and counting the controlled medications in the licensed nurses' cart, on [DATE] with the oncoming night shift at 9:30 PM, LN I found a discrepancy which revealed that R3's liquid [MEDICATION(S)] was at the 35 ml level. At that time the log for this controlled substance medication revealed it should only have 22.25 ml left in the bottle. This was a gain, over the shift period, in the amount of the liquid level in the bottle by 12.75 ml, indicating failure to safeguard this controlled medication with diversion indicated with the additional amount of unknown liquid in the bottle. On [DATE] at 06:44 PM, Licensed Nurse I reported that on [DATE] at 09:30 PM, while counting the controlled substance medications in the nurse's cart, being the oncoming nurse, he noticed the discrepancy of R3's liquid [MEDICATION(S)]. The liquid level was at 35 ml, and the control substance log read 22.25 ml. LN I immediately reported this discrepancy to Administrative Staff A. The drawer was locked until Administrative Staff A arrived at the facility and provided notification to Administrative Nurse B. On [DATE] at 10:45 AM, Administrative Staff A reported that LN I notified him that during report there was a discrepancy of R3's liquid [MEDICATION(S)]. Administrative Staff A, LN G, and LN I, inspected the [MEDICATION(S)] bottle. Once the staff members removed the lid of the [MEDICATION(S)] bottle, they found that the plastic seal and port appeared to be tampered with. The plastic seal had been pushed down into the [MEDICATION(S)] liquid. Administrative Staff A reported that the staff completed witness statements. He also called local law enforcement to report the incident. The law enforcement agency requested the [MEDICATION(S)] bottle for their investigation and it was given to them to take. On [DATE] at 11:54 AM, CMA R reported that LN G told her she was in a hurry when she left the facility and handed her the keys. CMA R reported that she immediately went to find Administrative Nurse A and give her the licensed nurses' keys. CMA R explained she should not have accepted LN G keys, that is not normal practice and she felt like LN G put her in a bad position when she gave her the keys and rushed out the door. The facility's Controlled Substance Administration & Accountability policy, dated [DATE], documented the facility will have safeguards in place in order to prevent loss, diversion, or accidental exposure. The facility failed to ensure adequate safeguarding of the resident's liquid [MEDICATION(S)] and any other residents with controlled narcotic medications in the licensed nurses' cart, when the nurse handed her keys to a non-licensed staff member.

The facility reported a census of 30 with 12 residents reviewed, which included five residents sampled for unnecessary medications. Based on observation, interview, and record review, the facility failed to act timely upon recommendations of the consultant pharmacist for two of the five residents, Resident (R) 7 for diabetic medications and R27, for medications for the gastro-intestinal system. Finding included: - The Order Summary Report, dated 03/17/21, for Resident (R) 27 included diagnoses of [CONDITION(S)] of liver (chronic [CONDITION(S)] disease of the liver) and gastroesophageal reflux disease (backflow of stomach contents to the esophagus). The Annual Minimum Data Set (MDS) dated [DATE], assessed R27 with a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. The medication, Order Summary Report, revealed R27 had an order dated 06/14/19 for [MEDICATION(S)] Capsule 20 milligrams (mg), give one capsule by mouth one time a day for heartburn. Review of the electronic medical record (EMR), under the progress note tab, revealed on 12/19/20, the consultant pharmacist completed a medication regimen review (MRR), and recommended to the physician to discontinue the [MEDICATION(S)] order, or switch to [MEDICATION(S)] if the resident required a medication for GI (gastro-intestinal) prophylaxis (action taken to prevent disease) since the duration of therapy for [MEDICATION(S)] with an indication of GERD (gastroesophageal reflux disease) should be 20 mg daily for four weeks. The pharmacy Note to Attending Physician/Prescriber, dated 12/19/20, lacked a physician response, signature, or date. The facility sent the recommendation to the physician on 12/23/20, however, the facility did not follow up when the physician did not respond to the pharmacist recommendation. The EMR lacked a response from the physician in reference to the pharmacist's recommendation. On 03/25/21 at 12:39 PM, Administrative Staff B, confirmed the facility did not receive a response from the physician for the recommendation letter. On 03/25/21 at 02:40 PM, Administrative Nurse D confirmed the pharmacist recommendation lacked a response and the policy lacked a timeline for completion of the pharmacy recommendations. The facility policy, Addressing Medication Regimen Review Irregularities, dated 11/01/21, lacked a time frame for responses from the physician, unless it was an urgent irregularity identified. The facility failed to act upon consultant pharmacist reviews in a timely manner for R27, related to this resident's GI medications. - The Order Summary Report, dated 03/02/21, for Resident (R)7, included a diagnosis of diabetes mellitus (when the body cannot use glucose, not enough insulin was made, or the body cannot respond to the insulin). The Annual Minimum Data Set, (MDS), dated [DATE], assessed R7 as having a Brief Interview of Mental Status (BIMS) score of 15, indicating cognitively intact, a diagnosis of diabetes mellitus, and the resident received insulin injections for seven days. The Nutritional Status Care Area Assessment, (CAA), dated 10/08/20, indicated R7 received a carbohydrate- controlled diet. The Care Plan, dated 01/26/21, indicated that R7 had a diagnosis of diabetes mellitus and received oral diabetic medication and insulin. The Order Summary Report, dated 03/02/21, included orders for the following medication: 1. On 12/23/20, [MEDICATION(S)] (diabetic medication) flex touch solution pen-injector, 100 unit per milliliter (mL), inject 30 units, subcutaneous, twice daily, related to diabetes mellitus. 2. On 11/16/20, [MEDICATION(S)], 500 milligrams (mg), every day, for diabetes mellitus. 3. On 03/02/20, Novolog (diabetic medication) solution, 100 mg per mL, inject eight units, subcutaneous, with meals, for diabetes mellitus, hold if the resident's blood glucose was less than 80. 4. On 09/11/20, [MEDICATION(S)] (diabetic medication) solution, pen-injector 18 mg per 3 mL, inject 1.2 mL, subcutaneous, every day, related to diabetes mellitus. The medical record included a hemoglobin A1c (HgbA1c-lab test used to evaluate the average amount of blood glucose in the blood over the last two to three months) drawn on 01/26/21, revealed a result of 8.2 (high-normal range 3.8-5.6), with an estimated average glucose of 189 (high-normal range 70-110). The pharmacy Note to Attending Physician/Prescriber, dated 02/17/21, indicated that R7 had an order for [MEDICATION(S)] (generic form of [MEDICATION(S)]) 500 mg, every day, and recommended increasing the dose of the order to 500 mg to 850 mg twice daily. The reason for the recommendation indicated the most recent HgbA1c, from 01/2021, was 8.2, and the guidelines recommended a maximum daily total dose of 2,000 mg. The pharmacist requested the physician to please consider one of three options: increase the order to 500 mg twice daily, increase the order to 850 mg twice daily or continue the current order because an increase is not medically necessary. The note contained a handwritten message that the facility faxed the note to the physician on 02/18/21 and 03/04/21. On 03/24/21, the physician signed the note and included new orders to increase the [MEDICATION(S)] to 850 mg, twice daily. The physician responded to the note 34 days after the facility faxed it to the physician office. On 03/23/21 at 02:01 PM, Administrative staff B revealed she should obtain the pharmacy reviews when they come back signed from the physician, and Administrative Nurse D had copies of the reviews that the physician had not signed. On 03/23/21 at 02:18 PM, Administrative staff B confirmed the physician had not returned the 02/17/21 pharmacy review. On 03/24/21 at 03:15 PM, Licensed Nurse (LN) G revealed that Administrative Nurse D was in charge of the pharmacy reviews. On 03/24/21 at 03:27 PM, Administrative Nurse D, revealed the physician returned the pharmacy recommendation dated 02/17/21 today, a total of 28 days. She usually waited a week or two before she would notify the physician by facsimile (fax- transmission of a document or image from one place to another electronically) if there had not been a response received. Administrative Nurse D verified a physician response greater than one month was not a timely response to a recommendation. Administrative Nurse D was unaware if the facility policy had a timeframe for physician responses from the consultant pharmacist medication review recommendations. On 03/24/21 at 04:11 PM, Administrative Nurse D revealed the policy for the pharmacist reviews did not specify a time frame. The facility policy Addressing Medication Regimen Review Irregularities, dated 11/01/20, lacked a time frame for responses from the physician, unless it was an urgent irregularity identified. The facility failed to ensure that the physician acted in a timely manner in response to a pharmacy consultant recommendation for R7.

The facility reported a census of 32 residents with four residents selected for medication review. Based on observation, interview and record review, the facility failed to prevent a significant medication error, when the facility failed to administer an injection of Vitamin K (a medication used to prevent abnormal bleeding) in a timely manner, as ordered by the physician, for one resident (R) 3, for a critically elevated INR (international normalized ratio which is a laboratory measurement of how long it takes blood to form a clot to prevent adverse bleeding). Findings included: - Resident (R ) 3's Quarterly Minimum Data Set (MDS), dated [DATE], assessed the resident with a BIMS (brief interview for mental status) score of 15, which indicated normal cognitive status. The resident had seven days of anticoagulant therapy in the seven day look-back period. The Care Plan, updated 05/23/20, instructed staff to monitor the resident for bleeding risk as [MEDICATION NAME] (anticoagulant medication) may cause major or fatal bleeding. Review of (R3's Physician order [REDACTED].) The Physician order [REDACTED]. A laboratory report, dated 07/07/20 revealed an INR of 5.6 (per Mayo Clinic Critical Laboratory Results, an INR greater than or equal to 5.0 is considered critical.) A Nursing Progress Note, dated 07/07/20 at 11:45 AM, documented the licensed nurse left a message on the called the physician's office voice mail and faxed the physician the laboratory results. A Physician order [REDACTED]. until a recheck of the INR in two days. A Nursing Progress Note, dated 07/07/20 at 01:37 PM, documented a physician ordered staff to administer Vitamin K one time injection, hold the [MEDICATION NAME] until the INR was 2.0, repeat the INR on 07/10/20 and then to restart the [MEDICATION NAME] 2 mg daily. A Nursing Progress Note, dated 07/08/20 at 03:11 PM, documented the pharmacy did not have the injectable Vitamin K, and the facility E (emergency) kit did not stock injectable Vitamin K, but did contain an oral Vitamin K. Licensed Nurse (LN) G telephoned the provider on 07/08/20 at 11:00 AM and 12:30 PM, and left messages regarding the Vitamin K availability. LN G documented in this note that the pharmacy delivered the medication at approximately 02:30 PM, and she administered it subcutaneously to the resident at that time. Interview, on 07/13/20 at 4:09 PM, with LN G, revealed she worked as charge nurse on 07/08/20. LN G stated she called the provider's office twice regarding the Vitamin K injectable availability and did not receive a return call. LN G stated the pharmacy delivered the medication to the facility at approximately 02:30 PM at which time she administered the medication (approximately 25 hours after the physician gave the order.) Interview, on 07/14/20 at 09:30 AM, with pharmacy consultant GG, confirmed the facility's E kit did not contain injectable Vitamin K, and the pharmacy did not stock injectable Vitamin K and had to order it from a supplier and did not know if other pharmacies carried it as oral administration was the preferred route of administration. Interview on 07/14/20 at 10:39 AM, with Administrative Nurse D confirmed the facility E kit did not stock injectable Vitamin K but did have oral Vitamin K. Nurse D confirmed the INR of 5.6 was a critical value and the facility Nurse D stated staff should have contacted the physician or the on call physician (for the provider and Nurse Practitioner when they are out of the office) to immediately obtain a change from injectable Vitamin K to oral Vitamin K. Nurse D stated the licensed nurse should have contacted administrative staff to assist in locating injectable Vitamin K. The facility policy Anticoagulation Therapy dated 07/10/20, instructs staff appropriate antagonist for anticoagulants will be available in the facility emergency kit, including Vitamin K. The facility policy Medication Errors, undated, instructs staff to report the error in detail on the incident report and significant medication errors are those which require medication intervention and/or result in possible or confirmed morbidity or mortality. The facility failed to prevent a significant medication error when they failed to administer Vitamin K injection in a timely manner, as ordered by the physician to counteract the critically elevated INR to prevent abnormal bleeding in this resident.

The facility reported a census of 26 residents with 3 residents selected for sample review of abuse. Based on observation, interview and record review the facility failed to ensure one resident (#1) of 3 reviewed received care and services in a dignified and non-threatening manner, when a licensed staff member verbally demeaned the resident and then performed unnecessary neurological checks to the resident, during the night time hours, following a fall. Findings included: - Resident #1's annual MDS (minimum data set), dated 10/13/18, included a BIMS (brief interview of mental status) of 15, which indicated intact cognition and lacked indicators of any mood or behavioral concerns. The assessment identified the resident as independent with ADLs (activities of daily living) and indicated the resident with falls since the prior assessment, including 1 non-injury and 1 non-major injury fall. A significant change MDS, dated [DATE], identified the resident continued with a BIMS of 15, without any mood or behavioral concerns, and evidenced the resident required limited to supervised assistance with all ADLs, was unsteady on his/her feet and unable to stabilize without human assistance. The resident experienced falls since the prior assessment, with 2 or more without injury and 2 or more with non-major injury. A 1/11/19 CAA (care area assessment) for falls, evidenced the resident with a history of falling prior to admission and continued since admission. The resident experienced several falls recently due to an increase in unsteady gait and weakness. The care plan, dated 1/14/19, instructed the staff in the following care needs for ambulation: 1) The resident needed assistance of one staff and use of a 4wheeled walker for ambulation. 2) Monitor/document/report PRN (as needed) any signs and symptoms of immobility, including fall related injury. 3) Physical and occupational therapy referrals as ordered, PRN. 4) Remind the resident to call for assistance to retrieve items from the floor, added 1/14/19. 5) Provided resident education to lock brakes on walker prior to standing, added 1/14/19. Review of the facility fall packet included a checklist with instructions to begin neurochecks if the resident struck their head or if an unwitnessed fall occurred. If the resident's BIMS score was 13 or higher and the resident stated that they did not hit their head and assessment lacked indications of hitting his/her head, then it only required the first neurocheck. Review of the facility investigation included a witness statement from the resident, dated 3/3/19, which indicated the resident reported to social services staff that on 3/1/19 the nurse on duty, lectured the resident after he/she slid out of his/her wheelchair, while performing his/her routine evening cares. The resident further reported, in a tearful voice, that the nurse just went on and on about the fall and lectured the resident on the risks of falling and that the resident should be calling for assistance when doing things. The resident reported he/she had never in his/her life been treated in such a manner and would prefer to die than ever be treated in such a manner again. The resident reported the staff member instructed him/her that the punishment for falling included being awakened all night long for checking of neurochecks (neurological checks/vital signs), which he/she reported the staff member did. An interview with the resident on 3/13/19 at 4:10 PM, verified this information, as accurate. A witness statement by direct care staff G documented, on 3/3/19, staff G assisted other staff in assisting the resident to stand up from the floor. During the interaction staff G noted the agency nurse speaking rudely and aggressively in his/her instructions about falling to the resident. Following assisting with the transfer, the agency nurse inquired to staff member G about neurochecks which staff member G indicated that normally if the resident was alert and able to indicate whether he/she hit his/her head then only one set of neurochecks was done. The agency nurse stated she planned to do neurochecks regardless. Staff G indicated the resident reported he/she did not hit his/her head, as he/she slipped off the edge of the wheelchair seat onto his/her bottom. An interview with staff G on 3/13/19 at 2:24 PM, verified this information, as accurate. A witness statement, completed by social services staff C, on 3/3/19 indicated that on 3/3/19 another staff member notified him/her that the resident was upset. Staff C went immediately to the resident's room, where he/she found the resident crying and upset. The resident reported to staff C that he/she felt the treatment he/she received after falling was inhumane and he/she had never been spoken to in that manner in his/her [AGE] years. The resident indicated to staff C that he/she instructed the agency nurse to get out of his/her room, and finally after telling the agency nurse that two times the nurse exited the room but returned every 15 minutes throughout the night as punishment for falling. A follow-up interview on 3/14/19 at 8:05 AM, verified the information as accurate. A witness statement, completed by licensed nursing staff D, on 3/4/19, reported he/she checked on the resident on 3/4/19 related to the fall. The resident reported to staff D he/she believed he/she had been scolded enough by the agency nurse and felt that he/she received punishment for falling. Unable to contact this staff for interview, during the investigation. A witness statement, completed by agency nurse E, on 3/4/19, indicated he/she went to the resident's room to administer bedtime medications and treatments on 3/1/19 at approximately 9:30-10:00 PM. Upon entering the resident's room, the staff saw the resident seated upright on the floor in front of his/her wheelchair. The staff member and the resident discussed wheelchair safety, the nurse completed a fall assessment and initiated neurochecks. The staff documented he/she was unaware of the resident being upset. Staff E documented he/she followed the protocol for neurochecks, as established by the facility and completed the last neurocheck at 3:00 AM. A follow-up interview with the resident on 3/13/19 at 4:05 PM verified the information as accurate. Direct care staff H reported and documented, on 3/13/19, that on the morning of 3/2 or 3/3/2019, the staff member walked past the resident's room and asked if the resident would like some help. The resident replied he/she did not want any help from anyone. The staff realized from the resident's tone that a problem existed. The staff entered the resident's room to determine what was wrong with the resident. The resident then informed staff H about the fall on 3/1/19 and how the agency nurse had been mean/rude to him/her and punished him/her for falling. Staff H further noted the resident remained in his/her room most of the day, which was not his/her normal habits. Direct care staff H immediately reported the resident's concern to the on-duty charge nurse and the manager on duty (social services staff C). A witness statement, completed by administrative nursing staff B, dated 3/4/19, documented discussing with the resident regarding his/her fall and the subsequent actions by agency nursing staff E. The staff documented regarding the resident being emotionally upset following the event. Observations, on 3/13/19 9:02 AM, 11:45 AM, and 2:30 PM identified the resident going about daily living tasks, including eating meals, self-propelling around the facility and visiting with a guest. On 3/13/19 at 4:10 PM, the resident, while seated in the recliner reported that on the evening that he/she fell , he/she had gone about the normal evening/nighttime routine of gathering items to start the next day, such as clothing and shoes. He/she placed the items into the seat of the wheelchair, behind his/her back, however, when reaching for an item, the resident slipped off the edge of the wheelchair seat and gently sat down on the floor. The resident reported he/she then crawled to the call light and turned it on. When the nurse entered the room, the resident explained what occurred. Initially the nurse obtained assistance in getting the resident up off the floor, and then he/she began to lecture the resident on wheelchair safety, how the resident should not attempt to be so independent and how much work a fall created for the staff. The resident reported he/she had enough of it and told the staff so, but he/she continued to remain in the resident's room and repeated him/herself over and over. The resident stated the second time that he/she had heard enough and told the agency nurse to leave the room. The resident indicated the nurse also told him/her that the punishment for falling would be getting awakened every 15 minutes all night to have vital signs taken. Lastly, the resident added, that was just what he/she did too. The resident indicated he/she had never been treated as cruelly as the agency nurse did, and felt the treatment was unnecessary. On 3/13/19 at 10:50 AM, direct care staff I reported following the incident with the agency nurse, the resident was really upset about being punished for falling, however, a week or so later seemed to have recovered from the incident and returned to his/her usual sweet self. On 3/13/19 at 11:20 AM, administrative nursing staff B reported that on 3/3/19 at 10:16 AM, social services staff C reported via phone conversation, regarding the agency nurse's behavior, as reported by the resident. Staff C indicated the resident was tearful and upset at the time. The staff instructed staff C to find a replacement and notify the agency of the nurse's behavior. Upon notification the agency indicated a lack of another nurse to work the 6PM to 6AM shift. When the shift was unable to be filled, the staff determined to allow the agency nurse to work on 3/3/19 from 6PM to 6AM, with the understanding that the staff member was not to go into resident #1's room without another staff member in attendance. Staff B indicated that on 3/4/19, the facility notified the agency that the nurse was not return to the facility. On 3/13/19 at 2:08 PM, direct care staff K reported working the weekend the resident had fallen and noted the resident's behavior as subdued and more quiet than usual. On 3/13/19 at 2:35 PM, licensed nursing staff J reported the morning after the resident's fall, (MONTH) 2, 2019, the off-going agency nurse indicated during shift report that the resident was not happy with the nurse, however he/she did not say why. The following day, an aide came and told staff J that the resident reported verbal abuse against the agency nurse. At that time, social services staff C was present in the building as the manager on duty and he/she went down to talk to the resident. Interview, on 3/13/19 at 4:48 PM, with agency staff E, reported that around 9:50 PM on 3/1/19 staff E found the resident on the floor. Staff E reported asking the resident what had happened, and the resident indicated he/she slid off the edge of the wheelchair seat. After completing a quick assessment and finding no injury, staff E notified additional staff to assist with picking the resident up off the floor. Noting that the seat of the wheelchair was full of other personal belongings, which did not allow the resident to sit back into the chair, staff E discussed safe mobility with the resident. Staff E reported beginning neurochecks, per policy, and continued with neurochecks until 3:00 AM in the morning. The staff indicated using a fall packet from the nursing desk area which included a fall checklist and instructions for neurochecks. The resident did not express any concerns throughout the night. Staff E reported apologizing for awakening the resident and he/she was cooperative. Staff E believed the last neurocheck finished around 3:00 AM. Upon return to work on 3/2/19 (6p-6a), the staff documented and completed another neurocheck. That evening the resident seemed concerned, tired and reported he/she just had no purpose any longer for living and was ready to die. Staff E inquired if he/she had a plan in place for that and the resident replied NO. Staff E reported attempting to provide comfort to the resident, and throughout the night staff E reported he/she checked in on the resident. The resident seemed to sleep well throughout the night. On 3/3/19 when staff E returned to work (6p-6a) he/she reported being informed by the off-going nurse that whenever he/she went into the resident's room, that staff E needed to take someone with them because the resident had reported that staff E punished the resident for falling by doing neurochecks all night. On 3/14/19 at 8:05 AM, social services staff C reported that when the resident told the staff member, on 3/3/19 about staff E's actions, staff C immediately notified the acting DON (director of nursing) and the administrator of the facility. The staff member indicated he/she then called the agency that employed staff E and asked for a replacement. The agency reported they did not have any other licensed nurse to send as a replacement. At that time, being unable to find a replacement, staff C again notified the acting DON and the decision was made to allow the nurse to work but only being with the resident with another staff member present. On 3/14/19 at 9:05 AM, administrative nursing staff B verified the actions of the staff were appropriate and confirmed that agency nurse E worked the following night after notification of alleged abuse, but only due to the facility being unable to replace that nurse. Staff B further reported the AP (alleged perpetrator) did not follow the protocol for neurochecks for an alert resident who indicated a lack of hitting his/her head. On 3/14/19 at 9:15 AM, administrative staff A, reported he/she had planned to meet with social services staff C and review the completeness and thoroughness of the investigation. The staff indicated that a lack of time and the lack of having a notary public available delayed the review of the investigation. The facility policy, dated 3/27/18, for Abuse, Neglect and Exploitation evidenced the facility's goal to achieve and maintain an abuse-free environment by training all staff and practitioners on resolving conflicts appropriately and with staff training. Additionally, protection of the residents included the AP would be immediately reassigned to duties that do not involve resident contact or will be suspended until the findings of the investigation were reviewed and found unsubstantiated. The facility failed to ensure this resident felt protected, safe and secure when a licensed staff member verbally demeaned the resident following a fall, in a manner that the resident felt was undignified, cruel, and as though he/she received punishment due to the fall. The resident experienced emotional harm (was tearful and stated he/she wanted to die) as a result of the licensed staff's actions.

The facility reported a census of 35 residents. The sample included 17 residents. Based on observation, record review and interview, the facility failed to implement effective interventions to prevent the development of a facility acquired unstageable pressure ulcer for 1 (#44) resident sampled for pressure ulcers. Findings included: - Review of the signed physician orders, dated 8/21/15, revealed the resident admitted on [DATE], with the following [DIAGNOSES REDACTED]. disorder characterized by failing memory, confusion). The admission MDS (minimum data set), dated 8/7/15, revealed the resident had a BIMS (brief interview for mental status) score of 4, indicating severely impaired cognition. The resident required total staff assistance for bed mobility, and locomotion; the resident required extensive staff assistance for transfers; and was independent in eating. The resident had functional limitations in range of motion to the upper extremities bilaterally and the lower extremity on one side; and utilized a walker and a wheelchair for mobility. The resident was occasionally incontinent of bladder, and always continent of bowel. The resident was at risk for pressure ulcers, and the MDS documented the resident without unhealed pressure ulcers. The resident had a pressure reducing device to the bed. The CAA (care area assessment), dated 8/13/15 for pressure ulcers, documented the resident had the potential for pressure ulcers, required assistance with transfers and repositioning, and was incontinent of bladder. The 14 day MDS, dated [DATE], revealed the following changes: the resident required extensive staff assistance for bed mobility, and transfers. The resident had a stage 1 pressure ulcer that was not present on admission; received pressure reducing device for chair, nutrition or hydration intervention to manage skin problems, and pressure ulcer care. The admission care plan for potential for pressure ulcers, dated 7/31/15, documented; --Extensive staff assistance of two with gait belt for transfers and toileting. --Assistance of 1 staff for dressing, and peri-care. --Provide peri-care after each incontinent episode. The care plan for an actual pressure ulcer, initiated on 8/13/15, documented the resident had a dark purple area to right inner ankle, and advised the following measures; --Skin prep to be applied daily to the resident's right heel. --Both heels to be floated when the resident was in the bed or recliner. --Heel protectors to be on when the resident was in the wheelchair. --Gripper socks to be on the resident for all transfers. --House supplement with all meals. --Weekly measurements of the area. --Keep the physician and the family notified of any deterioration. --Turn every 2 hours. --On 8/24/15 the care plan was updated to include a walking boot, on in AM and off at bedtime. The skin condition report, dated 8/13/15, documented, the pressure ulcer site was the right ankle, first observed 8/13/15, was a Stage 1, measured approximately 2.5 cm (centimeters) by 2 cm, and was without drainage, granulation or odor. Review of the Braden Scale for Predicting Pressure Sore Risk Assessment, dated 7/31/15, the resident had a score of 13. A score of 13-14 placed the resident at a moderate risk for pressure ulcers. Review of the admission Resident Data Collection Documentation form, dated 7/31/15, documented the resident had two incisions to the right hip, without further documented skin issues. The nurses notes, dated 8/13/15 at 9:00 PM, documented the resident had a decub (pressure area) located on the residents right inner ankle, measured approximately 2.5 cm by 2 cm. The area was described as dark purple in color, without depth, tender to touch, and heel protectors were applied. The staff elevated the resident's lower extremities. On 8/14/15, the physician ordered the staff to apply heel protectors to protect and prevent shearing, and was notified of the pressure ulcer. On 8/17/15, the physician ordered House Supplement with all meals for skin integrity. On 8/19/14, the physician ordered a walking boot on in AM and off at HS (bedtime). On 8/20/15, the skin condition report documented, the pressure ulcer to right inner ankle, measured approximately 2.5 cm by 2 cm, was darkish purple in color, and slightly soft to touch. The initial nutrition assessment, dated 8/24/15, documented the resident height was 64 inches and weighed 115 pounds, with a ideal and/or usual weight of 110 pounds. The resident with a pressure ulcer to right inner ankle, ambulatory, natural teeth, [MEDICATION NAME] degeneration and had had some confusion. The resident ' s usual percentage of his/her intake was 50-100% (percent) and received house supplement during snack times. The resident required 1245 kcal (calories), 50 gm (grams) of protein, and 1245 cc (cubic centimeters) of water. The assessment summary documented the resident had an area to right inner ankle. A treatment was in place and the facility used heel protectors as well. Recommendation: Please consider a daily vitamin with mineral to promote healing of the decub. Review of the resident's [MEDICATION NAME] level, dated 7/28/15 (while in the hospital), was 2.7, which was low. The normal range for [MEDICATION NAME] is 3.5-5.0. Also the resident had a Total Protein of 5.0, which was also low. The normal range for Total Protein was 6.3-8.2. On 8/24/15, the physician ordered a Multi-vitamin with minerals, 1 by mouth daily until pressure area was healed. On 8/27/15, the skin condition report documented, the resident with a pressure ulcer to right inner heel, measured approximately 3.0 cm, dark purple in color and spongy to touch and documented the pressure ulcer deteriorated without further explanation. The nurses notes, dated 8/27/15 at 3:45 PM, documented the staff notified physician office of the deterioration in the resident's right heel and the physician assistant staff X will be out the next day to assess the resident's heel. On 8/28/15, the physician ordered Zinc, 50 mg (milligrams) 1 by mouth daily, Vitamin C, 500 mg 1 by mouth daily, and an Arginade packet ordered daily for wound healing until the area decubitus healed. Review of the resident's August 2015 TAR (treatment administration record) revealed documentation of application of heel protectors starting on 8/14/15. The TAR failed to include the treatment of [REDACTED]. Review of the resident's clinical record lacked documentation of an order for [REDACTED]. On 8/26/15 at 10:00 AM, the resident was sitting in the recliner with his/her feet elevated on a pillow with his/her heels floated. The resident was without signs or symptoms of pain or discomfort. At 10:37 AM, direct care staff I offered the resident glass of house supplement and the resident declined. Direct care staff I then offered the resident apple juice and grape juice to drink and the resident declined. At 11:55 AM, direct care staff T asked the resident if he/she wanted to go to the dining room, and the resident stated no. Direct care staff T then offered the resident a drink of water and the resident requested to be taken to the bathroom. Direct care staff T placed a podus type boot (walking boot) on the resident's right foot. Then direct care staff T and direct care staff L ambulated the resident from the recliner to the bathroom. The resident was continent of bowel and bladder. The resident ambulated from the bathroom to the wheelchair and was taken to the dining room for lunch. On 8/26/15 at 2:00 PM, the resident was resting quietly in bed on his/her back with a podus boot to the right foot. The resident was without signs or symptoms of pain or discomfort. At 2:15 PM the resident remained in the same position. At 2:24 PM, the staff assisted the resident to a sitting position by direct care staff T, and ambulated to his/her wheelchair in the hall, approximately 25 feet with a walker. The resident had on a podus type boot to his/her right foot and a 2 inch cushion to his/her wheelchair. Observation revealed the resident without signs or symptoms of pain or discomfort. The staff wheeled the resident to the activity room for a music program. At 2:40 PM, 2:55 PM, 3:10 PM, the resident remained in the same position. At 3:20 PM, direct care staff U was in the dining room with the resident, encouraging the resident to drink his/her supplement. The resident refused his/her supplement. Direct care staff U stated he/she tried to get the resident to drink the house supplement, but the resident did not want it. Direct care staff U stated he/she would let the nurse know when a resident does not drink a supplement. At 3:35 PM, 3:50 PM, the resident remained in the same position. At 4:00 PM, the resident was sitting in his/her wheelchair at a dining room table. At 4:15 PM, 4:30 PM, and at 4:45 PM, the resident remained in the same position. At 4:48 PM, direct care staff N, U, and L, verified staff failed to reposition the resident since the time the program started. Furthermore, direct care staff L stated he/she was unsure if the resident had been repositioned because he/she worked a different hall today. At 5:08 PM, the resident was taken to the shower room by wheelchair by direct care staff W, direct care staff V, and licensed administrative staff G. The resident stood with staff assistance of direct care staff W and direct care staff V. Licensed nursing staff G checked the resident's skin and his/her buttocks were red, but blanchable. The resident's incontinent brief was dry. Licensed nursing staff G stated the pressure ulcer was not on the resident's ankle, but on the resident's heel. Direct care staff V took off the resident's podus type boot. Observation at this time revealed a dark purple fluid filled blister to the resident's right heel, not the right ankle. The area measured approximately 2.5 cm by 2 cm. The area around the blister was slightly red. The resident denied any pain or discomfort. Direct care staff W and V replaced the boot and transferred the resident to the wheelchair. The resident remained in the same position for 2 hours and 40 minutes. On 8/27/15 at 2:16 PM, the resident was in his/her recliner in his/her room with his/her heels floated. Nursing staff B lifted the resident's heel, and identified the area to the right heel had a dark purple, fluid filled blister, as the site of the pressure ulcer, and nursing staff B stated the area was soft to touch. Administrative nursing staff B and licensed nursing staff G measured the area to the right heel, and the site measured approximately a 3.0 cm circle. Licensed nursing staff G then applied skin prep to the heel. Observation revealed the resident without signs or symptoms of pain. Administrative nursing staff B stated when the area was found a couple of days after the resident was admitted . The staff thought the area was a bruise and documented the area as a Stage 1. Nursing staff watched the right heel and decided the area might be something else. Administrative nursing staff B stated he/she had circled on the figure (on the skin form) the area was the heel, however he/she documented the area as the ankle. The staff discussed whether this area to the resident's heel was a stage 1 pressure ulcer. At this point licensed nursing staff G stated the area on the heel was unstageble by the MDS definition, however, unstageable was not on the skin form so he/she wrote the area as a Stage 1. Administrative nursing staff B stated, the resident had a pressure relieving mattress and heel protectors when he/she came in. However, nursing staff B was worried the heel protectors might be causing the pressure area, and requested the walking boot (podus type boot) and the heel elevator. On 8/26/15 at 4:24 PM, consultant staff F stated he/she was at the facility to complete an initial nutritional assessment on the resident due to a pressure ulcer. Staff F stated he/she recommended a multivitamin. On 8/27/15 at 11:23 AM, direct care staff M stated the resident should be repositioned every hour when in bed, had a cushion to his/her wheelchair. The resident was to wear the walking boot during the day when he/she gets up for the day and the boot to be taken off at night. She takes some of his/her supplement sometimes. On 8/27/15 at 11:25 AM, direct care staff N stated when the resident goes to bed, the staff should take the walking boot off and put the blue foot device (heel elevator) in place and heel protectors. The resident should be repositioned every 2 hours. On 8/31/15 at 8:00 AM, licensed nursing staff G stated the area was first observed on 8/13/15 was facility acquired. The resident should be repositioned in the bed or the wheelchair at least every 2 hours, but he/she would like the resident to be repositioned every 1 hour. The resident was not on an individualized turning program. The resident had a pressure relieving mattress and the turn every 2 hours schedule. When the area was found to the right heel, the staff started floating the resident's heels, used heel protectors, and continued with repositioning every 2 hours. The resident did not have the heel protectors before he/she obtained the pressure area. A nursing order was written for the skin prep, 1 time daily to the right heel. Staff G reviewed the resident's physician orders [REDACTED]. If a resident had a change of condition it is the responsibility of the nurse to let the direct care staff know of any changes in the resident's care plan. The resident was at risk for skin breakdown when admitted to the facility. On 8/31/15 at 9:54 AM, administrative nursing staff B stated he/she thought the pressure ulcer was discovered a couple of days after admission, but since found out the area had been discovered about 2 weeks after admission. All the residents should be repositioned at least every 2 hours. The walking boot was for strengthening, however the walking boot also has the area to the heel which relieves pressure. He/she added the walking boot to the care plan. The staff will take the boot off during the day when he/she would be in bed or in the recliner and float the residents heels then. Staff B confirmed he/she was not aware the resident had not been repositioned and would have expected the staff to know when the resident had been repositioned last. On 8/31/15 at 12:12 PM, physician assistant staff X stated the resident was at risk for skin breakdown related to his/her age, the resident lost weight and had recent hip surgery. Staff X stated he/she was at the facility on 8/28/15 and observed the area to the right heel. He/she chose to leave the skin intact to the blister. He/she added the zinc, and vitamin C with the multivitamin and the arginade, until the area healed. On 8/31/15 at 3:00 PM, administrative nursing staff B stated the licensed nursing staff failed to assess the resident's skin weekly for the first 4 weeks due to having licensed agency nursing staff. On 8/31/15 at 3:27 PM, physician assistant staff X stated staff updated him/her of the resident's treatment of [REDACTED]. Staff X was unable to verify if staff notified him/her of the skin prep treatment. Review of the facility Pressure Ulcer Protocol, dated 8/15, documented the rationale was to document those residents who are at risk, and to prevent the development of pressure ulcers. All residents are assessed for skin at risk: upon admission, and weekly for the first 4 weeks after admission. Furthermore, the resident should be turned and repositioned at least once every 2 hours. The facility failed to complete weekly new admission skin assessments as directed by the facility's pressure ulcer protocol, and failed to initiate preventive measures, including heel protectors and repositioning every 2 hours, for this dependent resident identified at risk for pressure ulcer development who subsequently developed an unstageable pressure ulcer.